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What kind of training, supervision, and support do CHWs need to be successful?

Posted: 11 Jun, 2017   Recommendations: 2   Replies: 31

We call upon CHWs to be more than health care providers. We expect them to be leaders. We expect them to make history. To stop deaths from malaria, to transform health outcomes for expecting mothers, to stop disease outbreaks in their tracks. We expect them to achieve these feats in settings of extreme poverty, often distant from their health system teammates, those who would support and supervise them. And yet while we expect more of CHWs, CHWs often receive far less training and supervision support than other providers.

We can overcome these challenges by design. We can enable CHWs to maximize their impact and leadership through the way we design their training and the supervision structures that support them.

On the Muso team in Mali, we organize pre-service training around attaining core skills, using almost exclusively participatory learning methods. We avoid slide-show presentations or lectures. Participants discuss each concept until they can articulate and explain it to others, and practice each skill until they can demonstrate proficiency. Role-plays and theater-based methods provide an interactive mode for participants to master the “soft skills”—techniques of active listening, eliciting patient perspectives, and counseling.

We consider pre-service training to be just the first part of the training process. Muso deploys a system of 360 Supervision, designed to provide dedicated, in the field coaching and supportive supervision to Community Health Workers tailored to each CHW’s particular strengths and challenges. A CHW Dashboard, designed in partnership between Muso and Medic Mobile, provides precision feedback on the quantity, speed, and quality of care that each CHW provides.

Over the course of this week, we will share the challenges that Muso CHWs have faced and the design strategies we have deployed to overcome those challenges—including 360 Supervision, and the CHW Dashboard. We look forward to your thoughts and feedback on these approaches. We will also tap the collective experience of the GHD community to dig in on these core questions:

What challenges have you encountered to effective CHW training and supervision? What critical factors make CHW supervision effective or ineffective? What design innovations can be deployed to solve those challenges?

We look forward to hearing your thoughts and learning from you over the course of the week.

~ Ari Johnson

Les Agents de Santé Communautaire (ASC) prodiguent des soins de base et offrent des services à de millions de personnes dans le monde.

Malgré le grand apport de ces ASC en matière de soins de santé communautaire et de la promotion de la santé en général qui contribue ainsi à la réduction de mortalité maternelle et infantile, leurs interventions rencontrent un certain nombre de difficultés tant dans le domaine de la formation initiale et continue mais aussi des difficultés liées à la supervision.

Ces difficultés contribuent sans doute à créer une grande différence de qualités et quantité de soins, de performance entre l’utilisation des ASC par les pays mais aussi entre les ASC eux même d’un même programme.

Pour les aspects de formations, les difficultés sont liées entre autre aux outils utilisés pour les formations, les méthodologies d’apprentissage pour la plus part verticale, et le manque de plans de formation continue.

Pour la supervision, nous pouvons noter la disponibilité des ressources humaines pour la tâche, la distance géographique entre superviseurs et ASC, le manque ou l’insuffisance d’outils de supervision adéquate et l’insuffisance de supervision formative.

Pour palier a toutes ces difficultés, une grande synergie est nécessaire entre acteurs de mise en œuvre des programmes de soins de santé communautaire à travers les ASC pour réfléchir et mettre en place des structures, des ressources, des outils, stratégies et modèle efficaces.

~ Youssouf Keita



BOLATITO AIYENIGBA Replied at 10:02 AM, 12 Jun 2017

Thanks. Sounds very interesting what you are doing in MUSO. Looking forward to learning more as the days go by.

Ahishakiye Alain Replied at 12:14 PM, 12 Jun 2017

Thank you Ari Johnson and Youssouf keita. Sounds very interesting your suggestions.

Samuel Kudzawu Replied at 12:25 PM, 12 Jun 2017

Thanks for this topic.
For a CHW, the basic training aside of should be defined and tailored according to the background of the CHW. for example; tradional leaders must lead the advocacy aspect, whiles the spiritual and CSOs do the education. Those inclined to healing whether traditional or othordox should doing more of case detection, management and evaluation.
Ownership is very key to any intervention to succeed and be sustainable.

Sarah Jane Holcombe Replied at 12:55 PM, 12 Jun 2017

Thank you for sharing MUSO's very exciting model. It is all the more important, as MUSO works in a rural and socially conservative context.

I would be particularly interested to hear strategies for training CHWs that reduce (or at the very least do not reinforce) existing imbalances in power between CHWs and clients, and that equip CHWs (?and supervisors) with the skills and practices to serve their clients in a way that respects and strengthens their client's autonomy.

In some of the CHW projects offering rural community-based reproductive health services, particularly short-term contraception, that I have seen in Uganda, this has been a problem. Although the CHWs involved are generally very committed to improving the well-being of their communities, they at times can be very directive, and sometimes even judgemental, toward younger, female clients. CHWs can patronize clients, and not work to help/empower clients to make their own life decisions. As can happen anywhere, CHWs can bring some of the unhelpful beliefs and prejudices of their communities to their work.

I would like to hear of successful interventions to build CHW empathy and respect for clients, and to increase CHWs' ability to empower clients.

Amy Madore Replied at 6:26 PM, 12 Jun 2017

Hi all - David Gliber asked a great question in a different thread that is relevant to this topic of what tools and supports CHWs need to be successful. Sharing here in case folks can comment on their experience:

Hi All,

Has anyone had experience using the Motivational Interviewing techniques (Rollnick, Miller and Butler ) with CHW's or CHW supervisors? Their work provides guidelines for how to manage "change talk" and use asking, listening and informing to tap into the motivation of a patient in a "guiding style".

Abimbola Olaniran Replied at 6:55 PM, 12 Jun 2017

Many thanks for sharing your experience on training and supervision of CHWs. Training and supervision of CHWs seem to be an age-long challenge. I would be grateful for your thoughts on the role of Information Technology (IT) in frog-leaping this challenge:

1. A mix of "telephone supervision" and "on-site supervision": Programmes may consider that it may not be feasible to have facility-based and district-level supervisors visit CHWs in hard-to-reach regions as often as we wish. However, supporting telephone communication between CHWs and supervisors may mitigate the need for frequent visits while ensuring that CHWs are guided and supported in their health service delivery. Moreover, junior doctors and nurses use this channel to communicate with their senior colleagues and maybe CHWs can also benefit from it.
2. Telecasting recorded training videos to a group of CHWs with a senior CHW facilitating discussion. This may serve as a source of regular in-service training, and complement formal in-service training which may not be regular in many settings.
3. I am keen to hear about the CHW dashboard especially its suitability and sustainability in a low-resource setting.

In relation to MUSO's 360 supervisory model, I am keen to read how you addressed the various components of supervision and ensured that all these components were well-catered for:

1. "Administrative" or "Audit" form of supervision which measures performance against targets.
2. "Technical" supervision to ensure that CHWs are guided in service delivery with these services complying with recognised standards and guidelines.
3. "Supportive" supervision that seeks to identify and address CHWs challenges.

I eagerly look forward to the discussions.


Sidumo Gumbo Replied at 1:18 AM, 13 Jun 2017

Hi all and thank you for these important discussions. The major challenge on supervision and supporting of the CHWs is when they are engaged by different development partners from different programs where there are also different approaches and tools for service delivery in the communities and to mitigate these challenges it would be better if the coordination of these is done centrally and there should be a harmonisation of approaches and tools to avoid duplication of effort and improve quality of services.

George Ayeh Replied at 3:54 AM, 13 Jun 2017

Very interesting and insightful discussions on CHWs. From my experience and knowledge in working with CHWs in the Southern African region, CHWs are better supervised when they are linked to the health facility but work in the communities as mentioned earlier by Manzi and Dan Palazuelos. The facility based staff especially those in the health centers understand the complexities and challenges faced by CHWs and therefore design harmonized and coordinated CHW contributions.

VHWs are also more effective when they are given more focussed and specific tasks as compared to when they are given so many tasks spread over different kinds of diseases. Partners In Health have been successful in using CHWs to deliver MDR-TB community based MDR-TB care, Maternal Mortality Reduction Programs, PMTCT and HIV/TB care in Lesotho by focussing the tasks of the CHWS.

VICTOR LARA Replied at 4:59 AM, 13 Jun 2017

35 years ago (1982) I learned to work with community - based traditional
practitioners (midwives and healers) and volunteers in the amazon jungle of
Peru. Today, some of those areas are still in the same level healthcare
development as they were in 1987. I spent the last 30 years promoting that
work of solidarity and development of community based services in all
continents, just returned from 20 years of work in Asia and Africa and I
got the same inspiration and sense of hope when I seen these discussions.
One question for all: why are we still doing this? why people need to rely
in this solidarity and is not receiving more comprehensive service aligned
with the times and technology? anybody can essay a couple reasons? I need
to write about those reasons.

Ernest MUHIRWA Replied at 5:54 AM, 13 Jun 2017

Thanks so much for this conversation,
I am Ernest MUHIRWA, MPH Candidate and serve PIH Rwanda in Monitoring and Evaluation Department. I am also a Junior Researcher,
And I am experienced to work closerly with COMMUNITY HEALTH WORKERS from more than 5 Years.

One thing I can say, is that: You can remember that the CHWers are working as volunteers no payment.
So first thing is to support them as motivation for sustaining and keep them to continue to serve community
the second thing is to enable them having some basic needs including safe house, boot, transport and communication, give them the strong righting (Torch, lamp ...)
In terms of supervision their need to be supervised in Quality of Services deliveries.


Youssouf Keita Panelist Replied at 8:17 AM, 13 Jun 2017

Merci beaucoup à Sarah et à tous pour tout l’intérêt que vous portez sur notre modèle.
Effectivement les questions liées aux éventuels discordances/conflits qui peuvent exister entre les CHW et les communautés peuvent réduire l’efficacité de l’intervention des CHW donc doivent être bien traités.
Plusieurs paramètres sont à prendre en compte pour réduire ces discordances/conflits qui sont :
1. Le processus de recrutement des CHW
Comme décrit dans un de mes messages, faire participer la population au processus de recrutement des CHW à de grands avantages surtout liés à l’acceptabilité de la personne par la communauté qui naturellement réduit les conflits entre CHW et communauté (ce processus est bien décrit dans un autre message posté) mais nous serons ravi d’en parler de nouveau si besoins.
2. La formation
L’ONG Muso traite cette question de façon large lors du processus de formation des CHW.
Nous avons un manuel spécifique sur les questions liées à la justice sociale, les droits humains et droits à la santé les compétences nécessaires (bonne capacité d’écoute active, le leadership…) pour devenir un bon CHW ainsi que les valeurs d’un CHW (confidence, solidaire, le respect mutuel…).
C’est le premier module dispensé avant d’aborder les questions techniques liées aux prises en charges des maladies.
A l’issu de cette formation sur ce module, les CHW sont plus motivés, plus engagés à servir leur communauté dans le respect et dans la dignité et comprennent les bases fondamentales à l’accès aux soins qui sont très importantes pour la réussite des programmes CHW.
3. La supervision
Ces deux premiers paramètres son soutenus par un modèle de supervision des CHW mis en place par Muso basé sur la supervision dédiée et qui comprend 4 grandes étapes :
• La mise à disposition d’un tableau de bord qui présente les activités des CHW en termes de quantité, vitesse de prise en charge et qualité de la prise en charge ;
• La visite dans la communauté par le superviseur sans le CHW pour recueillir les besoins spécifiques des membres de la communauté et identifier les éventuels conflits entre CHW et communautés et bien d’autres choses.
• L’observation directe du CHW à la tache ;
• La rencontre individuelle en CHW et son superviseur avec partage du tableau de bord.
Nous développerons cette question de supervision dans un autre message.
Encore une fois merci et nous restons disponibles pour continuer les discussions.

Ari Johnson Panelist Replied at 10:48 AM, 13 Jun 2017

Sarah, thank you for raising this crucial question of patient respect, dignity, and agency. Making this happen is not easy, and as my teammate Dr. Keita points out, we work on this at each step. A few thoughts to complement Dr. Keita's insights:

1. To design for the patient, design with the patient: Muso's Proactive Community Case Management strategy emerged directly from the insights of patients, through a barrier mapping study we conducted. We had patients narrate, in depth, their experience of the health system and all the barriers they experience that delay or prevent their access to care. This study, published in Social Science and Medicine (see attached) enabled our patients to teach us by mapping out the barriers we must overcome to achieve timely universal access to care.

1. Pre-service simulations: Using a human rights framework, CHWs begin their training by examining inequities in health and their relationship with poverty. Through discussion, they position their own roles as changemakers, solving these inequities in partnership with patients. During pre-service training, role-play exercises facilitate training and mastery of active listening techniques, use of body language, verbal and non-verbal cues to signal respect and give our patients the honor they deserve. These role-play exercise are often done in a fish-bowl, with the other participants observing the role-play and actively taking notes on what techniques in the role play support patient respect/dignity/agency/communication and what changes could improve these elements.

2. Frequent in-person supervision: Supervision visits include direct observation of patient-provider communication dynamics, and provide monthly opportunities for CHWs to get coaching and mentoring support on improving their communication.

3. The Patient Satisfaction Audits: Our M&E department and our CHW Supervisors both conduct internal patient satisfaction audits on CHW care, calling or visiting a random selection of patients who receive CHW care. These audits have two main purposes: a) to collect patient insights and contributions on how quality of care could be improved and b) to verify the veracity of CHW reporting, protecting as a check against reporting bias.

I'd love to keep hear more experiences, and tools that folks in the GHD community have used to design CHW-led health systems to honor patient dignity and agency. Tell us about your challenges and your insights.

Ari Johnson Panelist Replied at 10:51 AM, 13 Jun 2017

Here is the barrier mapping study I referred to in the prior post.

Attached resource:

Youssouf Keita Panelist Replied at 12:34 PM, 13 Jun 2017

Merci a Ernest MUHIRWA pour soulever cette question pertinente qui est la motivation des CHW.
Il est a noter que sans une renumérotation, les objectifs assignés ne seront pas atteints avec les programmes de CHW et que les cas de démission seront fréquentes.

Je pense que beaucoup d'efforts ont été consentis par les pays et leurs partenaires par rapport a cette question de rémunération des CHW.
Au Mali, les partenaires se sont engagés a payer les CHW et continuent a le faire et parallèlement ils fonds un grand plaidoyer pour que l’état malien puise inclure les CHW dans la fonction publique des collectivités.

A Muso nous pensons même qu'au delà de cette renumérotation, il faut motiver d'avantage les CHW pour se faire en plus de la renumérotation, nous avons inscrit les CHW que nous soutenons a institut nationale de prévoyance sociale qui va leurs garantir une pension a la retraite et leurs permettre ainsi qu'a leurs ayant droits d’accéder a l'assurance maladie obligatoire.
En plus de cela pour le recrutement des superviseurs des CHW, les CHW peuvent postuler et prétendre a être un jour superviseur des CHW et bien d'autres choses.
Et nous continuons a réfléchir et travailler sur les questions de motivation des CHW.

Pouvez vous partager avec nous vos expériences en matière de motivation des CHW ?
Quelles sont les défis que vous rencontrez?

Merci pour tout

Abhishek Bilas Pant Replied at 6:33 AM, 14 Jun 2017

Thanks for the discussion. CHW , FCHW plays a major role in determining the
health indicator especially in the rural part and ultimately of the country.
Strengthening them is therefore very essential.

Richa Bisht Replied at 6:53 AM, 14 Jun 2017

It's good to get to learn so many ideas on strengthening CHWs and here of course training has a crucial role to play.As stated by various panelists ,the nature of the training could be purely technical or generalist depending upon the needs of the programme. But it is also important to work on soft skills of the CHWs since they come from the communities where we are working and they are not much different in terms of their education, income socials background ,experiences than the rest of the community. CHWs in most of the community based programmes are women ,so it is important to build their skills on managing professional and personal life and their own empowerment.I am aware that not many of the programs have budgets to include that in their training components but this would surely put an impact on the quality of services that they deliver in the community.

Ari Johnson Panelist Replied at 10:51 AM, 14 Jun 2017

Dear Ambimbola,

Thank you for raising these questions. In reply, I will start with an important challenge you raise: "Programmes may consider that it may not be feasible to have facility-based and district-level supervisors visit CHWs in hard-to-reach regions as often as we wish."

In fact, our partners at the Malian Ministry of Health came to us with this same challenge--CHWs not getting supervision as frequently as needed or planned. This challenge is not particular to Mali. In fact, we can see this challenge on infrequent supervision documented across three recent studies of national CHW scale-up published last year [1-3].

Our analysis of the root cause of this problem came down to feasibility. If we task facility-based providers with the additional responsibility of supervising CHWs, we are designing for failure. Because 1) they already have full-time responsibilities, so they don't have the time 2) their core job is facility based, the CHWs are community-based, and they cannot be in two places at the same time. So it's not surprising that national programs that depend on these facilities-based providers to provide primary supervision for CHWs do not achieve their supervision targets. Based on this analysis, we decided to take a different route--to change who is providing the primary supervision. In partnership with the Malian Ministry of Health and several academic partners, we have been assessing an approach we call 360 Supervision to try to solve this problem.

In 360 Supervision, a dedicated cadre of CHW Supervisors train and deploy to do nothing but supervise CHWs. These CHW Supervisors are each responsible for 15-20 CHWs, and are so able to conduct one in-the-field 360 Supervision visit for each CHW every month. We do not require advanced health degrees to become a CHW supervisor. In fact, we prioritize promoting CHWs into CHW Supervisor positions wherever possible, as some recent work from Ashraf and colleagues indicates that opening up this kind of promotion pathway for CHWs improves their performance.

CHW Supervisors collaborate closely with facility-based providers at government primary care centers, who play a crucial leadership role coordinating and integrating CHW care with facility-based primary care. They also serve as a resource for clinical questions from CHWs.

In recruiting CHW Supervisors, we test for skills in listening, coaching, and communication, as well as for a mastery of CHW clinical protocols.

We have found that when a dedicated cadre of CHW Supervisors deploys with feasible CHW: Supervisor ratios, they can achieve close to 100% coverage with monthly supervision visits. Because one supervisor can supervise up to 20 CHWs, we can achieve economies of scale and efficiencies, bringing down the unit cost of supervision, while increasing the performance of the health system.

In subsequent posts, I will share more on the workflow of a 360 Supervision visit, as well as on how 360 Supervisors use mobile technology to enhance their coaching.

Questions to the community: Have you encountered similar challenges in your work? If so, how did you solve for them? What delivery design approaches did you try? What worked, and what did not? What research has guided your approach to this challenge of who is best placed to supervise CHWs?

1. Amouzou A, Hazel E, Heidkamp R, Marsh A, Mleme T, Munthali S, Park L, Banda B, Moulton LH, Black RE, Hill K,
Perin J, Victoria CG, Bryce J, 2016. Independent evaluation of the integrated Community Case Management of Childhood Illness strategy in Malawi using a national evaluation platform design. Am J Trop Med Hyg 94 (3): 574-583.

2. Munos M, Guiella G, Roberton T, Maïga A, Tiendrebeogo A, Tam Y, Bryce J, and B Banza. 2016. Independent Evaluation of the Rapid Scale-Up Program to Reduce Under-Five Mortality in Burkina Faso. Am. J. Trop. Med. Hyg., 94 (3): 585-595.

3. Amouzou A, Hazel E, Shaw B, Miller NP, Tafesse M, Mekonnen Y, Moulton LH, Bryce J, Black RE. 2016. Effects of the integrated Community Case Management of Childhood Illness Strategy on Child Mortality in Ethiopia: A Cluster Randomized Trial. Am. J. Trop. Med. Hyg., 94(3), 2016, pp. 596-604.

Sascha Lamstein Replied at 2:42 PM, 14 Jun 2017

Thank you Ari for raising this important issue!

I work with the USAID-funded SPRING project. With regard to CHWs, our focus is on the integration of nutrition services into existing services and systems. We are very concerned about adding more to the workload of already overburdened CHWs. I suspect that this is a challenge for all of us. We believe that effective support needs to provide clear performance expectations; pre-servic and in-service training to build knowledge and skills; timely feedback on performance; remuneration and incentives to increase motivation; and an adequate environment, including information, tools, and supplies.

We also feel strongly that if supervision is not appropriately budgeted and planned, it will probably not be well implemented. Poor supervision has been shown to be as ineffective as no supervision. Studies in both Kenya and Benin showed that most health workers felt that supervision was an act of control and criticism and reported that it was infrequent, irregular, and lacking in feedback (Mathauer and Imhoff 2006). A recent study from Zambia makes it clear that supervision is not always perceived as helpful by the workers. Following introduction of CHWs into Zambia’s primary health care system, 78 percent of those interviewed reported regular (monthly) supervision, but 48 percent mentioned that supervision did not have any benefit to them. In this example, supervisors did not utilize a standardized method or checklist when conducting supervisory visits (Stekelenburg et al. 2003).

Unfortunately, in our research of published literature and program experience, we were unable to find a silver bullet for supporting nutrition services delivered by CHWs. But we believe that for sustainability and scalability this issue will need to be addressed at the foundation (with things like policies, protocols, and systems), with support for services, and demand. Countries will need to rely less on distance supervisors for CHWs since they are rarely or infrequently at the frontline either because they are not expected to be, not paid to be, or don't have transportation to get there. Facility managers or officers in charge can be trained to explain, demonstrate, coach, and mentor CHWs on their roles and tasks. Tasks can be listed on walls to clarify expectations and build teamwork, allowing workers to focus less on “my job” and more on “our job” in serving the community, their families, and their friends. And, finally, we feel strongly that team-based approaches, such as the quality improvement (QI) approach, that rely on peers and even clients, are critical for supporting and improving the quality for nutrition services.

I have shared links to a document we recently published on this topic as well as those referenced here. We are currently finalizing an approach to engaging a wide range of community actors and frontline workers in the delivery of nutrition-related services. I would love to hear about other approaches to supporting CHWs in the provision of nutrition services and in a sustainable and scalable fashion.

Thank you for reading!

Technical Advisor and Team Lead, Systems Thinking for Nutrition
Boston, MA 02210

Attached resources:

Mary Adam Replied at 4:46 AM, 15 Jun 2017

Supervision as criticism and the power dynamics are a part of the GAP I see in practice. Any suggestions on how to bridge this gap?

Madeleine Ballard Panelist Replied at 4:53 AM, 15 Jun 2017

Hey all,

Another resource pertinent to this discussion is from a discussion that took place on HIFA earlier this year where the following two questions were discussed:
1. When listening to CHWs needs and priorities, what do they say is needed to enable them to do their work more effectively? (see Wk 1 attachment)
2. How are these needs being addressed? Where are the gaps? (see Wk 2 attachment)

Attached resources:

Christopher Noble Replied at 10:38 AM, 15 Jun 2017

Dear colleagues,

During my schooling I came across an interesting quantitative tool that assesses the strength of preference and trade-offs of health workers towards different job characteristics, such as direct reimbursement for service, proximity to work/school/childcare, career advancement and other technical skill building and other in-kind compensations to measure the influence these incentives carry to support retention in rural and/or challenging settings.

I've attached a user guide that can be used by researchers and policy makers confronted with the challenges of rural imbalances, as such or as part of a broader training program on health services research and evaluation. It is hoped that its use will contribute to a more systematic analysis and a deeper understanding of the factors that inhibit recruitment and retention of qualified staff in remote and rural regions, and will help countries develop their own unique solutions to lifting this problem that are well-adapted to their country context.

The User Guide also includes two case studies from Tanzania and Uganda that demonstrate the application of this method in a real life context.

I believe USAID uses this tool in their CapacityPlus HRH project as well.

I hope it can be found useful!



Chris Noble, MPH
Research & Governance Coordinator NCD Synergies|Partners In Health
E: <mailto:>|C: 760-470-1011|S: @cnoble12go
800 Boylston Street, 3rd Floor, Boston, MA 02215<>

Ari Johnson Panelist Replied at 12:31 PM, 15 Jun 2017

Over the course of our operational and technical assistance work, we ran up against a fundamental structural challenge for CHW supervision: CHWs, by definition, are based in their communities, and their work is necessarily distant from the rest of the health care team. That means that most of the time, the supervisor and their teammates are not with them. How can CHW Supervisors effectively support CHWs, gain a thorough understanding of strengths, weaknesses, accomplishments and challenges, given that they are not physically there most of the time? We designed 360 Supervision to overcome this structural challenge, to enable CHW Supervisors to get a view of every angle of each CHW's work, so they can provide tailored coaching for each CHW on their team.

Within the 360 Supervision design, each CHW receives at least one 360 supervision visit each month from their supervisor. The visit includes 4 key steps:

Step 1) CHW Dashboard Review: Before departing for the field to supervise a CHW on their team, the CHW Supervisor studies their CHW Dashboard, an analytics tool created by Medic Mobile and Muso. The Dashboard displays the performance of that CHW in the month prior, in 3 categories: quantity/coverage, speed, and quality. How many patients did they reach, what percentage of their patients did they find within 24 hours of symptom onset, and what percentage of their patients did they treat without error. The dashboard also provides a histogram showing the frequency of each protocol error the CHW made in the prior month.

Step 2) Patient Satisfaction Audit: Next, the CHW Supervisor travels to the CHW's village, and visits a random selection of families. This audit serves two purposes. First, it enables supervisors to solicit perspectives from patients on what is going well and what can be done better, getting frank feedback in the absence of the CHW. Second, it enables the Supervisor to verify the veracity of the data reported by the CHW in their forms, providing a data quality/integrity check.

Step 3) CHW Shadowing: The CHW Supervisor meets up with the CHW and shadows their patient care. This enables them to assess elements of CHW work that require direct observation. Does she use her thermometer correctly? What verbal and non-verbal communication techniques does the CHW employ with her patients?

Step 4) One-on-One Coaching, Supportive Supervision: The Supervisor and CHW sit down together, and the CHW examines their own CHW Dashboard. The Supervisor elicits the CHW's analysis of her own strengths and weaknesses, as well as strengths and weaknesses on a systems level. The supervisor then provides feedback, with the requirement that they cite at least as many strengths to build on as they cite areas for improvement.

These four steps, integrated into a single, half day visit each month, are designed to provide a rich, multifaceted view of a CHW's work and a supportive supervision framework.

We are now in the process of evaluating 360 Supervision and in particular the CHW Dashboard, to determine whether this tool improves the quantity, speed, and quality of CHW performance, through a randomized controlled trial. Data collection for this trial is complete and data analysis underway. We are looking forward to learning from the study.

We look forward to your questions and feedback on this work in progress!

Attached resource:

Samira Rahat Afroze Replied at 10:24 PM, 15 Jun 2017

Good thinking.... this kind of work needs social motivation & political

Venice Ceballos Respondent Replied at 1:16 PM, 16 Jun 2017

Hello everyone, I am Venice Ceballos (CHW) and now serving as the CHW Program Manager at the ECHO Institute. I would like to comment on the "Supervision" part. I have had good, fair, excellent and poor supervision in the 15 years as a CHW. I advocate across the country the importance of having good supervision. I have seen and experienced high burnout and turnover amongst CHWs because they weren't supported in dealing with the hard work they do every day 24-7. I have grown to be a leader in this arena because I had "reflective supervision" and great mentors when I practiced as a CHW. Having reflective supervision in place allowed CHWs to process their own feelings related to the difficult cases along with processing personal "emotional triggers" that come up related to our own childhood experiences. We were also seen as equals and had shared power. Shared power amongst other medical staff comes over time and with a lot of work. We had the opportunity to provide feedback on training, and our Supervisors applied adult learning principles and weaved in popular education throughout everything they taught us. Always modeling the training application in the same way they wanted us to teach patients. I was thought leadership skills along this journey with the vision of promoting growth within the CHW profession to have a career ladder. I have been a keynote speaker for a CHW conference in Ohio and my speech was all about supervision and promoting leadership amongst CHWs. My wish is that all CHWs everywhere have a good support system to allow them to continue to do the great work they do every day. I am more than willing to share the speech that gives more detail of my own experience related to good supervision.

Connie Gates Replied at 1:22 PM, 16 Jun 2017

Sorry I am late at contributing to these conversations, and I’m in India now so it’s after 10pm my time – not my most ‘productive’ brain functioning, but I did want to write something, on most of the topics, but hope that just writing in a few of them, everyone will be able to read. And it’s my first time participating in GHDonline.

I work with the Comprehensive Rural Health Project, Jamkhed, India, started by Drs Raj & Mabelle Arole in 1970. In the early 1970s, they had organized men’s groups in various villages; they had placed ANMs in the villages to provide primary health care, but that didn’t work out because the ANMs were not accepted by the villagers. So what to do? The men asked the Aroles if one of their women couldn’t be trained to help with improving health in their communities. In the early 1970s women were illiterate, and the Aroles weren’t sure how much they could learn, but thought they could at least help with nutrition and other health education. Once they started working with these women, they were amazed at how eager they wanted to learn, how capable they were, and how motivated they were to share their knowledge and skills with others in their villages.

Training – initial training included personal development to help these women develop a healthy self-image and confidence that they could achieve a lot in and with their community. Training is conducted by the mobile health team, who then provides supportive ‘supervision’ through village visits (on-the-job training and observation) and regular on-going training at the health center, when the VHWs can come together and learn from each other. The ‘curriculum’ is based on what they are interested in, using adult learning principles – participatory learning, existing current problems, their interests – and of course, maternal and child care are always a concern; and since they have addressed infectious diseases, they are now focusing on NCDs including mental health. Newer VHWs are mentored by the older, experienced VHWs.

Aisha Baloo Replied at 1:50 PM, 16 Jun 2017

Hello fellow participants. My name is Aisha Baloo and I am a Training Support Analyst/Program lead for the ECHO Institute’s “Albuquerque Area Southwest Tribal Epidemiology Center (AASTEC) Partners in Good Heath and Wellness Community Health Representative (CHR) Training in Preventing and Managing Chronic Diseases.” I want to add to the discussion regarding cultural adaptation and modification of a training curriculum for CHWs/Tribal CHRs.

The AASTEC Partners in Good Health and Wellness CHR training focuses on Native American/Indigenous CHRs who are currently serving their tribal communities. The CHW team at ECHO culturally expanded and adapted Project ECHO’s Diabetes Community Resource Education Worker (CREW) Training curriculum, framing the curriculum that is effective and community-driven. We did this by consulting our funding partners, AASTEC, who have the cultural expertise to determine what is appropriate to teach, how we can frame trainings that are strength-based and community focused. The team hired a Native American team lead, nurse, and presenters to ensure cultural protocols were being followed—especially considering New Mexico has 27 different tribes.

For instance, we open the training day with a traditional “blessing,” facilitate community strengths activity, introduced social determinants of health within a tribal context, discussed the difference between commercial and traditional tobacco, implemented a self-care topic with holistic health (mental, emotional, spiritual, and physical health), how traditional foods impact nutritional health, and how depression is affected by historical trauma. During the virtual teleconferencing trainings, we implement case-based learning that emphasizes holistic health. Overall, each topic follows Adult Learning and Popular Education principles, in which we recognize the CHRs as community experts. CHRs are therefore able to build off their learnings from one another—creating a learning environment that is effective and relevant.

Dinesh Koirala Replied at 4:53 AM, 17 Jun 2017

Same is the situation here in Nepal. Females are suppressed. With time there is change. Now females are active in health works and its happy to see it..

Dr Julia Mwesigwa Replied at 5:58 AM, 17 Jun 2017

blockquote, div.yahoo_quoted { margin-left: 0 !important; border-left:1px #715FFA solid !important; padding-left:1ex !important; background-color:white !important; } Thank you for sharing the Malian experience intergration of CHWs with-in MOH structure This is very useful information

Dhiren Modi Replied at 6:34 AM, 17 Jun 2017

For CHWs Our experience in Tribal area of Gujarat, India said that On initiation they required basic training and every three month you can added one topic with refresher training for better performance at field level. In term of Monitoring we can rely on fact finding not fault finding for the CHWs. If we had faith in them with clear goal in mind than it works better on ground. On going support with drugs, forms, incentive, other bcc materials,interaction with village level leader regarding CHWs involvement for the betterment of Village , motivated them.Every Year sharing there dat with them with some indicators was useful to us to improve their performance. For reading kindly visit and read our first two publication.Thanks

Maimunat Alex-Adeomi Replied at 1:09 PM, 19 Jun 2017

Great discussion so far on training and supervision needed to make CHWs more successful.

Like has been rightly mentioned from the beginning that CHWs vary in description and scope of practice hence it would be great to tailor the training and supervision needs to each specific context.

A few countries in Sub-Saharan Africa have "elevated" the roles of the CHWs through training and certification allowing them to function in an increased capacity and thus be supervised by community health nurses and other clinical staff. Please link bewlo and attached with Ghana example.
While this has not necessarily solved the problem entirely, it has helped address the need to remunerate the CHWs in one way or another thus ensuring engagement and empowerment. The CHWs are also able to tap into existing training and supervision resources and structures that exist through the MoH or other stakeholders and regulatory bodies.


Attached resource:

Connie Gates Replied at 8:47 AM, 23 Jun 2017

Sorry I thought I had sent this last Friday with the other 2 comments, but I didn’t see it – so here it is. I’ll be sending more later today.

I work with the Comprehensive Rural Health Project, Jamkhed, India, started by Drs Raj & Mabelle Arole in 1970. In the early 1970s, they had organized men’s groups in various villages; they had placed ANMs in the villages to provide primary health care, but that didn’t work out because the ANMs were not accepted by the villagers. So what to do? The men asked the Aroles if one of their women couldn’t be trained to help with improving health in their communities. In the early 1970s women were illiterate, and the Aroles weren’t sure how much they could learn, but thought they could at least help with nutrition and other health education. Once they started working with these women, they were amazed at how eager they wanted to learn, how capable they were, and how motivated they were to share their knowledge and skills with others in their villages.

Training – initial training included personal development to help these women develop a healthy self-image and confidence that they could achieve a lot in and with their community. Training is conducted by the mobile health team, who then provides supportive ‘supervision’ through village visits (on-the-job training and observation) and regular on-going training at the health center, when the VHWs can come together and learn from each other. The ‘curriculum’ is based on what they are interested in, using adult learning principles – participatory learning, existing current problems, their interests – and of course, maternal and child care are always a concern; and since they have addressed infectious diseases, they are now focusing on NCDs including mental health. Newer VHWs are mentored by the older, experienced VHWs.

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