Global trends show increased focus on and endorsement of community health worker (CHW) programs to strengthen health systems and achieve health goals. Assessments of CHW programs find that factors like inadequate training, supervision, supplies and low status limit their quality and effectiveness. A global consultation identified key priorities for CHW programs including fully integrating CHWs into national health workforce plans, involving stakeholders, and ensuring adequate and ongoing support through training, supervision and incentives. Supporting CHWs as integral parts of health systems with clearly defined roles and career opportunities can help address current challenges and optimize their impact.

1. Global Trends in Community Health Worker ProgramsLauren CriglerDirector, Health Workforce DevelopmentUSAID Health Care Improvement Project

2. Global Context The health workforce is in crisis while demand is skyrocketing High disease burdens for infectious and non-communicable conditions Overburdened health workers and health systems Endorsement of MDG Goals in 2000 Meeting MDGs requires a productive, stable workforce in facilities as well as shifting some tasks to community health workers and volunteers Increasing evidence of high impact interventions at community level 2

3. USAID: Health Systems Strengthening Focus FY2008 USAID MCH Priority Increase functional CHWs by 100,000 PEPFAR II Health systems strengthening Specific target to increase health workers by 140,000 Global Health Initiative Health systems strengthening 3

4. WHO and Multilateral (G8) Focus Encouraging global health partners to take the following directions: More synergy between disease-oriented approaches (vertical) and strengthening of health systems (horizontal) Three major building blocks identified for health system strengthening (HSS): workforce, financing, and information Revitalization of primary healthcare (PHC) through human security approach

5. Human security as the core concept for global actions Health is the vital core of human lives and offers a concrete field for developing strategies for human security Strategies Empowerment enable people to develop capacity to cope with or prevent difficult conditions Protection set up by states, international agencies, NGOs, and the private sector to shield people from critical and pervasive threats and enable people to protect themselves

6. Human security approach to CHW Central government Top-down approach Protection Local government training, supervision & oversight, authorization, financing , logistics Community Health Committee selection of CHWs, identification of priorities Bottom-up approach Empowerment management, supervision & oversight participation OWNERSHIP motivation career advancement training mobilization Communities

7. Assessing of CHW programs according to global priorities

8. The CHW Assessment and Improvement Matrix (CHW AIM) Approach A recent approach developed by the HCI Project to assess and improve CHW programs applies criteria for the following 15 components as a way to measure functionality: Recruitment The CHW Role Initial Training Continuing Training Equipment and Supplies Supervision Performance Evaluation Incentives Community Involvement Referral System Opportunity for Advancement Documentation, Information Management Linkages to Health System Program Performance Evaluation Country Ownership 8

9. The CHW AIM Field Applications First field tests in Nepal and Benin Salvation Army in Zambia applied the CHW AIM to assess the Chikankata Child Survival Project Save the Children in Ethiopia to assess vCHWs and HEWs 2-year comparative study in Zambia with 5 partners to assess impact of applying CHW AIM as an improvement framework: Nyimba (Salvation Army Zambia) Chongwe (World Vision Zambia) Lusaka (CHAZ and Coptic Hospital) Chipembi (CHAZ and Chipembi Clinic) Kabwe (ZPCT Project/FHI) Choma (mothers2mothers) 9

10. Systematic review of 8 country programs – Global Health Workforce Alliance Reviewed reports on country experiences with CHWs for target 8 countries and programs (Pakistan, Bangladesh, Thailand, Ethiopia, Uganda, Mozambique, Brazil, Haiti) Applied the CHW Assessment and Improvement Matrix (CHW - AIM) to assess functionality Country visits to interview key personnel overseeing the program Information was compiled and reviewed on programs (description, job descriptions, role of CHWs) including evaluation reports and outcome assessments

11. Selected Key Results

12. Selected Key Results 12

13. Overall Results Factors limiting the range and quality of CHWs included: Insufficient initial and continuing education Inadequate and irregular supervision Shortage of basic drugs and irregular supplies of vaccines and commodities (e.g. condoms) Lack of equipment and non functional equipment Low social status and remuneration levels of CHWs adversely affect motivation Inadequate linkages with health system 13

14. Global Consultation on Community Health WorkersMontreux, Switzerland, 29 -30 April 2010 Meeting objective: Program managers, policy makers and experts review the recommendations of the global review, share experiences, and develop a broad agreement on key messages for countries to integrate CHWs into their national health workforce.

15. Global Health Workforce Alliance Key Messages Planning, Production and Deployment Attraction and Retention Performance Management

16. PLANNING, PRODUCTION AND DEPLOYMENT Integrate CHWs fully into national HRH plans and health systems. Involve key HRH stakeholders in the decision-making process. Ensure effective and robust monitoring and evaluation throughout the policy and implementation process or the scale-up of CWs. Any scale-up of CHWs has adequate support (including training, supervision, equipment and supplies, transport). Existing health system should provide enabling environment for CHW policies and planned interventions.

17. ATTRACTION AND RETENTION Prepare and engage the community throughout the process. Ensure a regular and sustainable stipend and, if possible, complement it with other rewards. Ensure a positive practice environment. Establish selection criteria, training duration, and scope of tasks that are clearly stated, publicized and respected by all stakeholders. Provide an ongoing continuing education for CHWs and, where possible, support opportunities for career advancement.

18. PERFORMANCE MANAGEMENT Governments should take responsibility for the quality assurance of CHWs, even if CHWs are trained and managed by civil society or private-not-for-profit groups. Performance management should be based on a minimum set of needs-based skills. The management and supervision of CHWs should be team-based and development focused, and integrated with that of other health workers.

19. Summary and Key Points Community health workers are integral to health systems strengthening and overall global health; Increasing services considered to be effective at the community level Global Health Initiative emphasizes linking CHWs to overall health system; and Pressure is on governments and non-governmental organizations to provide support to CHWs in key areas, including incentives, supervision, standardized training, supplies.

20. Thank you The HCI Project www.hciproject.org lcrigler@initiativesinc.com

21. Working Group Questions: Group 1: Given the trend to integrate CHWs into national health systems and support CHWs as part of that system: How can NGOs play a role in advancing this agenda? What impact will this have on locally implemented programs currently not linked to the health system?

22. Working Group Questions: Group 2: Providing incentives and offering career progression or advancement opportunities to CHWs surface repeatedly as both important and controversial: If CHWs are to be considered as part of the health system, should they also be rewarded and consider their work as a ‘job’ with a career path? How does the increasing role and numbers of tasks assigned (shifted) to CHWs affect traditional volunteerism?

23. The preceding slides were presented at the CORE Group 2010 Fall Meeting Washington, DC To see similar presentations, please visit: www.coregroup.org/resources/meetingreports