2. What is an Evidence Summit?
Decision
making
Questions of policy
Review the and programmatic
significance and relevance
evidence
Development
challenges
Academics +
development practitioners
3. Development Challenge
Global shortage of skilled,
motivated, and supported health workers
Strengthening health systems
Achieving MDGs and UHC
Achieving equity, reducing
poverty
4. Development Challenge
Global shortage of skilled,
motivated, and supported health workers
RESPONSE:
Emergence of alliances and coalitions to
address the challenge
Resurgence of interest in and attention to
Community Health Workers (CHWs)
5. Why Community Health Workers?
Extend the reach of inadequate health systems (provide
essential services to hard-to-reach, vulnerable populations)
Expand coverage of key interventions
Increased investment in large-scale programs
Concern about the strength of evidence behind existing
normative guidance (uncertain)
11. Findings: RQs, Hypothesis
• CHWs can successfully
deliver a range of
preventive, promotional,
and curative services
• CHWs can contribute to
improved coverage and
positive health outcomes
“Our findings show that indigenous community workers can effectively detect and treat
pneumonia, and reduce overall child mortality, even without other primary care activities.”
(Pandey, Daulaire, Starbuck, Houston and McPherson, 1991, The Lancet, Reduction in total
under-five mortality in western Nepal through community-based antimicrobial treatment of pneumonia)
12. Findings: RQs, Hypothesis
• CHWs receive technical
and social support, as
well as recognition, from
communities and health
systems
• Experts have identified
different kinds of support
provided by communities
and health systems likely
to improve CHW
performance at scale
13. Findings: RQs, Hypothesis
Community
• Community participation/involvement in CHW selection, all aspects of
CHW programming (design, mgmt., implementation, monitoring,
evaluation)
• Community structure support: health committees, oversight bodies,
women’s groups, family, kinship
• Community provision of non-financial, in-kind, financial incentives
Non-financial: praise, respect, feedback
In-kind: animals, food, gifts
Financial: fee for service, supplemental income from sale of
medicines and other health-related products; regular remuneration
• Community strengthening of relationships among CHWs (facilitation CHW
membership in CHW associations)
CONTEXT MATTERS!
13
14. Findings: RQs, Hypothesis
Formal health system
• Ensuring clarity of role/feasible, manageable scope of work
• Ensuring consistent availability of drugs, commodities, tools, supplies, equipment
• Providing high quality, competency-based pre- and in-service training
• Providing job aids and other materials
• Feedback, supervision, performance monitoring
• Incentives (financial and non-financial)
• Effective linkages with formal health system and health care workers
• Support from national and local government entities
CONTEXT MATTERS!
14
15. Findings: RQs, Hypothesis
Combined support from both systems
• Shared ownership of CHW programs through joint collaboration in program design
• Joint supervision
• Negotiated and coordinated package of incentives, whereby the formal health
system provides financial incentives, while community and health system provide
non-financial incentives
• Development of a practical information system that captures data from both the
formal health system (e.g., health records, supervisor observations, etc.) and
community system (e.g., community member feedback, individual CHW feedback,
etc.) that both systems use to enhance CHW performance
• Strengthen linkages between communities and health systems to enhance
performance and mitigate unintended consequences
CONTEXT MATTERS!
15
16. Findings: RQs/Hypothesis
However! • The EVIDENCE in support
of expert opinion is weak
Community • Not because rigorous
system studies demonstrate lack
of effect!
CHW
Formal • FQs about support-
health performance
system relationship not
commonly asked or
investigated with rigor!
17. Findings: RQs/Hypothesis
• Furthermore:
However! – Studies are often short-term, small-
scale pilots, rural focus
– Interventions often poorly
described
– Multi-arm comparisons of the
Community relative effectiveness of different
programmatic interventions
system (technical vs. social vs. recognition)
not investigated
CHW – Large-scale, system-level
interventions rarely studied
Formal – Bias toward distal measures of
performance with less
health understanding of intermediate
measures and even less of
system proximate
• Feasible, affordable, appropriate ways to
provide support not well documented
18. Findings: RQs/Hypothesis
Conclusion • We have strong colloquial
knowledge but weak evidence
about the support-performance
relationship!
Community
system • This knowledge comes primarily
from observation,
CHW implementation, M&E
Formal • This knowledge drives current
health guidance
system
• Undocumented or inaccessible
program experiences may address
these focal questions
20. Findings/CHW Stewardship
National:
1) Fragmentation: multiple actors/programs
making demands on CHWs
Q: Who is responsible for overall welfare of the CHWs?
Q: Specialized or all-purpose CHWs?
2) Variation linked to history and purpose
Global:
1) Fragmentation: concurrent meetings
2) Leadership: Is GHWA up to the
challenge?
21. Recommendations: Global
1. Refocused research agenda: answer RQ of policy and programmatic
significance for CHW programs operating at scale
2. Capacity building of LMIC investigators
3. Prospective/retrospective documentation of large-scale programs
(implementation science)
4. Better stewardship: country and global levels
5. Logic model to guide programming, M&E, OR
24. Stewardship
Challenges
1 Can we achieve an increased understanding of the depth
and breadth of USAID investment in CHW programming?
2 What is the value for money of current investments in
CHW programming?
3 How can we address the Summit focal questions through
existing and new OR efforts?
4 How can we increase Agency visibility/leadership vis-à-vis
external partners?
Notas del editor
I. Technical consultation on the role of community based providers in improving MNH (30 - 31 May 2012 - organized by Royal Tropical Institute, Netherlands)II. Evidence Summit on Community and Formal System Support for Enhanced Community Health Worker Performance (May 31 and June 1 - convened by USAID Global Health Bureau in Washington DC) III. Community Health Worker Regional Meeting (19 to 21 June - convened by USAID-funded Health Care Improvement Project, at Addis Ababa, Ethiopia)IV. Health workers at the Frontline – Acting on what we know: Consultation on how to improve front line access to evidence-based interventions by skilled health care providers (25-27 June, (convened by NORAD and coordinated by EQUINET at Nairobi, Kenya).