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USG CHW
Evidence
 Summit

-Highlights-




      Joseph F. Naimoli (OCS), Estelle Quain (OHA),
      Diana Frymus (OHA), Emily Roseman (OHA)
                                                      10/12/2012
What is an Evidence Summit?


             Decision
             making

                         Questions of policy
           Review the    and programmatic
                         significance and relevance
            evidence

         Development
          challenges

         Academics +
   development practitioners
Development Challenge

Global shortage of skilled,
motivated, and supported health workers



                    Strengthening health systems


                      Achieving MDGs and UHC


                    Achieving equity, reducing
                    poverty
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)
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)
Evidence Summit Phases




                         6
Pre-Summit



        Approximately 90% of
        work completed before
        the 2-day Summit Event!
Evidence Summit Event



May 31-June 1, 2012
Findings



             CHW
             Stewardship
FQs/
Hypothesis


                           9
Findings



             CHW
             Stewardship
FQs/
Hypothesis


                           10
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)
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
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
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
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
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!
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
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
Findings



             CHW
             Stewardship
FQs/
Hypothesis


                           19
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?
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
E2A Agenda
  USAID


      Publications




     Stewardship
Publications strategy

Summary      CHW Logic
  paper        Model


    Case Study
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?

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CHW Review_various_10.12.12

  • 1. USG CHW Evidence Summit -Highlights- Joseph F. Naimoli (OCS), Estelle Quain (OHA), Diana Frymus (OHA), Emily Roseman (OHA) 10/12/2012
  • 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)
  • 7. Pre-Summit Approximately 90% of work completed before the 2-day Summit Event!
  • 8. Evidence Summit Event May 31-June 1, 2012
  • 9. Findings CHW Stewardship FQs/ Hypothesis 9
  • 10. Findings CHW Stewardship FQs/ Hypothesis 10
  • 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
  • 19. Findings CHW Stewardship FQs/ Hypothesis 19
  • 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
  • 22. E2A Agenda USAID Publications Stewardship
  • 23. Publications strategy Summary CHW Logic paper Model Case Study
  • 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

  1. 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).