crigler community health_workers
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CORE Group Fall Meeting 2010. Global Trends in Community Health Worker Programs - Lauren Crigler, USAIDTRANSCRIPT
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Global Trends in Community Health Worker Programs
Lauren Crigler
Director, Health Workforce Development
USAID Health Care Improvement Project
USAID HEALTH CARE IMPROVEMENT PROJECT2
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
USAID HEALTH CARE IMPROVEMENT PROJECT3
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
USAID HEALTH CARE IMPROVEMENT PROJECT
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
USAID HEALTH CARE IMPROVEMENT PROJECT
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
–
Communities
motivationcareer advancement
training
Central government
Human security approach to CHW
Local government
Community Health Committee
Top-down approach
Protection
Bottom
-up approachE
mpow
erment
selection of CHWs, identification of priorities
participation management, supervision & oversight
mobilization
training, supervision & oversight, authorization, financing , logistics
OWNERSHIP
USAID HEALTH CARE IMPROVEMENT PROJECT
Assessing of CHW programs according to global priorities
USAID HEALTH CARE IMPROVEMENT PROJECT
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
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USAID HEALTH CARE IMPROVEMENT PROJECT
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)
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USAID HEALTH CARE IMPROVEMENT PROJECT
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
Selected Key ResultsCHW Program Production and
deployment Salaried/ volunteer
Attraction / retention
Performance management
Pakistan Lady Health Workers Program
- 4.7 times ↑ in 10 yrs- more for poor
USD 38/m Selling drugs Training 99.8%Supervision 85.3%Ratio: 1:25 4 (ext) evaluation carried out
BRAC Shasthyo Sebikas Program
-72 times ↑in 18 yrs -in poorest areas
Volunteer Incentives for performance
Ratio: 1:25-30Internal evaluation
Thailand Village Health Volunteer Program
2.4 times ↑in 26 years Volunteer -Free health-education grants
Supervision by PHC worker No formal evaluation
Brazil Family Health Program
-48 times ↑in 15 years -initially for poor & now for all
USD 112/m
Training 100% Supervision 100% Various ext evaluations
Haiti Zanmi Lazante’s Community Health Program
-3.3 times ↑in 24 years -90% coverage to poor
USD 50-130
Training 98%Various assessment publication
Ethiopia Health Extension Program
USD 40-63
Training 100% Supervision 50%Ratio : 1:3-5 No evaluation so far
Uganda Village Health Teams
Volunteer boots, rain coats, bicycles, transport / lunch allowance
No evaluation
Mozambique Agentes Polivalentes Elementares Program
USD 50/m No supervisors trained yet 1 evaluation has been carried out
Selected Key ResultsCHW Program Recruitment
Community involvement
Professional advancement
Referral system / information system
Pakistan Lady Health Workers Program
8 yrs of schooling + Married + Female 20-50 yrs +Resident
Involve in health promoting activities
After certain exp & edu supervisors
Implemented in a relatively weak health system / central record system
BRAC Shasthyo Sebikas Program
Female +25-45 yrs +Married children not less than 2 years + Resident +Few yrs of schooling
Community advocacy & support groups
-implemented in a relatively strong health system
Thailand Village Health Volunteer Program
Read & write + live and work in village
health promoting activities
Further education and edu grants
Strongly linked to wider health system
Brazil Family Health Program
Read and write + >18 yrs + resident
health committees
Free to peruse any path
Referral to formal health facility / digital records
Haiti Zanmi Lazante’s Community Health Program
Read and write + >18 yrs + resident
Community involvement in decision making
Promote to supervisors
Weak link with health system Web based med record system
Ethiopia Health Extension Program
>18 yrs + 10 yrs of schooling + resident
selection of CHWs
Upgrade edu & can become a nurse
Weak link with health system / Basic records with CHWs
Uganda Village Health Teams
Read and write + >18 yrs + resident
health promoting activities
-Not part of health system /Basic records with CHWs
Mozambique Agentes Polivalentes Elementares Program
Read and write+ Married + Female + 18-35 yrs + Resident
health promoting activities
Not considered as part of HRH
Weak link with health system / /Basic records with CHWs
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USAID HEALTH CARE IMPROVEMENT PROJECT
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
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USAID HEALTH CARE IMPROVEMENT PROJECT
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.
USAID HEALTH CARE IMPROVEMENT PROJECT
Global Health Workforce Alliance Key Messages
1. Planning, Production and Deployment
2. Attraction and Retention
3. Performance Management
USAID HEALTH CARE IMPROVEMENT PROJECT
PLANNING, PRODUCTION AND DEPLOYMENT
1. Integrate CHWs fully into national HRH plans and health systems.
2. Involve key HRH stakeholders in the decision-making process.
3. Ensure effective and robust monitoring and evaluation throughout the policy and implementation process or the scale-up of CWs.
4. Any scale-up of CHWs has adequate support (including training, supervision, equipment and supplies, transport).
5. Existing health system should provide enabling environment for CHW policies and planned interventions.
USAID HEALTH CARE IMPROVEMENT PROJECT
ATTRACTION AND RETENTION
6. Prepare and engage the community throughout the process.
7. Ensure a regular and sustainable stipend and, if possible, complement it with other rewards.
8. Ensure a positive practice environment.
9. Establish selection criteria, training duration, and scope of tasks that are clearly stated, publicized and respected by all stakeholders.
10. Provide an ongoing continuing education for CHWs and, where possible, support opportunities for career advancement.
USAID HEALTH CARE IMPROVEMENT PROJECT
PERFORMANCE MANAGEMENT
11. 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.
12. Performance management should be based on a minimum set of needs-based skills.
13. The management and supervision of CHWs should be team-based and development focused, and integrated with that of other health workers.
USAID HEALTH CARE IMPROVEMENT PROJECT
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.
USAID HEALTH CARE IMPROVEMENT PROJECT
Thank you
The HCI Project
www.hciproject.org
USAID HEALTH CARE IMPROVEMENT PROJECT
The preceding slides were presented at theCORE Group 2010 Fall Meeting
Washington, DC
To see similar presentations, please visit:www.coregroup.org/resources/meetingreports