CHWs on the Move

CORE Spring Meeting 2011

Background

An CHW Technical Advisory Group on CHW performance at scale met in December 2010 and

• reviewed current global CHW initiatives,• discussed large-scale CHW efforts in several

countries, and • defined knowledge gaps that, if addressed,

would further strengthen the global efforts related to CHWs.

Emerging Gaps• lack of a clear taxonomy that distinguishes different types of

community health work and provides typologies for selecting appropriate community health agent strategies;

• need for increased consideration of community health systems in achieving scale for community health work;

• a call for practical guidance that program managers and policy makers can utilize to design CHW programs that can operate effectively at scale based in the local cultural context;

• and a call for mechanisms to facilitate continuous learning on CHW issues.

What is happening Now

MCHIP continues to work with a wider group of individuals and organizations to move these recommendations forward and to generate common understanding and develop usable

• assessment tools, • checklists, • guidance and • community of practice

10. Representative Governance Bodies

Other CHVs

3. District

2. Community

11. Other resources, sectors, actors, associations, committees, CBOs, FBOs, NGOs, private & informal sector providers, businesses, schools

1. Household 8. MoH

7. District Health System

6. Health

Facility

5. Health Extension Worker

4. Community Health Volunteer

9. Health Sector

A

B

C

D

E

F

G

H

I

F

“CHWs”

Who is a CHW? How do they differ?Characteristics/Parameters that can be used to identify several different profiles for

CHWs:• Extent or coverage /country -wide or focused in marginalized or underserved

communities• CHW Programmatic contribution (at national scale) in terms of services provided• Relationship with MoH, NGO’s, community and other CHW cadres• Technical scope• Location of recruitment/ posting• Selection criteria • Households covered per CHW• Where based• Time worked • Compensation• Basic training• Functions• Community Context: Presence of local citizen bodies e.g. committees with ongoing

responsibility for health

Some suggestions on parameters of CHW typology:

• where is the nidus of responsibility in the MOH - MNCH/RH or Community Services

• urban vs rural - any differences in typology?• like to see more on supervision:who, where reside and education,

training of supervisor• financing source• is there a CHW policy in country and has it been instrumental in

facilitating implementation• CHW standardized drug/commodity kits or diversity in

drugs/commodities• Some of the programs may need to check more than one box,

since it is not always either, or but both...

CHW Typology

Benefits• Helps to classify

evolving Evidence• Easily identifies to

who evolving evidence could be easily applied to

• Helpful in Costing

Caveats• Classification of

CHWs is dynamic and cadres are dynamic

• Multiple CHW Cadres could coexist in a single country

Sample Typology 1Parameter Definition Example

Compensation (C) On Payroll (2) Malawi HSA

Not on Payroll (1) Uganda VHT

Distance to Household (D)

Household visitation via other volunteers (2)

Kenya CHEW

Work directly with households (1)

Mali Relay

Education (E) Health Professional (3) Ethiopia HEW

Literate but not Health Professional (2)

Malawi HSA

Illiterate to semi-illiterate (1)

Senegal Relay

Specialization (S) Specialized Cadre (2) Rwanda CHW

Generalized Cadre (1) Tanzania CHW

Sample Typology 1TYPOLOGY EXAMPLE

C1D1E1S1 Senegal Relay

C1D1E2S1 Liberia gCHV, Mali Relay, Tanzania CHW, Zambia CHW

C1D1E2S2 Rwanda CHW

C1D2E2S1 Uganda VHT, Mozambique Activista

C2D1E2S1 Angola CHW

C2D2E2S1 Malawi HSA

C2D2E3S1 Ethiopia HEW, Ghana CHO, Kenya CHEW

Sample Typology:Non-professionalizedA. ANGOLA CHW

B. RWANDA CHW

C. UGANDA VHT MOZAMBIQUE ACTIVISTA

D. ZAMBIA CHW LIBERIA GCHV SENEGAL RELAY MALI RELAY TANZANIA CHW

Sample Typology: Professionalized and Paid

A. X

B. X

C. GHANA COMMUNITY HEALTH OFFICER KENYA CHEW MALAWI HSA ETHIOPIA HEW

New Developments• Brief Overview of existing literature on the typologies of community-health

programs and prominent examples seen at scale (according to Bhutta et al 2010 GHWA report)

• Typologies [REF: Bhutta 2010]– Short to intermediate duration versus long duration training programs– Preventative and promotion tasks to curative tasks– Weak supervision versus strong supervision– Weak health system versus strong health system

• Example systems at scale– Ethiopia Health Extension Program (long training, preventative and basic

curative tasks, weak supervision system, weak health system)– Pakistan LHW system (long training, mixed tasks, strong supervision, weak

health systems)– Brazil FHP system (long training, mixed tasks, strong supervision, strong health

system)