|Title of paper||Key findings||Key implications||References|
|Overview and Tensions Confronting Large-Scale Programmes||
Across different settings, CHWs play diverse roles; in large-scale programmes they have functions related to both health education and helping extend or bridge to primary healthcare services|
CHWs fall along a spectrum from lay/volunteer to more professionalized
Nongovernmental organizations have played an important role in the development of CHW programmes and continue to engage with government in many public-sector CHW programmes
While evidence-informed models, interventions, and tools are important, for programmes to be effective, the approaches used also need to be responsive to the local context
Over the past several decades, CHWs have played important roles in vertically delivered disease control programmes; increasingly, they are taking on broader roles in more integrated primary healthcare services
The CHW is one actor in a complex, dynamic, primary healthcare system comprised of diverse interacting actors, each having agency, interests, perspectives, and values|
Robust delivery of services at the most peripheral level of the primary healthcare system—reaching all who could benefit—requires functional systems enabling CHWs to play a constructive part, and that, in turn, depends on their role being well understood and appropriately supported
|Planning, Coordination, and Partnerships||
CHW programmes in many countries have been shown to be effective in improving health. However, they are often hindered by weak health systems|
Poor planning, lack of coordination, and failed partnerships have produced lacklustre CHW programmes in countries
The development, strengthening, and governance of CHW programmes need to take into account the country’s health system’s socioeconomic and political context and tailor solutions to the country’s political economy
|The key principles on which there is broad agreement in making CHW programmes effective include strengthening planning, coordination, and partnerships|||
This paper discusses the following important questions that decision-makers need to consider in relation to governing CHW programmes:|
How and where within political structures are policies made for CHW programmes?
Who implements decisions regarding CHW programmes, and at what levels of government?
What laws and regulations are needed to support the programme?
How should the programme be adapted across different settings or groups within the country or region?
Governing CHW programmes is complex because of the location of these programmes at the interface between the formal health system and communities|
How CHW programmes are governed affects many other processes in these programmes, including management, resourcing, accountability, and ultimately performance and sustainability
The most appropriate and acceptable models for governing CHW programmes depend on communities, on local health systems, and on the political system in which the programme is located. Stakeholders in each setting need to consider what systems are currently in place and how they might be adapted to and aligned with local needs and systems
The development or revitalization of large-scale CHW programmes in a number of contexts provides opportunities to explore how different models of governing CHW programmes impact on the quality of care delivered, their responsiveness to local needs, and their sustainability
CHWs can be a cost-effective way to extend health services to hardest-to-reach communities|
Investing in CHWs can lead to short-term and long-term cost savings in the health system and help achieve broader societal goals such as women and youth empowerment
Investing in community health yields a 10:1 return on investment
Despite compelling evidence on their effectiveness, CHW programmes are inadequately funded
The lack of national political support and domestic funding for national CHW programmes is perhaps the most critical challenge facing these programmes. Sixty percent of funding for CHW programmes in sub-Saharan Africa is from donors, and most of this is for vertical disease-specific programmes
Determining CHW programme costs and funding requirements is critical for strengthening and expanding these programmes
Mobilizing political will is a prerequisite for moving forward with stronger financing for CHW programmes
Secure, long-term financing of CHW programmes is critically important for community health programmes to reach their full potential|
Making a compelling case based on the expected return on investment both for improving population health and for promoting socioeconomic development will be critical for generating the political will to ensure long-term domestic funding for CHW programmes
Countries need to be proactive in obtaining alternative, sustainable financing for CHW programmes in addition to the existing traditional funding from donors and domestic resources
|Roles and tasks||
This article provides a list of 10 questions that can help programme planners think about important issues when determining CHW roles and tasks:|
How effective and safe will it be to use CHWs to perform a specific task?
Are CHWs’ roles and tasks likely to be regarded as acceptable by CHWs and their clients and communities?
Are CHWs’ roles and tasks considered relevant by the community?
Is there a good match between the CHWs and the roles and tasks expected of them?
How many tasks and activities should each CHW take on?
What is most feasible for the health system?
When and where will CHWs deliver each task and how much workload will it require?
What kind of skills and training will the CHW need when performing specific tasks?
What type of health system support will the CHW require when performing the task?
How much will it cost to use CHWs to perform the task?
When planning new CHW roles or expanding the roles of existing CHWs, programme planners need to base their decisions on global and local evidence and guidance|
Planners need to consider the effectiveness and safety of relevant tasks performed by CHWs
They also need to assess whether the recommended CHW roles and tasks are considered acceptable and appropriate by their target population and by the CHWs themselves and those who support them
Finally, planners need to think about the practical and organizational implications of each task for their particular setting with regard to training requirements, health systems support, work location, workload, and programme costs
|Recruitment, training and continuing education||
Training is a comprehensive and dynamic (meaning not static and in need of continuous modification) element of CHW programmes that needs to be well funded and professionalized (meaning provided with a high level of skill and expertise)|
Training must be seen as much more than just pre-service training, but rather as ongoing iterative training
Training for effective CHW programmes also needs to be seen not only as training of CHWs, but also training the community, supervisors of CHWs, and others within the health system in order to help these stakeholders appreciate, understand, and make effective use of CHWs
Professionalism of CHW training means ongoing assessment of quality and continuous quality improvement, which will require programmes to have adequate capacity and resources for these activities|
CHW roles will continue to change over time, and therefore, ongoing and dynamic training updates will be an essential element of an effective CHW programme. This includes adding new evidence-based interventions and approaches in response to population health needs
Public health emergencies, such as the COVID-19 pandemic, bring further and urgent attention to the need for ongoing and responsive training of CHWs
CHWs are increasingly recognized as key contributors to and components of strong primary healthcare systems; training is a key prerequisite and incentive for CHWs to become and remain effective. Therefore, ensuring that training for CHWs is part of the larger and CHWs themselves are considered as part of the larger health workforce strategy and priorities is essential for achieving the Sustainable Development Goals and universal health coverage
A strategy for the growth and development of CHWs is needed, so that they have an opportunity to develop themselves through career advancement opportunities
|Recent advances in supervision||
A review of the recent academic literature and grey literature on supervision of CHWs revealed that:|
Supervisors in CHW programmes are expected to perform a variety of roles covering administrative, clinical, and supportive activities
Multiple supervision approaches are in use today: external supervision, community supervision, group supervision, peer supervision, and dedicated supervision
Inadequate support for supervisors is a major challenge. With the right support, supervisors can help CHWs acquire and obtain other elements needed for strong performance, such as pay/incentives, role clarity, tools/supplies, and knowledge
CHW programmes now have the opportunity and the necessity of instituting stronger supervision as one of the critical steps in moving to a higher level of performance|
Increased, dedicated funding from national governments with support from the international community will be required to try new approaches to supervision, scale up existing approaches deemed promising, and evaluate the quality and effectiveness of such approaches alongside other health system improvement initiatives
|Motivation and remuneration||
The article reviews what kinds of incentives and remuneration have been offered to CHWs, how these incentives have influenced CHW motivation, and how programmatic and contextual factors have shaped the relationships between incentives and CHW motivation|
There is a wide variety of incentives offered in CHW programmes around the world, and these function at individual as well as health system and community levels
CHW motivation can be affected by tensions between altruistic and material imperatives, by the social dimensions of their relationships to members of the health system and community, and by cultural, economic and political contexts
CHW motivations are likely to change over time, as circumstances change, which means that CHW programmes must be able to assess and respond to changes in the effectiveness of various incentives
WHO guidelines on CHWs have recently emphasized the importance of decent working conditions and fair labour practices in CHW programmes
Sustaining CHW motivation requires focused and consistent investment in locally meaningful and sustainable forms of incentives, typically with some clear support from or involvement from the state. CHW motivation cannot be sustained if CHWs are seen as a temporary solution to health system failures|
Sustaining CHW motivation requires thinking about incentives as multidimensional and about CHW motivation as something that changes over time
All of this in turn requires a health system that is functional and effective enough to provide a clear role and proper support for CHWs
|Relationships with communities and health systems||
A major challenge of large-scale CHW programmes is that CHWs need to establish and maintain constructive relationships with the actors in the national health system as well as with actors in the community, and they need to navigate these dynamic relationships over time|
For CHWs to be optimally effective, they need to be embedded in the community as members who are well known, trusted and appreciated by community leaders, community members, and influential local groups
CHWs need a clearly defined role that is well understood and respected, and they need to be provided with functional supports from the health system and from the community|
Community engagement in CHW programmes is a process that requires leadership at all levels in the CHW programme as well as support from the health sector, local government, and community organizations
A variety of existing frameworks is useful when assessing the performance of CHW programmes|
CHW programme performance assessments need to consider measurement of individual CHW performance and community-level outcomes, as well as to look at health systems and other contextual factors that influence CHW programme performance
CHW programme assessments ideally need to be based on data derived from a mix of reliable sources and by using a mix of methods to obtain these data|
Investment in CHW programme performance assessments is instrumental for continually innovating, upgrading, and improving CHW programmes at scale