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Community health workers

  • Core Roles and Competencies of Community Health Advisors | Community Resource

    The prominence of Community Health Advisors (CHAs) within the U.S.

  • Evaluation of the Quality of Community-based Integrated Management of Childhood Illness and Reproductive Health Programs in Madagascar | Publications

    Madagascar recently scaled up volunteer community health worker (CHV) programs in community‐based Integrated Management of Childhood Illness (c‐IMCI) and reproductive health and family planning (RH/FP) to provide health care to remote and underserved communities.

    Methods: A cross‐sectional observational evaluation was conducted using a systematic sample of 149 CHVs trained in c‐IMCI and 100 CHVs trained in RH/FP services. CHVs were interviewed on demographics, recruitment, training, supervision, commodity supply, and other measures of program functionality. CHVs were tested on knowledge of the case management guidelines or reproductive health and injectable contraception, respectively. Trained experts observed the performance of c‐IMCI‐trained CHVs as they each evaluated five ill children under 5 years old and RH/FP‐trained CHVs as they completed five simulated female client encounters with uninstructed volunteers at a health facility. Each ill child was clinically re‐assessed by a trained gold standard evaluator and results were compared to determine if c‐IMCI CHVs correctly performed essential assessment, classification, and treatment tasks. A c‐IMCI CHV performance score (on a scale of zero to 100) was calculated based on the mean percentage of tasks performed correctly for each ill child. A key outcome, the proportion of recommended treatments that were prescribed correctly by c‐IMCI CHVs compared to the gold standard, was determined. RH/FP CHVs were observed by trained experts as they discussed and counseled female clients in family planning options. A RH/FP CHV performance score (zero to 100) was developed scoring the CHVs’ ability to obtain basic information about a clients’ contraception needs, determine eligibility for the selected family planning method in which clients showed an interest, and the quality of counseling provided for the chosen method. Multivariable linear regression models were used to identify factors associated with CHV performance.

    Results: c‐IMCI CHVs evaluated a total of 745 ill children under 5 years old. Their mean overall performance score was 75.1% (95% confidence interval [CI]: 72.3, 77.8). Higher scores on the knowledge assessment, having more years of education, and more CHV responsibilities were associated with better performance; whereas distance of greater than 20 km from a health facility, 1–5 supervision visits in the previous 12 months, and children presenting with respiratory illness or diarrhea were associated with a lower performance score. When compared to a gold standard evaluator, c‐IMCI CHVs referred 68% of children with severe illness or other indications for immediate referral to a health facility, and chose the appropriate life‐saving treatment, when it was needed, 53% of the time for children presenting with a c‐IMCI treatable illness (uncomplicated diarrhea, pneumonia, or malaria). CHVs demonstrated good technical proficiency in performing and interpreting rapid diagnostics tests (RDTs) for malaria with 90% accuracy. However CHVs appropriately chose to use RDTs, when indicated, 55% of the time. RH/FP‐trained CHVs had a total of 500 clinical encounters with women to provide family planning counseling. RH/FP‐trained CHVs had a mean overall performance score of 73.9% (95% confidence interval [CI]: 70.3, 77.6). More education, more weekly volunteer hours, and receiving refresher training correlated with a higher performance score. For critical tasks, such as promoting informed choice, screening clients for pregnancy and potential medical contraindications to certain contraceptives, and providing instructions to ensure successful method use, RH/FP CHVs had a mean critical task performance score of 78.2% (95% CI: 75.5‐80.8%). Nevertheless, RH/CHVs did not always completely follow standard checklists to (1) rule out pregnancy (the complete checklist was used in only 69% of client encounters) or (2) assess contraindications for oral contraceptive use (all necessary questions asked during only 41% of encounters with women expressing interest in the oral contraceptive method).

    Conclusions: CHVs trained in c-IMCI in Madagascar frequently made errors in managing childhood illnesses similar to those reported for integrated community case management programs in other countries. c-IMCI CHVs performed well in identifying and evaluating a child’s symptoms, though treatment quality was low. Specific case management skills that require improvement were identified. CHVs demonstrated suboptimal performance in referring children with severe disease and poor performance in classifying and treating children with uncomplicated diarrhea, pneumonia, and fever when compared to a gold standard evaluator. The CHVs trained in RDTs demonstrated good technique in performing and interpreting RDTs correctly but did not always choose to perform one when indicated. Although areas of deficiency were identified, RH/FP-trained CHVs proved capable of providing high-quality contraception services, especially in conducting the most medically critical tasks. Multivariable linear regression analysis identified factors associated with performance, which could be used to tailor and strengthen programs and identify those CHVs needing additional supervision and training. The magnitudes of the associations measured were small; therefore the establishment of comprehensive monitoring and evaluation plans will be critical in determining which program changes improve service delivery, quality, and effective access to care in the future.

  • Community Health Volunteer Program Functionality and Performance in Madagascar: A Synthesis of Qualitative and Quantitative Assessments | Publications

    For more than a decade, the U.S. Agency for International Development (USAID) Mission in Madagascar and other partners have invested in the development of a national CHV system to improve access to life-saving primary health care services for rural and remote populations. Presently, the USAID/Santénet2 Project (SN2) aims to increase access to and availability of community-based interventions in 800 communes concentrated in 16 regions of eastern and southern Madagascar. SN2 provides local capacity building, training, and supervision to mobilize over 12,000 CHVs to offer lifesaving health services, including family planning counseling and short-acting contraceptives and maternal, newborn, and child health, including community case management for uncomplicated malaria, pneumonia, and diarrheal disease. In general, two CHVs have been elected by their communities from each of the 5,758 targeted villages located more than five kilometers from the nearest health center. MAHEFA, Santénet2’s sister project, is scaling up support for integrated community-based activities through an additional 3,500 CHVs in underserved western and northern Madagascar. 

    USAID/Madagascar asked the USAID Health Care Improvement Project (HCI) and the Global Health Technical Assistance (GH Tech) Project, with technical assistance from the U.S. Centers for Disease Control and Prevention (CDC), to conduct qualitative and cross-sectional studies, respectively, of CHV program functionality and performance. The purpose of this report is to synthesize the findings from the two assessments. Complete findings are available in the respective assessment reports (Wiskow et al. 2013 and Agarwal et al. 2013). 

    Based on the synthesized findings from the two assessments on CHV program functionality, the following recommendations are presented:

    ·         Linkages with the communities should be strengthened, including clarifying CHV roles
    ·         Ongoing trainings should be budgeted for and conducted in both service delivery and management of supplies
    ·         Linkages with the health system should be strengthened, particularly with respect to the referral system
    ·         Supportive supervision, especially visits to CHVs’ communities, should be planned and budgeted. Creative approaches to supervising CHVs who live far from the facilities should be explored and tested.
    ·         A national monitoring and evaluation system should be established to inform programmatic decision and performance monitoring. Knowledge and competency of CHVs should be assessed periodically as a means of identifying gaps in knowledge and opportunities for improving performance and quality of care.


  • Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions | Community Resource

    To provide cost guidance for developing a locally adaptable and nationally scalable community health worker (CHW) system within primary-health-care systems in sub-Saharan Africa.

  • Health Systems Strengthening Case Study: Demonstration Project to Strengthen Community Health System to Improve Performance of Health Extension Workers | Ethiopia | Publications

    This short report describes the work of the USAID Health Care Improvement Project (HCI) in Ehtiopia to apply a community health system strengthening approach to improve the competence and performance of health extension workers (HEWs), strengthen the linkage between the community and the health system, and improve the capacity of community groups to take ownership of health programs in their catchment areas and establish an effective community health system.

  • Qualitative study to identify solutions to local barriers to care-seeking and treatment for diarrhea, malaria and pneumonia - Report on findings from Nigeria | Community Resource

    The report is based on UNICEF's three country qualitative study to identify solutions to local barriers to care-seeking and treatment for diarrhoea, malaria and pneumonia. The study had three main objectives:

  • Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting: WHO recommendations | Community Resource

    The World Health Organization’s recommendations on optimizing the roles of health workers aim to help address critical health workforce shortages that slow down progress towards the health-related Millennium Development Goals (MDGs).

  • How effective are community health workers? | Community Resource

    Community Health Workers (CHWs) provide a critical and essential link with health systems and are a powerful force for promoting healthy behaviors in resource-constrained settings.

  • Qualitative study to identify solutions to local barriers to care-seeking and treatment for diarrhoea, malaria and pneumonia - Report on findings from Niger | Community Resource
    The report is based on UNICEF's three country qualitative study to identify solutions to local barriers to care-seeking and treatment for diarrhoea, malaria and pneumonia. The study had three main objectives:
    1. 1. To access perceptions and experiences of childhood malaria, diarrhoea and pneumonia and associated care-seeking and treatment (non-)uptake.
    2. 2. To determine the barriers and challenges intended beneficiaries face in accessing treatment for malaria, diarrhoea and pneumonia in children under five years.
  • Qualitative study to identify solutions to local barriers to care-seeking and treatment for diarrhoea malaria and pneumonia in select high burden countries: Report on findings from Kenya | Community Resource

    This report is based on UNICEF's three country qualitative study to identify solutions to local barriers to care-seeking and treatment for diarrhoea, malaria and pneumonia. The study had three main objectives:

  • A systematic review of strategies to increase demand, uptake and quality of community-based diagnosis and case management of malaria | Community Resource

    New MNCH Working Paper from UNICEF and the London School of Hygiene and Tropical Medicine presenting a systematic review of CCM for malaria

    UNICEF, in collaboration with the London School of Hygiene and Tropical Medicine, has just released a new MNCH Working Paper titled “A systematic review of strategies to increase demand, uptake and quality of community-based diagnosis and case management of malaria” by Lucy Smith Paintain, Barbara Willey, Alyssa Sharkey, Julia Kim, Valentina Buj, David Schellenberg & Ngashi Ngongo.

  • An Assessment of Community Health Volunteer Program Functionality in Madagascar | Publications

    Community health workers (CHWs) are internationally recognized for helping to reduce morbidity and mortality. Since 1978, the World Health Organization (WHO) has been promoting CHWs to perform selected health care tasks at the community level (WHO, 1989). “CHW” generally refers to individuals who, with limited training and support, provide health care and health education to people who live in their communities. Community health workers/volunteers are often recruited, managed, or supported through CHW programs of support—defined in this report as an organizational system that includes structures and processes providing operational and technical support to CHVs.

    The U.S. Agency for International Development (USAID) Mission in Madagascar requested an assessment of the functionality, effectiveness, and sustainability of programs supporting Malagasy CHVs to provide primary health care services in rural communities. The main assessment objectives were to:
    1. 1. Assess the functionality of CHV programs of support to identify strengths and weaknesses in three regions; and
    2. 2. Examine CHV supervisory practices.
    This report presents the findings of the qualitative assessment, which was done by the USAID Health Care Improvement Project (HCI). This component used the Community Health Worker Assessment and Improvement Matrix (CHW AIM) toolkit (Crigler et al., 2011) to assess the functionality of these programs at both the organizational and system levels and explored the use of supervisory tools and practices.


  • CHW Regional Meeting | Addis Ababa, Ethiopia, June 19-21, 2012 | Publications

    The USAID-sponsored Community Health Worker (CHW) Regional Meeting held in Addis Ababa, Ethiopia from June 19 to 21, 2012, was attended by over 60 government and nongovernmental (NGO) representatives from six African countries (Ethiopia, Kenya, Mali, Rwanda, Uganda, and Zambia) as well as participants from international NGOs and organizations. The meeting was planned by Initiatives Inc. under the USAID Health Care Improvement Project (HCI) and designed to share new tools and strategies to strengthen the functionality of government and NGO CHW programs; facilitate dialogue about challenges and best practices among participating countries and identify and support evidence-based strategies for scale-up. This report details proceedings from the meeting.  

  • Uganda| Community Support to Community Health Workers (CHWs) | Collaborative Profile
  • Ethiopia| Community Health Worker (CHW) Collaborative | Collaborative Profile
  • Senegal| Community-Based Collaborative | Collaborative Profile
  • Meeting the health information needs of health workers: What have we learned? | Community Resource

    The information challenges facing health workers worldwide include lack of routine systems for seeking and sharing information, lack of high-quality and current health information, and lack of locally relevant materials and tools. This article presents three studies of health information needs in India, Senegal, and Malawi that demonstrate these information challenges, provide additional insight, and describe innovative strategies to improve knowledge management and ensure health workers have the equipment and supplies they need.

  • Perceived barriers and motivating factors influencing student midwives' acceptance of rural postings in Ghana | Community Resource

    To meet Millennium Development Goal Five and the reproductive needs of all women, it is predicted that an additional 334,000 midwives are needed. Despite the ongoing efforts to increase this cadre of health workers there are still glaring gaps and inequities in distribution. In countries where there are too few health workers, deployment of midwives (including recruitment and retention) to rural postings is a continuing challenge.

  • Developing materials on HIV/AIDS/STIs for low-literate audiences | Community Resource

    This guide, Developing Materials on HIV/AIDS/STIs for Low-Literate Audiences, produced by FHI360, provides a comprehensive methodology for developing training materials for low-literate audiences in the context of a strategic behavior change (SBC) program. 

  • A Global Improvement Framework for Health Worker In-service Training: Guidance for Improved Effectiveness, Efficiency and Sustainability | Publications

    This short report describes how the USAID Health Care Improvement Project (HCI) is developing an improvement framework for in-service training programs in collaboration with key stakeholders. In-service training (IST) represents a significant proportion of investments made by Ministries of Health and development partners in building the capacity of health workers to competently, safely and efficiently provide quality health services.