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  • The Human Resources Collaborative:Improving Maternal and Child Care in Niger. Final Report. | Publications

    Amid a worldwide health workforce crisis, health providers carry a burdensome workload, are inadequately paid, and often work in environments that preclude quality care giving. They become disengaged while the demand for health services grows and investments in health workforce development are flat or declining. Niger is one of 36 countries in sub-Saharan Africa experiencing a human resources crisis. It has one doctor per 35,000 population and one nurse or midwife per 5000. An impoverished, desert country, it has high rates of maternal and child mortality: more than 600 maternal deaths per 100,000.

    The U.S. Agency for International Development (USAID) is funding programs to implement its strategy for mothers and newborns. The strategy calls for the implementation of high-impact, cost-effective interventions during the child-bearing and postnatal periods. Among those programs is the USAID Health Care Improvement Project (HCI), managed by University Research Co., LLC (URC), which provides technical leadership and assistance for improving health care delivery and health workforce management to USAID-assisted countries. In addition to its emphasis on improving maternal and newborn care, USAID, through its Office of HIV/AIDS (OHA), is also concerned with expanding the evidence base for effective approaches to fortify human resources for health.

    In 2009, Niger’s Ministry of Public Health and its regional health management office in Tahoua requested assistance from HCI to implement a program to address the health workforce crisis. With too few staff and no prospects for additional staff, the Ministry sought to improve the management of human resources in selected facilities and management offices in Tahoua Region. The predecessor project to HCI had successfully implemented quality improvement (QI) interventions in the same region. The new project would build on that experience and the country’s National Health Development Plan, which targets maternal/child health and human resources.  

    Intervention:HCI proposed applying the collaborative improvement approach to improve human resources management in Tahoua. HCI had adapted for use in developing countries the collaborative improvement approach successfully implemented in the U.S., Europe, and Canada. The approach features QI teams that work at their own facilities with QI experts from HCI and the national health ministry. The teams work with the experts to learn the evidence-based interventions that will improve health outcomes. For the HR collaborative, in addition to the facility/clinical teams, teams also formed comprising managers. These management teams supported the facility teams by strengthening supervision and management. What distinguished the Niger HR collaborative from others HCI had helped implement was that no clinical interventions were proposed, only HR interventions.

    The Niger Human Resources (HR) Collaborative began with a baseline assessment in May 2009 and ended with an endline assessment in December 2011.  To guide improvement work in human resources management, HCI supported teams to work through the steps of the Human Resources Performance Cycle. Teams began with having each staff person develop a job description with his/her supervisor and continue with articulating tasks, determining training needs, performance evaluation, etc. Participating facilities moved through these steps, monitoring and reporting their success in achieving them, with many nearly completing the cycle.

    Throughout this process, health worker teams and their supervisors worked to implement the performance cycle within the context of the clinical areas they had selected. Job descriptions were developed as they relate to the maternity goals, feedback was provided within the context of the performance in question, and data was collected monthly on how well they were doing against the clinical indicators on which they focused. Health workers and their supervisors collected the indicator data, and managers reviewed and spot-checked those data. Embedding such data collection – and its related analysis and dissemination – in quality improvement processes is a key feature of HCI’s work, and it enabled the collaborative not only to adapt care processes at the point of delivery but also to show whether its impact was favorable and/or widespread.

    Results: The clinical results proved exciting and compelling: All major indicators showed clear improvement, and in each case, a distinct shift occurred during the early to mid-point of implementation, signifying that the improvement was statistically significant, not accidental. Deliveries by qualified health workers rose from 27% to 45% and contraceptive prevalence from 9.6% to 36%; post-partum hemorrhage fell from 2% to 0.06%, and mortality in children under five from severe malaria dropped from 15% to 4% at the pediatrics hospital. To achieve these results, the teams made major changes in how health workers managed themselves and were supervised: They instituted feedback mechanisms, developed checklists to analyze skill gaps based on redesigned tasks and jobs, shared results with clients and other teams, and became engaged with the results. Managers improved supervision practices and began developing performance checklists, observing health workers, and reviewing results.

    Conclusions and Recommendations: Overall both health workers and managers felt very positive about the human resources improvement work and that it had a positive impact on both working conditions and performance. Health workers felt that aligning their work with the Ministry’s objectives was essential. Moustapha Boukary, Head of Tsernaoua Health Post, commented, ‘’Before the HR Collaborative, we worked in unclear and cloudy conditions, but when we started aligning goals and objectives, we saw a clear direction.”

    This innovative approach offers countries a new way to address the many challenges they face in the health and HR sectors. The above-cited clinical results are unquestionable and promising for a much larger scale. The success of the Performance Cycle process – and the combination of HR management and QI – should be refined, adapted, and improved, so that HR professionals are not left to struggle with too few health workers, and health workers are not left without the HR processes common in developing countries. 

    The change package is documented and sufficiently flexible to be used in other regions in Niger and beyond. To implement this process again, either in Niger or elsewhere, the authors recommend that:
    1. A management change package should be developed that could be tested at the same time as the facility-level package. A change package similar to that implemented in Tahoua could be developed for implementation in the Ministry departments and regional management offices.
    2. Management and facility levels should work together on HR issues. Facility teams should test changes for their level, and management should scale solutions and revise policy. 
    3. Temporal relationships should be examined: What must be done stepwise and what can be done at once. 
    4. Some Performance Cycle sub-steps can be implemented by sites alone.
    In summary, the approach of focusing on improving the performance of health workers by better managing the elements of their performance and helping them manage themselves can improve any program and should be a part of any clinical intervention. The process and change package could be simplified and adapted for different contexts. Niger’s experience of having health workers become invested in outcomes, communities more aware of available services, and the process of work improved to better serve women and children should be replicated elsewhere.
  • Improving CHW Program Functionality, Performance, and Engagement: Operations Research Results from Zambia | Publications


    The United Nations Millennium Project identified the large-scale training and deployment of community health workers (CHWs) as an important strategy to fill the human resources gap and achieve the Millennium Development Goals (MDGs). However, CHW programs are known to be fraught with significant human resources challenges. The USAID Health Care Improvement Project (HCI) developed the Community Health Worker Assessment and Improvement Matrix (CHW AIM) to help assess CHW program functionality and to provide benchmarks against which to measure program improvements. 
    Zambia’s large number and wide range of CHWs and the government’s openness to CHWs and recognition of their value made it an ideal country in which to conduct this operations research study to test whether the application of the CHW AIM tool contributes to CHW program functionality improvement. The CHW AIM operations research study was designed as a field intervention that applied the CHW AIM process twice over 13 months. It included a sample of six organizations (five intervention sites and one control site) and 156 CHWs. The CHW AIM process was applied at five organizations; engagement was assessed at all sites through an engagement survey, which was complemented with an in-depth engagement interview; CHW performance (task completion) in two HIV/AIDS service delivery areas that CHWs commonly provide, positive living and ART adherence counseling, was also assessed at all sites through analysis of service delivery audio recordings.  Data were collected between October 2010 and November 2011.
    The results indicate that the CHW AIM process contributed to program functionality improvement, but that improvement was neither linear nor consistent. Only two organizations improved their total program functionality scores, but every organization made gains in at least two program functionality elements that were direct results of plans made in response to findings of the first CHW AIM workshop. Important and positive changes were made in almost all of the CHW AIM elements.
    CHWs demonstrated “low performance” (<39%) in four of six sites at baseline and moderate performance (40-69%) in only two sites.  At endline, CHWs demonstrated moderate performance in four sites, for CHWs with matching baseline and endline data. There is a positive correlation between CHW AIM scores and performance, but a number of other factors also correlated positively with performance. These other factors included the time CHWs spent with clients (based on recording times), days of initial training (from CHW interviews), months worked as a CHW (from CHW interviews), average hours worked (as reported in CHW interviews), the type of incentive the CHW was provided (in-kind or cash), the value of CHW incentives, and three of the 15 CHW AIM elements.
    Organizations felt the CHW AIM process was useful and helped them take stock of their program and develop constructive actions to address issues. While measures of improvement captured through this study are inconclusive, the stories of improvement that come out of this study suggest that the tool can catalyze improvement.  It is worth noting that organizational investments in CHW programs varied greatly among sites that participated in the study. The CHW AIM process is fairly inexpensive to implement and should be feasible for most organizations to fund if it is incorporated in project plans and budgets.


  • CRS Guide to Working with Volunteers | Community Resource

    Volunteers are essential to many organizations. This guide is designed to help country programs address programmatic issues surrounding volunteer engagement such as: roles and responsibilities, incentives, recruitment, training and supervision. It includes checklists, tools and frameworks that can be adapted to local contexts to help organizations standardize how they work with volunteers.

  • Community Health Worker Intervention to Decrease Cervical Cancer Disparities in Hispanic Women | Community Resource

    This study presents the results of  a randomized trial of a promotora-led education intervention focused on cervical caner in a local South Philadelphia Hispanic community. The findings suggest that CHWs can provide a novel and culturally-appropriate model for addressing racial and ethnic health disparities in underserved populations.   

  • Lay Health Worker Attrition: Important but often ignored | Community Resource

     This case study examines lay health worker attrition by examining three questions: What is the magnitude of attrition in programs? What are the determinants of attrition? What are the most successful ways of reducing attrition? Several important factors have been identified including: supportive supervision, defined roles with specific tasks, locally relevant incentives, incentive systems combining monetary and nonmonetary benefits, recognition, training opportunities, community and policy support, and strong leadership.

  • Improving Outcomes with Community Health Workers | Community Resource

    Partner in Health's Program Management Guide discusses strategies to help organizations implement a CHW program to improve access as well as the quality of care that is provided in resource-limited areas. A CHW program can significantly improve health outcomes, particularly for the poorest members of the community. In PIH's accompaniment model of care, patients build a trusting relationship with one CHW who will remain with them until healthy.

  • Improving Pharmaceutical Service in the Primary Healthcare Sector Through the Training of Pharmacist Assistants | Improvement Report
  • Strengthening of Family Planning Service Delivery through 18 Urban Health Centers (UHCs) in 2 districts of Uttarakhand | Improvement Report
  • Championing Performance Standards to Increase Family Planning Use by Women after Postabortion Care at a Guinea Clinic | Improvement Report
  • Job stress among community health workers: a multi-method study from Pakistan | Community Resource

    This multi-method study investigated Lady Health Workers' (LHWs) viewpoints on their job description, the problems they face and the levels of stress they encounter. All LHWs in one rural sub-district in Rawalpindi, Pakistan, were surveyed. Around a quarter of LHWs were found to have significant occupational stress. The authors conclude that improvements in remuneration, administration of supplies and career opportunities would reduce stress and result in better performance among LHWs. In addition, they recommend that communication skills should an essential part of training for LHWs.

  • Supply Chain Models and Considerations for Community-Based Distribution Programs: A Program Manager's Guide | Community Resource

    This document provides guidance in the design of systems for community-based distribution (CBD) programs. The guide aims to assist program managers and other stakeholders in designing and implementing stronger and more sustainable supply chains for their CBD programs. The guide is intended to serve as a resource of tools that can be modified and adapted for use by any government or organization that implements CBD programs in any country.

  • New online resource about Community Health Workers | Publications

    CHW Central ( is a new interactive platform to facilitate information-sharing and dialogue about how to support and improve the effectiveness of community health workers, who serve in communities around the world providing health education and care. The website's features include:

    • Online facilitated discussions with experts on current and critical issues facing CHW programs;
    • A resource center of training materials, practical tools, and up-to-date guidelines; and
    • A member exchange forum where registered users can post questions and solicit input.

    Developed by the USAID Health Care Improvement Project, CHW Central draws on global resources and evidence from a number of organizations committed to improving and supporting community health workers, including USAID, The Global Health Workforce Alliance, CORE Group, CapacityPlus, and MCHIP.

    CHW Central is managed by Initiatives Inc., in collaboration with  University Research Co., LLC (URC) and Johns Hopkins Bloomberg School of Public Health Center for Communication Programs.
  • Community Health Worker Assessment and Improvement Matrix (CHW AIM): A Toolkit for Improving CHW Programs and Services | Community Resource

    A key element of USAID’s strategic approach to maternal and child health (MCH) is to increase the number of functional community health workers serving in USAID priority countries by at least 100,000 by 2013. At the request of the USAID MCH team, the Health Care Improvement Project (HCI) developed a tool that defines a set of key elements needed for community health worker programs to function effectively and that evaluate programs on specific criteria, which were defined by recent literature reviews on CHW programs (see link below) and by suggesti

  • Improving Performance of Community-Level Health and Nutrition Functionaries: A Review of Evidence in India | Community Resource

    This review of the National Rural Health Mission (NRHM) and the Integrated Child Development Scheme (ICDS) III which highlights lack of supervision, poor worker motivation, and related issues as critical challenges. It shows that programs often focus on training but other performance factors such as supportive supervision, clear performance expectations and motivation and recognition are often neglected. These factors may be constraints against improving health and nutrition programs in India.

  • Measuring engagement of community health workers to improve productivity, retention and quality of care | Community Resource

    This investigation looks at applying human resources (HR) concepts related to employee engagement that have been validated in developed countries to the context of volunteers in OVC programs in Ethiopia to the Strengthening Communities and Safety Nets Project. Worker engagement is defined as the extent to which people enjoy and believe in what they do and feel valued for doing it. Evidence has shown that engaged workers perform better and are more productive than disengaged workers.

  • Coming soon: CHW CENTRAL, a new web-based resource for Community Health Worker Programs | Page

    Community Health Workers (CHWs) play an important role in meeting the health Millennium Development Goals (MDGs) by addressing the global shortage of health care workers. In June 2011, the USAID Health Care Improvement Project is launching CHW Central, a website to facilitate sharing information and foster dialogues about CHWs. CHW Central contributes to strengthening CHW programs by sharing the latest developments in CHW research, practice and policy and connecting CHW experts, practitioners and supporters.

    The website features:

  • Strengthening Human Resources for Health to Improve Maternal Care in Niger’s Tahoua Region | Publications

    This short report describes the results of applying collaborative improvement to strengthen human resource management and improve the quality of maternal care in Tahoua Region of Niger.

  • Community Health Worker Assessment and Improvement Matrix (CHW AIM): A Toolkit for Improving CHW Programs and Services | Publications

    A key element of USAID’s strategic approach to maternal and child health (MCH) is to increase by at least 100,000 the number of functional community health workers serving in USAID priority countries by 2013. At the request of the USAID MCH team, the Health Care Improvement (HCI) Project developed a tool that defines a set of key elements that are needed for community health worker programs to function effectively and measures how well programs meet these criteria.  These elements were defined based on a review of recent literature on CHW programs (see link below) and suggestions from expert reviewers. The CHW Program Assessment and Improvement Matrix (CHW AIM) tool examines 15 programmatic components that CHW programs should consider as important to successfully supporting CHWs.  These include: recruitment; the CHW role; initial training; continuing training; equipment and supplies; supervision; individual performance evaluation; incentives; community involvement; referral system; opportunity for advancement; documentation and information management; linkages to the health system; program performance evaluation: and community ownership. 

    In applying the tool, each component is rated with a four-point scale ranging from non-functional to highly functional. In addition to assessing whether CHWs are part of functional programs, the tool includes lists of high impact, evidence-based interventions for MCH and HIV/TB services to guide assessment of which services the CHWs are currently performing.  

    The instrument can be applied in a stakeholder meeting to assess the current status of a specific program and determine if the program as a whole is functional. Health workers within that program are then considered to be functional. In addition to helping determine whether a CHW program is functional, the tool also provides an action planning and resources guide to assist program managers in strengthening their community health worker programs.

    The CHW AIM tool may be downloaded in its entirety below.  A brief review of recent literature on CHWs that helped to inform the development of the tool may also be downloaded.  Individual forms that are part of the tool may also be downloaded separately, by appendix, including comprehensive lists of maternal, newborn and child health and HIV/AIDS tasks that may be appropriate for CHWs. A powerpoint training for facilitators to use the CHW AIM toolkit is also provided below.