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CHW role

  • 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.


  • 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.

  • 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.

  • 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.  

  • Senegal| Community-Based Collaborative | Collaborative Profile
  • 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.   

  • Reliability of Community Health Worker Collected Data for Planning and Policy in a Peri-Urban Area of Kisumu, Kenya | Community Resource

    This article investigates the validity and reliability of Community Based Information collected by CHWs in Kenya. The study concludes that CHWs collect sufficient household data that can be used to inform decisions on health intervnetions  and to scale-up and develop new programs.  

  • Role Development of Community Health Workers | Community Resource

    This study reviews research on CHW programs and concludes there is an inconsistent reporting of selection and training processes for CHWs in the existing literature. It presents a conceptual model  for the role development of CHWs to guide future reporting of CHW programs in the intervention literature. 

  • Isibindi Model of Care for Vulnerable Children and Youth | Community Resource

    This document describes the Isibindi Model which uses community-based child and youth care workers in communities in an innovative team outreach program to support children and families affected by the HIV/AIDS pandemic. The aim is to enable children and youth to acquire skills that will increase their competency in their living environment and facilitate emotional support to children and youth.  

  • Facts for Life | Community Resource

    Facts for Life provides essential information on how to prevent child and maternal deaths, diseases, injuries and violence. Written in simple language, the messages are based on the latest scientific findings by medical and child development experts around the world.  The contents can promote dialogue, learning, communication and action among children, youth, families, communities, and social networks. 

  • World Vision: Peer Education Training Summary Report | Community Resource

    This report reviews World Vision's training and support for peer educators in  a school-based peer-led HIV prevention programme in three provinces of South Africa. The methodology is based on the Centre for the Support of Peer Education (CSPE) philosophy which encourages the use of peer educators to reach beneficiaries. Lessons learned are presented.   

  • Human Resources for Health in Maternal, Neonatal, and Reproductive Health at the Community Level: A Synthesis of the Literature with a focus on the Asia Pacific Region | Community Resource

    This literature review provides examples of lessons learned in the planning, implementation and evaluation of HRH interventions in maternal, neonatal and reproductive health (MNRH) at the community level in the Asia and Pacific regions. The review outlines interventions in the areas of HRH policy, management, and education and training. It synthesizes what are considered effective ways of working with the community and ways towards building supportive environments for health workers. 

  • Community health workers: Bringing family planning services to where people live and work | Community Resource
    CHWs provide health education, referral and follow up, case management, and basic preventive health care and home visiting services to specific communities. They provide support and assistance to individuals and families in navigating the health and social services system. 
  • Preventing malaria in pregnancy through community-directed interventions: evidence from Akwa Ibom State, Nigeria | Community Resource

    This study analyzes a community-based programme to determine the degree to which community-directed interventions delivered through volunteer community based distributions  can improve access to malaria prevention strategies for pregnant women, including use of ITNs, IPTp drugs and counseling. Results suggest that beyond  access to malaria prevention, access to formal health care in general, and antenatal care in particular increased.