Importance of Community Health Workers

DEFINING THE PROBLEM

Community Health Workers have been used in several countries dating back about 60 years ago, to address the gap experienced by the underserved members of these communities, with issues of access to health care. More importantly in Low and middle-income countries, Community Health Workers have particularly been helpful in reducing the impact of the shortage of skilled health workers. Community Health Workers can make valuable contributions to healthcare especially in the delivery of basic health care; however, across countries and individual programs there are varying and inconsistently established approaches on how they are recruited, trained, monitored, incentivized, as well as the roles and activities they perform. The lack of a standard structure globally and in CMMB countries creates several divisions of Community Health Workers, which may lead to poor monitoring, increased attrition, poor planning, budgeting and sustainable financing.

The Effect on Women and Children

Several programs have reported a high attrition rate which has led to the breakdown of the programs and is mostly due to problems with how these Programmes are structured or maintained. The initial purpose for which the CHW was set up was to link the communities with the formal health system, if the system fails, the underserved especially the vulnerable populations (women and children), in absence of quality health care are at risk of poorer health outcomes.

BACKGROUND.

Community health workers are adjunct health workers with a myriad of appellations across countries. According to WHO, they should be members of the community, selected by the community, trained and work within the community, answerable to the community, they should be supported by the health system but not necessary being a part of it, and have a shorter course of training than other professional workers. Although they function more at the peripheral of the health system, and their duties widely vary across countries and programs, their roles in the delivery of basic health care can not be overemphasized. In some countries, they also perform the role of record keeping.

Over the years, the use of CHWs has gained prominence, with several countries adopting the trend to mitigate the growing proportion of infectious diseases and a shortage of health workers, migrating for green pasture, however, not all CHW programs follow the WHO’s definition of CHW. In CMMB countries, the approach is also different across the in the individual countries.

RECRUITMENT, TRAINING, AND INCENTIVES

In Peru, the Ministry of health has specific regulations on how the CHWs program should be structured. CHWs in Peru are usually volunteers, they could receive incentives but they do not have contracts or salaries. They are appointed by the community organization at the general assembly or the social grassroots organization to which the community health agent belongs. There is variation in the duration of training the CHWs to receive in Peru. In South Sudan, there are no specific regulations in terms of services, CHW could receive incentives and could also be employed. They are trained in Basic health care service for 6 months whereas, in Zambia, the Implementing partners have different policies for training, recruitment, remuneration, and incentives for CHWs. Programs funded and managed by implementing partners are typically on contracts of two-to-five year but their remuneration and incentives vary across programs. The training also varies between 2-11 weeks depending on if it is affiliated with government health facility or an NGO and the Ministry of health’s CHW handbook, 2005 is used as a guideline.

ROLES AND ACTIVITIES

Several kinds of literature have grouped the CHWs as being either generalist or specialist in the way they are trained or work. Generalist perform a wide range of functions while the specialist has a program specific focus. In the CMMB countries, the CHWs are more generalist than they are a specialist or obscured in between. They are generally involved in implementing promotive and preventive health activities especially in providing family planning and immunization. In south Sudan, CHWs perform addition roles of supporting primary health care units as health staff to clerk patients and also work in the pharmacy. They follow up pregnant women receiving ART while in Zambia, CHWS, also provide basic curative services and refer cases if complicated, they performfollow-up care including home visits for patients with TB, AIDS, pregnant and postnatal mothers, tracing for malnourished children.

Most literature about CHWs and what they do, agree that they are important in improving access to care especially in areas where they are most needed. However, it is important to consider the local context where the CHW program will operate(culture, language, social norms, and values etc.) for the program to excel. The mode of selection of the CHWs, duration of training as well as the roles the CHWs would be performing should also be considered and possibly be unified across programs. In order to extrinsically motivate CHWs, it is important to also Incentivize them and a mechanism for monitoring and evaluating their activities would help assess problems in the program and health care delivery.

APPROACHES AND METHODOLOGIES

In order to encourage behavioral change and improve the quality of health care using CHWs, CMMB will be focusing on theses 3 approaches which have been applied in public health and have improved health outcomes: Positive deviance approach, Integrated community case management approach and make me a change agent approach.

Positive Deviance:

This is an approach based on the belief that unusual behavioral practices in communities among few members of the community who are called the positive deviants, help them find a better solution to problems and improve their outcomes compared other members of the same community that share similar exposures and resources, but poorer outcomes. The positive deviance is based on the principles that: (Pascale, Sternin, & Sternin ,2010)

1. Communities possess the solutions and expertise to solve their own problems.
2. Communities are self-organizing and possess the human resources with necessary assets to solve community problems.
3. communities have a Collective intelligence which is evenly distributed and is not dependent on the leadership of a community alone or in external experts.This collective intelligence is what the approach aim to draw out and capitalize on to solve community problems.
4. The bedrock of the approach is sustainability. The community is encouraged to observe and develop sustainable solutions based on observed positive deviants within the community.
5. Practicing encourages behavior change.

This approach has been used successfully in communities in the management of malnutrition and has contributed immensely to reducing the burden of malnutrition in communities where it is being practiced. The community health and families after an observation made by a positive deviant inquiry, practice better ways to cook their food with a particular interest in quality, feeding, and hygiene when managing malnourished children using local resources and technologies.

It is a proactive measure; harnessing the strength, knowledge, human resources locally available within the community to solve their community health problems. This approach ensures fast, sustainable, affordable, culturally acceptable solutions to solve community health problems and it also encourages local participation.

Integrated community case management:

This approach was adopted by WHO and UNICEF. The ICCM has been piloted in many underserved countries, where there is a major gap in access to care. The aim is to bring health care closer to the doorstep of these population and strategically increasing coverage of treatment using Community health workers who are appropriately trained, supervised and monitored. The CHWs are adequately supported with medical supplies. They are trained to identify, promptly and correctly manage or refer cases of common community diseases like malaria, pneumonia, diarrhea and malnutrition in children under 5 years.

ICCM uses interventions that are evidence based and it focuses on diagnosis, the community health workers are trained to make a quick diagnosis using portable diagnostic tools and appropriate treatment. common interventions used are antibiotics for dysentery and pneumonia, ORT for diarrheal diseases, antimalaria for malaria, nutritional rehabilitation for malnutrition.

The approach employs the use of CHWs who are members of the community and perform their duties either from their homes or selected community building, which is easily accessible to members of the community. Using CHWs from the community encourages trust and sustainability.

Make me a change agent:

To effectively improve the quality of health by encouraging behavior change, this approach which is used multi-sectorally will help the CHWs to become an effective change agent by developing their skills of effective communication, showing empathy, individual counseling. It also teaches the approach of using their individual testimonies and storytelling ability to encourage health behavioral change.

CHWs after acquiring skills from health training, have to effectively communicate their training to the community which is critically important in encouraging the patient to adhere to treatment and adopt preventive health behaviors. The CHWs are engaged in several activities that include role playing to help them understand the importance of respecting patient, good communication, active listening during conversations. There are several barriers that mitigate against behavioral change, the ability to circumvent these barriers would help the CHWs reach their target population and help them make them make the right behavior change. In order to effectively do this, the CHWs needs to be able to put themselves in the perspective of their audience, sharing their experiences which help foster a personal relationship and makes the change easier to communicate.

The approach also emphasizes the importance of storytelling and the use of individual testimonies to promote a particular health behavior by changing preformed misperceptions about the particular health behavior. The testimonials offer the audience the chance to appreciate changes made by someone else who is not different from them, who has had a positive result. These approach as a skill for encouraging behavioral change is easily remembered, the audience can relate to the story and have a pictural understanding of what the change is about. Moreso, it can be a source of external motivation to encourage change.

INTERVENTIONS:

The growing adoption of community health workers as part of the health system as a means to reach the underserved communities is met with the need to understand how to implement a sustainable CHW program in different countries across different programs. As field workers in underserved communities, we would also be employing the services of the CHWs in executing our goals. An effective process for managing (recruitment, training, supervision and support, Incentives) community health workers will help sustain the program.

RECRUITMENT:

Recruiting community health workers is dependent on the proposed health need they are supposed to meet. Some ministries of health have an established protocol for recruiting health workers. It is important to note that to sustain the program, several papers as well as WHO has suggested that community health workers should be selected by and from the community they are to work in. However, the primary criteria in selecting CHWs is that they should be members of the community they serve. This to harness the establish connections within the individual members of the community and the individual interest of the health worker towards the community.

The recruitment process may require the use of different social structures or organization within the communities like the clinics, community-based organizations e.g market women association, religious organizations, the ruling council, other CHWs etc. as sources of referral for the appointment of community members into several CHWs position. Recruitment should be formal, individuals should follow a process of recommendation, interview, and screening.

General characteristics of CHWs vary across countries and programs. Literacy is an important criterion for recruiting a CHW. Although not all programs require their CHWs to have any form of education, most programs require a primary level of education while some require a higher level of education. The least literacy level should be required; however, the higher the level of education the more preferable the CHW. The gender of the CHW should meet the cultural norm especially in places where there are limited interactions between males and females. The age of CHWs differ across programs but ranges from 20 – 45years. Finally, marriage status is an encouraging criterion for selection. CHWs with a married status are more likely to remain in the society for a longer period of time than those that are single.

TRAINING

The Success and quality of a CHWs program also depend on the process of training and continuous assessment of training. Training program varies across programs which depend on the length, depth, element, approach and authority. In some countries, a manual for training of CHWs have been developed; where necessary, it should be employed.

The length of training varies across programs and it is based on the services the community health worker would be rendering. It could be from days to weeks to years; however, it is important to space the training so that the CHW can have time in between training to have an in-depth review of the material. A process of a continuous training after the initial training can help improve the performance of CHWs through supervision and adding additional knowledge to the CHW.

The use of an interactive, skilled based setting that encourages participation should be employed as a style for training considering the varying educational background among the CHWs. The training material could be categorized into three major topics: skilled- based knowledge, relevant health knowledge, and research implementation knowledge. Training authority may vary, although WHO prefers the government of the countries to be involved in the training but more experienced CHWs, nurses and doctors can be part of the training team.

SUPERVISION AND SUPPORT

Long term sustainability of health programs involves active supervision and mentorship of the CHWs.The supervisors also provide support to CHWs. In most cases, the supervisor will be provided by the program’s main authority. They are usually of different professional backgrounds but have an understanding of the program, the roles of the CHWs and the aim of the program. They evaluate the performance of the CHWs, define their roles and expectations and also answer questions raised by the CHWs. The frequency of supervision which is variable across programs depends on the target goal of the program, the available funds e.tc.

Supervision as a general term could be practice in different styles and approaches. Group supervision involves a group of CHWs with a supervisor and has been implemented in many programs. Community supervision is another approach for CHWs. The innovative approach involves community’s participation by providing feedback and guidance to CHWs and their supervisors. Other methods that can be used are the peer supervision, clinical mentoring and mobile electronic devices.

It is also important to note that the supervisors also needs to be actively supported by the program’s main authority by providing material support e.g medical supplies, transportation etc. supporting the supervisors will help them perform their functions regularly.

INCENTIVES

The incentives for CHWs is one of the most controversial topics but it plays a significant role as it has been shown to be associated with CHWs performance, motivation and retention. many studies have debated on how compensations should be structured for the most effective way to incentivize CHWs. There are two categories of CHWs: the Volunteers and Full-time employees.

Some countries have a process for how the community health workers should be paid based on the type of appointment and who employs them. CHWs employed by the government on a full-time basis are on paid salaries while most, especially the volunteers are given either monetary or non-monetary incentive; however, it is important to recognize that an opportunity for career advancement in this field can be an incentive.

Full-time CHWS are comparatively rare to the part-time CHWs because of the financial implication on programs. A small amount of incentive is more commonly implemented in community-based programs. common monetary incentives are small monetary compensation for their time and transportation subsidies. How much monetary incentive is enough is unknown but it is important to give the CHWs some monetary incentives. The non-monetary incentive is also common. CHWs could get meals during training, bicycles for transportation, umbrellas etc. like the monetary incentive, there are no rules on how the authorities should incentivize their CHWs, or what item will effectively attract CHWs and motivate them.

ROLES AND ACTIVITIES IN MATERNAL AND CHILD HEALTH

The CHWs globally have been very effective in improving maternal and child health as well as reducing mortality especially in low-income countries. Their function varies across countries and programs; while in some countries, it is just preventive, in others it also involves diagnosis and treatment. The table below highlights how and areas where CHWs can work effectively to promote maternal and child health.

PREVENTION	DIAGNOSIS	TREATMENT
OBSTETRIC CARE
Anemia	*Nutrition Supplement, *Routine Haematinics	Nutrition Supplement
HIV	*HIV Counseling *Distribution of condom	Routine Followup on PMTCT
Malaria	*Distribution of Insecticide-treated net *Prevent therapy with sulfadoxine-pyrimethamine	Rapid Diagnostic kit	Antimalaria
Obstetric Care	Routine Tetanus toxiod	Routine ANC Visit
Post partum care PPH	*Breast feeding counselling *Distribution of misoprostol at home births.
GYNAECOLOGICAL CARE
Family planning	*Use of contraceptive
PEDIATRIC CARE
Diarrhea	*Health education on handwashing, food preparation and packaging	ORS Zinc supplement
Malaria	*Distribution of Insecticide-treated net	Rapid Diagnostic kit	Anitmalaria Antipyretics
Pneumonia	Antibiotics
Malnutrition	*Breast feeding Education *Growth monitoring	Nutrition supplement
Routine Immunization of Children
INFECTIOUS DISEASES
Tuberculosis	Direct observation of tuberculosis treatment

CHWs roles and activites are not limited to the above, there are also actively involved in diseases surveillance, home visits, record keeping, community health education, monitoring people with chronic diseases e.g hypertension , diabeties.

INTEGRATION INTO CMMB PROJECTS AND PROGRAMS

References:

Pascale, Sternin, & Sternin. (2010) The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems. Harvard Business Press. Print.