BackgroundWith the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries.MethodsA review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input.ResultsTwenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited.ConclusionsBetter data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

Despite strong interest and policy commitments from many countries, models for community-based primary health service delivery have been slow to achieve full scale or deliver quality that matches their potential. n Reform requires a carefully choreographed effort to enroll key stakeholders to support change by spotlighting a locally relevant gap in the existing health system's performance. n Designing and launching community health programs depends heavily on local context and must draw from models that are available within a given health system and that align with the resources, capabilities, and commitments of key stakeholders. n Reform should be viewed as an ongoing adaptive and evolutionary process; learning, governance, and management systems must be designed with this trajectory in mind. Key Implications Ministries of health, development partners, and other reform stakeholders can: n Use the principles in the reform cycle process to identify gaps and priorities for technical work or investment n Examine community health efforts to identify where technical approaches can be complemented by political, institutional, and reform approaches n Critically examine projects that implement termlimited, externally driven interventions and adapt designs to promote sustained, well-integrated community health programs at scale

Issues of power are not new to program evaluation. What is new is a consideration of how programming uses insights into incentives that shape and adapt implementation. How should one evaluate in a way that explicitly assesses the ways in which a program considers power? One of the innovative topics deriving from the democracy and governance space is the approach of thinking and working politically (TWP) which is seeing increased use in development programming. TWP suggests different mental models and practical approaches to achieving development objectives in ways that are more contextually grounded and informed by power dynamics. This article describes several of the core challenges to evaluation of TWP and also a rubric of considerations for more effective evaluation practices in this emerging field.