BackgroundThere is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients’ health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems – the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated.MethodsWe explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component.ResultsWe identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system.ConclusionsWe believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.

BackgroundThere is widespread agreement on the need for scaling up in the health sector to achieve the Millennium Development Goals (MDGs). But many countries are not on track to reach the MDG targets. The dominant approach used by global health initiatives promotes uniform interventions and targets, assuming that specific technical interventions tested in one country can be replicated across countries to rapidly expand coverage. Yet countries scale up health services and progress against the MDGs at very different rates. Global health initiatives need to take advantage of what has been learned about scaling up.MethodsA systematic literature review was conducted to identify conceptual models for scaling up health in developing countries, with the articles assessed according to the practical concerns of how to scale up, including the planning, monitoring and implementation approaches.ResultsWe identified six conceptual models for scaling up in health based on experience with expanding pilot projects and diffusion of innovations. They place importance on paying attention to enhancing organizational, functional, and political capabilities through experimentation and adaptation of strategies in addition to increasing the coverage and range of health services. These scaling up approaches focus on fostering sustainable institutions and the constructive engagement between end users and the provider and financing organizations.ConclusionsThe current approaches to scaling up health services to reach the MDGs are overly simplistic and not working adequately. Rather than relying on blueprint planning and raising funds, an approach characteristic of current global health efforts, experience with alternative models suggests that more promising pathways involve "learning by doing" in ways that engage key stakeholders, uses data to address constraints, and incorporates results from pilot projects. Such approaches should be applied to current strategies to achieve the MDGs.

BackgroundThere has been a resurgence of interest in national Community Health Worker (CHW) programs in low- and middle-income countries (LMICs). A lack of strong research evidence persists, however, about the most efficient and effective strategies to ensure optimal, sustained performance of CHWs at scale. To facilitate learning and research to address this knowledge gap, the authors developed a generic CHW logic model that proposes a theoretical causal pathway to improved performance. The logic model draws upon available research and expert knowledge on CHWs in LMICs.MethodsConstruction of the model entailed a multi-stage, inductive, two-year process. It began with the planning and implementation of a structured review of the existing research on community and health system support for enhanced CHW performance. It continued with a facilitated discussion of review findings with experts during a two-day consultation. The process culminated with the authors’ review of consultation-generated documentation, additional analysis, and production of multiple iterations of the model.ResultsThe generic CHW logic model posits that optimal CHW performance is a function of high quality CHW programming, which is reinforced, sustained, and brought to scale by robust, high-performing health and community systems, both of which mobilize inputs and put in place processes needed to fully achieve performance objectives. Multiple contextual factors can influence CHW programming, system functioning, and CHW performance.ConclusionsThe model is a novel contribution to current thinking about CHWs. It places CHW performance at the center of the discussion about CHW programming, recognizes the strengths and limitations of discrete, targeted programs, and is comprehensive, reflecting the current state of both scientific and tacit knowledge about support for improving CHW performance. The model is also a practical tool that offers guidance for continuous learning about what works. Despite the model’s limitations and several challenges in translating the potential for learning into tangible learning, the CHW generic logic model provides a solid basis for exploring and testing a causal pathway to improved performance.

A study was conducted in Togo to investigate the lack of acceptance of childhood immunization from a social science perspective. In each village focus group interviews were conducted with approximately 12 mothers to discuss their beliefs and knowledge, social and cultural norms and practices, and experiences with health services that hinder or promote the acceptability of childhood immunization. The problem of failure to complete the immunization series was explained in terms of mothers' lack of knowledge of when to return or their forgetfulness rather than inadequate knowledge about the importance of returning. Other barriers included the requirement to keep and present a vaccination card, waiting time at the clinic, lack of information about available services, and laziness. Rather than endorsing strategies that target individuals, mothers suggested increasing the level of social control exerted by decision makers in their communities (the village chief could direct the town crier to announce the passing of each week to help parents keep track of time between immunizations) and increasing the level of social support by having a meeting to support the importance of completing the vaccination series and to organize mothers who go to the clinic to inform others in their neighborhoods about vaccination.

Exposure to the intervention was strongly associated with adherence to the guidelines and correct prescribing of antibiotics 6-12 months after exposure. Many other factors may influence health worker performance.