National Community Health Worker Programs: How Can They Be Strengthened?

Abstract

This article is based on a collaborative research study of policy and practice in national community health worker (CHW) programs in developing countries. The study involved a review of the relevant literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop where the future of such programs was discussed. The findings of this research are discussed under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality. It is clear that existing national community health worker programs have suffered from conceptual and implementation problems. However, given the interest and political will, governments can address these problems by adopting more flexible approaches within their CHW programs, by planning for them within the context of all health sector activities rather than as a separate activity, and by immediately addressing weaknesses in task allocation, training and supervision. CHWs represent an important health resource, whose potential in extending coverage and providing a reasonable level of care to otherwise underserved populations must be fully tapped.

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“…Eight reviews were found that amalgamated lessons learned and suggested key enabling features that can increase likelihood of CHW program success. These were reports by Gilson et al (1989), OfosuAmaah (1983), Witmer et al (1995), Bhattacharyya et al (2001), Nemcek andSabatier (2003), Lehmann, Friedman and Sanders (2004), Haines et al (2007), Gilroy & Winch (2005) and Lehmann and Sanders (2007). In addition, two large reviews evaluated the literature on CHW programs to determine their effectiveness: Lewin et al (2005) and Swinder (2005).…”

“…Moreover, CHWs need strong supports because they receive only brief training and are equipped with a bare minimum of supplies (Gilson et al 1989). …”

“…Nurses often respond to this unwelcome burden by transforming CHWs into nurse assistants, removing them from their original role in the community and placing them in the clinic (Gilson et al 1989). Foisting program management onto an unequipped party can lead to frustration for all involved, lower quality service delivery, power struggles and high attrition rates.…”

“…While most programs state that CHWs should be selected by the community, in practice they tend to be selected at least in part by health personnel (Gilson et al 1989;Schneider, Hlophe, & van Rensburg 2008). Local people may have limited time and resources to devote to CHW selection and local politics and tradition may lead to the selection of higher status but inappropriate CHWs (Haines et al 2007).…”

“…Nonetheless, there is strong support for the implementation of ongoing training that includes multiple refresher and advancement sessions throughout the program's duration (Ashwell & Freeman, 1995;Ande, Oladepo & Brieger, 2004;Lehmann, Friedman & Sanders 2004). Skills-based competency training (Gilroy & Winch 2006) has become more popular in the last decade, whereas training that focused on the more abstract aspects of health and wellness used to be more prevalent (Gilson et al 1989). This shift could suggest that such technical training has been found to increase the likelihood of success; UNICEF in particular is a strong advocate of skills based competency training (Gilroy & Winch 2006).…”