Health Care Improvement Project’s CHW AIM Tool Strengthens Community Health Worker Programs

By Donna Bjerregaard, Senior Technical Advisor, Initiatives Inc.

Note: This blog was originally posted on Feb. 15, 2013, on the Knowledge for Health Blog.

The global shortage of health workers has created cracks in the bridge to health services for Africa’s communities. Many countries and donors are looking toward community health workers (CHWs), who have a vested interest in the health of their communities, to fill the gaps. Although CHWs have played a role in prevention and care for over 50 years, we have not had a way to evaluate whether the programs are meeting communities’ needs. We also don’t know the level of support CHWs receive to help them provide quality services.

It was this thinking that led Initiatives Inc. and the USAID-funded HCI Project to develop the Community Health Worker Assessment and Improvement Matrix (CHW AIM). Through a literature review and repeated testing, 15 components of a well-functioning program emerged, ranging from recruitment and training to community involvement and country ownership.

We designed the process to be used by program managers, CHWs, donors, and stakeholders. Led by a facilitator, the group engages in discussions about where they stand on each programmatic component on a scale from 0 (non-functional) to 3 (highly functional or best practice). In many cases, this is the first time ideas are shared from so many different perspectives. This can lead to awareness and sometimes confrontation, but the process also creates understanding and builds team spirit and commitment to improve. The group builds an action plan for the changes needed based on the assessment. Sue England of World Vision Australia observed, “The tools make it clear to all participants that we are assuming a lot and that’s why many programs fail.”

We have found the tool to be very versatile. For example, Zohra Lassi, a researcher for WHO at Aga Khan University in Pakistan was part of a team that used the matrix[1] to determine how well CHW programs function and support MDGs. “The assessment could not have been done without this tool! It allowed us to make recommendations for improving CHW work and scaling up effective intervention,” she said. A team from Earth Institute who applied the tool in Kenya and Uganda noted that just bringing stakeholders together at the program level to consider the areas of functionality was a great conversation starter. Furthermore, representatives from USAID, UNICEF, AMREF, World Vision, and the Kenyan Ministry of Health learned about the tool at the USAID-funded CHW Regional Meeting in Addis Ababa, Ethiopia, June 19-21, 2012[2], and committed to a country-wide roll-out of their CHW programs.

The feedback we collected shows the strength of combining the application of the matrix, widespread participation and shared action planning:

• World Vision International used the tool in Tanzania to bring people together from the ministry, the program, and the community to assess a CHW program. When they diagnosed that community involvement was weak, the government was quick to take responsibility for increasing community support. Debora Niyeha (World Vision Tanzania) stated, “The tool was user friendly; partners engaged in the whole exercise. It made distribution of tasks among all players easy and the action planning held everyone accountable for the tasks.”
• In a two-year study with four NGOs in Zambia, one NGO determined that continuous training was not routinely provided. They agreed to create a training plan with standards for implementation and guidelines for selecting training topics. By their second assessment, the plan was in place and implemented.
• In Kenya, discussions revealed that lack of transportation hindered supervision visits. The government purchased motorbikes and WVI supported driving lessons for CHWs. The partnership was forged because the right people were in the meeting.

The tool helps us learn where we need to focus to improve programs. The results of 19 program assessments show that country ownership, linkages with the health system, program evaluation, and opportunities for advancement score poorly. These areas have an impact on continued care, sustainability, and ultimately, CHW satisfaction. As feedback from the use of CHW AIM continues to grow, we will be able to share challenges and effective interventions to benefit all programs.

We would like to acknowledge Lauren Crigler, formerly of HCI, for her role in leading the conceptualization and development of CHW AIM.

[1] Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems Author(s): Bhutta AZ, Lassi ZS, Pariyo G, Huicho L, WHO 2010.

[2] Proceedings from the USAID-funded CHW Regional Meeting. Addis Ababa, Ethiopia, June 19-21, 2012 (PDF).