A brief history of CHW programmes

The vast and diverse history of CHW programmes internationally has recently been concisely summarised by Perry and colleagues.5 9 Training (often illiterate) community members to perform specific health service functions on a large scale has its (documented) origins in China in the 1950s, in what came to be known internationally as the barefoot doctors programme.1 Barefoot doctors became models and were emulated by countries in Africa, Asia and Latin America from the 1960s. The Alma Ata Declaration of 1978 established CHWs as essential elements of a comprehensive primary healthcare approach, ‘suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community’.

There were several examples of large-scale CHW programmes in Africa in the 1960s to 1980s (eg, Tanzania, Malawi, Mozambique and Zimbabwe) driven by the transformative rationale of the Alma Ata Declaration.10 With the oil crisis and the world economic recession of the 1970s, and subsequent structural adjustment programmes, many programmes collapsed—a collapse further facilitated by the fact that many large-scale programmes suffered from conceptual and implementation problems such as ‘unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality’ (11: 352)—a danger facing many programmes again today.

The recent renewal of interest in CHW programmes (and in Primary Health Care and community health systems more generally) in Africa (and internationally) has its roots in programmatic needs for incommunity providers exacerbated by the continuing constraints in formally trained health personnel. Such programmes prominently include communicable and non-communicable diseases and maternal and child health (MCH).

The state of the evidence to date

The renewed interest in CHW programmes has been accompanied by increased research productivity in the field. There has been a virtual explosion of scientific evidence on roles, activities and effectiveness of CHWs in low-income and middle-income countries (LMICs), and particularly in Africa, over the past few years.8 A large number of guides, substantial evaluation reports and numerous online resources, such as CHW Central (http://www.chwcentral.org/), provide further data, evidence and advice for CHW policy making in African countries.2

Despite the volume of literature, organised knowledge of CHW programmes, their effectiveness remains surprisingly limited.8 First, the literature reflects the already mentioned diversity of the field, covering different programmes, types and roles of CHWs, and management areas. Only few articles address issues of scale-up of programmes, or of policy and systems design and implementation specifically.

Second, much of the literature remains descriptive and consists of single case studies, with so far few articles that integrate and conceptualise the empirical work. Very few of the programmes studied were operating at scale.7 Nonetheless, the quantity and quality of case studies, even though limited in scope, and the convergence of findings allow for learning and extrapolating wider lessons to different aspects of programmes, and they confirm that CHW programmes can be effective in providing promotive, preventive and limited curative health services for common childhood illnesses (eg, diarrhoea, pneumonia) in Sub-Saharan Africa.

Furthermore, the evidence base for policy making and programme development has been substantially strengthened in recent years through the collation and publication of several large reviews,5 7 11 12 reports13 and guides,6 some of which specifically address themselves to large-scale programmes, basing their recommendations on rigorous reviews and country case studies.6 7

Key insights from the existing evidence and their relevance for policy and practice are reflected in the following systems requirements, which are the foundational elements of functioning community health systems and CHW programmes:

1. Embeddedness, connectivity and integration.

2. Cadre differentiation and role clarity.

3. Sound programme design and management.

4. Ongoing monitoring, learning and adapting.

While this categorisation of elements is innovative, it in fact reflects key themes in both the established (particularly (2) and (3)) and the more recent (particularly (1) and (4)) literature. These elements will be discussed in turn below.

Embeddedness, connectivity and integration

Despite their diversity and variation, all CHW programmes have three characteristics in common:

1. They are part of a larger system of healthcare delivery and the health workforce, never just stand-alone programmatic interventions.6 14 15

2. By their very nature they are ‘boundary spanners’ at the interface between the formal health system and communities, and thus have to be embedded in the health systems and in the communities they serve.14–16

3. They inevitably interface with other sectors, resources and actors, adding complexity to a web of relationships that needs to be harmonised and integrated.6 15 17

This has important implications for policy development and programme design:

1. Community systems are enormously diverse, even within countries and subregions, with complex, often ‘hidden’ structures, hierarchies, histories and traditions. Consequently, policy development for CHW programmes has to invest in understanding local systems, and design programmes that are flexible enough to ‘fit’ and be responsive to local realities.9 18–20

2. Strengthening local structures and processes has to be part of the investment in CHW programmes.10 21 22

3. Paying attention to and building on existing CHW projects and practices are critical. While many successful large-scale programmes have been built on the foundations of projects initiated to respond to specific crises or needs, programmes ‘helicoptered’ into local systems fail to embed and connect.6 17 19 23

4. Harmonising and integrating donor support and stakeholders from other sectors, as proposed by the Global Health Workforce Alliance in their CHW Framework,3 is an essential building block of CHW programme functionality.

Cadre differentiation and role clarity

The term ‘CHW’ has been used for a great diversity of cadres, roles, locations and identities. CHWs constituted of numerous close-to-community cadres, from paraprofessionals employed by the Ministry of Health with 1 year of training, providing services in health posts and communities, to volunteer workers and family carers with no or little training, support or link to the health system. Unfortunately, this conflation of healthcare providers at the community level into one cadre often obfuscates rather than enlightens our understanding of CHW programmes.24Table 1, which was developed as part of the technical paper and is reflected in the policy brief that informs this paper,3 provides a rough typology of the frequency and type of work that is assigned to CHWs. This is indicative rather than prescriptive, given the large variability in contexts and policy objectives of CHW programmes within and across countries. Other typologies have been developed inter alia by Olaniran et al4 and Perry and Zulliger5 (focusing particularly on the level of training and remuneration).

Very importantly cadre differentiation also has to address who becomes a CHW (gender, age, education level), how they are trained, supervised and supported, how their roles connect and integrate with other systems (eg, other layers of the health system, local government, education systems), and how such cadres fit into local contexts (histories, practices, experiences). The vast majority of the literature addresses some or all of these topics and has been reflected in all the reviews reflected in this paper.

For policy and programme design, the above means:

1. Being deliberate and explicit about what CHWs can and cannot do in the health system, focusing on aligning and clearly delineating educational criteria, roles and remuneration.

2. Regularly revisiting all elements of the above differentiation as well as their alignment to accommodate changes in services needs and human resource requirements (a monitoring and evaluation requirement).

Sound programme design and people management

Embedding community health programmes in wider contexts, being sensitive to local contexts and environments, and clarifying cadres and roles of CHWs will allow planning and management of programmes and people that fit and connect to existing (health and community) systems, and are relevant to the communities they aim to serve.6 21 Some of the key operational aspects of programme design are outlined below.

Ongoing monitoring, learning and adapting

Policy and programme design for CHW policies and programmes needs to be flexible enough to allow for continuous learning and adaptation to local contexts and requirements. Ongoing monitoring, learning and adaptation are thus essential to the success of programmes.6 31 32

Monitoring (of programmes, not just individual CHWs) relies on the collection and availability of accurate and timely data, which often is one of the weakest points of CHW programmes, particularly in large programmes. CHWs are dispersed in communities, with varying degrees of literacy, and often face severe time pressures when visiting households. Supervisors can play an important role in data collection, but have limited time as well. Evidence has shown that they should not spend too much of this time completing tick sheets instead of providing guidance and support to CHWs in their charge.6 14

Evidence also suggests that as far as possible CHW information systems should be designed to be integrated into existing routine primary healthcare information systems, taking care that essential, but not more than essential information is gathered.33 34 This is to ensure evidence-based planning and management without creating unnecessary burdens on health workers and duplications within the health system. Crucially, information collected should actively be used to understand programme implementation, strengths and weaknesses, challenges and mistakes. Throughout the system problems and even failures should be understood as learning opportunities, leading to adaptations and improvements.