Table 1

Key elements of the household model

Previous HIV/TB model of CHWs in Neno DistrictHousehold model
Role and recruitment
 Conditions AddressedHIV, TBHIV, TB, NCDs, STIs, family planning, maternal and neonatal health, paediatric malnutrition.
 Ratios1 CHW for ~5 to 8 HIV or patients with TB1 CHW for 20–40 households
  • CHWs nominated from community leadership.

  • Must live in catchment area and demonstrate willingness to work as a volunteer.

  • A mapping exercise to ensure every household was assigned a CHW was added to the process.

  • CHWs identified by HSAs and local leaders then vetted by the community. Then the endorsed candidates undergo literacy test and those who pass become CHWs after being trained.

Training and Mentorship1 day foundational training with quarterly refreshers.
  • 5- day foundational training with quarterly refreshers

  • Addition 2- day training for senior CHW cadre to perform additional duties of mentorship and quarterly spot-checks

AccreditationIn both models, CHWs who complete their training are given certificates signed by Partners In Health (PIH) and local Ministry of Health (MOH).
Equipment and SuppliesPaper registersPaper registers, home visit checklists, referral forms, MUAC tape, supplies for collecting sputum; job aids, bicycles for senior CHWs, carrier bags
SupervisionCHW cadre reported to CHW Site Supervisor with ratios up to 100:1Addition of senior CHW (box 1).
IncentivesMonthly flat stipend plus additional amount per patient assigned.Monthly flat stipend set, roughly equivalent to Malawi minimum wage, which represented a modest raise for the majority of CHWs
Community involvementCommunity groups are highly engaged during the recruitment process. Community leadership attends district meetings for programme and data review
Opportunity for advancementAd hoc advancement of exemplary CHWs to positions when open, eg promotion to senior CHW, site supervisor (box 1), or other programmatic roles, but not automatic. New opportunities for collaboration and training available as they arise
DataCHWs submitted paper-based monthly report on number of patients followed upCHWs used household registers, home visit checklists, and referral forms. Senior CHWs had forms for data aggregation, sputum collection, default tracking assignments and mentorship. Site supervisors used data aggregation forms, meeting agendas, HSA checklist, and mentorship forms. (not the data used in the analysis)
Linkages to Health SystemsSite Supervisors based at health facility to partner with clinical staff and HSAs.
  • Site supervisors supported with formal checklists to use with HSAs.

  • Clinic data for missed visits for HIV, NCDs provided directly to CHW programme for default tracking.

  • Senior CHWs collect sputum and use MOH TB registers and forms.

  • CHW, community health worker; HSAs, health surveillance assistants; MOH, Ministry of Health; MUAC, mid upper arm circumference; NCDs, non-communicable diseases; STIs, sexually transmitted infections.