The Health Care Improvement Project created the CHW AIM toolkit to help Ministries, donors, NGOs or other organizations assess and strengthen their CHW programs to improve their functionality. This is done by deepening understanding of the elements of successful programs and the use of best practices as an evidence-based approach to improvement.
The toolkit is framed around 2 key resources: a program functionality matrix with 15 key components used by participants to assess the current status of their programs and a service intervention matrix to determine how CHW service delivery aligns with program and national guidelines. The CHW AIM process involves a one-day participatory workshop in which organizations and their partners assess their performance in those 15 program functionality elements using a 4 level scoring system. Criteria for each element are defined in the tool. A score of 0 indicates no or very low capacity, while 3 indicates best practice. To be functional, an organization must score at least 2 in all of the 15 elements. The CHW AIM also includes intervention matrices which provide lists of services delivery activities for specific clinical areas such as MNCH, HIV, or TB. Workshop participants also assess these interventions to determine whether they are in compliance with the services and activities as defined in program and national guidelines. To be functional, all tasks in one activity must be completed. Throughout the workshop, participants keep lists of issues and actions which they develop into improvement action plans.
As you can see, the CHW AIM has been applied to a wide variety of country contexts. The CHW AIM was field tested in Benin and Nepal. Organizations which have used the tool to evaluate these programs include the WHO, URC, Save the Children, The Earth Institute, World Vision, and the Salvation Army. The countries in red are where the CHW AIM process is currently underway.
So, now we will turn to one of the latest applications of the CHW AIM, which took place in Zambia. I have pulled this example because it demonstrates how the CHW AIM can be complemented with other forms of data collection to provide a more comprehensive picture of a CHW program. First, some quick facts about Zambia:Population: 13 millionLife expectancy: 48 yearsHIV prevalence in adults: 13.5%Neonatal mortality: 35/1000Health workforce vacancies55% among nurses63% among clinical officers64% among doctors
The Zambia MOH is well aware of its human resource challenges and has been quite proactive in trying to address these critical shortages. In 2005 the MOH developed a national CHW Handbook to provide some guidelines for CHW work and training. The 2010 strategy was informed by an assessment which found that there were an estimated 23,500 active CHWs in the country. These CHWs contribute to a number of different health programs and are supported by numerous partners and programs using a diverse array of models. The assessment also noted that CHW training varied greatly in content and duration, though 97% of programs assessed did not provide follow-up training and many district medical officers felt that CHWs were ill prepared to carry out their duties. As a result of this assessment, the MOH developed a National Community Health Worker Strategy driven by the national objective to bring basic health services closer to the family. The strategy laid out the government’s plan to initiate a formal cadre of CHWs who will have a minimum education of 12th grade and 2 ‘O’ levels. They will also be trained for a year, be paid, and be stationed at health posts from where they will conduct community outreach. These new CHWs will not replace, but rather supplement, the existing community health workers, which the strategy distinguishes as community health volunteers. While this new cadre of CHWs was still in the works at the time of this research and were therefore not included in the assessment, it is important to know about the direction that the MOH is moving.
The theory underlying the CHW AIM tool is that by applying the tool and addressing program weaknesses identified through the process, organizations will be able to improve the functionality of their CHW programs. Therefore, the purpose of this research was to test this hypothesis. The Zambia case is the first time where the tool has been used repeatedly to see whether it contributed to improvement.
Data collection began with initial interviews with program managers to gather information about the program structure, the types of CHWs the program supports, the objectives of the program, and incentives, training and supervision provided to the CHWs. These initial interviews were followed up with midterm and endline interview to document any major changes in the programs, such as loss of funding. Then the CHW AIM process was applied twice in a 13 month period, with baseline in October 2010 and endline in November 2011. It included a sample of 156 CHWs who were assessed for engagement and performance. Here, engagement refers to an employee’s state of mind when she is satisfied with her job, motivated to do the work, and committed to doing it well. Engagement was assessed through a survey and an in-depth interview designed to capture descriptive information on the survey questions. CHW performance, or task completion, focused on 2 HIV/AIDS services delivery areas that CHWs commonly provide – positive living and ART adherence counseling. Costs related to training, incentives, and supervision were also gathered.
Overall, CHW AIM results suggest that only 2 organizations improved their total program functionality scores. But every organization made some gains in at least 2 program functionality elements, however these gains were typically countered by reductions of scores in other elements. As we can see in the figure here, only 2 organizations had a minimum mean score of 2, however each of these organizations had at least 4 of the 15 elements with a score of 1 at both baseline and endline. Therefore, by CHW AIM functionality definition, neither of these organizations were functional. While the mean scores suggest no statistically significant improvement in program functionality between baseline and endline, some important and positive changes were made. For example, program performance evaluation, defined as a general program evaluation of performance against targets, overall program objectives, and indicators carried out on a regular basis, received an average rating across all 5 programs of 1.4 at baseline, but rose to 2.2, making it the 3rd strongest element at endline. However, the functionality element of initial training fell from 2.4 at baseline to 2 at endline as programs struggled to maintain training systems, though it did remain functional.
At both baseline and endline, there was a statistically significant correlation between CHW AIM scores and CHW performance, indicating that programs with higher functionality scores are more likely to have better performing CHWs than programs with lower functionality scores. However, other factors also had a positive correlation with performance, including CHW AIM program functionality, incentive type, service time, incentive amount, and days of initial training. With respect to CHW engagement, there was no statistical correlation between CWH AIM scores and engagement at baseline, but there was a statistically significant correlation at endline. Three elements from the CHW AIM were correlated with engagement. Opportunities for advancement and individual performance evaluation were moderately strongly correlated. Incentives were not correlated at baseline, but weakly correlated at endline. The data suggest an association between these elements and engagement, but not a predictive relationship. Multivariate analysis of the data showed that total engagement scores had no statistical correlation with performance, suggesting that the total engagement score is not associated with performance and may only be marginally linked to CHW program functionality.
The one-day CHW AIM workshops were somewhat inexpensive. Differences in costs were associated with whether the workshop was held in a rural or urban location and whether the process was conducted for only one or multiple districts. The study sought to test out the cost effectiveness of the CHW AIM process. However, cost and program output data in terms of numbers of clients served by CHWs and in terms of outcomes such as defaulter rates, were either unavailable or too weak or limited to support a cost effectiveness analysis. However, we were able to get a rough estimate of costs invested in the programs relative to the numbers of clients served. Across sites, the cost per client ranged from 41 cents to $3.11. For the site where the cost per client was $3.11, the targets for clients served were not achieved so presumably, the cost per client would have been lower if they had seen the number of clients they had hoped to see.
As a result of the baseline CHW AIM process, organizations were able to identify areas of weakness and implement changes. For example, Site 2’s baseline CHW AIM found that CHWs had not had continuous training in over 12 months. In the action plan, the organization set out to develop a training plan that would include standards for how often training should be done and guidelines for selecting training topics. They also made an action to provide refresher training for all CHWs. By endline, the organization had a training plan in place and set a standard for training every 6 months. They also made sure that every CHW had a refresher training in the last 12 months. As a result of this change, the CHW AIM score for continuing training improved from 1 to 2 between baseline and endline and performance increased as well.
Organizations in Zambia felt that the CHW AIM process was helpful. While measures of improvement from the Zambia example are inconclusive, the stories of improvement that come from this research suggest that the tool can catalyze improvement. The Zambia experience brought forth 2 different categories of recommendations. Those specific to the revision or improvement of the CHW AIM process and those related to organizations and organizational needs.
1. The CHW AIMLessons from the Field Sarah C Smith, PhD, MPH, MA EnCompass LLC email@example.com www.hciproject.org 1
2. What is the CHW AIM?• Assesses CHW program functionality• Aids in improving program performance• Provides action planning and best practices2 USAID HEALTH CARE IMPROVEMENT PROJECT
3. How does the CHW AIM work?• One-day participatory workshop• Program functionality matrix• Intervention matrices• Action planning3 USAID HEALTH CARE IMPROVEMENT PROJECT
4. Functionality elements• Recruitment • Referral system• CHW role • Opportunity for• Initial training advancement• Continuing training • Documentation &• Equipment & supplies information management• Supervision • Linkages to health• Individual performance systems evaluation • Program performance• Incentives evaluation• Community involvement • Country ownership4 USAID HEALTH CARE IMPROVEMENT PROJECT
5. Applications• Bangladesh • Nepal• Benin • Pakistan• Brazil • Swaziland• Ethiopia • Sierra Leone• Haiti • Tanzania• Kenya • Thailand• Madagascar • Uganda• Mauritania • Zambia• Mozambique5 USAID HEALTH CARE IMPROVEMENT PROJECT
6. Zambia: Background• Population: 13 million• Life expectancy: 48 years• HIV prevalence in adults: 13.5%• Neonatal mortality: 35/1000• Health workforce vacancies – 55% among nurses – 63% among clinical officers – 64% among doctors 6 USAID HEALTH CARE IMPROVEMENT PROJECT
7. Zambia: CHWs• 2005 CHW Handbook• 2010 National Community Health Worker Strategy• Estimated 23,500 active CHWs7 USAID HEALTH CARE IMPROVEMENT PROJECT
8. Zambia: Study questions• Does application of the CHW AIM tool contribute to CHW program functionality improvement?• What is the relationship between program functionality, CHW engagement, and CHW performance?• What are the costs associated with implementing the CHW tool and what is the incremental cost effectiveness associated with its use? 8 USAID HEALTH CARE IMPROVEMENT PROJECT
9. Zambia: Data Collection• Program data• CHW AIM• Engagement survey• Engagement interview• CHW performance (positive living, ART adherence counseling)• Costing data 9 USAID HEALTH CARE IMPROVEMENT PROJECT
10. Zambia: Does the CHW AIM improve functionality?• 2/5 organizations improved functionality• 5/5 made gains in at least 2 program functionality elements as a result of interventions driven by baseline findings 3.0 2.5Mean CHW AIM Score 2.0 1.5 1.0 0.5 0.0 1 2 3 4 5 Baseline Endline Mean Site USAID HEALTH CARE IMPROVEMENT PROJECT 10
11. Zambia: Relationship between functionality, CHWengagement, and CHW performance?• Positive correlation between CHW AIM scores and CHW performance• Weak correlation between CHW AIM scores and CHW engagement – Opportunities for advancement – Individual performance evaluation – Incentives• No correlation between engagement scores and performance11 USAID HEALTH CARE IMPROVEMENT PROJECT
12. Zambia: Is the CHW AIM cost effective?• Cost/participant of CHW AIM process: $16.91 - $56• Limited data to support cost effectiveness analysis• Cost per client: $0.41 - $3.1112 USAID HEALTH CARE IMPROVEMENT PROJECT
13. Zambia: Examples of changes• Continuing training• Referral system• Opportunity for advancement 13 USAID HEALTH CARE IMPROVEMENT PROJECT
14. Looking forward• Recommendations for CHW AIM process – Investment – Technical assistance – Expectations – Prioritization – Timing – Resources – Facilitation• Recommendations for organizations – Leadership – Community challenges – Country ownership14 USAID HEALTH CARE IMPROVEMENT PROJECT