I. Technical consultation on the role of community based providers in improving MNH (30 - 31 May 2012 - organized by Royal Tropical Institute, Netherlands)II. Evidence Summit on Community and Formal System Support for Enhanced Community Health Worker Performance (May 31 and June 1 - convened by USAID Global Health Bureau in Washington DC) III. Community Health Worker Regional Meeting (19 to 21 June - convened by USAID-funded Health Care Improvement Project, at Addis Ababa, Ethiopia)IV. Health workers at the Frontline – Acting on what we know: Consultation on how to improve front line access to evidence-based interventions by skilled health care providers (25-27 June, (convened by NORAD and coordinated by EQUINET at Nairobi, Kenya).
USG CHWEvidence Summit-Highlights- Joseph F. Naimoli (OCS), Estelle Quain (OHA), Diana Frymus (OHA), Emily Roseman (OHA) 10/12/2012
What is an Evidence Summit? Decision making Questions of policy Review the and programmatic significance and relevance evidence Development challenges Academics + development practitioners
Development ChallengeGlobal shortage of skilled,motivated, and supported health workers Strengthening health systems Achieving MDGs and UHC Achieving equity, reducing poverty
Development ChallengeGlobal shortage of skilled,motivated, and supported health workers RESPONSE: Emergence of alliances and coalitions to address the challenge Resurgence of interest in and attention to Community Health Workers (CHWs)
Why Community Health Workers?Extend the reach of inadequate health systems (provideessential services to hard-to-reach, vulnerable populations)Expand coverage of key interventionsIncreased investment in large-scale programsConcern about the strength of evidence behind existingnormative guidance (uncertain)
Findings: RQs, Hypothesis • CHWs can successfully deliver a range of preventive, promotional, and curative services • CHWs can contribute to improved coverage and positive health outcomes“Our findings show that indigenous community workers can effectively detect and treatpneumonia, and reduce overall child mortality, even without other primary care activities.”(Pandey, Daulaire, Starbuck, Houston and McPherson, 1991, The Lancet, Reduction in totalunder-five mortality in western Nepal through community-based antimicrobial treatment of pneumonia)
Findings: RQs, Hypothesis• CHWs receive technical and social support, as well as recognition, from communities and health systems• Experts have identified different kinds of support provided by communities and health systems likely to improve CHW performance at scale
Findings: RQs, Hypothesis Community• Community participation/involvement in CHW selection, all aspects of CHW programming (design, mgmt., implementation, monitoring, evaluation)• Community structure support: health committees, oversight bodies, women’s groups, family, kinship• Community provision of non-financial, in-kind, financial incentives Non-financial: praise, respect, feedback In-kind: animals, food, gifts Financial: fee for service, supplemental income from sale of medicines and other health-related products; regular remuneration• Community strengthening of relationships among CHWs (facilitation CHW membership in CHW associations) CONTEXT MATTERS! 13
Findings: RQs, Hypothesis Formal health system• Ensuring clarity of role/feasible, manageable scope of work• Ensuring consistent availability of drugs, commodities, tools, supplies, equipment• Providing high quality, competency-based pre- and in-service training• Providing job aids and other materials• Feedback, supervision, performance monitoring• Incentives (financial and non-financial)• Effective linkages with formal health system and health care workers• Support from national and local government entities CONTEXT MATTERS! 14
Findings: RQs, Hypothesis Combined support from both systems• Shared ownership of CHW programs through joint collaboration in program design• Joint supervision• Negotiated and coordinated package of incentives, whereby the formal health system provides financial incentives, while community and health system provide non-financial incentives• Development of a practical information system that captures data from both the formal health system (e.g., health records, supervisor observations, etc.) and community system (e.g., community member feedback, individual CHW feedback, etc.) that both systems use to enhance CHW performance• Strengthen linkages between communities and health systems to enhance performance and mitigate unintended consequences CONTEXT MATTERS! 15
Findings: RQs/Hypothesis However! • The EVIDENCE in support of expert opinion is weakCommunity • Not because rigorous system studies demonstrate lack of effect! CHW Formal • FQs about support- health performance system relationship not commonly asked or investigated with rigor!
Findings: RQs/Hypothesis • Furthermore: However! – Studies are often short-term, small- scale pilots, rural focus – Interventions often poorly described – Multi-arm comparisons of theCommunity relative effectiveness of different programmatic interventions system (technical vs. social vs. recognition) not investigated CHW – Large-scale, system-level interventions rarely studied Formal – Bias toward distal measures of performance with less health understanding of intermediate measures and even less of system proximate • Feasible, affordable, appropriate ways to provide support not well documented
Findings: RQs/Hypothesis Conclusion • We have strong colloquial knowledge but weak evidence about the support-performance relationship!Community system • This knowledge comes primarily from observation, CHW implementation, M&E Formal • This knowledge drives current health guidance system • Undocumented or inaccessible program experiences may address these focal questions
Findings/CHW Stewardship National: 1) Fragmentation: multiple actors/programs making demands on CHWs Q: Who is responsible for overall welfare of the CHWs? Q: Specialized or all-purpose CHWs? 2) Variation linked to history and purpose Global: 1) Fragmentation: concurrent meetings 2) Leadership: Is GHWA up to the challenge?
Recommendations: Global1. Refocused research agenda: answer RQ of policy and programmaticsignificance for CHW programs operating at scale2. Capacity building of LMIC investigators3. Prospective/retrospective documentation of large-scale programs(implementation science)4. Better stewardship: country and global levels5. Logic model to guide programming, M&E, OR
Publications strategySummary CHW Logic paper Model Case Study
Stewardship Challenges1 Can we achieve an increased understanding of the depthand breadth of USAID investment in CHW programming?2 What is the value for money of current investments inCHW programming?3 How can we address the Summit focal questions throughexisting and new OR efforts?4 How can we increase Agency visibility/leadership vis-à-visexternal partners?