Literature Review, Commissioned of the One Million Community Health Workers Campaign by mPowering Frontline Health Workers, through support from USAID & Intel

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The Current State of Play in
CHW Training Programs in sub-
Saharan Africa & South Asia
Literature Review
Commissioned of the One Million Community Health Workers Campaign by
mPowering Frontline Health Workers, through support from USAID & Intel
12 December 2013
Overview
• Why CHW Training?
• Methodology
• Findings
• Recommendations
• Next Steps for the “Global Health Content for Local
Solutions” consultation?

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Why CHW Training?
• CHWs are not effectively trained, remunerated, or retained
• Hypothesis that CHW Training is important for:
• improving workforce quality and health outcomes; and
• successfully expanding CHW programs in scope (including quality) and
coverage (scale-up)
• CHW Training (its implementation & effectiveness) has not been
well studied
• A literature reviews allows us to:
• Know just what is out there,
• Draw conclusions based upon the evidence base, and
• Know what is lacking from the evidence base.
Methodology
• Literature:
• Published articles, grey literature and reports
• Selection criteria:
• Content: Describe/analyze/synthesize current CHW training practices
• Geography: Sub Saharan Africa, India, Pakistan, Nepal
• Exclude: High- and mid-level cadres of health workers
• Period: Published from year 2000 to present
• Language: English

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Methodology
• Sources:
• Databases: Cochrane Library, Google Scholar, PubMed, ProQuest
• Other: CHW Central, Frontline Health Workers Coalition (FHWC),
Global Health Workforce Alliance (GHWA), USAID, World Health
Organization (WHO), Pathfinder International, Millennium
Villages Project (MVP), etc.
• Selection:
• Approx. 100 articles and reports
• Time constraint:
• 3 weeks (commissioned 20 Nov., delivered 10 Dec.)
Results
• Synthesized the literature by category, for both Pre-
Service and In-Service Training evidence
• Diversity in training programs
• Geographic diversity
• Training effectiveness
• Gaps (in practice and in evidence)
• Best Practices identified
• Case studies:
• Ethiopia, Pakistan, Zimbabwe, Nepal

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Findings
Pre-Service In-Service
How long do CHW Trainings last?
How often are they held?
Where do they take place?
Who are CHW Training providers?
How are they taught?
How are they assessed?
What content is covered by CHW Trainings?
Findings
Pre-Service In-Service
How long do CHW
Trainings last?
5 days … 15 months 3 hours … 10 days
How often are they held? Unknown Monthly…Annually
Where do they take place? • On-site (community)
• Off-site (district or regional hospital, school, or
health facility)

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Findings
Pre-Service In-Service
Who are CHW Training
providers?
• NGOs
• Governments (national or local)
• Government/NGO partnerships
How are they taught? • Technique: didactic vs. interactive
• Objectives: theory vs. skill
How are they assessed? Rarely. Where testing is implemented, it is
useful for demonstrating CHW Training
effectiveness and knowledge retention.
Findings
Pre-Service In-Service
What content is covered by
CHW Trainings?
• Varies widely
• Inconsistencies
• Refreshers vs. new
• Comprehensive vs.
specific disease
Matrix of topic areas displayed on next slide…

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Findings
Acute
respiratory
infections
Antenatal
care
Behavior
change
Childbirth
Diarrhea
Family
planning
Gender
based
violence
HIV/
AIDS
Vaccines
Intestinal
worms
Malaria
Maternal,
newborn
and child
health
Mental
health
Newborn
care
Nutrition
Record
keeping +
data
management
Referral
practices
Sexually
transmitted
infections
TB
Vitamin
deficiencies
Water,
sanitation,
hygiene
So, what do we know
about CHW Training?
• Not much!
• Insufficient evidence: Gaps in evidence base
• Poor quality evidence: Existing research makes it difficult to
distinguish what is working from what isn’t, specifically for CHW cadres
• Observations:
• Duplication of curricula, provider categories, inconsistencies in
training duration (possibly due to lack of evidence or
methodology on training length), pedagogy (didactic vs.
interactive vs. mixed methods)
• Notable differences between SSA and South Asia
• Key best practices identified

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Best Practices Identified
• Planning
• Coordinating training approaches with other providers
• Incorporating CHW feedback to improve training methods and
curricula
• Teaching methodology
• Incorporating interactive teaching methods into CHW training
• Effective CHW training must have interactive components that are repetitive, and more
interactive than didactic
• Use of technology improves learning outcomes and should be more widely utilized
• Continuous assessment
• Using feedback from training participants to improve the training
curriculum and delivery
• Use of pre‐, post‐ and follow‐up tests, self‐assessments and feedback forms
• Allow CHWs to feel included in the process and foster a sense of ownership in their
education, which enhances CHW engagement
Suggestions for research
• More research on post‐training CHW competency is
needed to determine the effectiveness of the wide
array of training programs that exist and to establish
an evidence‐based curriculum
• Other gaps in the evidence base for CHW training
programs
• e.g. use of pictorial training for low‐literacy audiences?
• e.g. adaptation of curricula to local languages or cultural
contexts?

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Recommendations
1. Training program implementation and curricula should be
coordinated amongst training providers, including NGOs, civil
society organizations and governments;
2. Pedagogy of CHW training curricula should be made more
interactive to allow CHWs to engage with content in practical ways
similar to the working environments they will encounter on the job;
3. CHW feedback should be sought and acted upon, to improve the
quality of training content and delivery; and
4. CHW training providers should regularly monitor CHW competency
to refine pre-service trainings and drive in-service trainings.
Linking research on CHW Training to CHW scale-up:
Big picture considerations and information needed
• There is a disconnect in the way training programs are managed,
delivered and monitored.
• A more cohesive approach to CHW training programs is needed.
• Synergizing CHW training programs will ensure that more consistent,
evidence‐based trainings are provided to CHWs wherever they reside.
• à Positive impact on CHW effectiveness through increased competency
and improved service delivery
• à Ultimately impact MDG outcomes
Next Steps