Community-level Programming Considerations
MNC programs with a community or household component (especially those working with CHWs) should take into account the following considerations:[i]
- CHW Selection: A program using community agents should develop criteria to identify and select women and men to serve as CHWs in consultation with community members and in alignment with national policies. If CHWs already exist in the program area, the program should ask: Are they active? What responsibilities do they already have? Can they be trained to undertake additional activities?
- Training and supervision: CHWs must be trained after they are selected. Programs should also develop a plan for regular refresher and on-the-job training as part of regular supervision. For supervision and support, CHWs should be linked to the local health center and a government health worker. A health worker or supervisor’s task is to help CHWs do their work correctly and effectively by (1) reviewing reports and record keeping; (2) observing the CHW’s skills; (3) giving immediate, tactful feedback to correct errors in information or approach, to praise what the CHW does well, and to suggest areas where the CHW can improve; and (4) mentoring the CHW by carrying out activities with her or him and demonstrating the desired practice.
- Referral system: Inefficient referral links seriously can hamper efforts made at the community level. An MNC program needs to create or strengthen the referral system between communities and health facilities. Facility workers also can refer women and newborns back to CHWs to monitor them. As part of developing a referral system, programs need to assess the availability, type, and quality of facility-based services. Programs may consider short-term savings and loans programs to pay for transport.
- Volunteer management and motivation: Depending on the context, CHWs may be paid workers or volunteers. Volunteer CHWs typically receive modest incentives, such as supplies and increased status in the community. Programs should determine upfront how CHWs will be motivated and compensated and also make provisions for replacing CHWs who leave their positions. For example, if another organization that is operating among the same target population offers perceived better incentives, what implications will that have?
- Scale and sustainability plan: CHW programs may be implemented on a relatively small scale, depending on the level of training and support required. Ownership at the MOH level is essential for finding long-term support for supervision and refresher training to sustain CHW programs. A sustainability plan should be developed during the project planning phase, not at the end of the project when activities are being wrapped up. For example, if paid project staff members are implementing trainings or supervision activities, who will take over these responsibilities when the project ends and are these expectations reasonable?
- Logistics and supplies: Certain components of a community-based program may depend on having a reliable source of commodities and supplies, often through the local health center. CHWs must know the procedures for replenishing their supplies; know who is responsible for resupplying; and have a system to maintain good communication with their supplier.
Key Resources for Community-level Programming:
- ACCESS, 2005. Household-to-Hospital Continuum of Maternal and Newborn Care
- AMDD, 2014. Rethinking Referral Systems
- The Earth Institute. One Million Community Health Workers: Technical Task Force Report
- Perry H and Zulliger R, 2012. How Effective Are Community Health Workers?
- Bhutta Z, et al. Global Evidence of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems
- WHO, 2012. WHO Recommendations: Optimizing Health Worker Roles for Maternal and Newborn Health
- Initiatives, Inc., 2014. CHW Central
- POPPHI, 2009. A Guide for Training Community Health Workers–Volunteers to Provide Maternal and Newborn Messages
- Partners in Health, 2011. Improving Outcomes with Community Health Workers: Unit 7.
- Nkoni L, et al. Lay Health Worker Attrition: Important but Often Ignored. Bull of WHO 2011; 89: 919-923.
- Health Care Improvement Project, 2011. Community Health Worker Assessment and Improvement Matrix (CHW AIM): A Toolkit for Improving CHW Programs and Services
- BASICS, 2009. Integrated Maternal and Newborn Care: Supervisory and Evaluation Checklists