By: The 1mCHW Campaign
Across the globe, CHW programs vary in their management, operation and function but share a common commitment to linking health services to communities, especially in hard-to-reach areas and among vulnerable populations. Yet fragmented programs may not be the most effective way to meet the health needs of communities. The One Million Community Health Workers (1mCHW) Campaign aims to accelerate the expansion of CHW programs in sub-Saharan African countries by scaling them up to district, regional and national levels for greater impact on the Millennium Development Goals.
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Country Scale-up Needs:
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Launched in January 2013, the Campaign* is working toward rapid deployment of an estimated one million trained and equipped CHWs by 2015. Our goal is to increase not only the number of functional CHWs, but also ensure their professionalization and the quality of care they deliver by focusing on country specific planning, quality assurance, consistent management and supervision, community ownership, linkages with the health system, and coordination of efforts.
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Phased Scale-up Approach
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In our first six months, we have worked with African
governments and other partners to incrementally
increase financing for CHW programs and rally
around a common vision for CHW scale-up. The
Ministries of Health in Liberia, Ghana, Malawi, and
Nigeria have each begun the process by developing a
financial and operational “Roadmap” for building a
national CHW strategy aimed at achieving complete
rural coverage and addressing high priority health
needs.
To keep countries and stakeholders up to date, the Campaign is building a virtual “Operations Room”, an online platform that consolidates information and resources about existing CHW programs across sub-Saharan Africa.
The information, once collated, will enable sharing of best practices and resources (e.g., training curricula, supervisory tools, standardized checklists) for program design and implementation, and identifying opportunities for partnership building and expanding coverage.
The Operations Room’s interactive map will gather data on where CHWs operate, what training they have received, what services they provide, and help identify critical gaps in service. This feature will be publicly launched in late September/October. In the meantime, we would love to draw upon the practical knowledge of CHW Central members! If you have access to programmatic information about a public, private, or NGO-operated CHW program in sub-Saharan Africa, complete the Registration Form available here: http://goo.gl/TlWkg
For this discussion, we would like to draw on your experiences to inform a conversation around the following questions:
1. How do we build relationships between already established small-scale programs and larger governmental programs? What do you see as key elements to the success of such collaborations?
2. Based on your experiences, what do you see as the best way to structure these relationships between small and large-scale programs? (i.e. should they be partners, should smaller organizations serve as a resource, should they be consolidated, etc.)
3. Besides relationship building, what do you see as a main challenge in effective CHW scale-up? What are some strategies to successfully address these challenges?
*The Campaign, part of the United Nations Sustainable Development Solutions Network, is overseen by a steering committee comprised of a diverse group of partners, and managed by a modest secretariat based at the Earth Institute of Columbia University.
Authors:
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Ms Hannah Sarah Faich Dini Policy Advisor, Community Health Systems One Million Community Health Workers Campaign The Earth Institute, Columbia University |
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Ms Marilyn Perez Alemu Volunteer One Million Community Health Workers Campaign |
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1. How do we build
1. How do we build relationships between already established small-scale programs and larger governmental programs? What do you see as key elements to the success of such collaborations?
1.1 Learn and document the lessons of scale-up from Districts to the Regions or Provinces. Key element of success: present movement to Governance, decentralization, local tax raising, district and provincial planning (ex. Nigeria)
1.2 Place priority on a few selected Regions/ Provinces in each country (current strategy in many countries, e.g. with GF in Nigeria on HIV/AIDS, TB and Malaria programmes) and learn the lessons from these scale-up efforts to apply to national replication. Key element: joint partnerships between the Government/ local authorities and international partners (bi, multi-lateral, for ex the sub-recipients of the GF, and private) in joint planning and joint documentation of the lessons learned (for ex. as part of the joint reviews/ evaluations efforts). Synthesize the lessons learned at sub-national level to include them into national strategic plans of diseases in a coherent way. Key element: strong national guidance, commitment over time (ex. Ethiopia)
1.3 For some key technologies, such as medical education or e-health, build-up on a special joint venture between public and private partnerships at country level. Key element: use/ adapt current success stories, ex in India with INTEL on Medical education (p. 21) or BHARTI AIRTEL (p. 24) as per “Private Enterprise for Public Health” A Short Guide for Companies, 2012
http://who.int/pmnch/topics/part_publications/private_enterprise_for_public_health_guide.pdf
2. Based on your experiences, what do you see as the best way to structure these relationships between small and large-scale programs? (i.e. should they be partners, should smaller organizations serve as a resource, should they be consolidated, etc.)
2.1 Relationships should be structured such as the Global Fund with sub- Recipients (SRs) feeding and supported by Principal Recipients (PRs) BUT PRs should be responsible to learn the lessons and disseminate those, given smaller organizations may never share the lessons learned for one reason or another. Strategy: incorporate this in reviews/ evaluation terms of reference, create in-country learning platforms, feed those into the local or national strategic plans
2.2 Map out the smaller and larger organizations from private and the public sectors and their roles and responses at local level using existing tools/ experiences (ref. UNAIDS, WHO, GTZ, “Local Responses to HIV/AIDS” in late 1990s in 5 countries in Africa with example in Burkina Faso as a research study/ thesis, available at: http://pub.uni-bielefeld.de/pub?func=drec&id=2305617 ), or “Bridging the gap between the communities and the service provides by the way of local responses: the District Response Initiative in Uganda” (2003, pp. 37-40 in http://www.who.int/hiv/pub/prev_care/en/37564_OMS_interieur.pdf )
3. Besides relationship building, what do you see as a main challenge in effective CHW scale-up? What are some to successfully address these challenges?
3.1 Dispel the myth of high costs and unsustainability. To address these challenges, see experience of Ethiopia. Wide distribution and advocacy campaigns in MoHs and Ministries of Finance, partners. Separate the costs in investments and recurrent costs (the latter supported by local taxes, e.g. Uganda). Show return in investments and shared costs, e.g. CHWs working commonly in infectious and chronic diseases (e.g. Rwanda)
3.2 Document carefully and disseminate examples of scale-up of CHWs and the HOW, WHY it succeeded. See for ex. scale-up of ART in the early days of the 3 by 5 Initiative under Jim Kim at WHO/HIV
3.3 Build-up in the costed strategic plans advocated by large Initiatives (e.g. GAVI, GF) the costs of CHWs scale-up for national and district plans
3.4 Include CHWs training and support into the present efforts launched of training and updating health professionals with current efforts or opportunities such as the recently released 2013 WHO ARV guidelines
3.5 Documenting “effective” CHW scale-up by documenting the outcomes and impact attributed to the CHWs vs. presently the health services taking direct benefits of those (under operational research in various countries) and disseminating and using existing tools such as the Global Fund Community Systems Framework (2011) available at:
http://www.google.fr/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&ved=0CE8QFjAB&url=http%3A%2F%2Fwww.theglobalfund.org%2Fdocuments%2Fcivil_society%2FCivilSociety_CommunitySystemsStrengthening_Framework_en%2F&ei=iTc3UtjAItHSsga_3YGABg&usg=AFQjCNHvzIP_Ld1PHfGZSittQYkSqGho6Q&bvm=bv.52164340,d.Yms
3.6 Address POLICIES in Human Development: Community Health Workers (CHWs) are providing effective, community-based essential health services and demonstrated important contribution to health with a “dramatic advances in child survival” in Bangladesh (UNDP, Human Development Report 2013, The Rise of the South: Human Progress in a Diverse World, Box 3.7, p. 81) but Sub-Saharan Africa has the most inequality in health (op. cit. p. 14, p. 32). CHWs need to be perceived and understood by Governments as contributing to human development and beyond demonstrated impact in health, reducing inequity of access to health (e.g. rural areas), improving education in health, contributing to sustainable human development at low cost.
3.7 Address POLICIES in Global Health: the case still needs to be made to reach a consensus among all key stakeholders that Community Health Workers is a key solution to health and development in Sub-Saharan Africa using the appropriate political entry points and as an agenda item, e.g.: the “H8” health organizations (including Bill & Melinda Gates Foundation; the GAVI Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria, the various UN agencies, the World Bank, and large international NGOs such as CARE Inc. or Save the Children; and the same with the “H4” (UNICEF, WHO, UNFPA and the World Bank) with 6 focus countries with highest mortality. Use other bodies as appropriate, the UN Economic and Social Council (ECOSOC), the Human Rights Council, the UN General Assembly (UNGA). As such, some of the original agendas of the world leaders when taking office is an entry point, e.g. the UNAIDS Executive Director or the WHO Director-General in 2007 who declared that the effectiveness of WHO would be judged in terms of improvements in the health of the people of Africa and the health of women, and reaffirmed WHO’s commitment to primary health care. Use opportunities such as high level networks to leverage those, e.g. Mark Dybul, Jeffrey Sachs, and Bill Gates as per recent advocacy video (http://www.youtube.com/watch?v=fv3rAw4BxpU&feature=youtu.be )
Thanks so much, Cyril, for
Dear Cyril,
Thanks so much for your very thoughtful response! You have raised some really important points that we are also working on as a Campaign to address. As you mentioned, documentation of lessons learned at the sub-national level to include in national strategic plans is a key element to effective CHW scale-up. We have been working to fill this need, collaborating with partners to identify and increase availability of currently implemented resources and innovations to be used for CHW program improvement, and for countries to fully apply this existing knowledge to customize their national plans.
Speaking of partner collaboration, one of the issues we’ve been working on here at the 1mCHW Campaign is identifying the various organizations that have CHW programs in operation, which is a good first step for building relationships. Across the globe, CHW programs have been implemented and managed by diverse organizations, such as Non Governmental Organizations (NGOs), Community Based Organizations (CBOs), and various levels of governments. CHW roles and responsibilities vary widely among different programs and, in order to scale local CHW programs up to the regional or national level, collaboration between organizations with differing modes of operation will be essential. Because so many programs are run independently, and there has been little sharing of information about these programs, it is increasingly difficult for Governments to plan their human resources for health (HRH) needs.
The 1mCHW Campaign has been working with governments across sub-Saharan Africa to identify their HRH needs and plan for scale-up at the community level. As a Campaign, we define CHW scale-up as initiating, upgrading, and expanding comprehensive and sustainable CHW systems. This means not only increasing the number of CHWs, but also ensuring their professionalization and the quality of care they deliver. One challenge to scale-up that we have come across in our work is the issue of quality assurance and developing consistent (or at least complementary) performance standards. One issue we are continuously faced with in our work is establishing partnerships that are complementary yet non-competitive, especially when there are overlapping interests. We would love to hear from everyone in the CHW Central community about your experiences in addressing these challenges.
— Marilyn
One more thought!
One more thought!
Cyril, we completely agree with your point that it is necessary to demonstrate the impact of CHWs in contributing to human development beyond health outcomes. As a community, we need to increase our efforts in advocating for the long-term impact of CHWs! This has implications for research questions, such as estimating the macroeconomic benefit of investing in CHW systems – for their role in creating rural jobs, correcting gender inequities, and of course in improving the productivity of national economies no longer crippled by the effect of preventable diseases. To open this back up to the CHW Central community: what other suggestions do you have for demonstrating CHW impact?
–Hannah Sarah