Overcoming Scalability Challenges in CHW Programs_Sarah Sullivan_10.14.11
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This document summarizes a study on community health workers (CHWs) in global health programs at scale. It analyzes four national CHW programs in India, Pakistan, Ethiopia, and Brazil that have reached scale, noting their strengths and challenges. It also examines three cases of innovations in CHW program scalability through improved management, supervision, and integration with primary health care systems. The key finding is that innovations are needed in areas like deployment planning, linkages with local health systems, continuous quality improvement, and sustainable financing to enhance the scalability of large-scale CHW programs.
Overcoming Scalability Challenges in CHW Programs_Sarah Sullivan_10.14.11
- 1. CHWs in Global Health:Scale and ScalabilityAnne Liu, Sarah Sullivan, Mohammed Khan, Sonia Sachs and Prabhjot SinghMSJM 78:419-435, 2011
- 2. OverviewNEED: Focus on program design for scalability of CHW systemsHIGHLIGHT: Innovations responding to identified challenges in CHW systems at scaleCONCLUSION: Leveraging innovations in systems management, supervision, financial sustainability, deployment planning and integration with PHC systems will enhance scalability of CHW systems
- 3. BackgroundStrengthening PHC systems National scale focusLow-cost, simple and proven community-based interventionsHRH crisis and accessibility of primary careRenewed focus on CHW systems’ potential to address access to PHC in resource-poor areas
- 4. Approach4 Case Studies of CHW Programs at National Scale, Strengths and Challenges3 Case Studies of Innovations in Scalability through CHW system managementCases chosen for prominence, range and availability of program reports/evaluations
- 5. DefinitionsBroadly defined CHW: auxiliary health workers or community-based lay health workersScaleScalability
- 6. Case Studies: Programs at ScaleIndia’s ASHA Program Pakistan’s LHW ProgramEthiopia’s HEW ProgramBrazil’s Health Agents Program
- 7. Case Studies: Programs at ScaleReached scale through phased implementation approaches: Deployment at scale is achievableProgram design includes integration with the PHC systemLimited, emerging evidence of impact on health outcomes
- 8. Challenges at ScaleManagement and supervisory capacityIntegration with local governance for reliable financing and suppliesLimited execution of strong system management program designsStrength of PHC system support structures, ability to provide link to continuum of careProcess improvement lags
- 9. Case Studies: Innovations in ScalabilityBRAC: Cost recovery and Financial Sustainability innovationsPIH: Management, supervision and PHC system integrationMVP: Supervision and process improvement innovations, integrated PHC system management
- 10. Case Studies: Innovations in ScalabilityBRAC: Cost recovery and Financial Sustainability innovationsPIH: Management, supervision and PHC system integrationMVP: Supervision and process improvement innovations, integrated PHC system management
- 12. Case Studies: Innovations in ScalabilityDevelopment of well-managed scalable unitsInnovative programs address systems management challenges faced by programs at national scale in 5 key areas
- 13. Key FindingsInnovations are needed in key areas: A formal plan for deployment of CHWsTight linkages with local PHC systemContinuous improvement through active organizational managementIncorporation of new technologies to support remote case managementSustainable financing structures
- 14. Call for National Scale Application of Scalability InnovationsMulti-stakeholder technical taskforce Released June 2011 VHW Program Design in Nigeria direct output of this efforthttp://millenniumvillages.org/files/2011/06/1mCHW_TechnicalTaskForceReport.pdf
Editor's Notes
- #4: Nearly 50% of all deaths of children under 5 are due to pneumonia, diarrhea, malaria and malnutrition – al preventable, treatable conditions in a primary-care setting; coverage of these interventions – antibiotics for pneumonia, antimalarial drugs (testing), ORS/zinc for diarrhea is low, particularly for the most vulnerable populationsWhen managed effectively, a CHW program that is integrated into a well-functioning PHC system can promote care at the household level and function as a crucial link between community members and the PHC system (continuum of care)Large scale programs initiated in the 1960s, faded during the 1980s and now seeing a resurgence of interest in how to execute successful CHW programs at national scaleCHWs have been proven to make measurable impacts on health indicators across programmatic areas including management of childhood illness, increasing institutional delivery rates and directly observed therapy for infectious diseases
- #5: Reviewed comprehensive reviews: Global Health Workforce Alliance review of CHW programs (2010); national program and NGO program reports; peer-reviewed program evaluationsFilter: Focus on systems management challenges rather than on health outcomes (operational research versus health outcomes for programs design)
- #6: Scale: Recognition of an outer boundary, such as a national border, as the target area for deployment of HR and systems required to support HH servicesScalability: factors that ensure optimized functionality and sustainability of a program in the process of achieving scale
- #7: India’s ASHA Program (Accredited Social Health Activist) Pakistan’s LHW: National Program for Family and Primary Health CareEthiopia’s Health Extension Program’s Health Extension WorkersBrazil’s Health Agents (Agentes de Saude)
- #8: India’s ASHA Program (Accredited Social Health Activist) – over 462,000 ASHAs (95% of target) in 18 states by 2009 in under a decade, focused on institutional delivery through performance-based incentive structurePakistan’s LHW:in under a decade 100,000 LHWs in all states through phased scale up focused on program managementEthiopia: 30,000 in 5 years with 1 year of training each, facility-based managers of household extension volunteersBrazil: 240,000 across all states over 2 decades from 1 province’s innovative program
- #9: ASHAs – poor links to government systems for formal supervision as envisioned in policy docs – poor supervision, lack of clear understanding of task expectations among ASHAs, uneven implementation based on uneven PHC system may miss most vulnerableLHWs – strong program design, delayed implementation, supervisory turnover, deficient disbursements of funds and supplies and unwieldy information management system, uneven based on uneven PHC systemEthiopia – expanded more quickly than PHC system could absorb for adequate management, supervision and facilitiesBrazil – strong integration and management structures, strong local linkages and data feedback loops
- #10: BRAC: Bangladesh Rural Advancement Committee (largest NGO in the world, including CHV program which has expanded to 8 countries through 88,000 CHVs) – success at scale while innovating on cost recovery and financial sustainability mechanismsPIH accompagnateurs – linked explicitly to PHC system - PIH DOTS-Plus also uses integrated team model
- #11: BRAC: Bangladesh Rural Advancement Committee (largest NGO in the world, including CHV program which has expanded to 8 countries through 88,000 CHVs) – success at scale while innovating on cost recovery and financial sustainability mechanismsPIH accompagnateurs – linked explicitly to PHC system - PIH DOTS-Plus also uses integrated team model
- #12: BRAC: Bangladesh Rural Advancement Committee (largest NGO in the world, including CHV program which has expanded to 8 countries through 88,000 CHVs) – success at scale while innovating on cost recovery and financial sustainability mechanismsPIH accompagnateurs – linked explicitly to PHC system - PIH DOTS-Plus also uses integrated team model
- #14: The programs highlighted here on this panel are each addressing these key elements of scalability through their programmatic efforts#3 includes management of CHW system as a scalable unit; supervision focus; scaling of CHW system in tandem with PHC system for supervision and capacity to take on continuum of care responsibilities due to increased coverage; data usage; community engagement and beneficiary control over the sytem