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Table 2 The role of community and health sector actors in Community Health Worker (CHW) programming

From: A Community Health Worker “logic model”: towards a theory of enhanced performance in low- and middle-income countries

Technical support Community and health sector actors
1. Assist in CHW program design Community and health sector actors participate in:
• Initial needs assessment to determine (1) demand for CHW services , as well as (2) views, perspectives, beliefs, and attitudes of all health sector actors affecting demand for CHW services
• Mapping of existing community-level services and identifying opportunities for aligning with CHW programs
• Developing a vision for CHWs that is shared by all stakeholders
• Identifying CHW selection criteria and methods of CHW recruitment
• Defining the service mix and package complexity*
• Developing a written program plan that includes the following elements:
(1) clear goals and objectives for the CHW program
(2) explicit roles, responsibilities, and expected competencies of CHWs (job description)
(3) a clear deployment plan to ensure adequate coverage
(4) specific activities CHWs are expected to implement
(5) a supervisory schedule and appropriate supervisory tools (e.g., performance checklists)
(6) an incentive scheme
(7) monitoring protocol for tracking CHW level of effort, including individual performance measures
(8) evaluation protocol for determining CHW program effectiveness, including program performance measures
(9) a budget
• Identifying existing and new referral mechanisms
• Identifying appropriate means to inform the community about the availability of CHW services
• Developing job aids and other tools that CHWs can use in providing services (such as health promotion activities)
• Developing new communication technologies that CHWs can use in providing and reporting on service delivery*
• Conducting a baseline assessment of CHW skills and capacity to inform CHW curriculum and training needs
• Developing or adapting a curriculum and materials to train CHWs
• Branding CHWs and their activities
• Briefing all stakeholders of the CHW programs (NGOs, private sector, local-level government) regarding their roles and responsibilities*
Sound design should take into consideration characteristics of CHWs (age, sex, literacy/numeracy, social and economic status, tenure as a CHW (years of service), degree of embeddedness in community and social networks, indigenous knowledge, mobility, residence, education, cultural belief system, ethnicity, religion, language, personal health behavior) and clients (age, sex, ethnicity, residence, education, religion, cultural belief system, socio-economic status, political affiliation).
2. Assist in CHW program implementation and management Community and health sector actors participate in:
  • Conducting CHW Training of Trainers
  • Training CHWs (pre-service and continuing, preventive and curative care skills, interpersonal communication and record-keeping skills)
  • Orienting CHWs to local community context, as necessary
  • Supervising CHWs
  • Mentoring and coaching CHWs
  • Providing continuous, constructive, contextually appropriate feedback
  • Organizing and conducting demand-generation activities (via information sharing, education, communication, and advocacy)
  • Helping to organize/coordinate/manage service delivery events (household and community: health fairs, educational sessions)
  • Mobilizing local material support and resources for CHWs for the short- and long-term**
  • Arranging for transport of clients in emergency situations**
  • Ensuring positive client-CHW interactions
  • Ensuring functioning supply system for timely and sustainable availability of essential drugs, commodities, supplies, equipment, materials (including for record-keeping), tools, and technologies*
  • Ensuring logistics support
  • Organizing/coordinating service delivery events (household and community: health fairs, educational sessions)*
  • Ensuring proper financial management of CHW program funds
3. Assist in program monitoring and evaluation (M&E) Community and Health Sector actors participate in:
  • Developing monitoring and evaluation protocols*
  • Monitoring CHW level of effort through continuous collection of information (via meetings, household visits, etc.) about quality of CHW service delivery and the community’s access to, acceptability of, and satisfaction with services
  • Archiving information about CHW service delivery within local HMIS*
  • Evaluating CHW’s individual performance and overall program effectiveness
  • Providing continuous and appropriate feedback to CHWs, community, and health sector, including sharing information about best practices and lessons learnt from program implementation
  • Continuously adapting the program, as necessary based on M&E results
Social Support Community Actors Health Sector Actors
Develop partnerships, strengthen linkages, and enhance networks Assist CHWs in developing mutually reinforcing partnerships with formal structures and actors outside the community to support CHW program design, implementation, and M&E activities: Assist CHWs in developing mutually reinforcing partnerships with formal structures and actors outside the health system to support CHW program design, implementation, and M&E activities:
  • Health Sector actors • Community system structures and actors
  • Government at all administrative levels • Structures and actors in other government sectors
  • Media and journalists • Media and journalists
   • NGOs, community-based groups
  Orient CHWs and assist them in developing productive linkages with existing and new structures and actors (both health and non-health) within the community to support CHW program design, implementation, and M&E activities: Orient CHWs and assist them developing productive linkages with actors within the health system in helping to support CHW program design, implementation, and M&E activities:
  • Community leaders (who can raise broader community awareness and acceptance of and support for CHWs and their services) • Align roles and responsibilities of CHWs with those of other health system health care providers
  • Village health and development committees, advisory groups, coordination and oversight bodies • Integrate CHWs into formal health system by incorporating them in sub-systems for health workforce development (training and supervision), service delivery (ensuring functioning referral system), and logistics management
  • Women’s groups • Integrate CHW into health care service delivery teams
  • Religious groups • Promote and market CHW services within the formal health system to ensure health workforce buy-in for CHWs
  • Faith-based organizations • Provide continuous support to CHWs and manage potential conflict between CHWs and health professionals
  • Community-based organizations • Recruit health professionals to staff health committees, oversight bodies, and advisory groups to provide support and feedback to CHWs and communities
  • Non-governmental organizations  
  • Traditional structures and indigenous practitioners  
  • Local civic and social clubs  
  • Savings groups/loan associations  
  • Schools  
  Assist CHWs in strengthening their professional and personal networks: Assist CHWs in strengthening their professional and personal networks:
  • Facilitate CHW peer exchange and/or membership and participation in CHW associations to improve peer support • Facilitate CHW membership and participation in CHW associations to improve peer support
  • Recognize and applaud family, kinship group, and other community member support to CHWs • Recognize and applaud family, kinship group, and other community member support to CHWs
  • Publicly promote, market CHW role and services  
Incentives Community Actors Health Sector Actors
1. Non-financial • Community actors demand CHW services and expresses satisfaction with these services • Health Sector actors demonstrate publicly their appreciation of and respect for CHWs (via health system awards, annual days of honor and recognition, etc.)
  • Community actors express its appreciation for and praises CHW activities and achievements • Health Sector actors ensure public visibility of CHWs (e.g., by posting photos of CHWs and other branding activities)
  • Community actors accept, endorse, and trust CHWs • Health Sector actors provide learning and development and career advancement possibilities to increase CHW social status
  • CHW is elected by community actors to represent it on local councils and other decision-making bodies of influence • Acceptance by formal health system health care providers (i.e., legitimization of the role and value of CHWs)
  • Community provides CHWs with opportunities for self-improvement, increased social interaction and mobility, meaningful income, or further training  
  • Community provides constructive feedback to CHWs, community members, community groups, and government actors about CHW performance  
  • Community elevates CHWs’ status within the community  
2. In-kind • Special privileges: exemption from other community duties, access to free social services, etc. • Special privileges: health system funds health and social activities of communities served by CHWs
  • Goods: animals, food, gifts, etc. • Goods: branded umbrellas, bicycles, motorcycles, uniforms, badges, mobile phones, stationary, etc.
  • Services: farm labor, finance with local resources health activities led by CHWs, etc. • Services: provide CHWs with free or preferential access to health care; psychological support for CHWs and family members
  • Equipment: branded umbrellas, bicycles, badges, uniforms, stationary, mobile phones, etc.  
3. Financial • Cash compensation for services rendered (e.g., fee for service) • Permit CHWs to draw supplementary income/modest profit from sale of medicines, commodities, and other health-related products
  • Direct and regular salary payment from community health structures • Provide cash compensation for services rendered (e.g., fee for service)
  • Direct and regular stipend from community health structures • Provide some portion of CHWs’ direct and regular salary payment from formal health system structures
  • Allowance/benefit for transport or training • Provide direct and regular stipend from health system structures
  • Performance-based financial reward (where deemed appropriate) • Provide allowance/benefit for transport or training
  • Access to micro-credit funds • Provide performance-based financial reward (where ]deemed appropriate)
  1. *health sector actors only; **community actors only.