Table 8 Key findings and recommendations for management of CHWs in fragile contexts

Study findings

Literacy and gender played out in selection of CHWs.

Fragility disrupts education of community members—CHWs may not have the literacy levels required for role; implications for selection, role, training and performance of CHWs.

Selection policy ideals are mediated in practice by gendered community norms.

The modular, local and mix of practical and classroom teaching approach worked well in Sierra Leone and Liberia, helping to address gender and literacy challenges and served to develop a cohort of CHWs who support each other.

Training in DRC is ad hoc.

Multiple actors involved in supervision.

Peer supervision and some facility supervision seen as supportive.

There are challenges with overloaded facility staff, limited transport, and limited support for supervisors.

In Sierra Leone, relationships between facility health workers and CHWs are sometimes strained.

Delays in remuneration for CHWs in Sierra Leone and Liberia.

CHWs use own money to do their work within contexts of poverty.

Community think CHWs are paid and will not provide additional support.

DRC CHWs still expect financial incentives, despite volunteer role.

Challenges in the drug supply chain have led to a delay in CHWs receiving medicines on time to treat patients, meaning their role is mainly to refer.

Despite promises of equipment and materials most CHWs have not received these items. These are critical to CHW roles, reputation and community recognition and trust.

No written guidance on managing CHW performance. Managers use rewards, e.g. selecting active CHWs for programme activities, sharing food or small financial incentives during meetings, and providing verbal praise.

Challenging to sanction poorly performing CHWs.

Managers used encouragement, closer monitoring, additional training and support, and talking with the community to resolve performance problems.

Recommendations

Sensitise communities to encourage women to volunteer and to be selected at the same rates as men.

Embed literacy training into CHW training to address literacy challenges.

Support community development groups to create space for women’s active participation in community dialogue.

Cultivate community “ownership” and support of CHWs from selection and throughout their ongoing role through regular meetings.

Provide training in a flexible, module-based approach with a mix of classroom and practical teaching; and app based training when travel is restricted.

Learners can accumulate credits from modules, and pick up modules again if interrupted by conflict or other factors.

Develop sense of a cohort so that CHWs support and learn from each other and jointly problem solve.

Encourage mobile messaging or WhatsApp groups for ongoing peer support.

Build ongoing capacity development needs into systems as CHWs roles may change e.g. during COVID19 pandemic.

Use innovative models e.g. peer supervisors, group supervision.

Support the supervisors through training and recognition including in the provision of basic psycho-social support and strengthening CHW morale.

Capture local issues and solutions to inform health system priorities.

Encourage peer-to-peer discussions at routine CHW meetings at health facilities.

Encourage community members to play greater role in support and supervision.

Clearly and openly communicate remuneration package with CHWs, other health workers and community.

Develop robust system for timely payment and clearly communicate.

Provide drugs and other supplies on a regular basis.

Ensure CHW supplies are allocated to CHWs by involving community and supervisor in allocation.

Encourage sharing of resources within health system.

Reward good performance through recognition by peers and health system.

Encourage community support and value.

Develop a career pathway that reflects the needs of both female and male CHWs.