CHW programs can readily fail without proper design and implementation. Without appropriate structure and support, CHWs can face numerous barriers to the successful execution of their duties. For example, in a study conducted in rural KwaZulu-Natal, South Africa, CHWs reported feeling overwhelmed due to the large number of households for which they were responsible, the lack of needed supplies (including pens, bandages, gloves, etc.), and the lack of support from community health facilitators. Moreover, they were dissatisfied with their low stipends and the lack of support from supervisors while they experienced emotional strain, whether as a result of caring for the sick and dying or from helping the poor. The lack of supplies reflects the financial strains on the health system at large and also illustrates the need for health system strengthening. A variety of issues must be considered for quality program implementation.(1)
Based on an analysis of the literature concerning CHW program evaluations, Hermann et al. (2009) delineated eight conditions that a CHW program must fulfill in order to be successful in terms of its quality, sustainability, and scalability. The authors note that a program must meet all eight conditions or risk failure. The first five considerations are basic necessities, and the final three pertain to the program’s scalability. The following list is adapted from Hermann et al. (2009)(2):
Having studied CHW programs in Uganda, Namibia, Malawi, Ethiopia, and Brazil, Celletti et al. (2010) compiled a similar list of qualities that are necessary for ensuring CHW program quality, sustainability, and efficacy. The paper concluded that “The findings also show that certain conditions must be observed if CHWs are to contribute to well-functioning and sustainable service delivery. These conditions involve adequate systems integration with significant attention to: political will and commitment; collaborative planning; definition of scope of practice; selection and educational requirements; registration, licensure and certification; recruitment and deployment; adequate and sustainable remuneration; mentoring and supervision including referral system; career path and continuous education; performance evaluation; supply of equipment and commodities.” Added to the eight considerations above is collaborative planning. The authors stated that various organizations including Ministries of Health, Ministries of Education, Ministries of Rural Development, medical councils, nurses associations, non-governmental organizations, and other related international, national, and local organizations must be included in the design and implementation of the program. CHW programs that involve the Ministry of Health are often more successful because of the Ministry’s networking with various stakeholders.(7)
A study conducted in Mozambique concluded that CHWs should be better integrated into the healthcare system in order to avoid problems resulting from a limited vertical approach to care and the heterogeneous coverage of healthcare services. The Ministry of Health and Médecins Sans Frontières (MSF) collaborated to devise a plan to “maximize community participation in the management of a broad range of health problems via a community health team (CHT) [and] provide coverage of the most basic health needs for the target area .” In this system, one CHW serves as a team leader for 10- 15 CHWs who serve approximately 15,000 people. The CHWs meet with local authorities and community leaders to examine strategies used to combat health problems. In addition, each community is given two to three bicycle ambulances to facilitate CHW referrals to clinics and hospitals. T he CHWs are held accountable for their responsibilities and are given support from the community and existing health structures. In addition, primary care nurses work with the CHT to deliver services such as vaccinations and antenatal care. Working within an integrated system, CHWs can provide a broader range of health services and facilitate effective communication between communities and health facilities. The authors conclude that while NGOs can make valuable contributions through technical and financial support and innovation, the Ministry of Health must ultimately be responsible for the coordination and direction of CHW programs in Mozambique in order to develop an integrated, accountable, and expanded system of care.(8)
Ministries of health must advance the development of the entire healthcare system in addition to promoting the integration of CHWs. Hermann et al. (2009) explain that government CHW programs “ seem more attractive than the NGO-based programs for scaling up ART [antiretroviral therapy] and reaching coverage, as the CHWs are already part of the health system's structure, regulatory frameworks exist and career prospects can be created. However, we contend that they run the highest risk of neglecting quality assurance if their scale-up is not aligned with broader health systems strengthening.” If CHW programs are implemented with these criteria, they have the potential to expand health services for individuals without access to adequate care.(9)
CHW programs in the United States have historically received funding from short-term grants, or have relied on volunteers. Although this small-scale model has resulted in positive health outcomes in a number of communities, many public health officials recommend that the U.S. “implement a national agenda for CHW evaluation research” and standardize CHW training programs and certification requirements.(10) Martinez et al. (2011) suggest that such an expansion of the CHW role in the U.S. may be highly compatible with the Patient Protection and Affordable Care Act. The law emphasizes reducing health care costs while improving health care quality, particularly by using accountable care organizations and patient-centered medical homes, which “stress the importance of interdisciplinary, interprofessional health care teams, the ideal context for integrating CHWs”.(11)
Although it is financially tempting to rely on the efforts of unpaid CHWs, volunteerism can limit CHW programs. Most public health scholars agree that volunteer-based CHW programs are unsustainable, limited by economic and social demands on local volunteers. Jeffrey Sachs explains, in his review of Tina Rosenberg’s book, “Join the Club”, that unpaid CHW programs may be successful initially, but volunteer absenteeism will eventually increase, and morale will decrease with time. Sachs explains that “paid community health workers are necessary for the long haul…the social cure is not self-sufficient; it requires support from the outside”.(12) Martinez et al. (2011) argue that CHW program sustainability will best be achieved by a capitated payment system, in which health care providers are compensated at a fixed rate for each individual assigned to the provider. However, they note that several states have been successful in expanding CHW programs through Medicaid funding.(13) Regardless of the payment structure that the U.S. adopts, officials should remember lessons learned from CHW efforts in other countries: paying CHWs living wages, offering opportunities for educational advancement, and publicly valuing the role of CHWs. These will facilitate the expansion and acceptance of CHW programs by local communities and medical professionals.(14)
(1) Suri, Arjun, Kevin Gan, and Stephen Carpenter.”Voices from the Field: Perspectives from Community Health Workers on Health Care Delivery in Rural KwaZulu-Natal, South Africa.” Journal of Infectious Diseases. 196(2007): 505-511.
(2) Hermann, Katharina, Wim Van Damme, George W Pariyo, Erik Schouten, Yibeltal Assefa, Anna Cirera, and William Massavon. “Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities.” Human Resources for Health. 7(2009): 31.
(3) Schneider, Helen, Hlengiwe Hlophe, and Dingie van Rensburg. “Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects.” Health Policy and Planning 23(2008):179-187.
(7) Celletti, Francesca, Anna Wright, John Palen, Seble Frehywot, Anne Markus, Alan Greenberg, Rafael Augusto Teixeira de Aguiar, Francisco Campos, Eric Buch, and Badara Samb. “Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of multicountry study.” AIDS 24(2010): 45-57.
(8) Simon, Sandrine, Kathryn Chu, Marthe Frieden, Baltazar Candrinho, Nathan Ford, Helen Schneider, and Marc Biot. “An integrated approach of community health worker support for HIV/AIDS and TB care in Angonia district, Mozambique.” BMC International Health and Human Rights 9(2009): 13.
(9) Hermann, Katharina, Wim Van Damme, George W Pariyo, Erik Schouten, Yibeltal Assefa, Anna Cirera, and William Massavon. “Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities.” Human Resources for Health. 7(2009): 31.
(10) Balcazar, H., Rosenthal, E. L., Brownstein, J.N., Rush, C.H., Matos, S., Hernandez, L. (2011). Community health workers con be a public health force for change in the United States: three actions for a new paradigms. American Journal of Public Health, 101(12): 2199-203.
(11) Martinez, J., Ro, M., Villa, N.W., Powell, W., Knickman, J.R. (2011). Transforming the delivery of care in the post-health reform era: what role will community health workers play? American Journal of Public Health, 101(12):e1-5.
(12) Sachs, Jeffrey, D. 22 May 2011. “Help from the Herd”. The New York Times.
(13) Martinez, J., Ro, M., Villa, N.W., Powell, W., Knickman, J.R. (2011). Transforming the delivery of care in the post-health reform era: what role will community health workers play? American Journal of Public Health, 101(12):e1-5.
(14) Lola, D., Kim, J.Y., Farmer, P. 1 December 2006. “Where AIDS Efforts Lag; Shortages of Health Workers Undermine Advances”. The Washington Post.