Community Health Workers (CHW) for Achieving UHC:

Experience in using evidence to guide decision-making

for CHW programs

Prince Mahidol Award Conference (PMAC) Side Session Report

January 27, 2016

Session Background
The United States Agency for International Development (USAID), along with Health Systems
Global (HSG) Technical Working Group (TWG) on Community Health Workers and the
WHO/Health Workforce Department, co-organized a side session at the 2016 Prince Mahidol
Award Conference on Community Health Workers for Achieving Universal Health Care:
Experience in using evidence to guide decision-making for CHW programs.
Community Health Workers (CHWs) often serve as key frontline workers for advancing services
for HIV/AIDS and maternal and child health and in support of control of other infectious
diseases. There has been an increasing focus on their contributions to these health services.
Additionally, emphasis has been placed on addressing identified evidence gaps for CHWs in
order to strengthen the fragmented CHW program landscape within countries.
There has been a definite resurgence of focus on CHWs- of diverse typology- across the globe
in recent years. If one looks to the African Continent alone, in the past year, there are many
multiple examples- Ghana, Liberia, Sierra Leone, Burkino Faso, Nigeria, Kenya, Uganda- of
countries with ongoing efforts for developing and strengthening CHW cadres, especially at the
national level. The resurgence of focus and attention to CHWs across the globe has led to the
creation of consultative and decision-making entities, involving extensive stakeholder
engagement (e.g. development of national steering committees, working groups, etc.) and the
use of other evidence-gathering and analysis tools. Yet, the extent to which this evidence and
engagement is used by decision-making entities is unclear.
The session examined three key areas: how evidence is used to inform decision-making, the
effectiveness of different approaches to facilitate decision making, and how to support the use
of evidence and capacity for decision-making in priority setting for CHWs. The session opened
with a moderated panel that included representation from LVCT Kenya, Jhpiego, Harvard
School of Public Health, and the WHO. The panel was followed by session participant
roundtable discussions around the need and demand for mechanisms and forthcoming WHO
normative guidance on community-based practitioners to maximize impact and advance
evidence- driven decision-making.
The half-day session was joined by diverse representation from representatives from country
governments, academia, implementing partners and donors.

Panelists
Dr. Lilian Otiso, LVCT Health, Kenya
Dr. Otisos presentation described REACHOUT, a healthcare project supporting and
strengthening the work of close-to-community health care providers. REACHOUTs aim is to
maximize the equity, effectiveness and efficiency of services in six countries: Mozambique,
Indonesia, Kenya, Malawi, Bangladesh and Ethiopia.

Dr. Emma Sacks, Johns Hopkins University and USAIDs Maternal and Child Survival Program
(MCSP), USA
Dr. Sacks presentation focused on the use of evidence to inform planning for CHW
programming. Dr. Sacks discussed the pilot testing of an Excel-based tool, the USAID MSCP
CHW Coverage and Capacity (C3) tool, in Tanzania, and its use for examining options for CHW
allocation and engagement in order to make informed, rational decisions about CHW priorities.
Dr. Jan-Walter De Neve, Harvard School of Public Health, USA
Dr. De Neves presentation focused on using evidence from four country case studies that
examined the (i) coordination, (ii) integration, and (iii) sustainability of CHW programs delivering
HIV services.
CHW programs have been found to be poorly coordinated, with multiple disparate CHW
programs often observed in a single country, poorly integrated into national health systems, and
lacking sustainable long-term support. Duplication of services, fragmentation, and the lack of
resources may have impeded the full realization of the potential impact of CHWs.
This presentation provided some of the first qualitative evidence from country case studies to
inform decision-making to harmonize community health programs and more strongly integrate
them into national health systems. It provided a set of policy recommendations and identified
facilitating and impedimentary factors to the harmonization of CHW programs for HIV.
Dr. Weerasak Putthasri, Department of Health Workforce, World Health Organization
Dr. Putthasri spoke about the purpose and development of forthcoming WHO Guidelines on
Community Based Practitioners. He presented an overview of how CHWs are presented as
single cadre but encompasses a range of paid and unpaid, lay and educated, formal and
informal health workers with a wide range of training, experience, scope of practice, and
integration in health systems. The proposed terminology of community-based practitioners
(CBPs) better reflects the diverse nature of these cadres of health workers.

Roundtable Discussions
After the panelists presentations, the session attendees participated in roundtable discussions.
The purpose of the discussions was to discuss the need and demand for mechanisms and
normative guidance on CHWs to advance evidence-driven decision-making. The participants
discussed three questions. Discussions are summarized below:
Q1. How is evidence currently drawn and utilized to inform decision-making in the countries you
are working in?
Session attendees had different experiences regarding the implementation of guidelines and
standards for CHW programs. In some countries, global reference materials and publications
are used and implemented, and local evidence is used to adapt to fit the context of the
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community. In these situations, the political economy is a driving force in the decision-making
process, sometimes overriding the evidence base.
Other attendees pointed towards gaps in evidence and information needed to inform decisionmaking. A lot of countries conform to the WHO guidelines but do not engage with the WHO.
(Thus, WHO CHW guidelines would be considered very important at country level). There is a
lack of evidence on the role of the political economy in decision-making as well as a lack of
resources for countries not in the global agenda. At times, disease-specific programs are
steering CHW efforts.
Overall, there was consensus that guidance should be based on best practices and evidence. It
needs to capture the importance of using country specific data and using evidence to inform
decisions about CHWs. It would be important for it to include examination of the costeffectiveness of CHWs work, engagement in decision-making, and how stakeholders interact to
get results. There needs to be increased government engagement in research and data
processes with researchers and others.
Country-specific examples of evidence adaptation

Rwanda Quick and small pilot programs (mainly around family planning) are
held to collect data to inform the larger national/government programs.
Bangladesh The commitments to put CHWs in every county are politicallybased and not necessarily evidence-based.
Cambodia The political economy is often a driver of decision-making.
Kenya Evidence is needed to convince non-health actors to put CHWs in every
county, if this would have health benefit.

Q2. What are areas that are mostly debated in your countries for CHW programs?
Session attendees commonly cited the following areas:
Recruitment and Role
of CHWs
Compensation and
benefits

Motivations for becoming and staying a CHW

Urbanization and adapting the role of the CHW
Process/fairness of CHW selection
Payment mechanisms
Payment level
Benefits package/package of services

CHWs as stopgaps CHWs are being used when PHC

(primary health care?) is lacking enough human resources
(e.g. in hospitals)
Is there a role for CHWs even in a good formal health
system?

Workload

Equipment needs

Cell phones
Technical support
4

Education, training,
and qualifications
Professional
development

Transportation
Other technology

School level university or further needed?

Need for increased attention to the voices of CHW in policy

and decision making
Career ladder opportunities
Focus on safety, especially for female CHWs

Q3. What areas/questions would you like to see addressed in the new WHO CBP guidelines?
The session participant discussion highlighted the following areas that would benefit from further
attention and focus in the upcoming WHO guidelines.
Area

Sustainability Issues

Regulatory/Quality
Framework

CHW Typology

Measurement

Examples
Guidance for governments on managing and maintaining
better structures
Guidance on transforming existing structures to meet country
context instead of creating new structures
Guidance on acceptable workload
Linkages to national and legal system and community
Critical partnerships
Connections to formal health systems

Professionalization of cadre
Career growth/options for CHWs
Role of CHW voice and integration of CHW views into health
system
Authority/Oversight
Quality Assurance
CHW selection and recruitment
Safety/security

Coverage of tasks
Number of technical activities
Tiering of tasks/responsibilities by cadre type
Gender issues

Performance indicators/monitoring of programs

Tracking performance and productivity e.g. how many
people are seen, tasks performed

Conclusion
Session participants identified many common areas debated across country context for CHWs.
There was greater variability across participant experience of how evidence was utilized for
CHW decision-making. Participants agreed that having stronger global guidance would be
helpful to drive decision-making. It was identified that guidance that covered issues pertaining to
sustainability, regulation and quality, typology, and measurement would be of greatest utility to
participants.

Appendix
Side-session Participant List

Name

Organization

Country

Diana Frymus

US Agency for International Development

United States

Lilian Otiso

LVCT Health

Kenya

Dr. Emma Sacks

MCSP/Johns Hopkins School of Public Health

United States

Dr. Jan-Walter De Neve

Harvard T.H. Chan School of Public Health

United States

Dr. Weerasak Putthasri

World Health Organization

Switzerland

Thomas Drake

University of Oxford

Myanmar

Ariella Camera

US Agency for International Development

United States

Dr. Maria Isabela Makinano

Surigao del Norte Provincial Health Office

Philippines

Dr. Abou Bakarr Kamara

International Growth Centre

Sierra Leone

Masaaki Uechi

Institute for Health Policy and Practice

N/A

Emily Brown

University of Canberra

Australia

Thang Nguyen Thi

HHI Vietnam

Vietnam

Sreytouch Vong

Cambodia Development Resource Institute

(CDRI)

Cambodia

Christian Edward L. Nuevo

Alliance for Improving Health Outcomes, Inc.

Philippines

Karma Chhoden

RENEW Secretariat

Bhutan

Maika Bagunu

Department of Health

Philippines

Dr. Edmundo Villa

Southern Leyte Provincial Health Office

Philippines

Dr. Joy Gomez

Bulacan Provincial Health Office

Philippines

Kitti Sranacharoenpong

Mahidol University Institute of Nutrition

Thailand

Dr. Paulin Basinga

Rwanda Biomedical Centre

Rwanda

Nguyen Thi Thuy

Health Strategy and Policy Institute

Vietnam

Name

Organization

Country

Dr. Nadia Miniclier Cobb

Department of Family and Preventive Medicine, United States

University of Utah

Dr Than Win

Ministry of Health

Myanmar

Dr. Melissa Sena

Department of Health

Philippines

Dr. Olivia Tulloch

Overseas Development Institute

Great Britain

Dr. Rosemary Morgan

Johns Hopkins University

United States

Dr Sarath Samarage

WHO Sri Lanka

Sri Lanka

Prof. Priscilla Reddy

Human Sciences Research Council

South Africa

Karen Cavanaugh

US Agency for International Development

United States

Dr. Sarah Ssali

Makerere University, School of Public Health

(MUSPH)/ School of Women and Gender
Studies

Uganda

Dr. Boshoff Steenekamp

Metropolitan Health Risk Management

South Africa

Dr. Tamar Gabunia

USAID Georgia Tuberculosis Prevention

Project, University Research

Georgia

Dr. Mushtaque Chowdhury

BRAC

Bangladesh

Wee Mekwilai

Department of Mental Health

Thailand

Rudchadaporn Enija

Department of Mental Health

Thailand

Catherine Pitt

Department of Global Health and Development, United Kingdom

London School of Hygiene & Tropical Medicine

Minerva P Molm

Department of Health

Philippines

Dr. Nimfa Torrizo

Department of Health

Philippines

Dr. Rosalind Vianzon

Department of Health

Philippines

Yanika Valocittikal

International Federation of Medical Students

Associations (IFMSA)

Macedonia

Name

Organization

Country

Warinrumphal Vanichranun

International Federation of Medical Students

Associations (IFMSA)

Macedonia

Dr. Mari Honda

National Center for Global Health and Medicine Japan

Ariella Rotenberg

Council on Foreign Relations

United States

Thida HCA

Ministry of Health

Myanmar

Dr. Kyi Larim

Ministry of Health

Myanmar

Dr. Kabir Sheikh

Public Health Foundation of India

India

Yukie Yoshimura

Japan International Cooperation Agency (JICA) Japan