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Question 1: Who are CHWs?
What are the criteria for the selection of CHWs?
Common Points
-literacy
-commitment to serve community
-recognition by community
-context/community specific requirements with regards to age, gender choice, minimum education
Group Specific Emphasis
-“Personal attributes may be more important than education: need role models/dedicated public servants” – group 3
-“Good communicator” – group 5
-“Should be both male and female-so as not to isolate men, men often are be on board as decision makers of the traditional household” – group 2
How are CHWs selected?
Common Points
-Community involvement is critical
-Level of outside involvement is unclear
-Sensitivity to gender issues
-Process should be sensitive to corruption/nepotism
Group Specific Emphasis
-“Two stage process: 1) Community gives 3-4 names based on predetermined criteria for selection. Consent of candidates (and family) required. 2) Interview and assessment of representative tasks assessed by body that CHW reports. One person is selected, second person on waiting list; scores are openly reported for transparency.” – Group 5
-“Sensitivity to local resource pool; some criteria marginalize populations (i.e. literacy, if majority of women are illiterate). Participatory and iterative involvement of the community is required.” – group 3
-“Community decision including women in formal or informal group, with an appeal process for claims of corruption or nepotism.” – group 2
-“Should there be a quota for women?” – group 4
Is there a difference between CHWs, village health workers, and volunteer health workers?
Common Points
-Yes, CHWs are paid, volunteers are not
-Management of volunteer system is different from the paid system
-There must be clear recognition of roles and responsibilities of each
-Volunteer may have more circumscribed roles
-Training for volunteers is shorter and more specific
Group Specific Emphasis
-‘Not generic. There is an auxiliary role for volunteers within a well-managed CHW program as long as roles and expectations are clearly defined.” – group 1
-“Government cannot manage a volunteer system.” – group 2
-“Informal vs. formal system within the healthcare framework-volunteers could be informal.” – group 2
-“Volunteering can be a track to becoming a paid worker.” – group 2
-“Volunteers are not trained as well.” – group 3
-“Volunteer health workers are appointed by CHWs.” – group 5
What are the advantages and disadvantages of having different types of CHWs?
Advantages
-Alleviate generalist worker overload
-Training is more targeted
-Can build on initial training sets
Disadvantages
-More difficult to supervise
-Training becomes more complex
-House-holds will be visited multiple times, potentially disruptive
-Lose an integrated approach
Group Specific Emphasis
-“Potentially increased patient satisfaction with specialists.” – group 1
-“CHWs can expand their training over time.” – group 3
-“Specialists are demand driven, higher awareness and motivation, possibility of rotation.” – group 2
-“There should be no specialization in the context of a small village.” – group 5
Question 2: What do CHWs do?
What package of services do CHWs offer?
Common Points
-Focus on health promotion/prevention, including high-impact curative interventions like vaccinations, family planning, maternal and child health, malaria treatment, DOT adherence, HIV/AIDS
-Focus on community needs, not necessarily entire package of CHW services
-Specialized CHWs can address complicated/sensitive topics
-Advocacy/mobilization: increase access, health education
-Health system information: data collection, disease surveillance
Group Specific Emphasis
-“Sanitation and hygiene, mental health” – group 5
-“Community based health information system” – group 5
“CHW should offer a wide range of services between curative, preventative, and environmental, adapted by country. The framework of thinking must be applied within adaptation to specific local settings.” – group 4
-“Communicable disease control, epidemiology.” – group 2
Should CHW prescribe or administer medicine?
Common Points
-Yes, but:
-Dependent on level of CHW training/specialization
-Dependent on complication of delivery
-Dependent on impact of intervention (life saving)
-Scope should be narrow and well-defined
-Supervision is very important
-Record keeping is critical
Group Specific Emphasis
-“No diagnosis/prescription of ARVS, but provision of adherence support.” – group 1
-“Based on health system/regulation of country- should be challenged.” – group 2
-“Should not prescribe, but should be able to dispense (sensitive to medical/nursing councils)” – group 3
What should the relationship between CHWs and professional health providers be?
Common Points
-Roles should be clearly defined
-Professional health providers should be responsible for supervision and training of CHWs
-CHWs should know when to refer to professional care
-Role of CHWs should be formally appreciated within the public health care system
-Groups differed on hierarchy/subordination
Group Specific Emphasis
-“Professionalizing of CHWs is necessary: integration into system with medical and nursing societies.” – group 3
-“Professional health providers need to delegate.” – group 5
-“Clinicians and nurses must consider CHWs as part of their team.” – group 3
-“Professionals should not overload CHWs.” – group 1
What is the mechanism for referral by CHWs?
Common Points
-Specific guidelines should dictate referral
-Referrals should be up and down for continuity of care/follow-up
-Information about referrals must go both ways for feedback and follow up
-Must distinguish between acute emergencies and complicated cases that allow time for referral
-Modes of transportation/communication (radio/phone) should be in place
-A credible reference place must be available
Group Specific Emphasis
-“CHWs should accompany the patient to health center for support and feedback.” – group 5
-“Referral system should respect decision by CHW.” – group 2
-“There is a role for CHWs to motivate individuals to be referred.” – group 1
-“CHWs are not a panacea; referral levels must be strengthened to receive referred patients.” – group 1
Points for discussion
-What should the title be?
-Should they be paid or volunteers?
-What will determine CHWs’ success and sustainability?
-Are CHWs health professionals?
-What are the implications of standardization for migration?
Question 3: What is the training of CHWs?
How long should pre-service training be?
Common Points
-Highly dependent on role and specialty and outcome of Questions 1 and 2
-Modular if possible
Group Specific Emphasis
-“6-12 months: curative interventions require more time.” – group 7
-“Training should be life-long; pre and in-service training is an outmoded idea.” – group 6
-“2 weeks to 3 months; CHWs should work for 3 months before learning another module.” – group 8
-“5-15 days of basic health promotion, with modular courses from 6-9 months.” – group 10
What should the curriculum for CHWs include?
Common points
-Hygiene
-Preventative/promotion aspects of community health
-Family planning
-Nutrient supplementation
-Safe childbirth services
-Infectious diseases
-Curative services
-Life saving skills (i.e. child health, malaria)
-Social mobilization skills
-Communication skills
-Reporting skills
Group Specific Emphasis
-“Treatment/diagnosis should be based on 1) level of training, 2) distance to hospital, 3) symptoms of patient: guidelines for treatment and when to refer should be clear.” – group 8
-“Management skills: data collections/analysis, gender consideration, IEC skills, concurrent evaluation of impact, indicators for performance and quality of service, referrals/” – group 9
-“Pain relief.” – group 10
Where should training take place?
Common Points
-As close to community as possible (with disease burdens reflective of future location of work).” – four groups
-Combination of theoretical and practical
-Exposure to appropriate clinical environment relevant to skills
Group Specific Emphasis
-“Community/locality as well as in health center or hospital setting.” – groups 8 and 9
Who should train CHWs?
Common Points
-Trained health professionals, trained as trainers – adult learning
-Multifaceted team of NGO/nurses/doctors to impart experience
Group Specific Emphasis
-“Trained professionals with public health experience.” – Group 8
“Peer training is important as well.” – group 8
-“Innovative technologies: e-learning videos.” – group 6
-“Nearby health facility staff for apprenticeship.” – group 6
-“NGOs could be involved, health facility staff, national training personnel.” – Group 7
-“Clinical staff with local knowledge/” – group 10
Describe what pre-service training for CHWs, including duration, substance, etc. should be
Common Points
-Lack of consensus on training length: dependent on CHW roles
-Training should include theoretical and practical learning
-Training scenarios in specific situations (culturally adaptive)
Group Specific Emphasis
-“CHWs should at minimum focus on nutrition, treatment of infectious disease and reproductive health and health promotion an prevention, making sure people are taking drugs when they should, but training should also be adaptive (i.e. culturally sensitive and specific to situation of location.” – group 8
-“Core skills: hygiene, growth monitoring, basic healthcare recording, referral system, nutrition, ethics, social mobilization.” – group 10
-“Limits must be established for all curative measures” – group 10
Describe what the in-service training for CHWs, including duration, substance, etc. should be
Common Points
-Training should be continuous throughout service
-Should not be disruptive
-Potentially linked to evaluation
Group Specific Emphasis
-“Training should be oriented to new policies and guidelines; in service training should be as brief as possible as not to impede care.” – group 7
-“Exemplary CHWs should be able to move onto higher cadres with additional training.” – group 6
-“If pre-service training is short, the in-service training can focus on more intensive skills such as life-saving skills, treatment.” – group 8
-“Evaluations will help determine future trainings and help CHWs to further develop their skills with additional attention and training.” – group 8
-“Absolute minimum is once a year for refreshment training, including organizational challenges and not just clinical.” – group 9
-“Substance: re-motivation, refresher courses, technical skills and new courses.” – group 10
Question 4: How are CHWs managed?
Who manages?
Common Points
-Linked to the public health systems an the national health structure, but can be operationalized through various providers, e.g. government, NGOs, FBOs
-Multi-layered management structures need to be identified
-One ultimate supervisor but regular interaction with community and stakeholders
Group Specific Emphasis
-“The government is the ultimate authority however they might have multiple stakeholders to report to (data) – government supervisors, health committee, NGOs, district office.” – group 6
-“An MOU should be established between stakeholders to define roles and responsibilities.” – group 6
-“Village health committee that provides feedback on any issues or challenges that arise from the community health work. Gives them an opportunity to communicate their expectations.” – group 7
-“Involve traditional structures in the community.” – group 9
How should they be supervised and by whom?
Common Points
-Professionals (i.e. nurses/doctors) and community members (i.e. village health committees) should be involved
-Feedback via evaluative tools (both theoretical/practical) should be employed
-Data collection by CHWs and supervisors is integral to the evaluation process
-“Adequate resources for supervision and support – transport, commodities etc. are essential – in short, all the elements of health system strengthening
Group Specific Emphasis
-“Existing facility nurses should not be overloaded with the additional responsibility.” – group 6
-“Monthly meetings to address concerns/questions, officer can monitor service delivery at this point.” – group 8
-“Training ream should be involved on an overview basis.” – group 10
How should supervisors be trained?
Common Points
-The specifics of training not detailed, but need to be tailored
-Supervisory training should include CHW management
-Supervisors should have leadership/facilitation training
-Direct supervisors should be in the locality and know the local situation
Group Specific Emphasis
-“Village health committees need terms of reference and orientation, while formal supervisors need training regarding supportive supervision.” – group 7
-“Village health committees should be strengthened and existing supervisory personnel should receive further CHW specific training.” – group 6
-“National level supervision tools should be adapted/devised and training deployed.” – group 10
Should the CHWs be paid or volunteer? (3 groups discussed)
Common Points
-If working significant time they should be paid
-Other incentives should be provided, such as continuing learning, certification, and bicycles
Group Specific Emphasis
-“Recognition that the CHW is an occupation within the health system and should be in the national legal framework.” – group 10
Are the supervisors paid or volunteer? (4 groups discussed)
Common Points
-If they are part of an existing paid structure, then they should not be paid extra
-Community committees should not be compensated for participation in management
Group Specific Emphasis
-“Clinical level supervisors should be paid by the ministry of health.” – group 8
-“This is part of their job description and should therefore not be paid extra 9but should be compensated for travel costs).” – group 10
-“Payment of village health committee is a local decision and should use local resources, whereas administrative and technical supervisors are already salaried.” – group 7
Points for Discussion
-Duration of training- overall and modular?
-CHWs and development of overall health system- what is needed for scale-up?
-Interrelationship between government and civil society- how to develop CHWs
-What should happen to existing vertical paid CHWs?
