USG CHW Evidence Summit

-Highlights-

10/12/2012

Joseph F. Naimoli (OCS), Estelle Quain (OHA),Diana Frymus (OHA), Emily Roseman (OHA)

What is an Evidence Summit?

Decision

making

Review the

evidence

Development challenges

Academics + development practitioners

Questions of policyand programmaticsignificance and relevance

Development Challenge

Global shortage of skilled, motivated, and supported health workers

Strengthening health systems

Achieving MDGs and UHC

Achieving equity, reducing poverty

Development Challenge

Global shortage of skilled, motivated, and supported health workers

RESPONSE:

Emergence of alliances and coalitions toaddress the challenge

Resurgence of interest in and attention toCommunity Health Workers (CHWs)

Why Community Health Workers?

Extend the reach of inadequate health systems (provide essential services to hard-to-reach, vulnerable populations)

Expand coverage of key interventions

Increased investment in large-scale programs

Concern about the strength of evidence behind existing normative guidance (uncertain)

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Evidence Summit Phases

I. Pre-summit

II. Summit

III. Evidence-to-Action

Pre-Summit

Preliminary conceptual thinking

Focal questions/hypothesis

Assembly of the literature

Convening of evidence review teams and assignment of FQs

ERT refinements (conceptual frameworks, questions, literature)

Literature review and synthesis

Approximately 90% of work completed beforethe 2-day Summit Event!

Evidence Summit Event

150 Summiteers (incl. ERTs)

Non-ERT summiteers reviewed, reacted to ERT

work

Country experiences (Liberia, So. Africa, Vietnam, Zambia, India)

May 31-June 1, 2012

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Findings

FQs/Hypothesis

CHWStewardship

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Findings

FQs/Hypothesis

CHWStewardship

Findings: RQs, Hypothesis

• CHWs can successfully deliver a range of preventive, promotional, and curative services

• CHWs can contribute to improved coverage and positive health outcomes

“Our findings show that indigenous community workers can effectively detect and treat pneumonia, and reduce overall child mortality, even without other primary care activities.”

(Pandey, Daulaire, Starbuck, Houston and McPherson, 1991, The Lancet, Reduction in total under-five mortality in western Nepal through community-based antimicrobial treatment of pneumonia)

Findings: RQs, Hypothesis

• CHWs receive technical and social support, as well as recognition, from communities and health systems

• Experts have identified different kinds of support provided by communities and health systems likely to improve CHW performance at scale

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Findings: RQs, Hypothesis Community

• Community participation/involvement in CHW selection, all aspects of CHW programming (design, mgmt., implementation, monitoring, evaluation)

• Community structure support: health committees, oversight bodies, women’s groups, family, kinship

• Community provision of non-financial, in-kind, financial incentives Non-financial: praise, respect, feedback

In-kind: animals, food, gifts Financial: fee for service, supplemental income from sale of medicines

and other health-related products; regular remuneration

• Community strengthening of relationships among CHWs (facilitation CHW membership in CHW associations)

CONTEXT MATTERS!

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Findings: RQs, Hypothesis Formal health system

• Ensuring clarity of role/feasible, manageable scope of work

• Ensuring consistent availability of drugs, commodities, tools, supplies, equipment

• Providing high quality, competency-based pre- and in-service training

• Providing job aids and other materials

• Feedback, supervision, performance monitoring

• Incentives (financial and non-financial)

• Effective linkages with formal health system and health care workers

• Support from national and local government entitiesCONTEXT MATTERS!

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Findings: RQs, Hypothesis Combined support from both systems

• Shared ownership of CHW programs through joint collaboration in program design

• Joint supervision

• Negotiated and coordinated package of incentives, whereby the formal health system provides financial incentives, while community and health system provide non-financial incentives

• Development of a practical information system that captures data from both the formal health system (e.g., health records, supervisor observations, etc.) and community system (e.g., community member feedback, individual CHW feedback, etc.) that both systems use to enhance CHW performance

• Strengthen linkages between communities and health systems to enhance performance and mitigate unintended consequences

CONTEXT MATTERS!

Findings: RQs/Hypothesis

• The EVIDENCE in support of expert opinion is weak

• Not because rigorous studies demonstrate lack of effect!

• FQs about support-performance relationship not commonly asked or investigated with rigor!

Community system

Formal health system

CHW

However!

Findings: RQs/Hypothesis

• Furthermore:– Studies are often short-term, small-

scale pilots, rural focus– Interventions often poorly described– Multi-arm comparisons of the

relative effectiveness of different programmatic interventions (technical vs. social vs. recognition) not investigated

– Large-scale, system-level interventions rarely studied

– Bias toward distal measures of performance with less understanding of intermediate measures and even less of proximate

• Feasible, affordable, appropriate ways to provide support not well documented

Community system

Formal health system

CHW

However!

Findings: RQs/Hypothesis

• We have strong colloquial knowledge but weak evidence about the support-performance relationship!

• This knowledge comes primarily from observation, implementation, M&E

• This knowledge drives current guidance

• Undocumented or inaccessible program experiences may address these focal questions

Community system

Formal health system

CHW

Conclusion

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Findings

FQs/Hypothesis

CHWStewardship

Findings/CHW Stewardship

National:

1) Fragmentation: multiple actors/programs making demands on CHWs Q: Who is responsible for overall welfare of the CHWs?

Q: Specialized or all-purpose CHWs?

2) Variation linked to history and purpose

Global:

1) Fragmentation: concurrent meetings

2) Leadership: Is GHWA up to the challenge?

Recommendations: Global

1. Refocused research agenda: answer RQ of policy and programmatic significance for CHW programs operating at scale

2. Capacity building of LMIC investigators

3. Prospective/retrospective documentation of large-scale programs (implementation science)

4. Better stewardship: country and global levels

5. Logic model to guide programming, M&E, OR

E2A AgendaUSAID

Publications

Stewardship

Publications strategy

Summary paper

CHW Logic Model

Case Study

StewardshipChallenges

1 Can we achieve an increased understanding of the depth and breadth of USAID investment in CHW programming?

2 What is the value for money of current investments in CHW programming?

3 How can we address the Summit focal questions through existing and new OR efforts?

4 How can we increase Agency visibility/leadership vis-à-vis external partners?