Webinar report: The unfinished agenda in community health

Sunday, 23 Jun 2019

By Lynda Keeru

The unfinished agenda in community health: the design, governance and quality of Community Health Worker (CHW) programs webinar was held on 22nd May 2019. It focused on two key issues the design of CHW programs and how best they can be linked with the wider evidence base.

The first presentation was by Helen Schneider who asked whether we should be considering who, first and foremost global “best practice” transferable across countries or national and local contexts (“best fit”) when it comes to designing, strengthening and governing national CHW programmes. This is particularly relevant as many national CHW programs – such as the Ethiopian Health Extension Worker Programme, the Indian Accredited Social Health Activists, or the Brazilian Family Health Teams - all have unique histories, cadres, characteristics and identities.

The second presentation by Lilian Otiso of LVCT Health, highlighted that in spite of investment in scale-up of CHW programs, the overall quality of care delivered by CHW programs is variable. Although quality is central to the new WHO guidelines for optimising CHW programs, they do not explicitly state how quality should be systematically measured and improved. There remains a paucity of quality improvement models applied to community health, and existing approaches are geared towards facility-based health care. The presentation shared a model developed by USAID SQALE, which successfully integrated quality improvement in CHW programs to improve maternal and child health outcomes in Kenya.

In a simple slide, Helen defined “best fit” as a concept in which programs are optimally adapted to the political, social and economic context. Such programs can take advantage of a plurality of possible solutions, which can be deployed flexibly. They often work at multiple levels simultaneously – from community to national and even global policy levels – in order to facilitate and bring about change.

Helen expounded that in order to successfully implement the “best fit” approach, there is need for programmers to understand the context. This is vital because deciding what can be replicated as is and what elements require adaptation. There is also need to recognize relational complexity which includes aspects like every day communication and relationships of trust in these particular communities. We were also encouraged to take into account the community’s history and capabilities - which encompasses their assets, governance and social characteristics - as these influence their decisions and actions. Design choices emerge from history and context and there is need to strengthen capacity for “best fit” governance.

Lilian explored the importance of embedding quality into community health programs. Kenya has a Kenya Quality Model for health for facilities but quality has been missing in community health programs. The USAID SQALE model adapted quality improvement to community Health and encouraged innovation and aligned with existing community health worker’s institutional structures and working practices to improve results. The process was led by the Ministry of Health leadership at different levels. The team found that overloading communities with complex concepts and theories does not work, and that short trainings with periods of implementation and support were most effective.  The challenges that were faced included a lack of tools (such as Government reporting forms) and other basic resources, a lack of stipends for CHWs, and health worker strikes.

The webinar sent the strong message that evidence and learning are critical to promote the scale up of CHW programs. This can include learning events as well as using platforms like collective communities of practice. “There is as much need for rigour and science in answering questions of ‘how to work’ as there is in answering questions of ‘what works,” said Helen.

The core of all programs should be to ensure empowerment of the communities they work in and careful not to apply one model in different contexts without considering the variations. Much stronger capacity is required for embedded research in CHW programs and more opportunities for South to South learning.  A paradigm shift and new agendas are needed in knowledge generation in community health and as one participant in the webinar observed, “We need to reverse the way we discuss community health programs and get more information and knowledge from the ground.”

There is need to continue strengthening the data collected at community level to ensure that it is used in decision making. The opportunity on the global movement around implementation research and quality improvement needs to be seized and integrated into donor and governments’ agendas and conversations.

Watch the webinar!