Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach.
BACKGROUND
There is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients' health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems - the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated.


METHODS
We explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component.


RESULTS
We identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system.


CONCLUSIONS
We believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.
United States Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington, DC, 20523, USA. jnaimoli@usaid.gov.
Joseph F
JF
Naimoli
Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA. heperry@jhsph.edu.
Henry B
HB
Perry
Population Council, 4301 Connecticut Avenue, NW, Washington, DC, 20008, USA. jtownsend@popcouncil.org.
John W
JW
Townsend
United States Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington, DC, 20523, USA. dfrymus@usaid.gov.
Diana E
DE
Frymus
Training Resources Group, 4401 Wilson Boulevard, Arlington, VA, 22203, USA. jmccaffery@trg-inc.com.
James A
JA
McCaffery
D002983:Clinical Competence; D003150:Community Health Workers / Q000458:organization & administration* / Q000592:standards; D003159:Community-Institutional Relations; D003299:Cooperative Behavior; D003906:Developing Countries; D006298:Health Services Administration; D006801:Humans; D009042:Motivation; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration* / Q000592:standards; D035502:Trust