Abstract
BackgroundWith the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries.MethodsA review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input.ResultsTwenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited.ConclusionsBetter data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.
Highlights
With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all
We identified 34 frameworks (Box 1) that peripherally addressed this objective, including but not limited to the CHW Assessment and Improvement Matrix (CHW Community Health Worker Assessment and Improvement Matrix (AIM)) [18], CHW logic model proposed by Naimoli et al [6], United States Agency for International Development (USAID) Community Health Framework [19], and the Primary Health Care Performance Initiative (PHCPI) conceptual framework [20]
The proposed framework and indicators are a critical first step to addressing a long-acknowledged gap in identifying relevant, pragmatic, and contextually appropriate indicators to monitor the performance of CHW programs
Summary
With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. The 40th anniversary of the Declaration of Alma-Ata was a global call to re-invigorate efforts to achieve health for all through strengthening PHC systems [2, 3]. Since Alma-Ata, community health worker (CHW) programs in LMICs have been promoted to strengthen broad-based health efforts within community settings. CHWs, who for the purposes of this paper, refer to frontline health workers with up to 6 months of initial training, serve as the first point of contact for community members, especially for individuals living in low-income or rural communities whose access to facility-based health care may be limited. Often as community members themselves, CHWs possess a unique understanding of the local context, including barriers and facilitators to accessing timely and quality PHC, and can facilitate the most effective linkages to care
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