Developing and Strengthening Community Health Worker Programs at Scale A Reference Guide and Case Studies for Program Managers and Policymakers Henry Perry and Lauren Crigler, Editors Steve Hodgins, Technical Advisor The Maternal and Child Health Integrated Program (MCHIP) is the United States Agency for International Development (USAID) Bureau for Global Health’s flagship maternal, neonatal and child health program. MCHIP supports programming in maternal, newborn and child health, immunization, family planning, malaria and HIV/AIDS, and strongly encourages opportunities for integration. Cross- cutting technical areas include water, sanitation, hygiene, urban health and health systems strengthening. www.mchip.net This report was made possible by the generous support of the American people through USAID, under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-08-00002-00. The contents are the responsibility of MCHIP and do not necessarily reflect the views of USAID or the United States Government. © 2014 by Jhpiego Corporation. All rights reserved. Table of Contents SECTION 1: SETTING THE STAGE Chapter 1. Introduction (Steve Hodgins, Lauren Crigler, and Henry Perry) Chapter 2. A Brief History of Community Health Worker Programs (Henry Perry) Chapter 3. National Planning for Community Health Worker Programs (Jessica Gergen, Lauren Crigler, and Henry Perry Chapter 4. Governing Large-Scale Community Health Worker Programs (Simon Lewin and Uta Lehmann) Chapter 5. Financing Large-Scale Community Health Worker Programs (Henry Perry, Francisco Sierra-Esteban, and Peter Berman) Chapter 6. Coordination and Partnerships for Community Health Worker Initiatives (Muhammad Mahmood Afzal and Henry Perry) SECTION 2: HUMAN RESOURCES Chapter 7. Community Health Worker Roles and Tasks (Claire Glenton and Dena Javadi) Chapter 8. Recruitment of Community Health Workers (Wanda Jaskiewicz and Rachel Deussom) Chapter 9. Training Community Health Workers for Large-Scale Community-Based Health Care Programs (Iain Aitken) Chapter 10. Supervision of Community Health Workers (Lauren Crigler, Jessica Gergen and Henry Perry) Chapter 11. What Motivates Community Health Workers? Designing Programs that Incentivize Community Health Worker Performance and Retention (Christopher J. Colvin) SECTION 3: CHW PROGRAMS IN CONTEXT Chapter 12. Community Health Worker Relationships with Other Parts of the Health System (Henry Perry, Steve Hodgins, Lauren Crigler, and Karen LeBan) Chapter 13. Community Participation in Large-Scale Community Health Worker Programs (Karen LeBan, Henry Perry, Lauren Crigler, and Chris Colvin) i SECTION 4: ACHIEVING IMPACT Chapter 14. Scaling Up and Maintaining Effective Large-Scale Community Health Worker Programs (Steve Hodgins, Lauren Crigler, Simon Lewin, Sharon Tsui, and Henry Perry) Chapter 15. Measurement and Data Use for Services Provided by Community Health Workers (Steve Hodgins, Dena Javadi, and Henry Perry) Chapter 16. Wrap-Up (Henry Perry, Lauren Crigler, and Steve Hodgins) APPENDIXES Appendix A. Case Studies of Large-Scale Community Health Worker Programs: Examples from Afghanistan, Bangladesh, Brazil, Ethiopia, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe (Henry Perry, Rose Zulliger, Kerry Scott, Dena Javadi, Jessica Gergen, Katharine Shelley, Lauren Crigler, Iain Aitken, Said Habib Arwal, Novia Afdhila, Yekoyesew Worku, Jon Rohde, and Zayna Chowdhury) Appendix B. Current Perspectives on Large-Scale Community Health Worker Programs: Summary of Findings from Key Informant Opinions (Sharon Tsui, Elizabeth Salisbury- Afshar, Rose Zulliger, and Henry Perry) Appendix C. Important Resources (Henry Perry) ii Authors and Their Affiliations SENIOR WRITING TEAM Lauren Crigler, Crigler Global Consulting, formerly with the USAID-funded Health Care Improvement (HCI) Project Claire Glenton, Norwegian Knowledge Centre for the Health Services Steve Hodgins, Saving Newborn Lives, formerly with Maternal and Child Health Integrated Program (MCHIP) Karen LeBan, the CORE Group Simon Lewin, Norwegian Knowledge Centre for the Health Services and Medical Research Council of South Africa Henry Perry, Department of International Health, Johns Hopkins Bloomberg School of Public Health OTHER SENIOR AUTHORS Muhammad Mahmood Afzal, Coordinator, Global Health Workforce Alliance Iain W. Aitken, Advisor on Community-Based Health Care to the Ministry of Public Health, Afghanistan, through Management Sciences for Health from 2004 to 2012 Christopher Colvin, School of Public Health and Family Medicine, University of Cape Town (South Africa) Jessica Gergen, Johns Hopkins Bloomberg School of Public Health Wanda Jaskiewicz, CapacityPlus/IntraHealth International Sharon Tsui, Johns Hopkins Bloomberg School of Public Health COLLABORATING AUTHORS Novia Afdhila, Johns Hopkins Bloomberg School of Public Health Shelly Amieva, Johns Hopkins Bloomberg School of Public Health Said Habib Arwal, Community-Based Health Care Department, Ministry of Public Health, Afghanistan Peter Berman, Harvard School of Public Health Zaynah Chowdhury, Johns Hopkins Bloomberg School of Public Health Rachel Deussom, CapacityPlus/IntraHealth International Dena Javadi, Johns Hopkins Bloomberg School of Public Health Uta Lehman, University of Western Cape School of Public Health (South Africa) iii Jon Rohde, James P. Grant School of Public Health, BRAC University (Bangladesh) Elizabeth Salisbury-Afsar, Johns Hopkins Bloomberg School of Public Health Kerry Scott, Johns Hopkins Bloomberg School of Public Health Katharine Shelley, Johns Hopkins Bloomberg School of Public Health Francisco Sierra-Esteban, London School of Hygiene and Tropical Medicine Yekoyesew Worku, Clinton Health Access Initiative/Zambia Rose Zulliger, Johns Hopkins Bloomberg School of Public Health iv Acknowledgments This volume summarizes the collective knowledge, experience, and wisdom of many people, programs, and organizations. We are grateful to the many contributors to this work. We are particularly grateful to MCHIP and USAID for the financial support which made this work possible. Earlier drafts of this volume were reviewed in whole or in part by many people, and we appreciate all the comments that led to a stronger product than would have been the case otherwise. Those whose comments on earlier drafts were limited to a single chapter are acknowledged in that chapter. Others who reviewed all or large parts of this document whose contributions we deeply appreciate include Jon Rohde, David Sanders, William Brieger, Anne Liu, Muhammad Mahmood Afzal, John Stanback, Mary Lou Fisher, Seyi Soremekun, Vikas Dwivedi, members of the CORE Group staff, attendees at the CORE Group meeting in the fall of 2013, and numerous staff members at the USAID Bureau of Global Health. v Preface and Guide to the Reader Welcome to Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers (the CHW Reference Guide). This guide is a long and detailed volume that is not intended to be read from cover to cover but rather to be used as a document that can be referred to as specific issues or questions arise. In this sense, you will find some repetition. We have also tried to refer the reader to other chapters where appropriate because many topics and issues are covered in various ways in different chapters. For readers who want a quicker and perhaps easier-to-use reference, we encourage a look at the recently released Decision-Making Tool for CHW Programs (the CHW Decision Tool) developed by the Health Care Improvement Project, Applying Science to Strengthen and Improve Systems Project of the University Research Corporation (URC) , supported by USAID. This tool is designed to support national and local decision-makers through the design, planning, and scale- up of CHW programs. The CHW Reference Guide is a more in-depth review of issues and questions that should be considered when addressing key issues relevant for large-scale CHW programs. Like the CHW Decision Tool, the CHW Reference Guide is designed for new CHW programs that are beginning the planning process as well as for existing programs that are being strengthened or scaled up. Like the CHW Decision Tool, the CHW Reference Guide is meant for in-country use by national- level policymakers and planners as well as program implementers. It has many practical examples from CHW programs around the world. Unlike the CHW Decision Tool, the CHW Reference Guide is meant to be a stand-alone document that is read essentially like a reference book. It provides an in-depth look at specific questions of central relevance to large-scale CHW programs. It also has appendixes with a summary of in-depth interviews with key informants who have had extensive experience in working with large-scale CHW programs; a series of in- depth and detailed case studies of CHW programs from Afghanistan, Bangladesh, Brazil, Ethiopia, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe; and a list of important resources for CHW program managers and policymakers. • Both CHW resources offer guidance and support on issues related to CHW program governance, planning, financing, health system support, community collaboration, recruitment and selection, tasks and roles of the CHW, training, incentives, logistical support, scaling up, and monitoring and evaluation (M&E). The CHW Reference Guide contains a history of CHW programming around the world. The CHW Decision Tool contains links