Community Health Workers around the World Preliminary Results from the Community Health Systems Catalog 2017 CHW Symposium Kampala, Uganda February 21, 2017

Advancing Partners & Communities Project Objectives for community health systems strengthening Country Level: provide technical assistance in policy development, analysis, and implementation Global Level: support harmonization and community health policy efforts by developing practical tools and approaches

Community Health Systems (CHS) Catalog Documenting policy guidance across 25 countries First developed in 2014 Fills knowledge gaps about community health policy fragmentation  harmonization Accessed by researchers, policymakers, donors, and program managers Updating in 2016-2017 to reflect changing landscape of community health

Community Health Systems (CHS) Catalog Capturing health system components Leadership & governance Human resources for health Health management information systems Supply management Service delivery

Key questions What CHW approaches exist in each country? What are the CHW trends across countries? What are the policy gaps in CHW guidance?

Methods How was the CHS Catalog developed? Country experts: collected and reviewed country policy documents completed an electronic survey >50 questions about CHW programs >140 interventions CHWs deliver APC staff: verified information compiled and synthesized preliminary CHW data

Updated information for 15 countries Afghanistan Ghana Haiti India Liberia Madagascar Malawi Mali Nepal Nigeria Pakistan (Punjab) Philippines Senegal South Sudan Zambia

Policy guidance Across 15 countries… 59 main policies guiding community health (avg 3-4 per country) Over half (57.6%) created since 2012 Nearly a quarter (23.7%) since 2015 Quality: Clarity Consistency Comprehensiveness

CHW cadres 44 CHW cadres (avg 2-3 per country) CHW definitions differ: Volunteers Formally paid cadres Professionally trained Comprehensive primary health care services Specific health areas (e.g., FP, HIV)

Selection criteria Which criteria are important?

Selection process How are CHWs chosen? In Malawi, district-level officials recruit health surveillance assistants by posting advertisements and holding interviews.

Training How are CHWs trained? Duration varies from 2 days to 2 years 20% have a month or less of training Refresher trainings for 34.1% of cadres

Number of CHWs How many CHWs are recommended? How many exist? Varies by country and type of CHW No recommended number for 47.7% No actual number for 27.3% India example: CHW Recommended Actual GAP Aganwadi Worker (AWW) 1,366,766 1,174,388 -192,378 Accredited Social Health Activist (ASHA) 961,113 859,331 -101,782 Auxiliary Nurse Midwife (ANM) 178,963 212,185 +33,222

Coverage ratios What is a CHW’s coverage area? Expressed in terms of people; households; facilities; villages; etc. Often a range Adjust by context urban/rural (India, Zambia) geographic area (north/south) (Mali) terrain (hill/mountain/terai) (Nepal, India) No information (18.2%)

Coverage ratios How many people to each CHW? :

Coverage ratios How many households to each CHW? :

Incentives What type of incentives do CHWs receive?

Incentives What type of incentives do CHWs receive? Ghana, Haiti, India, Malawi, Mali, Nepal, Nigeria, Pakistan and Zambia all have salaried cadres Formal social recognition top nonfinancial incentive. In-kind payments Preferred access to loans Scholarships for CHWs’ children Free legal services Tickets for pilgrimages to holy sites

Incentives What type of financial incentives do CHWs receive? Ghana, Haiti, India, Malawi, Mali, Nepal, Nigeria, Pakistan and Zambia all have salaried cadres

CHWs in Senegal may receive tickets for pilgrimages to holy sites Incentives What type of nonfinancial incentives do CHWs receive? CHWs in Senegal may receive tickets for pilgrimages to holy sites

Accessing clients How do CHWs access clients? 84.1% of CHWs walk to their clients 61.4% may have clients come to them at a facility or their homes 43.2% may use bicycles 25.0% may use public transport 9.1% may use boats

Supervision Who supervises CHWs? In Madagascar, CHWs receive supervision and guidance from four different stakeholders. Who supervises CHWs? Three quarters of CHW cadres have more than one supervisor.

Health areas In which health areas do CHWs provide services? Over half of CHW cadres provide at least one service in ALL health areas.

Family planning Which family planning methods do CHWs provide?

Limitations Information is from policy Some community health activities not documented in policy Difficult to catch a moving target

Conclusions What are the key takeaways? More CHW information is available than previously Gaps in guidance include: Limited data on the number of CHWs Less information about processes (selection, supervision, training) Unclear information about the CHW scope of service

Thank you! Questions?

Photo credits: Slide 1/Cover: Dominic Chavez/World Bank; Morgana Wingard (USAID); Puskar Khanal (JSI-CNCP) Slide 5: Lauren Seibert Slide 8: Direct Relief Slide 9: Dave Llorito (WB) Slide 14: Puskar Khanal (JSI-CNCP) Slide 24: Graham Crouch (WB) Slide 25: Dominic Chavez/World Bank Slide 26: Graham Crouch (WB) Icons: http://www.flaticon.com/authors/ocha https://icons8.com/web-app/4359/Clinic http://www.freepik.com/free-vector/variety-of-family-icons_788328.htm