Community Health Workers

CHW Central Webinar - Integrating and scaling mobile community health data systems: Experience from India, Ethiopia and Madagascar


Mobile technologies show great promise in improving community health data, but how do we ensure they are integrated with national HMIS systems and how do we scale them to meet the need?

Measuring productivity and its relationship to community health worker performance in Uganda: a cross-sectional study

The Ugandan Ministry of Health (MoH) established Village Health Teams (VHT) to empower communities to take part in the decisions that affect their health. In Busia District these teams, comprised entirely of volunteers, are responsible for mobilizing their communities for health programs and strengthening the delivery of health services at the household level, especially for people living with HIV.

Tasks that these community health volunteers perform are critical and life-saving, such as:

  • mapping HIV patients in the community; linking patients to care;
  • engaging community groups to provide HIV patients with nutritional, psychosocial and financial support; and
  • supporting patient self-care through health goal setting.

This study, funded by PEPFAR through USAID, explores the relationship between productivity of community health volunteers and their performance. It aims to contribute to the global evidence on strategies to improve community health worker/volunteer (CHW/CHV) productivity and performance with an eye toward better understanding factors that could increase their effectiveness given the essential role that CHWs and CHVs play in health systems worldwide.

Read the full article in BMC Health Services Research.

How female community health workers navigate work challenges and why there are still gaps in their performance: a look at female community health workers in maternal and child health in two Indian districts through a reciprocal determinism framework

Accredited Social Health Activists (ASHAs) are community health workers tasked with delivering health prevention services and messages within communities, and linking the community services to the health care sector. This paper examines the social, cultural, and institutional influences that either facilitate or impede ASHAs’ ability to deliver services effectively through the lens of the reciprocal determinism framework of social cognitive theory.

This study was conducted through 98 semi-structured, in-depth interviews with ASHAs (n = 49) and their family members (n = 49) in Gurdaspur and Mewat districts in India.

We found that while the work of ASHAs led to some positive health changes in the community (which provided them with a sense of self-worth and motivation), community norms and beliefs, as well as health system attitudes and practices, limited their capacity as community health workers.

In the conclusion of this paper, we outline potential mechanisms for improving ASHA capacity, such as improved sensitization about religious, cultural, and gender norms; enhanced communication skills; and discuss how greater advocacy and support of their work by health and state officials could improve their ability to provide effective health messages and services in the community.

Read the full article on BioMed Central.

Improving Maternal and Newborn Care in Northern Uganda Change Package

A synthesis of the most robust, high-impact and evidence-based changes that resulted in facility and community-level improvements in the processes and systems of providing maternal and newborn care services

Uganda’s maternal and newborn mortality remains unacceptably high (438 maternal deaths per 100,000 live births and 27 per 1,000 live births respectively). Most of these deaths occur around the time of labour, delivery and immediate postpartum. The Saving Mothers, Giving Life (SMGL) initiative launched in 2012 focused on implementing existing high impact and evidence-based interventions to accelerate the reduction of maternal and newborn deaths in sub-Saharan African countries, starting with Uganda and Zambia (Phase I). It was designed to address the three major delays in health service delivery that are often associated with maternal and newborn deaths: a) delays in seeking appropriate care, b) inability to access the most appropriate care in a timely manner, and c) inconsistencies in the quality of care provided at health facilities.

Phase II of the initiative was scaling up to six districts of northern Uganda. This was supported by USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project through funding from USAID. Part of this phase was the community component which addressed the factors affecting pregnant women and their facilities to make decisions and reach facilities in a timely manner. The interventions to prevent and address gaps became the focus of USAID ASSIST’s quality improvement efforts.

This change package presents a synthesis of the most robust and effective changes in improving maternal and newborn care at health facilities and communities in 6 districts of northern Uganda. This package has two sections. Section I presents the community and Section II the facility level aims, indicators, results and key change ideas. Each result area describes a key change idea and detailed description of how the change was implemented and the result. The ideas are focused around the improvement objectives and results achieved.

Facilities and communities are to use these change ideas which they believe may work in their context. As they adopt these ideas they are to monitor performance using data to see whether it works in their setting or modify the ideas. Teams can use the change concepts to generate other change ideas.

Improving retention of clients on antiretroviral therapy through expert patients: Involving people living with HIV in Alebtong District, Northern Uganda

The World Health Organization’s (WHO) Integrated Approach to HIV Prevention, Care, and Treatment (IMAI) recommends adoption of people living with HIV (PLHIV) as community health workers (CHWs) to track patients who have not appeared at the clinic for at least three months (lost to follow-up [LTFU]) through contact tracing (home visits).

Since February 2015, the USAID Applying Science to Strengthen and Improve Systems (ASSIST) project has supported 137 health facilities in 15 northern Uganda districts to implement strategies to engage CHWs to ensure retention of HIV positive clients who are lost to follow up using a quality improvement (QI) approach. ASSIST, in collaboration with the district and health facilities in Alebtong District initiated a QI project to track and re-activate care for PLHIV who had not been seen in the clinic for at least three months at five antiretroviral therapy (ART) centers.

A baseline assessment conducted in January 2016 found only 88% (2591/ 2921) ever enrolled clients were active in care. Facility QI teams came up with an improvement aim to return 100% of the LTFU clients within 3 months and tested changes like: reviewing the ART registers and generating lists of LTFU clients; and assigning each lost client to be followed up by community linkage facilitators (CLF) who reside in the same or nearby village. Results received in April-June 2016 showed that of the 330 LTFU clients, 262 (79%) had been found alive and not on treatment and were brought back to care, 54 (19%) had self-transferred, and 12 (4%) had died. Involving expert clients to track LTFU from their own villages can help to bridge gaps related to retention rates and clients without additional human and financial resources.

Read the full case study here.


Read how David, an expert patient is taking lead in securing a future of people living with HIV at Rachuonyo patient support center in Kenya.


Improving community health worker performance and productivity: Findings from USAID-supported studies in Swaziland and Uganda

Community health workers (CHWs) play an essential role in HIV prevention, care, and treatment by improving linkages between those that need care and those that can provide it and by supporting retention in care and self-management for improved clinical outcomes. For this reason, the performance of CHWs in these roles is an important contributor towards increasing enrollment into care, reducing loss to follow-up, reaching care and treatment goals, and achieving the UNAIDS 90-90-90 targets.

The U.S. Government hosted an Evidence Summit in 2012 in which 49 experts reviewed over 400 publications to learn how best to support CHWs and optimize their performance. The final report from the summit concluded that “Despite many years of empirical inquiry on CHWs, the Summit found that the relationship between support—from both community and formal health systems—and CHW performance is still not well understood.” Current evidence does not provide answers to the questions of what are the most efficient and effective strategies to ensure optimal, sustained performance of CHWs at scale.

To help address the evidence gap for improving the performance and productivity of CHWs, the United States Agency for International Development (USAID), with funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), commissioned several studies through the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project to identify factors that increase CHW productivity and performance and facilitate evaluation and policy towards improvement in CHW performance. 

This short report describes the main findings from two of these studies: the Swaziland CHW program performance evaluation, and the Uganda village health team productivity and performance study. Papers with complete findings are in preparation.

Sustaining CHW Programs in the HIV Response: Lessons Learned from the United States

Community health workers (CHWs) have an important role in the HIV response globally, especially to increase coverage, uptake, and retention of HIV services at the community level, to reach the 90-90-90 targets. In HIV-burdened countries, PEPFAR has recognized the need to strengthen CHW program functions to increase the impact and sustainability of HIV services. These key functions include training, supervision, mentorship, role definition, recognition, linkages, incentives, and career advancement.

The rich experience with CHWs in the United States offers lessons for PEPFAR-supported countries about building, growing, and sustaining strong CHW associations; providing training, mentorship, and advocacy; and engaging CHWs with the formal health system. CHWs in the United States are culturally diverse and work in underserved areas, much like communities served by CHWs globally.

To explore lessons from the US experience for CHW programs in the HIV response, USAID, the USAID ASSIST Project, and CHW Central organized a webinar on November 30, 2016 that brought together CHW leaders and organizers from California, Florida, Massachusetts, and Wisconsin. This short report summarizes key themes and takeaways from the webinar.

Empowering women health care workers through quality improvement

Taroub Faramand

Founder and President, WI-HER, LLC

(Staff at an ASSIST-supported health facility. Photo by Taroub Faramand, WI-HER, LLC)