Strengthening CHW Programs

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.

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 health workers to improve health and nutrition services for males and females in Zambia

Elizabeth Romanoff Silva


Last month I had the opportunity to travel to Zambia to provide gender technical assistance to the USAID ASSIST-supported nutrition assessment, counseling and support (NACS) services. Gender inequality is a major factor affecting vulnerability to malnutrition, especially for people living with HIV, so I was especially interested in working with health workers to identify the different issues preventing males and females from accessing services, issues affecting their nutrition status, and to identify the root causes preventing improved nutrition among women, men, girls and boys, and developing changes to test to find solutions.

Supporting close-to-community providers through a community health system approach: case examples from Ethiopia and Tanzania

This Case Study, published in Human Resources for Health (2015) 13:12, describes how the Community Health System Strengthening model, developed with support from PEPFAR as a strategy to improve community health worker performance, was applied in Ethiopia and Tanzania to increase HIV testing and enrollment and retention in care.

Community Health System


A Community Health Worker “logic model”: towards a theory of enhanced performance in low- and middle-income countries

This article published in Human Resources for Health (2014; 12:56  doi:10.1186/1478-4491-12-56) describes a generic logic model for community health worker (CHW) performance that posits that optimal CHW performance is a function of high quality CHW programming, which is reinforced, sustained, and brought to scale by robust, high-performing health and community systems, both of which mobilize inputs and put in place processes needed to fully achieve performance objectives. The article discusses the multiple contextual factors that influence CHW programming, system functioning, and CHW performance.

The value of this model is that it places CHW performance at the center of the discussion about how to strengthen CHW programming, reflecting the current evidence and experience about support for improving CHW performance. The model is also a practical tool that offers guidance for continuous learning about what works. Despite the model’s limitations and several challenges in translating the potential for learning into tangible learning, the CHW generic logic model provides a solid basis for exploring and testing a causal pathway to improved performance.
Generic CHW Logic Model