Reviews of community health programs have shown these five components are most important to a successful program:
1) Community Health Workers (CHWs) are chosen by the community in which they live and they maintain close ties with the community.
Some programs have allowed CHW positions to be "rewarded" positions based on local politics. When positions are simply political rewards or when the workers are not local, they may lack the needed motivation.
2) CHWs have clearly defined roles.
As stated in the Lancet, "CHWs will probably perform better with clearly defined roles and a limited set of specific tasks than if they are expected to undertake a wide range of tasks."
3) Effective training and ongoing supportive supervision.
Training is not enough. It has been shown that a plan for regular supportive supervision of CHWs is important to their success, their morale, and their continued satisfaction as CHWs.
Effective training focuses not on curative care but on health education and prevention. It has been found that most CHW trainings focus overwhelmingly on curative care despite their stated goal of providing preventive training, and this generally makes CHWs less effective than they can be. As a Lancet review paper states, "much greater attention should be given to practical, task-oriented training….Curative care provided by CHWs is unlikely to have a significant impact on mortality." Again, "CHW programs have often included simple curative care to create interest and meet felt needs, and there is a marked tendency to neglect the preventive and promotive services."
4) Incentive systems.
Most early studies of community health programs assumed that volunteers were best, but, since those early days, most studies have shown than an incentive system, monetary or otherwise, retains more workers and keeps them more satisfied in their role. High worker attrition destabilizes a program and can prevent it from gaining momentum because of the need for continuous replacements, the high training costs, and the increased difficulty of managing such a program. Some effective programs have salaried workers, others give honorariums, and others provide t-shirts, badges, bags, and other non-monetary incentives. Whatever is done, most effective programs provide their CHWs with some form of incentives.
5) Support for the CHWs and their work by health professionals.
Several studies have concluded that the single most important factor in determining the success of a CHW program is the support and respect that the workers receive from health professionals. Yet, the cultural gaps between the health professionals and the community workers are usually so great that this becomes the single biggest barrier to an effective community health program.
I will use the next post to further explain what the studies show about the relationship between community health workers and health professionals and how that relationship is so critical to an effective CHW program.