CHWs (15) What are your thoughts on the Guideline? (7) 15 policy questions

3 June, 2019

Dear Amelia, (we invite input from HIFA members who have been involved in the development of the WHO Guideline - please see below)

You make an important point: "As we go through each recommendation and discussion, we should keep in mind the questions that the guideline addressed, and the ones it omitted. There are opportunities for future research and some nuanced understanding that may not have been settled by the guideline. Where should we go from here in our research?"

The WHO Guideline (fulltext version) provides some background on this (page 24), as follows:

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The guideline follows a health system approach. Specifically, it identifies the policy and system enablers required to optimize design and performance of CHW initiatives; within this overall structure, a gender and decent work lens was adopted, in particular in relation to recommendations where those aspects were most relevant. The 15 policy questions that guided the research and informed the recommendations can be structured into three broad categories:

SELECTION, EDUCATION AND CERTIFICATION

1. For CHWs being selected for pre-service training, what strategies for selection of applications for CHWs should be adopted over what other strategies?

2. For CHWs receiving pre-service training, should the duration of training be shorter versus longer?

3. For CHWs receiving pre-service training, should the curriculum address specific versus non- specific competencies?

4. For CHWs receiving pre-service training, should the curriculum use specific delivery modalities versus not?

5. For CHWs who have received pre-service training, should competency-based formal certification be used versus not used?

MANAGEMENT AND SUPERVISION

6. In the context of CHW programmes, what strategies of supportive supervision should be adopted over what other strategies?

7. In the context of CHW programmes, should practising CHWs be paid for their work versus not?

8. In the context of CHW programmes, should practising CHWs have a formal contract versus not?

9. In the context of CHW programmes, should practising CHWs have a career ladder opportunity or framework versus not?

INTEGRATION INTO AND SUPPORT BY HEALTH SYSTEM AND COMMUNITIES

10. In the context of CHW programmes, should there be a target population size versus not?

11. In the context of CHW programmes, should practising CHWs collect, collate, and use health data versus not?

12. In the context of CHW programmes, should practising CHWs work in a multi-cadre team versus in a single-cadre CHW system?

13. In the context of CHW programmes, are community engagement strategies effective in improving CHW programme performance and utilization?

14. In the context of CHW programmes, should practising CHWs mobilize wider community resources for health versus not?

15. In the context of practising CHW programmes, what strategies should be used for ensuring adequate availability of commodities and consumable supplies over what other strategies?

These questions have not been addressed through previous WHO guidelines and represent the core focus of this guideline.

This guideline did not appraise critically the body of evidence on which specific health services CHWs can deliver to

quality standards, and thus it contains no recommendations regarding these aspects. Published evidence and existing WHO guidelines encourage the delegation of certain tasks relating to prevention, diagnosis, treatment and care, for example for HIV, tuberculosis (TB), malaria, other communicable and noncommunicable diseases, a range of reproductive, maternal, newborn and child health services, hygiene and sanitation, ensuring clients’ adherence to treatment, rehabilitation and services for people affected by disabilities, and advocating and facilitating underserved groups’ access to services (Figure 2 and Annex 2). Current (and future) disease-specific WHO guidelines remain the primary source of normative guidance on which specific preventive, promotive, diagnostic, curative and care services CHWs are effective in providing (Annex 3).

In addition to the delivery of interventions at the individual and family levels, there is long-standing recognition of the potential for CHWs to play a social and political role at the community level, related to the action on social determinants of health for the transformation of living conditions and community organization. This dimension includes participatory identification with the community of health problems and a reorientation of the concept and the model of health care (26, 27).

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It would be really excellent to hear more from HIFA members who were involved in the development of the guideline and, specifically, in the identification and selection of the 15 research questions.

(One might note that all WHO guidelines are developed in a hugely more rigorous and systematic manner than they were less than 20 years ago. Prior to that, they were based largely on expert opinion. Since 2003 WHO

guidelines emphasize systematic reviews of evidence.)

Best wishes, Neil

Coordinator, HIFA Project on Community Health Workers

http://www.hifa.org/projects/community-health-workers

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org