A male health care worker attends to a small child as he sits in his mother’s arm.
An Ethiopian health extension worker measures the mid-upper arm circumference of a child.

Integrating national community health worker programs into health systems

One of the challenges for community health systems is the linkage with the formal public health system. The WHO community health worker guidelines note that ‘successful CHW programs are integrated in the communities they serve and the health systems to which they connect’ (WHO, 2018, pg. 7).

Why do you think integration into communities and linkage with the formal health system might be a challenge?

One way to look at this is to consider that the CHW is between the community and the formal health system, but may not be accepted as a full member of either – not really a ‘proper’ health worker, and yet not an ordinary community member.

We can look at this challenge from each side:

From the perspective of the health system, it has been found that a CHW program is more acceptable to the health system if:

  • It helps solve a pressing problem, and does not disrupt existing professional privileges;
  • There is high level political support; and
  • The CHW program is compatible with the health systems’ governance, financing and training functions.

Factors that inhibited the integration process included:

  • too rapid scale-up;
  • discrimination against CHWs based on social, gender and economic status;
  • inappropriate incentive structures;
  • inadequate infrastructure and supplies; and
  • problems related to communication processes.

You can read more about this in the article by Zulu and colleagues (2014) in the ‘see also’ section below.

The integrated community case management of childhood illness (iCCM) program is an example of expanding an existing health service program (the integrated management of childhood illness or IMCI) by integrating with a community health element. While the IMCI program targets care of children in health facilities, the iCCM program targets care of sick children in the community.

For example, in Ethiopia, CHWs (Health Extension Workers or HEWs) were provided with a six-day training in iCCM, strengthened supervision, and essential commodities to implement the iCCM program. An evaluation found that HEWs in the intervention areas performed basic assessment tasks and correctly managed approximately two-thirds of all children with minimal over-prescription of drugs; while adherence to clinical guidelines was as high as those for health workers at hospitals and health centres (Miller et al, 2014).

Interestingly, despite the good quality of care provided by the HEW through the iCCM program, very few children - and virtually no children under 2 months of age - accessed care from HEWs. This suggests that the community engagement side of the program needed further strengthening, which leads us to the second side of the CHW’s role, engaging the community.

WHO guidelines recommend:

  • Involving communities in selecting CHWs and promoting program use;
  • Engaging relevant community representatives in planning, priority setting, monitoring, evaluation and problem-solving; and
  • Supporting CHWs in engaging the community and mobilising local resources to address key health problems.

However, the issue of the role and position of CHWs between the health system and the community remains contentious.

The last word on the integration of CHW programs into country health systems is yet to be said. Many argue that to retain their community orientation, CHW programs should actively resist absorption within formal health services, with better embedment within communities rather than greater integration with the health system as the aspiration.

But assuming that there are benefits of better integration of CHW programs within health systems, the broader principles of integration still hold. Only those functions which when integrated will lead to gains in efficiency, effectiveness and equity, should be integrated, and not all.


What do you think the benefits of greater integration into the formal health system might be for CHWs and for the programs they deliver?

What do you think might be the potential problems or issues that could arise from too much integration? (Think about how CHW might be viewed by the community; and how they might be used or abused by other health workers in the formal system).


References
Miller, NP, Amouzou, A, Tafesse, M, Hazel, E, Legesse, H, Degefie, T, Victora, CG, Black, RE & Bryce, J, 2014, ‘Integrated community case management of childhood illness in Ethiopia: implementation strength and quality of care’, The American journal of tropical medicine and hygiene, vol. 91, no. 2, pp. 424-434.
World Health Organization, 2018, ‘WHO guideline on health policy and system support to optimize community health worker programmes’, World Health Organization.
World Health Organization, 2018, ‘WHO guideline on health policy and system support to optimize community health worker programmes – Selected highlights’, World Health Organization.
Zulu, JM, Kinsman, J, Michelo, C & Hurtig, AK, 2014, ‘Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries’, BMC public health, vol. 14, no. 1, p. 987.

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