Moving Toward a Better Vision of What Community Health Worker Programs Can Be

By Lauren Crigler and Donna Bjerregaard, Initiatives Inc.

Initiatives Inc

Community health workers (CHWs) are the ultimate frontline health workers in many health systems around the globe, playing a vital role in extending services to the most underserved populations.  Last month, 60 decision-makers, program implementers, and partners representing six African countries gathered in Addis Ababa, Ethiopia to find common ground on tools and approaches that can realize the full potential of CHW programs, which have grown in size and scope across the world. The positive effects of CHW programs in contributing to better maternal and child health outcomes have been documented, but so too have the multiple challenges of managing CHW programs and ensuring quality services.

The meeting, sponsored by USAID through its Health Care Improvement Project, and with support of the Federal Ministry of Health of Ethiopia and UNICEF, focused on three major issues facing CHW programs: functionality (quality performance and effectiveness), sustainability (capacity of countries to continue programs that currently rely on donor funding and implementation assistance), and scalability (how to scale up programs to cover more communities or service needs).

Six countries were represented: Ethiopia, Uganda, Rwanda, Kenya, Zambia and Mali. The Ministry of Health of each country presented on their CHW program, including both NGO/partner-supported and government- supported efforts. The presentations demonstrated that with strong government support, a variety of large-scale CHW mechanisms are possible across different countries—from the salaried Health Extension Workers of Ethiopia to the 45,000-strong cadre of volunteer community health workers in Rwanda.

Part of the meeting focused on how implementers have used a tool developed with USAID support to guide implementers in identifying weak areas in CHW programs and identifying specific actions to improve program functionality.  The CHW Assessment and Improvement Matrix (CHW AIM) tool facilitates participatory self-assessment about program strengths and weaknesses and action planning. Many participants commented that CHW AIM helped them create a platform for identifying what their critical CHW program issues were, while others were using its criteria for functionality to strengthen specific program components, like supervision.

While the meeting did not generate grand statements, there was a strong feeling among those of us gathered that we now have a broad consensus about how to make CHW programs function well. There is solid agreement that CHWs, whether paid or volunteer, need certain kinds of support and that communities do need to be involved in selecting, supporting, and supervising CHWs.  In her keynote address, Dr. Miriam Were of Kenya recognized that many different options for such support are possible, including team-based support, peer-to-peer support, and community involvement.

There is also more acceptance now that CHWs need opportunities for growth and advancement. For example, professional advancement—five years ago, people weren’t sure this was an appropriate issue for CHWs.  Now, we think few would question its relevance to sustaining the engagement of community level health agents.

Two key needs emerged from country decision-makers: They want evidence to help guide decision-making about how to operate CHW programs at national scale, and, once programs are functional, how do you sustain that?    Participants brainstormed about scalability and sustainability to identify key questions that needed to be addressed before a program should move to scale up and questions to guide the design of sustainable programs. Questions generated in small group discussions were discussed in plenary, consolidated and re-presented to the participants on the final day of the conference in the form of checklist for assessing readiness for scalability of CHW programs.  These questions will continue to be discussed on, an online community that supports CHW program implementers.

Ideas from the meeting are now informing the development of a CHW program decision-making tool—a new tool to help decision-makers grapple with the tough questions about how to design (e.g., pay or not pay) and discuss the implications of each.

Overall feedback from the participants was very positive; each country left with an action plan to help them introduce new ideas in their CHW programs. As one participant said, “It was wonderful to have so many stakeholders from our corner of the world sharing relevant ideas, experiences, and feedback. I feel like we’re really moving toward a better vision of what our programs can be, what they can achieve, and how. I’m looking forward to seeing how this meeting will impact all of the countries who were represented. I know I wasn’t the only one who left feeling re-inspired.”


Lauren Crigler and Donna Bjerregaard are Senior Technical Advisors with Initiatives Inc., a women-owned small business is aimed at strengthening health systems, improving quality health care, and reinforcing NGO and community organizations.  Initiatives is a partner with URC on the USAID Health Care Improvement Project.

Mobile Application Reinforces Frontline Health Workers’ Knowledge, Confidence, and Credibility

By: Corinne Farrell and Girdhari Bora, IntraHealth International

Mobile Application Reinforces Frontline Health Workers’ Knowledge, Confidence, and Credibility

Photo Credits: IntraHealth

Mobile Application Reinforces Frontline Health Workers’ Knowledge, Confidence, and Credibility

In rural India, frontline health workers—called accredited social health activists (or ASHAs)—are improving the health of women and families in their own communities by offering key preventive health services. Through the Manthan Project, IntraHealth International is testing a promising multi-media mobile phone application called mSakhi as a tool to make ASHAs’ jobs both easier and more effective.

Although India has seen a 60% decline in maternal deaths in the last three decades, more women die in India from pregnancy-related causes than anywhere else in the world—an estimated 117,000 women each year [1. Hogan, Margaret C. et al. 2010. Maternal mortality for 181 countries, 1980-2008 : a systematic analysis of progress towards Millennium Development Goal 5. The Lancet 375:1609-1623. ] . [2. Center for Reproductive Rights. 2008. Maternal Mortality in India: Using International and Constitutional Law to Promote Accountability and Change. ]  ASHAs are a critical component of India’s National Rural Health Mission’s strategy to prevent maternal and child deaths and to meet Millennium Development Goals 4 and 5.

Frontline Health Workers: Reaching People Where They Are

Since 2006, the Government of India has trained over 820,000 ASHAs to reach some of the most impoverished and remote communities with services including: pregnancy counseling and health education, accompaniment of women in labor to skilled delivery care, and promotion of immunizations and appropriate newborn care. While ASHAs have demonstrated the potential to substantially improve maternal health in areas of extreme poverty [3. National Health Systems Resource Centre. ASHA: Which way forward? Evaluation of the ASHA Programme. 2011. ] , challenges also persist.

ASHAs receive 23 days of training over the course of four years and are supervised by another cadre of frontline health workers—auxiliary nurse midwives. The ability to quickly train ASHAs is part of the reason India’s approach to community health is scalable; however, health workers with such condensed training need ongoing support and refresher trainings to sustain quality care. Studies [4. Bajpai, Nirupam and Ravindra H. Dholakia. 2011. Improving the Performance of Accredited Social Health Activists in India. Columbia Global Centers, South Asia, Columbia University. ] have identified the need to reinforce training messages, improve the ability of ASHAs to effectively share health messages with community members, and provide ASHAs with more consistent and supportive supervision.

In the State of Uttar Pradesh, IntraHealth is helping the Department of Family Welfare test the effectiveness and scalability of innovations that have the potential to improve the health of mothers and newborns, including improving the performance and impact of ASHAs in two districts: Jhansi and Bahraich. One such innovation is mSakhi.

mSakhi: A ‘Mobile Friend’ Providing Ongoing Support to Frontline Health Workers

Mobile technology has quickly penetrated the Indian market with the country approaching one billion mobile phone subscribers [5. Tak, Siddarth. Has mobile penetration reached saturation point? May 1, 2012.] . Increasingly the Government of India is looking at ways to leverage the vast reach of mobile technology to address some of its biggest health issues. Last year, IntraHealth pilot-tested an intervention designed to support ASHAs in communicating with and caring for their patients through the use of the mSakhi mobile application.

mSakhi, which means mobile friend in Hindi, is an interactive tutorial that offers 65 key health messages on prenatal and delivery care, postpartum mother and newborn care, immunization, postpartum family planning, and nutrition using a combination of text messages, audio, and illustrations all contextualized with localized illustrations and dialects. Developers created the educational content based on the National Rural Health Mission’s curriculum for ASHAs and sought feedback from ASHAs through a series of focus groups. The mHealth tool was then developed on the open source CommCare platform.

The pilot included 30 ASHAs in two districts in the state of Uttar Pradesh. The ASHAs received initial training on how to use mobile phones, how to operate the mSakhi application, and how to use the application interactively during visits with women and families. Refresher trainings and technical support were also provided. After 12 weeks, a follow-up assessment showed:

  • The number of ASHAs who recognized fewer than two danger signs in prenatal, delivery, and postpartum maternal and newborn care decreased from 13 to 2.
  • Five ASHAs could identify 6 or more danger signs compared to only 1 at baseline.
  • Qualitative data also indicated that after using the tool, the AHSA were more confident in their abilities, felt they were seen as more credible among their clients, and offered better counseling during home visits.

Taking an mHealth Intervention from Pilot to Scale

A common criticism of mHealth interventions is that they remain in pilot studies that never get tested at scale. Moving beyond the pilot, IntraHealth is currently undertaking operations research with 90 ASHAs in the Bahraich District. This research is using a quasi-experimental design to test the effectiveness of the mSakhi tool by comparing the knowledge of 45 ASHAs and the adoption of health behaviors of 480 of their beneficiaries in an experimental group with 45 ASHAs and 480 beneficiaries in a control group. ASHAs in the control group receive training and support with the same content but using conventional training materials and job aids such as flip books.

The study will not only assess the impact of the tool but will also calculate the cost of this intervention to provide the Government of Uttar Pradesh with an assessment of the benefits, feasibility, and costs of scaling up this mHealth intervention.

The Manthan Project is led by IntraHealth International and funded by the Bill & Melinda Gates Foundation.

Female Frontline Health Worker Braves Conflict to Improve Lives of Afghan Women and Children

By: Sonia Lowman, International Medical Corps

Dr. Shamail
Photo Credit: International Medical Corps.

Female Frontline Health Worker Braves Conflict to Improve Lives of Afghan Women and Children

With one of the highest maternal mortality rates in the world, an extremely low female literacy rate, and a high prevalence of gender-based violence, Afghan women face enormous obstacles to development. Nonetheless, powerful role models do exist, such as Dr. Shamail Azimi of International Medical Corps, the first female physician to enter Afghanistan after the fall of the Taliban in December 2001.

At tremendous personal risk, Dr. Shamail has exhibited extraordinary courage in devoting herself to improving the lives of refugee women and children affected by war and violence in Afghanistan and Pakistan.  Born and raised in Kabul, Dr. Shamail completed her medical studies in 1985 after aiming to be a doctor from an early age. She remembers, “My father motivated and encouraged me. He always told me that Afghan women needed female doctors.”  But in 1993, Dr. Shamail’s father was killed during the brutal Soviet occupation of Afghanistan, forcing Dr. Shamail to flee with her mother and sister and take refuge in neighboring Pakistan.  There she joined International Medical Corps’ Pakistan staff, overseeing health programs for more than 150,000 Afghan refugees living in camps in the volatile Northwest Frontier Province.  Still, she hoped to go home to help rebuild her country one day.

After the fall of the Taliban in 2001, Dr. Shamail got her chance, leading a team of female physicians into Afghanistan to deliver lifesaving maternal and child health care. One isolated community she encountered, Franjil, had no traditional birth attendants or female health professions to serve its 10,000 residents.  The people of Franjil pleaded, “Please save our mothers and keep our children from becoming orphaned.” So with Dr. Shamail at the helm, International Medical Corps opened Emergency Obstetric Care centers in Charikar (easily accessible from Franjil), Maidan Wardak, and Kunrar provinces.  To bolster capacity for maternal health care, Dr. Shamail has trained hundreds of health care professionals throughout Afghanistan, including general physicians, community health workers, traditional birth attendants, and obstetricians working in emergency care facilities.  Today, she continues to be at the forefront of reinvigorating Afghanistan’s professional medical community and rebuilding the country’s health care infrastructure.

No doubt, the communities that Dr. Shamail helps desperately need her.  And, it seems, she needs them too:  “I am very happy that International Medical Corps has given me the chance to work for my people—especially women and children. When I see their happiness, it encourages me more because these people have serious needs and International Medical Corps has made my help possible.”

Since its inception nearly 30 years ago, International Medical Corps’ mission has been consistent: relieve the suffering of those impacted by war, natural disaster and disease, by delivering vital health care services that focus on training. This approach of helping people help themselves is critical to returning devastated populations to self-reliance.

A Healthy Start: My Breastfeeding Journey

By: Samantha Edelmann, Save the Children

Left: Scarlett, age 2, at The Big Latch On in Brookfield CT. Photo by Sarah Settanni for Save the Children Right:  Miamouna Bagayoko, age 4, in Satiguila, Mali. Photo by Joshua Roberts for Save the Children


From the moment I found out I was expecting my entire world started to change.  Like most mothers, my mind began flooding with exciting and nerve-racking questions.  As I started focusing on the important and often difficult decisions, one effortless decision was breastfeeding.  In my work at Save the Children and my upbringing around women who all breastfed their children, this was a no-brainer.

Two months before my son was born I purchased the Le Leche League (LLL) book “The Womanly Art of Breastfeeding”.  I sought out my local LLL meeting group and began my journey as a nursing mom.  After my son was born, I was often asked the same set of questions: “What’s his name?”, “How much does he sleep?”, and “Are you nursing?”  Every time I was proud to announce that my little guy was healthy and benefiting from all the wonderful things breastfeeding has to offer.  That, of course, is not to suggest that it wasn’t a rocky and challenging adventure.  With the support of my local LLL leaders and Lactation Consultants I was able to overcome latching obstacles, supply challenges and provide the most beneficial source of nutrition and the healthiest start for my child.

Six months later my son and I are going strong and I see no end in sight.  In fact, the American Academy of Pediatrics recommends exclusive breastfeeding for the first six months of a baby’s life, followed by breastfeeding in combination with the introduction of foods until at least 12 months of age.  The World Health Organization recommends an additional year of breastfeeding.

In this year’s State of the World’s Mothers report, Save the Children highlighted six low-cost nutrition interventions with the greatest potential to save lives and breastfeeding was among them.  Not only does human milk provide all the nutrients newborns need for healthy development, it also prevents babies from ingesting contaminated water that could be mixed with infant formula.  Breastfed children are at least six times more likely to survive in the early months than non-breastfed children.

To celebrate World Breastfeeding Week the LLL, moms and nursing babies around the world joined together at The Big Latch On, an event that aims to provide breastfeeding support and promotion.  This past Saturday August 4th over 8,000 nursing moms gathered in over 600 locations in 23 countries to raise awareness on breastfeeding support and knowledge available in communities, help communities positively support breastfeeding in public places, and make breastfeeding a normal part of the day-to-day life at a local community level.

As this celebratory week comes to an end I am left reflecting on my journey as a nursing mom and realizing how lucky I am to be in a place where resources like the LLL are so readily available.  However, I am left struggling with the concept that there are mothers and newborns in parts of the world where support is not an option and hope my son will live to experience a world where health workers reach more moms and children.  

Written by:Samantha Edelmann, Save the Children. Save the Children is a member of the Frontline Health Workers Coalition, a dynamic and influential coalition of 25+ NGOs working together to urge greater and more strategic U.S. investment in frontline health workers in the developing world as the most cost-effective way to save lives and foster a healthier, safer and more prosperous world.

The 19th International AIDS Conference

By: Joan Holloway, IAPAC

The 19th International AIDS Conference, held in Washington, DC last week, was attended by nearly 30,000 health care providers, policy makers, researchers, press and grassroots caregivers. The overwhelming message from the conference was one of hope that someday, in the not too distant future, we can see an end to AIDS. It is estimated that 8 million people globally are now receiving antiretroviral medications and support for these medications is increasingly being provided by low-and-middle income countries. However, it is also estimated that 34.2 million people around the world are currently infected with HIV. This fact alone emphasizes the need for additional financial support from international donors as well as the continuing need for caregivers to care for those who are sick and unable to access medications, to monitor and support adherence to medications, and to provide  support to affected families.

There were several sessions at the conference that addressed health workforce needs, but the most exciting to me was a session on Tuesday, July 24  Healthcare Workforce: Who Cares and Where. Participants included US Global AIDS Coordinator, Ambassador Eric Goosby, Malawi SWAP Director Dr, Ann Phoya, Dr. Mubashar Sheik, Executive Director of the Global Health Workforce Alliance and Ms. Florence Enyogu, the Home-based Care Alliance. While the other presenters spoke of the extent of the global health workforce crisis, international and country efforts to address the crisis, Ms. Enyogu spoke about the caregivers. She represents a movement of home-based caregivers who have organized for self-representation at the national and international levels and for support for the essential services, care and resources they provide to their communities. The Alliance represents more than 30,000 caregivers in 11 African countries ( Benin, Cameroon, Ethiopia, Ghana, Kenya, Malawi, Nigeria, South Africa, Uganda, Zambia, Zimbabwe) who are advocating for recognition of the contributions of home-bases caregivers to care and support; reimbursement for their work; and financing and support for the Alliance.

Ms. Enyogu’s recommendations included: transforming the health care workforce by recruiting caregivers for higher level CHW roles; direct funding to the caregivers at the community level; and involving the caregivers and the Alliance as partners in transforming the health care workforce and not as beneficiaries of the process.

These are recommendations that the Frontline Health Workers Coalition can and should embrace.

Written by: Joan Holloway, IAPAC. IAPAC is a member of the Frontline Health Workers Coalition, a dynamic and influential coalition of 25+ NGOs working together to urge greater and more strategic U.S. investment in frontline health workers in the developing world as the most cost-effective way to save lives and foster a healthier, safer and more prosperous world.