Smisha Agarwal, an associate at the Population Council leads the Frontline Health project, a 3 year Bill and Melinda Gates funded project, focused on standardising the measurement of community health worker programs around the world, identifying critical gaps in knowledge in strengthening these programs, and conducting operational research studies to answer those questions.

An interview by Rachael Tembo

What were the objectives of this workshop?

The Frontline Health project brings together three donor agencies, USAID, UNICEF, and Bill and Melinda Gates Foundation, and seven Integrating Community Health (ICH) partners from, Kenya, Uganda, DRC, Mali, Haiti, Liberia, and Bangladesh to work together to strengthen community health worker programs. The Population Council convened this workshop to bring these implementing partners together to allow opportunities for cross-learning because each partner has strengths in different areas. We brought them together with their ministry of health representatives involved in community health, to also gear the ministry of health representatives with information about what other countries are doing, and what is working in other countries.

The second objective was to introduce and identify, as a group, some areas of measurement to strengthen community health worker programs. Measurement of these programs introduces several challenges. It is typically not where ministries or implementers are able to focus on, because measurement is typically difficult and it is secondary to service delivery. However, specifically in the area of community health systems, it is critical. If we look back at the history of community health,  in the 1970s, the earliest models of community health demonstrated monumental improvements in child and maternal deaths. Data from Jamkhed, India suggested a 20-30% decline in maternal and perinatal mortality resulting from an integrated community-centred health worker program. Similarly, SEARCH in Gadchiroli, India showed that community-case management of childhood pneumonia and home-based neonatal care resulted in as much as a 70% decline in infant deaths over a ten-year period. Other similar programs started scaling up around the world, however, they were not standardised and monitored for quality and they didn’t have the same impact as the initial programs. They lost favour, funding and interest from the international community. But now we have a second opportunity to focus on these programs, so it is important to ensure that we are not just scaling these programs but instituting measures to ensure that these programs are scaled well with adequate attention to quality. That’s why routine measurement is critical, so we don’t want to lose sight of quality services. Primary care and universal health coverage should not translate into poor healthcare for poor people.

The third objective of this workshop was to advance in-country advocacy for community health worker programs in partnership with the ministry officials here and Last Mile Health. To identify best approaches for advocating in country for these programs and use this opportunity to emphasise to the ministry officials that there is tremendous international interest in supporting these programs.

Was there an M&E framework before that you are trying to strengthen now or each partner was using its own set of metrics?

Each partner has a different focus, some focus more heavily on service delivery, some more on advocacy, others more on civil society organisations, others on governance structures and systems, others on building policy on training community health workers etc. By virtue of different foci, they have different metrics they are currently monitoring, and varying levels of emphasis on monitoring.

Are you trying to come up with standardised M&E framework and metrics?

Yes, we are trying to come up with standardised areas for measurement and standardised indicators. It will be an iterative process of development – first we will put out some indicators which we would like the broader CH community to vote and provide comments on. We will take the feedback and test the ones that still need more work. Eventually, as we build consensus on the “what to measure”, we will start developing tools on “how to measure”, which can be shared beyond the 7 countries with the broader community.

What are your next steps from this workshop?

The workshop was a great success with tremendous interest from all participating countries, including the francophone countries and their ministries. The immediate follow up is to develop these standardised metrics. We welcome the participation of the members of the CH-CoP on this as we identify priority concerns and measurement areas and will be sure to share the measurement framework that will be collaboratively developed through this process. We will be working closely with the seven partners to test and support the adoption of these metrics, where feasible.  Additionally, we will also work with partners in these seven countries to figure out the most pressing knowledge gaps to scale CHW programs and implement research that can help them with in-country advocacy and to contribute to the global learning agenda.

We are thrilled to see growing interest in community health and look forward to working together to keep advancing these programs!