Reflection and collective learning: the issue of best fit and quality of CHW programs

The piece summarises the webinar organised by the Community Health- Community of Practice on the issue of assessing quality and understanding what will be a ‘best fit’ for community health workers (CHW) programs.

By Sanghita Bhattacharyya, Helen Schneider, Lilian Otiso, Jerome Pfaffmann Zambruni and Bruno Meessen

This webinar, 6th of the series, carried forward the collective reflection that the CH-CoP is trying to facilitate around how best to strategize CHW programs in the context in which they function. The first presentation by Prof. Helen Schneider raised the issue of uniform (best practice) vs context-driven (best-fit) approaches to the design and governance of CHW programs. The ‘from what to how’ issue for managing the CHW programs was highlighted in the second presentation by Dr. Lilian Otiso where she presented a model how quality can be integrated as part of CHW programs. 

You can access the full presentations here.

From best practices to the best fit

When one tries to understand what is the “best fit”, three key dimensions of context relevant to CHW programs were highlighted by Helen. First, the relational context of local health systems, including the nature of communication and trust relationships with formal primary health care providers, which are necessary not only  for supportive supervision but more generally for CHWs to function optimally. Secondly, the capability of the community in terms of how it acts, how it decides and what the community can provide are also key areas to be considered when one is developing a CHW program. The aspects of social characteristic, assets and governance of the communities were also well reflected in one of our earlier webinars.  The third dimension is the prior history and experiences of CHW programs, which shape design choices (as in the illustration). These histories are reflected in the unique features and identities of programs like HIV/ AIDS community based care support in South Africa, India’s Accredited Social Health Activist program or Ethiopia’s Health Extension Worker.

pic 1- Helen

Applying the best fit approach for quality improvement

There is a growing consensus that the international community has to move from the ‘what to do’ to the ‘how to do’ question. It was captured in the second presentation how the USAID SQALE project in Kenya developed and implemented a model of quality improvement for community health system. Lilian highlighted the key principles applied in the SQALE model: simplicity, having a small set of quality indicators; data quality for data use, setting well-defined roles for teams and integrating the community voices to strengthen the community- facility linkage.  The key aspect for success of the model was the ability of the work improvement teams to use their own data to come up with solutions based on their context, to inspire, innovate and most important to involve the community. An interesting example was that of a community health extension worker who developed an app  to ease data collection as a result of QI implementation! (illustration)

It was emphasised that one needs to get the fundamentals right in order to embed a program and that can be achieved by developing leadership for quality improvement at all levels, team work, availing basic resources like tools / job-aids, supportive supervision and continuous capacity building through coaching and mentoring. Lilian discussed some of the solutions that emerged from SQALE on how to sustain pilot projects. These were; the involvement of the government right from the design stage; engagement with local administration at community level; capacity building through coaching; integrate tools, manuals with the existing programs and lastly liaison at policy level to ensure budgetary provision.

Pic 2- Lilian

Trust as a central factor for CWH program

The webinar had rich discussions and one is the central importance of trust for effective CHW programs. The network analysis in Helen’s presentation reveals the huge gap which can exist between the network of people the CHWs communicate with and the network of people they actually trust. “If trust is the central variable for successful population health programs, are we not developing programs on very weak foundations? We bring outsiders to act as professional supervisors, while the real connectors and brokers could actually be some respected CHWs active in the area. We have extrapolated the top-down approach of vertical programs to community health with the assumption that trust would just trickle down with our resources and dedication. But you do not bring trust in four wheel drives!” The huge difficulties encountered in the response against the Ebola outbreak in East Congo suggest much more modesty and the need to focus our effort on searching for the best fit.  These are fundamental questions. Obviously, we need much more research to investigate this hypothesis. And as put by another participants, we have also to check whether CHWs, as technicians, are themselves trust by their communities. 

Towards ‘learning health systems’

A second discussion we felt very close was the one of the central place of systematic learning in the best-fit approach. Learning is not seen any more first as an external undertaking (the compilation of evidence or best practices through some transnational systematic review and the follow-up adoption of these lessons by the country) but more as one of building capacities for learning ‘within’ the system. This can have multiple applications.

As rightly pointed in the discussion it is actually the principle of ‘bottom-up approach’ promoting programs adapted to local context, empowering community capabilities so that CHW programs can be embedded within the local settings. It was emphasised the need for more knowledge produced from the ground and CHW programs move from a project mode to an approach of institutionalisation. The time duration plays a key role for building partnership between the community and government, as pointed by Asha George, which needs to be taken into account by funding bodies. This also calls for systematic approaches to opening the black box of ‘best fit’ in terms of understanding the local complexity, bringing aggregation and synthesis of different approaches. One can also make a link with some recent multi-country research carried out by two other CoPs on the extent to which “UHC systems are learning systems”.

Transnational learning with the CoPs

This view in favour of systemic learning does not mean that we have to throw away transnational learning (an agenda dear to CoPs). But it suggests that to synthesize collective learning across geography and across systems, there is a need for multi-cultural, multi- linguistic channel of communications. This view in favour of systemic learning also suggests that diffusion of ideas needs to percolate where the research and knowledge community speaks with the practitioners and program managers. Again, a central hypothesis of our community of practice! We have to build strategies breaking the existing asymmetry (nicely captured in a slide of the first presentation showing the dominant role of Western academic institutions in the research on community health). We have to build more bridges for south-south knowledge networks. A true diffusion of innovations where ideas can be communicated leading to embedding of innovations in the system can be a collective effort of different communities – the researcher, the donors, the health system managers, the policy makers.

Finally some interesting ideas were suggested, which we can take up in our next webinar like issue of measuring ‘equity’ as part of community health system strengthening program and how data and quality can help reduction of health inequalities. So please share your views how best and what areas we can collectively discuss and debate. Based on the mandate of the CH- CoP we will try to play a role by creating the channel of communications across global south, dialogue and discussion between different health system stakeholders with the academics, donors and technical support groups.

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