Supporting community health workers in community case management
programmes in Africa: A preliminary investigation
Workshop Report
18-20 June 2014
Introduction
This is a brief report of the workshop, which took place at the Foresight Centre, Liverpool in June 2014. The workshop covered: reviews of findings from the country case
studies, synthesis of the country case studies and findings from CHW literature reviews and CHW costing study; development of research questions; and next steps for
finalising reports, dissemination, and development of full research project. Please note that the presentations are embedded in this document (double click to view).
Objectives
1.
2.
3.
4.
To review a synthesis of human resource management (HRM) strategies used in the country case studies
Identify lessons from carrying out research on the management of CHWs
To identify research gaps in the HRM of CHWs
Develop initial ideas for the full research study on HRM of CHWs
Inputs
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Country case studies (draft reports)
Comments on country case studies by relevant research team
“Strategies for performance management, attraction, and retention of community health workers: a review of the literature” (Draft July 2012)
Project proposal document
Outputs


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Revision to country case studies and identification of further review tasks
List of potential research questions for full scale project
Lessons on methods for researching HRM for CHWs
Agreed work plan for completing project
Participants
Attending all sessions
Name
Institution
Stephen Buzuzi
Biomedical Research and Training Institute, Zimbabwe
Patricia Akweongo
School of Public Health, University of Ghana
Amuda Baba
IPASC, Democratic Republic of Congo
Tim Martineau
LSTM, Liverpool
Joanna Raven
LSTM, Liverpool
Ed Roome
LSTM, Liverpool
Sophie Witter
Queen Margaret’s University, Edinburgh
Attending some sessions
Sally Theobald
LSTM, Liverpool
Skype only
Rozi McCollum
Sebastian Baine
LSTM, Liverpool (REACHOUT project)
Makerere School of Public Health, Uganda
Neither the Uganda not the Senegal teams were able to attend, but we managed to be in contact with Sebastian Baine from Uganda by skype during the workshop.
Timetable
Times
9.00
9.30
Wednesday
Coffee and conversation
Introductions: (Tim)

Participants

Overview of the project

Overview of the workshop
HRM framework (Tim)
Times
9.00
9.30
Thursday
Coffee and conversation
Conference call with Senegal and Uganda
teams (Tim)
Times
9.00
9.30
Friday
Coffee and conversation
Conference call with Senegal and Uganda teams
(Tim)
10.00
Review of tasks of CHWs
Discussion
10.00
Further development of study design
(Tim, Jo, Sophie)
11.00
11.15
Tea break
Country case studies (Jo)
Who is a CHW?
Overview of data methods and analysis
Presentation of synthesised findings
11.00
11.30
Tea break
Fulfilment of CHWs’ expectations
Discussion
Applicability of performance
management strategies (against HRM
framework)
Discussion
11.00
11.30
1.00
2.00
Lunch
Discussion of synthesis of findings (Jo)
1.00
2.00
Lunch
Development of research questions: In
pairs and plenary
1.00
Tea break
Further development of study design (continued)
Next steps: (Tim)
 Finalising country reports
 Developing and finalising overall project
report
 Developing full research project
Close
Lunch
3.00
Literature reviews
CHW and incentives literature review (Tim)
REACHOUT literature review (Sally and Rozi)
10.00
4.00
4.15 –
4.30
5.30
GHWA CHW costing study (Sophie Witter)
Tea break
Wrap up of the day (Tim)
Close
Lecture: Malcolm McNeil (DfID Research),
4.00
4.15 –
4.30
5.00
Tea break
Wrap up of the day (Jo)
Close
Dinner
Commentary
WEDNESDAY 18 T H JUNE
Introduction (30 minutes)



Introduction of participants
Overview of research project
Overview of the workshop
Introduction.pptx

Presentation:
HRM Framework presentation (60 minutes)
The HRM framework for research on the management of CHWs. This will provide the thinking behind the design of the project including the framework for reviewing
attraction, retention and performance management strategies and the relationships between the management actors. It will also describe the synthesis framework used
in the country reports.
Presentation:
Human resource
management of CHWs.pptx
Country Case Studies (105 minutes)


Who is a CHW? Each partner presents themselves as a CHW from their case study: RECO Benoit for DRC; ?? from Zimbabwe; ?? from Ghana
Brief overview of data collection methods
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Brief description of process of data collection by country
Description of data analysis methods
Presentation of synthesised findings
Presentation:
Country case studies
presentation and discussion.pptx
Discussion of synthesis of findings (60 minutes)
1.
2.
3.
Questions for clarification
Reactions from country researchers to synthesis of findings
Key questions: have we included all the key findings in the synthesis? What does this tell us about the appropriateness of the current HRM strategies? What does it
tell us about the management structures in place?
Literature reviews (60 minutes)

Key points from the CHW and incentives literature review
TDRlitreview.pptx
Presentation:

Key points from REACHOUT overview and literature review
Presentation:

REACHOUT overview
TDR.pptx
Key points from GHWA CHW costing study
Presentation:
Summary CHW cost
eff study.pptx
Wrap up of the day (15 minutes)
Evening: attend Malcom McNeil’s lecture for the consultancy course
Lecture by Malcolm McNeil, DfiD: “This is a fine mess that you got me into! Common blunders in international health consultancy and how to avoid them”.
THURSDAY 19 T H JUNE
Conference call with Uganda teams (30 mins)
Shared discussions and outputs of day 1 with Uganda team
Review of tasks of CHWs from case studies (60 minutes)
(1)
Extension of the formal health service

home based treatment of malaria, diarrhoea, ARI… (case management)

follow up of TB/HIV patients

assisting in clinics (weighing, record keeping)

health education; data collection (community register); disease surveillance

attending births (?emergency)

antenatal (drugs, education, surveillance, referral) and postnatal (monitoring newborn danger signs)
(2)
Promotion/distribution/organising function
 EPI: defaulter tracing, mobilisation (e.g. promoting health insurance scheme)
 health education
 bed nets, distributing, checking use
 HIV/AIDS prevention
 nutrition/cookery classes/breastfeeding

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(3)
hygiene/sanitation/personal health
family planning education and contraceptive distribution
MDA – distribution; house-to-house (annual)
general home visit
stimulating demand for and raising awareness of formal health services/referrals
referrals of STI, ANC, complications in pregnancy, under 5s, HIV testing and counselling, burns/injuries
Community organisation

encouraging community to undertake specific tasks (ambulance, addressing specific health issues e.g. clean-up and tidying tasks, collecting water for
the health centre, health facility maintenance/repairs)

assisting in health-related campaigns (e.g. introduction of new drugs)

advocacy for community ownership of programmes (e.g. support to CHO and CHPS programme)

represent community at meetings (health committee, development committee)

linking with other volunteers (e.g. working with other NGOs)
Fulfilment of CHW’s expectations (60 minutes)
Expectations
**Bridge into paid health worker role
(enhancing employability)
 lacking qualifications
 seeking work experience
Fit with other roles (e.g. teachers)
Fulfilled
?some move on to other health jobs,
but quite rate (cf. average job tenure
in case studies)
Conditions
Creating career pathways
?No
Coordination of demands on CHWs / general coordination
of incentives
 Manageable with day job and other responsibilities
More flexibility, unpredictability of job requirements
Skill + knowledge enhancement
 enhancing skills for their other main jobs
 enhancing health skills to serve their families at home
 ability to travel outside community
Yes
More negotiation with donors and national programmes –
how to prioritise what CHWs can reasonably do
Certificates
Refresher training – frequency and quality (HS)
*Non-financial benefits
 free or subsidised treatment
 **help with farming
 **exemption from community labour + levy
 **priority access to health programmes + employment
Social status and prestige
 t-shirts/uniforms
 boots, brollies, bags, badges
 ‘Doctor’ – community status and respect
 recognition as a health worker
Financial
 per diems for training and events (T&T; travel)
 fixed stipends – per time (national prog) or per activity
(vertical)
 entry into comm jobs e.g. with NGOs
**Serving community
 Fulfilling socio-cultural (or religious) obligations to
serve community
 Desire to save lives and make a difference to people’s
health (?intrinsic motivator)
 inheriting the job (family ownership)
 non-dismissable (no matter how poor performance is)
Yes
No
?
Yes
Varied (not always valued in
community)
Uniform has to fit!
Regularity of supplies (HS)
Take seriously (HS)
Comm leaders organise involve them
Legitimacy of selection (Comm/HS)
?Irregular/insufficient
HS or community has to provide (comm/HS)
+Costs (some CHWs are in effect
paying to do the job!)
Managing community expectations/dialogue with
community
+varied
Applicability of performance management strategies (against HRM framework) (30 minutes)
The set of strategies presented in the HRM session was reviewed for suitability and possible adaptation for use with volunteer CHWs.
Direction


Induction – OK (check content and length; celebrate status)
Job descriptions – OK (need to develop between HS and community/leaders)
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Work plans – OK (simple and flexible to meet wider obligations e.g. gender implications)
Appraisal – OK (360 degree involving community)
Supportive supervision – OK (major issue in REACHOUT analysis)
Team meetings – OK (recognition by formal HWs; networking; must be efficient use of time - has financial/resource costs for CHWs)
Resources
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Availability of equip, drugs and supplies – OK (major issue)
Infrastructure (e.g. buildings)
Transport – OK (inc maintenance e.g. bikes)
Information systems – OK (limitation and coordination of data collection to reduce burden)
Finance – OK (regularity, adequacy, fairness, coordination, reality vs rhetoric of community contributions)
Community support – Yes including labour and exemptions
Boots, bags and brollies - Yes
Competencies


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Merit based recruitment – OK (realism to labour market; legitimacy of selection in eyes of community)
Appraisal – OK (assessing quality of service and technical ability)
Training and development – OK (need harmonised curriculum; ?follow-up)
Rewards and sanctions
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Team incentives based on performance – scope to do better?
Individual incentives based on performance – will come more
Additional responsibilities – formalise the career structure and providing opportunities for advancement (even within CHW role)
Transfer staff to more desirable posting - NO
Issue verbal and written warnings – NO (people can just walk)
Withhold pay – NO (people can just walk)
Dismissal – can but culturally difficult (making it very rare)
Community recognition – YES
Development of research questions (120 minutes)
The following steps were used:
1.
2.
3.
4.
Working in pairs to write possible questions on post-it notes
Grouping of post-its
Scoring of research questions by relevance/importance (choice of 5 in order of preferences with 5 = highest)
Adding scores for each group to prioritise (see Table x with priority questions produced)
Table 1: Research questions generated in Liverpool CHW workshop 20 June 2014
Table 1: Research questions prioritised
Coping strategies
Coordination and priorities
1.
What are the coping strategies of CHWs in
different contexts?
7.
How can demands on CHWs be better
coordinated?
2.
What are the coping strategies of CHWs in
different contexts?
8.
How do the different stakeholders coordinate
their expectations in using CHWs?
3.
What are the real costs of working as a
volunteer CHW? (CHW perspective)
9.
4.
Are there other forms of reward that we don’t
know about? Unintended consequences?
5.
What are the CHW expectations? Are they met?
What happens if not? (Positive deviance).
How can we integrate/ harmonise and prioritise
work of CHWs (national and community level)?
How do CHWs prioritise activities and how do
they cope with family obligations?
How do CHWs prioritise activities and how this
relates to incentives?
How to CHWs manage competing demands?
a. Resign
b. Stay but inactive
c. Prioritise
d. Find coping strategies
e. Suffer
6.
How do CHWs prioritise their work given
multiple expectations – efforts / outputs /
inputs?
10.
11.
12.
Performance management
13. How to manage non-performing CHWs? (in
absence of formal sanctions)
14. How can we adapt standardised performance
management strategies for CHWs? What works
and how?
15. How can we foster supportive supervision (peer
to peer supervision) for CHWs?
16. What factors influence CHW competencies?
17. Are there differences in expectations between
active and non-active CHWs?
Evening: dinner
Followed by World Cup: England (1) vs Uruguay (2)
FRIDAY 20 T H JUNE
Conference call with Uganda team (30 minutes)
Shared discussions and outputs of day 2 with Uganda team
Further development of study design (150 minutes)
Through animated discussions, we developed the following research questions and ideas for methods (see figures 1 and 2)
Figure 1: Study questions refined
Figure 2: Ideas on methods added
Next steps (45 minutes)
1.
Completing and dissemination of country case studies
a.
Jo to send additional reviewer comments and revised table by 4th July
b.
Partners to send comment by 18th July
c.
LSTM to send final copy by early August
d.
Partners to check with district managers for factual errors and send feedback by 31st August
2.
Dissemination of country reports - partners to decide on most appropriate process and implement
3.
Finalisation of synthesis report
a.
LSTM to develop and distribute draft by mid-August
b.
Partners to comments by 31st August
c.
LSTM to develop presentation for Cape Town (abstract accepted) by mid-September
d.
Submit report by 30th October
e.
Develop and submit paper to special issue on CHWs in HRH journal by 24th November 2014
4.
Design full study
a.
Small working group to meet in afternoon of 20th and develop more detailed plans
b.
TDR to be consulted at an early stage of proposal development
c.
Drafts to be shared when ready
d.
Specific country information may be requested from partners
Close
Lunch