ABSTRACT
Community health workers (CHWs) are integrated into health systems through a variety of designs. Partners In Health (PIH), a nongovernmental organization with more than 30 years of experience in over 10 countries, initially followed a vertical approach by assigning CHWs to individual patients with specific conditions, such as HIV, multidrug resistant-TB, diabetes, and other noncommunicable diseases, to provide one-on-one psychosocial and treatment support. Starting in 2015, PIH-Malawi redesigned their CHW assignments to focus on entire households, thereby offering the opportunity to address a wider variety of conditions in any age group, all with a focus on working toward effective universal health coverage. Inspired by this example, PIH-Liberia and then PIH-Mexico engaged in a robust cross-site dialogue on how to adapt these plans for their unique nongovernmental organization-led CHW programs. We describe the structure of this “household model,” how these structures were changed to adapt to different country contexts, and early impressions on the effects of these adaptations. Overall, the household model is proving to be a feasible and functional method for organizing CHW programs so that they can contribute toward achieving universal health coverage, but there is no “one-size-fits-all” approach. Other countries planning on adopting this model should plan to analyze and adapt as needed.
Resumen en español al final del artículo.
BACKGROUND
Although community health workers (CHWs) are an essential part of the health workforce, how to best incorporate them into health care systems continues to generate considerable debate and innovation. The scope of work given to CHWs often reflects larger assumptions and ambitions; in the era of selective primary health care and vertical funding for only select diseases, CHWs were usually positioned to focus on individual patients, on only a small number of priority conditions, or primarily on prevention efforts. In the recent push for universal health coverage (UHC), CHWs are increasingly called to focus their energies on entire households and individuals with multiple diseases.
The Household Model at Partners In Health
Partners In Health (PIH), a nongovernmental organization with more than 30 years of experience working in over 10 countries, has responded to the UHC call by incorporating a CHW approach, called the “household model” (HHM), in 3 countries where larger health care system strengthening partnerships already exist. PIH always works within the public sector, and any clinical spaces or materials provided are done in partnership with the national ministries of health (MOHs), with full ownership maintained by the public sector. The HHM approach has been a PIH initiative to demonstrate to MOH colleagues the benefits of providing CHW coverage to every household in a service area to detect, refer, and follow up on a range of priority health issues through regular home visits (Figure). This integrated approach supports the broader needs of entire households and is presented as a feasible and scalable mechanism for further expanding UHC by linking the household to the health system. Although structuring CHW workflow via home visits has historically been a core experience of both successful nongovernmental organization programs (such as the census-based impact-oriented model in Bolivia)1 and exemplar national programs (such as in Costa Rica),2 PIH set out to adapt and modernize the tools and techniques from such experiences for 3 new contexts. The authors of this article engaged in a robust cross-site dialogue to spark further innovation and improve quality in their respective programs. The most important insights have been captured here via an online collaborative authoring process in which the first author (DP) provided the article's structure, and then authors from each program added text, comments to other authors' additions, and edits. The first and final authors then sculpted a final product that responded to peer reviewers' comments.
Diagrama of the Partners In Health Household Model
Abbreviation: CHW, community health worker.a Cartoon images courtesy of Mango Tree, Jesse Hamm, Petra Rohr-Rouendaal, and Rebecca Ruhlmann.
The household model uses an integrated approach to support the needs of entire households by linking them to the health system–a feasible and scalable mechanism for expanding UHC.
COUNTRY SPECIFICS
Malawi
Malawi is one of the poorest nations on the planet, and health spending per capita is only US$35 (as of 2018).3 PIH began working in the remote district of Neno, Malawi, in 2007 to support the MOH in responding to the growing burden of HIV and TB. Locally known as Abwenzi Pa Za Umoyo, in partnership with the government, PIH built 2 government hospitals and revitalized several facilities, connecting them to a wide network of CHWs who provided direct support to HIV and TB patients. Combined with efforts in staffing and supply chain, Neno district achieved the highest rate in the country for retention in care for people living with HIV,4 improved uptake of maternal services,5 greatly expanded care for noncommunicable diseases (NCDs),6 and provided services for diseases that are generally undertreated in rural systems, such as Kaposi's Sarcoma.7 In 2016, Abwenzi Pa Za Umoyo started transitioning their CHW program to the HHM, in which CHWs were expected to visit each of their assigned households monthly with the goal of becoming the “foot soldiers” for health surveillance assistants (HSAs), the national CHW cadre in Malawi. HSAs largely focus on curative care in health posts, and the HHM supports them by focusing more on active case finding and referral, education, and treatment support for chronic diseases in the home. Data from routine HHM visits are aggregated for monitoring and supervision purposes and reported to the HSAs and the MOH. To determine whether the HHM is effective and to understand any unintended consequences, the team is currently analyzing a stepped-wedge randomized trial of the program.8
The HHM in Malawi supports the government-employed HSAs by focusing on case finding, referral, education, and treament support for chronic diseases.
Liberia
Liberia is also one of the poorest nations on the planet, and health spending per capita is only $US45 (as of 2018).3 PIH began working in Liberia in response to the Ebola epidemic of 2014–2016. Committed to supporting the government to rebuild the health system, PIH maintained operations after the epidemic subsided. Similar to Malawi, the PIH team in Liberia revitalized a government rural hospital and connected it to a growing network of CHWs who focused on supporting individual patients with HIV, TB, or leprosy. These CHWs were seen as critical for helping to achieve some of the best clinical results in the country for these diseases.9 After the Ebola epidemic, the Liberian MOH launched a community health program that focused primarily on supporting CHWs in remote communities more than 5 kilometers from the nearest health facility. These CHWs— called community health assistants (CHAs)—provide a polyvalent package of primary health care services and epidemic surveillance in 15 counties, serving approximately 29% of the total Liberian population.10 The Liberian MOH is currently finalizing a strategic plan to launch another cadre—called community health promoters (CHPs)—for communities located within 5 kilometers of a health facility. Since September 2019, PIH has been a key collaborator in helping to form and refine the strategy for the CHP cadre by partnering with the government to launch a CHP experiment that utilizes the HHM approach to organize how the CHPs engage with beneficiaries within 5 kilometers of 1 PIH-revitalized rural hospital in Maryland county, Liberia. The program's goal is to leverage CHW referrals to increase health facility utilization, improve retention in care, and build trust between the community and the health system. Embedded in the roll-out of the PIH program is a pre- and post-demographic and health survey to provide evidence on the program's impact.
Community health worker Ida Mathala visits the home of Steria Kenoon, 38, and Evance Keneson, 47, in Mtengula Village, Lower Neno, Malawi. The visit covered an noncommunicable disease/diabetes lesson and verbal TB screening. Ida has worked with this family for 3 years and works with 38 other homes in the village. © 2018 Zack DeClerk/Partners In Health
Community health workers Hne-Nma Clark and Jacob Yieh lead a community education session on family planning in Wuduken community, Liberia. © 2020 Miry Choi/Partners In Health
In Liberia, the HHM was deployed to increase health facility use, improve retention in care, and build trust between the community and the health system.
Mexico
Mexico is an upper middle-income country, but there remain pockets of the country, such as in the southern state of Chiapas, that struggle with extreme poverty and very limited access to quality health care. PIH supported community health efforts in Chiapas, Mexico, for nearly 2 decades before officially launching PIH-Mexico (locally known as Compañeros En Salud, or CES) in 2011. Working with the local health authorities in rural communities in the Sierra Madre mountains, CES revitalized nearly a dozen rural clinics and connected them to 4 cadres of CHWs (locally known as Acompañantes) that were initially focused on providing treatment support for: (1) NCDs, (2) maternal and newborn health, (3) mental health, and (4) child development and nutrition (including early childhood stimulation). Although a stepped-wedge analysis showed that the NCD-focused CHW program had helped achieve some of the best rates of clinical control for NCDs in the region,11,12 the team saw the potential for the NCD and maternal/newborn health cadres to be collapsed into a single cadre through the HHM. In 2019, after regular consultation with the teams in Malawi and Liberia, the Mexico team piloted a new CHW program that moved away from a physician-directed vertical care model, toward a model where CHWs could have more autonomy to use algorithms for screening, follow-up, and referral to the health center.
In Mexico, the HHM helped streamline multiple different CHW cadres into 1 and move toward a model where CHWs had more autonomy.
THE HHM CROSS-SITE LEARNING INITIATIVE
Teams in Malawi designed the PIH approach on how to assign CHWs to households, including relevant programmatic architecture. They then worked with community health leadership in Liberia and Mexico, both remotely and on-site, to adapt these plans for their contexts. We offer a review and comparison of internal programmatic decisions and iterative adjustments as the programs were adapted to different local realities. Programmatic inputs and parameters decided upon per country are shown in the Table.
Characteristics of Each Partners In Health Household Model Across 3 Country Contexts
Benefits of Adopting the HHM
Greater Coverage of Multiple Health Conditions, Integration with Health Facilities, Acceptance, and Social Connectedness
In Malawi, expanding from HIV/TB to several other conditions, initial data demonstrate improved uptake of antenatal care, improved communication across health facilities and CHWs, and greater social connectedness. In Mexico, adding clinical tasks to the scope of work (e.g., blood pressure/diabetes screening) led some community members to express seeing greater credibility in the CHWs' work. In Liberia, vulnerable communities within 5 kilometers of a health facility face significant barriers to care beyond geographic barriers; the CHWs' greater presence in households through regular visits is providing a format by which to build greater familiarity with, and trust in, the health care team.
Community health worker Maribel Huerta Luna visits the home of Máximo González López, 61, in Laguna del Cofre, Chiapas, Mexico. The visit covered a hypertension follow-up during the monthly routine household visit. His hypertension is under clinical control, so he receives a visit only once a month. © 2020 Ariwame Jiménez/Partners In Health
Greater Opportunities to Focus on “Upstream” Determinants of Health
In Liberia, the arrival of the CHP program presented an opportunity to reengage with previously dormant community health committees in the region where PIH works. These committees were elected by the community to collaborate directly with the CHPs on identifying the community's needs and coordinating health messaging. Embedding CHPs within community social structures increased their legitimacy and opened new opportunities to address public health issues. One CHP, for example, worked with their community health committee to organize a local cleanup of trash.
Greater CHW Autonomy
With more disease priorities to focus on, and a wider range of ages, the CHWs have had to seek greater autonomy to address the myriad challenges that arise. In Malawi, for example, the CHWs came to know the complexities of their households such that they could decide which to visit more or less frequently. In Liberia, some CHPs and their supervisors independently planned health outreaches to other communities not yet integrated into the HHM. In Mexico, the CHWs were transitioned from nurse- and doctor-led supervision to a more autonomous unit that coordinates with the local clinic but has freedom to make decisions that affect their workflow.
Reduced Stigma for Patients and CHWs
In all 3 countries, a major concern of the patient-centered model was that home visits were a public announcement that someone had a particular disease (e.g., TB or HIV). As such, a number of patients had declined treatment support. In the HHM, a home visit could be for any family member for a wide variety of conditions, so anonymity was inherently easier to maintain. Similarly, because many of the CHWs in the previous model in Malawi and Liberia were themselves living with HIV, a common perception was that all CHWs working with PIH had HIV; this type of bias has not been seen with the HHM.
Challenges With Adopting the Household Model
Imperfect Coordination With Health Facilities Has Consequences
Patient satisfaction with the HHM is often determined by how they are received once referred to the clinic. In Liberia, the CHPs faced difficulties in integrating with the clinical staff at the outpatient department: clinicians would not share patients' diagnoses or treatment regimens with CHPs because of misperceptions that they weren't health providers, and clinicians expressed anger that the CHPs increased the workload with new referrals (but without new investments in the facility). Therefore, CHPs faced both dismissal at the health facilities and in turn frustration from community members who blamed them for negative interactions in the clinic. In Mexico, although CES works actively to improve primary care, similar frustrations were encountered.
Encountering Unanticipated Salary Challenges
Moving from a single-disease model to the HHM required increased work expectations, and therefore required an increase in CHW salaries and supervision. In Mexico, however, labor laws were seen by program leadership as a barrier that prevented hiring CHWs full time; paying CHWs a full-time salary as a formal employee added an additional 30% fringe and would have given CHWs the right to be paid a severance fee if the program were to downsize. The PIH-Mexico team was in agreement with the sentiment that CHWs should be afforded such benefits, but current budgeting did not allow for this level of investment. In Liberia, the national community health policy adopted in 2015 that established the CHA cadre also standardized CHA salaries, and as such, PIH had to decrease the CHP cadre salary to align with government regulations. This led to concerns by many CHWs that the salary was not proportional to the increase in work and responsibilities.
Transition Pains
In Mexico, CHWs voiced concerns that moving from a single-patient single-disease model to a broader focus with more patients and more conditions diluted and distracted their ability to connect therapeutically. In addition, the new model demanded full-time work year-round, but this was not always possible during the short but intensive coffee harvest period that provided the family with the majority of their yearly income. In Malawi, implementation challenges included long distances to travel between houses, poor transportation options, lack of transportation funds, and demotivation when finding a house empty upon arriving. To address this, households were redistributed to be closer to CHWs' homes. Similarly, in Liberia CHPs received a monthly transportation stipend to assist in physically escorting patients to the health facility, but due to the large demand they could escort only a few before the funds ran out.
Managing New Volumes of Data
In Malawi and Liberia, paper data collection systems were aggregated at multiple levels for monitoring and evaluation. This system provided leadership with high level trends but did not allow for real-time analyses to guide decision making (i.e., to adequately support and supervise the CHWs and to measure whether vulnerable populations were reached). As such, Abwenzi Pa Za Umoyo in collaboration with Medic Mobile is piloting the use of mobile health solutions (a smartphone-based mobile application called YendaNafe that enables CHWs to maintain digital records of their work, synchronizing these records in real time with a centralized system). Mexico hopes to learn from this experience to also implement a completely paper-free digital health solution that will include digital elements of supervision.
LESSONS LEARNED
The HHM is inspired by the principle of “accompaniment,” which is both a philosophical stance and a rubric for programmatic design.13 Incorporating community health is guided by 3 principles: (1) CHWs must be professionalized; (2) CHWs must be positioned as bridges to care, not islands; and (3) CHW program budgets must make room for community work and not health work alone.14 Although all 3 country programs were philosophically aligned and in regular communication, local adaptations to the HHM were necessary to respond to local realities and pressures. During this process, common lessons arose. Some align with other analyses, such as was described in the CHW Performance Measurement Framework,15 and others are unique to this experience.
Recruit Effectively, With an Eye for Growth
It is important to fully map out what the job entails so the right people can be recruited (i.e., the right attributes, skill sets, geographic distribution, and time expectations). Similarly, if the intervention is to substantially grow in scope, the CHWs recruited need to have the ability to grow with the program through retraining and flexibility with restructuring. This approach is consistent with the CHW development domain of the Performance Measurement Framework. When selecting candidates, the use of written tests and interviews with clear scoring criteria16 should be balanced with concerns that literacy criteria might exclude representation from traditionally disenfranchised groups.
Work to Better Integrate CHWs Into the Health System
CHWs in the HHM are meant to serve as a bridge between facilities and households. Therefore, community members naturally perceive them as an extension of the health facility and sometimes transfer resentment or frustration with the health facility to CHWs. The transition to the HHM has to develop specific and actionable procedures to intentionally engage health facility leadership before, during, and after its implementation.17
Discuss Salary Expectations Early
CHWs should be remunerated fairly through financial compensation.18 How much they are paid depends on a variety of contextual factors including local labor laws, other salary benchmarks in the area, and what CHWs perceive as the value of their work. Starting these conversations early and explicitly (i.e., during recruitment), can save considerable debate and discord later. Non-financial incentives may include anything that improves the employment experience (e.g., good training, career growth opportunities, positive interactions with supervisors, etc.) but should be considered and handled separately from salary negotiations.
Expand CHW Autonomy While Building Functioning Support Systems
To achieve UHC, CHWs will have to be entrusted to operate more autonomously within thoughtfully structured roles in the health system. In line with the CHW Performance Measurement Framework's15 goals of job satisfaction, empowerment, and credibility, CHWs should be set up to succeed, including having clear job aids and decision-support algorithms, referral and counter-referral systems, and supportive supervision that empowers them instead of focuses on correcting errors.
Accept That Trade-offs Are Inevitable
CHW programs hoping to contribute to UHC will inevitably have to make decisions about what is included in the scope of practice and what is not. A common, yet erroneous, tactic seen elsewhere is to simply add more tasks without empowering CHWs to actually take on those tasks, such as by shifting time from other responsibilities or by increasing their salaries so that they can work more hours. If health systems aim to provide coverage for more health conditions, then investments will need to increase to meet new opportunities adequately.
Cross-national Learning Is Best Done On-site
For organizations hoping to improve multinational sharing and learning, we found that a number of factors facilitated this process. The most useful activity was getting country leadership to visit partner countries. This is in opposition to online conference calls and/or flights to conferences and meetings in the global north. Such on-site “learning trips” build functional relationships, facilitate material sharing, and allow for a deeper understanding of how the programs actually work in their full complexity. What also helped was consistent messaging around how the programs could learn from each other, which reinforced a growing narrative around why the programs were aligned (what has been described by community organizers as “the story of self, us, and now”)19 – sites were encouraged to see themselves as connected and then awarded with learning trips when they expressed wanting to connect deeper. This process decentralized the power to teach from a central “expert” in the global north to the network of talented and engaged practitioners on-site.
CONCLUSION
PIH found that it was possible to adapt the core principles of the HHM across different contexts by utilizing an iterative approach and operational judgment honed from past efforts. The PIH experience with implementing the HHM offers important lessons for other CHW program leaders looking at polyvalent CHW programs embedded within health systems to support progress toward UHC.
Funding
The Samuel Family Foundation provided funding for implementing the HHM in Malawi and partly in Liberia, and the AbbVie Foundation provided funding for piloting the HHM in Mexico. The Sall Family Foundation provided funding to support the cross-site dialogue that made multisite implementation possible. The opinions expressed in this paper are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development.
Competing interests
Dr. Palazuelos reports personal fees from the Community Health Academy, outside the submitted work; no other conflicts to declare.
Translation
En Español
Lecciones Iniciales del Lanzamiento de un Modelo Innovador de Salud Comunitaria a Través de Visitas a Hogares en Tres Contextos Nacionales
Mensajes clave: El asignar hogares en vez de individuos a trabajadores comunitarios de salud es un método viable y funcional de estructurar la salud comunitaria para contribuir a la cobertura universal de salud.
El Resumen
Los sistemas de salud integran a trabajadores comunitarios de salud (TCS) de manera variada. Partners in Health (PIH), una organización no gubernamental con más de 30 años de experiencia en más de 10 países, inicialmente aplicó un enfoque vertical, asignando TSC a individuos con enfermedades específicas, como VIH, MDR-TB, diabetes y otras enfermedades no transmisibles para brindar apoyo psicosocial y de tratamiento individualizado. A partir de 2015, PIH-Malawi rediseñó sus asignaciones de TCS para enfocarse en todos los habitantes del hogar, cubriendo una variedad más amplia de condiciones en todas las edades, con el propósito de avanzar una cobertura de salud universal y efectiva.
Inspirados por esta experiencia, PIH-Liberia y luego PIH-México iniciaron un firme diálogo internacional con el fin de adaptar el modelo para sus necesidades particulares. Describimos la estructura de este “Modelo Hogar”, los cambios realizados para adaptar el modelo a sus contextos particulares y los hallazgos iniciales producto de estas adaptaciones. En general, el modelo hogar está demostrando ser un método viable y funcional para organizar a los TCS, de manera que avance la meta de cobertura universal de salud. La experiencia indica también que no existe un modelo de “talla única” y que otros países que consideren adoptar este modelo deberán analizarlo y adaptarlo a su realidad.
Peer Reviewed
Cite this article as: Palazuelos D, Jabateh LM, Choi M, et al. Early lessons from launching an innovative community health household model across 3 country contexts. Glob Health Sci Pract. 2021;9(Suppl 1):S168-S178. https://doi.org/10.9745/GHSP-D-20-00405
- Received: July 31, 2020.
- Accepted: December 3, 2020.
- Published: March 15, 2021.
- © Palazuelos et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-20-00405
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