Table 5 Indicator activities to implement PHC principles in national or large-scale community health worker programs

UNIVERSAL HEALTH COVERAGE

Service Provision

•Provide maternal, newborn and child health services

•Provide medical care services for physical and mental health

•Provide outreach services to remote areas

•Horizontal integration at the service delivery level

Selection and placement of CHWs

•Select CHWs based on a broad criteria not limited by a literacy threshold

•Have CHWs in all areas of the country, even the remotest hamlets

•Distribute CHWs across a population to make it feasible for the CHW workload and individual care seeking

Defined catchment area

•Define the catchment area with reference to the population that is to be served by the CHW program. This would facilitate needs assessment, service provision and connection to the formal health system in an organised manner

Community Sensitization

•Inform the community about the core activities of the coverage

•Ensure the community is aware of their right to have access to the needed care

Needs assessment

•Identify varying needs of sub-population groups to provide equity-based care

•Assess the staff and material needs of sub-population to distribute them accordingly

•Assess what could work or not in each community in a manner (sensitive to social, economic and cultural aspects) and with a social determinants of health lens – Comprehensiveness

Equity

Planning

•Plan services that address the local inequities in service coverage and health outcomes across different types of demographics

•Plan services with an understanding about dynamics of discrimination within the local context

Implementation

•Provide services according to the needs of disadvantaged groups

Address financial and geographic barriers to health care

•No user fee especially in rural health centres

•Provide PHC services close to the community through outreach

Access

Identification of the causes of low demand and utilization

•Identify physical barriers and other supply-based barriers like access to quality care and human resources for health, supplies and commodities

Promote community access to the program

•Ensure that all community members can access the program irrespective of distance, ethnic or religious group, gender, age, social status, physical and mental state, and ability to pay

Ensure privacy and confidentiality

•Train CHWs to provide services considering privacy and confidentiality of the community members

Comprehensiveness

Provision of health services along the spectrum of preventive, curative, and rehabilitative services

•Presence of a functional health unit within the catchment area with primary health care activities

Linkages with secondary and tertiary level services

•Establish linkages with other service providers and referral pathways to ensure comprehensiveness of a service package, especially if very few or no curative services are being provided directly by the CHWs

•Collaborate in governance structures from local to national level

COMMUNITY PARTICIAPTION

Joint ownership and design of CHWPs

•Engage community representatives to make sure that they are aware and involved in the design, implementation and evaluation of the program

•Involve community at all levels of decision making from planning, training, selecting and oversight of CHWs

•Ensure feedback from the community

Availability of health data to the community

•Ensure that the community is informed, provide feedback and participate in decision-making

•Establish a practical monitoring system incorporating data from communities and the health system

INTERSECTORAL COORDINATION

Representation of non-health organisations on planning and governance structures of CHWPs

•Negotiate to promote health and addressing needs of water, sanitation, food, housing and transport

Public private partnership

•CHW program works with [other actors] in the community development sector

•CHW program works with government officials

•Provide benefit packages to particular populations (e.g. cash transfers for pregnant and lactating woman or households below the poverty line)

APPROPRIATENESS

Context specific program design and implementation

•Plan and implement interventions which adhere to community culture and demand

Evidence-based interventions

Prioritize technically sound and operationally manageable service packages with maximum health impact

Effectiveness

Monitoring health outcomes

•Assess health outcomes with reference to the stated goals and from an equity lens

•Ensure that quality of care is an integral part of the monitoring systems

Monitoring performance

•Assess the competence of CHWs regularly on to make sure that they are skilled to address poor health and confident to be pro-active in using these skills

Well-resourced CHWs

•Provide regular training, supplies and supervision to CHWs in order to ensure intended health outcomes

Cultural acceptability

Community involvement in the selection of the CHWs

•Consider factors influencing care-seeking by underserved groups e.g. language and other cultural norms

Health Literacy

•Monitor that messages shared by CHW program [are such] to which people [relate to] and understand

Affordability

Cost effective interventions

•Assess the chosen and alternate interventions financially and in a context-specific manner

•Assess if the full spectrum of treatment needed is affordable by the CHW program

Identify and address financial barriers to health care

•Assess if transport cost is a barrier and provide subsidy/transport if necessary

Manageability

Adequate human resources

•Supervisors, program managers and frontline health staff must have the capacity, clear role, time and resources to provide adequate supportive supervision and performance review

Proportionate service provision

•Consider the range and complexity of services along with the size of the population to be served

Continuous adjustment of the role of CHWs as the program evolves with respect to communities’ needs

•Full-time, salaried CHW versus part-time, voluntary CHW

•Make sure that the time commitment and renumeration of the CHWs are according to service package and catchment area