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The Current State of Play in

CHW Training Programs in sub-Saharan Africa & South Asia

Literature Review

Commissioned of the One Million Community Health Workers Campaign by mPowering Frontline Health Workers, through support from USAID & Intel

12 December 2013

Overview

•  Why CHW Training?

•  Methodology

•  Findings

•  Recommendations

•  Next Steps for the “Global Health Content for Local Solutions” consultation?

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Why CHW Training?

•  CHWs are not effectively trained, remunerated, or retained

•  Hypothesis that CHW Training is important for: •  improving workforce quality and health outcomes; and •  successfully expanding CHW programs in scope (including quality) and

coverage (scale-up)

•  CHW Training (its implementation & effectiveness) has not been well studied

•  A literature reviews allows us to: •  Know just what is out there, •  Draw conclusions based upon the evidence base, and •  Know what is lacking from the evidence base.

Methodology

•  Literature: •  Published articles, grey literature and reports

•  Selection criteria: •  Content: Describe/analyze/synthesize current CHW training practices

•  Geography: Sub Saharan Africa, India, Pakistan, Nepal

•  Exclude: High- and mid-level cadres of health workers

•  Period: Published from year 2000 to present

•  Language: English

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Methodology

•  Sources: •  Databases: Cochrane Library, Google Scholar, PubMed, ProQuest

•  Other: CHW Central, Frontline Health Workers Coalition (FHWC), Global Health Workforce Alliance (GHWA), USAID, World Health Organization (WHO), Pathfinder International, Millennium Villages Project (MVP), etc.

•  Selection: •  Approx. 100 articles and reports

•  Time constraint: •  3 weeks (commissioned 20 Nov., delivered 10 Dec.)  

Results

•  Synthesized the literature by category, for both Pre-Service and In-Service Training evidence •  Diversity in training programs

•  Geographic diversity

•  Training effectiveness

•  Gaps (in practice and in evidence)

•  Best Practices identified

•  Case studies: •  Ethiopia, Pakistan, Zimbabwe, Nepal

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Findings

Pre-Service

In-Service

How long do CHW Trainings last?

How often are they held?

Where do they take place?

Who are CHW Training providers?

How are they taught?

How are they assessed?

What content is covered by CHW Trainings?

Findings

Pre-Service In-Service

How long do CHW Trainings last?

5 days … 15 months 3 hours … 10 days

How often are they held? Unknown Monthly…Annually

Where do they take place? •  On-site (community) •  Off-site (district or regional hospital, school, or

health facility)

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Findings

Pre-Service In-Service

Who are CHW Training providers?

•  NGOs •  Governments (national or local) •  Government/NGO partnerships

How are they taught? •  Technique: didactic vs. interactive •  Objectives: theory vs. skill

How are they assessed? Rarely. Where testing is implemented, it is useful for demonstrating CHW Training effectiveness and knowledge retention.

Findings

Pre-Service In-Service

What content is covered by CHW Trainings?

•  Varies widely •  Inconsistencies

•  Refreshers vs. new •  Comprehensive vs.

specific disease

Matrix of topic areas displayed on next slide…

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Findings

Acute respiratory infections

Antenatal care

Behavior

change

Childbirth

Diarrhea

Family planning

Gender based

violence

HIV/AIDS

Vaccines

Intestinal worms

Malaria

Maternal, newborn and child

health

Mental health

Newborn care

Nutrition

Record keeping +

data management

Referral practices

Sexually transmitted infections

TB

Vitamin deficiencies

Water, sanitation,

hygiene

So, what do we know about CHW Training?

•  Not much! •  Insufficient evidence: Gaps in evidence base

•  Poor quality evidence: Existing research makes it difficult to distinguish what is working from what isn’t, specifically for CHW cadres

•  Observations: •  Duplication of curricula, provider categories, inconsistencies in

training duration (possibly due to lack of evidence or methodology on training length), pedagogy (didactic vs. interactive vs. mixed methods)

•  Notable differences between SSA and South Asia •  Key best practices identified

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Best Practices Identified

•  Planning •  Coordinating training approaches with other providers •  Incorporating CHW feedback to improve training methods and

curricula

•  Teaching methodology •  Incorporating interactive teaching methods into CHW training •  Effective CHW training must have interactive components that are repetitive, and more

interactive than didactic •  Use of technology improves learning outcomes and should be more widely utilized

•  Continuous assessment •  Using feedback from training participants to improve the training

curriculum and delivery •  Use of pre‐, post‐ and follow‐up tests, self‐assessments and feedback forms •  Allow CHWs to feel included in the process and foster a sense of ownership in their

education, which enhances CHW engagement

Suggestions for research

•  More research on post‐training CHW competency is needed to determine the effectiveness of the wide array of training programs that exist and to establish an evidence‐based curriculum

•  Other gaps in the evidence base for CHW training programs •  e.g. use of pictorial training for low‐literacy audiences?

•  e.g. adaptation of curricula to local languages or cultural contexts?

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Recommendations

1.  Training program implementation and curricula should be coordinated amongst training providers, including NGOs, civil society organizations and governments;

2.  Pedagogy of CHW training curricula should be made more interactive to allow CHWs to engage with content in practical ways similar to the working environments they will encounter on the job;

3.  CHW feedback should be sought and acted upon, to improve the

quality of training content and delivery; and

4.  CHW training providers should regularly monitor CHW competency to refine pre-service trainings and drive in-service trainings.

Linking research on CHW Training to CHW scale-up: Big picture considerations and information needed

•  There is a disconnect in the way training programs are managed,

delivered and monitored.

•  A more cohesive approach to CHW training programs is needed.

•  Synergizing CHW training programs will ensure that more consistent, evidence‐based trainings are provided to CHWs wherever they reside.

•  à Positive impact on CHW effectiveness through increased competency and improved service delivery

•  à Ultimately impact MDG outcomes

Next Steps