Introduction
Sierra Leone | Liberia | Democratic Republic of Congo | Africa region | Global | |
---|---|---|---|---|---|
Maternal mortality ratio (per 100 000 live births) | 1360 | 725 | 693 | 525 | 211 |
Under 5 mortality (per 1000 live births) | 110.5 | 74.7 | 91.1 | 75.9 | 38.6 |
Neonatal morality rate (per 1000 live births) | 33.5 | 25.1 | 28.9 | 27.2 | 17.7 |
Incidence of TB (per 100 000 population) | 301.0 | 308.0 | 377.0 | 237.0 | 134.0 |
UHC tracer index (0–100) | 49.5 | 51.4 | 43.9 | N/A | N/A |
SDG Global Rank (out of 162 countries) | 155 | 157 | 160 | N/A | N/A |
Methods
Study design
Study settings
Data collection
Sierra Leone | Liberia | DRC | Total | |
---|---|---|---|---|
Decision makers at national and provincial level | 4 (2F; 2M) | 3 (3M) | 2 (1F; 1M) | 9 |
District-level managers | 4 (1F; 3M) | 3 (3M) | 3 (1F; 2M) | 10 |
Facility and community-level managers | 11 (4F; 7M) | 4 (2F; 2M) | 3 (1F; 2M) | 18 |
Total | 19 | 10 | 8 | 37 |
Gender | Age (years) | Experience (years) | Total | ||||||
---|---|---|---|---|---|---|---|---|---|
Female | Male | 20–29 | 30–39 | 40+ | < 5 | 6–10 | 10+ | ||
Kenema | 4 | 4 | 2 | 3 | 3 | 5 | 3 | 0 | 8 |
Bonthe | 5 | 2 | 1 | 3 | 3 | 1 | 5 | 1 | 7 |
Total | 9 | 6 | 3 | 6 | 6 | 6 | 8 | 1 | 15 |
Analysis
Code | Sub-codes |
---|---|
Range of CTC providers | |
Reasons for becoming a CHW | |
Role and responsibilities | Scope of work and services Workload and hours Number of CHWs Gender differences |
Perceptions of being a CHW | Positive and negative Effects on family life Acceptance by community |
Selection and recruitment | Selection process Effectiveness Challenges Recommendations Gender considerations |
Attraction and retention | Strategies Effectiveness Recommendations Gender considerations |
Provision of equipment, drugs, etc. | Ways that equipment, etc., supplied Effectiveness Recommendations Gender considerations |
Supervision | Peer supervision Community supervision PHU supervision District-level supervision Central-level supervision Gender considerations |
Training | Training needs Training provided Effectiveness Recommendations Gender considerations |
Performance, rewards and sanctions | How CHW performance is assessed How CHWs are rewarded and sanctioned Effectiveness Recommendations Gender considerations Career pathway for CHWs |
Monthly allowance | Amount and frequency Perceptions Recommendations |
Community engagement | Community structures or people supporting CHWs Effectiveness of community engagement Recommendations |
CHW integration into health system | Relationships with other health workers Views on integration Recommendations for better integration |
Results
HR outcomes
Attraction: wanting to serve their community
Selection: the tricky issues of literacy and gender
When it comes to community affairs, only men show up, women don’t, they don’t even talk. Should they show up, then the community members would have selected them. (District manager, male, Sierra Leone).
“Here in our health district, where you find nearly half of community health workers are female, there are women associations, but where there are no women associations, you find that there are more male community health workers”. (District manager, male, DRC)
Training and development—opportunities for learning and supporting each other
Sierra Leone | Liberia | DRC | |
---|---|---|---|
Initial training | Standardised package that includes three modules: (1) Community health basics (e.g. communication, community entry, household registration, surveillance, health education, preventive care for children, identification of pregnant women); (2). Integrated community case management “plus” (e.g. assessment, referral, treatment and counselling, follow-up care for sick child or child with malnutrition; assess and treat adults with malaria; (3). Reproductive, maternal, newborn and child health (e.g. RMNCH continuum of care, family spacing, pregnancy visits, newborn visits, child visits). 6-8 days training for each module, face to face, with additional 1-2 days practical. No record of training evaluation. | Integrated and standardised training package includes modules on promotive, preventive and curative services, logistics, monitoring and surveillance. Each module is a month long with a 1-week face to face training delivered alongside implementation of services/practical experience. They must pass proficiency tests and supervision to progress to the next training module and function as a CHW. No record of training evaluation. | Site CHWs: 7 days’ training on treatment of common illnesses of children in the community such as simple malaria, diarrhoea, acute respiratory infections, and malnutrition. Promotion CHWs: 7 days training on health education and communication. Disease-programme CHWs: receive training specific to the programme. No description of mode of training or evaluation. |
Refresher | Annual refresher training—no details in policy. | Twice a year training based on findings from supervision visits, and training needs assessments. | CHWs should receive refresher training, but no mention of frequency, duration or content. |
Supervision—complex and challenging
Sierra Leone | Liberia | DRC |
---|---|---|
Peer supervisor (CHWs with additional training): monthly visits to observe the CHWs work, check drug supplies and reports and coordinate monthly meeting of CHWs at Peripheral Health Unit. | CHSS: provides field-based supervision to 10 CHWs working in remote catchment communities, collates reports from CHWs and takes to the facility. | Chair of CHW group: organises monthly meetings, reports to the head nurse, who then reports to the District Health Office. |
Peripheral health unit manager: regular visits to each CHW, attend monthly CHW meeting, provide advice and training to CHW, distribute drugs and supplies, compiles CHWs reports and sends to District CHW focal person. | Facility Manager: checks CHWs reports and clarify any issues, and report to the district health team. | Facility head nurse: regular visits to observe CHW work and records, provide training when needed such as implementing a specific programme or when a health problem increases. |
District CHW focal person: provides training, visits the CHWs and the peer supervisors, collates reports from facilities and compiles district report for District Health Office and National Hub. |
Every week the peer supervisor visits. It wakes me up to do my work. (CHW, male, Sierra Leone)
Well the meeting is good, it brings cordiality and makes the work easier because any issue you do not understand you can bring it up and they explain it to you. (CHW, male, Sierra Leone)
...for the supervision, we go on the ground, we see what they are doing … at the facilities level, there are other orientations we give them, for example organising census within the health catchment area. (Facility manager, female, DRC)
I have to walk on seven hours distance to go for supervision, and then I have to supervise the CHAs on two hours. Before I come back, darkness will catch me and I will sleep there. No compensation. I spend more time in the field, so they should see about compensating me for accommodation and feeding. These things can really affect performance. (Community manager, female, Liberia).
Remuneration—delays and repercussions for retention and performance
We want them to increase our salary - pay us monthly and increase on the amount. Monthly payment is the best as we have personal commitments that require financial inputs and the amount is small, we want them to look into it critically ….and also they should take into consideration that the job is an everyday job and it involves us working with our community, it is very tedious and we even work at night when there are emergencies. (CHW, female, Sierra Leone)
...as they have to work voluntarily in context where finding a paying job is not easy. So, at the same they have to work for their survival and also for community. In a poverty context, their work is not easy. (District manager, male, DRC)
Provision of supplies—promised but not always received
The distance we cover from our own community to the PHU, we go for drugs and drugs are not available, they will inform us that they haven’t received supply. (CHW, male, Sierra Leone)
CHWs need kits and identification card - some people will not speak to them or accept them without ID card, kits, rain boots, rain coats. (Community Manager, male, Sierra Leone)
Performance management—the challenges of rewarding and sanctioning volunteers
They told me they cannot go to the man because he is always drunk so we have to change that CHW. (District manager, male, Sierra Leone)
Strategies | Challenges | |
---|---|---|
Rewarding CHWs “We think that the high performing CHWs should be recognised and awarded. This will make a big difference to how they feel appreciated”. (National decision maker, male, Liberia). | Selecting active CHWs for programme activities where they will be given a financial incentive | Not enough rewards and recognition |
Sharing food or small financial incentives during meetings | Create annual awards, certificates and radio announcement | |
Providing verbal praise | Community recognition needs to be stronger in some areas: community members need to support CHWs with their farm work so that they can focus on their health work. | |
Assuring CHWs that they have the community’s and God’s recognition | ||
Sanctioning CHWs “You know, it is not easy in our context to manage someone who works voluntarily, and does not benefit from financial incentives. It is just too difficult to objectively manage them”. (Facility manager, female, DRC). | More closely monitoring the CHWs and providing encouragement | Difficult to dismiss poorly performing CHWs |
Providing additional training and support | Time and resource consuming to replace CHWs | |
Talking with the community to try to resolve performance problems | ||
Occasionally, threatening not to submit the CHW report to the facility which would prevent them receiving their allowance. |
As for rewards, we do not do something special, as we do not have money. But, whenever there is a meeting, we prepare food, and we eat together, and get to know each other much better. (Facility manager, female, DRC)I didn't give them any reward, but the means…when a programme came, I didn't just let one keep working and working I started to rotate them when different programmes came and that allowed them to re-engage. (Facility manager, male, Liberia)
The community people sometimes give me words of moral boost and sometimes give me food items like fish, cassava. (CHW, male, Sierra Leone)To make my job easier the community should at least assist me not financially but like if I want to make a cassava garden, they help me out, but they had not started doing that. (CHW, male, Sierra Leone)
Discussion
Attraction and selection | Training and development | Supervision | Remuneration | Provision of supplies | Performance management | |
---|---|---|---|---|---|---|
Study findings | Literacy and gender played out in selection of CHWs. Fragility disrupts education of community members—CHWs may not have the literacy levels required for role; implications for selection, role, training and performance of CHWs. Selection policy ideals are mediated in practice by gendered community norms. | The modular, local and mix of practical and classroom teaching approach worked well in Sierra Leone and Liberia, helping to address gender and literacy challenges and served to develop a cohort of CHWs who support each other. Training in DRC is ad hoc. | Multiple actors involved in supervision. Peer supervision and some facility supervision seen as supportive. There are challenges with overloaded facility staff, limited transport, and limited support for supervisors. In Sierra Leone, relationships between facility health workers and CHWs are sometimes strained. | Delays in remuneration for CHWs in Sierra Leone and Liberia. CHWs use own money to do their work within contexts of poverty. Community think CHWs are paid and will not provide additional support. DRC CHWs still expect financial incentives, despite volunteer role. | Challenges in the drug supply chain have led to a delay in CHWs receiving medicines on time to treat patients, meaning their role is mainly to refer. Despite promises of equipment and materials most CHWs have not received these items. These are critical to CHW roles, reputation and community recognition and trust. | No written guidance on managing CHW performance. Managers use rewards, e.g. selecting active CHWs for programme activities, sharing food or small financial incentives during meetings, and providing verbal praise. Challenging to sanction poorly performing CHWs. Managers used encouragement, closer monitoring, additional training and support, and talking with the community to resolve performance problems. |
Recommendations | Sensitise communities to encourage women to volunteer and to be selected at the same rates as men. Embed literacy training into CHW training to address literacy challenges. Support community development groups to create space for women’s active participation in community dialogue. Cultivate community “ownership” and support of CHWs from selection and throughout their ongoing role through regular meetings. | Provide training in a flexible, module-based approach with a mix of classroom and practical teaching; and app based training when travel is restricted. Learners can accumulate credits from modules, and pick up modules again if interrupted by conflict or other factors. Develop sense of a cohort so that CHWs support and learn from each other and jointly problem solve. Encourage mobile messaging or WhatsApp groups for ongoing peer support. Build ongoing capacity development needs into systems as CHWs roles may change e.g. during COVID19 pandemic. | Use innovative models e.g. peer supervisors, group supervision. Support the supervisors through training and recognition including in the provision of basic psycho-social support and strengthening CHW morale. Capture local issues and solutions to inform health system priorities. Encourage peer-to-peer discussions at routine CHW meetings at health facilities. Encourage community members to play greater role in support and supervision. | Clearly and openly communicate remuneration package with CHWs, other health workers and community. Develop robust system for timely payment and clearly communicate. | Provide drugs and other supplies on a regular basis. Ensure CHW supplies are allocated to CHWs by involving community and supervisor in allocation. Encourage sharing of resources within health system. | Reward good performance through recognition by peers and health system. Encourage community support and value. Develop a career pathway that reflects the needs of both female and male CHWs. |