Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach.

BACKGROUND: There is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients' health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems - the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated. METHODS: We explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component. RESULTS: We identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system. CONCLUSIONS: We believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.

Overcoming the hurdle of implementation: putting human resources for health tools into action.

The global human resources for health (HRH) challenge remains persistent. In 2006, the World Health Report identified 57 crisis countries, and, despite increased attention and investment in strengthening the workforce, those countries are still in crisis. While chronic HRH problems still exist, progress has been made in some countries where innovative programs have been implemented that show promise, or specific initiatives have been scaled up. Yet, these have not been substantive enough to move countries out of the "crisis" category. While many countries have HRH plans, this paper asserts that a major reason countries remain in crisis is the lack of sustained implementation to achieve concrete workforce strengthening results. This is true despite the fact that there have been major investments in a broad range of tools and resources aimed to support implementation of plans and initiatives.Given this picture, the paper states that it is critical for HRH leaders to take action to ensure that already available tools are disseminated, adapted and used to foster effective implementation at the country level. The paper highlights four such tools as examples that can be used to build implementation capacity, and acknowledges more like them. Having highlighted these tools, the paper concludes by offering recommendations as to how to support more results-oriented implementation. These recommendations are organized around three linked components: 1) providing sufficient advocacy to leadership at the national level to mobilize and commit them to implementation action, 2) assembling and managing the requisite assets (including the institutional arrangements, people and money) into a coherent and powerful whole, and 3) using accountability as a foundational tool to assess progress in implementation, track key indicators, celebrate achieving key milestones and identify problems when indicators are not achieved.

Superando el obstáculo de la implementación: poniendo en acción las herramientas para la promoción de recursos humanos en salud / Overcoming the hurdle of implementation: putting human resources for health tools into action

Los desafíos de los recursos humanos en salud (RHS) aún persisten a nivel mundial. El Informe Sobre la Salud en el Mundo identificó a 57 países en situación crítica los que, a pesar de la atención e inversión crecientes en el fortalecimiento de la fuerza laboral, siguen en crisis. Pese a la existencia de problemas crónicos en RHS, se ha logrado progresos en algunos países en los que se ha aplicado programas innovadores basados en iniciativas concretas. Sin embargo, este esfuerzo no ha sido suficiente para poder solucionar la crisis de los países involucrados. Una de las razones principales para ello es que pese a que muchos paises tienen planes para los RHS, la falta de implementación sostenida impide alcanzar resultados concretos que fortalezcan la fuerza laboral. Esto es así a pesar de que ha habido grandes inversiones en una amplia gama de herramientas y recursos para apoyar la aplicación de planes e iniciativas. Ante este panorama, es crítico que quienes tienen a su cargo los RHS tomen medidas para garantizar que las herramientas ya disponibles se difundan, se adapten, se utilicen y se apliquen efectivamente a nivel nacional. Este documento destaca cuatro herramientas como ejemplos que pueden utilizarse para construir capacidad de ejecución, se ofrece recomendaciones sobre cómo apoyar la aplicación orientada a resultados. Estas recomendaciones están organizadas alrededor de tres componentes ligados entre sí: 1) proporcionar suficiente abogacía al liderazgo a nivel nacional para movilizar y comprometerles a la acción de implementación, 2) recopilar y gestionar los activos necesarios (incluyendo los acuerdos institucionales, personal y financiamiento) en un todo coherente y 3) utilizar la "rendición de cuentas" de actividades como una herramienta fundamental para evaluar los progresos en la aplicación, realizar un seguimiento de los indicadores claves, celebrar el alcance de hitos clave e identificar problemas subyacentes cuando no se logra el cumplimiento de los indicadores.

The global human resources for health (HRH) challenge remains persistent. In 2006, the World Health Report identified 57 crisis countries, and, despite increased attention and investment in strengthening the workforce, those countries are still in crisis. While chronic HRH problems still exist, progress has been made in some countries where innovative programs have been implemented that show promise, or specific initiatives have been scaled up. Yet, these have not been substantive enough to move countries out of the "crisis" category. While many countries have HRH plans, this paper asserts that a major reason countries remain in crisis is the lack of sustained implementation to achieve concrete workforce strengthening results. This is true despite the fact that there have been major investments in a broad range of tools and resources aimed to support implementation of plans and initiatives.Given this picture, the paper states that it is critical for HRH leaders to take action to ensure that already available tools are disseminated, adapted and used to foster effective implementation at the country level. The paper highlights four such tools as examples that can be used to build implementation capacity, and acknowledges more like them. Having highlighted these tools, the paper concludes by offering recommendations as to how to support more results-oriented implementation. These recommendations are organized around three linked components: 1) providing sufficient advocacy to leadership at the national level to mobilize and commit them to implementation action, 2) assembling and managing the requisite assets (including the institutional arrangements, people and money) into a coherent and powerful whole, and 3) using accountability as a foundational tool to assess progress in implementation, track key indicators, celebrate achieving key milestones and identify problems when indicators are not achieved.