Community Health Workers

A training session with the new accompagnateurs curriculum in
Burera, Rwanda.

Catalysts to Improving Health Care

PIH’s community-based model of care is designed to strengthen and complement existing public health systems to assure universal and sustained access to high-quality health services.

Often, however, public health facilities are in physical disrepair, with few medications and diagnostics and a poorly paid and disheartened staff. The public health system is especially underfunded and underused in the rural areas where PIH works, such as central Haiti or the mountains of Lesotho. While refurbishing and upgrading these facilities is critical, community health workers (CHWs) are the catalysts for revitalizing and expanding access to health services. They help ensure continuity of care in settings where there are few health professionals, where travel is difficult, and where chronic diseases require complex treatment regimens and ongoing monitoring. CHWs are the bridge between the health system and the community. As respected and knowledgeable members of the community, CHWs also broaden the clinical staff's understanding of the environments in which their patients live.

The key role played by community health workers, often referred to as accompagnateurs at PIH to reflect their role in accompanying patients through their illness, has been borne out by PIH’s success in treating AIDS in rural Haiti and multidrug-resistant tuberculosis (MDR TB) in the shantytowns of Lima, Peru: in both cases, CHWs oversee complex treatment regimens in patients’ homes. CHWs do much more than supervise the ingestion of pills, however; they provide social and emotional support, standing in solidarity with the poorest and most vulnerable members of the community, and help develop trust and confidence in the health sector. Today, PIH’s community-based approach has been adapted to programs in Rwanda, Lesotho, Malawi, Russia, and the United States.

In the following sections you will find descriptions of the main elements of PIH’s CHW programs, with guides and examples highlighting how the basic philosophical underpinnings have been adapted to meet the needs of communities in a variety of settings.

As this a work in progress, we welcome your feedback in the comments area and hope you will exchange ideas with us—sharing your own experiences, lessons learned, examples, and comments to help us promote the delivery of high quality health care to the world’s poorest communities.

Recruitment

Based in the community

While there are often few physicians and nurses in resource-poor settings, a large number of underemployed or unemployed persons are frequently available. CHWs are always recruited from the communities they support. Recommendations are sought from respected members of the community such as village elders, spiritual leaders, nurses and teachers. Some programs have organized community meetings to find CHWs, while others have advertised through local newspapers and radio announcements. Religious groups, schools, and other community-based organizations providing outreach activities are also good places to find potential CHWs. Patients are another source as they are able to serve themselves and to recommend people in their village who are trustworthy and caring.

The programs in Lesotho, Haiti and Rwanda have, whenever possible, integrated community workers who are already in place - village health workers, agents de santé and animateurs de santé, respectively - into the newly formed community health worker teams.

Requirements

The CHW must be an adult (usually over 18 years of age) and preferably literate.

Since the CHW is in daily contact with patients in their homes, he or she should live in or close to the community served; having lived in the community for a specific number of years is often required.

The CHW should have a background that is similar to the background of the patients so that they feel comfortable sharing their concerns. This also enables the CHW to have first-hand knowledge of the problems and obstacles patients face every day. In some cases, CHWs are themselves HIV positive or former TB patients. They frequently know someone who has HIV or TB in their community.

Motivation and character are critical requirements. A CHW must be a trustworthy and respected member of the community with a strong desire to help the needy and a strong sense of empathy with those who are vulnerable and sick. A CHW’s work is not only focused on improving health status, but also on social justice and solidarity with the community, through working to support affected individuals and households and reduce social isolation. The profile of a successful accompagnateur at Inshuti Mu Buzima, Rwanda highlights many of these requirements.

Interviewing CHW candidates

The clinical team usually interviews people who wish to become CHWs to see if they meet the above requirements. Team members that may be involved in the interveiw process include doctors, nurses, social workers or program managers. The candidate may be asked to take a basic literacy test. He/she may also be called upon to read a medication label or write his/her name, to distinguish medications by color and size and to count the number of pills in a month's supply. In some programs, preference is given to candidates who are extremely poor and could therefore particularly use the additional income and skills-training. Given the specific vulnerabilities of women in the HIV epidemic, women may be preferred.

Pairing a patient with a CHW

CHWs are chiefly selected by patients themselves. In the case of an established program, a patient may already know a CHW in his community, and may even have been referred to the health center by him/her.

If the patient does not know any CHWs, or doesn’t feel comfortable with the one(s) he/she knows, then the clinical team suggests a possible candidate from those CHWs who live in the vicinity of the patient.

Roles and functions

CHWs serve as counselors, educators, treatment supervisors, and advocates experienced in identifying the needs of their communities. They:

1. Provide home-based care
2. Provide psychosocial support to patients undergoing treatment
3. Act as the link between the patient and the health center
4. Carry out active casefinding
5. Educate the community on a variety of health topics

1. Provide home-based care

At PIH programs, CHWs provide the bulk of daily care to patients, especially in supporting those who have chronic illnesses such as HIV and TB. CHWs are responsible for administering all outpatient TB- and HIV-related medications. They directly observe the ingestion of pills at the same time once or twice a day in the patient’s home and record the patient’s adherence (example: Adherence form).

By working to ensure that patients adhere to medications, CHWs fulfill an essential function in optimizing patients’ clinical outcomes and preventing or delaying the emergence of drug-resistant disease. CHWs also routinely visit HIV-positive patients who are not receiving ART to assess their ongoing needs and those of the family.

CHWs explain the importance of adherence to medication and work with the patient to identify and address obstacles to adherence. Through their daily visits, CHW teach patients how to manage complex drug treatments and cope with possible side effects. CHWs ensure that they safely store the medications they provide to patients, keep them away from children, away from sunlight, in a dry place and in the same container in which they come from the health center. The CHWS are also responsible for ensuring that drugs are taken with the appropriate food and drink if required, and that any allergic reactions or side effects to medicines are quickly identified and reported to the health center.

In PIH’s Prevention and Access to Care and Treatment (PACT) Program in Boston, United States, CHWs work with patients who have long histories of poor adherence to AIDS treatment. These patients need extra support to improve their clinical outcomes and quality of life. The PACT Project involves two types of CHWs. Health Promoters (HP) make weekly home visits to assess adherence (PACT adherence form), provide extensive adherence counseling, and accompany patients to medical and social service appointments. For those patients who need more intensive support in maintaining adherence, a DOT specialist visits the patient daily and observes ART.

CHWs are also a vital link between the health center and pregnant women in the community (see Accompagnateurs curriculum section – Women and HIV/AIDS). CHWs stress the importance of prenatal and postnatal care and encourage pregnant women to visit the health center for check-ups, undergo HIV testing, and deliver at the health center. In the case of a home delivery, they encourage women to bring their babies to the health center as soon as possible after the birth.

2. Provide psychosocial support to patients undergoing treatment

As the primary contact with the patient and the patient’s family through daily visits, CHWs see first-hand the stresses that affect a patient’s health status and adherence to treatment and health status. Through their own experience as members of the same community, and their knowledge, commitment, and ability to access to other resources, CHWs can support the patient and his/her family in important non-medical ways during treatment and beyond.

CHWs respect the privacy and confidentiality of the patient (see Accompagnateurs curriculum section – Psychosocial Support and Effective Communication). When the patient and the CHW start working together, they establish ways to respond to questions about their relationship. Some patients may prefer to describe the CHW as a friend or a cousin. Following the wishes of the patient and keeping information about him/her confidential are crucial for building trust.

CHWs provide emotional and practical support to patients by helping reduce their sense of isolation and by encouraging them to discuss their illness with their families (see Accompagnateurs curriculum section – Stigma and Discrimination). They alert the staff at the health center if the patient’s mental, social, or economic state is precarious.

CHWs may also provide counseling and facilitate referrals on mental heath, substance abuse, domestic violence and other social issues, as they do in the PACT Program (PACT Progress Report).

3. Act as the link between the patient and the health center

Community Health Workers are the eyes and ears of the clinical team in the community. CHWs also accompany their patients to the health center, sometimes assisting with arranging transportation, childcare, or other logistics.

At the same time, they advocate for the patient by assessing, monitoring, and attending to patients’ need for food, housing, safe water, education, or financial assistance (example: Addressing Basic Needs at PIH Lesotho). They notify the clinical staff and the social worker at the health center when these non-medical problems impact patients’ adherence, treatment or overall health.

4. Carry out active casefinding

As CHWS are living and working in the community, they may be able to proactively identify sick or otherwise needy people, especially family members or other close contacts of patients. They may recognize opportunistic infections or TB symptoms and encourage these people to undergo testing and treatment at the health center; CHWs should pay particular attention to groups at particular risk for TB: children, people living with HIV/AIDS, and malnourished people. CHWs may also identify social and economic obstacles that impact on health, such as problems with children’s schooling, or housing or economic hardship, and help to obtain support for these social needs.

5. Educate the community on a variety of health topics

CHWs provide accurate information about chronic diseases such as HIV/AIDS and TB, explain how to prevent them, encourage community members to undergo testing, and correct people’s misunderstandings or myths. They also encourage community members to accept and provide support to people living with HIV/AIDS, especially orphans. Beyond AIDS and TB, CHWs formally and informally educate the community on a wide array of health center activities and health topics, ranging from vaccination campaigns to hygiene and sanitation.

The multifaceted work of a community health worker is highlighted in this example from PIH’s program in Rwanda.

Payment

Community Health Workers should be paid for their efforts

Community Health Workers should be paid for their efforts. CHWs are trained to carry out essential care, often under very difficult circumstances. Furthermore, CHWs’ role in identifying patients in need of care and in ensuring adherence to treatment results in significant short- and long-term cost savings through earlier initiation of treatment and by preventing or delaying the emergence of drug resistant-disease. They should not be asked to volunteer their services in settings of great poverty. Rather, their efforts should be fairly compensated. Salarying CHWs in settings with high unemployment and overall poverty helps jump-start economic activity in addition to being a critical recognition of the vital services they provide.

How the payment is calculated

In determining how much to pay CHWs, it is important to keep in mind local pay scales for public sector employees, from schoolteachers to staff at health facilities. When a new CHW program is established in an area where community health workers already exist, the payment for both groups should be harmonized as much as possible.

Other considerations include the extent and scope of the CHW role, including whether the job duties are considered part-time or full-time. Some programs provide a flat fee to CHWs (example: payment at PIH’s program in Haiti), while other programs pay different salaries depending on the number of households served and the number of visits the CHWs make to the health centers (example: payment at PIH’s program in Rwanda).

The CHWs are paid monthly at the health center by a designated staff member. At Inshuti Mu Buzima in Rwanda, the community health nurse disburses payments. At Zanmi Lasante in Haiti, the accountant is responsible for the CHW payments.

Training

Organization

Before they begin supporting patients, CHWs receive an orientation from the clinical staff at the health center as well as participate in a rigorous training program designed by PIH.

PIH’s current pilot curriculum for CHWs comprises 15 units, with a focus on AIDS and tuberculosis. The training is tailored to be given over seven consecutive or separate days. Each training day consists of 6.5 hours of training, 1 hour for lunch, and two 15-minute breaks.

The number of participants varies according to need; 25 participants or fewer is ideal. All participants are provided with meals and a stipend.

Trainers and facilitators are drawn from the staff at the health centers and should have experience in training or education to ensure that they are knowledgeable about and competent in participatory-based learning and training methods suited to low-literate adult learners.

Regardless of the specific content areas covered, the primary objective of CHW training is consistent: to instill a sense of solidarity and social justice in supporting patients, households and the community. Specific goals include:

• Providing correct information about treatment, prevention, and risk factors for HIV, TB, malaria, and other infectious diseases.

• Defining the roles and responsibilities of CHWs.

• Helping CHWS recognize and reduce stigma and discrimination in their communities.

• Developing CHWs' competence in active casefinding for diseases and social needs.

• Helping CHWs improve their skills related to effective communication and psychosocial support.

• Directing CHWS to additional resources or people at the health center and in the community who can guide or assist their work.

Training principles

Based upon adult learning principles, the CHW training curriculum presented here incorporates a variety of participatory approaches to teaching and learning that build upon the existing knowledge, skills, and experiences of the participants, including:
• Large- and small-group activities and discussions
• Role plays
• Case studies
• Brainstorming
• Panel discussions
• Peer teaching

Continuing education

After the initial program, CHWs participate in ongoing monthly education sessions for one year and beyond, with additional training in areas such as nutrition, malaria, pediatric HIV/AIDS, diarrheal disease, family planning, active casefinding, worms and parasites, chronic disease, first aid, the role of traditional healers, and oral hygiene. Trainings are led by health center staff or other available teachers.

Shadowing a CHW

After completing his/her initial training, the new CHW joins a veteran CHW in conducting patient visits. This provides a practical, hands-on learning experience and helps the new CHW develop a support network of fellow CHWs.

Supervision

Historically, PIH’s CHWs have been directly supervised by clinical staff, usually a doctor or nurse involved in the care of HIV or TB patients. As our programs have grown, we have increasingly recognized a need for more formal supervision structures that take advantage of the experience and skills of more senior CHWs. Recently, we have introduced the role of Accompagnateur Leader at several of the program sites.

CHW leaders

Most often, the leader is an existing CHW who has been chosen based on the high quality of his/her work, leadership qualities and standing in the community. The length of time the CHW has been working as an accompagnateur and his/her level of education are also factors.

The number of CHWs supervised by each CHW leader varies. In the PIH program in Rwanda, a CHW leader supervises between 15 and 25 CHWs (Accompagnateur leader duties and weekly report), while in the PIH program in Haiti a CHW leader may oversee up to 50 CHWs.

Roles and responsibilities

The primary responsibility of the CHW leader is to ensure that the CHWs are visiting their patients daily, administering medications correctly, and vigilantly monitoring patient health. The leader also helps the clinical team by answering patients’ questions, joining the team on patient visits, and identifying problems between CHWs and patients. See examples of supervision at Zanmi Lasante, Haiti and at Inshuti Mu Buzima, Rwanda.

Another point of supervision is at the pharmacy, which CHWs visit regularly to pick up medications for their patients. Pharmacy logs and interactions with the pharmacist are important points of supervision.

The CHW leader and other members of the health center identify problems between CHWs and patients through unannounced visits to patients’ homes. When a conflict does arise, the CHW is called to the health center to discuss the situation.

CHW leaders meet regularly with health center staff to exchange information and discuss common issues. CHWs meet monthly with health center staff for ongoing training and to discuss any problems or concerns.

Implementation

Begin with community

Establishing services in a community begins with an informal (and ongoing) process of surveys and meetings with the local population to find out their specific needs and desires.

Organizational structure

The CHW represents the health center to the community and is an integral part of the medical team, interacting continually with the rest of the staff. It is important that he/she knows the different staff roles and responsibilities in order to direct medical and non-medical issues to the appropriate person.

The number of Community Health Workers

The CHW-to-patient ratio varies from site to site depending on how many CHWs can be recruited or how many CHWs already exist, population density, the logistical demands of the area’s topography, and the types of patients being supported.

Project	CHW:patient ratio
PACT Project Boston*	20 to 25 patients per Health Promoter 7 to 10 patients per DOTS Specialist
Zanmi Lasante Haiti	Up to a maximum of six patients per CHW
PIH-Lesotho	Up to a maximum of five patients per CHW
Socios En Salud Peru	Up to a maximum of five patients per CHW
Inshuti Mu Buzima Rwanda	The ideal ratio is 1 CHW per 6 patients. Each CHW can have a maximum of 8 patients from a maximum of 4 households

*The Health Promoters provide ongoing adherence counseling and support, accompaniment to medical/social service appointments and coordination of care. The DOT Specialists visit patients daily, and help them take their medications.

Work schedule

After the initial training, the CHW meets with those patients he/she will support who are undergoing or about to start ARV or TB treatment. The CHW can be chosen by the patient, or, with the patient’s agreement, the CHW may be assigned to a patient depending on where he/she lives.

Ideally, CHW-patient pairings remain stable over the course of treatment/care. While the schedule of visits varies according to the population and geographic spread of the community and their specific health needs, there is a common set of visits that occurs in all the programs.

At the patient’s home

Once a patient begins AIDS or TB treatment, the CHW visits the patient’s home once a day to administer medications. The CHW should watch the patient take his/her medication. If the patient is having trouble with ART, the CHW visits twice a day to observe both doses.
CHWs meet with the members of the health center team when the team makes home visits to patients, or when the CHW leader makes unannounced visits to meet with patients and monitor the work of the CHWs.

At the health center

The CHW accompanies his/her AIDS patients for a consultation with clinical staff two weeks after ART initiation. In some programs, each AIDS patient is assigned to a group based on the starting date of treatment. Each group is assigned a specific day of the week for visits to the health center, thus allowing for coordinated care and monitoring of patient cohorts.
Additional visits when:
— A patient is ill and needs to be seen by clinical staff.
— A CHW identifies a person in the community who shows symptoms of HIV, TB, or other illness.
— A CHW is assigned to a new patient.
— The staff at the health center asks to meet with the CHW.
Twice a month
— If supervising TB patients, visit the health center to collect TB medicines.
Once a month
— Visit the health center to collect ART if supervising AIDS patients.
— Collect salary.
— Attend ongoing training and education sessions, CHW meetings, and meetings with health center staff.
— In some programs:
º Accompany HIV and TB patients for their monthly consultations.
º Accompany pregnant women enrolled in the PMTCT program for their monthly consultations.
º Accompany HIV-positive mothers and their newborns for biweekly consultations.

Conclusion

In a recent article in PLOS Medicine, more than 200 experts were asked the question, "Which single intervention would do the most to improve the health of those living on less than $1 per day?"

Here is Paul Farmer’s reply:

"Hire community health workers to serve them. In my experience in the rural reaches of Africa and Haiti, and among the urban poor too, the problem with so many funded health programs is that they never go the extra mile: resources (money, people, plans, services) get hung up in cities and towns. If we train village health workers, and make sure they're compensated, then the resources intended for the world's poorest—from vaccines, to bednets, to prenatal care, and to care for chronic diseases like AIDS and tuberculosis—would reach the intended beneficiaries. Training and paying village health workers also creates jobs among the very poorest."