Community Health Workers (CHWs) play a critical role in delivering quality care as part of an integrated primary health system, often serving as the only connection between the health system and vulnerable, remote populations. In recent years, and particularly in the face of the COVID-19 pandemic, there has been growing recognition that CHWs are effective in delivering preventive, promotive and curative health services while reducing inequities in access to care and contributing to global progress toward Universal Health Coverage (UHC).
However, not all CHW programs are created equal. While we know what it takes to deliver quality community healthcare, as evidenced by resources such as the 2018 WHO Guideline on Health Policy and System Support to Optimise Community Health Worker Programmes and the Community Health Worker Assessment and Improvement Matrix (CHW AIM), the reality of CHW program implementation doesn’t always represent best practice. CHWs are often overburdened with significant workloads, delivering healthcare services to large and dispersed communities, while supported by limited resources and inadequate supervision.
A recent article published as part of a new BMC series, Community Health Workers at the Dawn of a New Era, calls out the essential role that supervision, defined as the “process of guiding, monitoring, and coaching workers to promote compliance with standards of practice and assure the delivery of quality care service,” plays in optimizing CHW performance. The authors of this article note various examples where digital technologies are being utilized to facilitate and strengthen CHW supervision and performance management, but that evidence remains limited. In this digital age, mHealth solutions have been widely deployed as part of health systems worldwide, primarily as tools to collect data and provide program implementers and policy makers with information about the needs of populations and care being provided on the front lines. Yet they are still rarely structured to improve the day-to-day work of the CHWs tasked with utilizing them.
Digital solutions have the potential to strengthen support and supervision of CHWs working on the front lines of community health, but the pathway to achieving technology-supported community health teams remains unclear. To begin tackling this important question, the Johnson & Johnson Center for Health Worker Innovation recently asked 13 experts in the field, from digital innovators to community health implementers and leaders in philanthropy, for their insights. Here is what they say needs to happen:
1. Make CHW supervision a priority
Recent research shows that CHW supervision is an essential element of effective CHW programs. Yet there remains a dearth of evidence on the characteristics and competencies of an effective CHW supervisor, how CHW supervision programs should be structured and delivered, and how to maximize the impact of CHW supervision. In practice there are at least five different types of CHW supervision—external supervision, community supervision, group supervision, peer supervision and dedicated supervision—which are often used in combination.
Digital solutions hold great potential for better supporting CHW teams and linking them to the primary healthcare system, but they will not achieve the desired impact unless built upon and informed by strong foundational systems and processes. Addressing the underlying community health team composition and ensuring the CHWs using digital tools are adequately supported with clear processes for clinical coaching, team communication, case referral and accountability are critical steps to achieving impact using digital solutions.
“We know community health workers can play a vital role in the delivery of quality primary healthcare—but to achieve this, they must be paid professionals with effective supportive supervision,” says Dr. Kathrin Schmitz, Director of Programmes at mothers2mothers, an African NGO with a frontline workforce of around 2,000 digitally-enabled CHWs across 10 African countries. “COVID-19 has magnified the importance of the CHW and patient relationship and shone a spotlight on how digital tools can be used to maintain and even enhance this relationship during a time of disruption. Of course, this makes supportive supervision even more complex and critical.”
2. Design digital solutions with and for CHWs and their supervisors
Digital solutions designed to be used by CHWs should address the needs and realities of CHWs by enabling an easier workflow for the user. According to Ari Johnson, CEO of Muso, an NGO implementing community health programs in Mali, “…many digital tools add extra work for CHWs who already have a full plate.” Rather than focusing on how to extract data from CHWs’ day-to-day activities, tools should allow data to support CHWs, through customizations such as personalized dashboards that enable performance management and two-way communication at the CHW and supervisor level. According to Johnson, “When we prioritize building a job aid, supporting CHWs to solve the problems they face, these digital tools can become an indispensable part of CHWs' workflow. This means the data they collect while using the tool becomes more complete and useful as well.”
This also means designing digital tools that strengthen CHWs’ connection to their supervisors and the primary health system, rather than replacing human relationships. A common misconception is that mHealth can reduce the need for close contact with remote CHWs. According to Neal Lesh, Chief Strategy Officer at Dimagi, the social enterprise behind CommCare, “…design of community health tools should amplify human intention, not undermine it.”
Dr. Schmitz adds: “Effective supportive supervision can never be fully digital. Like the delivery of health services themselves, in-person meetings are essential for supervisors and workers to build rapport, understand nuance, and solve complex problems together.” says Dr. Schmitz. “The richer data available through digital supportive supervision and health service delivery … allows frontline workers and their supervisors to see what they have achieved, together, in real time, which can be incredibly motivating and forge closer relationships.”
3. Facilitate collaboration
For supervision-enabling functions to move from the rare, optional add-on within digital health tools to the normative way all mHealth providers structure their solutions for CHWs, there needs to be greater consensus and collaboration among all stakeholders involved. While insights into best practices can be gained through individual pilots and design initiatives led by one or two organizations, field-wide change will require everyone to come to the table. Bringing together all the digital innovators building technology solutions for community health, as well as program implementers who bring operational expertise and the insights of providers and patients, will allow the creation of solutions for the whole field.
From Neal Lesh, “Digitally-enabled systems require innovation and effort that is a combination of technology and teams. Take the example of Airbnb. They are not a software company. They are creating and deploying a new and interesting model for how people find places to stay.”
4. Build a body of evidence
Key to moving this effort forward will be the creation of a body of evidence showing the real impacts of supervision-enhancing digital tools on community health teams. According to Chuck Slaughter, Founder and President of Living Goods and a Senior Advisor to TPG Global, “The task at hand is to see if these tools change behavior of CHWs and outcomes for patients. Do these tools increase the likelihood that patients seek care, the timeliness of that care, and how likely it is that they get that care?”
Ranju Sharma, Director of Delivery at Medic, highlighted the fact that “evidence is what will push policy.” While individual efforts to expand supervisory support through digital solutions are already happening in several pilots around the world, they will not deliver field-wide change without producing evidence.
5. Plan for scale from day one
According to Tim Wood, a Senior Program Officer at the Bill and Melinda Gates Foundation, “Building evidence is necessary, and it needs to be done in the context of a program designed to operate at scale.” One of the most common challenges in global health is taking innovations to scale and achieving sustainable impact. Often some of the most innovative and exciting changes are driven by small organizations with limited reach, but flexible resources and the ability to take risks. While they can pilot important innovations, adoption of those solutions by governments and global programs can be particularly challenging because of the vastly different requirements and restrictions for large scale implementation.
For CHW supervision-enhancing technologies to be scalable, they should be designed in collaboration with government actors who understand the needs and limitations of existing systems. Addressing issues such as interoperability with existing digital health information systems utilized by local and national actors up front will enable uptake of successful efforts in the long term.
There is exciting progress being made in the field and bright spots where evidence is building for the development of digital tools that strengthen CHW supervision and performance management. For example, a randomized controlled trial published by Muso and Medic in 2018 on “Improving Community Health Worker performance by using a personalised feedback dashboard for supervision,” concluded that dedicated CHW supervision and personalized feedback using performance dashboards increased productivity. In addition, groups like Living Goods have released their best practices in performance management and are currently deploying a Performance Management Supervisory App across their programs. However, as a field we are a long way from these solutions becoming the norm and truly supporting CHWs to deliver quality care.
It cannot be a surprise that CHWs—like any workforce, anywhere—perform best when supported with effective supervision. This includes clinical oversight, individual performance management, and efforts to strengthen the integration of CHWs within the larger primary care team. For decades, providing this supervision was made uniquely challenging by the last mile distribution of CHWs, leading to variable quality and results across CHW programmes. For the first time, ubiquitous mobile technologies are providing an opportunity to re-write the script, linking individual CHWs to their clients, their peers, their supervisors, and their facility-based colleagues. There is an opportunity to use this connectivity to strengthen communication, quality, accountability, and team morale, but it requires a cross-sector commitment to designing, testing, and optimizing data-driven systems of CHW supervision.