CHW AIM.

The Community Health Worker Assessment and Improvement Matrix

An evidence-based tool for designing, assessing, and optimizing community health programs.

Community health workers (CHWs) are vital to healthcare systems across the world.

Robust international evidence demonstrates that CHWs:

improve access to care.
reduce maternal, newborn, and child mortality.
facilitate better outcomes for chronic disease.
help to manage and prevent disease outbreaks (including COVID and malaria).

But despite their overall success, not all CHW programs are equal.

To better understand and respond to this disparity in outcomes, in 2018, Community Health Impact Coalition (CHIC), in partnership with USAID, UNICEF, and Initiatives Inc., conducted a comprehensive review of the Community Health Worker Assessment and Improvement Matrix Toolkit (CHW AIM).

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CHW AIM is a multi-purpose tool for community health program design, assessment, and optimization. It can be used for the implementation of new programs, to evaluate and improve existing services, and to promote professional CHW (proCHW) policies and practices.

The CHW AIM Review Process

The CHW AIM Toolkit was initially developed in 2011 to help organizations assess and improve community health program functionality and performance.

Since that time, investment in CHW-led health delivery continued to grow and the body of research related to CHW effectiveness substantially increased. This warranted a revision of the CHW AIM tool.

In 2018, CHIC and partners reviewed and analyzed all available contemporary research on CHW effectiveness. To enhance the usability and effectiveness of the product, expert practitioners, funders, policymakers, and program implementers were widely consulted in the review process.

The end result was an updated program functionality matrix which provides an assessment framework to guide organizations through a review of ten key CHW program components.

CHW AIM is designed to be used in a facilitated workshop, with involvement from multiple stakeholders knowledgeable about the program being assessed and the region within which it functions. Intended users and uses are detailed in Figure 1.

Application of the CHW AIM Tool.

CHW AIM enables organizations to assess strengths, weaknesses, and opportunities in CHW program design and operation. Results can then be used to inform quality improvement activities and proactively manage any risks to future service integrity.

Here’s how a government partner from Kenya described the process:

“This exercise is a great way to look at the performance of our community health worker program without feeling a sense of judgment/being judged. We objectively looked at what is working/not working and articulated action items to help us improve the performance of our programs. I recommend the use of this tool more regularly to enable us to understand where the program is performing and spur us forward.”

Nyaya Health Nepal

Programmatic Components.

At the core of the CHW AIM tool are 10 key components demonstrated through research and practitioner expertise to be highly correlated with CHW program success:

Role and Recruitment: How the community, CHW, and health system design and achieve clarity on the CHW role and from where the CHW is identified and selected.

Training: How pre-service training is provided to the CHW to prepare for his/her role and ensure s/he has the necessary skills to provide safe and quality care; and, how ongoing training is provided to reinforce initial training, teach CHWs new skills, and to help ensure quality.

Accreditation: How health knowledge and competencies are assessed and certified prior to practicing and recertified at regular intervals while practicing.

Equipment and Supplies: How the requisite equipment and supplies are made available when needed to deliver expected services.

Supervision: How supportive supervision is carried out such that regular skill development, problem solving, performance review, and data auditing are provided.

Incentives: How a balanced incentive package reflecting job expectations, including financial compensation in the form of a salary, and non-financial incentives, is provided.

Community Involvement: How a community supports the creation and maintenance of the CHW program.
Opportunity for Advancement: How CHWs are provided career pathways. Data: How community-level data flow to the health system and back to the community and how they are used for quality improvement.
Linkages to the National Health System: The extent to which the Ministry of Health has policies in place that integrate and include CHWs in health system planning and budgeting and provides logistical support to sustain district, regional and/or national CHW programs.

Program functionality assessment

To evaluate the functionality of a CHW program, stakeholders engage in a facilitated workshop assessment approach that allows host governments to quickly and efficiently map and assess programs using a rating scale informed by evidence-based best practices.

During the assessment, each of the 10 components in the Program Functionality Matrix is subdivided into four levels of functionality. This graphic shows an example of component 3, Accreditation.

The 1-4 scoring method enables organizations to clearly identify domains in which their CHW program is functioning well and those with room for improvement. A plan can then be made to address flagging areas, and if desired, maintain high performance in stronger domains.

When utilized for the design of new services, the program functionality matrix provides a comprehensive foundation to guide the development of high-performing community health programs.

Run your own workshop.

Do you want to run your own facilitated workshop? The following CHW AIM materials are available to freely adapt and use.

Workshop Slide Template
Workshop Participant Selection Form
Validation Questionnaire
Score Rationale Worksheet
Action Planning Framework
Workshop Facilitator Guide

To receive these materials in a language of your choosing, please email us.

Wuqu Kawoq

Examples of CHW AIM in Action.

The best way to understand the real-world applications of CHW AIM, is through case studies of the tool in action.

Togo – Taking Action to Improve Data Alignment with Ministry Partners

Integrate Health is supporting the Ministry of Health in Togo to achieve its universal health access goals. They helped build one of the most effective HIV care programs in the country. And in 2015, community members asked Integrate Health to expand services to include comprehensive primary healthcare. Integrate Health used the AIM tool to evaluate their program in 2018.

Key findings and actions included:

Identifying programmatic component nine, data, as an area requiring improvement.
Despite CHWs documenting visits and providing data in a standardized format, Integrate Health failed to consistently report data to public-sector monitoring and evaluation systems.
The roadblock identified was a lack of alignment between the Ministry of Health’s District Health Information System (DHIS-2) and the indicators used in Integrate Health’s data collection.
After a series of collaborative workshops and system re-design, Integrate Health’s data systems were organized so that data is now routinely entered into the national DHIS-2 system.

Outcome:

The Ministry of Health has much greater visibility into the work of Integrate Health. The two organizations now speak the same language and have the same basis for monitoring and evaluating programs.

Rwanda & Zimbabwe – Helping Ministries and Funders Optimize Community Health Investments

The Financing Alliance for Health (FAH) used CHW AIM to guide governments in Rwanda and Zimbabwe to strengthen their CHW programs.

Rwanda.

Following an assessment of Rwanda’s CHW program by the Liverpool School of Tropical Medicine and Hygiene (LSTM), the FAH was tasked with recommending improvements that would enhance performance and foster financial sustainability.

Through utilizing the CHW AIM tool, the following priority areas were identified:

CHW recruitment and training
Supervision and mentorship
Financial stability
Data accountability

Zimbabwe.

The FAH supported the Ministry of Health and Child Care in the development of the National Community Health Strategy 2020-2025. At the beginning of the engagement, the FAH co-facilitated a workshop pairing the CHW AIM tool with the WHO guideline on health policy and system support to optimize community-based health worker programs.

The workshop resulted in:

Refining Village Health Worker (VHW) roles and recruitment practices.
Redefining supervision duties, activities, and frequency across different supervision levels.
The CHW AIM tool was used to advocate for a dedicated unit/team at the national and sub-national level to oversee the governance and coordination of community health.

Additional CHW AIM Case Studies.

Further case studies of the CHW AIM process in action:

Kenya – Government-NGO Partnerships to Assess and Improve CHW Programs
Madagascar – Application of the CHW AIM tool in High-Impact Research
Burkina Faso – The Role of Digital Tools in Strengthening CHW Programs

Malawi_1018_MtengulaHomeVisit_ZDeClerck_88.JPG APZU MTENGULA VILLAGE, MALAWI – OCTOBER 2, 2018: (left to right) CHW Ida Mathala shows eductaional health materials to Evance Keneson, 47, Steria Kenoon, 36, and grandson Nickson Cedrick, 1, during a home visit in Mtengula Village, Lower Neno. ….The visit covered an NCD/diabetes lesson and verbal TB screening. Ida has worked with this family for three years and works with 38 other homes in the village.

A Blueprint for Community Health Worker Success.

Despite overall consensus around the effectiveness of CHW programs in supporting health for all and access to primary healthcare, some regions continue to see poor results.

Fortunately, we know the key elements that make CHW programs successful. And after more than a decade of experience utilizing CHW AIM in dozens of communities, there is an evidence-based, rigorously field-tested process that governments and community health partners can use to bolster struggling CHW programs and implement proCHW practices.

Access the toolkit and get started today.

Resource Library

CHW Advocates are seizing power.

For too long, discussions about community health workers (CHWs) have been happening without CHWs in the room. It’s time for a change. Community health workers are seizing power.

The Community Health Worker Speaker Bureau.

For too long, discussions about CHWs have been happening without CHWs. It’s time for a change. Book a CHW Speaker!

Harnessing Expertise to Optimize Community Health.

How six innovative partners joined forces to accelerate the adoption of high-impact community health systems design.