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Community Health Workers
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 A training session with the new
expanding access to health services. They help ensure continuity accompagnateurs curriculum in
of care in settings where there are few health professionals, where Burera, Rwanda.
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
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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.
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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
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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
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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.
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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.
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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.
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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 20 to 25 patients per Health Promoter
Boston* 7 to 10 patients per DOTS Specialist
Zanmi Lasante
Up to a maximum of six patients per CHW
Haiti
PIH-Lesotho Up to a maximum of five patients per CHW
Socios En Salud
Up to a maximum of five patients per CHW
Peru
Inshuti Mu Buzima The ideal ratio is 1 CHW per 6 patients. Each CHW can have
Rwanda
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.
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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
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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."
Appendix: Forms & Examples
Please find below all the downloadable forms and examples accompanying the PIH Model Community Health
Worker section.
Recruitment
Profile of a successful accompagnateur at Inshuti Mu Buzima, Rwanda (32 KB .pdf)
Roles and Functions
Adherence Form (90.6 KB .pdf)
PACT Adherence Form (50.5 KB Word Doc)
Accompagnateurs curriculum section on Women and HIV/AIDS
Accompagnateurs curriculum section on Psychosocial Support and Effective Communication
Accompagnateurs curriculum section on Stigma and Discrimination
PACT Progress Report (57.5 KB Word Doc)
Addressing Basic Needs at Bo-Mphato Litsebeletsong tsa Bophelo, Lesotho (32.5 KB .pdf)
DOs and DON'Ts for Accompagnateurs at Inshuti Mu Buzima, Rwanda (35 KB .pdf)
Payment
Payment for Accompagnateurs at Zanmi Lasante, Haiti (27.5 KB .pdf)
Payment for Accompagnateurs at Inshuti Mu Buzima, Rwanda (29.5 KB .pdf)
Training
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Accompagnateurs curriculum
Supervision
Duties and Responsibilities for Accompagnateur Leaders at Inshuti Mu Buzima, Rwanda (40 KB .pdf)
Accompagnateur Leader Weekly Report at Inshuti Mu Buzima, Rwanda (36 KB .pdf)
Accompagnateur supervision at Zanmi Lasante, Haiti (55.5 KB .pdf)
Accompagnateur supervision at Inshuti Mu Buzima, Rwanda (40.5 KB .pdf)
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