Volunteer community or village health workers (CHWs) are crucial human resources to increase and sustain coverage of malaria interventions. Small and large scale training programs have abounded over the years stimulated by the philosophy of the Alma Ata Declaration on Primary Health Care. Unfortunately, CHW programs often fade after a few years because a donor supported project closed or funds dried up for a public health program and the health staff who trained the CHWs loose touch with them.
Without supervision and encouragement CHWs loose interest and forget what they learned. The challenge therefore is to design an appropriate supervisory system for limited resource settings.
Experience with village health workers for primary care and community community directed distributors for onchocerciasis control have demonstrated that effective and appropriate supervision of CHWs requires three main components or partners as seen in the attached diagram.
Staff of the health facility nearest to the community should have initially reached out to the community to assess their interest in community health interventions and helped them organize. Included in this organization is selection of trusted community volunteers to serve as CHWs.Â These health staff provide technical supervision on the health services being provided (case management, net distribution) and management processes (good service records and reports).
Health staff may not be able to visit each village in their service catchment areas frequently, but they can host monthly or quarterly meetings where CHWs bring their service records, collect new supplies and receive technical updates. Health staff review the records for accuracy and give pointers to improve data and service quality.
The second partner in CHW supervision are the community members who actually selected the volunteers. The CHWs must be held accountable to the people who selected them. CHWs can be asked to report at community meetings about progress and services provided, and community members can give feedback on the quality of these services.
The third partner is the CHWs themselves.Â Often CHWs in a locality form an association and meet regularly.Â These meetings create a form of peer supervision.Â CHWs share their experiences and lessons learned. They advise each other and jointly solve common problems such as communityÂ refusal to talke certain medicines or hand up their bednets. CHWs can even take turn reviewing the basic lessons they learned at the start.
Supervision does require that people get together and have a dialogue about their work. This often means some degree of travel. Here is where we need to rely on local knowledge and make supervision convenient for all. for example, health staff can schedule such gatherings on market days when CHWs and other villagers would normally come to town.
Until we move to the local level and find locally appropriate solutions to supervision, we will not be able to achieve universal coverage.