The performance of community health workers in an integrated community case management program in Burkina Faso
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BACKGROUND: Integrated community case management (iCCM) is receiving increasing attention as a strategy to reduce child mortality in low-resource settings, yet the evidence for how to effectively implement large-scale iCCM programs is limited. A better understanding of community health worker (CHW) performance, and the factors that influence performance, will help to improve program implementation and impact. This dissertation examines CHW performance in an iCCM program in Burkina Faso. METHODS: Quantitative data were collected from a cross-sectional survey of CHWs (n=386) using a structured questionnaire, inspection of drug kits and patient registers, and direct observation of 1 or 2 sick-child consultations per CHW, with gold standard re-examination by a trained clinician. Summary measures of performance were constructed and multi-linear regression analysis was used to explain variation in these measures. Qualitative data were collected from CHWs (n=52), supervisors (n=27), and caregivers (n=120), using in-depth interviews and focus groups, and analyzed by comparing and contrasting transcripts coded according to pre-established themes. RESULTS: CHW performance varies greatly by task and district. Most illnesses are correctly classified (77%), but, on average, CHWs have only 38% of the drugs they need, and when CHWs do have drugs, they correctly treat illnesses in only 33% of cases. Performance is associated with a CHW’s age, literacy, and education, and health system factors such as district and the time since most recent supervision. Qualitative analysis affirmed supervision as an important determinant of performance, not only for skills development, but for motivation and for facilitating relationships between CHWs and village members. High- and low-performing CHWs struggle with health-facility stockouts, lack of financial incentives, and minimal community support. CONCLUSIONS: Measuring CHW performance is important for overcoming iCCM implementation challenges. Summary measures of CHW performance that reflect multiple domains of performance could, along with other measures and data use approaches, help to strengthen data use and improve decision-making. Proactive supervision from motivated supervisors has a profound effect on CHW performance. Strategies to improve performance should emphasize the quality of program processes, recognizing the importance of how national policies are put into practice at the district, health facility, and village level.