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BackgroundThere is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients’ health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems – the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated.MethodsWe explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component.ResultsWe identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system.ConclusionsWe believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.

BackgroundWith the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries.MethodsA review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input.ResultsTwenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited.ConclusionsBetter data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

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Women and children from four Guatemalan villages participated in a voluntary food supplementation program for seven years. In two of the villages, they received a vitamin and mineral fortified, high-protein calorie supplement. In the other two villages, the vitamin-mineral fortified supplement contained no protein and a relatively small number of calories.Cognitive tests were administered regularly to children ages three to seven, and anthropometric measures obtained. In addition, measures offamilies' social milieu were collected at several points in time.Using multiple regression analysis, we find that bothDuring the past 20 years, there has been a proliferation of studies of the effects of childhood malnutrition on physical and mental development.' The continued concern with the impact of malnutrition on physical and mental development is related to an inability to control population growth in lesser-developed countries, marginal food production on a world-wide basis, and inequitable food distribution even within our most industrialized countries. It is further stimulated by competition for the resources of governments, international agencies, and private foundations by advocates of nutrition intervention programs and those whose priorities lie in such other sectors as education and rural economic development. In addition to the press for findings to support policies and programs of nutrition intervention, the spate of investigation is an effort to extend and clarify animal studies of the relationship between malnutrition and neurological development, learning patterns, and other behaviors.25Over the several decades of work, attention has shifted to a large extent from studies of the cognitive performance of severely malnourished children to investigations of those with mild and moderate protein-calorie deficiencies. An estimated three per cent of the world's children undergo one or more episodes of severe malnutrition prior to their fifth birthday.6 In comparison, it is estimated that fully one-half of the pre-school children in lesser-developed countries are suf- August 20, 1980. nutritional and social environmental measures are related to various dimensions of cognitive competence. The results suggest that nutritional intake, independent of social factors, affects cognitive development. There is also some evidence that the children who receive the high-protein calorie supplement (and whose mothers received it during pregnancy and lactation) are more likely to score high in cognitive performance. Our results, while not diminishing social environmental explanations of differences in cognitive function, suggest benefits from nutrition intervention programs in rural areas of lesser-developed countries. (Am J Public Health 1980; 70:1277-1285 fering from mild to moderate protein-calorie deficits, as well as a small, but critical, proportion of children in low-income families in industralized nations.7Extrapolating the findings of early studies documenting a presumably causal link between children's...