Recommendation 1 of the Guideline states
WHO suggests using the following criteria for selecting CHWs for pre-service training:
- minimum educational level that is appropriate to the task(s) under consideration;
- membership of and acceptance by the target community;
- gender equity appropriate to the context (considering affirmative action to preferentially select women to empower them and, where culturally relevant, to ensure acceptability of services by the population or target group);
- personal attributes, capacities, values, and life and professional experiences of the candidates (e.g. cognitive abilities, integrity, motivation, interpersonal skills, demonstrated commitment to community service, and a public service ethos).
As with most of the recommendations, the strength of the recommendation is 'conditional'. (The Guideline does not explicitly define the term 'conditional', but the note for one of the Recommendations (3) says 'The recommendation was framed as a conditional one, recognizing both the importance of adapting it to national and local context and the moderate certainty and very limited scope of the underpinning evidence'.
Under 'Interpretation of the evidence and other considerations by the GDG (in relation to Recommendation 1), the Guideline notes the following:
Level of education. The most appropriate level of primary or secondary education prior to CHW training may depend on the complexity of the tasks undertaken by CHWs. While a higher level of prior education may be associated with improved knowledge and performance, attrition (due to better and more diverse work opportunities) might be higher among more educated CHWs. A requirement for relatively higher levels of education may restrict excessively the pool of potential candidates, risks excluding women in particular in many contexts, and would be difficult to implement in contexts with low levels of educational attainment. The minimum level of education considered to be appropriate will depend on the tasks to be delivered, the context of the services and the training support available. Testing for certain competencies during selection (for example, literacy and numeracy) may be considered as an alternative approach
in contexts where employing strict education attainment requirements would imply restricting excessively the applicant pool, for women in particular.
Membership of target community. The GDG considered that membership of and acceptance by the target community (whether defined in geographical terms or in relation to population group, such as nomadic communities, people living with HIV, caste, religion or cultural beliefs) may represent an important criterion in the selection process.
Age. No evidence was found to justify age as a selection criterion (beyond adherence to the minimum legal working age). Age can be an important factor in some contexts, but it is not necessarily clear in which way it can or should be used: educating younger CHWs may theoretically contribute to a longer working lifespan, but at the same time there are reports of higher turnover among younger CHWs. Individual values and capacities gained through previous life experience may be more important than age. The GDG considered that from an equity and rights-based perspective, the potential harms of discriminating based on age would probably outweigh potential benefits under most circumstances.
Age should therefore not be a restricting factor; personnel responsible for selection should prioritize other criteria, such as relevant life experience, acceptability, caring attitude, commitment and other relevant individual attributes.
Gender. No evidence was found supporting gender as a selection criterion. The GDG considered that from an equity and rights perspective, it is necessary to avoid unfair discrimination based on gender. Considering the existing gender inequities, particularly in low-resource settings,
the GDG noted the importance of adopting in the selection process criteria that would be instrumental in improving gender equity. Recruitment and selection procedures that maximize women’s participation and promote women’s empowerment should be encouraged. The GDG also recognized that in certain cultural contexts it is necessary for certain services – particularly reproductive, maternal, newborn and child health – to be rendered by female providers. The choice on the use of gender as a selection criterion under certain circumstances and for certain services should be made on the basis of the local sociocultural context and the specific role expected of the CHWs.
Marital status. Marital status is used as a selection criterion in some contexts. However, no evidence was found to support the use of marital status as a selection criterion. In contrast to other selection criteria, the GDG considered that there are no circumstances under which any theoretical (and unproven) benefits of the use of marital status can plausibly outweigh its negative implications. The use of this criterion therefore can limit the potential for recruitment of effective CHWs and could represent an unjustifiable discrimination and violate human and labour rights. With the aims to improve equity and the potential pool of effective CHWs, the GDG therefore adopted a strong recommendation against the use of marital status as a selection criterion.
We look forward to your comments on any of the above.
Best wishes, Neil
Coordinator, HIFA Project on Community Health Workers
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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: facebook.com/HIFAdotORG firstname.lastname@example.org