Journal of Community Health

, Volume 43, Issue 5, pp 908–919 | Cite as

Performance Evaluation of Community Health Workers: Case Study in the Amazon of Peru

  • Christopher Westgard
  • Renuka Naraine
  • Diego Mauricio Paucar Villacorta
Original Paper


A shortage in human resources for health is a growing crisis that has led to an inability to provide adequate health services to impoverished populations. By “task-shifting”, health systems can delegate certain activities, such as health promotion and referral, to trained community members to help fill the human resource gap. An effective community health agent program can improve maternal and child health and overall effectiveness of rural health systems. Such a program is most effective when the community health agents receive supervision and evaluation of their performance. There is a shortage of literature that provides instruction and example on how to conduct a performance evaluation in the developing world to improve maternal and child health outcomes. The current study provides a case study of a performance evaluation in the Amazon region of Peru and how the findings can be used to make program adjustments. A set of instruments to measure the performance of CHWs was adapted from the literature and then implemented in the field. The instruments were used to measure the quality of home visits by the CHWs, their knowledge of the health topics, and structural activities. Three communities with an active CHW program in Loreto, Peru were chosen to receive the evaluation. All CHWs in the communities were evaluated. The scores from the evaluation were compared internally to identify strengths and weaknesses of the program and within the population of CHWs. The evaluation was completed on 52 home visits and 27 CHWs in three communities. The CHWs were found to be most effective at creating good relationships with caregivers and delivering health messages, and least effective at interacting with the child during the home visit and using material to deliver health messages. The evaluation instruments were well suited for the CHW program that utilizes home visits to teach about child health and development.


Health systems Community health Human resources for health Implementation science Child health 



We give thanks to the Municipality of Indiana, Mazan, and Napo for coordinating the community health agent program and assisting in the coordination of the program evaluation. Special thanks to Natalia Rivadeneyra Villafuerte for providing advisory services regarding environmental issues and governmental policies.

Author Contributions

CW conceived the study, gathered data, performed analysis, and wrote report. RA assisted in literature review, creation of survey instruments, gathered data, and wrote report. DMPV assisted in the literature review, creation of the instruments, and gathered data. All authors read and approved the final manuscript.


This research was supported by Elementos, Peru.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no competing interests.

Ethics Approval and Consent to Participate

The community health agents gave written consent to participate in the outreach program and consent to be involved in the performance evaluation. The investigators only observed the community health agents interact with the families, and so no written consent was requested from the families. The ethics committee from the Research and Institutional Ethics Committee of National Hospital San Bartolome (Hospital Nacional Docente Madre Niño San Bartolome) provided original approval for the community outreach program and child development evaluations and activities (approval Exp. N 00445-17).


  1. 1.
    Aracena, M., Leiva, L., Undurraga, C., Krause, M., Pérez, C., Cuadra, V., … Bedregal, P. (2011). Evaluación de la efectividad de programas de visitas domiciliarias para madres adolescentes y sus hijos/as. Revista Médica de Chile, 139(1), 60–65. Scholar
  2. 2.
    Basic Support for Institutionalizing Child Survival (BASICS) and the Prevention of Postpartum, & Hemorrhage Initiative (POPPHI). (2009). Training Community Health Workers to Give Maternal and Newborn Health Messages: A Guide for Trainers. Arlington, Va., USA: for the United States Agency for International Development (USAID).Google Scholar
  3. 3.
    Bhattacharyya, K., Winch, P., LeBan, K., & Tien, M. (2001). Community health worker incentives and disincentives: How they affect motivation, retention, and sustainability. In Basic support for institutionalizing child survival project (BASICS II) for the United States agency for international development. Arlington, VAGoogle Scholar
  4. 4.
    Brenner, J. L., Kabakyenga, J., Kyomuhangi, T., Wotton, K. A., Pim, C., Ntaro, M., … Singhal, N. (2011). Can Volunteer Community health workers decrease child morbidity and mortality in Southwestern Uganda? An impact evaluation. PLoS ONE. Scholar
  5. 5.
    Cáritas del Perú. (2012). Las Educadoras Comunales En Nutricion, y la Reduccion de la Desnutricion Cronica: Sistematización de una estrategia exitosa para la reducción de la desnutrición crónica en comunidades rurales dispersas de la Sierra: 2007–2011.Google Scholar
  6. 6.
    Chang-Say Chong, A. (2014). La comunicación en los proyectos de lucha contra la desnutrición crónica infantil: el caso Ally Micuy (Áncash). Pontificia Universidad Católica del Perú. Retrieved from
  7. 7.
    Christensen, P. B., & Karlqvist, S. (1990). Community health workers in a Peruvian slum area: An evaluation of their impact on health behavior. Retrieved from
  8. 8.
    Crigler, L., Hill, K., Furth, R., & Bjerregaard, D. (2013). Community Health Worker Assessment and Improvement Matrix (CHW AIM): A Toolkit for Improving Community Health Worker Programs and Services. Revised Version. Published by the USAID Health Care Improvement Project. Bethesda, MD: University Research Co., LLC (URC).Google Scholar
  9. 9.
    Crispin, N., Wamae, A., Ndirangu, M., Wamalwa, D., Wangalwa, G., Watako, P., & Mbiti, E. (2012). Effects of selected socio-demographic characteristics of Community Health Workers on performance of home visits during pregnancy: A cross-sectional study in Busia District, Kenya. Global Journal of Health Science, 4(5), 78–90. Scholar
  10. 10.
    El Arifeen, S., Blum, L. S., Hoque, D. M. E., Chowdhury, E. K., Khan, R., Black, R. E., … Bryce, J. (2004). Integrated management of childhood illness (IMCI) in Bangladesh: Early findings from a cluster-randomised study. Lancet, 364(9445), 1595–1602. Scholar
  11. 11.
    Fernández, S., & Yonah, R. (2007). Aplicación de ensayos domiciliarios para evaluar la adopción de prácticas mejoradas de alimentación complementaria en madres. Centro materno infantil Juan Pablo II. Villa El Salvador, Lima. 2005. Universidad Nacional Mayor de San Marcos. Retrieved from
  12. 12.
    Ferraz, L., & Aerts, D. R. (2005). Daily activities by community health workers in the Family Health Program in Porto Alegre, Brazil. Ciência & Saúde Coletiva, 10(2), 347–355. Scholar
  13. 13.
    Gilmore, B., & McAuliffe, E. (2013). Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: A systematic review. BMC Public Health, 13, 847. Scholar
  14. 14.
    Glenton, C., Colvin, C. J., Carlsen, B., Swartz, A., Lewin, S., Noyes, J., & Rashidian, A. (2013). Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: Qualitative evidence synthesis. The Cochrane Database of Systematic Reviews, 10, CD010414. Scholar
  15. 15.
    Global Health Workforce Alliance, & World Health Organization. (2010). Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems.Google Scholar
  16. 16.
    Haines, A., Sanders, D., Lehmann, U., Rowe, A. K., Lawn, J. E., Jan, S., … Bhutta, Z. (2007). Achieving child survival goals: Potential contribution of community health workers. The Lancet, 369(9579), 2121–2131. Scholar
  17. 17.
    Hill, Z., Dumbaugh, M., Benton, L., Källander, K., Strachan, D., ten Asbroek, A., & Meek, S. (2014). Supervising community health workers in low-income countries—a review of impact and implementation issues. Global Health Action, 7(1), 24085. Scholar
  18. 18.
    Howard, K. S., & Brooks-Gunn, J. (2009). The role of home-visiting programs in preventing child abuse and neglect. The Future of Children, 19(2), 119–146.CrossRefPubMedGoogle Scholar
  19. 19.
    Instituto Nacional de Salud. (2017). Peru: Indicadores Nutricionales en Niños Sistema de Informacion del Estado Nutricional Periodo: Enero - Marzo 2017.Google Scholar
  20. 20.
    Jones, G., Steketee, R. W., Black, R. E., Bhutta, Z. A., & Morris, S. S. & Bellagio Child Survival Study Group. (2003). How many child deaths can we prevent this year?. Lancet, 362(9377), 65–71. Scholar
  21. 21.
    Kelley, E., Geslin, C., Djibrina, S., & Boucar, M. (2001). Improving performance with clinical standards: the impact of feedback on compliance with the integrated management of childhood illness algorithm in Niger, West Africa. The International Journal of Health Planning and Management, 16(3), 195–205. Scholar
  22. 22.
    Kluthcovsky, A. C. G. C., & Takayanagui, A. M. M. (2006). Community health agent: a literature review. Revista Latino-Americana de Enfermagem, 14(6), 957–963. Scholar
  23. 23.
    Lanata, C. F., Fischer-Walker, C. L., Olascoaga, A. C., Torres, C. X., Aryee, M. J., & Black, R. E., & Child Health Epidemiology Reference Group of the World Health Organization and UNICEF (2013). Global causes of diarrheal disease mortality in children < 5 years of age: A systematic review. PLOS ONE, 8(9), e72788. Scholar
  24. 24.
    Leer, J., Lopez-Boo, F., Exposito, P., A., & Powell, C. (2016). A Snapshot on the Quality of Seven Home Visit Parenting Programs in Latin America and the Caribbean. Washington, D.C.: Inter-American Development Bank.Google Scholar
  25. 25.
    Lehmann, U., & Sanders, D. (2007). Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs an impact on health outcomes of using community health workers. World Health Organization. Retrieved from
  26. 26.
    Martínez, Á (2011). Fortalecimiento comunitario desde el rol de las madres líderes: apuntes preliminares. Reflexión Investigativa, 7(12), 73–81.Google Scholar
  27. 27.
    Medina, A., & Sofía, I. Evaluation protocol application of tasks for the socio—cognitive development in children from 37 to 71 months in the Program of Comprehensive Attention to Early Childhood Modality Family Environment District Secretariat of Social Integration. Retrieved August 3, 2017, from
  28. 28.
    Miller, W., & Rollnick, S. (2003). Motivational interviewing: Preparing people for change, 2nd edn. Journal for Healthcare Quality, 25(3), 46.CrossRefGoogle Scholar
  29. 29.
    Paulsell, D., Avellar, S., Martin, E. S., & Grosso, P. D. (2010). Home visiting evidence of effectiveness review: Executive summary. Mathematica Policy Research. Retrieved from
  30. 30.
    Perry, H. B., Sacks, E., Schleiff, M., Kumapley, R., Gupta, S., Rassekh, B. M., & Freeman, P. A. (2017), Comprehensive review of the evidence regarding the effectiveness of community–based primary health care in improving maternal, neonatal and child health: 6. strategies used by effective projects. Journal of Global Health. Scholar
  31. 31.
    Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-, middle-, and high-income countries: An overview of their history, recent evolution, and current effectiveness. Annual Review of Public Health, 35(1), 399–421. Scholar
  32. 32.
    Perry, H., & Crigler, L. (2014). Developing and strengthening Community Health Worker Programs at Scale: A reference guide and case studies for program managers and policymakers. Maternal and Child Health Integrated Program. Retrieved from
  33. 33.
    Peterson, C. A., Luze, G. J., Eshbaugh, E. M., Jeon, H.-J., & Kantz, K. R. (2007). Enhancing parent-child interactions through home visiting: Promising practice or unfulfilled promise? Journal of Early Intervention, 29(2), 119–140. Scholar
  34. 34.
    Prasad, B., & Muraleedharan, V. (2007). Community Health Workers: A review of concepts, practice and policy concerns1. A Review as Part of Ongoing Research of International Consortium for Research on Equitable Health Systems (CREHS).Google Scholar
  35. 35.
    Riate, E. (2017). Interview with local Municipality representative.Google Scholar
  36. 36.
    Richard, S. A., Zavaleta, N., Caulfield, L. E., Black, R. E., Witzig, R. S., & Shankar, A. H. (2006). Zinc and iron supplementation and malaria, diarrhea, and respiratory infections in children in the Peruvian Amazon. The American Journal of Tropical Medicine and Hygiene, 75(1), 126–132. Scholar
  37. 37.
    Riley, S., Brady, A. E., Goldberg, J., Jacobs, F., & Easterbrooks, M. A. (2008). Once the door closes: Understanding the parent–provider relationship. Children and Youth Services Review, 30(5), 597–612. Scholar
  38. 38.
    Roggman, L. A., Christiansen, K., Cook, G. A., Jump, V. K., Boyce, L. K., & Peterson, C. A. (2006). Home visits: Measuring how they work. Presentation in the Early Intervention Research Institute, Mini-Conference, Logan, UT. Presented at the Presentation in the Early Intervention Research Institute, Mini-Conference, Logan, UT.Google Scholar
  39. 39.
    Roggman, L. A., Cook, G. A., Innocenti, M. S., Jump Norman, V., Boyce, L. K., Christiansen, K., & Peterson, C. A. (2016). Home visit quality variations in two early head start programs in relation to parenting and child vocabulary outcomes. Infant Mental Health Journal, 37(3), 193–207. Scholar
  40. 40.
    Rowe, A. K., de Savigny, D., Lanata, C. F., & Victora, C. G. (2005). How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet, 366(9490), 1026–1035. Scholar
  41. 41.
    Santos, K. T., dos, Saliba, N. A., Moimaz, S. A. S., Arcieri, R. M., & de Carvalho, M. L. (2011). Agente comunitário de saúde: Perfil adequado a realidade do Programa Saúde da Família? Ciência & Saúde Coletiva. Retrieved from
  42. 42.
    Schodt, S., Parr, J., Caridad Araujo, M., & Rubio-Codina, M. (2015). Measuring the quality of home-visiting services: A review of the literature. Inter-American Development Bank, IDB Technical Note (881).Google Scholar
  43. 43.
    Singh, V., Ahmed, S., Dreyfuss, M. L., Kiran, U., Chaudhery, D. N., Srivastava, V. K., … West, K. P. (2017). Non-governmental organization facilitation of a community-based nutrition and health program: Effect on program exposure and associated infant feeding practices in rural India. PloS ONE, 12(9), e0183316. Scholar
  44. 44.
    Strachan, D. L., Källander, K., ten Asbroek, A. H. A., Kirkwood, B., Meek, S. R., Benton, L., … Hill, Z. (2012). Interventions to improve motivation and retention of community health workers delivering integrated community case management (iCCM): Stakeholder perceptions and priorities. The American Journal of Tropical Medicine and Hygiene, 87(5 Suppl), 111–119. Scholar
  45. 45.
    Swider, S. M. (2002). Outcome effectiveness of community health workers: an integrative literature review. Public Health Nursing, 19(1), 11–20. Scholar
  46. 46.
    Tavrow, P., Kim, Y.-M., & Malianga, L. (2002). Measuring the quality of supervisor-provider interactions in health care facilities in Zimbabwe. International Journal for Quality in Health Care, 14, 57–66.CrossRefPubMedGoogle Scholar
  47. 47.
    The Earth Institute. (2013). Millennium villages project. Community Health Worker Trainer’s Manual. A guide to Home Based Services (Version 2.1). Columbia University. Retrieved from
  48. 48.
    Tran, N. T., Portela, A., de Bernis, L., & Beek, K. (2014). Developing capacities of community health workers in sexual and reproductive, maternal, newborn, child, and adolescent health: A mapping and review of training resources. PLoS ONE. Scholar
  49. 49.
    Travis, P., Bennett, S., Haines, A., Pang, T., Bhutta, Z., Hyder, A. A., … Evans, T. (2004). Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet, 364(9437), 900–906. Scholar
  50. 50.
    Vogel, C. A., Caronongan, P., Thomas, J., Bandel, E., Xue, Y., Henke, J., … Murphy, L. (2015). Toddlers in Early Head Start: A Portrait of 2-Year-Olds, Their Families, and the Programs Serving Them. Volume 1: Age 2 Report. OPRE Report 2015-10. Administration for Children & Families. Retrieved from
  51. 51.
    Walker, C. L. F., Friberg, I. K., Binkin, N., Young, M., Walker, N., Fontaine, O., … Black, R. E. (2011). Scaling up diarrhea prevention and treatment interventions: A Lives Saved Tool analysis. PLOS Medicine, 8(3), e1000428. Scholar
  52. 52.
    Walker, S. P., Powell, C., Chang, S. M., Baker-Henningham, H., Grantham-McGregor, S., Vera-Hernandez, M., & López-Boo, F. (2016). Estrategias de apoyo parental a través de los servicios de salud en el Caribe (Working Paper). BID. Retrieved from
  53. 53.
    Westgard, C., & Alnasser, Y. (2017). Developmental delay in the Amazon: The social determinants and prevalence among rural communities in Peru. PLoS ONE, 12(10), e0186263. Scholar
  54. 54.
    WHO (2006). The world health report 2006: Working together for health. Geneva: World Health Organization.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of ResearchElementos, PeruLimaPeru
  2. 2.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  3. 3.Department of SociologyUniversidad Nacional Mayor de San MarcosLimaPeru

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