Health policy and system support to optimise community health worker programmes: an abridged WHO guideline

Development of a Blended Learning Approach to Delivering HIV-Assisted Contact Tracing in Malawi: Applied Theory and Formative Research

BACKGROUND

Despite progress toward the Joint United Nations Programme on HIV/AIDS "95-95-95" targets (95% of HIV-positive persons tested, 95% of tested persons on treatment, and 95% of treated persons virally suppressed), a gap remains in achieving the first 95% target. Assisted contact tracing (ACT), in which health workers support HIV-positive index clients to recruit their contacts (sexual partners and children) for HIV testing, efficiently identifies HIV-positive persons in need of treatment. Although many countries, including Malawi, began implementing ACT, testing outcomes in routine settings have been worse than those in trial settings.

OBJECTIVE

The aim of this paper is to use formative research and frameworks to develop and digitize an implementation package to bridge the gap between ACT research and practice.

METHODS

Semistructured qualitative research was conducted in 2019 in Malawi with key informants. Barriers and facilitators to intervention delivery were identified using the Consolidated Framework for Implementation Research. Approaches to digitization were examined using human-centered design principles.

RESULTS

Limited clinic coordination and health worker capacity to address the complexities of ACT were identified as barriers. Ongoing individual training consisting of learning, observing, practicing, and receiving feedback, as well as group problem-solving were identified as facilitators. Important features of digitization included (1) culturally relevant visual content, (2) capability of offline use, and (3) simple designs and basic editing to keep costs low.

CONCLUSIONS

Formative research and frameworks played a key role in designing and digitizing an implementation package for ACT delivery in a low-income setting such as Malawi.

Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice

Background

The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve?

Methods

We searched six academic databases for recent (2014–2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis.

Results

One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps.

Conclusion

In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity.

Trial registration

PROSPERO registration number CRD42020177333.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01615-y.

Multilevel determinants of community health workers for an effective maternal and child health programme in sub-Saharan Africa: a systematic review

Background

Countries in sub-Saharan Africa (SSA) continue to have the highest maternal and under-five child deaths in the world. The ongoing COVID-19 pandemic is amplifying the problems and overwhelming already fragile health systems. Community health workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in improving maternal and child health (MCH). However, evidence is limited on multilevel determinants of an effective CHWs programme using CHWs’ perspective. The objective of this systematic review is to examine perceived barriers to and enablers of different levels of the determinants of the CHWs’ engagement to enhance MCH equity and a resilient community health system in SSA.

Methods

We systematically conducted a literature search from inception in MEDLINE complete, EMBASE, CINAHL complete and Global Health for relevant studies. Qualitative studies that presented information on perceived barriers to and facilitators of effectiveness of CHWs in SSA were eligible for inclusion. Quality appraisal was conducted according to the Critical Appraisal Skills Programme qualitative study checklist. We used a framework analysis to identify key findings.

Findings

From the database search, 1561 articles were identified. Nine articles met the inclusion criteria and were included in the final review. Using socio-ecological framework, we identified the determinants of CHWs’ effectiveness at 4 levels: individual/CHWs, interpersonal, community and health system logistics. Under each level, we identified themes of perceived barriers such as competency gaps, lack of collaboration, fragmentation of empowerment programmes. In terms of facilitators, we identified themes such as CHW empowerment, interpersonal effectiveness, community trust, integration of CHWs into health systems and technology.

Conclusion

Evidence from this review revealed that effectiveness of CHW/MCH programme is determined by multilevel contextual factors. The socio-ecological framework can provide a lens of understanding diverse context that impedes or enhances CHWs’ engagement and effectiveness at different levels. Hence, there is a need for health programme policy makers and practitioners to adopt a multilevel CHW/MCH programme guided by the socio-ecological framework to transform CHW programmes. The framework can help to address the barriers and scale up the facilitators to ensuring MCH equity and a resilient community health system in SSA.

Qualitative Case Study: A Pilot Program to Improve the Integration of Care in a Vulnerable Inner-City Community

Introduction:

There is a strong correlation between vulnerable populations and poor health outcomes. Growing evidence suggests that person-centred interventions using ‘link workers’ can support communities to navigate and engage with health and community services, leading to improved health service access. We describe the initial phase and qualitative evaluation of a Healthy Living Program, supported by a link worker role. The Program aimed to improve health service access for residents of an Australian inner-city suburb.

Methods:

To inform future program development, semi-structured interviews were conducted with clients and stakeholders (n = 21). The interviews were analysed thematically to understand program impact, success factors, constraints and potential improvements.

Results:

Key themes relating to impacts were a new model of working with community, improved access to services, and responsiveness to community need. Key factors for success included being a trusted, consistent presence, having knowledge of the community and health system, and successful engagement with the community and stakeholders. The constraints included difficulty influencing health system change and lack of community input. Suggested improvements were expanding the service, enhancing health system change and increasing community involvement.

Conclusion:

Knowledge gained from this study will inform future integrated approaches in health districts to address health inequities in areas of need.

Geo-analysis: the distribution of community health workers in relation to the HIV prevalence in KwaZulu-Natal province, South Africa

BACKGROUND

The South African Ward Based Primary Health Care Outreach Team (WBPHCOT) policy framework states that the distribution of community health workers (CHWs) should be proportional to levels of poverty and disease within the population. We aimed to describe the spatial distribution of CHWs in relation to the prevalence of the Human Immunodeficiency Virus (HIV) which has itself been associated with poverty in previous studies.

METHODS

This was a descriptive, cross-sectional study in which secondary data was used for geospatial analysis. Based on the extrapolation from the norm of one WBPHCOT per 6000 individuals, we utilized geographic information system (GIS) methods to visualize the distribution of CHWs in relation to the prevalence of HIV in KwaZulu-Natal (KZN). Dot density mapping was used to visualize the random distribution of CHWs in relation to HIV prevalence and population in the districts. The districts' HIV prevalence, number of PLWH, ratio of CHW: people living with HIV (PLWH), ratio of CHW: population and poverty scores were mapped using choropleth mapping. MapInfo Pro 17.0 was used to map geospatial presentation of the data.

RESULTS

Overall, KZN province showed under allocation of CHWs with a CHW: people ratio of 1: 1156 compared to the estimated norm of 1: 600-1000. At district level, only two of 11 districts met the suggested norm of CHW: PLWH (1: 109-181). This indicates shortages and misallocation of CHWs in the nine remaining districts. Furthermore, our findings showed extensive geospatial heterogeneity with no clear pattern in the distribution of CHWs. There was no relationship between CHW distribution and HIV prevalence or poverty scores in the districts.

CONCLUSION

This study shows inequality in the distribution of CHWs which may be associated with inequalities in the provision of HIV related services. It is critical to strengthen the response to the HIV epidemic through the appropriate distribution of CHWs especially in those districts with high levels of HIV prevalence and poverty.

Supportive supervision from a roving nurse mentor in a community health worker programme: a process evaluation in South Africa

BACKGROUND

Many low and middle- income countries (LMICs) are repositioning community health worker (CHW) programmes to provide a more comprehensive range of promotive and preventive services and referrals to the formal health service. However, insufficient supervision, fragmented programmes, and the low literacy levels of CHWs often result in the under-performance of the programmes. We evaluate the impact of a roving nurse mentor working with CHW teams proving supportive supervision in a semi-rural area of South Africa.

METHODS

We conducted a longitudinal process evaluation, using in-depth interviews, focus groups and observations prior to the intervention, during the intervention, and 6 months post-intervention to assess how the effects of the intervention were generated and sustained. Our participants were CHWs, their supervisors, clients and facility staff members and community representatives.

RESULTS

The nurse mentor operated in an environment of resource shortages, conflicts between CHWs and facility staff, and an active CHW labour union. Over 15 months, the mentor was able to (1) support and train CHWs and their supervisors to gain and practice new skills, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs' activities, resulting in improved service provision. Towards the end of the intervention the direct employment of the CHWs by the Department of Health and an increase in their stipend added to their motivation and integration into the local primary care clinic team. However, given the communities' focus on accessing government housing, rather than better healthcare, and volatile nature of the communities, the nurse mentor was not able to establish a collaboration with local structures.

CONCLUSIONS

A roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors to support CHWs activities. A roving nurse mentor can contribute to the knowledge and skills development of the CHWs and enhance the capacity of junior supervisors. However, the long-term sustainability of the effects of intervention is dependent on CHWs' formal employment by the Department of Health.

HIV Prevention and Treatment Behavior Change and the Situated Information Motivation Behavioral Skills (sIMB) Model: A Qualitative Evaluation of a Community Health Worker Intervention in Rakai, Uganda

A community health worker (CHW) model can promote HIV prevention and treatment behaviors, especially in highly mobile populations. In a fishing community in Rakai, Uganda, the Rakai Health Sciences Program implemented a CHW HIV intervention called Health Scouts. The situated Information, Motivation, and Behavioral Skills (sIMB) framework informed the design and a qualitative evaluation of the intervention. We interviewed 51 intervention clients and coded transcripts informed by sIMB framework dimensions. Clients reported that Health Scouts provided information about HIV prevention and treatment behaviors and helped them manage personal and social motivations to carry out health-promoting behavior. Prominent barriers which moved clients away from behavior change included daily pill burdens, anticipated stigma, serostatus disclosure, substance use at social gatherings, and anticipated reactions of partners. Our study adds to the evidence establishing CHWs as facilitators of behavior change, positioned to offer supportive encouragement and navigate contextualized circumstances.

Contested notions of challenges affecting Community Health Workers in low- and middle-income countries informed by the Silences Framework

Despite increasing evidence of the challenges affecting Community Health Workers (CHWs) such as those related to training, supportive supervision and remuneration, there is a need to explore concerns and challenges from the perspective of CHWs themselves. This commentary highlights some of the contested and unexplored notions of challenges affecting CHWs in low- and middle-income countries (LMICs) informed by the Silences Framework. This framework defines experiences that are under-explored, misunderstood or difficult to share because of the often invisible power relations within communities, but also in setting the research agenda. These challenges include the heavy workload imposed by several stakeholders, dealing with religious and cultural practices, and gendered barriers of care. The workload of CHWs is a major source of stress and anxiety as they have to balance both government and other stakeholders' agendas to deliver interventions with their own need to provide for their families for those whose work is unpaid. The tensions of CHWs carrying out their work among members of the community whose religious or cultural beliefs are different from theirs also needs to be considered. Gender issues are an impediment to the work of CHWs, particularly with community members of the opposite sex around sensitive health issues. Lastly, CHWs have found themselves victims of domestic suspicion while fulfilling their duties in communities, such as when seen having conversations with spouses of other individuals in the community. Solutions to these challenges need to be co-produced with CHWs to both to strengthen their relationship with the communities they serve and shape more sustainable interventions for delivery of healthcare in LMICs.

Motivation and Performance of Community Health Workers: Nothing New Under the Sun, and Yet…

We know that both financial and nonfinancial incentives matter if we want community health workers (CHWs) who are motivated and performing. What are the practical implications for CHWs themselves and for effective management of viable CHW programs?

Diabetic retinopathy service delivery and integration into the health system in Pakistan-Findings from a multicentre qualitative study

This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments’ priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.

Pilot-Testing a Blended Learning Package for Health Care Workers to Improve Index Testing Services in Southern Malawi: An Implementation Science Study

BACKGROUND

HIV index testing, an intervention in which HIV-positive "indexes" (persons diagnosed with HIV) are supported to recruit their "contacts" (sexual partners and children) efficiently identifies HIV-infected persons in need of treatment and HIV-uninfected persons in need of prevention. However, index testing implementation in sub-Saharan African health care settings has been suboptimal. The objective of this study was to develop and pilot test a blended learning capacity-building package to improve index testing implementation in Malawi.

METHODS

In 2019, a blended learning package combining digital and face-to-face training modalities was field tested at 6 health facilities in Mulanje, Malawi using a pre-/post- type II hybrid design with implementation and effectiveness outcomes. Health care worker (HCW) fidelity to the intervention was assessed via observed encounters before and after the training. Preliminary effectiveness was examined by comparing index testing program indicators in the 2 months before and 4 months after the training. Indicators included the mean number of indexes screened, contacts elicited, and contacts who received HIV testing per facility per month.

RESULTS

On a 30-point scale, HCW fidelity to index testing protocols improved from 6.0 pre- to 25.5 post-package implementation (P = 0.002). Index testing effectiveness indicators also increased: indexes screened (pre = 63, post = 101, P < 0.001); contacts elicited (pre = 75, post = 131, P < 0.001); and contacts who received HIV testing (pre = 27, post = 41, P = 0.014).

CONCLUSIONS

The blended learning package improved fidelity to index testing protocols and preliminary effectiveness outcomes. This package has the potential to enhance implementation of HIV index testing approaches, a necessary step for ending the HIV epidemic.

Indicators for dental appointment scheduling in primary health care: a national cross-sectional study

Background

Integrated dental services within the Health System, particularly at primary health care, are crucial to reverse the current impact of oral diseases, which are among the most prevalent diseases worldwide. However, the use of dental services is determined by complex phenomena related to the individual, the environment and practices in which care is offered. Therefore, factors associated with dental appointments scheduling can affect positively or negatively the use of dental services. The aim of the present study was to evaluate the indicators for dental appointment scheduling in Primary Health Care (PHC).

Methods

The present is a cross-sectional analytical study that used data from the external assessment of the third cycle of the National Program for Improving Access and Quality in Primary Care (PMAQ-AB), carried out between 2017 and 2018, in Brazil. The final sample consisted of 85,231 patients and 22,475 Oral Health teams (OHTs). The outcome variable was the fact that the user sought for a dental appointment at the Primary Health Care Unit. A multilevel analysis was carried out to verify the association between individual variables (related to users) and contextual variables (related to the OHTs) in relation to the outcome.

Results

Only 58.1% of the users interviewed at these Primary Health Care Units seek the available dental care. The variables with the greatest effect on the outcome were the patient’s age up to 42 years old (OR = 2.03, 95% CI: 1.96–2.10), at individual level, and ‘oral health teams that assisted no more than a single family health team (FHT)’ (OR = 1.29, 95% CI: 1.23–1.36) at contextual level. Other variables were also associated with the outcome, but with a smaller effect size.

Conclusion

In conclusion, users’ age and work process of OHT were indicators for dental appointment scheduling. Our results suggest that when OHT put the National Oral Health Policy guidelines into practice, by assisting only one FHT, the chance for PHC users seeking dental appointments is higher than OHTs that assist more than one FHT. Regarding age, patients aged up to 42 years are more likely to seek an appointment with a dentist.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12319-x.

Assessing the Feasibility of an Online Training Designed to Enable Community Health Workers to Deliver a Comprehensive, Evidence-Based Weight Loss Intervention for Rural African Americans of Faith

Obesity is a critical modifiable risk factor in cancer prevention, control, and survivorship. Comprehensive weight loss interventions (e.g., Diabetes Prevention Program (DPP)) have been recommended by governmental agencies to treat obesity. However, their high implementation costs limit their reach, especially in underserved African American (AA) communities. Community health workers (CHWs) or trusted community members can help increase access to obesity interventions in underserved regions facing provider shortages. CHW-led interventions have increased weight loss. However, in-person CHW training can be costly to deliver and often requires extensive travel to implement. Web-based trainings have become common to increase reach at reduced cost. However, the feasibility of an online CHW training to deliver the DPP in AAs is unknown. The feasibility of an online CHW training to deliver the DPP adapted for AAs was assessed. The online training was compared to an in-person DPP training with established effectiveness. CHW effectiveness and satisfaction were assessed at baseline and 6 weeks. Nineteen participants (in-person n = 10; online n = 9) were recruited. At post-training, all scored higher than the 80% on a knowledge test required to deliver the intervention. All participants reported high levels of training satisfaction (88.9% of online participants and 90% of in-person participants rated the training as at least 6 on a 1-7 scale) and comfort to complete intervention tasks (78% of online participants and 60% of in-person participants scored at least 6 on a 1-7 scale). There were no significant differences in outcomes by arm. An online CHW training to deliver the DPP adapted for AAs faith communities produced comparable effectiveness and satisfaction to an evidence-based in-person CHW training. Further research is needed to assess the cost-effectiveness of different CHW training modalities to reduce obesity.

Association between supportive supervision and performance of community health workers in India: a longitudinal multi-level analysis

INTRODUCTION

Community health workers (CHWs) deliver services at-scale to reduce maternal and child undernutrition, but often face inadequate support from the health system to perform their job well. Supportive supervision is a promising intervention that strengthens the health system and can enable CHWs to offer quality services.

OBJECTIVES

We examined if greater intensity of supportive supervision as defined by monitoring visits to Anganwadi Centre, CHW-supervisor meetings, and training provided by supervisors to CHWs in the context of Integrated Child Services Development (ICDS), a national nutrition program in India, is associated with higher performance of CHWs. Per program guidelines, we develop the performance of CHWs measure by using an additive score of nutrition services delivered by CHWs. We also tested to see if supportive supervision is indirectly associated with CHW performance through CHW knowledge.

METHODS

We used longitudinal survey data of CHWs from an impact evaluation of an at-scale technology intervention in Madhya Pradesh and Bihar. Since the inception of ICDS, CHWs have received supportive supervision from their supervisors to provide services in the communities they serve. Mixed-effects logistic regression models were used to test if higher intensity supportive supervision was associated with improved CHW performance. The model included district fixed effects and random intercepts for the sectors to which supervisors belong.

RESULTS

Among 809 CHWs, the baseline proportion of better performers was 45%. Compared to CHWs who received lower intensity of supportive supervision, CHWs who received greater intensity of supportive supervision had 70% higher odds (AOR 1.70, 95% CI 1.16, 2.49) of better performance after controlling for their baseline performance, CHW characteristics such as age, education, experience, caste, timely payment of salaries, Anganwadi Centre facility index, motivation, and population served in their catchment area. A test of mediation indicated that supportive supervision is associated indirectly with CHW performance through improvement in CHW knowledge.

CONCLUSION

Higher intensity of supportive supervision is associated with improved CHW performance directly and through knowledge of CHWs. Leveraging institutional mechanisms such as supportive supervision could be important in improving service delivery to reach beneficiaries and potentially better infant and young child feeding practices and nutritional outcomes.

TRIAL REGISTRATION

Trial registration number:  https://doi.org/10.1186/ISRCTN83902145.

Scorecard metrics for assessing the extent of integration of community health worker programmes into national health systems

BACKGROUND

The effectiveness of community health workers (CHWs) in delivering community-based preventive services is often curtailed by inadequate or complete lack of integration of the CHW programmes into national health systems. Although literature has defined the context and guidelines for integrating CHW programmes into health systems, indicators to quantitatively assess the extent of integration are inadequately addressed.

AIM

This article presents an integration scale - CHW Programme Integration Scorecard Metrics (CHWP-ISM) - for measuring the extent of CHW programme integration into national health systems.

SETTING

Literature review and policy documents were focused on sub-Saharan Africa, while interview participants were drawn from six African countries.

METHODS

A deductive-inductive approach to item and measurement scale development was employed. Information obtained from a combination of diverse literature sources, subject matter expert (SME) interviews and documentary abstraction from publicly available policy documents advised item generation for the proposed CHWP-ISM. The study qualitatively captured the sectoral CHW integration, thematically analysed the data and culminated in the quantitative integration metrics.

RESULTS

Analysis of the responses from six SMEs and abstraction from policy documents resulted in the compilation of metrics with a total of 100 indicators for the CHWP-ISM scale that could be used to assess the level of CHW programmes integration into national health systems. The indicators were categorised along the six World Health Organization's (WHO) health systems building blocks. Subject matter expert responses corresponded well with abstracted results from the 18 country CHW programmes, indicating content validity.

CONCLUSION

The proposed scorecard metrics can be used to quantitatively rate the extent of CHW programmes integration into health systems, in an attempt to strengthen health systems to improve health outcomes.

Lay testing cadres and point-of-care diagnostic tests for HIV and other diseases: An essential combination in health service delivery

Zibusiso Ndlovu and Tom Ellman discuss the potential value of task sharing in provision of testing for HIV and other infectious diseases.

Community health workers at the dawn of a new era: 10. Programme performance and its assessment

BACKGROUND

While the evidence supporting the effectiveness of community health worker (CHW) programmes is substantial, there is also considerable evidence that many of these programmes have notable weaknesses that need to be addressed in order for them to reach their full potential. Thus, considerations about CHW programme performance and its assessment must be taken into account as the importance of these programmes is becoming more widely appreciated. In this paper, the tenth in our 11-paper series, "Community health workers at the dawn of a new era", we address CHW programme performance and how it is assessed from a systems perspective.

METHODS

The paper builds on the 2014 CHW Reference Guide, a compendium of case studies of 29 national CHW programmes, the 2018 WHO guideline on health policy and system support to optimize CHW programmes, and scientific studies on CHW programme performance published in the past 5 years.

RESULTS

The paper provides an overview of existing frameworks that are useful for assessing the performance of CHW programmes, with a specific focus on how individual CHW performance and community-level outcomes can be measured. The paper also reviews approaches that have been taken to assess CHW programme performance, from programme monitoring using the routine health information system to national assessments using quantitative and/or qualitative study designs and assessment checklists. The paper also discusses contextual factors that influence CHW programme performance, and reflects upon gaps and needs for the future with regard to assessment of CHW programme performance.

CONCLUSION

Assessments of CHW programme performance can have various approaches and foci according to the programme and its context. Given the fact that CHW programmes are complex entities and part of health systems, their assessment ideally needs to be based on data derived from a mix of reliable sources. Assessments should be focused not only on effectiveness (what works) but also on contextual factors and enablers (how, for whom, under what circumstances). Investment in performance assessment is instrumental for continually innovating, upgrading, and improving CHW programmes at scale. Now is the time for new efforts in implementation research for strengthening CHW programming.

Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All"

BACKGROUND

This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era".

METHODS

We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes.

RESULTS

CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness.

CONCLUSION

A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

Community health workers at the dawn of a new era: 9. CHWs' relationships with the health system and communities

BACKGROUND

This is the ninth paper in our series, "Community Health Workers at the Dawn of a New Era". Community health workers (CHWs) are in an intermediary position between the health system and the community. While this position provides CHWs with a good platform to improve community health, a major challenge in large-scale CHW programmes is the need for CHWs to establish and maintain beneficial relationships with both sets of actors, who may have different expectations and needs. This paper focuses on the quality of CHW relationships with actors at the local level of the national health system and with communities.

METHODS

The authors conducted a selective review of journal articles and the grey literature, including case study findings in the 2020 book Health for the People: National CHW Programs from Afghanistan to Zimbabwe. They also drew upon their experience working with CHW programmes.

RESULTS

The space where CHWs form relationships with the health system and the community has various inherent strengths and tensions that can enable or constrain the quality of these relationships. Important elements are role clarity for all actors, working referral systems, and functioning supply chains. CHWs need good interpersonal communication skills, good community engagement skills, and the opportunity to participate in community-based organizations. Communities need to have a realistic understanding of the CHW programme, to be involved in a transparent process for selecting CHWs, and to have the opportunity to participate in the CHW programme. Support and interaction between CHWs and other health workers are essential, as is positive engagement with community members, groups, and leaders.

CONCLUSION

To be successful, large-scale CHW programmes need well-designed, effective support from the health system, productive interactions between CHWs and health system staff, and support and engagement of the community. This requires health sector leadership from national to local levels, support from local government, and partnerships with community organizations. Large-scale CHW programmes should be designed to enable local flexibility in adjusting to the local community context.

Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes

BACKGROUND

Community health worker (CHW) programmes are again receiving more attention in global health, as reflected in important recent WHO guidance. However, there is a risk that current CHW programme efforts may result in disappointing performance if those promoting and delivering them fail to learn from past efforts. This is the first of a series of 11 articles for a supplement entitled "Community Health Workers at the Dawn of a New Era".

METHODS

Drawing on lessons from case studies of large well-established CHW programmes, published literature, and the authors' experience, the paper highlights major issues that need to be acknowledged to design and deliver effective CHW programmes at large scale. The paper also serves as an introduction to a set of articles addressing these issues in detail.

RESULTS

The article highlights the diversity and complexity of CHW programmes, and offers insights to programme planners, policymakers, donors, and others to inform development of more effective programmes. The article proposes that be understood as actors within community health system(s) and examines five tensions confronting large-scale CHW programmes; the first two tensions concern the role of the CHW, and the remaining three, broader strategic issues: 1) What kind of an actor is the CHW? A lackey or a liberator? Provider of clinical services or health promoter? 2) Lay versus professional? 3) Government programme at scale or nongovernmental organization-led demonstration project? 4) Standardized versus tailored to context? 5) Vertical versus horizontal?

CONCLUSION

CHWs can play a vital role in primary healthcare, but multiple conditions need to be met for them to reach their full potential.

Community health workers at the dawn of a new era: 6. Recruitment, training, and continuing education

BACKGROUND

This is the sixth of our 11-paper supplement entitled "Community Health Workers at the Dawn of New Era". Expectations of community health workers (CHWs) have expanded in recent years to encompass a wider array of services to numerous subpopulations, engage communities to collaborate with and to assist health systems in responding to complex and sometimes intensive threats. In this paper, we explore a set of key considerations for training of CHWs in response to their enhanced and changing roles and provide actionable recommendations based on current evidence and case examples for health systems leaders and other stakeholders to utilize.

METHODS

We carried out a focused review of relevant literature. This review included particular attention to a 2014 book chapter on training of CHWs for large-scale programmes, a systematic review of reviews about CHWs, the 2018 WHO guideline for CHWs, and a 2020 compendium of 29 national CHW programmes. We summarized the findings of this latter work as they pertain to training. We incorporated the approach to training used by two exemplary national CHW programmes: for health extension workers in Ethiopia and shasthya shebikas in Bangladesh. Finally, we incorporated the extensive personal experiences of all the authors regarding issues in the training of CHWs.

RESULTS

The paper explores three key themes: (1) professionalism, (2) quality and performance, and (3) scaling up. Professionalism: CHW tasks are expanding. As more CHWs become professionalized and highly skilled, there will still be a need for neighbourhood-level voluntary CHWs with a limited scope of work. Quality and performance: Training approaches covering relevant content and engaging CHWs with other related cadres are key to setting CHWs up to be well prepared. Strategies that have been recently integrated into training include technological tools and provision of additional knowledge; other strategies emphasize the ongoing value of long-standing approaches such as regular home visitation. Scale-up: Scaling up entails reaching more people and/or adding more complexity and quality to a programme serving a defined population. When CHW programmes expand, many aspects of health systems and the roles of other cadres of workers will need to adapt, due to task shifting and task sharing by CHWs.

CONCLUSION

Going forward, if CHW programmes are to reach their full potential, ongoing, up-to-date, professionalized training for CHWs that is integrated with training of other cadres and that is responsive to continued changes and emerging needs will be essential. Professionalized training will require ongoing monitoring and evaluation of the quality of training, continual updating of pre-service training, and ongoing in-service training-not only for the CHWs themselves but also for those with whom CHWs work, including communities, CHW supervisors, and other cadres of health professionals. Strong leadership, adequate funding, and attention to the needs of each cadre of CHWs can make this possible.

Community health workers at the dawn of a new era: 8. Incentives and remuneration

BACKGROUND

This is the eighth in our series of 11 papers on "CHWs at the Dawn of a New Era". Community health worker (CHW) incentives and remuneration are core issues that affect the performance of individual CHWs and the performance of the overall CHW programme. A better understanding of what motivates CHWs and a stronger awareness of the social justice dimensions of remuneration are essential in order to build stronger CHW programmes and to support the professionalization of the CHW workforce.

METHODS

We provide examples of incentives that have been provided to CHWs and identify factors that motivate and demotivate CHWs. We developed our findings in this paper by synthesizing the findings of a recent review of CHW motivation and incentives in a wide variety of CHW programmes with detailed case study data about CHW compensation and incentives in 29 national CHW programmes.

RESULTS

Incentives can be direct or indirect, and they can be complementary/demand-side incentives. Direct incentives can be financial or nonfinancial. Indirect incentives can be available through the health system or from the community, as can complementary, demand-side incentives. Motivation is sustained when CHWs feel they are a valued member of the health system and have a clear role and set of responsibilities within it. A sense of the "do-ability" of the CHW role is critical in maintaining CHW motivation. CHWs are best motivated by work that provides opportunities for personal growth and professional development, irrespective of the direct remuneration and technical skills obtained. Working and social relationships among CHWs themselves and between CHWs and other healthcare professionals and community members strongly shape CHW motivation.

CONCLUSION

Our findings support the recent guidelines for CHWs released by WHO in 2018 that call for CHWs to receive a financial package that corresponds to their job demands, complexity, number of hours worked, training, and the roles they undertake. The guidelines also call for written agreements that specify the CHW's role and responsibilities, working conditions, remuneration, and workers' rights.

Community health workers at the dawn of a new era: 2. Planning, coordination, and partnerships

BACKGROUND

Community health workers (CHWs) play a critical role in grassroots healthcare and are essential for achieving the health-related Sustainable Development Goals. While there is a critical shortage of essential health workers in low- and middle-income countries, WHO and international partners have reached a consensus on the need to expand and strengthen CHW programmes as a key element in achieving Universal Health Coverage (UHC). The COVID-19 pandemic has further revealed that emerging health challenges require quick local responses such as those utilizing CHWs. This is the second paper of our 11-paper supplement, "Community health workers at the dawn of a new era". Our objective here is to highlight questions, challenges, and strategies for stakeholders to consider while planning the introduction, expansion, or strengthening of a large-scale CHW programme and the complex array of coordination and partnerships that need to be considered.

METHODS

The authors draw on the outcomes of discussions during key consultations with various government leaders and experts from across policy, implementation, research, and development organizations in which the authors have engaged in the past decade. These include global consultations on CHWs and global forums on human resources for health (HRH) conferences between 2010 and 2014 (Montreux, Bangkok, Recife, Washington DC). They also build on the authors' direct involvement with the Global Health Workforce Alliance.

RESULTS

Weak health systems, poor planning, lack of coordination, and failed partnerships have produced lacklustre CHW programmes in countries. This paper highlights the three issues that are generally agreed as being critical to the long-term effectiveness of national CHW programmes-planning, coordination, and partnerships. Mechanisms are available in many countries such as the UHC2030 (formerly International Health Partnership), country coordinating mechanisms (CCMs), and those focusing on the health workforce such as the national Human Resources for Health Observatory and the Country Coordination and Facilitation (CCF) initiatives introduced by the Global Health Workforce Alliance.

CONCLUSION

It is imperative to integrate CHW initiatives into formal health systems. Multidimensional interventions and multisectoral partnerships are required to holistically address the challenges at national and local levels, thereby ensuring synergy among the actions of partners and stakeholders. In order to establish robust and institutionalized processes, coordination is required to provide a workable platform and conducive environment, engaging all partners and stakeholders to yield tangible results.

Community health workers at the dawn of a new era: 4. Programme financing

BACKGROUND

This is the fourth of our 11-paper supplement on "Community Health Workers at the Dawn of New Era". Here, we first make the case for investing in health programmes, second for investing in human resources for health, third for investing in primary healthcare (PHC) workers, and finally for investing in community health workers (CHWs).

METHODS

Searches of peer-reviewed journals and the grey literature were conducted with a focus on community health programme financing. The literature search was supplemented with a search of the grey literature for information about national health sector plans, community health strategies/policies, and costing information from databases of various countries' ministries of health, and finally a request for information from in-country partners.

RESULTS

The global shortage of human resources for health is projected to rise to 18 million health workers by 2030, with more acute shortages in Africa and South Asia. CHWs have an important role to play in mitigating this shortage because of their effectiveness (when properly trained and supported) and the feasibility of their deployment. Data are limited on the costs of current CHW programmes and how they compare to government and donor expenditures for PHC and for health services more broadly. However, available data from 10 countries in Africa indicate that the median per capita cost of CHW programmes is US$ 4.77 per year and US$ 2574 per CHW, and the median monthly salary of CHWs in these same countries is US$ 35 per month. For a subset of these countries for which spending for PHC is available, governments and donors spend 7.7 times more on PHC than on CHW programming, and 15.4 times more on all health expenditures. Even though donor funding for CHW programmes is a tiny portion of health-related donor support, most countries rely on donor support for financing their CHW programmes.

CONCLUSION

The financing of national CHW programmes has been a critical element that has not received sufficient emphasis in the academic literature on CHW programmes. Increasing domestic government funding for CHW programmes is a priority. In order to ensure growth in funding for CHW programmes, it will be important to measure CHW programme expenditures and their relationship to expenditures for PHC and for all health-related expenditures.

Pursuing health systems strengthening through disease-specific programme grants: experiences in Tanzania and Sierra Leone

Introduction

Disease-specific ‘vertical’ programmes and health system strengthening (HSS) ‘horizontal’ programmes are not mutually exclusive; programmes may be implemented with the dual objectives of achieving both disease-specific and broader HSS outcomes. However, there remains an ongoing need for research into how dual objective programmes are operationalised for optimum results.

Methods

A qualitative study encompassing four grantee programmes from two partner countries, Tanzania and Sierra Leone, in the Comic Relief and GlaxoSmithKline ‘Fighting Malaria, Improving Health’ partnership. Purposive sampling maximised variation in terms of geographical location, programme aims and activities, grantee type and operational sector. Data were collected via semi-structured interviews. Data analysis was informed by a general inductive approach.

Results

51 interviews were conducted across the four grantees. Grantee organisations structured and operated their respective projects in a manner generally supportive of HSS objectives. This was revealed through commonalities identified across the four grantee organisations in terms of their respective approach to achieving their HSS objectives, and experienced tensions in pursuit of these objectives. Commonalities included: (1) using short-term funding for long-term initiatives; (2) benefits of being embedded in the local health system; (3) donor flexibility to enable grantee responsiveness; (4) the need for modest expectations; and (5) the importance of micro-innovation.

Conclusion

Health systems strengthening may be pursued through disease-specific programme grants; however, the respective practice of both the funder and grantee organisation appears to be a key influence on whether HSS will be realised as well as the overall extent of HSS possible.

Moving From Community-Based to Health-Centre Based Management: Impact on Urban Community Health Worker Performance in Ethiopia

Community health worker (CHW) performance is influenced by the way in which management arrangements are configured vis-a-vis the community and health services. While low/middle-income contexts are changing, the literature provides few examples of country efforts to strategically modify management arrangements to support evolving CHW roles (e.g. chronic disease care) and operating environments (e.g. urbanization). This paper aims to understand the performance implications of changing from community-based to health centre-based management, on Ethiopia's Urban Health Extension Professionals (UHEPs), and the tensions/trade-offs associated with the respective arrangements. We conducted semi-structured interviews/focus groups to gather perspectives and preferences from those involved with the transition (13 managers/administrators, 5 facility-based health workers, 20 UHEPs). Using qualitative content analysis, we deductively coded data to four program elements impacted by changed management arrangements and known to affect CHW performance (work scope; community legitimacy; supervision/oversight/ownership; facility linkages) and inductively identified tensions/trade-offs. Community-based management was associated with wider work scope, stronger ownership/regular monitoring, weak technical support, and weak health center linkages, with opposite patterns observed for health center-led management. Practical trade-offs included: heavy UHEP involvement in political/administrative activities under Kebele-based management; resistance to working with UHEPs by facility-based workers; and, health centre capacity constraints in managing UHEPs. Whereas the Ministry of Health/UHEPs favoured health centre-led management to capitalize on UHEPs' technical skills, Kebele officials were vested in managing UHEPs and argued for community interests over UHEPs' professional interests; health facility managers/administrators held divided opinions. Management arrangements influence the nature of CHW contributions towards the achievement of health, development, and political goals. Decisions about appropriate management arrangements should align with the nature of CHW roles and consider implementation setting, including urbanization, political decentralization, and relative capacity of managing institutions.

Factors influencing motivation and job satisfaction of community health workers in Africa and Asia-A multi-country study

As key stakeholders continue to affirm the relevance of community health workers (CHWs) in universal health coverage, there is a need for a commensurate focus on their motivation and job satisfaction especially in low- and middle-income countries (LMICs) where they play prominent roles. Despite the wealth of literature on motivation and job satisfaction, many studies draw on research conducted in high-income settings. This study explored factors influencing motivation and satisfaction among CHWs in LMICs. Thirty-two focus group discussions and 116 key informant interviews were conducted with CHWs, programme staff, health professionals and community leaders in Bangladesh, India, Kenya, Malawi and Nigeria. Data were analysed using thematic analysis. Overall, CHWs desired: (1) CHW programmes with manageable workload; work schedules that address concerns of female CHWs on work-life balance; clear career pathway; and a timely, regular and sustainable remuneration. However, no remuneration type guaranteed satisfaction because of an insatiable quest for additional financial reward. (2) Relationship with stakeholders that enhances their reputation. This was more important for unsalaried CHWs. (3) Opportunities to support community members. This was popular among all cadres as it resonated with their altruistic values. This study provides insights for developing a 'comprehensive motivation package' for CHWs.

Feasibility of community health workers as teleaudiology patient-site facilitators: a multilevel training study

OBJECTIVE

We evaluated the feasibility of a multi-level teleaudiology patient-site facilitator training program for Community Health Workers (CHWs) at a partnering health centre in southern Arizona.

DESIGN

Three levels were offered: Introductory, with basic information on hearing loss and teleaudiology; Intermediate, on technology, team roles, and access issues; and Facilitator, on further knowledge and hands-on skills to serve as patient-site facilitators in synchronous hearing aid service delivery. Six domains of feasibility were addressed using a mixed-methods design. Quantitative data included survey responses and observation of hands-on skills. Qualitative data included field notes from group discussion and open-ended survey questions, and were analysed using CHW core competencies.

STUDY SAMPLE

Twelve CHWs participated in the introductory training, ten moved on to intermediate, and three continued to the facilitator.

RESULTS

Quantitative outcomes indicated that the trainings were feasible according to each of the six domains. CHWs in the facilitator training passed the practical hands-on skill assessment. Qualitative analyses revealed CHWs comments addressed eight of the ten possible CHW core competencies, and focussed on service coordination/navigation, and capacity building.

CONCLUSIONS

Teleaudiology trainings for CHWs were feasible, increasing service capacity for a potential pathway to improve access to hearing health care in low-resource areas.

Application of the Ultra-Poverty Graduation Model in understanding community health volunteers' preferences for socio-economic empowerment strategies to enhance retention: a qualitative study in Kilifi, Kenya

BACKGROUND

A significant shortage of healthcare workforce exists globally. To achieve Universal Healthcare coverage, governments need to enhance their community-based health programmes. Community health volunteers (CHVs) are essential personnel in achieving this objective. However, their ability to earn a livelihood is compromised by the voluntary nature of their work; hence, the high attrition rates from community-based health programmes. There is an urgent need to support CHVs become economically self-reliant. We report here on the application of the Ultra-Poverty Graduation (UPG) Model to map CHVs' preferences for socio-economic empowerment strategies that could enhance their retention in a rural area in Kenya.

METHODS

This study adopted an exploratory qualitative approach. Using a semi-structured questionnaire, we conducted 10 Focus Group Discussions with the CHVs and 10 Key Informant Interviews with County and Sub-county Ministry of Health and Ministry of Agriculture officials including multi-lateral stakeholders' representatives from two sub-counties in the area. Data were audio-recorded and transcribed verbatim and transcripts analysed in NVivo. Researcher triangulation supported the first round of analysis. Findings were mapped and interpreted using a theory-driven analysis based on the six-step Ultra-Poverty Graduation Model.

RESULTS

We mapped the UPG Model's six steps onto the results of our analyses as follows: (1) initial asset transfer of in-kind goods like poultry or livestock, mentioned by the CHVs as a necessary step; (2) weekly stipends with consumption support to stabilise consumption; (3) hands-on training on how to care for assets, start and run a business based on the assets transferred; (4) training on and facilitation for savings and financial support to build assets and instil financial discipline; (5) healthcare provision and access and finally (6) social integration. These strategies were proposed by the CHVs to enhance economic empowerment and aligned with the UPG Model.

CONCLUSION

These results provide a user-defined approach to identify and assess strategic needs of and approaches to CHVs' socio-economic empowerment using the UPG model. This model was useful in mapping the findings of our qualitative study and in enhancing our understanding on how these needs can be addressed in order to economically empower CHVs and enhance their retention in our setting.

Health systems effects of successive emergency health and nutrition projects: an embedded retrospective case study analysis in Sudan and Pakistan

Despite increasing attention to the concept of a humanitarian-development nexus in recent years, limited research is available to improve health systems strengthening practice within humanitarian programmes. We used an exploratory, systematic, embedded, multiple case study design to discern systems effects of successive Save the Children chronic emergency health and nutrition projects implemented in Sudan and Pakistan between 2011 and 2018. We used textual analysis to code 63 documents focused on eight themes using NVivo 11.0. This was supplemented by six key informant interviews. Findings offer a complex and mixed picture, with contributions to systems strengthening in community systems, their linkages to health management structures, and human resources for health. Projects with primary mandates for urgent service delivery progressively found systems strengthening opportunities, through a combination of tacit choices and explicit objectives. In both countries, some 'parallel systems' were set in place initially, with immediate gains (e.g. quality of services) only occasionally accompanied by enhanced systems capacity to sustain them. Cycles of implementation, however, achieved financial transition of 'macro-costs' to the government (e.g. facilities in Sudan, staff in Pakistan) through indirect pathways and the influence of pluralistic governmental structures themselves. Opportunities were taken, or missed, based on dynamic relationships within the government-development partners eco-system. Transition steps also came with unintended effects and drops in intensity. Both project contributions to systems strengthening and our own study were limited by substantial gaps in evaluation and documentation processes. We provide cautious recommendations based on the literature and our two case studies. Even mid-size chronic emergency projects can and should make meaningful and explicit contributions to systems strengthening. This contribution will, however, depend on the development eco-system context, and development of better collective intelligence (coordination, evaluation and learning, benchmarking, accountability) to improve individual projects' adaptive management efforts to improve fit with evolving national systems.

Community health workers and early detection of breast cancer in low-income and middle-income countries: a systematic scoping review of the literature

Background

Breast cancer is the leading cause of female mortality in low-income and middle-income countries (LMICs). Early detection of breast cancer, either through screening or early diagnosis initiatives, led by community health workers (CHWs) has been proposed as a potential way to address the unjustly high mortality rates. We therefore document: (1) where and how CHWs are currently deployed in this role; (2) how CHWs are trained, including the content, duration and outcomes of training; and (3) the evidence on costs associated with deploying CHWs in breast cancer early detection.

Methods

We conducted a systematic scoping review and searched eight major databases, as well as the grey literature. We included original studies focusing on the role of CHWs to assist in breast cancer early detection in a country defined as a LMIC according to the World Bank.

Findings

16 eligible studies were identified. Several roles were identified for CHWs including awareness raising and community education (n=13); history taking (n=7); performing clinical breast examination (n=9); making onward referrals (n=7); and assisting in patient navigation and follow-up (n=4). Details surrounding training programmes were poorly reported and no studies provided a formal cost analysis.

Conclusions

Despite the relative paucity of studies addressing the role of CHWs in breast cancer early detection, as well as the heterogeneity of existing studies, evidence suggests that CHWs can play a number of important roles in breast cancer early detection initiatives in LMICs. However, if they are to realise their full potential, they must be appropriately supported within the wider health system.

The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability

This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as 'CHWs and equity.'CHWs are intended to comprise a 'bridge' between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs' bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.

Optimising geographical accessibility to primary health care: a geospatial analysis of community health posts and community health workers in Niger

Background

Little is known about the contribution of community health posts and community health workers (CHWs) to geographical accessibility of primary healthcare (PHC) services at community level and strategies for optimising geographical accessibility to these services.

Methods

Using a complete georeferenced census of community health posts and CHWs in Niger and other high-resolution spatial datasets, we modelled travel times to community health posts and CHWs between 2000 and 2013, accounting for training, commodities and maximum population capacity. We estimated additional CHWs needed to optimise geographical accessibility of the population beyond the reach of the existing community health post network. We assessed the efficiency of geographical targeting of the existing community health post network compared with networks designed to optimise geographical targeting of the estimated population, under-5 deaths and Plasmodium falciparum malaria cases.

Results

The per cent of the population within 60-minute walking to the nearest community health post with a CHW increased from 0.0% to 17.5% between 2000 and 2013. An estimated 10.4 million people (58.5%) remained beyond a 60-minute catchment of community health posts. Optimal deployment of 7741 additional CHWs could increase geographical coverage from 41.5% to 82.9%. Geographical targeting of the existing community health post network was inefficient but optimised networks could improve efficiency by 32.3%–47.1%, depending on targeting metric.

Interpretations

We provide the first estimates of geographical accessibility to community health posts and CHWs at national scale in Niger, highlighting improvements between 2000 and 2013, geographies where gaps remained and approaches for optimising geographical accessibility to PHC services at community level.

Community Health Workers Can Provide Psychosocial Support to the People During COVID-19 and Beyond in Low- and Middle- Income Countries

The COVID-19 pandemic has been the most challenging public health issue which not only affected the physical health of the global population but also aggravated the mental health conditions such as stress, anxiety, fear, depression and anger. While mental health services are seriously hampered amid this COVID-19 pandemic, health services, particularly those of Low- and Middle- Income Countries (LMICs) are looking for alternatives to provide psychosocial support to the people amid this COVID-19 and beyond. Community Health Workers (CHWs) are an integral part of the health systems in many LMICs and played significant roles such as health education, contact tracing, isolation and mobilization during past emergencies and amid COVID-19 in many LMICs. However, despite their potentials in providing psychosocial support to the people amid this COVID-19 pandemic, they have been underutilized in most health systems in LMICs. The CHWs can be effectively engaged to provide psychosocial support at the community level. Engaging them can also be cost-saving as they are already in place and may cost less compared to other health professionals. However, they need training and supervision and their safety and security needs to be protected during this COVID-19. While many LMICs have mental health policies but their enactment is limited due to the fragility of health systems and limited health care resources. CHWs can contribute in this regard and help to address the psychosocial vulnerabilities of affected population in LMICs during COVID-19 and beyond.

Efficacy of a Community Health Worker-Based Intervention in Improving Dietary Habits Among Community-Dwelling Older People: A Controlled, Crossover Trial in Japan

Background. Community health workers (CHWs), often called "health promotion volunteers" in Japan, are individuals who act as a natural helping resource in the community. Aim. This study tested the efficacy of a CHW-based intervention to improve dietary habits among community-dwelling older people in Japan, using a controlled, crossover design. Method. Seventy-eight people aged 65 to 74 years with poor dietary variety living in four administrative districts in Hikone City (Shiga Prefecture, Japan) were nonrandomly allocated to an immediate-intervened group (IIG; n = 41) or a delayed-intervened group (DIG; n = 37). Participants joined a biweekly, four-session program (120 minutes/session), comprising "CHW drama-style lectures," "group discussion among participants and CHWs," "tasting of dishes," and "take-home practical activities." For the initial 2-month period, the IIG received the intervention and the DIG did not. The groups were crossed over for the subsequent 2-month period. The primary outcome measure was participants' dietary variety score (score range: 0-10). Results. The dietary variety score in the IIG significantly increased in the initial 2-month period compared with the DIG (effect size 1.60 points; 95% confidence interval: 0.75, 2.45). The intervention had a similar effect in the DIG in the subsequent 2-month period. Moreover, an analysis within the IIG showed that the intervention effects persisted for at least 2 months after the intervention. Conclusions. The CHW-based intervention improved dietary habits among older people. Our findings provide evidence that a CHW-based natural helping approach is a possible solution to promote healthy aging in the community.

Increasing utilisation of skilled attendants at birth in sub-Saharan Africa: A systematic review of interventions

BACKGROUND

Maternal mortality is a critical global public health concern, especially in low- and middle-income countries in sub-Saharan Africa. Although maternal mortality rates have declined by approximately 39% in sub-Saharan Africa over the last decade, maternal deaths during pregnancy and in childbirth remain high. Interventions to improve mothers' use of skilled birth attendants may decrease maternal mortality in sub-Saharan African countries.

OBJECTIVES

This systematic literature review examines components of and evaluates the effectiveness of interventions to increase use of skilled birth attendants in sub-Saharan Africa.

METHODS

Guided by the PRISMA model for systematic reviews, the PubMed, Web of Science, and CIHNAL databases were searched for studies from years 2003 through June 2020.

RESULTS

The 28 articles included in this review reported on interventions incorporating community health workers, phone or text messages, implementation of community-level initiatives, free health care, cash incentives, an international multi-disciplinary volunteer team, and a group home for pregnant women, which improved use of skilled birth attendants to varying degrees. Only one study reported improved outcomes with the use of community health workers. All of the interventions using text messages increased hospital utilization for births.

CONCLUSIONS

Interventions implemented in sub-Saharan Africa hold promise for improving maternal health. Multi-level interventions that involve community members and local leaders can help address the multi-faceted issue of poor maternal health outcomes and mortality. Interventions should focus on capacity building and on training and mentoring of formally-trained health care providers and community health workers in order to expand access.

Capitalizing on facilitators and addressing barriers when implementing active tuberculosis case-finding in six districts of Ho Chi Minh City, Vietnam: a qualitative study with key stakeholders

BACKGROUND

Vietnam has a high burden of undetected tuberculosis (TB). The Vietnamese National TB Strategic Plan highlights active case-finding (ACF) as one strategy to find people with TB who are currently unreached by the existing government health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented across six districts of Ho Chi Minh City, 2017-2019. We aimed to explore the facilitators and barriers for ACF implementation during the IMPACT TB project to understand how and why the intervention achieved high yields.

METHODS

This was an exploratory qualitative study based on 39 semi-structured key-informant interviews with TB patients who were diagnosed through ACF, employees and volunteers who implemented ACF, and leaders from district, national, or international institutions and organizations in Vietnam. Thematic analysis was applied, using an implementation science framework by Grol and Wensing.

RESULTS

We generated three main themes: (1) the studied ACF model used in Vietnam provided a conducive social and organizational context for ACF implementation with areas for improvement, including communication and awareness-raising, preparation and logistics, data systems and processes, and incentives; (2) employees and volunteers capitalized on their strengths to facilitate ACF implementation, e.g., experience, skills, and communication; and (3) employees and volunteers were in a position to address patient-level barriers to ACF implementation, e.g., stigma, discrimination, and mistrust. These themes covered a variety of facilitators and barriers, which we divided into 17 categories. All categories were mentioned by employees and volunteers, except the category of having a network that facilitates ACF implementation, which was only mentioned by volunteers. This study also highlighted examples and ideas of how to address facilitators and barriers.

CONCLUSIONS

IMPACT TB provided a favorable social and organizational context for ACF implementation. Individual employees and volunteers still determined the success of the project, as they had to be able to capitalize on their own strengths and address patient-level barriers. Volunteers especially used their networks to facilitate ACF. Knowledge of both facilitators and barriers, and how to address them can inform the planning and implementation ACF in Vietnam and similar contexts across low- and middle-income countries worldwide.

Health for the People: Past, Current, and Future Contributions of National Community Health Worker Programs to Achieving Global Health Goals

National community health worker programs are at the dawn of a new era, given the growing recognition of their importance for achieving global health goals and for controlling the COVID-19 pandemic. Now is the time to provide them with the respect and funding that they need and deserve.

Measuring Knowledge of Community Health Workers at the Last Mile in Liberia: Feasibility and Results of Clinical Vignette Assessments

We integrated clinical vignettes into routine programmatic supervision to assess community health worker knowledge of integrated community case management in rural Liberia. Results included higher rates of correct diagnosis and lifesaving treatment for uncomplicated disease than for more severe cases, with accurate recognition of danger signs posing a challenge.

Introduction:

Community health workers (CHWs) can provide lifesaving treatment for children in remote areas, but high-quality care is essential for effective delivery. Measuring the quality of community-based care in remote areas is logistically challenging. Clinical vignettes have been validated in facility settings as a proxy for competency. We assessed feasibility and effectiveness of clinical vignettes to measure CHW knowledge of integrated community case management (iCCM) in Liberia's national CHW program.

Methods:

We developed 3 vignettes to measure knowledge of iCCM illnesses (malaria, diarrhea, and pneumonia) in 4 main areas: assessment, diagnosis, treatment, and caregiver instructions. Trained nurse supervisors administered the vignettes to CHWs in 3 counties in rural Liberia as part of routine program supervision between January and May 2019, collected data on CHW knowledge using a standardized checklist tool, and provided feedback and coaching to CHWs in real time after vignette administration. Proportions of vignettes correctly managed, including illness classification, treatment, and referral where necessary, were calculated. We assessed feasibility, defined as the ability of clinical supervisors to administer the vignettes integrated into their routine activities once per year for each CHW, and effectiveness, defined as the ability of the vignettes to measure the primary outcomes of CHW knowledge of diagnosis and treatment including referrals.

Results:

We were able to integrate this assessment into routine supervision, facilitate real-time coaching, and collect data on iCCM knowledge among 155 CHWs through delivery of 465 vignettes. Diagnosis including severity was correct in 65%–82% of vignettes. CHWs correctly identified danger signs in 44%–50% of vignettes, correctly proposed referral to the facility in 63% of vignettes including danger signs, and chose correct lifesaving treatment in 23%–65% of vignettes. Both diagnosis and lifesaving treatment rates were highest for malaria and lowest for severe pneumonia.

Conclusion:

Administration of vignettes to assess knowledge of correct iCCM case management was feasible and effective in producing results in this setting. Proportions of correct diagnosis and lifesaving treatment varied, with high proportions for uncomplicated disease, but lower for more severe cases, with accurate recognition of danger signs posing a challenge. Future work includes validation of vignettes for use with CHWs through direct observation, strengthening supportive supervision, and program interventions to address identified knowledge gaps.

Early Lessons From Launching an Innovative Community Health Household Model Across 3 Country Contexts

Community health worker programs can contribute substantively to health systems working to implement universal health coverage, but there is no one-size-fits-all model. Program leaders should anticipate needing to adapt their plans as local realities demand, but lessons learned in other contexts can provide guidance on how to best proceed.

Community health workers (CHWs) are integrated into health systems through a variety of designs. Partners In Health (PIH), a nongovernmental organization with more than 30 years of experience in over 10 countries, initially followed a vertical approach by assigning CHWs to individual patients with specific conditions, such as HIV, multidrug resistant-TB, diabetes, and other noncommunicable diseases, to provide one-on-one psychosocial and treatment support. Starting in 2015, PIH-Malawi redesigned their CHW assignments to focus on entire households, thereby offering the opportunity to address a wider variety of conditions in any age group, all with a focus on working toward effective universal health coverage. Inspired by this example, PIH-Liberia and then PIH-Mexico engaged in a robust cross-site dialogue on how to adapt these plans for their unique nongovernmental organization-led CHW programs. We describe the structure of this “household model,” how these structures were changed to adapt to different country contexts, and early impressions on the effects of these adaptations. Overall, the household model is proving to be a feasible and functional method for organizing CHW programs so that they can contribute toward achieving universal health coverage, but there is no “one-size-fits-all” approach. Other countries planning on adopting this model should plan to analyze and adapt as needed.

Applying the Community Health Worker Coverage and Capacity Tool for Time-Use Modeling for Program Planning in Rwanda and Zanzibar

Community health worker (CHW) programs are a critical component of health systems, notably in lower- and middle-income countries. However, when policy recommendations exceed what is feasible to implement, CHWs are overstretched by the volume of activities, implementation strength is diluted, and programs fail to produce promised outcomes. To counteract this, we developed a time-use modeling tool-the CHW Coverage and Capacity (C3) Tool-and used it with government partners in Rwanda and Zanzibar to address common policy questions related to CHW needs, coverage, and time optimization.In Rwanda, the C3 Tool was used to analyze 2 well-established cadres of CHWs and 1 new one. The well-established CHW cadres were within a "manageable" workload range whereas the new cadre was projected to achieve less than half of assigned activities. This is informing ongoing changes to the CHWs' scopes of work. In Zanzibar, the C3 Tool was used to update the national community health strategy to include community health volunteers (CHVs) for the first time and determine how many CHVs were needed. The tool projected that 2,200 CHVs could achieve approximately 90% coverage of all defined services. Based on these figures, Zanzibar updated its national community health strategy, which officially launched in February 2020.We discuss lessons from these 2 experiences. Translating analysis into decision making depends not only on the programmatic will and motivation of governments but also on finding opportune timing for when policy and program processes allow for optimization of CHW investments. Further research is needed but our experience supports the value of a modeling tool to ground program plans within estimated constraints on CHW time.

Community-based postnatal care services for women and newborns in Kenya: an opportunity to improve quality and access?

Background

In resource-constrained settings, Community Health Workers (CHWs) are the first point of contact between communities and the health system, as providers of maternal and newborn health services. However, little is known of the quality of community-based postnatal care (PNC). We assessed the content of PNC provided by CHWs and women’s experiences of care in two Kenyan counties.

Methods

We used a cross-sectional, mixed methods design to examine the quality of PNC services provided by CHWs. Trained observers attended PNC home visits to assess technical quality using a 25-item checklist covering four PNC domains: infant health warning signs, maternal health warning signs, essential newborn care, and breastfeeding. The observers completed an 8-item communication quality checklist. We conducted follow-up surveys with observed PNC clients to assess their experiences of care. Finally, we used in-depth interviews with CHWs and focus group discussions with observed PNC clients to understand the experiential quality of care.

Results

Observations suggest shortcomings in the technical quality of PNC home visits. CHWs completed an average of 6.4 (standard deviation SD = 4.1) of the 25 PNC technical quality items. CHWs often lacked essential supplies, and only six percent carried all four of the CHW job aids and tools specified in the national guidelines for maternal health at community level. However, CHWs completed an average of 7.3 (SD = 1.1) of the 8 communication quality items, and most PNC clients (88%) reported being satisfied during follow-up interviews. Higher technical quality scores were associated with older mothers, better communication, longer visit duration, and CHWs who carried at least three job tools. CHWs expressed a strong sense of responsibility for care of their clients, while clients underscored how CHWs were trusted to maintain their clients’ confidentiality and were a valuable community resource.

Conclusion

This study identified gaps in the technical quality of CHW PNC practices, while also recognizing positive elements of experiential quality of care, including communication quality, and trusting relationships. This study also demonstrated the strength of the CHWs’ role in establishing linkages between the community and facilities, as long as the CHW are perceived as, and enabled to be, an integral part of the PHC network in Kenya.

Opportunities for and Perceptions of Integrating Community Health Workers Via the Affordable Care Act: Medicaid Health Homes

CONTEXT

The Affordable Care Act created opportunities for innovative, cost-saving measures to improve health care access. Community health workers (CHWs) are frontline public health workers who have a close understanding of the communities they serve. States that expanded Medicaid coverage could also create Medicaid Health Homes (MHHs)-virtual health care networks-to coordinate care for people with chronic conditions. New York was the second state to implement MHHs and gave the option to include CHWs as part of the health care team.

OBJECTIVE

To understand the perceptions of MHH administrators regarding CHW engagement in MHHs, as well as the facilitators and barriers to adoption in MHHs that are unknown.

DESIGN, SETTING, AND PARTICIPANTS

Semistructured qualitative interviews (n = 18) were conducted with MHH administrators throughout New York State guided by the Diffusion of Innovations (DOI) framework. Qualitative thematic analysis was used to explore the domains and themes.

RESULTS

Most MHH administrators believed that CHWs fit within MHHs. The DOI constructs of compatibility and complexity and the Consolidated Framework for Implementation Research construct of external policies helped explain CHW integration. CHWs were compatible with MHHs by enrolling patients, helping coordinate patient care, and providing social support. The complexities of CHW integration into MHHs included barriers to CHW integration, no direct reimbursement for their services, lack of clarity for CHW roles and responsibilities, and no explicit external policy for their use in MHHs.

CONCLUSIONS

CHWs can, and have, been integrated into the relatively novel Health Home system. While some barriers have prevented their integration into all MHHs, lessons learned could provide guidance for CHW integration into other health care systems in the United States.

Can public sector community health workers deliver a nurturing care intervention in South Africa? The Amagugu Asakhula feasibility study

Background

Nurturing care interventions have the potential to promote health and development in early childhood. Amagugu Asakhula was designed to promote developmentally important dietary and movement behaviours among children of preschool age (3–5 years) in South Africa. An initial formative study in Cape Town found the intervention to be feasible and acceptable when delivered by community health workers (CHWs) linked to a community-based organisation. This study evaluated the delivery of the Amagugu Asakhula intervention by CHWs linked to a public sector primary health care facility in Soweto, as this mode of delivery could have more potential for sustainability and scalability.

Methods

A qualitative design was utilised to assess feasibility, acceptability, adoption, appropriateness, implementation, fidelity and context. CHWs (n = 14) delivered the intervention to caregivers (n = 23) of preschool-age children in Soweto over 6 weeks. Following the completion of the intervention, focus group discussions were held with CHWs and caregivers. Further data were obtained through observations, study records and key informant interviews (n = 5). Data were analysed using deductive thematic analysis guided by a process evaluation framework.

Results

The delivery of the Amagugu Asakhula intervention through CHWs linked to a primary health care facility in Soweto was not found to be feasible due to contextual challenges such as late payment of salaries influencing CHW performance and willingness to deliver the intervention. CHWs expressed dissatisfaction with their general working conditions and were thus reluctant to take on new tasks. Despite barriers to successful delivery, the intervention was well received by both CHWs and caregivers and was considered a good fit with the CHWs’ scope of work.

Conclusions

Based on these findings, delivery of the Amagugu Asakhula intervention is not recommended through public sector CHWs in South Africa. This feasibility study informs the optimisation of implementation and supports further testing of the intervention’s effectiveness when delivered by CHWs linked to community-based organisations. The present study further demonstrates how implementation challenges can be identified through qualitative feasibility studies and subsequently addressed prior to large-scale trials, avoiding the wasting of research and resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00802-6.

Compensation models for community health workers: Comparison of legal frameworks across five countries

Background

Despite the life-saving work they perform, community health workers (CHWs) have long been subject to global debate about their remuneration. There is now, however, an emerging consensus that CHWs should be paid. As the discussion evolves from whether to financially remunerate CHWs to how to do so, there is an urgent need to better understand the types of CHW payment models and their implications.

Methods

This study examines the legal framework on CHW compensation in five countries: Brazil, Ghana, Nigeria, Rwanda, and South Africa. In order to map the characteristics of each approach, a review of the regulatory framework governing CHW compensation in each country was undertaken. Law firms in each of the five countries were engaged to support the identification and interpretation of relevant legal documents. To guide the search and aid in the creation of uniform country profiles, a standardized set of questions was developed, covering: (i) legal requirements for CHW compensation, (ii) CHW compensation mechanisms, and (iii) CHW legal protections and benefits.

Results

The five countries profiled represent possible archetypes for CHW compensation: Brazil (public), Ghana (volunteer-based), Nigeria (private), Rwanda (cooperatives with performance based incentives) and South Africa (hybrid public/private). Advantages and disadvantages of each model with respect to (i) CHWs, in terms of financial protection, and (ii) the health system, in terms of ease of implementation, are outlined.

Conclusions

While a strong legal framework does not necessarily translate into high-quality implementation of compensation practices, it is the first necessary step. Certain approaches to CHW compensation – particularly public-sector or models with public sector wage floors – best institutionalize recommended CHW protections. Political will and long-term financing often remain challenges; removing ecosystem barriers – such as multilateral and bilateral restrictions on the payment of salaries – can help governments institutionalize CHW payment.

Integrated care by community health workers in Malawi: Rehabilitation and blood pressure monitoring

Background

Community health workers (CHWs) are essential providers of integrated care for people in low-resourced settings with a high burden from noncommunicable diseases (NCDs).

Aims

The purpose of this study was to evaluate a CHW training program in rural Malawi integrating blood pressure (BP) monitoring into rehabilitation care.

Methods

This was a retrospective cross-sectional study. The participants were a convenience sample of home-based palliative care CHWs at the local hospital (n = 59). Data collected included: a written pre- and post-knowledge test, skills competency checklist and a post-training program survey. Descriptive frequencies and paired t-tests (a = 0.05) were used for quantitative analyses. Themes in narrative responses in the post-training survey were analyzed qualitatively.

Results

Participant knowledge regarding BP monitoring procedures improved significantly on the post-test (M = 8.24, SD = 1.654) compared to the pre-test (M = 6.59, SD = 1.683), Z (49) = −5.569, p < 0.001. The pre-and post-tests were scored 0–10 points. All participants demonstrated competency in 100% of the skills. Participants reported the lack of transportation, teamwork and resources as barriers to their work. They reported trainings and opportunities to collaborate as facilitators to their work.

Discussion

This study demonstrated the effectiveness of a training program for CHWs which integrated BP monitoring with rehabilitation care for people with NCDs. This retention of knowledge and application to clinical practice serve as strong indicators of the feasibility and sustainability of the CHW training and care delivery program in resource-limited settings.

Conclusion

Our findings help demonstrate that training CHWs can be an effective way to help bridge the gap in health care access for people with disabilities in resource-limited countries.