Epistemic communities in global health and the development of child survival policy: a case study of iCCM

The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions

Introduction

Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes.

Methods

We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices.

Results

The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings.

Conclusion

The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.

Framing and the formation of global health priorities

Health issues vary in the amount of attention and resources they receive from global health organisations and national governments. How issues are framed could shape differences in levels of priority. We reviewed scholarship on global health policy making to examine the role of framing in shaping global health priorities. The review provides evidence of the influence of three framing processes-securitisation, moralisation, and technification. Securitisation refers to an issue's framing as an existential threat, moralisation as an ethical imperative, and technification as a wise investment that science can solve. These framing processes concern more than how issues are portrayed publicly. They are socio-political processes, characterised by contestation among actors in civil society, government, international organisations, foundations, and research institutions. These actors deploy various forms of power to advance particular frames as a means of securing attention and resources for the issues that concern them. The ascription of an issue as a security concern, an ethical imperative, or a wise investment is historically contingent: it is not inevitable that any given issue will be framed in one or more of these ways. A health issue's inherent characteristics-such as the lethality of a pathogen that causes it-also shape these ascriptions, but do not fully determine them. Although commonly facing resistance, global health elites often determine which frames prevail, raising questions about the legitimacy of priority-setting processes. We draw on the review to offer ideas on how to make these processes fairer than they are at present, including a call for democratic representation even as necessary space is preserved for elite expertise.

The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique

Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.

The role of governance in implementing sustainable global health interventions: review of health system integration for integrated community case management (iCCM) of childhood illnesses

Improving health outcomes in countries with the greatest burden of under-5 child mortality requires implementing innovative approaches like integrated community case management (iCCM) to improve coverage and access for hard-to-reach populations. ICCM improves access for hard-to-reach populations by deploying community health workers to manage malaria, diarrhoea and pneumonia. Despite documented impact, challenges remain in programme implementation and sustainability. An analytical review was conducted using evidence from published and grey literature from 2010 to 2019. The goal was to understand the link between governance, policy development and programme sustainability for iCCM. A Governance Analytical Framework revealed thematic challenges and successes for iCCM adaptation to national health systems. Governance in iCCM included the collective problems, actors in coordination and policy-setting, contextual norms and programmatic interactions. Key challenges were country leadership, contextual evidence and information-sharing, dependence on external funding, and disease-specific stovepipes that impede funding and coordination. Countries that tailor and adapt programmes to suit their governance processes and meet their specific needs and capacities are better able to achieve sustainability and impact in iCCM.

A systems approach to assessing complexity in health interventions: an effectiveness decay model for integrated community case management

Complexity is inherent to any system or program. This is especially true of integrated interventions, such as integrated community case management (iCCM). iCCM is a child health strategy designed to provide services through community health workers (CHWs) within hard-to-reach areas of low-and-middle-income countries (LMICs). It is comprised of many interlinked program components, processes and stakeholders. Elucidating the complexity of such programs is essential to designing interventions that respond to local contexts and successfully plan for sustainable integration. A pragmatic approach has yet to be developed that holistically assesses the many dimensions of iCCM or other integrated programs, their alignment with local systems, and how well they provide effective care. We propose an accessible systems approach to both measuring systems effectiveness and assessing its underlying complexity using a combination of systems thinking tools. We propose an effectiveness decay model for iCCM implementation to measure where patient loss occurs along the trajectory of care. The approach uses process mapping to examine critical bottlenecks of iCCM processes, their influence on effectiveness decay, and their integration into local systems; regression analysis and structural equation modeling to determine effects of key indicators on programmatic outcomes; and qualitative analysis with causal loop diagramming to assess stakeholder dynamics and their interactions within the iCCM program. An accurate assessment of the quality, effectiveness, and strength of community-based interventions relies on more than measuring core indicators and program outcomes; it requires an exploration of how its actors and core components interact as part of a system. Our approach produces an interactive iCCM effectiveness decay model to understand patient loss in context, examines key systems issues, and uses a range of systems thinking tools to assess the dynamic interactions that coalesce to produce observed program outcomes.

How actors, processes, context and evidence influenced the development of Malawi's Health Sector Strategic Plan II

Health sector strategic plans are health policies outlining health service delivery in low- and middle- income countries, guiding health sectors to meet health needs while maximizing resources. However, little research has explored the formulation of these plans. This study utilized qualitative methods to explore the formulation of Malawi's Health Sector Strategic Plan II, including processes utilized, actors involved, important contextual factors and the use of evidence-based decision-making. Thirteen semi-structured key informant interviews with health policy actors were conducted to explore perceptions and experiences of formulating the policy. Data analysis used an inductive-deductive approach and interpretation of the data was guided by an adapted version of the Walt and Gilson Health Policy Triangle. Our results indicate that HSSP II formulation was complex and inclusive but that the Ministry of Health may have given up ownership of the formulation process to development partners to ensure their continued involvement. Disagreements between actors centered around inclusion of critical services in the Essential Health Package and selection of performance-based financing as purchasing strategy. Resource constraints and the Cashgate Scandal are critical contextual elements influencing the formulation and content of the policy. Evidence-based decision-making contributed to the plan's development despite respondents' divergent opinions regarding evidence availability, quality and the weight that evidence carried. The study raises questions regarding the roles of policy actors during health policy formulation, the inclusivity of health policy processes and their potential influence on government ownership of health policy, as well as the use of evidence in developing health sector strategic plans.

Thematic areas and complexity of integrated community case management (iCCM) design, implementation, and evaluation: protocol for a scoping review

BACKGROUND

Integrated community case management (iCCM) is a community-based child health strategy designed to reduce deaths due to pneumonia, malaria, and diarrhea in low-income countries. Due to the integrated nature of the intervention and the diversity of its stakeholders and activities, iCCM is complex and comprises many systems elements. However, the extent to which studies examine these different elements is unknown. The purpose of this scoping review is to summarize the key areas of emphasis of the iCCM literature and assess the extent to which this takes into account systems complexity.

METHODS

This study will be guided by Arksey and O'Malley's scoping review methodology. We will systematically screen MEDLINE, Web of Science, and the specialized platform Community Case Management (CCM) Central Library for published literature in English related to the design, implementation, and evaluation of iCCM. Two investigators will independently screen the full list of titles and abstracts for eligibility, followed by a full-text review of selected titles divided between investigators. Emergent themes will be categorized according to a thematic tool iteratively developed to guide the charting and analysis process. To compare the extent to which the literature assesses systems factors, we will compare our results with the iCCM Interagency Framework. We will use the Intervention Complexity Tool for Systematic Reviews (iCAT_SR) to assess how literature measures complexity. Results will be presented in narrative fashion, supplemented by interactive graphical interfaces.

DISCUSSION

The results of this scoping review will identify the priorities and deficiencies of the analysis and evaluation of iCCM programs and may illustrate the need for systems approaches. Bottom-up emergent iCCM themes can help researchers, policymakers, and implementers target and better emphasize true priorities of iCCM. Understanding how complexity is considered and examined in iCCM may result in greater attention to this critical dimension of iCCM program assessment, resulting in the design and development of more robust and sustainable iCCM programs.

A Critical Enquiry into Variability of Insecticidal Net Use in Cambodia: Implications for Assessing Appropriateness of Malaria Elimination Interventions

Distributing long-lasting insecticidal nets (LLINs) to individuals living in malaria-endemic regions is a cornerstone of global malaria control. National malaria control programs aim to achieve "universal coverage" of at-risk populations to reach LLINs' full potential to reduce malaria, progress of which is then measured by indicators constructed from standardized questionnaires. Through an exploration of variability in LLIN use in Cambodia, we argue that indicators of universal coverage of LLINs are not sufficiently commensurate with the realities they are intended to measure, limiting the suitability of the data to serve program and policy purposes in a malaria elimination era. Reflecting on the various sources of variability in LLIN use, we apply and extend the concept of "appropriateness" as a third prong to the widely used "efficacy" and "effectiveness" criteria for evaluating LLINs as a tool for malaria prevention. Describing first the different dimensions of the intervention and the sociocultural context separately, we will further show how the variability underlying both is affected and induced by inappropriate aspects of the intervention and the measurements of its impact. We consider the gap between "net use" and the numerical representations of such local net use justifies further exploration of potential strategies to improve LLIN use in subgroups where persisting malaria transmission clusters.

Integrated community case management: planning for sustainability in five African countries

Background

The World Health Organization (WHO) launched an initiative to plan for the sustainability of integrated community case management (iCCM) programmes supported by the Rapid Access Expansion (RAcE) Programme in five African countries in 2016. WHO contracted experts to facilitate sustainability planning among Ministries of Health, WHO, nongovernmental organisation grantees, and other stakeholders.

Methods

We designed an iterative and unique process for each RAcE project area which involved creating a sustainability framework to guide planning; convening meetings to identify and prioritise elements of the framework; forming technical working groups to build country ownership; and, ultimately, creating roadmaps to guide efforts to fully transfer ownership of the iCCM programmes to host countries. For this analysis, we compared priorities identified in roadmaps across RAcE project sites, examined progress against roadmaps via transition plans, and produced recommendations for short-term actions based on roadmap priorities that were unaddressed or needed further attention.

Results

This article describes the sustainability planning process, roadmap priorities, progress against roadmaps, and recommendations made for each project area. We found a few patterns among the prioritised roadmap elements. Overall, every project area identified priorities related to policy and coordination of external stakeholders including funders; supply chain management; service delivery and referral system; and communication and social mobilisation, indicating that these factors have persisted despite iCCM programme maturity, and are also of concern to new programmes. We also found that a facilitated process to identify and document programme priorities in roadmaps, along with deliberately planning for transition from an external implementer to a national system could support the sustainability of iCCM programmes by facilitating teams of stakeholders to accomplish explicit tasks related to transitioning the programme.

Conclusions

Certain common elements are of concern for sustaining iCCM programmes across countries, among them political leadership, supply chain management, data processes, human resources, and community engagement. Adapting and using a sustainability planning approach created an inclusive and comprehensive dialogue about systemic factors that influence the sustainability of iCCM services and facilitated changes to health systems in each country.

Research collaboration on community health worker programmes in low-income countries: an analysis of authorship teams and networks

BACKGROUND

Global health research partnerships, which promote the exchange of ideas, knowledge and expertise across countries, are considered key to addressing complex challenges facing health systems. Yet, many studies report inequalities in these partnerships, particularly in those between high and low-and-middle-income countries (LMICs).

OBJECTIVE

This paper examines global research collaborations on community health worker (CHW) programmes, specifically analysing the structures of authorship teams and networks in publications reporting research on CHW programmes in low-income countries (LICs).

METHODS

A sub-set of 206 indexed journal articles reporting on CHW programmes in LICs was purposefully selected from a prior review of research authorship on CHW programmes in all LMICs over a five year period (2012-2016). Data on country and primary organisational affiliation and number of publications for all individual authors, programme area (e.g. maternal child health) and total citations per paper were extracted and coded in excel spreadsheets. Data were then exported and analysed in Stata/ICV.14 and Gephi.

RESULTS

The 206 papers were authored by 1045 authors from 299 institutions, based in 43 countries. Half (50.1%) the authors came from LIC-based institutions, 43.8% from high-income country (HIC) institutions, 2.9% from middle-income country (MIC) institutions and 3.2% had different first affiliations in different publications. Authors based in the USA (302) and UK (68) accounted for just over a third (35.4%) of all authors. Partnership patterns revealed a primary mode of North-South collaboration with authors from the US, and to a lesser extent the UK, playing central bridging roles between institutions. Strong network clusters of multiple-affiliated authors were evident in research on MCH and HIV/TB aspects of CHW programmes.

CONCLUSION

Knowledge production on CHW programmes in LICs flows predominantly through a pool of connected HIC authors and North-South collaborations. There is a need for strategies harnessing more diverse, including South-South, forms of partnership.

The Making of a New Medical Specialty: A Policy Analysis of the Development of Emergency Medicine in India

BACKGROUND

Medical specialization is an understudied, yet growing aspect of health systems in low- and middleincome countries (LMICs). In India, medical specialization is incrementally, yet significantly, modifying service delivery, workforce distribution, and financing. However, scarce evidence exists in India and other LMICs regarding how medical specialties evolve and are regulated, and how these processes might impact the health system. The trajectory of emergency medicine appears to encapsulate broader trends in medical specialization in India - international exchange and engagement, the formation of professional associations, and a lengthy regulatory process with the Medical Council of India. Using an analysis of political priority setting, our objective was to explore the emergence and recognition of emergency medicine as a medical specialty in India, from the early 1990s to 2015.

METHODS

We used a qualitative case study methodology, drawing on the Shiffman and Smith framework. We conducted 87 in-depth interviews, reviewing 122 documents, and observing six meetings and conferences. We used a modified version of the 'Framework' approach in our analysis.

RESULTS

Momentum around emergency medicine as a viable solution to weak systems of emergency care in India gained traction in the 1990s. Public and private sector stakeholders, often working through transnational professional medical associations, actively pursued recognition from Medical Council of India. Despite fragmentation within the network, stakeholders shared similar beliefs regarding the need for specialty recognition, and were ultimately achieved this objective. However, fragmentation in the network made coalescing around a broader policy agenda for emergency medicine challenging, eventually contributing to an uncertain long-term pathway. Finally, due to the complexities of the regulatory system, stakeholders promoted multiple forms of training programs, expanding the workforce of emergency physicians, but with limited coordination and standardization.

CONCLUSION

The ideational centrality of postgraduate medical education, a challenging national governance system, and fragmentation within the transnational stakeholder network characterized the development of emergency medicine in India. As medical specialization continues to shape and influence health systems globally, research on the evolution of new medical specialties in LMICs can enhance our understanding of the connections between specialization, health systems, and equity.

Socialization, legitimation and the transfer of biomedical knowledge to low- and middle-income countries: analyzing the case of emergency medicine in India

BACKGROUND

Medical specialization is a key feature of biomedicine, and is a growing, but weakly understood aspect of health systems in many low- and middle-income countries (LMICs), including India. Emergency medicine is an example of a medical specialty that has been promoted in India by several high-income country stakeholders, including the Indian diaspora, through transnational and institutional partnerships. Despite the rapid evolution of emergency medicine in comparison to other specialties, this specialty has seen fragmentation in the stakeholder network and divergent training and policy objectives. Few empirical studies have examined the influence of stakeholders from high-income countries broadly, or of diasporas specifically, in transferring knowledge of medical specialization to LMICs. Using the concepts of socialization and legitimation, our goal is to examine the transfer of medical knowledge from high-income countries to LMICs through domestic, diasporic and foreign stakeholders, and the perceived impact of this knowledge on shaping health priorities in India.

METHODS

This analysis was conducted as part of a broader study on the development of emergency medicine in India. We designed a qualitative case study focused on the early 1990s until 2015, analyzing data from in-depth interviewing (n = 87), document review (n = 248), and non-participant observation of conferences and meetings (n = 6).

RESULTS

From the early 1990s, domestic stakeholders with exposure to emergency medicine in high-income countries began to establish Emergency Departments and initiate specialist training in the field. Their efforts were amplified by the active legitimation of emergency medicine by diasporic and foreign stakeholders, who formed transnational partnerships with domestic stakeholders and organized conferences, training programs and other activities to promote the field in India. However, despite a broad commitment to expanding specialist training, the network of domestic, diasporic and foreign stakeholders was highly fragmented, resulting in myriad unstandardized postgraduate training programs and duplicative policy agendas. Further, the focus in this time period was largely on training specialists, resulting in more emphasis on a medicalized, tertiary-level form of care.

CONCLUSIONS

This analysis reveals the complexities of the roles and dynamics of domestic, diasporic and foreign stakeholders in the evolution of emergency medicine in India. More research and critical analyses are required to explore the transfer of medical knowledge, such as other medical specialties, models of clinical care, and medical technologies, from high-income countries to India.

Patterns of authorship on community health workers in low-and-middle-income countries: an analysis of publications (2012-2016)

Introduction

Studies of authorship provide a barometer of local research capacity and ownership of research, considered key to defining appropriate research priorities, developing contextualised responses to health problems and ensuring that research informs policy and practice. This paper reports on an analysis of patterns of research authorship of the now substantial literature on community health workers (CHWs) in low-and-middle-income countries (LMICs) for the 5-year period: 2012–2016.

Methods

A search of five databases identified a total of 649 indexed publications reporting on CHWs in LMICs and meeting the inclusion criteria. The country, region and income classification of studies, affiliations (country, organisation) of lead (first) and last authors, proportions of all authors locally affiliated, programme area (eg, maternal child health) and funding source were extracted.

Results

The 649 papers reported experiences from 51 countries, 55% from middle-income countries (MICs) and 32% from low-income countries (LICs), with the remaining 13% multicountry studies. Overall, 47% and 54% of all the papers had a high-income country (HIC) lead and last author, respectively. Authorship followed three patterns: (1) a concentrated HIC pattern, with US-based authors numerically dominating LIC-based and multicountry studies; (2) an MIC pattern of autonomy, with a handful of countries—India, South Africa and Brazil, in particular—leading >70% of their CHW publications and (3) a pattern of unevenness among LICs in their lead authorship of publications varying from 14% (Malawi) to 54% (Uganda). Region, programme area and funding source were all associated with the distribution of authorship across country income categories.

Conclusion

The findings in this analysis mirror closely that of other authorship studies in global health. Collectively these provide a common message—that investments in global health programmes in the Millennium Development Goal era may have benefited health but not necessarily capacity for knowledge generation in LMICs.

Generating global political priority for urban health: the role of the urban health epistemic community

Over the past decade there has been much discussion of the challenges posed by rapid urbanization in the developing world; yet the health of the urban poor, and especially those residing in low- and middle-income countries, continues to receive little political priority in most developing countries and at the global level. This research applies social science scholarship and a public policy analytical framework to assess the factors that have challenged efforts to make health in urban poor settings a priority. We conducted 19 semi-structured phone interviews with key urban health proponents and experts representing agencies that shape opinions and manage resources in global health. We also conducted a literature review, which included published scholarly literature and reports from organizations involved in urban health provision and advocacy. Utilizing a process-tracing method, we triangulated among these sources of data to create a historical narrative and analyse the factors that shape the global level of attention to and resources for urban health. The urban health agenda continues to be challenged by six factors, three of which concern the political context or characteristics of the issue: long-standing competition with the dominant development agenda that is rural health oriented; limited data and measurement tools that can effectively gauge the extent of the problem; and lack of evidence on how to best to address the issue. The other three factors are directly under the control of the urban health community: the community's ineffective governance; little common understanding among its members of the problem and how to address it; and an unconvincing framing of the issue to the public. The study offers suggestions as to what advocates can do to secure greater attention and resources in order to help address the health needs of the urban poor.

Policy entrepreneurs and structural influence in integrated community case management policymaking in Burkina Faso

Policy entrepreneurs are individuals who attempt to influence the policy process and its outcomes through their opportunistic or incremental actions. Their success in the policy-making process has been associated with the convergence of four factors: behavioural traits; institutional factors; network position and political capital. Policy entrepreneurs have received little study in low- and middle-income country policy research despite observations of individualized decision-making, informal institutions and the unequal distribution and exercise of power in policymaking. This article aims to identify whether policy entrepreneurs were present in the policy process around integrated community case management (iCCM) in Burkina Faso, whether they were successful in achieving policy change, and whether success or failure can be explained using existing policy entrepreneur frameworks from high-income polities. This mixed methods policy study collected data from in-depth qualitative interviews and social network surveys of actors involved in iCCM policymaking [known locally as C-integrated management of childhood illness (IMCI)]; data were analysed based on the framework categories. Interview data pointed to one key individual who played a significant role in the inclusion of pneumonia treatment into the country’s iCCM policy, an issue that had been a point of contention between government policy elites and development partners. Social network data confirmed that this actor was strategically located in the policy network to be able to reach the most other actors and to be able to control the flow of information. Although some development partner actors were as strategically located, none had the same level of authority or trust as was imbued by being a member of the government civil service. The entrepreneur’s mid-level rank in the health ministry may have encouraged him/her to invest political capital and take risks that would not have been feasible or attractive to a more senior actor. This study highlights the convergence of factors needed to be an entrepreneur, as well as the role of development partner actors in creating a facilitating environment.

Dengue research networks: building evidence for policy and planning in Brazil

BACKGROUND

The analysis of scientific networks has been applied in health research to map and measure relationships between researchers and institutions, describing collaboration structures, individual roles, and research outputs, and helping the identification of knowledge gaps and cooperation opportunities. Driven by dengue continued expansion in Brazil, we explore the contribution, dynamics and consolidation of dengue scientific networks that could ultimately inform the prioritisation of research, financial investments and health policy.

METHOD

Social network analysis (SNA) was used to produce a 20-year (1995-2014) retrospective longitudinal evaluation of dengue research networks within Brazil and with its partners abroad, with special interest in describing institutional collaboration and their research outputs.

RESULTS

The analysis of institutional co-authorship showed a significant expansion of collaboration over the years, increased international involvement, and ensured a shift from public health research toward vector control and basic biomedical research, probably as a reflection of the expansion of transmission, high burden and increasing research funds from the Brazilian government. The analysis identified leading national organisations that maintained the research network connectivity, facilitated knowledge exchange and reduced network vulnerability.

CONCLUSIONS

SNA proved to be a valuable tool that, along with other indicators, can strengthen a knowledge platform to inform future policy, planning and funding decisions. The paper provides relevant information to policy and planning for dengue research as it reveals: (1) the effectiveness of the research network in knowledge generation, sharing and diffusion; (2) the near-absence of collaboration with the private sector; and (3) the key central organisations that can support strategic decisions on investments, development and implementation of innovations. In addition, the increase in research activities and collaboration has not yet significantly affected dengue transmission, suggesting a limited translation of research efforts into public health solutions.

The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014

BACKGROUND

There has been a substantial increase in publications and interest in community health workers (CHWs) in low- and middle-income countries (LMIC) over the last years. This paper examines the growth, geographical distribution and programmatic orientations of the indexed literature on CHWs in LMIC over a 10-year period.

METHODS

A scoping review of publications on CHWs from 2005 to 2014 was conducted. Using an inclusive list of terms, we searched seven databases (including MEDLINE, CINAHL, Cochrane) for all English-language publications on CHWs in LMIC. Two authors independently screened titles/abstracts, downloading full-text publications meeting inclusion criteria. These were coded in an Excel spreadsheet by year, type of publication (e.g. review, empirical), country, region, programmatic orientation (e.g. maternal-child health, HIV/AIDS, comprehensive) and CHW roles (e.g. prevention, treatment) and further analysed in Stata14. Drawing principally on the subset of review articles, specific roles within programme areas were identified and grouped.

FINDINGS

Six hundred seventy-eight publications from 46 countries on CHWs were inventoried over the 10-year period. There was a sevenfold increase in annual number of publications from 23 in 2005 to 156 in 2014. Half the publications were reporting on initiatives in Africa, a third from Asia and 11 % from the Americas (mostly Brazil). The largest single focus and driver of the growth in publications was on CHW roles in meeting the Millennium Development Goals of maternal, child and neonatal survival (35 % of total), followed by HIV/AIDS (16 %), reproductive health (6 %), non-communicable diseases (4 %) and mental health (4 %). Only 17 % of the publications approached CHW roles in an integrated fashion. There were also distinct regional (and sometimes country) profiles, reflecting different histories and programme traditions.

CONCLUSIONS

The growth in literature on CHWs provides empirical evidence of ever-increasing expectations for addressing health burdens through community-based action. This literature has a strong disease- or programme-specific orientation, raising important questions for the design and sustainable delivery of integrated national programmes.