A process evaluation of performance-based incentives for village health workers in Kisoro district, Uganda

Community Health Workers' Targeting of Women For Health and Nutrition Home Visits in Rural Tanzania: A Mixed-Methods Study

Background

Community health workers (CHWs) are utilized in many health systems to provide education and messaging to families in their catchment areas. However, CHWs responsible for large geographic areas often must make important decisions about whom to visit. Factors that influence these decisions are understudied.

Objectives

This study assessed coverage and targeting for home visits by CHWs within a large social and behavioral change health program in rural Tanzania.

Methods

This implementation research was a cross-sectional, mixed-methods study. Data collection included a census with households and surveys with females, surveys with CHWs, and interviews with CHWs. Survey data also included the collection of household location data for females and CHWs. Quantitative data were analyzed using linear probability models, and qualitative data were analyzed using inductive thematic analysis.

Results

Only 13% of eligible households in our study sites reported receiving a home visit from a CHW. Although CHWs were more likely to reach households with infants, other program priority populations, such as poor and food insecure households, were frequently missed. Global positioning system data showed that distance was 1 of the greatest barriers for CHWs in providing home visits. Qualitative data indicated that although CHWs were motivated and engaged to improve maternal and child health in their communities, they faced challenges in visiting households that were further away or lacked economic resources to improve their health behaviors. CHWs also found it difficult to provide health education during home visits to mothers with no formal schooling.

Conclusions

Programs relying on community volunteers need to set realistic workloads, especially when volunteer CHWs also work full-time in their primary occupations. Implementation could also be strengthened by providing extra support for CHWs so that they can effectively provide services to community members who are more difficult to visit but may be the most in need.

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.

Effectiveness of four interventions in improving community health workers' performance in western Kenya: a quasi-experimental difference-in-differences study using a longitudinal data

Background:

Community health workers (CHWs) are up-front health workers delivering the most effective life-saving health services to communities. They are the key driver to achieve Universal Health Coverage. However, maintaining CHWs’ performance is one of the challenges in sustaining their effectiveness. This article assessed the effectiveness of the four interventions and their combinations on the CHWs’ performance in terms of health knowledge, job satisfaction, and household coverage.

Methods:

We used the longitudinal survey data collected in western Kenya. Our study participants were the representative of all CHWs working in the four districts, Kenya. The four types of interventions were composed of a basic core intervention (i.e., refresher training with/without defaulter tracing) and three supplementary interventions (i.e., provision of a bicycle, frequent supportive supervision, and financial incentives). We performed the three fixed-effect models to assess the effectiveness of the four interventions and their combinations on the three performance indicators.

Results:

Three single and combination interventions significantly increased CHWs’ health knowledge: refresher training only [Coef.: 48.43, 95% CI: 42.09–54.76, P < 0.001]; refresher training plus defaulter-tracing [Coef.: 38.80, 95% CI: 32.71–44.90, P < 0.001]; combination of refresher training plus defaulter-tracing and frequent supervision [Coef.: 17.02, 95% CI: 7.90–26.15, P < 0.001]. Financial support was the only intervention that significantly increased job satisfaction among CHWs [Coef.: 4.97, 95% CI: 0.20–9.75, P = 0.041]. There was no single intervention that significantly increased household coverage. Yet, the combinations of the interventions significantly increased household coverage.

Conclusions:

There was no single intervention to improve all the aspects of CHWs’ performance. The refresher training significantly improved their health knowledge, while financial incentive enhanced the level of their job satisfaction. The combinations of regular refresher training and other intervention(s) are the recommended as the effective interventions in improving and further sustaining CHWs’ performance.

Family health sheets: a vital instrument for village health workers providing comprehensive healthcare

INTRODUCTION

Community Health Worker (CHW) programs have long been used to provide acute care for children and women in healthcare shortage areas, but their provision of comprehensive longitudinal care for chronic problems is rare. The Village Health Worker (VHW) program, initiated in 2007, is an example of a long standing "horizontal" CHW program in rural Southwestern Uganda that has delivered village-level care for chronic disease based on a biannual village health census that identifies individual and family health risks. To facilitate continuity of care for problems identified, health census data were electronically transformed into family-specific Family Health Sheets (FHS) in 2016 which summarize the pertinent demographic and health data for each family, as well as health topics the family would like to learn more about. The FHS, evaluated and discussed here, serves as an epidemiologically-informed "bedside" tool to help VHWs provide longitudinal care in their villages.

METHODS

48 VHWs in the program completed a survey on the utility of the FHS and 24 VHWs participated in small discussion groups. Responses were analyzed using both quantitative and standard conceptual content analysis models RESULTS: 46 out of 48 VHWs reported that the FHS made them a "much better VHW." In addition to helping target interventions in child health, women's health, and sanitation, the FHS assisted follow-up of non-communicable diseases in the community. In discussion groups, VHWs reported that the FHS helped them understand risks for future disease, facilitated earning stipends, and increased credibility and trust in the community. Limitations cited were the infrequent updates of the FHS, only biannually with the census, and the lack of cross-reference capability by health problem.

DISCUSSION

The FHS supports VHWs in providing longitudinal and comprehensive healthcare of chronic diseases in their villages. Limitations, potential solutions, and future directions are discussed.

Community Perceptions of Village Health Workers in Kisoro, Uganda

Background:

Village health workers (VHWs) can serve as a valuable resource to address public health needs in resource-limited settings such as Uganda. However, the successful implementation of VHW programs can be limited by poor acceptability among community members. Kisoro District Hospital (KDH) in Kisoro District, Uganda operates a VHW program and, at the time of the study, was expanding its services to 11 additional villages.

Objective:

The objective of this study was to evaluate community perceptions of VHWs in villages of Kisoro District with no prior exposure to the KDH VHW program in order to improve community acceptance when expanding the program to additional villages.

Methods:

We administered surveys to 658 community members from 11 villages to evaluate their perceptions of VHWs prior to receiving VHW services. Additionally, we conducted focus group discussions among 97 participants to explore perceptions of VHWs in further depth.

Findings:

Community members were generally accepting of VHWs. They preferred that VHWs provide both curative and preventive services across a broad range of health domains as opposed to a single disease. Expectations of the responsibilities of a VHW were influenced by agricultural occupational and household responsibilities, particularly for women. Participants expressed a preference to be actively involved in the selection and oversight of VHWs and that VHWs receive compensation.

Conclusions:

1) Community members’ expectations of VHWs are shaped by environmental, cultural, and social factors. 2) Active community engagement in the VHW program is key. 3) Aligning a VHW program with community perceptions may improve acceptance, in turn influencing effectiveness and sustainability. These findings were used to expand the KDH VHW Program into the participating villages in a manner consistent with community preferences. Our findings may provide guidance on enhancing the uptake of community-based VHW programs for VHW stakeholders and policymakers in other settings.

A realist review to assess for whom, under what conditions and how pay for performance programmes work in low- and middle-income countries

Pay for performance (P4P) programmes are popular health system-focused interventions aiming to improve health outcomes in low-and middle-income countries (LMICs). This realist review aims to understand how, why and under what circumstance P4P works in LMICs.We systematically searched peer-reviewed and grey literature databases, and examined the mechanisms underpinning P4P effects on: utilisation of services, patient satisfaction, provider productivity and broader health system, and contextual factors moderating these. This evidence was then used to construct a causal loop diagram.We included 112 records (19 grey literature; 93 peer-reviewed articles) assessing P4P schemes in 36 countries. Although we found mixed evidence of P4P's effects on identified outcomes, common pathways to improved outcomes include: community outreach; adherence to clinical guidelines, patient-provider interactions, patient trust, facility improvements, access to drugs and equipment, facility autonomy, and lower user fees. Contextual factors shaping the system response to P4P include: degree of facility autonomy, efficiency of banking, role of user charges in financing public services; staffing levels; staff training and motivation, quality of facility infrastructure and community social norms. Programme design features supporting or impeding health system effects of P4P included: scope of incentivised indicators, fairness and reach of incentives, timely payments and a supportive, robust verification system that does not overburden staff. Facility bonuses are a key element of P4P, but rely on provider autonomy for maximum effect. If health system inputs are vastly underperforming pre-P4P, they are unlikely to improve only due to P4P. This is the first realist review describing how and why P4P initiatives work (or fail) in different LMIC contexts by exploring the underlying mechanisms and contextual and programme design moderators. Future studies should systematically examine health system pathways to outcomes for P4P and other health system strengthening initiatives, and offer more understanding of how programme design shapes mechanisms and effects.

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

BACKGROUND

Pay for performance (P4P) schemes provide financial incentives to health workers or facilities based on the achievement of pre-specified performance targets and have been widely implemented in health systems across low and middle-income countries (LMICs). The growing evidence base on P4P highlights that (i) there is substantial variation in the effect of P4P schemes on outcomes and (ii) there appears to be heterogeneity in incentive design. Even though scheme design is likely a key determinant of scheme effectiveness, we currently lack systematic evidence on how P4P schemes are designed in LMICs.

METHODS

We develop a typology to classify the design of P4P schemes in LMICs, which highlights different design features that are a priori likely to affect the behaviour of incentivised actors. We then use results from a systematic literature review to classify and describe the design of P4P schemes that have been evaluated in LMICs. To capture academic publications, Medline, Embase, and EconLit databases were searched. To include relevant grey literature, Google Scholar, Emerald Insight, and websites of the World Bank, WHO, Cordaid, Norad, DfID, USAID and PEPFAR were searched.

RESULTS

We identify 41 different P4P schemes implemented in 29 LMICs. We find that there is substantial heterogeneity in the design of P4P schemes in LMICs and pinpoint precisely how scheme design varies across settings. Our results also highlight that incentive design is not adequately being reported on in the literature - with many studies failing to report key design features.

CONCLUSIONS

We encourage authors to make a greater effort to report information on P4P scheme design in the future and suggest using the typology laid out in this paper as a starting point.

A Performance-Based Incentives System for Village Health Workers in Kisoro, Uganda

BACKGROUND

Village health worker (VHW) programs in Uganda have achieved limited success, due in part to a reliance on volunteerism and a lack of standardized incentive mechanisms. However, how to best incentivize VHWs remains unclear. Doctors for Global Health developed a performance-based incentives (PBI) system to pay its VHWs in Kisoro, Uganda, based on performance of tasks or achievement of targets.

OBJECTIVES

1. To describe the development of a PBI system used to compensate VHWs. 2. To report cost and health services delivery outcomes under a PBI system. 3. To provide qualitative analysis on the successes and challenges of PBI.

METHODS

Internal organization records from May 2016 to April 2017 were retrospectively reviewed. The results of descriptive and analytic statistics were reported. Qualitative analysis was performed by the authors.

FINDINGS

In one year, 42 VHWs performed 23,703 remunerable health actions, such as providing care of minor ailments and chronic disease. VHWs earned on average $237. The total cost to maintain the program was $29,844, or $0.72 per villager. There was 0% VHW attrition. Strengths of PBI included flexibility, accountability, higher VHW earnings, and improved monitoring and evaluation.

CONCLUSIONS

PBI is a feasible and sustainable model of compensating VHWs. At a time where VHW programs are sorely needed to address limitations in healthcare resources, yet are facing challenges with workforce compensation, PBI may serve as a model for others in Uganda and around the world.

How do gender relations affect the working lives of close to community health service providers? Empirical research, a review and conceptual framework

Close-to-community (CTC) providers have been identified as a key cadre to progress universal health coverage and address inequities in health service provision due to their embedded position within communities. CTC providers both work within, and are subject to, the gender norms at community level but may also have the potential to alter them. This paper synthesises current evidence on gender and CTC providers and the services they deliver. This study uses a two-stage exploratory approach drawing upon qualitative research from the six countries (Bangladesh, Indonesia, Ethiopia, Kenya, Malawi, Mozambique) that were part of the REACHOUT consortium. This research took place from 2013 to 2014. This was followed by systematic review that took place from January-September 2017, using critical interpretive synthesis methodology. This review included 58 papers from the literature. The resulting findings from both stages informed the development of a conceptual framework. We present the holistic conceptual framework to show how gender roles and relations shape CTC provider experience at the individual, community, and health system levels. The evidence presented highlights the importance of safety and mobility at the community level. At the individual level, influence of family and intra-household dynamics are of importance. Important at the health systems level, are career progression and remuneration. We present suggestions for how the role of a CTC provider can, with the right support, be an empowering experience. Key priorities for policymakers to promote gender equity in this cadre include: safety and well-being, remuneration, and career progression opportunities. Gender roles and relations shape CTC provider experiences across multiple levels of the health system. To strengthen the equity and efficiency of CTC programmes gender dynamics should be considered by policymakers and implementers during both the conceptualisation and implementation of CTC programmes.

Supporting and retaining Village Health Teams: an assessment of a community health worker program in two Ugandan districts

BACKGROUND

Uganda's national community health worker program involves volunteer Village Health Teams (VHTs) delivering basic health services and education. Evidence demonstrates their positive impact on health outcomes, particularly for Ugandans who would otherwise lack access to health services. Despite their impact, VHTs are not optimally supported and attrition is a growing problem. In this study, we examined the support needs and existing challenges of VHTs in two Ugandan districts and evaluated specific factors associated with long-term retention. We report on findings from a standardized survey of VHTs and exploratory interviews with key stakeholders and draw conclusions that inform efforts to strengthen and sustain community health care delivery in Uganda.

METHODS

A mixed-methods approach was employed through a survey of 134 individual VHT members and semi-structured interviews with six key stakeholders. Descriptive and bivariate regression analysis of quantitative survey data was performed along with thematic analysis of qualitative data from surveys and interviews. In the regression analysis, the dependent variable is 10-year anticipated longevity among VHTs, which asked respondents if they anticipate continuing to volunteer as VHTs for at least 10 more years if their current situation remains unchanged.

RESULTS

VHTs desire additional support primarily in the forms of money (e.g. transportation allowance) and material supplies (e.g. rubber boots). VHTs commonly report difficult working conditions and describe a lack of respect from their communities and other health workers. If their current situation remains unchanged, 57% of VHTs anticipate remaining in their posts for at least 10 years. Anticipated 10-year longevity was positively associated with stronger partnerships with local health center staff and greater ease in home visiting.

CONCLUSIONS

Supporting and retaining Uganda's VHTs would be enhanced by building stronger partnerships between VHTs and other health workers and regularly providing supplies and transportation allowances. Pursuing such measures would likely improve equity in access to healthcare for all Ugandans.

Linking communities to formal health care providers through village health teams in rural Uganda: lessons from linking social capital

BACKGROUND

Community-based programmes, particularly community health workers (CHWs), have been portrayed as a cost-effective alternative to the shortage of health workers in low-income countries. Usually, literature emphasises how easily CHWs link and connect communities to formal health care services. There is little evidence in Uganda to support or dispute such claims. Drawing from linking social capital framework, this paper examines the claim that village health teams (VHTs), as an example of CHWs, link and connect communities with formal health care services.

METHODS

Data were collected through ethnographic fieldwork undertaken as part of a larger research program in Luwero District, Uganda, between 2012 and 2014. The main methods of data collection were participant observation in events organised by VHTs. In addition, a total of 91 in-depth interviews and 42 focus group discussions (FGD) were conducted with adult community members as part of the larger project. After preliminary analysis of the data, we conducted an additional six in-depth interviews and three FGD with VHTs and four FGD with community members on the role of VHTs. Key informant interviews were conducted with local government staff, health workers, local leaders, and NGO staff with health programs in Luwero. Thematic analysis was used during data analysis.

RESULTS

The ability of VHTs to link communities with formal health care was affected by the stakeholders' perception of their roles. Community members perceive VHTs as working for and under instructions of "others", which makes them powerless in the formal health care system. One of the challenges associated with VHTs' linking roles is support from the government and formal health care providers. Formal health care providers perceived VHTs as interested in special recognition for their services yet they are not "experts". For some health workers, the introduction of VHTs is seen as a ploy by the government to control people and hide its inability to provide health services. Having received training and initial support from an NGO, VHTs suffered transition failure from NGO to the formal public health care structure. As a result, VHTs are entangled in power relations that affect their role of linking community members with formal health care services. We also found that factors such as lack of money for treatment, poor transport networks, the attitudes of health workers and the existence of multiple health care systems, all factors that hinder access to formal health care, cannot be addressed by the VHTs.

CONCLUSIONS

As linking social capital framework shows, for VHTs to effectively act as links between the community and formal health care and harness the resources that exist in institutions beyond the community, it is important to take into account the power relationships embedded in vertical relationships and forge a partnership between public health providers and the communities they serve. This will ensure strengthened partnerships and the improved capacity of local people to leverage resources embedded in vertical power networks.

Active Tuberculosis Case Finding in Port-au-Prince, Haiti: Experiences, Results, and Implications for Tuberculosis Control Programs

Background. Haiti has the highest tuberculosis (TB) prevalence in the Americas with 254 cases per 100,000 persons. Case detection relies on passive detection and TB services in many regions suffer from poor diagnostic and clinical resources. Methods. Mache Chache ("Go and Seek") was a TB REACH Wave 3 funded TB case finding project in Port-au-Prince between July 2013 and September 2014, targeting four intervention areas with insufficient TB diagnostic performance. Results. Based on a verbal symptom screen emphasizing the presence of cough, the project identified 11,150 (11.75%) of all screened persons as TB subjects and 2.67% as smear-positive (SS+) TB cases. Enhanced case finding and strengthening of laboratory services led to a 59% increase in bacteriologically confirmed cases in the evaluation population. In addition, smear grades dropped significantly, suggesting earlier case detection. Xpert® MTB/RIF was successfully introduced and improved TB diagnosis in HIV-infected, smear-negative clinic patients, but not in HIV-negative, smear-negative TB suspects in the community. However, the number needed to screen for one additional SS+ case varied widely between clinic and community screening activities. Conclusion. Enhanced and active TB case finding in Haiti can improve TB diagnosis and care. However, screening algorithms have to be tailored to individual settings, necessitating long-term commitment.

Effects of three interventions and determinants of full vaccination among children aged 12-59 months in Nyanza province, Kenya

OBJECTIVES

The purpose of this study is to describe the effects of the three main interventions and identify the individual and community determinants of full vaccination coverage among children aged 12-59 months in Nyanza province, Kenya.

STUDY DESIGN

Cross-sectional study.

METHODS

We utilized three datasets. One is the Nyanza Province County-based Multiple Indicator Cluster Survey 2011. The other two datasets are the lists of community units and health facilities in Nyanza Province, Kenya. A three-level multilevel logistic regression analysis was performed.

RESULTS

In the final model, the highest wealth quintile (AOR: 2.49; 95% CI: 1.333-4.642; P = 0.004), the community with high coverage of media devices (AOR: 1.50; 95% CI: 1.029-2.198; P = 0.035), the participation of mass immunization campaigns (AOR: 1.63; 95% CI: 1.153-2.303; P = 0.006) were the significant determinants of complete child vaccination.

CONCLUSIONS

In conclusion, further implementation of mass immunization campaigns is the recommended intervention to increase the uptake of required vaccinations among children. In addition, further attention to the poor and the low coverage of media devices is necessary, since they are the most vulnerable population in terms of accessibility of vaccination services. Implementation community based activity, such as community health workers, would have a positive impact on vaccination coverage, if their performance is continuously high.

Toward universal coverage in Afghanistan: A multi-stakeholder assessment of capacity investments in the community health worker system

Global efforts to scale-up the community health workforce have accelerated as a result of the growing evidence of their effectiveness to enhance coverage and health outcomes. Reconstruction efforts in Afghanistan integrated capacity investments for community based service delivery, including the deployment of over 28,000 community health workers (CHWs) to ensure access to basic preventive and curative services. The study aimed to conduct capacity assessments of the CHW system and determine stakeholder perspectives of CHW performance. Structured interviews were conducted on a national sample from 33 provinces and included supervisors, facility providers, patients, and CHWs. Formative assessments were also conducted with national policymakers, community members and health councils in two provinces. Results indicate that more than 70% of the NGO's provide comprehensive training for CHWs, 95% CHWs reported regular supervision, and more than 60% of the health posts had adequate infrastructure and essential commodities. Innovative strategies of paired male and female CHWs, institution of a special cadre of community health supervisors, and community health councils were introduced as systems strengthening mechanisms. Reported barriers included unrealistic and expanding task expectations (14%), unsatisfactory compensation mechanisms (75%), inadequate transport (69%), and lack of commodities (40%). Formative assessments evidenced that CHWs were highly valued as they provided equitable, accessible and affordable 24-h care. Their loyalty, dedication and the ability for women to access care without male family escorts was appreciated by communities. With rising concerns of workforce deficits, insecurity and budget constraints, the health system must enhance the capacity of these frontline workers to improve the continuum of care. The study provides critical insight into the strengths and constraints of Afghanistan's CHW system, warranting further efforts to contextualize service delivery and mechanisms for their support and motivation.