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Idriss-Wheeler D, Ormel I, Assefa M, Rab F, Angelakis C, Yaya S, Sohani S. Engaging Community Health Workers (CHWs) in Africa: Lessons from the Canadian Red Cross supported programs. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002799. [PMID: 38236795 PMCID: PMC10796059 DOI: 10.1371/journal.pgph.0002799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/10/2023] [Indexed: 01/22/2024]
Abstract
Universal Health Coverage (UHC) will not be achieved if health care worker shortages, estimated to increase to 18 million by 2030, are not addressed rapidly. Community-based health systems, which pivot to effective engagement of community health workers (CHW), may have an essential role in linking communities with health care facilities and reducing unmet health services needs caused by these shortages. The Canadian Red Cross (CRC) has partnered with different National Red Cross/Red Crescent Societies and Ministries of Health in Africa in the implementation of programs where CHWs contributed to the provision of various health services. This study reports on key findings (i.e., beneficiaries reached, CHWs engaged, programs implemented, intervention outcomes) and lessons learned from CRC supported CHW programs in Africa over the last 15 years (2007-2022). Qualitative methodology was employed to conduct document analysis on 17 sets of reports from each CRC-supported community health worker project in Africa over the past 15 years. Focus was on identifying challenges, facilitators, and lessons learned. CRC supported projects have trained over 9000 CHWs, benefiting nearly 7.5 million people across Africa. Key success factors include adaptability and agility in programming and project management, and considering contextual factors (political, social, and cultural systems). Investing in essential training for CHWs, staff, and volunteers is crucial, alongside employing an evidence-based approach to inform all aspects of programming and implementation. Additionally, projects prioritizing protection, gender and inclusion (PGI) while leveraging existing community structures and partnerships important for successful implementation. Despite challenges (i.e., weak health systems, lack of political commitment, insufficient funding, inadequate training) CHWs are recognized as crucial in promoting community-based health, improving access to care, addressing disparities, and contributing to achieving (UHC). Their unique position within communities enables them to provide culturally appropriate and localized primary health care- particularly in remote, resource limited and poverty-stricken regions.
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Affiliation(s)
- Dina Idriss-Wheeler
- Faculty of Health Sciences, Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
- Health Intelligence Research and Development, Canadian Red Cross, Ottawa, Ontario, Canada
| | - Ilja Ormel
- Health Intelligence Research and Development, Canadian Red Cross, Ottawa, Ontario, Canada
| | - Mekdes Assefa
- Health Intelligence Research and Development, Canadian Red Cross, Ottawa, Ontario, Canada
| | - Faiza Rab
- Health Intelligence Research and Development, Canadian Red Cross, Ottawa, Ontario, Canada
| | - Christina Angelakis
- Health Intelligence Research and Development, Canadian Red Cross, Ottawa, Ontario, Canada
| | - Sanni Yaya
- Faculty of Social Sciences, School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
- The George Institute for Global Health, Imperial College London, London, United Kingdom
| | - Salim Sohani
- Health Intelligence Research and Development, Canadian Red Cross, Ottawa, Ontario, Canada
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Samsamshariat T, Madhivanan P, Reyes Fernández Prada A, Moya EM, Meza G, Reinders S, Blas MM. Hear my voice: understanding how community health workers in the Peruvian Amazon expanded their roles to mitigate the impact of the COVID-19 pandemic through community-based participatory research. BMJ Glob Health 2023; 8:e012727. [PMID: 37832965 PMCID: PMC10583076 DOI: 10.1136/bmjgh-2023-012727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/30/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic led to the collapse of the Peruvian health system, disrupting healthcare access for indigenous communities in the Amazon. Our study analysed how community health workers (CHWs) from indigenous communities in the Peruvian Amazon expanded their roles to mitigate the effects of the COVID-19 pandemic. METHODS Fourteen CHWs from Loreto, Peru, participated in a community-based participatory research project using Photovoice, a technique encouraging vulnerable groups to take photos and develop stories illustrating their lived experiences. Participants were recruited from Mamás del Río, a local university-based programme, through purposive sampling. CHWs were asked to photograph how the pandemic affected their lives and work. Participants met four times over 5 months to share photos and develop action items. Data were organised into key themes using thematic analysis. CHWs shared photo galleries with policy-makers in Loreto and Lima. RESULTS CHWs produced 36 photos with 33 texts highlighting their roles during COVID-19. Three core themes emerged: the (1) collapse of health infrastructure, (2) use of medicinal plants versus pharmaceuticals and (3) community adaptations and struggles. The leadership of CHWs emerged as a cross-cutting theme as CHWs supported COVID-19 efforts without government training or resources. CHWs asked policy-makers for formal integration into the health system, standardisation of training and management of community pharmacies. CONCLUSION CHWs demonstrated their leadership and expanded their roles during the pandemic with little to no training from the government. Global investment in robust CHW programmes can fortify healthcare delivery.
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Affiliation(s)
- Tina Samsamshariat
- The University of Arizona College of Medicine, Phoenix, Arizona, USA
- Department of Emergency Medicine, LAC USC Medical Center, Los Angeles, California, USA
| | - Purnima Madhivanan
- Mel & Enid Zuckerman College of Public Health, University of Arizona Medical Center - University Campus, Tucson, Arizona, USA
| | | | - Eva M Moya
- Department of Social Work, The University of Texas, El Paso, Texas, USA
| | - Graciela Meza
- Faculty of Medicine, Universidad Nacional de la Amazonia Peruana, Iquitos, Peru
| | - Stefan Reinders
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Magaly M Blas
- Epidemiology, STD, HIV Research Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
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Katzen LS, Skeen S, Dippenaar E, Laurenzi C, Notholi V, le Roux K, le Roux I, WaluWalu N, Mbewu N, Borus MJR, Tomlinson M. Community Health Workers' experiences of a package providing increased support and supervision - a qualitative study of a home visiting model in rural South Africa. RESEARCH SQUARE 2023:rs.3.rs-3333610. [PMID: 37841874 PMCID: PMC10571624 DOI: 10.21203/rs.3.rs-3333610/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Deploying Community Health Workers is a crucial strategy to improve health at a community level in low and middle income countries. While there is substantial evidence for CHW effectiveness, there is a need for more research on the mechanisms through which these programs work. Understanding CHWs experiences of how programmes function is important. This article examines CHW's experiences of three key programmatic domains; training, logistical support and supervision. Data were gathered using a qualitative study embedded within a cluster randomized controlled trial of an enhanced supervision package delivered to government-employed CHWs in the rural Eastern Cape, South Africa. We interviewed CHWs (n = 16) and two supervisors. Three overarching areas and five sub-themes emerged from our interviews. CHW knowledge and confidence increased through additional training, that CHW motivation and community acceptance improved because of added logistical support, and that CHW supervision led to improved sense of accountability, feelings of respect, and sense of being supported. Our findings highlight the importance of a functional support system within which CHWs can operate, in a context where most CHWs operate in isolation and without support. CHWs receiving supportive supervision reported positive impacts on their motivation and ability to carry out their work effectively.
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Méllo LMBDDE, Santos RCD, Albuquerque PCD. Community Health Workers: what do international studies tell us? CIENCIA & SAUDE COLETIVA 2023. [DOI: 10.1590/1413-81232023282.12222022en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Abstract This is a narrative review whose objective is to understand the state of the art of the literature on Community Health Worker (CHW) programs worldwide, identifying their nomenclatures, practices, training, and working conditions. The major concentration of CHW programs can still be found in low- and middle-income countries in Africa (18), Asia (12), and Latin America (05), with a few experiences in high-income countries in North America (02) and Oceania (01). In total, 38 experiences were cataloged, and the practices of care, surveillance, education, health communication, administrative practices, intersectoral articulation, and social mobilization were described. The levels and duration of CHW training were characterized, as were the different working conditions in each country. Much of the work is precarious, often voluntary and carried out by women. This review provided a comparative overview that can contribute to enrich the view of managers and decision-makers in contexts of the implementation, expansion, and reconfiguration of such programs.
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Méllo LMBDDE, Santos RCD, Albuquerque PCD. Community Health Workers: what do international studies tell us? CIENCIA & SAUDE COLETIVA 2023; 28:501-520. [PMID: 36651403 DOI: 10.1590/1413-81232023282.12222022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/12/2022] [Indexed: 01/18/2023] Open
Abstract
This is a narrative review whose objective is to understand the state of the art of the literature on Community Health Worker (CHW) programs worldwide, identifying their nomenclatures, practices, training, and working conditions. The major concentration of CHW programs can still be found in low- and middle-income countries in Africa (18), Asia (12), and Latin America (05), with a few experiences in high-income countries in North America (02) and Oceania (01). In total, 38 experiences were cataloged, and the practices of care, surveillance, education, health communication, administrative practices, intersectoral articulation, and social mobilization were described. The levels and duration of CHW training were characterized, as were the different working conditions in each country. Much of the work is precarious, often voluntary and carried out by women. This review provided a comparative overview that can contribute to enrich the view of managers and decision-makers in contexts of the implementation, expansion, and reconfiguration of such programs.
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Masquillier C, Cosaert T. Community health workers: A sustainable health system innovation or just an emergency response? Front Public Health 2022; 10:1040539. [PMID: 36561858 PMCID: PMC9763587 DOI: 10.3389/fpubh.2022.1040539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- Caroline Masquillier
- Department of Sociology, University of Antwerp, Antwerp, Belgium,Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium,*Correspondence: Caroline Masquillier
| | - Theo Cosaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Satav AR, Satav KA, Bharadwaj A, Pendharkar J, Dani V, Ughade S, Raje D, Simões EAF. Effect of home-based childcare on childhood mortality in rural Maharashtra, India: a cluster randomised controlled trial. BMJ Glob Health 2022; 7:bmjgh-2022-008909. [PMID: 35851283 PMCID: PMC9297228 DOI: 10.1136/bmjgh-2022-008909] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/18/2022] [Indexed: 11/12/2022] Open
Abstract
Background Melghat, an impoverished rural area in Maharashtra state, India; has scarce hospital services and low health-seeking behaviour. At baseline (2004) the under-five mortality rate (U5MR) (number of deaths in children aged 0–5 years/1000 live births) was 147.21 and infant mortality rate (IMR) (number of deaths of infants aged under 1 year/1000 live births) was 106.6 per 1000 live births. We aimed at reducing mortality rates through home-based child care (HBCC) using village health workers (VHWs). Methods A cluster-randomised control trial was conducted in 34 randomly assigned clusters/villages of Melghat, Maharashtra state, between 2004 and 2009. Participants included all under-five children and their parents. Interventions delivered through VHWs were patient–public involvement, newborn care, disease management and behaviour change communications. Primary outcome indicators were U5MR and IMR. Secondary outcome indicators were neonatal mortality rate (NMR) (number of neonatal deaths aged 0–28 days/1000 live births) and perinatal mortality rate (PMR) (number of stillbirths and early neonatal deaths/1000 total births). Analysis was by intention-to-treat at the individual level. This trial was extended to a service phase (2010–2015) in both arms and a government replication phase (2016–2019) only for the intervention clusters/areas (IA). Findings There were 18 control areas/clusters (CA) allocated and analysed with 4426 individuals, and 16 of 18 allocated IA, analysed with 3230 individuals. The IMR and U5MR in IA were reduced from 106.60 and 147.21 to 32.75 and 50.38 (reduction by 69.28% and 65.78%, respectively) compared with increases in CA from 67.67 and 105.3 to 86.83 and 122.8, respectively, from baseline to end of intervention. NMR and PMR in IA showed reductions from 50.76 to 22.67 (by 55.34%) and from 75.06 to 24.94 (by 66.77%) respectively. These gains extended to villages in the service and replication phases. Interpretation This socio-culturally contextualised model for HBCC through VHWs backed up with institutional support is effective for significant reduction of U5MR, IMR and NMR in impoverished rural areas. This reduction was maintained in the study area during the service phase, indicating feasibility of implementation in large-scale public health programmes. Replicability of the model was demonstrated by a linear decline in all the mortality rates in 20 new villages during the government phase. Trial registration number NCT02473796.
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Affiliation(s)
- Ashish Rambhau Satav
- Community Medicine, MAHAN Trust, Dharni, Amaravati, Maharashtra, India .,Medicine, Mahatma Gandhi Tribal Hospital, Amaravati, Maharashtra, India
| | | | | | | | | | - Suresh Ughade
- Preventive and Social Medicine, Government Medical College and Hospital Nagpur, Nagpur, Maharashtra, India
| | | | - Eric A F Simões
- Department of Paediatrics, University of Colorado School of Medicine and Professor of Epidemiology, Aurora, Colorado, USA
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Al-Jallad N, Ly-Mapes O, Hao P, Ruan J, Ramesh A, Luo J, Wu TT, Dye T, Rashwan N, Ren J, Jang H, Mendez L, Alomeir N, Bullock S, Fiscella K, Xiao J. Artificial intelligence-powered smartphone application, AICaries, improves at-home dental caries screening in children: Moderated and unmoderated usability test. PLOS DIGITAL HEALTH 2022; 1:e0000046. [PMID: 36381137 PMCID: PMC9645586 DOI: 10.1371/journal.pdig.0000046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/15/2022] [Indexed: 06/16/2023]
Abstract
Early Childhood Caries (ECC) is the most common childhood disease worldwide and a health disparity among underserved children. ECC is preventable and reversible if detected early. However, many children from low-income families encounter barriers to dental care. An at-home caries detection technology could potentially improve access to dental care regardless of patients' economic status and address the overwhelming prevalence of ECC. Our team has developed a smartphone application (app), AICaries, that uses artificial intelligence (AI)-powered technology to detect caries using children's teeth photos. We used mixed methods to assess the acceptance, usability, and feasibility of the AICaries app among underserved parent-child dyads. We conducted moderated usability testing (Step 1) with ten parent-child dyads using "Think-aloud" methods to assess the flow and functionality of the app and analyze the data to refine the app and procedures. Next, we conducted unmoderated field testing (Step 2) with 32 parent-child dyads to test the app within their natural environment (home) over two weeks. We administered the System Usability Scale (SUS) and conducted semi-structured individual interviews with parents and conducted thematic analyses. AICaries app received a 78.4 SUS score from the participants, indicating an excellent acceptance. Notably, the majority (78.5%) of parent-taken photos of children's teeth were satisfactory in quality for detection of caries using the AI app. Parents suggested using community health workers to provide training to parents needing assistance in taking high quality photos of their young child's teeth. Perceived benefits from using the AICaries app include convenient at-home caries screening, informative on caries risk and education, and engaging family members. Data from this study support future clinical trial that evaluates the real-world impact of using this innovative smartphone app on early detection and prevention of ECC among low-income children.
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Affiliation(s)
- Nisreen Al-Jallad
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Oriana Ly-Mapes
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Peirong Hao
- Department of Computer Science, University of Rochester, United States of America
| | - Jinlong Ruan
- Department of Computer Science, University of Rochester, United States of America
| | - Ashwin Ramesh
- Department of Computer Science, University of Rochester, United States of America
| | - Jiebo Luo
- Department of Computer Science, University of Rochester, United States of America
| | - Tong Tong Wu
- Department of Biostatistics and computational biology, University of Rochester Medical Center, Rochester, United States of America
| | - Timothy Dye
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, United States of America
| | - Noha Rashwan
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Johana Ren
- University of Rochester, United States of America
| | - Hoonji Jang
- Temple University School of Dentistry, Pennsylvania, United States of America
| | - Luis Mendez
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Nora Alomeir
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, United States of America
| | | | - Kevin Fiscella
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Jin Xiao
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, United States of America
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Kok M, Crigler L, Musoke D, Ballard M, Hodgins S, Perry HB. Community health workers at the dawn of a new era: 10. Programme performance and its assessment. Health Res Policy Syst 2021; 19:108. [PMID: 34641901 PMCID: PMC8506096 DOI: 10.1186/s12961-021-00758-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | | | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Madeleine Ballard
- Community Health Impact Coalition, New York, NY, USA
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steve Hodgins
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Perry HB, Chowdhury M, Were M, LeBan K, Crigler L, Lewin S, Musoke D, Kok M, Scott K, Ballard M, Hodgins S. Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All". Health Res Policy Syst 2021; 19:111. [PMID: 34641891 PMCID: PMC8506098 DOI: 10.1186/s12961-021-00755-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | | | | | | | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway and Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Independent Consultant, Toronto, Canada
| | - Madeleine Ballard
- Community Health Impact Coalition, New York, NY, USA
- Department of Health System Design and Global Health, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Steve Hodgins
- School of Public Health, University of Alberta, Edmonton, AB, Canada
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11
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Hodgins S, Kok M, Musoke D, Lewin S, Crigler L, LeBan K, Perry HB. Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes. Health Res Policy Syst 2021; 19:109. [PMID: 34641886 PMCID: PMC8506102 DOI: 10.1186/s12961-021-00752-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Stephen Hodgins
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Simon Lewin
- Norwegian Institute of Public Health, Oslo Town, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Lauren Crigler
- Crigler Consulting, LLC, Hillsborough, NC, United States of America
| | - Karen LeBan
- Independent Consultant, Washington, DC, United States of America
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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12
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Schleiff MJ, Aitken I, Alam MA, Damtew ZA, Perry HB. Community health workers at the dawn of a new era: 6. Recruitment, training, and continuing education. Health Res Policy Syst 2021; 19:113. [PMID: 34641898 PMCID: PMC8506097 DOI: 10.1186/s12961-021-00757-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Meike J. Schleiff
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Iain Aitken
- Management Sciences for Health, Ministry of Public Health, Kabul, Afghanistan
| | | | | | - Henry B. Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Lewin S, Lehmann U, Perry HB. Community health workers at the dawn of a new era: 3. Programme governance. Health Res Policy Syst 2021; 19:129. [PMID: 34641914 PMCID: PMC8506073 DOI: 10.1186/s12961-021-00749-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) can play a critical role in primary healthcare and are seen widely as important to achieving the health-related Sustainable Development Goals (SDGs). The COVID-19 pandemic has emphasized the key role of CHWs. Improving how CHW programmes are governed is increasingly recognized as important for achieving universal access to healthcare and other health-related goals. This paper, the third in a series on "Community Health Workers at the Dawn of a New Era", aims to raise critical questions that decision-makers need to consider for governing CHW programmes, illustrate the options for governance using examples of national CHW programmes, and set out a research agenda for understanding how CHW programmes are governed and how this can be improved. METHODS We draw from a review of the literature as well as from the knowledge and experience of those involved in the planning and management of CHW programmes. RESULTS Governing comprises the processes and structures through which individuals, groups, programmes, and organizations exercise rights, resolve differences, and express interests. Because CHW programmes are located between the formal health system and communities, and because they involve a wide range of stakeholders, their governance is complex. In addition, these programmes frequently fall outside of the governance structures of the formal health system or are poorly integrated with it, making governing these programmes more challenging. We discuss the following important questions that decision-makers need to consider in relation to governing CHW programmes: (1) How and where within political structures are policies made for CHW programmes? (2) Who implements decisions regarding CHW programmes and at what levels of government? (3) What laws and regulations are needed to support the programme? (4) How should the programme be adapted across different settings or groups within the country or region? CONCLUSION The most appropriate and acceptable models for governing CHW programmes depend on communities, on local health systems, and on the political system in which the programme is located. Stakeholders in each setting need to consider what systems are currently in place and how they might be adapted to local needs and systems.
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Affiliation(s)
- Simon Lewin
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Uta Lehmann
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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Abstract
BACKGROUND There is now rapidly growing global awareness of the potential of large-scale community health worker (CHW) programmes not only for improving population health but, even more importantly, for accelerating the achievement of universal health coverage and eliminating readily preventable child and maternal deaths. However, these programmes face many challenges that must be overcome in order for them to reach their full potential. FINDINGS This editorial introduces a series of 11 articles that provide an overview highlighting a broad range of issues facing large-scale CHW programmes. The series addresses many of them: planning, coordination and partnerships; governance, financing, roles and tasks, training, supervision, incentives and remuneration; relationships with the health system and communities; and programme performance and its assessment. Above all, CHW programmes need stronger political and financial support, and this can occur only if the potential of these programmes is more broadly recognized. The authors of the papers in this series believe that these challenges can and will be overcome-but not overnight. For this reason, the series bears the title "Community Health Workers at the Dawn of a New Era". The scientific evidence regarding the ability of CHWs to improve population health is incontrovertible, and the favourable experience with these programmes at scale when they are properly designed, implemented, and supported is compelling. CHW programmes were once seen as a second-class solution to a temporary problem, meaning that once the burden of disease from maternal and child conditions and from communicable diseases in low-income countries had been appropriately reduced, there would be no further need for CHWs. That perspective no longer holds. CHW programmes are now seen as an essential component of a high-performing healthcare system even in developed countries. Their use is growing rapidly in the United States, for instance. And CHWs are also now recognized as having a critically important role in the control of noncommunicable diseases as well as in the response to pandemics of today and tomorrow in all low-, middle-, and high-income countries throughout the world. CONCLUSION The promise of CHW programmes is too great not to provide them with the support they need to achieve their full potential. This series helps to point the way for how this support can be provided.
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Affiliation(s)
- Joseph M. Zulu
- Health Promotion and Education Department, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Henry B. Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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