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Basu S, Patel SY, Robinson K, Baum A. Financing Thresholds for Sustainability of Community Health Worker Programs for Patients Receiving Medicaid Across the United States. J Community Health 2024; 49:606-634. [PMID: 38311699 PMCID: PMC11306546 DOI: 10.1007/s10900-023-01290-w] [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] [Accepted: 09/28/2023] [Indexed: 02/06/2024]
Abstract
States have turned to novel Medicaid financing to pay for community health worker (CHW) programs, often through fee-for-service or capitated payments. We sought to estimate Medicaid payment rates to ensure CHW program sustainability. A microsimulation model was constructed to estimate CHW salaries, equipment, transportation, space, and benefits costs across the U.S. Fee-for-service rates per 30-min CHW visit (code 98960) and capitated rates were calculated for financial sustainability. The mean CHW hourly wage was $23.51, varying from $15.90 in Puerto Rico to $31.61 in Rhode Island. Overhead per work hour averaged $43.65 nationwide, and was highest for transportation among other overhead categories (65.1% of overhead). The minimum fee-for-service rate for a 30-min visit was $53.24 (95% CI $24.80, $91.11), varying from $40.44 in South Dakota to $70.89 in Washington D.C. The minimum capitated rate was $140.18 per member per month (95% CI $105.94, $260.90), varying from $113.55 in South Dakota to $176.58 in Washington D.C. Rates varied minimally by metro status but more by panel size. Higher Medicaid fee-for-service and capitated rates than currently used may be needed to support financial viability of CHW programs. A revised payment estimation approach may help state officials, health systems and plans discussing CHW program sustainability.
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Affiliation(s)
- Sanjay Basu
- Clinical Product Development, Waymark Care, San Francisco, USA.
| | - Sadiq Y Patel
- Department of Health Care Policy, Harvard Medical School, Boston, USA
| | - Kiiera Robinson
- Clinical Product Development, Waymark Care, San Francisco, USA
| | - Aaron Baum
- Icahn School of Medicine, Mount Sinai, New York, USA
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2
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Matsi MM, Lekalakala-Mokgele ES, Madumo MM. Community health workers' experiences of supervision by nurses at clinics in Limpopo Province. Health SA 2023; 28:2330. [PMID: 38204862 PMCID: PMC10778378 DOI: 10.4102/hsag.v28i0.2330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 09/06/2023] [Indexed: 01/12/2024] Open
Abstract
Background Supervision of community health workers (CHWs) is considered, among others, a strategy to achieve universal healthcare globally. In South Africa, it is incorporated in the ward-based primary healthcare (PHC) outreach teams' policy and strategy, a national health insurance policy component. Supervision of CHWs by nurses in the policy is considered a measure to facilitate PHC service provision to communities. However, CHWs experienced varying levels of supervision from nurses and other workers globally and in South Africa. Aim This study explored and described the experiences of CHWs about supervision received from nurses at PHC facilities in Limpopo Province. Setting Participants were drawn from seven PHC facilities in Polokwane and Lepelle-Nkumpi subdistricts of the Capricorn District. Methods A qualitative exploratory-descriptive and contextual study design was employed. Participants were selected utilising a purposive sampling method. Semi-structured interviews were conducted to collect data. Data were analysed according to themes and their associated categories. Measures to ensure rigour and ethical principles were applied. Results Two main themes emerged: positive supervision experienced by CHWs and supervision challenges experienced by CHWs. Conclusion The varying experiences of CHWs about supervision from nurses emerged and reflected the need for functioning supervision mechanisms. Contribution The experiences of CHWs indicated inconsistent delivery of supervision by nurses in PHC facilities. The findings highlighted the need for effective supervision measures that are vital for the success of the CHW supervision programme.
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Affiliation(s)
- Makwena M Matsi
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Eucebious S Lekalakala-Mokgele
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mary M Madumo
- Department of Nursing Sciences, Faculty of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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3
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Collins D, Griffiths U, Birse S, Dukhan Y, Bocoum FY, Driwale A, Nsona H, Pfaffmann-Zambruni J, Dini HSF, Gilmartin C. Calculating the Costs of Implementing Integrated Packages of Community Health Services: Methods, Experiences, and Results From 6 sub-Saharan African Countries. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200472. [PMID: 37903585 PMCID: PMC10615248 DOI: 10.9745/ghsp-d-22-00472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 09/13/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Ensuring access to a package of integrated primary health care services is essential for achieving universal health coverage. In many countries, community health programs are necessary for primary health care service provision, but they are generally underfunded, and countries often lack the necessary evidence on costs and resource requirements. We conducted prospective cost analyses of community health programs in 6 countries in sub-Saharan Africa using the Community Health Planning and Costing Tool. METHODS The Community Health Planning and Costing Tool is a spreadsheet-based tool designed to cost key programmatic elements of community health services packages, including training, equipment, incentives, supervision, and management. In each country, stakeholders defined a package of community health services and corresponding standard treatment guidelines to estimate normative costs, which were applied to program scale-up targets. The data were entered into the tool, and cost models were prepared for different geographical and service utilization scenarios. The results were reviewed and validated with the governments, implementing partners, and expert panels. Additional scale-up scenarios were modeled, taking into account probable constraints to increasing community health service provision and potential funding limitations. RESULTS The services and scope of community health service packages varied by country, depending on contextual factors and determined health priorities. The package costs also varied significantly depending on the size and contents of the service package, the service delivery approach, the remuneration of the community health workers, and the cost of medicines and supplies. CONCLUSIONS Community health programs and service packages are different in every country and change over time as they evolve. They should be routinely costed as an integral part of the planning and budgeting process and to ensure that sufficient resources are allocated for their effective and efficient implementation.
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Affiliation(s)
- David Collins
- Boston University School of Public Health, Boston, MA, USA
| | | | - Sarah Birse
- Management Sciences for Health, Medford, MA, USA
| | | | - Fadima Yaya Bocoum
- Institut de Recherche en Sciences de la Sante, Bobo-Dioulasso, Burkina Faso
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4
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Rotheram-Borus MJ, le Roux KW, Norwood P, Stansert Katzen L, Snyman A, le Roux I, Dippenaar E, Tomlinson M. The effect of supervision on community health workers' effectiveness with households in rural South Africa: A cluster randomized controlled trial. PLoS Med 2023; 20:e1004170. [PMID: 36862754 PMCID: PMC9980736 DOI: 10.1371/journal.pmed.1004170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 01/06/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Community health workers (CHWs) can supplement professional medical providers, especially in rural settings where resources are particularly scarce. Yet, outcomes of studies evaluating CHWs effectiveness have been highly variable and lack impact when scaled nationally. This study examines if child and maternal outcomes are better when existing government CHWs, who are perinatal home visitors, receive ongoing enhanced supervision and monitoring, compared to standard care. METHODS AND FINDINGS A cluster randomized controlled effectiveness trial was conducted comparing outcomes over 2 years when different supervision and support are provided. Primary health clinics were randomized by clinic to receive monitoring and supervision from either (1) existing supervisors (Standard Care (SC); n = 4 clinics, 23 CHWs, 392 mothers); or (2) supervisors from a nongovernmental organization that provided enhanced monitoring and supervision (Accountable Care [AC]; n = 4 clinic areas, 20 CHWs, 423 mothers). Assessments were conducted during pregnancy and at 3, 6, 15, and 24 months post-birth with high retention rates (76% to 86%). The primary outcome was the number of statistically significant intervention effects among 13 outcomes of interest; this approach allowed us to evaluate the intervention holistically while accounting for correlation among the 13 outcomes and considering multiple comparisons. The observed benefits were not statistically significant and did not show the AC's efficacy over the SC. Only the antiretroviral (ARV) adherence effect met the significance threshold established a priori (SC mean 2.3, AC mean 2.9, p < 0.025; 95% CI = [0.157, 1.576]). However, for 11 of the 13 outcomes, we observed an improvement in the AC compared to the SC. While the observed outcomes were not statistically significant, benefits were observed for 4 outcomes: increasing breastfeeding for 6 months, reducing malnutrition, increasing ARV adherence, and improving developmental milestones. The major study limitation was utilizing existing CHWs and being limited to a sample of 8 clinics. There were no major study-related adverse events. CONCLUSIONS Supervision and monitoring were insufficient to improve CHWs' impact on maternal and child outcomes. Alternative strategies for staff recruitment and narrowing the intervention outcomes to the specific local community problems are needed for consistently high impact. TRIAL REGISTRATION Clinicaltrials.gov, NCT02957799.
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Affiliation(s)
- Mary Jane Rotheram-Borus
- Dept. of Psychiatry and Biobehavioral Sciences, Semel Institute, University of CA, Los Angeles, California, United States of America
| | - Karl W. le Roux
- Institute for Life Course Health Research, Dept. of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Dept. of Family Medicine, Walter Sisulu University, Mthatha, South Africa
- Primary Health Care Directorate, Old Main Building, Groote Schuur Hospital, Cape Town, South Africa
- Zithulele Training and Research Centre, Zithulele Hospital, Mqanduli District, Eastern Cape, South Africa
| | - Peter Norwood
- Dept. of Psychiatry and Biobehavioral Sciences, Semel Institute, University of CA, Los Angeles, California, United States of America
| | - Linnea Stansert Katzen
- Institute for Life Course Health Research, Dept. of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Andre Snyman
- Zithulele Training and Research Centre, Zithulele Hospital, Mqanduli District, Eastern Cape, South Africa
| | - Ingrid le Roux
- Philani Maternal, Child Health and Nutrition Trust, Khayelitsha, Cape Town, South Africa
| | - Elaine Dippenaar
- Zithulele Training and Research Centre, Zithulele Hospital, Mqanduli District, Eastern Cape, South Africa
| | - Mark Tomlinson
- Institute for Life Course Health Research, Dept. of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- School of Nursing and Midwifery, Queens University, Belfast, United Kingdom
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5
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Goudge J, Babalola O, Malatji H, Levin J, Thorogood M, Griffiths F. The effect of a roving nurse mentor on household coverage and quality of care provided by community health worker teams in South Africa: a longitudinal study with a before, after and 6 months post design. BMC Health Serv Res 2023; 23:186. [PMID: 36814259 PMCID: PMC9948528 DOI: 10.1186/s12913-023-09093-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 01/23/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE Community health workers (CHW) are undertaking more complex tasks as part of the move towards universal health coverage in many low- and middle-income settings. They are expected to provide promotive and preventative care, make referrals to the local clinic, and follow up on non-attendees for a range of health conditions. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle due to inadequate supervision, low levels of CHW literacy, and the marginalized status of CHW in the health system. In this paper, we assess the effect of a roving nurse mentor on the coverage and quality of care of the CHW service in two vulnerable communities in South Africa. PARTICIPANTS CHW, their supervisors, household members. INTERVENTION Roving professional nurse mentor to build skills of supervisors and CHW teams. METHODS Three household surveys to assess household coverage of the CHW service (baseline, end of the intervention, and 6 months after end of intervention); structured observations of CHW working in households to assess quality of care. RESULTS The intervention led to a sustained 50% increase in the number of households visited by a CHW in the last year. While the proportion of appropriate health messages given to household members by CHW remained constant at approximately 50%, CHW performed a greater range of more complex tasks. They were more likely to visit new households to assess health needs and register the household in the programme, to provide care to pregnant women, children and people who had withdrawn from care. CHW were more likely to discuss with clients the barriers they were facing in accessing care and take notes during a visit. CONCLUSION A nurse mentor can have a significant effect both on the quantity and quality of CHW work, allowing them to achieve their potential despite their marginalised status in the health system and their limited prior educational achievement. Supportive supervision is important in enabling the benefit of having a health cadre embedded in marginalised communities to be realised.
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Affiliation(s)
- Jane Goudge
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Olukemi Babalola
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Hlologelo Malatji
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jonathan Levin
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Margaret Thorogood
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Warwick Medical School, Warwick University, Coventry, UK
| | - Frances Griffiths
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Warwick Medical School, Warwick University, Coventry, UK
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6
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Emerson C, Meline J, Linn A, Wallace J, Kapella BK, Venkatesan M, Steketee R. End Malaria Faster: Taking Lifesaving Tools Beyond “Access” to “Reach” All People in Need. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-22-00118. [PMID: 35487558 PMCID: PMC9053156 DOI: 10.9745/ghsp-d-22-00118] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022]
Abstract
To “reach the unreached” with preventive and curative malaria services, we must know which individuals and communities remain unreached and then bring tailored services from the clinic to the community and home.
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Affiliation(s)
- Courtney Emerson
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Jed Meline
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Anne Linn
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Julie Wallace
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Bryan K Kapella
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Meera Venkatesan
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, DC, USA
| | - Richard Steketee
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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7
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Rodrigues SM, Kanduri A, Nyamathi A, Dutt N, Khargonekar P, Rahmani AM. Digital Health-Enabled Community-Centered Care: Scalable Model to Empower Future Community Health Workers Using Human-in-the-Loop Artificial Intelligence. JMIR Form Res 2022; 6:e29535. [PMID: 35384853 PMCID: PMC9021941 DOI: 10.2196/29535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 01/29/2022] [Accepted: 02/19/2022] [Indexed: 11/13/2022] Open
Abstract
Digital health-enabled community-centered care (D-CCC) represents a pioneering vision for the future of community-centered care. D-CCC aims to support and amplify the digital footprint of community health workers through a novel artificial intelligence-enabled closed-loop digital health platform designed for, and with, community health workers. By focusing digitalization at the level of the community health worker, D-CCC enables more timely, supported, and individualized community health worker-delivered interventions. D-CCC has the potential to move community-centered care into an expanded, digitally interconnected, and collaborative community-centered health and social care ecosystem of the future, grounded within a robust and digitally empowered community health workforce.
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Affiliation(s)
- Sarah M Rodrigues
- Sue & Bill Gross School of Nursing, University of California, Irvine, CA, United States
| | - Anil Kanduri
- Department of Computing, University of Turku, Turku, Finland
| | - Adeline Nyamathi
- Sue & Bill Gross School of Nursing, University of California, Irvine, CA, United States
| | - Nikil Dutt
- Department of Computer Science, University of California, Irvine, CA, United States
| | - Pramod Khargonekar
- Department of Electrical Engineering and Computer Science, University of California, Irvine, CA, United States
| | - Amir M Rahmani
- Sue & Bill Gross School of Nursing, University of California, Irvine, CA, United States
- Department of Computer Science, University of California, Irvine, CA, United States
- Department of Electrical Engineering and Computer Science, University of California, Irvine, CA, United States
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8
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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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9
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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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10
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LeBan K, Kok M, Perry HB. Community health workers at the dawn of a new era: 9. CHWs' relationships with the health system and communities. Health Res Policy Syst 2021; 19:116. [PMID: 34641902 PMCID: PMC8506091 DOI: 10.1186/s12961-021-00756-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [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: 11/26/2022] Open
Abstract
BACKGROUND This is the ninth paper in our series, "Community Health Workers at the Dawn of a New Era". Community health workers (CHWs) are in an intermediary position between the health system and the community. While this position provides CHWs with a good platform to improve community health, a major challenge in large-scale CHW programmes is the need for CHWs to establish and maintain beneficial relationships with both sets of actors, who may have different expectations and needs. This paper focuses on the quality of CHW relationships with actors at the local level of the national health system and with communities. METHODS The authors conducted a selective review of journal articles and the grey literature, including case study findings in the 2020 book Health for the People: National CHW Programs from Afghanistan to Zimbabwe. They also drew upon their experience working with CHW programmes. RESULTS The space where CHWs form relationships with the health system and the community has various inherent strengths and tensions that can enable or constrain the quality of these relationships. Important elements are role clarity for all actors, working referral systems, and functioning supply chains. CHWs need good interpersonal communication skills, good community engagement skills, and the opportunity to participate in community-based organizations. Communities need to have a realistic understanding of the CHW programme, to be involved in a transparent process for selecting CHWs, and to have the opportunity to participate in the CHW programme. Support and interaction between CHWs and other health workers are essential, as is positive engagement with community members, groups, and leaders. CONCLUSION To be successful, large-scale CHW programmes need well-designed, effective support from the health system, productive interactions between CHWs and health system staff, and support and engagement of the community. This requires health sector leadership from national to local levels, support from local government, and partnerships with community organizations. Large-scale CHW programmes should be designed to enable local flexibility in adjusting to the local community context.
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Affiliation(s)
| | - Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Henry B Perry
- Department of International Health, Health Systems Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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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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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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Glenton C, Javadi D, Perry HB. Community health workers at the dawn of a new era: 5. Roles and tasks. Health Res Policy Syst 2021; 19:128. [PMID: 34641903 PMCID: PMC8506082 DOI: 10.1186/s12961-021-00748-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 12/02/2022] Open
Abstract
BACKGROUND This is the fifth of our 11-paper supplement on "Community Health Workers at the Dawn of a New Era." When planning new community health worker (CHW) roles or expanding existing roles, programme planners need to analyse global and local research evidence and evidence-based guidance on the effectiveness and safety of relevant tasks performed by CHWs. METHODS In this paper, we explore key areas of consideration when selecting roles and tasks; present current knowledge regarding these issues; and suggest how decision-makers could consider these issues when assigning tasks in their setting. This paper draws on the chapter "Community Health Worker Roles and Tasks" in Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, as well as on a recently published compendium of 29 case studies of national CHW programmes and on recently published literature pertaining to roles and tasks of CHWs. RESULTS This paper provides a list of questions that aim to help programme planners think about important issues when determining CHW roles and tasks in their setting. Planners need to assess whether the recommended roles and tasks are considered acceptable and appropriate by their target population and by the CHWs themselves and those who support them. Planners also need to think about the practical and organizational implications of each task for their particular setting with regard to training requirements, health systems support, work location, workload, and programme costs. CONCLUSION When planning CHW roles and tasks, planners, programme implementers, and policy-makers should draw from global guidance and research evidence, but they also need to engage with the experiences, needs, and concerns of local communities and health workers. By drawing from both sources of information, they will stand a better chance of developing programmes that are effective in achieving their goals while remaining acceptable to those affected by them, feasible to implement, and sustainable over time.
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Affiliation(s)
- Claire Glenton
- Global Health Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
- TRS Centre for Rare Disorders, Sunnaas Hospital, Nesodden, Norway
| | - Dena Javadi
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA, United States of America
| | - Henry B Perry
- Department of International Health, Health Systems Program, 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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