Assessing community health worker service delivery in humanitarian settings

Do cash or digital payment modalities affect community health worker performance? - a case study of a remote refugee settlement in Western Uganda

BACKGROUND

There is inadequate evidence about the influence of digital and cash payment modalities on the performance of Community Health Workers (CHWs) in underserved communities, such as refugee settlements.

OBJECTIVE

To compare the performance of CHWs when paid in cash or digitally in Kyaka II refugee settlement, Uganda.

METHODS

A comparative cross-sectional mixed methods design was used. Secondary data comprising 247 CHW reports during a six-month period of cash and digital payments were analyzed using Stata v14. Eleven focus group discussions, four in-depth interviews, and ten key informant interviews were conducted among the settlement stakeholders to explore perceptions of the payment methods. Qualitative data were analyzed thematically using Atlas.ti v9.

RESULTS

CHWs performed better when paid cash than digital payments (t = 5.28; df = 246; p < 0.001). During the cash payment period, at least secondary education (APR 1.71 CI: 1.14-2.58) and having a side occupation (APR 1.58; CI: 1.13-2.21) were positively associated with performance. For digital payments, being male (APR 0.58; CI: 0.34-0.98), serving longer than 9 years (APR 0.87; CI: 0.82-0.93), and being allocated more than 60 households per month (APR 0.31; CI: 0.19-0.52) were negatively associated with CHW performance. Qualitative data revealed that most stakeholders preferred cash due to inconsistent and delayed digital payments.

CONCLUSION

CHWs preferred and performed better with cash payments because digital payments were associated with delays and payment shortfalls that demotivated them. Implementers should invest towards averting digital payment shortfalls in remote settings to enhance CHW motivation and performance.

Effectiveness of decentralizing outpatient acute malnutrition treatment with community health workers and a simplified combined protocol: a cluster randomized controlled trial in emergency settings of Mali

Background

Outpatient treatment of acute malnutrition is usually centralized in health centers and separated into different programs according to case severity. This complicates case detection, care delivery, and supply chain management, making it difficult for families to access treatment. This study assessed the impact of treating severe and moderate cases in the same program using a simplified protocol and decentralizing treatment outside health centers through community health workers (CHWs).

Methods

A three-armed cluster randomized controlled trial under a non-inferiority hypothesis was conducted in the Gao region of Mali involving 2,038 children between 6 and 59 months of age with non-complicated acute malnutrition. The control arm consisted of 549 children receiving standard treatment in health centers from nursing staff. The first intervention arm consisted of 800 children treated using the standard protocol with CHWs added as treatment providers. The second intervention arm consisted of 689 children treated by nurses and CHWs under the ComPAS simplified protocol, considering mid-upper arm circumference as the sole anthropometric criterion for admission and discharge and providing a fixed dose of therapeutic food for severe and moderate cases. Coverage was assessed through cross-sectional surveys using the sampling evaluation of access and coverage (SLEAC) methodology for a wide area involving several service delivery units.

Results

The recovery rates were 76.3% in the control group, 81.8% in the group that included CHWs with the standard protocol, and 92.9% in the group that applied the simplified protocol, confirming non-inferiority and revealing a significant risk difference among the groups. No significant differences were found in the time to recovery (6 weeks) or in anthropometric gain, whereas the therapeutic food expenditure was significantly lower with the simplified combined program in severe cases (43 sachets fewer than the control). In moderate cases, an average of 35 sachets of therapeutic food were used. With the simplified protocol, the CHWs had 6% discharge errors compared with 19% with the standard protocol. The treatment coverage increased significantly with the simplified combined program (SAM +42.5%, MAM +13.8%).

Implications

Implementing a simplified combined treatment program and adding CHWs as treatment providers can improve coverage while maintaining non-inferior effectiveness, reducing the expenditure on nutritional intrants, and ensuring the continuum of care for the most vulnerable children.

A framework for community health worker optimisation in conflict settings: prerequisites and possibilities from Northwest Syria

BACKGROUND

The world will face a human resource gap of 10 million health workers in 2030. Community health workers (CHWs) can contribute to mitigating this workforce gap while improving equitable access to care and health outcomes. However, questions on how to best implement and optimise CHW programmes, especially across varied contexts, remain. As each context has its determinants for a successful CHW programme, this research identifies and assesses pertinent factors needed for optimal CHW programmes in conflict settings, specifically Northwest Syria.

METHODS

A mixed-methods study in Northwest Syria consisting of a literature and document review, semistructured interviews with CHWs' team leaders and programme managers, key informant interviews with policymakers and a survey with CHWs was conducted across three research phases from 2018 to 2022. The three phases aimed to identify, refine and finalise a framework for CHW optimisation in humanitarian conflict contexts, respectively. Qualitative data were analysed thematically, and quantitative data were statistically analysed to identify critical trends.

RESULTS

16 interviews and 288 surveys were conducted, supplemented by key reports and literature. The framework underwent two iterative rounds of refinement, reflecting varying stakeholders' perceptions of CHW optimisation. The resulting framework presents important implementation factors with subthemes across identified topics of institutionalisation, integration and representation for CHW optimisation in Northwest Syria and other humanitarian conflict contexts. The presented factors are similar in various ways to other fragile low/middle-income country settings. However, in protracted conflict settings like Syria, careful consideration should be given to strategic dimensions such as integration and representation.

CONCLUSION

For CHW programmes to impact health outcomes in humanitarian conflict settings, they require a set of implementation and design factors relevant to the context. The dynamics of humanitarian funding restrictions, health system capacity and governance structures confront achieving these requirements. Nevertheless, pioneering projects which use available resources are possible. Evidence is needed to understand the impact of CHWs' interventions and further support implementation across humanitarian contexts.

Exploring how outreach team leaders perceive community health workers' experiences of providing HIV services in KwaZulu-Natal, South Africa

Objectives: In 2018, the KwaZulu-Natal Department of Health launched the ward-based primary health care outreach teams policy framework which sought to expand the community health worker (CHW) programme's provision of longitudinal patient support, including human immunodeficiency virus (HIV) services in communities. This study sought to explore the perceptions of outreach team leaders who supervise CHWs on their experiences of providing HIV services in the province.Study design: This was a qualitative, phenomenology study.Methods: Convenience sampling was done to select one outreach team leader from each of the 11 KwaZulu-Natal health districts to be interviewed using an interview guide. Thematic analysis, guided by the Ritchie and Spencer framework analysis, was used to analyse the data.Results: The challenges faced by CHWs in delivering HIV services were: the absence of individuals when CHWs visited their homes, self-HIV stigma, rejection of CHWs' HIV services due to traditional beliefs, CHW shortages, lack of other resources, low levels of CWH education and a lack of training. On the other hand, the provision of HIV services was fascilitated by: supportive supervision, training, having cell phones and having a positive attitude towards providing HIV services by CHWs that were HIV-positive.Conclusion: The CHWs in KwaZulu-Natal face more challenges than enablers in the provision of HIV services. The delegation of HIV services to CHWs should be aligned with their holistic empowerment by eliminating barriers to the provision of HIV services.

Community health workers at the dawn of a new era: 5. Roles and tasks

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.

Validity of using mobile phone surveys to evaluate community health worker program in Mali

Background

The monitoring and evaluation of public health programs based on traditional face-to-face interviews in hard-to-reach and unstable regions present many challenges. Mobile phone-based methods are considered to be an effective alternative, but the validity of mobile phone-based data for assessing implementation strength has not been sufficiently studied yet. Nested within an evaluation project for an integrated community case management (iCCM) and family planning program in Mali, this study aimed to assess the validity of a mobile phone-based health provider survey to measure the implementation strength of this program.

Methods

From July to August 2018, a cross-sectional survey was conducted among the community health workers (ASCs) from six rural districts working with the iCCM and family planning program. ASCs were first reached to complete the mobile phone-based survey; within a week, ASCs were visited in their communities to complete the in-person survey. Both surveys used identical implementation strength tools to collect data on program activities related to iCCM and family planning. Sensitivity and specificity were calculated for each implementation strength indicator collected from the phone-based survey, with the in-person survey as the gold standard. A threshold of ≥ 80% for sensitivity and specificity was considered adequate for evaluation purposes.

Results

Of the 157 ASCs interviewed by mobile phone, 115 (73.2%) were reached in person. Most of the training (2/2 indicators), supervision (2/3), treatment/modern contraceptive supply (9/9), and reporting (3/3) indicators reached the 80% threshold for sensitivity, while only one supervision indicator and one supply indicator reached 80% for specificity. In contrast, most of the stock-out indicators (8/9) reached 80% for specificity, while only two indicators reached the threshold for sensitivity.

Conclusions

The validity of mobile phone-based data was adequate for general training, supervision, and supply indicators for iCCM and family planning. With sufficient mobile phone coverage and reliable mobile network connection, mobile phone-based surveys are useful as an alternative for data collection to assess the implementation strength of general activities in hard-to-reach areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01317-7.

"Eternally restarting" or "a branch line of continuity"? Exploring consequences of external shocks on community health systems in Haiti

Background

Community health systems (CHS) are integral in promoting well-being in humanitarian settings, like Haiti, a country plagued by disruptive socio-political and environmental shocks over the past two decades. Haiti’s community health workers (CHWs) as critical intermediaries have persisted throughout these contextual shocks. This study explores how shocks influence CHS functionality and resilience in Haiti.

Methods

We applied an inductive and deductive qualitative approach to understand the lived experience of CHS actors. A desk review of peer-review and grey literature searched 393 and identified 25 relevant documents on community health policies, guidelines, and strategies implemented over the last fifteen years in Haiti. In-depth interviews with policy and program stakeholders (n = 12), CHWs (n = 24), and CHW supervisors and community health auxiliary nurses (n = 15) were conducted.

Results

Various shocks – political transitions, natural disasters, and disease outbreaks – describe Haiti’s protracted complex humanitarian setting and reveal distinct influences on CHS functionality (challenges and enablers), resilience, and mediating factors (eg, policy, financing, governance, parallel systems). Consequences of civil unrest and lockdowns (political transitions), internal displacement and infrastructural damage (natural disasters), and livelihood depletion and food insecurity (natural disasters and disease outbreaks) affect CHS functioning. CHW resilience is rooted in their generalized scope of work, intrinsic motivation, history in the community, trusting relationships, self-regulatory capacity, and adaptability. Mental health and safety among CHS actors and communities they serve pose challenges to CHS functionality and resilience, while reinforcing collaborations that promote CHW coverage and support and sustain CHS. Participants recommended government support for CHWs, collaborations stewarded by the government and complemented by partners, sub-national autonomy, and integration of disaster preparedness for all CHWs.

Conclusions

Political transitions, natural disasters, and disease outbreaks in Haiti continue to profoundly influence CHS functioning, despite mitigating policy and programming efforts. This study documents the relevance of CHS in maintaining primary health care for a country in protracted crises and suggests that propositions of CHW resilience can be explored in complex humanitarian settings globally.