scholarly journals Community health workers at the dawn of a new era: 9. CHWs’ relationships with the health system and communities

2021 ◽  
Vol 19 (S3) ◽  
Author(s):  
Karen LeBan ◽  
Maryse Kok ◽  
Henry B. Perry
Keyword(s):  
Health System ◽  
Community Health ◽  
Community Health Workers ◽  
Large Scale ◽  
Health Workers ◽  
Local Level ◽  
Grey Literature ◽  
Community Context ◽  
New Era

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.

scholarly journals Community health workers at the dawn of a new era

2021 ◽  
Vol 19 (S3) ◽  
Author(s):  
Joseph M. Zulu ◽  
Henry B. Perry
Keyword(s):  
Community Health ◽  
Population Health ◽  
Community Health Workers ◽  
Low Income ◽  
Large Scale ◽  
Health Workers ◽  
The United States ◽  
Noncommunicable Diseases ◽  
Full Potential ◽  
New Era

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.

scholarly journals Community health workers at the dawn of a new era: 3. Programme governance

2021 ◽  
Vol 19 (S3) ◽  
Author(s):  
Simon Lewin ◽  
Uta Lehmann ◽  
Henry B. Perry
Keyword(s):  
Health System ◽  
Community Health ◽  
Community Health Workers ◽  
Health Workers ◽  
Critical Role ◽  
Decision Makers ◽  
Local Health ◽  
New Era ◽  
Wide Range ◽  
Health Related

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.

scholarly journals Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes

2021 ◽  
Vol 19 (S3) ◽  
Author(s):  
Stephen Hodgins ◽  
Maryse Kok ◽  
David Musoke ◽  
Simon Lewin ◽  
Lauren Crigler ◽  
...  
Keyword(s):  
Community Health ◽  
Community Health Workers ◽  
Large Scale ◽  
Health Workers ◽  
Vital Role ◽  
Full Potential ◽  
List Type ◽  
New Era ◽  
Strategic Issues

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: What kind of an actor is the CHW? A lackey or a liberator? Provider of clinical services or health promoter? Lay versus professional? Government programme at scale or nongovernmental organization-led demonstration project? Standardized versus tailored to context? 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.

scholarly journals Community health workers at the dawn of a new era: 4. Programme financing

2021 ◽  
Vol 19 (S3) ◽  
Author(s):  
Lizah Masis ◽  
Angela Gichaga ◽  
Tseday Zerayacob ◽  
Chunling Lu ◽  
Henry B. Perry
Keyword(s):  
Human Resources ◽  
Community Health ◽  
Community Health Workers ◽  
Health Workers ◽  
Human Resources For Health ◽  
Grey Literature ◽  
Critical Element ◽  
New Era ◽  
Donor Support ◽  
Health Related

Abstract Background This is the fourth of our 11-paper supplement on “Community Health Workers at the Dawn of New Era”. Here, we first make the case for investing in health programmes, second for investing in human resources for health, third for investing in primary healthcare (PHC) workers, and finally for investing in community health workers (CHWs). Methods Searches of peer-reviewed journals and the grey literature were conducted with a focus on community health programme financing. The literature search was supplemented with a search of the grey literature for information about national health sector plans, community health strategies/policies, and costing information from databases of various countries’ ministries of health, and finally a request for information from in-country partners. Results The global shortage of human resources for health is projected to rise to 18 million health workers by 2030, with more acute shortages in Africa and South Asia. CHWs have an important role to play in mitigating this shortage because of their effectiveness (when properly trained and supported) and the feasibility of their deployment. Data are limited on the costs of current CHW programmes and how they compare to government and donor expenditures for PHC and for health services more broadly. However, available data from 10 countries in Africa indicate that the median per capita cost of CHW programmes is US$ 4.77 per year and US$ 2574 per CHW, and the median monthly salary of CHWs in these same countries is US$ 35 per month. For a subset of these countries for which spending for PHC is available, governments and donors spend 7.7 times more on PHC than on CHW programming, and 15.4 times more on all health expenditures. Even though donor funding for CHW programmes is a tiny portion of health-related donor support, most countries rely on donor support for financing their CHW programmes. Conclusion The financing of national CHW programmes has been a critical element that has not received sufficient emphasis in the academic literature on CHW programmes. Increasing domestic government funding for CHW programmes is a priority. In order to ensure growth in funding for CHW programmes, it will be important to measure CHW programme expenditures and their relationship to expenditures for PHC and for all health-related expenditures.

scholarly journals Community health workers at the dawn of a new era: 7. Recent advances in supervision

2021 ◽  
Vol 19 (S3) ◽  
Author(s):  
Carey Westgate ◽  
David Musoke ◽  
Lauren Crigler ◽  
Henry B. Perry
Keyword(s):  
Community Health ◽  
Case Studies ◽  
Community Health Workers ◽  
Large Scale ◽  
Health Workers ◽  
Local Context ◽  
Small Scale ◽  
Exploratory Research ◽  
New Era ◽  
Over Time

Abstract Background Supervision is essential for optimizing performance and motivation of community health workers (CHWs). This paper, the seventh in our series, “Community health workers at the dawn of a new era”, supplements the existing evidence on CHW supervision in low- and middle-income countries by reviewing what supervision approaches are employed in specific contexts, identifying potential facilitators of CHW supervision including mobile health (mHealth) interventions, and noting challenges of supervision including the relationship between supervision and other CHW programme elements. Methods For this exploratory research study on CHW supervision, we reviewed the supervisory interventions described in a compendium of 29 case studies of large-scale CHW programmes, performed an electronic search of multiple databases to identify articles related to CHW supervision published between 15 June 2017 and 1 December 2020, and from those articles followed additional references that appeared to be relevant for our results. Results We reviewed 55 case studies, academic articles, and grey literature resources as part of this exploratory research. A variety of supervision approaches have been adapted over time, which we grouped into five categories: external supervision, community supervision, group supervision, peer supervision, and dedicated supervision. These approaches are frequently used in combination. Digital (mHealth) technologies are being explored as potential facilitators of CHW supervision in both small- and large-scale programmes; however, evidence of their effectiveness remains limited to date. Inadequate support for supervisors is a major challenge, particularly given the numerous and varied roles they are expected to fulfil, spanning administrative, clinical, and supportive activities. Supervisors can help CHWs acquire other critical elements needed from the health system for them to perform more effectively: incentives to foster motivation, clarity of roles and tasks, adequate tools and supplies, appropriate knowledge and skills, and a safe work environment. Conclusion In the absence of a universal “best approach” for CHW supervision, our recommendation is that countries and programmes prioritize homegrown evolution over time to suit the local context. In some cases, this may involve scaling up novel approaches that have proven effective at small scale or testing approaches that have worked in other countries.

Stock-Outs of Essential Medicines Among Community Health Workers (CHWs) In Low- And Middle-Income Countries (LMICs): A Systematic Literature Review of The Extent, Reasons, And Consequences

2021 ◽  
Author(s):  
Abimbola Olaniran ◽  
Jane Briggs ◽  
Ami Pradhan ◽  
Erin Bogue ◽  
Benjamin Schreiber ◽  
...  
Keyword(s):  
Community Health ◽  
Community Health Workers ◽  
Health Workers ◽  
Grey Literature ◽  
Community Level ◽  
Health Centers ◽  
Essential Medicines ◽  
Middle Income ◽  
Middle Income Countries ◽  
Low And Middle Income

Abstract Background: This paper explores the extent of community-level stock-out of essential medicines among Community Health Workers (CHWs) in Low- and Middle-Income Countries (LMICs) and identifies the reasons for and consequences of essential medicine stock-outs. Methods: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted. Five electronic databases were searched with a prespecified strategy and the grey literature examined, January 2006 - March 2021. Papers containing information on (i) the percentage of CHWs stocked out or (ii) reasons for stock-outs along the supply chain and consequences of stock-out were included and appraised for risk of bias. Outcomes were quantitative data on the extent of stock-out, summarized using descriptive statistics, and qualitative data regarding reasons for and consequences of stock-outs, analyzed using thematic content analysis and narrative synthesis. Results: Two reviewers screened 1083 records; 78 evaluations were included. Over the last fifteen years, CHWs experienced stock-outs of essential medicines nearly one third of the time and at a significantly (p < 0.01) higher rate than the health centers to which they are affiliated (28.93% [CI 95%: 28.79 - 29.07] vs 9.17 % [CI 95%: 8.64 - 9.70], respectively). A comparison of the period 2006-2015 and 2016-2021 showed a significant (p < 0.01) increase in CHW stock-out level from 26.36% [CI 95%: 26.22 -26.50] to 48.65% [CI 95%: 48.02- 49.28] while that of health centers increased from 7.79% [95% CI: 7.16 - 8.42] to 14.28% [95% CI: 11.22- 17.34]. Distribution barriers were the most cited reasons for stock-outs. Ultimately, patients were the most affected: stock-outs resulted in out-of-pocket expenses to buy unavailable medicines, poor adherence to medicine regimes, dissatisfaction, and low service utilization. Conclusion: Community-level stock-out of essential medicines constitutes a serious threat to achieving universal health coverage and equitable improvement of health outcomes. This paper suggests stock-outs are getting worse, and that there are particular barriers at the last mile. There is an urgent need to address the health and non-health system constraints that prevent the essential medicines procured for LMICs by international and national stakeholders from reaching the people who need them the most.

scholarly journals Assessing inequities in community health worker’s interaction and its impact in Uttar Pradesh, India

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
S Gupta ◽  
S Tomar ◽  
A Dey ◽  
D Chandurkar
Keyword(s):  
Health Service ◽  
Health Outcomes ◽  
Community Health ◽  
Community Health Workers ◽  
Service Utilization ◽  
Health Service Utilization ◽  
Health Workers ◽  
Uttar Pradesh ◽  
Economic Determinants

Abstract Given the high Neo-natal mortality in the state of Uttar Pradesh, India, an emphasis has been given to community health workers (CHW). CHW provides behavior push to pregnant women for utilizing health services, through the strategies of household contact and messaging. However, the disparity in health outcomes and interaction of CHW is profoundly affected by socio-economic determinants; still, the evidence is limited. This study aims to explore socio-economic inequities in quantity and quality of contacts by the CHW and its differential effect on health service utilization. Multistage sampling design identified live births in the last 12 months across the 25 highest-risk districts of Uttar Pradesh(n = 3703). Regression models described the relation between household demographics and CHW contact & specific messaging and interactions of demographics and CHW contact & messaging in predicting health service utilization ( &gt; = 4 antenatal care (ANC) visits, Institutional delivery and 100 iron folic acid (IFA) consumption). No differential likelihood in contact of CHW and specific messaging is found. Further, association of CHW contacts and specific messaging with health outcomes were significantly affected by socio-economic determinants.2 or more contacts along with specific messaging increased the odds of 4+ ANC to a higher degree among illiterate women compared to literate women(AOR:3.39, 95% CI:2.28-5.04 vs AOR:1.44, 95% CI:1.09-1.92). Similarly, the odds of facility delivery increased to a higher degree among lower wealth women compared to higher wealth women (AOR:3.41, 95% CI:2.47-4.71 vs. AOR:1.53, 95% CI: 1.09-2.15). Specific messaging, along with CHW contacts, have a higher magnitude of effects on the marginalized population. This study provides evidence for adjusting implementation strategies based on socio-economic determinants to achieve equitable health service utilization. However, further research on training of CHW on heterogeneous interaction is recommended Key messages There exists differential effects of quantity and quality of contact by community health workers on health service utilization across the different socio-economic strata. Implementation agencies in the LMIC can reduce health inequity by shifting from coverage-oriented target approach towards more prioritized and focused interaction across socio-economic groups.

What are the roles of community health workers? Looking back at the philosophies of primary health care

2019 ◽  
Vol 27 (2) ◽  
pp. 117-120
Author(s):  
Marietou Niang
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Community Development ◽  
Health System ◽  
Community Health ◽  
Community Health Workers ◽  
Health Workers ◽  
Primary Health ◽  
Looking Back

This commentary discusses the different roles of community health workers (CHWs), their challenges and limitations in a historical perspective of primary health care (PHC). We first try to show that the comprehensive philosophy of PHC promulgated in Alma-Ata proposed the role of CHWs as actors who work in community development. On the other hand, in the 1980s, with the emergence of the selective philosophy of PHC, CHWs’ role was more affiliated with the health system. We conclude our pitch about the balance that can exist between these different roles by suggesting that CHWs can work in continuity with the health system, but they should not be considered as affordable labor. Also, they must be supported in their activities to develop their communities, allowing them to participate effectively in programs and policies that concern them and their community.

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