Labour conditions in dual-cadre community health worker programmes: a systematic review

'Community people are the most powerful resources': qualitative critical realist analysis and framework to support co-produced responses to zoonotic disease threats with(in) Nepali communities

BACKGROUND

Co-production between researchers, service providers, and members of affected communities is an old concept renewed by current efforts to decolonise global health, reduce exploitative practices, and develop more sustainable, context-relevant interventions to address global health issues. Working with communities- how ever defined- is central to healthcare improvement but engaging with communities and identifying priorities remains challenging for disease control professionals. Co-production aims to help ensure community members have some control over the design and implementation of any intervention, and greater ownership of processes and outcomes. We aimed to identify what would encourage co-production of activities to prevent potential transmission of zoonoses.

METHODS

In this qualitative study, we (British and Nepali researchers) interviewed 73 participants from six communities across Nepal, with 10 participating in photovoice. We also interviewed 20 healthcare professionals and policymakers, 14 representing human and six representing animal health. We interpreted data using reflexive thematic analysis.

RESULTS

Thirty-nine people in six communities participated in interviews, with another 34 in 5 focus groups. We generated three overarching themes: (i) constrained healthcare-seeking behaviours, (ii) experience of community programmes, and (iii) community priorities and co-production. Community participants, despite strong opinions and desire to participate in disease control interventions, had experienced little or no attempt by intervention organisers to engage them in design, implementation, evaluation, or accountability. Most had no experience of programmes at all. Participants highlighted the significance of working in 'local' languages, respecting religious and cultural realities, relating initiatives to lived experience, and ensuring that local leaders are involved.

CONCLUSIONS

Meaningful co-production requires recognising communities- through legitimate leadership/representation- as expert and equal partners who can 'work alongside' at all stages of any initiative. Implications from this research include the importance of promoting trust in communities through inclusion of influential community members (community health volunteers, traditional medicine practitioners, women's group leaders); the use of indigenous languages; the acceptability of different media for interventions (theatre, drama); and the need to be pragmatic about available resources, to manage the expectations of community members.

Moving away from volunteerism in community health? Motivations and wellbeing among urban and rural Ethiopian volunteers

Questions about the fairness, efficacy, and sustainability of volunteerism in community health have led some states and programs to attempt to scale back their reliance on "volunteer" labor. Such attempts demand theory-driven, comparative ethnographic research that makes sense of how such moves unfold and impact the lives of CHWs and the programs surrounding them. Guided by theory of the interaction of political and moral economies, this article comparatively analyzes two predominantly female community health workforces in Ethiopia, who worked as unpaid volunteers when their federal government was supposedly "moving away from volunteerism" in community health: (1) HIV/AIDS-focused, home-based caregivers in Addis Ababa (2007-9) organized by NGOs; and (2) primary health care-focused members of the Women's Development Army in rural Amhara (2012-16) organized by the state. Ethnographic and mixed methods, including surveys of volunteers' wellbeing (n = 110 in Addis Ababa; n = 73 in rural Amhara), were used to assemble each dataset. These data show 1) how exploitation of "volunteer" community health labor by states, NGOs, and partnerships between them is maintained through discourses of sacrifice and related notions; 2) what the deprivation, distress, and desires of community health workers reveal about the "voluntariness" of their labor; 3) how CHWs organize themselves into collectives seeking better working conditions; and 4) how these experiences and processes are gendered. In this post-COVID-19 era of persistent inequalities in health globally, comparative ethnographic research of efforts to move away from volunteerism can provide useful lessons for CHWs, policymakers, and advocates.

Comparing apples with apples: A proposed taxonomy for "Community Health Workers" and other front-line health workers for international comparisons

This paper proposes a taxonomy for Community Health Workers (CHWs) and others engaged in front-line community health activities, encompassing formally-employed workers extending government primary health care (PHC) service delivery as well as a range of other actors with roles at the nexus of government PHC and communities. The taxonomy is grounded in current definitions from the World Health Organization and the International Labor Organization, and proposes some refinements for future iterations of guidance from these agencies. The designation, "Community Health Worker" is currently used to cover a broad range of roles. Furthermore, there are programs engaging workers or community members in roles closely adjacent to those generally recognized as CHWs that use other designations, not commonly included under the rubric of "CHW". This potentially confusing range of roles and nomenclature leads at times to over-generalizations, applying insights and principles relevant for one type of worker or community member that are not necessarily relevant for another. It also leads to a failure to consider occupational groups not commonly thought of as CHWs-but engaged in PHC service delivery at the most peripheral level-in community-based-PHC planning and management arrangements. Building on ILO and WHO classifications and standards, a further clarification of terms and a taxonomy is proposed, with the intention of contributing to clearer communication and shared understanding and, ultimately, sounder community health policy, program planning, and implementation; and more substantial progress towards Universal Health Coverage.

Cost-effectiveness of leveraging existing HIV primary health systems and community health workers for hypertension screening and treatment in Africa: An individual-based modeling study

BACKGROUND

Cardiovascular disease (CVD) morbidity and mortality is increasing in Africa, largely due to undiagnosed and untreated hypertension. Approaches that leverage existing primary health systems could improve hypertension treatment and reduce CVD, but cost-effectiveness is unknown. We evaluated the cost-effectiveness of population-level hypertension screening and implementation of chronic care clinics across eastern, southern, central, and western Africa.

METHODS AND FINDINGS

We conducted a modeling study to simulate hypertension and CVD across 3,000 scenarios representing a range of settings across eastern, southern, central, and western Africa. We evaluated 2 policies compared to current hypertension treatment: (1) expansion of HIV primary care clinics into chronic care clinics that provide hypertension treatment for all persons regardless of HIV status (chronic care clinic or CCC policy); and (2) CCC plus population-level hypertension screening of adults ≥40 years of age by community health workers (CHW policy). For our primary analysis, we used a cost-effectiveness threshold of US $500 per disability-adjusted life-year (DALY) averted, a 3% annual discount rate, and a 50-year time horizon. A strategy was considered cost-effective if it led to the lowest net DALYs, which is a measure of DALY burden that takes account of the DALY implications of the cost for a given cost-effectiveness threshold. Among adults 45 to 64 years, CCC implementation would improve population-level hypertension control (the proportion of people with hypertension whose blood pressure is controlled) from mean 4% (90% range 1% to 7%) to 14% (6% to 26%); additional CHW screening would improve control to 44% (35% to 54%). Among all adults, CCC implementation would reduce ischemic heart disease (IHD) incidence by 10% (3% to 17%), strokes by 13% (5% to 23%), and CVD mortality by 9% (3% to 15%). CCC plus CHW screening would reduce IHD by 28% (19% to 36%), strokes by 36% (25% to 47%), and CVD mortality by 25% (17% to 34%). CHW screening was cost-effective in 62% of scenarios, CCC in 31%, and neither policy was cost-effective in 7% of scenarios. Pooling across setting-scenarios, incremental cost-effectiveness ratios were $69/DALY averted for CCC and $389/DALY averted adding CHW screening to CCC.

CONCLUSIONS

Leveraging existing healthcare infrastructure to implement population-level hypertension screening by CHWs and hypertension treatment through integrated chronic care clinics is expected to reduce CVD morbidity and mortality and is likely to be cost-effective in most settings across Africa.

How does community health feature in Global Financing Facility planning documents to support reproductive, maternal, newborn, child and adolescent health and nutrition (RMNAH-N)? insights from six francophone West African countries

BACKGROUND

Community health is key for improving Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). However, how community health supports integrated RMNCAH-N service delivery in francophone West Africa is under-researched.

OBJECTIVE

We examined how six francophone West African countries (Burkina Faso, Côte d'Ivoire, Guinea, Mali, Niger, and Senegal) support community health through the Global Financing Facility for Women, Children and Adolescents (GFF).

METHODS

We conducted a content analysis on Investment Cases and Project Appraisal Documents from selected countries, and set out the scope of the analysis and the key search terms. We applied an iterative hybrid inductive-deductive approach to identify themes for data coding and extraction. The extracted data were compared within and across countries and further grouped into meaningful categories.

RESULTS

In country documents, there is a commitment to community health, with significant attention paid to various cadres of community health workers (CHWs) who undertake a range of preventive, promotive and curative roles across RMNCAH-N spectrum. While CHWs renumeration is mentioned, it varies considerably. Most community health indicators focus on CHWs' deliverables, with few related to governance and civil registration. Challenges in implementing community health include poor leadership and governance and resource shortages resulting in low CHWs performance and service utilization. While some countries invest significantly in training CHWs, structural reforms and broader community engagement are lacking.

CONCLUSIONS

There is an opportunity to better prioritize and streamline community health interventions, including integrating them into health system planning and budgeting, to fully harness their potential to improve RMNCAH-N.

Changing power narratives: an exemplar case study on the professionalisation of community health workers in Liberia

Despite their central role in achieving health equity and Universal Health Coverage, only a minority of community health workers (CHWs) is formally recognised as health workforce and receives a salary. Community health policies are formed within the power dynamics of global health practice. We argue that critical investigations of the power dynamics that influence the design of CHW programmes can contribute system-level insights to strengthen their roles.We present a national-level case study of the Liberian Community Health Assistant programme as an exemplar case of successfully introducing a nationwide CHW policy that professionalises CHWs. Using a theory of how power is exercised (Steven Lukes) for our analysis, we argue that Liberia's success in overcoming external funder push-back on the payment of CHWs was enabled by strong political commitment and (re-)claiming government authority in and outside of decision-making processes. Consensus-building across government departments strengthened the government's decision-making power. The availability and strategic use of suitable and contextualised evidence focused on the rights of CHWs allowed for proactive engagement with external funders' concerns. To draw on learnings from the experience of Liberia, we recommend looking beyond the common effectiveness-oriented narratives in academic literature that focus on CHW's functional role. By focussing on how power is exerted through policy negotiations around professionalisation, it could be possible to reframe conventional approaches to the role of CHW in other contexts as well.

Documenting Community Health Worker Compensation Schemes and Their Perceived Effectiveness in Seven sub-Saharan African Countries: A Qualitative Study

INTRODUCTION

Community health worker (CHW) incentives and remuneration are core issues affecting the performance of CHWs and health programs. There is limited documentation on the implementation details of CHW financial compensation schemes used in sub-Saharan African countries, including their mechanisms of delivery and effectiveness. We aimed to document CHW financial compensation schemes and understand CHW, government, and other stakeholder perceptions of their effectiveness.

METHODS

A total of 68 semistructured interviews were conducted with a range of purposefully selected key informants in 7 countries: Benin, Burkina Faso, Ghana, Malawi, Mali, Niger, and Zambia. Thematic analysis of coded interview data was conducted, and relevant country documentation was reviewed, including any documents referenced by key informants, to provide contextual background for qualitative interpretation.

RESULTS

Key informants described compensation schemes as effective when payments are regular, distributions are consistent, and amounts are sufficient to support health worker performance and continuity of service delivery. CHW compensation schemes associated with an employed worker status and government payroll mechanisms were most often perceived as effective by stakeholders. Compensation schemes associated with a volunteer status were found to vary widely in their delivery mechanisms (e.g., cash or mobile phone distribution) and were perceived as less effective. Lessons learned in implementing CHW compensation schemes involved the need for government leadership, ministerial coordination, community engagement, partner harmonization, and realistic transitional financing plans.

CONCLUSION

Policymakers should consider these findings in designing compensation schemes for CHWs engaged in routine, continuous health service delivery within the context of their country's health service delivery model. Systematic documentation of the tasks and time commitment of volunteer status CHWs could support more recognition of their health system contributions and better determination of commensurate compensation as recommended by the 2018 World Health Organization Guidelines on Health Policy and System Support to Optimize Community Health Worker Programs.

Vitamin A supplementation coverage and associated factors for children aged 6 to 59 months in integrated and campaign-based delivery systems in four sub-Saharan African countries

BACKGROUND

Vitamin A deficiency (VAD) is a leading contributor to the poor health and nutrition of young children in sub-Saharan Africa. Funding constraints are compelling many countries to shift from longstanding campaigns to integrating vitamin A supplementation (VAS) into routine health services. We assessed child VAS coverage and associated factors for integrated delivery systems in Mozambique, Senegal, and Sierra Leone and for a campaign-based delivery strategy in Tanzania.

METHODS

Data were obtained using representative household surveys administered to primary caregivers of N = 16,343 children aged 6-59 months (Mozambique: N = 1,659; Senegal: N = 7,254; Sierra Leone: N = 4,149; Tanzania: N = 3,281). Single-dose VAS coverage was assessed and bivariate and multivariable associations were examined for child VAS receipt with respect to rural or urban residence; child age and sex; maternal age, education, and VAS program knowledge; and household wealth.

RESULTS

VAS coverage for children aged 6-59 months was 42.8% (95% CI: 40.2, 45.6) in Mozambique, 46.1% (95% CI: 44.9, 47.4) in Senegal, 86.9% (95% CI: 85.8, 87.9) in Sierra Leone, and 42.4% (95% CI: 40.2, 44.6) in Tanzania and was significantly higher for children 6-11 vs. 24-59 months in Mozambique, Senegal, and Tanzania. In Sierra Leone, children aged 12-23 months (aOR = 1.86; 95% CI: 1.20, 2.86) and 24-59 months (aOR = 1.55; 95% CI: 1.07, 2.25) were more likely to receive VAS, compared to those 6-11 months. Maternal awareness of VAS programs was associated with higher uptake in Mozambique (aOR = 4.00; 95% CI: 2.81, 5.68), Senegal (aOR = 2.72; 95% CI: 2.35, 3.15), and Tanzania (aOR = 14.50; 95% CI: 10.98, 19.17). Increased household wealth was associated with a higher likelihood of child VAS in Senegal and Tanzania.

CONCLUSIONS

Our findings indicate routine delivery approaches for VAS are not achieving the level of coverage needed for public health impact in these settings. Intensive outreach efforts contributed to the higher coverage in Sierra Leone and highlight the importance of reducing the burdens associated with seeking supplementation at health facilities. As countries move towards incorporating VAS into routine health services, the essentiality of informed communities and potential losses for older children and socio-economically disadvantaged populations are key considerations in the sub-Saharan African context.

An anthropological history of Nepal's Female Community Health Volunteer program: gender, policy, and social change

BACKGROUND

Community health workers (CHWs) are central to Primary Health Care globally. Amidst the current flourishing of work on CHWs, there often is a lack of reference to history-even in studies of programs that have been around for decades. This study examines the 35-year trajectory of Nepal's Female Community Health Volunteers (FCHVs).

METHODS

We conducted a content analysis of an archive of primary and secondary research materials, grey literature and government reports collected during 1977-2019 across several regions in Nepal. Documents were coded in MAXQDA using principles of inductive coding. As questions arose from the materials, data were triangulated with published sources.

RESULTS

Looking across four decades of the program's history illuminates that issues of gender, workload, and pay-hotly debated in the CHW literature now-have been topics of discussion for observers and FCHVs alike since the inception of the program. Following experiments with predominantly male community volunteers during the 1970s, Nepal scaled up the all-female FCHV program in the late 1980s and early 1990s, in part because of programmatic goals focused on maternal and child health. FCHVs gained legitimacy as health workers in part through participation in donor-funded vertical campaigns. FCHVs received a stable yet modest regular stipend during the early years, but since it was stopped in the 1990s, incentives have been a mix of activity-based payments and in-kind support. With increasing outmigration of men from villages and growing work responsibilities for women, the opportunity cost of health volunteering increased. FCHVs started voicing their dissatisfaction with remuneration, which gave rise to labor movements starting in the 2010s. Government officials have not comprehensively responded to demands by FCHVs for decent work, instead questioning the relevance of FCHVs in a modern, medicalized Nepali health system.

CONCLUSIONS

Across public health, an awareness of history is useful in understanding the present and avoiding past mistakes. These histories are often not well-archived, and risk getting lost. Lessons from the history of Nepal's FCHV program have much to offer present-day debates around CHW policies, particularly around gender, workload and payment.

"Entonces, Como Promotores, Pues, No Somos Intérpretes": Reconciling Medical Interpretation & Community Health Work in Indiana and South Carolina

Community health workers (CHWs) and promotores de salud are frontline health workers who typically come from the communities they serve. Despite providing crucial services, they are not institutionalized (or integrated) within much of the U.S. health care system. Many work, either officially or unofficially, as medical interpreters-restricting their full impact as CHWs/ promotores . In this paper, we detail the misemployment and its effects among a subsample of CHWs/ promotores in two geographically distinct, exploratory projects. We encourage that collaborative research with CHWs/ promotores continue and that fidelity to the CHW model be ensured to realize their true potential.

'We need to get paid for our value': Work-place experiences and role definitions of peer recovery specialists/community health workers

Despite growing research on peer recovery specialists and community health workers (CHWs) in fields such as substance use disorder (SUD) treatment and recovery support, their workplace experiences are little understood. Through semi-structured interviews with 21 CHWs and peer recovery specialists working within substance use disorder treatment and/or traditional health care settings, we identified six prevalent themes: Benefits/Pleasures of the Role; Reciprocity; Challenges; Duality of Lived Experience; Relationships with Medical Professionals and Supervisors; and Defining Metrics. These themes reveal a complex narrative of system failures, organizational hierarchies, and experiential realities in which shared experiences and personal connections with clients undergird both positive and negative aspects of the role. In the words of one study participant: "We have not taken a vow of poverty, we need to get paid for our value."