Expanding the use of community health workers in urban settings: a potential strategy for progress towards universal health coverage

Scaling severe acute malnutrition treatment with community health workers: a geospatial coverage analysis in rural Mali

BACKGROUND

In 2015, the Ministry of Health in Mali included the treatment of severe acute malnutrition (SAM) into the package of activities of the integrated Community Case Management (iCCM). This paper aims to analyze the impact of including community health workers (CHWs) as treatment providers outside the Health Facilities (HFs) on the coverage of SAM treatment when scaling up the intervention in the three largest districts of the Kayes Region in Mali.

METHODS

A baseline coverage assessment was conducted in August 2017 in the three districts before the CHWs started treating SAM. The end-line assessment was conducted one year later, in August 2018. Coverage was assessed by the standardized methodology called Semi-Quantitative Evaluation of Access and Coverage (SQUEAC). The primary outcome was treatment coverage and other variables evaluated were the geographical distribution of the HFs, CHW's sites and overlapping between both health providers, the estimation of children with geographical access to health care and the estimation of children screened for acute malnutrition in their communities.

RESULTS

Treatment coverage increased in Kayes (28.7-57.1%) and Bafoulabé (20.4-61.1%) but did not in Kita (28.4-28.5%). The decentralization of treatment has not had the same impact on coverage in all districts, with significant differences. The geospatial analyses showed that Kita had a high proportion of overlap between HFs and/or CHWs 48.7% (39.2-58.2), a high proportion of children without geographical access to health care 70.4% (70.1-70.6), and a high proportion of children not screened for SAM in their communities 52.2% (51.9-52.5).

CONCLUSIONS

Working with CHWs in SAM increases treatment coverage, but other critical aspects need to be considered by policymakers if this intervention model is intended to be scaled up at the country level. To improve families' access to nutritional health care, before establishing decentralized treatment in a whole region it must be considered the geographical location of CHWs. This previous assessment will avoid overlap among health providers and ensure the coverage of all unserved areas according to their population densities need.

TRIAL REGISTRATION

ISRCTN registry with ID 1990746. https://doi.org/10.1186/ISRCTN14990746.

Family health sheets: a vital instrument for village health workers providing comprehensive healthcare

INTRODUCTION

Community Health Worker (CHW) programs have long been used to provide acute care for children and women in healthcare shortage areas, but their provision of comprehensive longitudinal care for chronic problems is rare. The Village Health Worker (VHW) program, initiated in 2007, is an example of a long standing "horizontal" CHW program in rural Southwestern Uganda that has delivered village-level care for chronic disease based on a biannual village health census that identifies individual and family health risks. To facilitate continuity of care for problems identified, health census data were electronically transformed into family-specific Family Health Sheets (FHS) in 2016 which summarize the pertinent demographic and health data for each family, as well as health topics the family would like to learn more about. The FHS, evaluated and discussed here, serves as an epidemiologically-informed "bedside" tool to help VHWs provide longitudinal care in their villages.

METHODS

48 VHWs in the program completed a survey on the utility of the FHS and 24 VHWs participated in small discussion groups. Responses were analyzed using both quantitative and standard conceptual content analysis models RESULTS: 46 out of 48 VHWs reported that the FHS made them a "much better VHW." In addition to helping target interventions in child health, women's health, and sanitation, the FHS assisted follow-up of non-communicable diseases in the community. In discussion groups, VHWs reported that the FHS helped them understand risks for future disease, facilitated earning stipends, and increased credibility and trust in the community. Limitations cited were the infrequent updates of the FHS, only biannually with the census, and the lack of cross-reference capability by health problem.

DISCUSSION

The FHS supports VHWs in providing longitudinal and comprehensive healthcare of chronic diseases in their villages. Limitations, potential solutions, and future directions are discussed.

Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All"

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.

Community health worker models in South Africa: a qualitative study on policy implementation of the 2018/19 revised framework

South Africa has a long history of community health workers (CHWs). It has been a journey that has required balancing constrained resources and competing priorities. CHWs form a bridge between communities and healthcare service provision within health facilities and act as the cornerstone of South Africa’s Ward-Based Primary Healthcare Outreach Teams. This study aimed to document the CHW policy implementation landscape across six provinces in South Africa and explore the reasons for local adaptation of CHW models and to identify potential barriers and facilitators to implementation of the revised framework to help guide and inform future planning. We conducted a qualitative study among a sample of Department of Health Managers at the National, Provincial and District level, healthcare providers, implementing partners [including non-governmental organizations (NGOs) who worked with CHWs] and CHWs themselves. Data were collected between April 2018 and December 2018. We conducted 65 in-depth interviews (IDIs) with healthcare providers, managers and experts familiar with CHW work and nine focus group discussions (FGDs) with 101 CHWs. We present (i) current models of CHW policy implementation across South Africa, (ii) facilitators, (iii) barriers to CHW programme implementation and (iv) respondents’ recommendations on how the CHW programme can be improved. We chronicled the differences in NGO involvement, the common facilitators of purpose and passion in the CHWs’ work and the multitude of barriers and resource limitations CHWs must work under. We found that models of implementation vary greatly and that adaptability is an important aspect of successful implementation under resource constraints. Our findings largely aligned to existing research but included an evaluation of districts/provinces that had not previously been explored together. CHWs continue to promote health and link their communities to healthcare facilities, in spite of lack of permanent employment, limited resources, such as uniforms, and low wages.

Community-based health workers implementing universal access to HIV testing and treatment: lessons from South Africa and Zambia-HPTN 071 (PopART)

The global expansion of HIV testing, prevention and treatment services is necessary to achieve HIV epidemic control and promote individual and population health benefits for people living with HIV (PLHIV) in sub-Saharan Africa. Community-based health workers (CHWs) could play a key role in supporting implementation at scale. In the HPTN 071 (PopART) trial in Zambia and South Africa, a cadre of 737 study-specific CHWs, working closely with government-employed CHW, were deployed to deliver a ‘universal’ door-to-door HIV prevention package, including an annual offer of HIV testing and referral services for all households in 14 study communities. We conducted a process evaluation using qualitative and quantitative data collected during the trial (2013–2018) to document the implementation of the CHW intervention in practice. We focused on the recruitment, retention, training and support of CHWs, as they delivered study-specific services. We then used these descriptions to: (i) analyse the fidelity to design of the delivery of the intervention package, and (ii) suggest key insights for the transferability of the intervention to other settings. The data included baseline quantitative data collected with the study-specific CHWs (2014–2018); and qualitative data from key informant interviews with study management (n = 91), observations of CHW training events (n = 12) and annual observations of and group discussions (GD) with intervention staff (n = 68). We show that it was feasible for newly recruited CHWs to implement the PopART intervention with good fidelity, supporting the interpretation of the trial outcome findings. This was despite some challenges in managing service quality and CHW retention in the early years of the programme. We suggest that by prioritizing the adoption of key elements of the in-home HIV services delivery intervention model—including training, emotional support to workers, monitoring and appropriate remuneration for CHWs—these services could be successfully transferred to new settings.

Community health workers' efforts to build health system trust in marginalised communities: a qualitative study from South Africa

INTRODUCTION

Community health workers (CHWs) enable marginalised communities, often experiencing structural poverty, to access healthcare. Trust, important in all patient-provider relationships, is difficult to build in such communities, particularly when stigma associated with HIV/AIDS, tuberculosis and now COVID-19, is widespread. CHWs, responsible for bringing people back into care, must repair trust. In South Africa, where a national CHW programme is being rolled out, marginalised communities have high levels of unemployment, domestic violence and injury.

OBJECTIVES

In this complex social environment, we explored CHW workplace trust, interpersonal trust between the patient and CHW, and the institutional trust patients place in the health system.

DESIGN, PARTICIPANTS, SETTING

Within the observation phase of a 3-year intervention study, we conducted interviews, focus groups and observations with patients, CHWs, their supervisors and, facility managers in Sedibeng.

RESULTS

CHWs had low levels of workplace trust. They had recently been on strike demanding better pay, employment conditions and recognition of their work. They did not have the equipment to perform their work safely, and some colleagues did not trust, or value, their contribution. There was considerable interpersonal trust between CHWs and patients, however, CHWs' efforts were hampered by structural poverty, alcohol abuse and no identification documents among long-term migrants. Those supervisors who understood the extent of the poverty supported CHW efforts to help the community. When patients had withdrawn from care, often due to nurses' insensitive behaviour, the CHWs' attempts to repair patients' institutional trust often failed due to the vulnerabilities of the community, and lack of support from the health system.

CONCLUSION

Strategies are needed to build workplace trust including supportive supervision for CHWs and better working conditions, and to build interpersonal and institutional trust by ensuring sensitivity to social inequalities and the effects of structural poverty among healthcare providers. Societies need to care for everyone.

A Cross-Sectional Survey Analyzing Community Perception and Utilization of Village Health Workers Stratified by the Urban-Rural Divide Within the Kingdom of Bhutan

Village health workers (VHWs) serve as an integral health resource for many resource limited nations, including the Kingdom of Bhutan. As such, we aimed to identify community perceptions as well as utilization rates and types with relation to VHWs based on the urban-rural divide. Our team conducted a randomized survey of 429 community members in 14 villages within the Western region of Bhutan. Our findings indicate VHWs in rural communities are requested for their services twice as much as their urban counterparts. More specifically, urban VHWs are utilized 2.5 times more for general community services, while rural VHWs are utilized more for accessing medications. Additionally, our research indicates a need to increase training of VHWs as well as overall program promotion relating to the specific services that VHWs can provide. These investigations indicate the importance of differentially allocating resources, programming, and training based on the urban-rural divide.

Developing a Common Understanding of Networks of Care through a Scoping Study

The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.

Connecting communities to primary care: a qualitative study on the roles, motivations and lived experiences of community health workers in the Philippines

Background

Community health workers (CHWs) are an important cadre of the primary health care (PHC) workforce in many low- and middle-income countries (LMICs). The Philippines was an early adopter of the CHW model for the delivery of PHC, launching the Barangay (village) Health Worker (BHW) programme in the early 1980s, yet little is known about the factors that motivate and sustain BHWs’ largely voluntary involvement. This study aims to address this gap by examining the lived experiences and roles of BHWs in urban and rural sites in the Philippines.

Methods

This cross-sectional qualitative study draws on 23 semi-structured interviews held with BHWs from barangays in Valenzuela City (urban) and Quezon province (rural). A mixed inductive/ deductive approach was taken to generate themes, which were interpreted according to a theoretical framework of community mobilisation to understand how characteristics of the social context in which the BHW programme operates act as facilitators or barriers for community members to volunteer as BHWs.

Results

Interviewees identified a range of motivating factors to seek and sustain their BHW roles, including a variety of financial and non-financial incentives, gaining technical knowledge and skill, improving the health and wellbeing of community members, and increasing one’s social position. Furthermore, ensuring BHWs have adequate support and resources (e.g. allowances, medicine stocks) to execute their duties, and can contribute to decisions on their role in delivering community health services could increase both community participation and the overall impact of the BHW programme.

Conclusions

These findings underscore the importance of the symbolic, material and relational factors that influence community members to participate in CHW programmes. The lessons drawn could help to improve the impact and sustainability of similar programmes in other parts of the Philippines and that are currently being developed or strengthened in other LMICs.