The Governance of National Community Health Worker Programmes in Low- and Middle-Income Countries: An Empirically Based Framework of Governance Principles, Purposes and Tasks.

Helen Schneider

doi:10.15171/ijhpm.2018.92

Abstract

Background: National community health worker (CHW) programmes are increasingly regarded as an integral component of primary healthcare (PHC) in low- and middle-income countries (LMICs). At the interface of the formal health system and communities, CHW programmes evolve in context specific ways, with unique cadres and a variety of vertical and horizontal relationships. These programmes need to be appropriately governed if they are to succeed, yet there is little evidence or guidance on what this entails in practice. Based on empirical observations of South Africa’s community-based health sector and informed by theoretical insights on governance, this paper proposes a practical framework for the design and strengthening of CHW programme governance at scale. Methods: Conceptually, the framework is based on multi-level governance thinking, that is, the distributed, negotiated and iterative nature of decision-making, and the rules, processes and relationships that support this in health systems. The specific purposes and tasks of CHW programme governance outlined in the framework draw from observations and published case study research on the formulation and early implementation of the Ward Based Outreach Team strategy in South Africa. Results: The framework is presented as a set of principles and a matrix of 5 key governance purposes (or outputs). These purposes are: a negotiated fit between policy mandates and evidence, histories and strategies of community-based services; local organisational and accountability relationships that provide community-based actors with sufficient autonomy and power to act; aligned and integrated programme management systems; processes that enable system learning, adaptation and change; and sustained political support. These purposes are further elaborated into 17 specific tasks, distributed across levels of the health system (national, regional, and local). Conclusion: In systematising the governance functions in CHW programmes, the paper seeks to shed light on how best to support and strengthen these functions at scale.

Highlights

The last decade has seen a massive growth of interest in community health worker (CHW) programmes and their role in achieving health outcomes and universal health coverage.[1]
EPublished: 18 September 2018 horizontal relationships. These programmes need to be appropriately governed if they are to succeed, yet there is little evidence CorlegmuideatnAceskonhewihmat, tKhirsisetnitnailHs iengpgreanct,iEcei.vBinasdedEonngeembrpeirtisceanl o**bservations of South Africa’s community-based health sector and informed by theoretical insights on governance, this paper proposes a practical framework for the design and strengthening of CHW programme governance at scale
Drawing on a combination of empirical observations of reforms to South Africa’s community-based health sector, conducted by the author, and conceptual thinking on health system governance, this paper proposes a multi-level framework for the governance of national CHW programmes in low- and middle-income countries (LMICs), relevant to federal or decentralised health systems

Summary

Introduction

The last decade has seen a massive growth of interest in community health worker (CHW) programmes and their role in achieving health outcomes and universal health coverage.[1]. The current generation of reforms to community-based sectors is occurring on the back of longer histories,[4,5] which have shaped attitudes, sometimes sceptical, towards national CHW programmes, but have led to multiple, fragmented and uncoordinated initiatives on the ground.[6] In many countries, new interventions in this sector are in effect a revitalisation, consolidation or expansion of existing forms of delivery that evolved over decades. These new initiatives have to take into account the varied and context-specific nature of existing community health systems if they are to be successfully implemented.[3]

Methods

Results

Discussion

Conclusion