National Community Health Worker Programme Research Articles

Measuring Health System Responsiveness in a national community health worker primary care program in rural Liberia.

As many low- and middle-income countries scale up community health worker (CHW) programs to achieve universal health coverage, ensuring quality as well as access is critical. Health system responsiveness (HSR) is a core domain of quality patient-centred care, but has not been widely measured in CHW-delivered care. We report results from a household survey measuring HSR and health systems quality of CHW-delivered care in two Liberian counties where the national CHW program of Community Health Assistants (CHAs) for communities five kilometres or more from a health center has been implemented. We conducted a cross-sectional population-based household survey in 2019 in Rivercess (RC) and Grand Gedeh (GG) counties, using a two-stage cross-sectional cluster sampling approach. We included validated HSR questions on six responsiveness domains and patient-reported health system outcomes, such as satisfaction and trust in the CHA's skills and abilities. The HSR questions were administered to women aged 18-49 who reported seeking care from a CHA in the three months prior to the survey. A composite responsiveness score was calculated and divided into tertiles. Multivariable analysis using Poisson regression with log link and adjusting for respondent characteristics was used to determine the association between responsiveness and patient-reported health system outcomes. The proportion of individuals rating responsiveness as very good or excellent were similar across all domains within a district, with ratings were lower in RC (23-29%) than GG (52-59%). High ratings in both counties were seen for high trust in the CHA's skills and abilities (GG 84%, RC 75) and high confidence in CHA (GG 58%, RC 60%). Compared with women in the lowest responsiveness tertile (score ≤3), women in the highest tertile (score 4.25) were significantly more likely to report high quality of CHA-delivered care (prevalence ratio, PR=14.1), very good/excellent at meeting health needs (PR=8.0), high confidence in the CHA to provide future care (PR=2.4), and high level of trust in CHA's skills and abilities (PR=1.4). Controlling for respondent characteristics, the composite responsiveness score was significantly associated with all patient-reported health system outcomes (P<0.001). We found that HSR was associated with important patient-reported health system quality outcomes, including satisfaction, trust, and confidence in the CHA. Measuring patients' experience and outcomes of care is important to complement more common measures of technical quality for CHW-delivered care to ensure that this domain of quality is central to community health program design and delivery.

Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia.

National community health worker (CHW) programmes were central to the vision of primary health care that emerged from the Alma-Ata declaration of 1978. CHWs were identified as agents who could offer basic medical treatment and promote community participation and empowerment. Despite the ambitions of this era, many national CHW programmes were neglected, starved of funding, or discontinued in the decades that followed. These programmes were difficult to sustain in a context of rising debt and structural adjustment, but they also suffered due to poor implementation and a lack of clarity about the role and identity of CHWs. Nevertheless, national CHW programmes have returned to the policy agenda in the past fifteen years and key figures and organisations within global health have begun to argue that they offer a way of strengthening health systems and achieving universal health coverage (UHC). Based on ethnographic research conducted between 2019 and 2020, this article examines a new national CHW programme that has been introduced in Zambia. However, as I show in this article, Zambia's new CHW programme has suffered from many of the same key problems that affected the programmes of the Alma-Ata era: insufficient funding, poor implementation, and a lack of clarity about the role of CHWs. This article shows how these mistakes have been repeated and asks why the lessons of the Alma-Ata era have been lost. Three central problems are identified: national CHW programmes continue to be underfunded and regarded as a "cheap" solution; global health organisations and actors today prioritise technical and quantitative approaches when they design and implement these programmes and therefore overlook the historical experiences and qualitative research of the past thirty years; and, finally, policymakers continue to gloss over the tensions and contradictions within the idea of the "community health worker" itself, creating unclear and unrealistic expectations for CHWs.

Application of primary healthcare principles in national community health worker programmes in low-income and middle-income countries: a scoping review

ObjectiveTo identify which primary healthcare (PHC) principles are reflected in the implementation of national community health worker (CHW) programmes and how they may contribute to the outcomes of these programmes...

Improvements in malaria testing and treatment after a national community health worker program in rural Liberia

Background Progress in reducing malaria incidence and deaths has stalled, in part due to limited access to quality malaria testing and treatment amongst rural populations. This time-series analysis aims to describe changes in rural malaria diagnosis and treatment before and during the rollout of Liberia’s National Community Health Assistant (CHA) program. It also explores how malaria service delivery changed during the COVID-19 epidemic. Methods Malaria diagnosis and treatment data from 315 rural health facility catchments supported by Liberia’s National CHA Program were collected from Liberia’s Health Management Information System and analyzed. Trends in malaria service delivery coverage and quality were assessed between January 2011 and December 2020. Results By 2020, four years after the program’s introduction, Liberia’s Community Health Assistants diagnosed 50% of rapid diagnostic test (RDT) or microscopy-confirmed malaria cases and carried out 51% of malaria treatments amongst children under age five in rural areas where CHAs were present. Furthermore, the percentage of malaria diagnoses that were confirmed by microscopy or RDT increased from 71% prior to the program to 95% in 2020. These results were effectively sustained in rural and remote communities during COVID-19 in 2020. Conclusions The introduction of Liberia’s CHA program was associated with improvements in the quality of malaria diagnoses and contributed to treating a significant share of the malaria burden amongst children under age five in remote rural communities across Liberia, and these improvements were sustained during COVID-19. Investments made in rural community health systems can be leveraged by policy makers to strengthen malaria diagnosis, treatment and control, especially in the age of COVID-19.

Two metres or one: what is the evidence for physical distancing in covid-19?

<h3>Objective</h3> To identify which primary healthcare (PHC) principles are reflected in the implementation of national community health worker (CHW) programmes and how they may contribute to the outcomes of these programmes in the context of low-income and middle-income countries (LMICs). <h3>Design</h3> Scoping review. <h3>Data sources</h3> A systematic search was conducted through PubMed, CINAHL, EMBASE and Scopus databases. <h3>Eligibility criteria</h3> The review considered published primary studies on national programmes, projects or initiatives using the services of CHWs in LMICs focused on maternal and child health. We included only English language studies. Excluded were programmes operated by non-government organisations, study protocols, reviews, commentaries, opinion papers, editorials and conference proceedings. <h3>Data extraction and synthesis</h3> We reviewed the application of four PHC principles (universal health coverage, community participation, intersectoral coordination and appropriateness) in the CHW programme’s objectives, implementation and stated outcomes. Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was not performed in this scoping review. <h3>Results</h3> From 1280 papers published between 1983 and 2019, 26 met the inclusion criteria. These 26 papers included 14 CHW programmes from 13 LMICs. Universal health coverage and community participation were the two commonly reported PHC principles, while intersectoral coordination was generally missing. Similarly, the cultural acceptability aspect of the principle of appropriateness was present in all programmes as these programmes select CHWs from within the communities. Other aspects, particularly effectiveness, were not evident. <h3>Conclusion</h3> The implementation of PHC principles across national CHW programmes in LMICs is patchy. For comprehensiveness and improved health outcomes, programmes need to incorporate all attributes of PHC principles. Future research may focus on how to incorporate more attributes of PHC principles while implementing national CHW programmes in LMICs. Better documentation and publications of CHW programme implementation are also needed.

Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa

IntroductionIn 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national...

The National Village Health Guide Scheme in India: lessons four decades later for community health worker programs today and tomorrow

BackgroundBased in part on the success of India’s early community health worker (CHW) programs, the Government of India launched in 1977 a national CHW scheme—the Village Health Guides (VHGs)—to provide preventive, promotive, and basic curative care to rural populations. Although this program had promising origins in smaller demonstration projects, it failed to deliver the hoped-for impact at scale and was abandoned. Based on extensive evidence and experience, the World Health Organization and the World Health Assembly have strongly endorsed the value of national CHW programs and their integration into national health systems. Surprisingly, given the scale and importance of the VHG program and its pioneering nature as a national CHW program, little has been published describing this experience. This article is the second in a series that focuses on critical issues that face the effectiveness of large-scale CHW programs.Case presentationSeveral systemic factors emerge as main contributors to the failure of the VHG Scheme, namely, a lack of support from the formal health sector, an overly hasty implementation of the scheme, and poor communication between the government and health centers about the role of the VHGs. The remuneration structure and the VHG selection process were at the root of the program’s shortcomings at the implementation level.ConclusionNational CHW schemes are an increasingly important tool for achieving universal health coverage and ending maternal and child deaths by 2030. Although the VHG Scheme was initiated over 40 years ago, the lessons described in this case highlight important considerations to help both current and future large-scale CHW programs avoid the same pitfalls.

Integrating community health workers into the formal health system to improve performance: a qualitative study on the role of on-site supervision in the South African programme

ObjectivesTo explore the role of on-site supervision in community health worker (CHW) programmes and CHW integration into the health system. We compared the functioning of CHW teams reporting to a...

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

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.

Next wave of interventions to reduce under-five mortality in Rwanda: a cross-sectional analysis of demographic and health survey data

BackgroundSustained investments in Rwanda’s health system have led to historic reductions in under five (U5) mortality. Although Rwanda achieved an estimated 68% decrease in the national under U5 mortality rate between 2002 and 2012, according to the national census, 5.8% of children still do not reach their fifth birthday, requiring the next wave of child mortality prevention strategies.MethodsThis is a cross-sectional study of 9002 births to 6328 women age 15–49 in the 2010 Rwanda Demographic and Health Survey. We tested bivariate associations between 29 covariates and U5 mortality, retaining covariates with an odds ratio p < 0.1 for model building. We used manual backward stepwise logistic regression to identify correlates of U5 mortality in all children U5, 0–11 months, and 12–59 months. Analyses were performed in Stata v12, adjusting for complex sample design.ResultsOf 14 covariates associated with U5 mortality in bivariate analysis, the following remained associated with U5 mortality in multivariate analysis: household being among the poorest of the poor (OR = 1.98), child being a twin (OR = 2.40), mother having 3–4 births in the past 5 years (OR = 3.97) compared to 1–2 births, mother being HIV positive (OR = 2.27), and mother not using contraceptives (OR = 1.37) compared to using a modern method (p < 0.05 for all). Mother experiencing physical or sexual violence in the last 12 months was associated with U5 mortality in children ages 1–4 years (OR = 1.48, p < 0.05). U5 survival was associated with a preceding birth interval 25–50 months (OR = 0.67) compared to 9–24 months, and having a mosquito net (OR = 0.46) (p < 0.05 for both).ConclusionsIn the past decade, Rwanda rolled out integrated management of childhood illness, near universal coverage of childhood vaccinations, a national community health worker program, and a universal health insurance scheme. Identifying factors that continue to be associated with childhood mortality supports determination of which interventions to strengthen to reduce it further. This study suggests that Rwanda’s next wave of U5 mortality reduction should target programs in improving neonatal outcomes, poverty reduction, family planning, HIV services, malaria prevention, and prevention of intimate partner violence.

Supporting and retaining Village Health Teams: an assessment of a community health worker program in two Ugandan districts

BackgroundUganda’s national community health worker program involves volunteer Village Health Teams (VHTs) delivering basic health services and education. Evidence demonstrates their positive impact on health outcomes, particularly for Ugandans who would otherwise lack access to health services. Despite their impact, VHTs are not optimally supported and attrition is a growing problem. In this study, we examined the support needs and existing challenges of VHTs in two Ugandan districts and evaluated specific factors associated with long-term retention. We report on findings from a standardized survey of VHTs and exploratory interviews with key stakeholders and draw conclusions that inform efforts to strengthen and sustain community health care delivery in Uganda.MethodsA mixed-methods approach was employed through a survey of 134 individual VHT members and semi-structured interviews with six key stakeholders. Descriptive and bivariate regression analysis of quantitative survey data was performed along with thematic analysis of qualitative data from surveys and interviews. In the regression analysis, the dependent variable is 10-year anticipated longevity among VHTs, which asked respondents if they anticipate continuing to volunteer as VHTs for at least 10 more years if their current situation remains unchanged.ResultsVHTs desire additional support primarily in the forms of money (e.g. transportation allowance) and material supplies (e.g. rubber boots). VHTs commonly report difficult working conditions and describe a lack of respect from their communities and other health workers. If their current situation remains unchanged, 57% of VHTs anticipate remaining in their posts for at least 10 years. Anticipated 10-year longevity was positively associated with stronger partnerships with local health center staff and greater ease in home visiting.ConclusionsSupporting and retaining Uganda’s VHTs would be enhanced by building stronger partnerships between VHTs and other health workers and regularly providing supplies and transportation allowances. Pursuing such measures would likely improve equity in access to healthcare for all Ugandans.

Community health worker programmes after the 2013-2016 Ebola outbreak.

The 2013-2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security. (1) Chronically fragile and under-resourced health systems (2) enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11310 deaths (as of 5 May 2016) (3) in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating. (4) Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public's lack of access to health services. (1) Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilization of communities when an outbreak has been identified. In this paper we make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems. Community health workers provide health education, gather information and deliver basic curative and preventive services at the community and household levels. They were first deployed in China nearly a century ago and have been deployed by both nongovernmental organizations (NGOs) and national governments over the past half-century. (5) Although community health workers play diverse roles, they share common features: they receive limited formal training and are recruited from and work in their own communities. (6) They are therefore uniquely positioned to promote healthy household practices and appropriate health-care-seeking behaviours. Large-scale national community health worker programmes are the cornerstones of primary health-care systems in many countries that have been pacesetters in improving the health of their populations, such as Brazil, Ethiopia, Malawi, Nepal and Rwanda. (7) Yet the failure of several national community health worker programmes in the 1970s and 1980s resulted in a loss of momentum for the movement. As a result of the growing success of the current programmes, (5,7) there is renewed global interest in using community health workers to strengthen primary health-care systems towards the goals of achieving universal health coverage and ending preventable child and maternal deaths. During the most recent Ebola outbreak, community health workers played several important roles. They worked with community leaders, going house to house to provide important information about Ebola and searching for active cases and contacts, (8) and they helped local religious leaders to expand their education and outreach strategies, especially in efforts to reduce transmission during funerals and burials. Many community-based agents, including community health workers working with NGOs, were deployed for contact tracing, community sensitization, promotion of epidemiologically and culturally appropriate protective practices, and data collection. (8) Networks of community health workers played key roles in limiting the spread of Ebola virus infection within Nigeria in July 2014. (9) Community health workers who were normally engaged in polio eradication initiatives were rapidly redeployed to detect patients with Ebola virus and trace their contacts. …

Selection and performance of village health teams (VHTs) in Uganda: lessons from the natural helper model of health promotion.

BackgroundCommunity health worker (CHW) programmes have received much attention since the 1978 Declaration of Alma-Ata, with many initiatives established in developing countries. However, CHW programmes often suffer high attrition once the initial enthusiasm of volunteers wanes. In 2002, Uganda began implementing a national CHW programme called the village health teams (VHTs), but their performance has been poor in many communities. It is argued that poor community involvement in the selection of the CHWs affects their embeddedness in communities and success. The question of how selection can be implemented creatively to sustain CHW programmes has not been sufficiently explored. In this paper, our aim was to examine the process of the introduction of the VHT strategy in one rural community, including the selection of VHT members and how these processes may have influenced their work in relation to the ideals of the natural helper model of health promotion.MethodsAs part of a broader research project, an ethnographic study was carried out in Luwero district. Data collection involved participant observation, 12 focus group discussions (FGDs), 14 in-depth interviews with community members and members of the VHTs and four key informant interviews. Interviews and FGD were recorded, transcribed and coded in NVivo. Emerging themes were further explored and developed using text query searches. Interpretations were confirmed by comparison with findings of other team members.ResultsThe VHT selection process created distrust, damaging the programme’s legitimacy. While the Luwero community initially had high expectations of the programme, local leaders selected VHTs in a way that sidelined the majority of the community’s members. Community members questioned the credentials of those who were selected, not seeing the VHTs as those to whom they would go to for help and support. Resentment grew, and as a result, the ways in which the VHTs operated alienated them further from the community. Without the support of the community, the VHTs soon lost morale and stopped their work.ConclusionAs the natural helper model recommends, in order for CHW programmes to gain and maintain community support, it is necessary to utilize naturally existing informal helping networks by drawing on volunteers already trusted by the people being served. That way, the community will be more inclined to trust the advice of volunteers and offer them support in return, increasing the likelihood of the sustainability of their service in the community.

Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects

After a decline in enthusiasm for national community health worker (CHW) programmes in the 1980s, these have re-emerged globally, particularly in the context of HIV. This paper examines the case of South Africa, where there has been rapid growth of a range of lay workers (home-based carers, lay counsellors, DOT supporters etc.) principally in response to an expansion in budgets and programmes for HIV, most recently the rollout of antiretroviral therapy (ART). In 2004, the term community health worker was introduced as the umbrella concept for all the community/lay workers in the health sector, and a national CHW Policy Framework was adopted. We summarize the key features of the emerging national CHW programme in South Africa, which include amongst others, their integration into a national public works programme and the use of non-governmental organizations as intermediaries. We then report on experiences in one Province, Free State. Over a period of 2 years (2004--06), we made serial visits on three occasions to the first 16 primary health care facilities in this Province providing comprehensive HIV services, including ART. At each of these visits, we did inventories of CHW numbers and training, and on two occasions conducted facility-based group interviews with CHWs (involving a total of 231 and 182 participants, respectively). We also interviewed clinic nurses tasked with supervising CHWs. From this evaluation we concluded that there is a significant CHW presence in the South African health system. This infrastructure, however, shares many of the managerial challenges (stability, recognition, volunteer vs. worker, relationships with professionals) associated with previous national CHW programmes, and we discuss prospects for sustainability in the light of the new policy context.