Background: Community health workers (CHWs) can play vital roles in increasing coverage of basic health services. However, there is a need for a systematic categorisation of CHWs that will aid common ...understanding among policy makers, programme planners, and researchers.
Objective: To identify the common themes in the definitions and descriptions of CHWs that will aid delineation within this cadre and distinguish CHWs from other healthcare providers.
Design: A systematic review of peer-reviewed papers and grey literature.
Results: We identified 119 papers that provided definitions of CHWs in 25 countries across 7 regions. The review shows CHWs as paraprofessionals or lay individuals with an in-depth understanding of the community culture and language, have received standardised job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community. CHWs can be categorised into three groups by education and pre-service training. These are lay health workers (individuals with little or no formal education who undergo a few days to a few weeks of informal training), level 1 paraprofessionals (individuals with some form of secondary education and subsequent informal training), and level 2 paraprofessionals (individuals with some form of secondary education and subsequent formal training lasting a few months to more than a year). Lay health workers tend to provide basic health services as unpaid volunteers while level 1 paraprofessionals often receive an allowance and level 2 paraprofessionals tend to be salaried.
Conclusions: This review provides a categorisation of CHWs that may be useful for health policy formulation, programme planning, and research.
Community health workers (CHWs) have been identified as a critical bridge to reaching many communities with essential health services based on their social and geographical proximity to community ...residents. However, various challenges limit their performance, especially in low-and middle-income countries. With the view to guiding global and local stakeholders on how best to support CHWs, this study explored common challenges of different CHW cadres in various contexts. We conducted 36 focus group discussions and 131 key informant interviews in Bangladesh, India, Kenya, Malawi, and Nigeria. The study covered 10 CHW cadres grouped into Level 1 and Level 2 health paraprofessionals based on education and training duration, with the latter having a longer engagement. Data were analysed using thematic analysis. We identified three critical challenges of CHWs. First, inadequate knowledge affected service delivery and raised questions about the quality of CHW services. CHWs' insufficient knowledge was partly explained by inadequate training opportunities and the inability to apply new knowledge due to equipment unavailability. Second, their capacity for service coverage was limited by a low level of infrastructural support, including lack of accommodation for Level 2 paraprofessional CHWs, inadequate supplies, and lack of transportation facilities to convey women in labour. Third, the social dimension relating to the acceptance of CHWs' services was not guaranteed due to local socio-cultural beliefs, CHW demographic characteristics such as sex, and time conflict between CHWs' health activities and community members' daily routines. To optimise the performance of CHWs in LMICs, pertinent stakeholders, including from the public and third sectors, require a holistic approach that addresses health system challenges relating to training and structural support while meaningfully engaging the community to implement social interventions that enhance acceptance of CHWs and their services.
Background Community health workers (CHWs) have been identified as a critical bridge to reaching many communities with essential health services based on their social and geographical proximity to ...community residents. However, various challenges limit their performance, especially in low-and middle-income countries. With the view to guiding global and local stakeholders on how best to support CHWs, this study explored common challenges of different CHW cadres in various contexts. Methods We conducted 36 focus group discussions and 131 key informant interviews in Bangladesh, India, Kenya, Malawi, and Nigeria. The study covered 10 CHW cadres grouped into Level 1 and Level 2 health paraprofessionals based on education and training duration, with the latter having a longer engagement. Data were analysed using thematic analysis. Results We identified three critical challenges of CHWs. First, inadequate knowledge affected service delivery and raised questions about the quality of CHW services. CHWs’ insufficient knowledge was partly explained by inadequate training opportunities and the inability to apply new knowledge due to equipment unavailability. Second, their capacity for service coverage was limited by a low level of infrastructural support, including lack of accommodation for Level 2 paraprofessional CHWs, inadequate supplies, and lack of transportation facilities to convey women in labour. Third, the social dimension relating to the acceptance of CHWs’ services was not guaranteed due to local socio-cultural beliefs, CHW demographic characteristics such as sex, and time conflict between CHWs’ health activities and community members’ daily routines. Conclusion To optimise the performance of CHWs in LMICs, pertinent stakeholders, including from the public and third sectors, require a holistic approach that addresses health system challenges relating to training and structural support while meaningfully engaging the community to implement social interventions that enhance acceptance of CHWs and their services.
Optimising community health worker (CHW) programmes requires evidence-based policies on their education, deployment, and management. This guideline aims to inform efforts by planners, policy makers, ...and managers to improve CHW programmes as part of an integrated approach to strengthen primary health care and health systems. The development of this guideline followed the standard WHO approach to developing global guidelines. We conducted one overview of reviews, 15 systematic reviews (each one on a specific policy question), and a survey of stakeholders' views on the acceptability and feasibility of the interventions under consideration. We assessed the quality of systematic reviews using the AMSTAR tool, and the certainty of the evidence using the GRADE methodology. The overview of reviews identified 122 eligible articles and the systematic reviews identified 137 eligible primary studies. The stakeholder perception survey obtained inputs from 96 respondents. Recommendations were developed in the areas of CHW selection, preservice education, certification, supervision, remuneration and career advancement, planning, community embeddedness, and health system support. These are the first evidence-based global guidelines for health policy and system support to optimise community health worker programmes. Key considerations for implementation include the need to define the role of CHWs in relation to other health workers and plan for the health workforce as a whole rather than by specific occupational groups; appropriately integrate CHW programmes into the general health system and existing community systems; and ensure internal coherence and consistency across different policies and programmes affecting CHWs.
As countries continue to invest in quality improvement (QI) initiatives in health facilities, it is important to acknowledge the role of context in implementation. We conducted a qualitative study ...between February 2019 and January 2020 to explore how a QI initiative was adapted to enable implementation in three facility types: primary health centres, public hospitals and private facilities in Lagos State, Nigeria.
Despite a common theory of change, implementation of the initiative needed to be adapted to accommodate the local needs, priorities and organisational culture of each facility type. Across facility types, inadequate human and capital resources constrained implementation and necessitated an extension of the initiative’s duration. In public facilities, the local governance structure was adapted to facilitate coordination, but similar adaptations to governance were not possible for private facilities. Our findings highlight the importance of anticipating and planning for the local adaptation of QI initiatives according to implementation environment.
Over 80,000 pregnant women died in Nigeria due to pregnancy-related complications in 2020. Evidence shows that if appropriately conducted, caesarean section (CS) reduces the odds of maternal death. ...In 2015, the World Health Organization (WHO), in a statement, proposed an optimal national prevalence of CS and recommended the use of Robson classification for classifying and determining intra-facility CS rates. We conducted this systematic review and meta-analysis to synthesise evidence on prevalence, indications, and complications of intra-facility CS in Nigeria.
Four databases (African Journals Online, Directory of Open Access Journals, EBSCOhost, and PubMed) were systematically searched for relevant articles published from 2000 to 2022. Articles were screened following the PRISMA guidelines, and those meeting the study's inclusion criteria were retained for review. Quality assessment of included studies was conducted using a modified Joanna Briggs Institute's Critical Appraisal Checklist. Narrative synthesis of CS prevalence, indications, and complications as well as a meta-analysis of CS prevalence using R were conducted.
We retrieved 45 articles, with most (33 (64.4%)) being assessed as high quality. The overall prevalence of CS in facilities across Nigeria was 17.6%. We identified a higher prevalence of emergency CS (75.9%) compared to elective CS (24.3%). We also identified a significantly higher CS prevalence in facilities in the south (25.5%) compared to the north (10.6%). Furthermore, we observed a 10.7% increase in intra-facility CS prevalence following the implementation of the WHO statement. However, none of the studies adopted the Robson classification of CS to determine intra-facility CS rates. In addition, neither hierarchy of care (tertiary or secondary) nor type of facility (public or private) significantly influenced intra-facility CS prevalence. The commonest indications for a CS were previous scar/CS (3.5-33.5%) and pregnancy-related hypertensive disorders (5.5-30.0%), while anaemia (6.4-57.1%) was the most reported complication.
There are disparities in the prevalence, indications, and complications of CS in facilities across the geopolitical zones of Nigeria, suggestive of concurrent overuse and underuse. There is a need for comprehensive solutions to optimise CS provision tailor-made for zones in Nigeria. Furthermore, future research needs to adopt current guidelines to improve comparison of CS rates.
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 was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five electronic databases were searched with a prespecified strategy and the grey literature examined, January 2006–March 2021. Papers containing information on (1) the percentage of CHWs stocked out or (2) 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 15 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.
Conclusions
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.
Abstract
Background
The consequences of delays in travel of pregnant women to reach facilities in emergency situations are well documented in literature. However, their decision-making and actual ...experiences of travel to health facilities when requiring emergency obstetric care (EmOC) remains a ‘black box’ of many unknowns to the health system, more so in megacities of low- and middle-income countries which are fraught with wide inequalities.
Methods
This in-depth study on travel of pregnant women in Africa’s largest megacity, Lagos, is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Following familiarisation, coding, and searching for patterns, the data was analysed for emerging themes.
Results
Despite recognising danger signs, pregnant women are often faced with conundrums on “when”, “where” and “how” to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choices vary depending on socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time was between 5 and 240 min in daytime and 5–40 min at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had a personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women.
Conclusion
If the goal, to leave no one behind, remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved. Advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored.
Female genital mutilation (FGM) is an age-old practice that has since been linked with many health problems. This review aims to highlight some of the controversies trailing the relationship between ...FGM and FJIV transmission in sub-Saharan Africa. A literature search was conducted on the subject matter. This was done using articles published in English while limiting the geographical coverage to sub-Saharan Africa. Three themes were noted. These themes include: Direct causal link between FGM and HIV transmission; indirect causal link between FGM and HIV transmission and a negative or no association between FGM and HIV transmission. While many of the arguments are within scientific reasoning, the researches supporting the views seem to lack the necessary objectivity. This study underscored the need for a more objective lens in viewing and conducting research on the relationship between FGM and HIV transmission in sub-Saharan Africa. Les mutilations génitales féminines (MGF) est une pratique séculaire qui a depuis été lié à de nombreux problèmes de santé. Cet examen vise à ressortir certaines des controverses suscitées par la relation entre les MGF et la transmission du VIH en Afrique subsaharienne. Une recherche bibliographique a été menée sur le sujet. Cela a été fait en utilisant des articles publiés en anglais, tout en limitant la couverture géographique à l'Afrique subsaharienne. Trois thèmes ont été notés. Ces thèmes sont les suivants: Lien de causalité direct entre les MGF et la transmission du VIH; le lien indirect de causalité entre les MGF et la transmission du VIH et une association négative ou nulle entre les MGF et la transmission du VIH. Alors que la plupart des arguments sont dans le raisonnement scientifique, les recherches qui soutiennent les opinions ne semblent pas avoir l'objectivité nécessaire. Cette étude souligne la nécessité d'une lentille plus objective dans la visualisation et la recherche sur la relation entre les MGF et la transmission du VIH en Afrique subsaharienne.
ObjectiveMaking sure the right type of health workers are available in the right place is crucial to achieve universal health coverage. The Global Fund Strategic Initiative 2020-2023 aims to improve ...the distribution of health workers at decentralized level in Chad, DRC, Mali, Niger and Nigeria. Within this project, technical support is provided to governments to strengthen priority setting processes for the selection of health workforce interventions. This study aims to share lessons learned on the contextualization of technical support across five different countries.MethodsBetween September 2021-February 2022, for each country, a document review was done to understand health worker issues and the policy context. An inventory was made of available health workforce data and evidence. About 15 stakeholder per country were interviewed on their roles, knowledge, interests and power related to health workforce issues. An institutional capacity assessment studied the capability of ministry of health to facilitate the priority setting process. The researchers collected lessons learned on the contextualization process using project update sheets.ResultsContextual factors that played a role in the adaptation of technical support were decision space at decentralized level, covid-19 pandemic, travel security, fiscal space for health workforce interventions, stakeholders views on health workers issues, stakeholder’s interest and political support for specific interventions, data and evidence base, timing of future policy processes, presence and potential synergy with other technical support projects and capacity of the government health workforce focal point in convening stakeholders.DiscussionThis is one of the first studies reporting on technical support for priority setting for health workforce interventions. In contextualizing technical support a broad range of factors need to be taken into account which may be relevant for other settings too. In contextualization a critical reflection is needed on the influence of the funder and provider of technical support.
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