Community health workers at the dawn of a new era: 3. Programme governance

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Abstract

Background

Community health workers (CHWs) can play a critical role in primary healthcare and are seen widely as important to achieving the health-related Sustainable Development Goals (SDGs). The COVID-19 pandemic has emphasized the key role of CHWs. Improving how CHW programmes are governed is increasingly recognized as important for achieving universal access to healthcare and other health-related goals. This paper, the third in a series on “Community Health Workers at the Dawn of a New Era”, aims to raise critical questions that decision-makers need to consider for governing CHW programmes, illustrate the options for governance using examples of national CHW programmes, and set out a research agenda for understanding how CHW programmes are governed and how this can be improved.

Methods

We draw from a review of the literature as well as from the knowledge and experience of those involved in the planning and management of CHW programmes.

Results

Governing comprises the processes and structures through which individuals, groups, programmes, and organizations exercise rights, resolve differences, and express interests. Because CHW programmes are located between the formal health system and communities, and because they involve a wide range of stakeholders, their governance is complex. In addition, these programmes frequently fall outside of the governance structures of the formal health system or are poorly integrated with it, making governing these programmes more challenging. We discuss the following important questions that decision-makers need to consider in relation to governing CHW programmes: (1) How and where within political structures are policies made for CHW programmes? (2) Who implements decisions regarding CHW programmes and at what levels of government? (3) What laws and regulations are needed to support the programme? (4) How should the programme be adapted across different settings or groups within the country or region?

Conclusion

The most appropriate and acceptable models for governing CHW programmes depend on communities, on local health systems, and on the political system in which the programme is located. Stakeholders in each setting need to consider what systems are currently in place and how they might be adapted to local needs and systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-021-00749-3.

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Most cited references 51

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Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness.

Henry Perry, Rose Zulliger, Michael M Rogers (2014)

Over the past half-century, community health workers (CHWs) have been a growing force for extending health care and improving the health of populations. Following their introduction in the 1970s, many large-scale CHW programs declined during the 1980s, but CHW programs throughout the world more recently have seen marked growth. Research and evaluations conducted predominantly during the past two decades offer compelling evidence that CHWs are critical for helping health systems achieve their potential, regardless of a country's level of development. In low-income countries, CHWs can make major improvements in health priority areas, including reducing childhood undernutrition, improving maternal and child health, expanding access to family-planning services, and contributing to the control of HIV, malaria, and tuberculosis infections. In many middle-income countries, most notably Brazil, CHWs are key members of the health team and essential for the provision of primary health care and health promotion. In the United States, evidence indicates that CHWs can contribute to reducing the disease burden by participating in the management of hypertension, in the reduction of cardiovascular risk factors, in diabetes control, in the management of HIV infection, and in cancer screening, particularly with hard-to-reach subpopulations. This review highlights the history of CHW programs around the world and their growing importance in achieving health for all.

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Stakeholder analysis: a review.

R. Brugha (2000)

The growing popularity of stakeholder analysis reflects an increasing recognition of how the characteristics of stakeholders--individuals, groups and organizations--influence decision-making processes. This paper reviews the origins and uses of stakeholder analysis, as described in the policy, health care management and development literature. Its roots are in the political and policy sciences, and in management theory where it has evolved into a systematic tool with clearly defined steps and applications for scanning the current and future organizational environment. Stakeholder analysis can be used to generate knowledge about the relevant actors so as to understand their behaviour, intentions, interrelations, agendas, interests, and the influence or resources they have brought--or could bring--to bear on decision-making processes. This information can then be used to develop strategies for managing these stakeholders, to facilitate the implementation of specific decisions or organizational objectives, or to understand the policy context and assess the feasibility of future policy directions. Policy development is a complex process which frequently takes place in an unstable and rapidly changing context, subject to unpredictable internal and external factors. As a cross-sectional view of an evolving picture, the utility of stakeholder analysis for predicting and managing the future is time-limited and it should be complemented by other policy analysis approaches.

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Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.

Simon Lewin, Susan Munabi-Babigumira, Claire Glenton … (2010)

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions. To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases. For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers. Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients. Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained. Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective. LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.

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Author and article information

Contributors

Uta Lehmann:

ORCID: http://orcid.org/0000-0002-2627-8954

ulehmann@uwc.ac.za

Henry B. Perry:

ORCID: http://orcid.org/0000-0003-0561-0492

hperry2@jhu.edu

Journal

Journal ID (nlm-ta): Health Res Policy Syst

Journal ID (iso-abbrev): Health Res Policy Syst

Title: Health Research Policy and Systems

Publisher: BioMed Central (London )

ISSN (Electronic): 1478-4505

Publication date (Electronic): 12 October 2021

Publication date PMC-release: 12 October 2021

Publication date Collection: 2021

Volume: 19

Issue : Suppl 3 Issue sponsor : Publication costs were covered by the Bill & Melinda Gates Foundation. Supplement Editors were not involved in the peer review for any article that they co-authored. The articles have undergone the journal's standard peer review process for supplements. The Supplement Editors declare that they have no other competing interests.

Electronic Location Identifier: 129

Affiliations

[1 ]GRID grid.418193.6, ISNI 0000 0001 1541 4204, Division of Health Services, Norwegian Institute of Public Health, ; Oslo, Norway

[2 ]GRID grid.415021.3, ISNI 0000 0000 9155 0024, Health Systems Research Unit, , South African Medical Research Council, ; Cape Town, South Africa

[3 ]GRID grid.8974.2, ISNI 0000 0001 2156 8226, School of Public Health, , University of the Western Cape, ; Cape Town, South Africa

[4 ]GRID grid.21107.35, ISNI 0000 0001 2171 9311, Health Systems Program, Department of International Health, , Johns Hopkins Bloomberg School of Public Health, ; Baltimore, MD United States of America

Author information

Simon Lewin http://orcid.org/0000-0001-7521-9515

Uta Lehmann http://orcid.org/0000-0002-2627-8954

Henry B. Perry http://orcid.org/0000-0003-0561-0492

Article

Publisher ID: 749

DOI: 10.1186/s12961-021-00749-3

PMC ID: 8506073

SO-VID: d1cd7b99-d403-437b-8e4c-0818105eb0eb

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 16 June 2021

Date accepted : 17 June 2021

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;

Award ID: ID OPP 1197181

Award Recipient : Henry B. Perry

Custom metadata

ScienceOpen disciplines: Health & Social care

Keywords: community health workers,lay health workers,governance,governing,health systems,health workforce,sustainable development goals (sdgs),universal health coverage

Data availability:

ScienceOpen disciplines: Health & Social care

Keywords: community health workers, lay health workers, governance, governing, health systems, health workforce, sustainable development goals (sdgs), universal health coverage

Community health workers at the dawn of a new era: 3. Programme governance

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Abstract

Background

Methods

Results

Conclusion

Supplementary Information

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Novel Coronavirus Disease COVID-19

Most cited references 51

Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness.

Stakeholder analysis: a review.

Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases.

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Contributors

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