Evidence-Based Guidelines and Practitioner Expertise to Optimise Community Health Worker Programmes

The rapid increase in scale and scope of community health worker (CHW) programmes highlights a clear need for guidance to help programme providers optimise programme design. A new World Health Organization (WHO) guideline in this area [1] is therefore particularly welcome, and provides a complement to existing guidance based on practitioner expertise.[2] The authors of the WHO guideline undertook an overview of existing reviews (N=122 reviews with over 4,000 references included), 15 separate systematic reviews of primary studies (N=137 studies included), and a stakeholder perception survey (N=96 responses). The practitioner expertise report was developed following a consensus meeting of six CHW programme implementers, a review of over 100 programme documents, a comparison of the standard operating procedures of each implementer to identify areas of alignment and variation, and interviews with each implementer.

The volume of existing research, in terms of the number of eligible studies included in each of the 15 systematic reviews, varied widely, from no studies for the review question “Should practising CHWs work in a multi-cadre team versus in a single-cadre CHW system?” to 43 studies for the review question “Are community engagement strategies effective in improving CHW programme performance and utilization?”. Across the 15 review questions, only two could be answered with “moderate” certainty of evidence (the remainder were “low” or “very low”): “What competencies should be included in the curriculum?” and “Are community engagement strategies effective?”. Only three review questions had a “strong” recommendation (as opposed to “conditional”): those based on Remuneration(do so financially), Contracting agreements(give CHWs a written agreement), and Community engagement(adopt various strategies). There was also a “strong” recommendation not to use marital status as a selection criterion.

The practitioner expertise report provided recommendations in eight key areas and included a series of appendices with examples of selection tools, supervision tools and performance management tools. Across the 18 design elements, there was alignment across the six implementers for 14, variation for two (Accreditation– although it is recommended that all CHW programmes include accreditation – and CHW:Population ratio), and general alignment but one or more outliers for two (Career advancement– although supported by all implementers, and Supply chain management practices).

There was general agreement between the two documents in terms of the design elements that should be considered for CHW programmes (Table 1), although notincluding an element does not necessarily mean that the report authors do not think it is important. In terms of the specific content of the recommendations, the practitioner expertise document was generally more specific; for example, on the frequency of supervision the WHO recommend “regular support” and practitioners “at least once per month”. The practitioner expertise report also included detail on selection processes, as well as selection criteria: not just what to select for, but how to put this into practice in the field. Both reports rightly highlight the need for programme implementers to consider all of the recommendations within their own local contexts; one size will not fit all. Both also highlight the need for more high quality research. We recently found no evidence of the predictive validity of the selection tools used by Living Goods to select their CHWs,[3] although these tools are included as exemplars in the practitioner expertise report. Given the lack of high quality evidence available to the WHO report authors, (suitably qualified) practitioner expertise is vital in the short term, and this should now be used in conjunction with the WHO report findings to agree priorities for future research.

Table 1: Comparison of design elements included in the WHO guideline and Practitioner Expertise report

— Celia Taylor, Associate Professor

References:

1. World Health Organization. WHO guideline on health policy and system support to optimize community health worker programmes. Geneva, Switzerland: WHO; 2018.
2. Community Health Impact Coalition. Practitioner Expertise to Optimize Community Health Systems. 2018.
3. Taylor CA, Lilford RJ, Wroe E, Griffiths F, Ngechu R. The predictive validity of the Living Goods selection tools for community health workers in Kenya: cohort study. BMC Health Serv Res. 2018; 18: 803.

An Intervention So Big You Can See it From Space

Over the last two decades there have been innumerable health service interventions around the world. But there has been nothing as large as the development of lay Community Health Workers (CHWs). By way of example, Africa is set to acquire around one million CHWs by the end of this year.[1] Moreover, the success of CHWs in low- and middle-income countries (LMICs) has inspired policy makers to increase CHW deployment in high-income countries (HICs), in places as far apart as New York [2] and Wales.[3]

In a previous blog we showed RCT and observational evidence that attests to the overall effectiveness of CHWs.[4] [5] They appear most effective when they are well supported, both in their communities and in the local health service. Much is made in sociological studies of the local roots of CHWs – they are ‘of the people, for the people’. Their motivation rests on their close link to the communities they serve and is strongly related to the esteem in which they are held.[6]

However, the fundamental nature of CHWs is changing. To an ever-greater extent, governments in LMICs are turning to CHWs to solve pressing problems. As they are doing the bidding of the government, they increasingly get paid for their work. Their emoluments might not be great, but all public expenditure must be accounted for. So CHWs no longer just ‘emerge’ – they must be appointed and trained, and they can be fired. India, for example, provides employment for no less than 600,000 CHWs on the basis of fee-for-service.[7] Their link to the health services is becoming more formal – they are a part of the family health teams in Brazil, for example. It would appear that the cadre of CHWs is being professionalised, albeit at different rates in different places.

It is appropriate to ask whether something may be lost in this process of professionalisation. For example, it has been shown that extrinsic motivation can ‘crowd out’ intrinsic motivation.[8] If the direction of travel is towards professionalisation, then this has implications for management of the service. It may be advisable to go with the grain and provide or facilitate privileges that other professions have, such as professional societies and well sign-posted opportunities for advancement and promotion. It will also be important to recognise that the market-clearing price for CHWs is likely to inflate, in part because of the putative crowding out of intrinsic motivations, but also because of generally improving salaries in emerging economies.

The CLAHRC WM Director hypothesises that many CHWs are going through an uncomfortable period, where they lose some of the satisfaction and kudos that comes with being a volunteer, but still lack the status, pay, and camaraderie of a fully-fledged profession. Different countries will deal with this phenomenon in different ways – in Ethiopia, for example, two cadres of CHWs have come into existence, one more formal than the other. CLAHRC Africa is actively studying education for CHWs and the ideal work configurations in two projects supported by the Medical Research Council, UK. This work complements CLAHRC WM studies on the use of unpaid lay health workers in improving outcomes for pregnant women with high social risk, e.g. single teenage parents (see previous blog).

— Richard Lilford, CLAHRC WM Director

References:

1. Singh P, Sachs JD. 1 million community health workers in sub-Saharan Africa by 2015. Lancet. 2013; 382: 363-5.
2. Peretz PJ, Matiz LA, Findley S, et al. Community Health Workers as Drivers of a Successful Community-Based Disease Management Initiative. Am J Public Health. 2012; 102(8): 1443-6.
3. Johnson CD, Noyes J, Haines A, et al. Learning from the Brazilian community health worker model in North Wales. Global Health. 2013; 9: 25.
4. Lilford R. Lay Community Health Workers. CLAHRC WM News Blog. April 10 2015.
5. Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010; 3: CD004015.
6. Glenton C, Colvin CJ, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev. 2013; 10: CD010414.REF
7. Singh P, & Chokshi DA. Community Health Workers – A Local Solution to a Global Problem. N Engl J Med. 2013; 369(10): 894-6.
8. Frey BS. How Intrinsic Motivation is Crowded Out and In. Rationality Society. 1994; 6(3): 334-52.