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.

Between Policy and Practice – the Importance of Health Service Research in Low- and Middle-Income Countries

There is a large and growing literature on disease and its causes in low- and middle-income countries (LMICs) – not only infectious disease, but also non-communicable diseases. Endless studies are published on disease incidence and prevalence, for example. There is also a substantial literature on policy / health systems,[1] much captured in the Health Systems Evidence database.[2] This deals with topics such as general taxation vs. contributory insurance, financial incentives for providers, and use of private providers to extend coverage.

However, how to provide health services given general policy and a certain profile of disease is less well studied. Issues such as skill mix (e.g. who should do what), distribution of services (e.g. hospital vs. clinic vs. home) and coverage (e.g. how many nurses or clinics are needed per head of population) are less well studied. For example, there have been calls for Africa to increase the capacity of Community Health Workers (CHW) to one million, but no-one knows the optimal mix of CHWs to nurses to medical officers to doctors, for example. Likewise, the mix of outreach services (e.g. CHWs), clinics, pharmacies, private facilities, and traditional healers that can best serve populations is very unclear according to a recent Lancet commission.[3] The situation in slums is positively chaotic. One could sit in an arm chair and propose a service configuration for slum environments of 10,000 people that looks like this:

The role of CHWs could be narrow (vaccination, child malnutrition), intermediate (vaccination, child malnutrition, sexual and reproductive health), or broad (all of the above, plus hypertension, obesity prevention, adherence to treatment, detection of depression, etc.). HIV and TB screening and treatment maintenance could be separate or included in the above, and so on.

Note that decisions about workforce and how and where the workforce is deployed have to be made irrespective of how care is financed, or whether financial or other incentives are used – decisions are still needed about who is to be incentivised to do what. And people do not appear overnight, so training (and the associated costs) must be included in cost and economic models. Of course, the range of possibilities according to per capita wealth in a country is large, but we do not know what good looks like in countries of approximately equal wealth. Here is the rub – it is much easier to study a diseases and its determinants than to study health services. Yet another study to link pollution to illness is easy to write as an applicant and understand as a reviewer. But talk about skill mix and eyes glaze over. Yet there is little point in measuring disease ever more precisely if there is no service to do anything about it.

— Richard Lilford, CLAHRC WM Director

References:

1. Mills A. Health Care Systems in Low- and Middle-Income Countries. New Engl J Med. 2014; 370: 552-7.
2. McMaster University. Health systems evidence. Hamilton, Canada: McMaster University. 2017.
3. McPake B, & Hanson K. Managing the public–private mix to achieve universal health coverage. Lancet. 2016; 388: 622-30.

CHWonomics

Watching NoCounter interact with “Aunty” Martha (not their real names) in Mahwaqe, South Africa, and learning about NoCounter’s roles as Martha’s health advocate, personal trainer and medication manager was anything but dismal. So as a dismal scientist, I was fascinated by how Community Health Workers (CHWs) seem to contradict one of our most famous founders, Adam Smith. To help explain one of the concepts for which he would become famous, “the invisible hand”, Smith wrote: “I have never known much good done by those who affected to trade for the public good”.[1]

To consider whether NoCounter and other CHWs are an exception to this statement, there are three questions that need to be considered:

Is the CHW doing good?
Almost all of the available research evidence suggests that CHWs are effective in enhancing the health of their communities,[2] and since the World Health Organization also see CHWs as playing a pivotal role in helping countries achieve health-related Millennium Development Goals,[3] it is most likely that CHWs are “doing good”. In Mahwaqe, we saw how NoCounter helped Martha do the chair yoga exercises that now mean she can walk and explained her medications, which helped Martha understand the importance of adherence.

Is the CHW trading?
NoCounter is giving up her time (working around 50% FTE) and in return, receives a stipend from an NGO of around R800 (~£36) per month and as such, is trading. However, as a maid in South Africa, she could earn around R1,200 (~£54) per month for the same hours, so NoCounter does not seem to be receiving the full monetary value of her time. If approximate role equivalence can be assumed, compared to a CHW in the US, NoCounter’s time is undervalued by a factor of around 8.5: a US CHW working for an hour could buy 3.3 McDonald’s Big Macs; NoCounter could buy 0.4.[4] [5] NoCounter is also using her skills and experience to provide care, but economics would describe these as “non-rivalrous” and thus not directly tradable.

Is the CHW doing so for the public good or her own self-interest?
Adam Smith might be confused by NoCounter, because her aim doesn’t seem to be wealth maximisation. However, a “utility maximising” economist would argue that NoCounter is making up for not being paid the full monetary value of her time by obtaining utility either from substitutes for money or from directly helping her community.[6] Even if NoCounter obtains utility from the latter, her motivation would still be to do public good. With regards to money substitutes, CHWs may also receive non-monetary incentives such as community respect, housing and access to health care and/or be motivated in their roles via the support of their families.[6] [7] Furthermore, the CHW role is particularly desirable in areas where residents have a high marginal rate of substitution for leisure over consumption, since CHWs do not have to commute to their place of work. Finally, a by-product of NoCounter’s work as a CHW from which she benefits directly is that she lives in a healthier community: by encouraging vaccination of new-borns, for example, she is lowering her own risk of TB.

On this last question, the relative importance of the different reasons why CHWs undertake their role for a wage lower than they appear to be worth, we cannot be certain about the answer. Research in this area is critical given the push to eliminate the under-supply of CHWs.[8] There are also additional pre-conditions – the organisational structure required to implement a successful CHW programme [9] – that also must be met before the demand for CHWs can be realised (made “effective”) in practice. Nevertheless, it is critical to determine whether all of the additional CHWs required to meet demand would also offer their labour at a low relative price. This was assumed in a costing exercise of a CHW roll-out programme,[10] but which prima facie contradicts basic economic theory of demand and supply.

Fortunately for me, economics provides one approach to studying the interaction between monetary and non-monetary incentives with respect to the supply of labour, for example using discrete choice experiments, where CHWs would be asked to make a choice between a series of pairs of packages of stipend/salary, level of health produced, and non-monetary incentives (see [11] for an example). Such experiments would need to be repeated in (and possibly also within) different countries, since the relative value of “doing good” by volunteering may well differ according to a country’s stage in economic development. Such work would help to provide evidence regarding the sustainability of CHWs as a cadre of health care providers. Here, we hypothesise a U-shaped curve if propensity to volunteer is plotted against GDP per capita

— Celia Taylor, Senior Lecturer

References:

1. Smith A. An Inquiry into the Nature and Causes of the Wealth of Nations. London: Strahan and Cadell, 1776.
2. Perry H, Zulliger R. How Effective are Community Health Workers? An Overview of Current Evidence with Recommendations for Strengthening Community Health Worker Programs to Accelerate Progress in Achieving the Health-related Millennium Development Goals. Baltimore, MD: John Hopkins Bloomberg School of Public Health, 2012.
3. World Health Organization and Global Health Workforce Alliance. Global Consultation on Community Health Workers. Geneva, Switzerland: World Health Organization, 2010.
4. Payscale Homepage. 2015.
5. The Economist. The Big Mac Index. 2015.
6. Greenspan JA, McMahon SA, Chebet JJ, Mpunga M, Urassa DP, Winch PJ. Sources of community health worker motivation: a qualitative study in Morogoro Region, Tanzania. Hum Resour Health. 2013; 11: 52.
7. Dambisya YM. A review of non-financial incentives for health worker retention in east and southern Africa. In: EQUINET Discussion Paper Number 44 with ESCA-HC. Loewenson R (Editor). Harare, Zimbabwe: EQUINET, 2007.
8. One Million Community Health Workers Campaign. One Million Community Health Workers Campaign. 2015.
9. World Health Organization, Policy Brief. Community health workers: What do we know about them? Geneva, Switzerland: World Health Organization, 2007
10. McCord GC, Liu A, Singh P. Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions. Bull World Health Organ. 2012; 91(4):244-53B.
11. Kasteng F, Settumba S, Källander K, Vassall, A, inSCALE Study Group. Valuing the work of unpaid community health workers and exploring the incentives to volunteering in rural Africa. Health Policy Plan. 2016: 31(2): 205-16.

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.

Lay Community Health Workers

In discussing possible solutions to health problems in CLAHRC Africa, the role of Lay Community Health Workers (LCHWs) often comes up. In fact, there is seldom a large-scale health problem that someone does not suggest can be laid at the door of LCHWs.

What are LCHWs?

1. LCHWs (sometimes referred to as Lay Health Workers or Community Health Workers) cover a range of functions. However, LCHWs tend to have the following features:
2. They are of the community in the sense that they live among the people they serve. They tend to be nominated/selected by their local community.
3. They have a connection to the health service – for example, they have established lines of communication and can refer.
4. They are not full-time and generally have other roles/jobs in the community.
5. They may receive some monetary payment from health services, but this is small in amount relative to substantive health care workers.

What is the history of LCHWs?

The CLAHRC WM Director finds it difficult to follow the evolution of present day LCHWs, but he fancies that some people have differentiated themselves to provide services to their community from the beginning of time, for example, providing birth assistance. The present day CHW:

1. is differentiated from traditional healers and hews, to some extent at least, to an Enlightenment-based scientific model;
2. performs a role that forms part of, or complements, the local health service.

Recent examples of initiatives that relied on LCHWs include:

1. The “barefoot doctor” programme in China.[1]
2. An extensive reproductive health programme in Iran associated with a steep drop in fertility.[2]
3. An extensive child health programme in Brazil that was associated with a large (over 50%) and precipitate drop in childhood mortality.[3]
4. The anti-retroviral programme in Africa where LCHWs played a part in identifying cases and helping clients adhere to exacting treatment regimes. [4]

Lay workers are also found in high-income countries and may even be making something of a come-back. Our CLAHRC, for instance, has evaluated the role of such volunteer support workers in the case of vulnerable women over the perinatal period.[5]

Are LCHWs effective?

This question invites the response “compared to what?” They played a large (arguably essential) part in the above programmes and the programmes were themselves successful. LCHWs make a small call on the public purse and so there are good reasons to think they are cost-effective compared to health service personnel who might be deployed to perform the same function. There is empirical support for the theoretical idea that being part and parcel of the local community and being selected by local people provides credibility and enhances the effectiveness of LCHWs. A collaborator of the CLAHRC WM Director, Dr Alex Plowright, argues that the empathy they display is especially important where health systems are weak and staff are often disaffected. Summative evaluations (82 RCTs) show that LCHWs are effective on average, but the results, as with many service interventions, are heterogeneous.[6] This reflects, at least in part, the fact that LCHWs are deployed in very different social and political environments that might be neutral, supportive, or antipathetic to their efforts.[7] [8] Salient questions include the education of LCHWs (how much, in what form, over what time periods), whether LCHWs should specialise, and what functions they should perform.

Towards a theory of LCHWs deployment

The argument proposed here has two premises:

1. LCHWs do not tend to have detailed theoretical knowledge, nor a deep understanding of patho-physiological pathways. If they did, they would not be LCHWs.
2. Most health gains in deprived communities in low- and middle-income countries turn not on intensive medical practice, but on a small number of conceptually straightforward processes – basic nutrition, bed nets, oral rehydration, vaccination, access to contraception, and so on.

Putting these two ideas together can help shape an answer to the above question relating to role definitions. First, it would suggest that LCHWs should not become a type of “dumping ground” for all ills – mental health, untreated ear disease, skin infections, etc. Rather, they should learn what the red flags are and have a generally low threshold of referral to a health facility. A corollary of this idea is that LCHWs should not be required to specialise, though this is not to say that they should not develop a special interest. Childbearing might be an exception, since a type of CHW called a traditional birth attendant can improve outcomes of labour, at least where trained midwives are not available.[9] Once the above fundamentals are covered, then one can imagine a role in health promotion – for example, discouraging salt and sugar and perhaps checking for the silent killer that is hypertension, as recommended by Margaret Thorogood.[10]

— Richard Lilford, CLAHRC WM Director

References:

1. Rosenthal MM, & Greiner JR. The Barefoot Doctors of China: From Political Creation to Professionalization. Hum Organ. 1982; 41(4): 330-341.
2. Hoodfar H, & Assadpour S. The Politics of Population Policy in the Islamic Republic of Iran. Stud Family Plann. 2000; 31(1): 19-34.
3. UNICEF. The State of the World’s Children 2008. New York, NY: UNICEF. 2007.
4. Hermann K, Van Damme W, Pariyo GW, Schouten E, Assefa Y, Cirera A, Massovon W. Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities. Hum Resour Health. 2009; 7: 31.
5. Lilford R. Improve long-term development of children. 20 Feb 2015. [Online].
6. 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.
7. 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.
8. Kok MC, Kane SS, Tulloch O, et al. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Res Policy Syst. 2015; 13(1): 1.
9. Jokhio AH, Winter HR, Chang KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med. 2005; 352(20): 2091-9.
10. Thorogood M, Goudge J, Bertram M, et al. The Nkateko health service trial to improve hypertension management in rural South Africa: study protocol for a randomised controlled trial. Trials. 2014; 15: 435.