Community health workers and accountability: reflections from an international “think-in”

This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programsthe relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we 'know' as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation. Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented? We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategyits objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behavior are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.

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“…Other pathways to social accountability are described by Hernández and colleagues [56], Schaff and colleagues [57] and by Joshi [58].…”

Section: Transformationmentioning

confidence: 93%

When accountability meets power: realizing sexual and reproductive health and rights

Sen

Iyer

Chattopadhyay³

et al. 2020

Int J Equity Health

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“…Furthermore, as argued elsewhere, CHWs are part of a larger ecosystem of health system wherein ensuring trust and accountability is essential, more so during a pandemic. 49 Implications for research We took a broad scoping approach in the RES to understand issues around CHWs in pandemic response. Conduct of research related to health workers during pandemics is extremely challenging and, as such, highquality evidence from trials may be neither feasible nor ethical.…”

Section: Key Considerations For Effectively Mobilising Chw In a Pandemicmentioning

confidence: 99%

Community health workers for pandemic response: a rapid evidence synthesis

et al. 2020

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IntroductionCoronavirus disease (COVID-19), affects 213 countries or territories globally. We received a request from National Health Systems Resource Centre, a public agency in India, to conduct rapid evidence synthesis (RES) on community health workers (CHWs) for COVID-19 prevention and control in 3 days.MethodsWe searched PubMed, websites of ministries (n=3), public agencies (n=6), multilateral institutions (n=3), COVID-19 resource aggregators (n=5) and preprints (n=1) (without language restrictions) for articles on CHWs in pandemics. Two reviewers screened the records independently with a third reviewer resolving disagreements. One reviewer extracted data with another reviewer cross-checking it. A framework on CHW performance in primary healthcare not specific to pandemic was used to guide data extraction and narrative analysis.ResultsWe retrieved 211 records and finally included 36 articles. Most of the evidence was from low-and middle-income countries with well-established CHW programmes. Evidence from CHW programmes initiated during pandemics and for CHW involvement in pandemic response in high-income countries was scant. CHW roles and tasks change substantially during pandemics. Clear guidance, training for changed roles and definition of what constitutes essential activities (ie, those that must to be sustained) is required. Most common additional activities during pandemics were community awareness, engagement and sensitisation (including for countering stigma) and contact tracing. CHWs were reported to be involved in all aspects of contact tracing - this was reported to affect routine service delivery. CHWs have often been stigmatised or been socially ostracised during pandemics. Providing PPE, housing allowance, equal training opportunities, transportation allowance, improving salaries (paid on time and for a broad range of services) and awards in high-profile public events contributed to better recruitment and retention. We also created inventories of resources with guiding notes on guidelines for health workers (n=24), self-isolation in the community (n=10) and information, education and counselling materials on COVID-19 (n=16).ConclusionsCHWs play a critical role in pandemics. It is important to ensure role clarity, training, supportive supervision, as well as their work satisfaction, health and well-being. More implementation research on CHWs in pandemics is required.

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“…The subsequent development of the review was informed partly by issues arising at the think-in. 34 We explain in detail.…”

Section: Introduction Backgroundmentioning

confidence: 99%

The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability

Schaaf¹,

Warthin

Freedman

et al. 2020

BMJ Glob Health

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This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as ‘CHWs and equity.’CHWs are intended to comprise a ‘bridge’ between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with other community-based structures, health system treatment of CHWs, community perceptions of CHWs, and extent and type of CHW unionisation and collectivisation.Synthesising these findings, we elaborated several analytic propositions relating to the self-reinforcing nature of the factors shaping CHWs’ bridging function; the roles of local and national governance; and the human resource and material capacity of the health system. Importantly, community embeddedness, as defined by acceptability, social connections and expertise, is a crucial attribute of CHW ability to foment local government accountability to communities.

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Community health workers and accountability: reflections from an international “think-in”

Cited by 30 publications

References 10 publications

When accountability meets power: realizing sexual and reproductive health and rights

When accountability meets power: realizing sexual and reproductive health and rights

Community health workers for pandemic response: a rapid evidence synthesis

The community health worker as service extender, cultural broker and social change agent: a critical interpretive synthesis of roles, intent and accountability

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