Harmonizing community-based health worker programs for HIV: a narrative review and analytic framework

Abstract

BackgroundMany countries have created community-based health worker (CHW) programs for HIV. In most of these countries, several national and non-governmental initiatives have been implemented raising questions of how well these different approaches address the health problems and use health resources in a compatible way. While these questions have led to a general policy initiative to promote harmonization across programs, there is a need for countries to develop a more coherent and organized approach to CHW programs and to generate evidence about the most efficient and effective strategies to ensure their optimal, sustained performance.MethodsWe conducted a narrative review of the existing published and gray literature on the harmonization of CHW programs. We searched for and noted evidence on definitions, models, and/or frameworks of harmonization; theoretical arguments or hypotheses about the effects of CHW program fragmentation; and empirical evidence. Based on this evidence, we defined harmonization, introduced three priority areas for harmonization, and identified a conceptual framework for analyzing harmonization of CHW programs that can be used to support their expanding role in HIV service delivery. We identified and described the major issues and relationships surrounding the harmonization of CHW programs, including key characteristics, facilitators, and barriers for each of the priority areas of harmonization, and used our analytic framework to map overarching findings. We apply this approach of CHW programs supporting HIV services across four countries in Southern Africa in a separate article.ResultsThere is a large number and immense diversity of CHW programs for HIV. This includes integration of HIV components into countries’ existing national programs along with the development of multiple, stand-alone CHW programs. We defined (i) coordination among stakeholders, (ii) integration into the broader health system, and (iii) assurance of a CHW program’s sustainability to be priority areas of harmonization. While harmonization is likely a complex political process, with in many cases incremental steps toward improvement, a wide range of facilitators are available to decision-makers. These can be categorized using an analytic framework assessing the (i) health issue, (ii) intervention itself, (iii) stakeholders, (iv) health system, and (v) broad context.ConclusionsThere is a need to address fragmentation of CHW programs to advance and sustain CHW roles and responsibilities for HIV. This study provides a narrative review and analytic framework to understand the process by which harmonization of CHW programs might be achieved and to test the assumption that harmonization is needed to improve CHW performance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12960-017-0219-y) contains supplementary material, which is available to authorized users.

Harmonization of community health worker programs for HIV: A four-country qualitative study in Southern Africa

“…We used an analytic framework developed ex ante to map overarching findings and inform the design of our semistructured questionnaires. Additional details on our narrative review and analytical framework are provided in S1 Text and elsewhere [ 41 ]. Second, to assess key constructs of our framework for each country, we analyzed data from interviewees.…”

Categorization of Factors Influencing Community Health Workers from a Socio-Technical Systems Perspective

“…The study further postulates that the programming activities categorized under social, technical and incentives support functions are influenced by a range of contextual factors in both community and health sectoral systems [16]. However, the narrative presented in the previous studies alludes there is unbalanced attention on the impact of the complex and diverse context-specific nature within which CHWs work and live in [17]. As a result, De Neve et al [17] propose the need for countries to develop coherent and context-specific approaches to ensure optimal performance by CHWs through the consideration of the broader context, including demographic, socioeconomic, political, legislative, ecological, sociocultural, and technological factors contributing towards facilitating or inhibiting the success of many CHWs initiatives [18,19].…”

“…However, the narrative presented in the previous studies alludes there is unbalanced attention on the impact of the complex and diverse context-specific nature within which CHWs work and live in [17]. As a result, De Neve et al [17] propose the need for countries to develop coherent and context-specific approaches to ensure optimal performance by CHWs through the consideration of the broader context, including demographic, socioeconomic, political, legislative, ecological, sociocultural, and technological factors contributing towards facilitating or inhibiting the success of many CHWs initiatives [18,19]. Some of the solutions to achieve what is postulated in the studies include coordinating the health system and community system to prioritize factors that inhibit or facilitate the understanding of CHWs programs' compatibility with community structures, cultural values, and perception, socio-economic context and support system [20].…”

“…In addition, integrating and adopting interventions supported by technological solutions, and the sustainability of these interventions should be considered when exploring efforts until the desired health outcomes are achieved to gain a better understanding of CHWs programs and their roles in LMICs [17]. Previous research that was focused on CHWs and their performance placed emphasis on developing frameworks that provide a broad context of the CHW's position in a larger environment by describing the interrelations of intrapersonal, family, community, and organizational settings as health professionals [6,10].…”

“…Most programs have not been able to effectively address the gap between research evidence and the routine practicality of CHWs as health professions, hence the poor integration of CHWs within the healthcare system and an even poorer understanding of their roles within their communities. Subsequently, the implication of this postulates the need for a comprehensive approach to plan and design programs that can be integrated with the formal healthcare system's approach to healthcare service delivery through CHWs roles and organizations [17].…”