How equitable are community health worker programmes and which programme features influence equity of community health worker services? A systematic review

Abstract

BackgroundCommunity health workers (CHWs) are uniquely placed to link communities with the health system, playing a role in improving the reach of health systems and bringing health services closer to hard-to-reach and marginalised groups. A systematic review was conducted to determine the extent of equity of CHW programmes and to identify intervention design factors which influence equity of health outcomes.MethodsIn accordance with our published protocol, we systematically searched eight databases from 2004 to 2014 for quantitative and qualitative studies which assessed access, utilisation, quality or community empowerment following introduction of a CHW programme according to equity stratifiers (place of residence, gender, socio-economic position and disability). Thirty four papers met inclusion criteria. A thematic framework was applied and data extracted and managed, prior to charting and thematic analysis.ResultsTo our knowledge this is the first systematic review that describes the extent of equity within CHW programmes and identifies CHW intervention design features which influence equity. CHW programmes were found to promote equity of access and utilisation for community health by reducing inequities relating to place of residence, gender, education and socio-economic position. CHWs can also contribute towards more equitable uptake of referrals at health facility level. There was no clear evidence for equitable quality of services provided by CHWs and limited information regarding the role of the CHW in generating community empowerment to respond to social determinants of health. Factors promoting greater equity of CHW services include recruitment of most poor community members as CHWs, close proximity of services to households, pre-existing social relationship with CHW, provision of home-based services, free service delivery, targeting of poor households, strengthened referral to facility, sensitisation and mobilisation of community. However, if CHW programmes are not well planned some of the barriers faced by clients at health facility level can replicate at community level.ConclusionsCHWs promote equitable access to health promotion, disease prevention and use of curative services at household level. However, care must be taken by policymakers and implementers to take into account factors which can influence the equity of services during planning and implementation of CHW programmes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3043-8) contains supplementary material, which is available to authorized users.

Household coverage of Swaziland's national community health worker programme: a cross‐sectional population‐based study

“…Similarly, both wealth and education were negatively associated with coverage, which again may be explained by a higher probability of poor health among the socioeconomically disadvantaged. Overall, it is thus plausible that the RHM programme reduces social inequities in access to health care in Swaziland similar to what a recent systematic review has found to be the case for several other CHW programmes in LMICs . A limitation of this study is that we are unable to disentangle the reasons for which RHMs were more likely to visit households that were poor and less educated.…”

“…Such contexts most typically include countries with large rural populations and/or with overextended and under-resourced human resources for health (HRH). The use of CHWs in such areas is thought to be a key strategy for increasing horizontal equity in access to health care between rural and urban populations as well as between individuals from different socio-economic backgrounds [4].…”

“…Lastly, because CHW visits usually take place at the patient's home, CHW programmes may increase access to care by eliminating patients' transport costs to the healthcare facility (which have been shown to pose a considerable financial burden on clients [6]) and reducing patients' tendency to put off non-urgent visits to the future ('present bias') [7]. Indeed, there is some evidence to show that CHWs are able to help decrease horizontal inequities in access to health care, increase health system capacity by sharing workload, and improve health outcomes [4,[8][9][10].…”

Development and validation of a search filter to identify equity-focused studies: reducing the number needed to screen

“…no. reviews contributing termsReviews contributing terms‘Place’Place of residence5No-5No-5[10–14]‘Race’Race / ethnicity / culture / language3Yes →69No-9[11, 15–22]Occupation6No-6No-6[11], [13], [16], [23], [24], [25]‘Gender’Gender / sex1Yes →67No-7[16], [17], [18], [19], [26], [27], [28]Religion0Yes →11Yes →23[17, 29, 30]Education7No-7No-7[11, 13, 16, 24, 25, 31, 32]‘SES’Socio-economic status12No-12No-12[11], [13], [15], [23], [24], [25], [31], [32], [33], [34], [35], [36]Social capital0Yes →11Yes →45[17, 37–40]Other category not encompassed by PROGRESS-Plus6No-...…”

Accompanimeter 1.0: creation and initial field testing of a tool to assess the extent to which the principles and building blocks of accompaniment are present in community health worker programs

“…We believe that the three principles and five building blocks enable programs to help health systems best reach the three dimensions of Universal Health Coverage: (1) coverage, (2) scope of services, and (3) financial protection. In addition, they add a very important focus on equity, highlighting the imperative for well-designed CHW programs to reach the most vulnerable [26].…”