What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

Abstract

ObjectiveTo synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems.MethodsWe searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards.FindingsWe identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance.ConclusionEvidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.Electronic supplementary materialThe online version of this article (10.1186/s12960-018-0304-x) contains supplementary material, which is available to authorized users.

Health system strengthening—Reflections on its meaning, assessment, and our state of knowledge

“…Evidence of effects on retention is mixed—short‐range evaluation of the Zambian Health Worker Retention Scheme showed positive effects, but a longer‐range piece across workforce cadres did not support these findings Skills mix (task shifting) approaches have been successfully used to address shortages of more highly skilled but scarcer professional groups supporting particular areas of service delivery . Nonformal cadres of health workers such as community health workers can help address staff shortages, as long as the tasks are not too complex …”

Longitudinal analysis of the capacities of community health workers mobilized for seasonal malaria chemoprevention in Burkina Faso

“…The progress is significant even though the baselines are already quite high and margins for progress are naturally limited. Research suggests that the capacities of community health workers tend to wane rather quickly [11,23,24] and that refresher training effectively enhances their performance [12,25,26]. The CBDs of the 2017 and 2018 campaigns thus seemed to have benefited from the cumulative contribution of each initial campaign training session, the supervision provided by the health teams during each round, and the regular refresher training preceding each round.…”

“…Many studies have shown that the personal characteristics of community health workers can be associated with their performance [8,11,15,27], suggesting that the CBDs to be trained should be carefully selected [11,28]. However, recent reviews reveal that results, particularly with regard to performance compared by type and sex, are not always consistent [12], and that "studies of workers with lower baseline performance showed greater improvements in prescribing medications…, vaccinating children,… and counseling…" [29]. As well, the more educated CBDs, who are traditionally more productive, are also less committed and more likely to drop out [8,11,15,27].…”

“…However, research on CBDs' performance has been quite limited to date, and little is known about their ability to properly accomplish the whole set of technical, relational, and recording/notification tasks assigned to them. Training and supervision are often identified as major contributors to CBDs' knowledge, skills, and motivation [7][8][9][10][11][12]. It has nonetheless been suggested that more evidence is needed about effective approaches to training [8,10,12], including in malaria programmes [13].…”

The status of Ghanaian community health workers’ supervision and service delivery: descriptive analyses from the 2017 Performance Monitoring and Accountability 2020 survey

“…As the world strives to achieve Universal Health Coverage and the Sustainable Development Goals, primary healthcare is foundational to meeting these goals 1,2 . Community healthcare systems serve critical roles within strong primary healthcare delivery [2][3][4] . The World Health Organization's recent guidelines 5 for best practices of community health workers (CHWs) offer important guidance to policy makers and program implementers about how to develop strong community health service delivery and support low-and middle-income countries along the path towards universal health coverage.…”