Challenges facing community health workers in Brazil's Family Health Strategy: A qualitative study

Community health worker (CHW) programs are implemented in many low‐ and middle‐income countries such as Brazil to increase access to and quality of care for underserved populations; CHW programs have been found to improve certain indicators of health, but few studies have investigated the daily work of CHWs, their perspectives on what both helps and hinders them from fulfilling their roles, and ways that their effectiveness and job satisfaction could be increased. To examine these questions, we observed clinic visits, CHW home visits, and conducted semistructured interviews with CHWs in 7 primary care centers in Brazil—2 in Salvador, Bahia, and 5 in São Paulo, SP—in which CHWs are incorporated into the work of all primary care health teams. In addition to enhancing communication between the medical system and the community, CHWs consider their key roles to be helping persuade community members to seek medical care and increasing health professionals' awareness of the social conditions affecting their patients' health. Key obstacles that CHWs face include failure to be fully integrated into the primary care team, inability to follow‐up on identified health needs due to limited resources, as well as community members' lack of understanding of their work and undervaluing of preventative medicine. Increased training, better incorporation of CHWs into clinic flow and decision making, and establishing a clear community awareness of the roles and value of CHWs will help increase the motivation and effectiveness of CHWs in Brazil.     

Community-based health care in Kibwezi, Kenya: 10 years in retrospect

In response to the interest of the Kenya government in community-based health care, the Kibwezi Rural Health Scheme was developed by the African Medical and Research Foundation (AMREF) in a semi-arid district in eastern Kenya. Based on a community co-operative philosophy and focussing on health promotion and prevention, the scheme includes the following: a health centre with a 15-bed in-patient unit including four maternity beds, out-patient services, and a 15-bed nutrition rehabilitation unit; a cadre of volunteer community health workers, trained by AMREF, who form the backbone of the project; maternal child health/family planning and nutrition services including an applied nutrition programme, a water project; and a mobile health unit. Designed as a replicable model health programme, the intention was that services would be gradually taken over by the Ministry of Health of Kenya. Much has been learned in the development of the project which should be meaningful to others considering similar endeavours. One of the first lessons learned was that the time taken to sensitize the community to community-based health care is critical to the success of the project and may need to be as long as 1-2 years. Another was that gaining the support of the community for the community health workers (CHW) requires a considerable effort on the part of project staff, but seems to be the only viable solution to the remuneration and recognition of the CHW's work. It also became apparent that preventive and promotive health services should be integrated structurally and operationally with curative health services to provide the most benefits for the community served. Finally, although there are some differences of opinion, it is felt that with some refinements, the project could be replicated in other parts of Kenya.     

Effect of multiple interventions on community health workers' adherence to clinical guidelines in Siaya district, Kenya

Evaluation of a community health worker (CHW) programme in Siaya district, Kenya, showed CHWs commonly made errors in managing childhood illness. We assessed the effect of multiple interventions on CHW healthcare practices. A sample of 192 ill-child consultations performed by 114 CHWs in a hospital outpatient department between February and March 2001 were analysed. The mean percentage of assessment, classification and treatment procedures performed correctly for each child was 79.8% (range 13.3-100%). Of the 187 children who required at least one treatment or referral to a health facility, only 38.8% were prescribed all treatments (including referral) recommended by the guidelines. Multivariate analyses found no evidence that the intervention-related factors studied (refresher training, supervision, involvement of community women in the CHW selection process, adequacy of medicine supplies, and use of a guideline flipchart during consultations) were significantly associated with overall or treatment-specific guideline adherence. A multivariate linear regression analysis revealed that several non-intervention-related factors, such as patient characteristics, were significantly associated with overall guideline adherence. Given that our study was cross-sectional and our measurement of exposure to several interventions was based on CHW recall, the estimated effects of the interventions should be interpreted with caution. Despite these limitations, however, our results raise questions about the effectiveness, in the setting of Siaya district, of several interventions commonly used to improve the quality of care given by CHWs.     

The emergence of community health worker programmes in the late apartheid era in South Africa: An historical analysis

There is re-emerging interest in community health workers (CHWs) as part of wider policies regarding task-shifting within human resources for health. This paper examines the history of CHW programmes established in South Africa in the later apartheid years (1970s–1994) – a time of innovative initiatives. After 1994, the new democratic government embraced primary healthcare (PHC), however CHW initiatives were not included in their health plan and most of these programmes subsequently collapsed. Since then a wide array of disease-focused CHW projects have emerged, particularly within HIV care.     

‘I have a lot of faith in her’: Value of community health workers in addressing family planning in rural Ghana

ABSTRACT

In rural settings with shortages in trained health care workers, community health workers (CHWs) play an important role in the delivery of health care services. The Ghana Health Service initiated a national CHW programme in 2016 to expand health services to rural populations. This study explored the perceived role and value of CHWs in addressing family planning issues in the Amansie West district of Ghana. The study included in-depth interviews (IDIs) with 28 women in the community, ages 18–49, and 30 CHWs. Using inductive thematic analysis, IDIs were coded to explore opinions on the CHWs’ role and perceived value in the delivery of family planning. Participants explained that CHWs provided family planning as part of a healthcare package through household visits and referrals to government services. The value of CHWs in delivering family planning was seen in confidentiality, accessibility, and comfort. Participants recommended an enlarged CHW workforce with a range of commodities and programmatic support. The findings suggest CHWs play an important role in promoting family planning, by serving as a bridge between the community and clinics. In rural communities where resources are scarce, CHWs are an invaluable part of the broader healthcare system.     

上海市长宁区家庭责任医生制度设计与实施方案

家庭责任医生制度是贯彻政府提供基本卫生服务宗旨的一项重要措施,是实施居民家庭健康管理服务的制度。上海市长宁区通过为居民提供连续、综合、协调的基本医疗卫生服务,逐步实现社区首诊、逐级转诊的工作目标,为切实发挥居民“健康守护人”和“经费守门人”作用奠定基础。本文介绍了上海市长宁区家庭责任医生制度设计与实施方案,以期为其它地区探索家庭责任医生制度提供借鉴。     

Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects

After a decline in enthusiasm for national community health worker (CHW) programmes in the 1980s, these have re-emerged globally, particularly in the context of HIV. This paper examines the case of South Africa, where there has been rapid growth of a range of lay workers (home-based carers, lay counsellors, DOT supporters etc.) principally in response to an expansion in budgets and programmes for HIV, most recently the rollout of antiretroviral therapy (ART). In 2004, the term community health worker was introduced as the umbrella concept for all the community/lay workers in the health sector, and a national CHW Policy Framework was adopted. We summarize the key features of the emerging national CHW programme in South Africa, which include amongst others, their integration into a national public works programme and the use of non-governmental organizations as intermediaries. We then report on experiences in one Province, Free State. Over a period of 2 years (2004--06), we made serial visits on three occasions to the first 16 primary health care facilities in this Province providing comprehensive HIV services, including ART. At each of these visits, we did inventories of CHW numbers and training, and on two occasions conducted facility-based group interviews with CHWs (involving a total of 231 and 182 participants, respectively). We also interviewed clinic nurses tasked with supervising CHWs. From this evaluation we concluded that there is a significant CHW presence in the South African health system. This infrastructure, however, shares many of the managerial challenges (stability, recognition, volunteer vs. worker, relationships with professionals) associated with previous national CHW programmes, and we discuss prospects for sustainability in the light of the new policy context.     

Communities of solution: the Folsom Report revisited

Efforts to address the current fragmented US health care structure, including controversial federal reform, cannot succeed without a reinvigoration of community-centered health systems. A blueprint for systematic implementation of community services exists in the 1967 Folsom Report--calling for "communities of solution." We propose an updated vision of the Folsom Report for integrated and effective services, incorporating the principles of community-oriented primary care. The 21st century primary care physician must be a true public health professional, forming partnerships and assisting data sharing with community organizations to facilitate healthy changes. Current policy reform efforts should build upon Folsom Report's goal of transforming personal and population health.     

Are large-scale volunteer community health worker programmes feasible? The case of Sri Lanka

National community health worker (CHW) programmes supported by Ministries of Health have been introduced in a number of countries as part of their primary health care policy. Although in many of these programmes the CHWs are salaried or receive an honorarium, there are a number of large-scale programmes in which CHWs work as unpaid volunteers. This paper looks at one such programme in Sri Lanka, in order to understand the motivation of such volunteers and to consider the feasibility of relying on volunteers to support primary health care policies. The lessons from the Sri Lanka case are generalized to other studies. The conclusion is that large-scale community level volunteer programmes will be characterized by high attrition and low activity rates and will only be sustainable under particular enabling conditions.     

Community health care and hospital attendance: a case study in rural Ghana

This study assesses the influence of coverage with a network of PHC clinics as well as private clinics in Dormaa District, Ghana on, hospital attendance. This influence is measured by analysing hospital attendance among inhabitants during 6 months in 1984 and 1986. Several conditioning factors are analysed: the type of modern health care present in the community and the experience of the community health worker (CHW); the distance between community and hospital; the time factor (1984 and 1986); the sex and age of the attendants; the diagnosis made at the hospital. It appears that fewer people attend the hospital if a community participates in the PHC programme and if the CHW is experienced. When people from these communities attend the hospital they do so less unnecessarily than those from other communities. Simple analysis of routine hospital data may contribute to any PHC assessment programme set up around the hospital.     

How do health service managers respond to qualitative research?

During 1992 a qualitative evaluation of a government health service-run community health worker (CHW) project in South Africa found that project workers were doing good work despite serious structural shortcomings related to lack of community participation and inadequate integration of the project in the health district system. Recommendations were made to develop the project in order to enhance community involvement, to build closer integration between the project and the services offered at the health centre, and to collaborate with non-government CHW projects in neighbouring areas.The evaluation study was followed up one year later by interviews with health managers to determine their response to the evaluation. The managers reported that they had found the qualitative data valuable for understanding how clients perceived the health service, and for planning a more community-responsive service.Despite this, the recommendations from the evaluation were not implemented and political developments in the district resulted in the CHW project being closed down. It is concluded that qualitative evaluators need to carefully explore the political context of primary health care interventions in order that their research provides useful data for decision-making.     

‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala

Background

In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s health issues required more than just hospital-based and physician-centered policies. The declaration called for a paradigm change that would allow governments to provide essential care to their population in a universally acceptable manner. The figure of the community health worker (CHW) remains a central feature of participation within the PHC approach, and being a CHW is still considered to be an important way of participation within the health system.

Methods

This study explores how the values and personal motivation of community health workers influences their experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, we used an ethnographic approach and collected data in January-March of 2009 and 2010 by using participant observation and in-depth interviews.

Results

We found that the CHWs in the municipality had a close working relationship with the mobile health team and with the community, and that their positions allowed them to develop leadership and teamwork skills that may prove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is a key value in Palencia, but there is a lack of infrastructure and growth opportunities.

Conclusion

Attention should be paid to keeping the high levels of commitment and integration within the health team as well as keeping up supervision and economic funds for the program.     

Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh

Background

Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh.

Methods

Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel.

Results

Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay.

Conclusions

The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition.     

基本医疗卫生与公共卫生服务整合的国际经验及启示

探索基本医疗卫生与公共卫生服务的整合是创新医疗卫生服务模式和完善公共卫生服务项目的重要课题之一。本文介绍了近年来国际上关于基本医疗卫生与公共卫生服务整合代表性的理论框架,对世界卫生组织、欧洲和美国整合的原则、模式和典型案例进行了总结和分析。结合目前我国对于医防融合的发展需求,为促进我国基本医疗卫生与公共卫生服务的整合提出以下建议:(1)加强基本医疗卫生服务人员公共卫生能力的建设;(2)加快基本医疗卫生与公共卫生信息化的建设;(3)促进社区参与基本医疗卫生与公共卫生服务的整合。     

积极开展农村社区卫生服务不断提高初级卫生保健水平

实施“农民健康工程”,紧紧围绕为人民健康和经济建设、服务这一中心,以初级卫生保健为目标,以卫生机构改革、管理一体化为基础,以合作医疗为保障,大力开展农村社区卫生服务,有效缓解农民群众看病贵、看病难的问题。     

Achieving progress in maternal and neonatal health through integrated and comprehensive healthcare services – experiences from a programme in northern Tanzania

Background  

An integrated and comprehensive hospital/community based health programme is presented, aimed at reducing maternal and child mortality and morbidity. It is run as part of a general programme of health care at a rural hospital situated in northern Tanzania. The purpose was through using research and statistics from the programme area, to illustrate how a hospital-based programme with a vision of integrated healthcare may have contributed to the lower figures on mortality found in the area. Such an approach may be of interest to policy makers, in relation to the global strategy that is now developed in order to meet the MDGs 4 and 5.     

Will primary health care efforts be allowed to succeed?

It is suggested that the consequence of following Primary Health Care (PHC) principles as guidelines for health care development must of necessity lead to socio-economic and political restructuring in most countries. We are well aware that health status is determined more by the social and economic situation of population groups than by curative health services. The holistic approach of primary health care includes a concern with such factors. PHC, if it is to succeed, must ultimately lead to a reduction in the greater benefit for the few to the greater benefit for the many. This will receive strong opposition.The situation of a PHC programme in Guatemala is presented as a case of PHC efforts which were succeeding being violently opposed. This is compared with PHC development efforts in Tanzania where, unlike Guatemala, there has been a conscious effort at restructuring the society and where national development policies are in tune with PHC principles. The future of PHC in Tanzania will depend more on whether or not the organization and management of selection, training and implementation processes, and the minimal available resources, will lead to success, than on whether or not it will be allowed to succeed.It is concluded that the situation in most countries comes closer to that of Guatemala than of Tanzania and that many people and institutions in hierarchical, non-egalitarian societies will spend a great deal of energy to prevent PHC programmes from succeeding. This forces us to consider the promotion of PHC in a much more serious manner than we might wish.     

Exploring the roles and factors influencing community health workers’ performance in managing and referring severe acute malnutrition cases in two subdistricts in South Africa

As primary providers of preventive and curative community case management services in low‐ and middle‐income countries (LMICs), community health workers (CHWs) have emerged as a formalised part of the health system (HS). However, discourses on their practices as formalised cadres of the HS are limited. Therefore, we examined their role in care, referral (to clinics) and rehabilitation of severe acute malnutrition (SAM) cases. Focusing on SAM was essential since it is a global public health problem associated with 30% of all South Africa's (SA's) child deaths in 2015. Guided by a policy analysis framework, a qualitative case study was conducted in two rural subdistricts of North West province. From April to August 2016, data collected from CHW's training manuals and guideline reviews, 20 patient record reviews and 15 in‐depth interviews with four CHW leaders and 11 CHWs. Using thematic content analysis which was guided by the Walt and Gilson policy triangle, data was manually analysed to derive emerging themes on case management and administrative structures. The study found that although CHWs were responsible for identifying, referring, and rehabilitating SAM cases, they neglected curative roles of stabilisation before referral and treatment of uncomplicated cases. Such limitations resulted from restrictive CHW policies, inadequate training, lack of supportive supervision and essential resources. Concurrently, the CHW program was based on weak operational and administrative structures which challenged CHWs practices. Poor curative components and weak operational structures in this context compromised the use of CHWs in LMICs to strengthen primary healthcare. If CHWs are to contribute to Sustainable Development Goal (SDG) 3 by reducing SAM mortality, strategies on community management of acute malnutrition coupled with thorough training, supportive supervision, firm operational structures, adequate resources and providers’ motivation should be adopted by governments.     

我国21世纪城市卫生发展战略探讨

随着城市化进程的加快，我国城市卫生发展的问题日趋重要。城市卫生发展不仅与广大城市居民的健康息息相关，对农村卫生事业的发展也将起着极其重要的作用，因此，在未来的一段时期，应加强城市医疗制度的改革，积极推行全民健康保险；加强预防医学发展的力度，防疾病于未燃，把初级卫生保健引向深入，建立与之相适应的城市初级卫生保健体系，积极做好区域卫生规划，管理好有限的卫生资源，重视城市人口发展态势，做地老年人的卫生保