How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature

Abstract

BackgroundCommunity health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs.MethodsWe searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized.ResultsFew studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes.ConclusionsResearch on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-015-0001-3) contains supplementary material, which is available to authorized users.

The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa

“…292 However, the performance of interventions and programmes is greatly influenced by numerous contextual factors, an area that requires further study. 293 It is important to distinguish between community members who volunteer for a few hours a week and full-time CHWs. All CHWs need adequate training, certification, and supervision; full-time CHWs should be remunerated, have opportunities for career advancement, and be formally recognised as part of the health system.…”

Community-based screening for cardiovascular risk using a novel mHealth tool in rural Kenya

“…Community health workers (CHWs), defined as members of a community with minimal formal nursing or medical training who provide basic health and medical care to their community, are increasingly recognised as an essential part of the health workforce needed to fill this gap in human resources and achieve public health goals in LMICs 7 , 8. CHWs can have many responsibilities within a community, including social support, linking to resources and health teaching 9.…”

Decentralization and health system performance – a focused review of dimensions, difficulties, and derivatives in India

“…It concluded that research on CHW programs often did not capture the context in which CHW interventions take place, and that future health systems research recognize and address the complexity of contextual influences on programs [63]. Bardhan argued that control rights in governance structures should be placed with local people for better health outcomes [64].…”