Human Resources

Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice
Ahmed S; Chase LE; Wagnild J; et al: International Journal for Equity in Health 21, doi:, 2022

This systematic review aimed to synthesise research findings on the Community Health Worker (CHW) effectiveness at reaching the most disadvantaged groups in low- and middle-income countries (LMIC) contexts, and in reducing health inequities in the populations they serve. One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps. In order to optimise the equity impacts of CHW programmes, the authors propose moving beyond seeing CHWs as a temporary sticking plaster, and instead building meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity.

Community Health Workers in Pandemics: Evidence and Investment Implications
Ballard M; Johnson A; Mwanza I; et al: Global Health: Science and Practice 10(2):e2100648; doi:, 2022

Community health workers (CHWs) have been a critical part of health care delivery across diverse contexts for over a century. This article argues that a strong and accessible national health system, including at the community level, is critical for pandemic preparedness and response. Community health workers who are equipped, trained, and paid as part of a well-functioning health system can help prevent epidemics from becoming pandemics and maintain health care delivery amid significant disruption. To achieve resilient health systems, bi/multilateral aid and private philanthropies need to review their investment practices to replace those that cause harm (high transaction costs, earmarking, short-termism, appropriation of sovereignty) with practices that ensure timely and effective implementation of priorities set by government stakeholders (pooling, longer commitments, and alignment with evidence-based guidelines).

Qualitative assessment of community health workers’ perspective on their motivation in community-based primary health care in rural Malawi
Ndambo M K; Munyaneza F; Aron M B; et al: BMC Health Services Research 22(179), 1-13, 2022

Few studies have described the Community Health Worker (CHW) perspective on their intrinsic and extrinsic motivation in relation to their activities. Data was collected in 8 focus group discussions with 90 CHWs in October 2018 and March–April 2019 in seven purposively selected catchment areas. The results indicate that enabling factors are primarily intrinsic, such as positive patient outcomes, community respect, and recognition by the formal health care system, but that this can lead to the challenge of increased scope and workload. Extrinsic factors such as the increased scope and workload from original expectations, lack of resources for their work, and rugged geography present challenges, but with a positive work environment and supportive relationships between CHWs and supervisors enabling the CHWs. The authors suggest that challenges can be mitigated through focused efforts to limit geographical distance, manage workload, and strengthen CHW support to reinforce their recognition and trust, and by giving focus to enhancing motivational factors in primary health care systems.

It was hell in the community’: a qualitative study of maternal and child health care during health care worker strikes in Kenya
Scanlon M L; Maldonado L Y; Ikemeri J E; et al: International Journal for Equity in Health 20:210, 1-12, 2021

This paper investigated maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers, and health facility managers, using in-depth interviews and focus group discussions. Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt poor households, particularly poor women, were most affected since they were more likely to rely on public services, while community health volunteers highlighted their own poor working conditions. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care and highlighted and exacerbated inequities in the health system.

When will the doctor be around so that I come by?!’ Geo-socio effects on health care supply, access and utilisation: experiences from Kalangala Islands, Uganda
Kwiringira J N; Mugisha J; Akugizibwe M; et al.: BMC Health Services Research 21:1163, 1-13, 2021

This study explored the intersecting geographical, ecological and social factors affecting access to health care in a social epidemiology analysis in Uganda, using literature review and an ethnographic exploration of the lived experiences of community members while seeking and accessing health care, understanding that health system activities are diverse but interconnected in a complex way. When and how to travel for care was beyond a matter of having a health need/ being sick and need arising. A motivated workforce was found to be as critical as health facilities themselves in determining healthcare outcomes, and geography alone is not a sufficient factor in determining health outcomes..

Health workers’ perceptions on where and how to integrate tobacco use cessation services into tuberculosis treatment; a qualitative exploratory study in Uganda
Rutebemberwa E; Nyamurungi K; Joshi S; et al: BMC Public Health 21(1464), 1-9, 2021

The authors explored perceptions of health workers on where and how to integrate tobacco use cessation services into TB treatment programs in Uganda, using nine focus group discussions and eight key informant interviews in high volume health centres, general hospitals and referral hospitals. Respondents highlighted that just like TB prevention starts in the community and TB treatment goes beyond health facility stay, integration of tobacco cessation should be started when people are still healthy and extended to those who have been healed as they go back to communities. Tobacco cessation activities should be provided in a continuum with coordination of different organizations like peers, the media and TB treatment supporters. TB patients needed regular follow up and self-management support for both TB and tobacco cessation. Patients needed to be empowered to know their condition and their caretakers needed to be involved. Effective referral between primary health facilities and specialist facilities was needed. Clinical information systems should identify relevant people for proactive care and follow up. In order to achieve effective integration, the health system needed to be strengthened especially health worker training and provision of more space in some of the facilities.

South African physician emigration and return migration, 1991–2017: a trend analysis.
Nwadiuko J; Switzer G; Stern J; et al: Health Policy and Planning, doi: 10.1080/17441692.2021.1900316, March 2021

This study used physician registry data to analyse patterns of emigration and return migration only among South Africa-trained physicians registered to practice in top destination countries such as Australia, Canada, New Zealand, the USA or the UK between 1991 and 2017, which represent the top five emigration destinations for this group. It found a 6-fold decline in emigration rates from SA between 1991 and 2017, with declines in emigration to all five destination countries. About one in three South Africa physicians returned from destination countries as of 2017. Annual physician emigration fell by 0.16% for every $100 rise in South Africa gross domestic product per capita. As of 2017, 21.6% of all South Africa physicians had active registration in destination nations, down from a peak of 33.5% in 2005, a decline largely due to return migration. Changes to the UK’s licensing regulations were seen to be likely affected migration patterns while the Global Code of Practice on International Recruitment contributed little to changes. The authors propose that return migration monitoring be incorporated into health workforce planning.

Approaches to motivate physicians and nurses in low- and middle-income countries: a systematic literature review
Gupta J; Patwa M; Khuu A; Creanga A: Hum Resources for Health 19(4), 1-20, 2021

The paper reviews evidence on interventions used to motivate health workers in low- and middle-income countries. The review found supervision, compensation interventions and systems support to play a role. The authors found there is limited evidence on successful interventions to motivate health workers in low- and middle-income countries and the authors call for studies that use validated and culturally appropriate tools to assess worker motivation.

Community health workers’ involvement in the prevention and control of non-communicable diseases in Wakiso District, Uganda
Musoke D; Atusingwize E; Ikhile D; Nalinya S; et al: Globalization and Health 17(7), 1-11, 2021

This paper assessed the involvement of Community health workers (CHWs) in the prevention and control of non-communicable diseases (NCDs)in Wakiso District, Uganda with a focus on their knowledge, attitudes and practices, as well as community perceptions, through a cross-sectional mixed-methods study. The majority of CHWs correctly defined what NCDs are and mentioned high blood pressure, diabetes and cancer. Many CHWs said that healthy diet, physical activity, avoiding smoking/tobacco use, and limiting alcohol consumption were very important to prevent NCDs. The majority of CHWs who were involved in NCDs prevention and control reported challenges including inadequate knowledge, lack of training, and negative community perception towards NCDs. Community members were concerned that CHWs did not have enough training on NCDs and the community did not have much confidence in them regarding NCDs and rarely consulted them concerning these diseases. The authors recommend enhanced training and community engagement for CHWs to contribute to the prevention and control of NCDs.

How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo
Raven J; Wurie H; Idriss A; Bah A; et al: Human Resources for Health 18(58), 1—14, doi:, 2020

This paper presents evidence from Sierra Leone, Liberia and Democratic Republic of Congo on how community health workers (CHWs) are .managed, the challenges they face and potential solutions. According to the findings: fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role; with implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs’ scope of work is varied and may change over time, requiring ongoing training. The modular, local and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is argued to be vital to the retention and performance of CHWs, as are predictable supervision, supplies, community recognition and allowances.