To harness the potential of community health workers (CHWs) to extend health services to poor and marginalized populations the authors argue that there is a need to better understand how CHW programs can be optimized. This paper presents the experience of and insights from application by selected organizations that have developed high-impact CHW programs with governments and communities in different countries globally. They present a series of design principles that, in their experience, drive programmatic quality and are debated or not commonly found in programs across the globe: CHWs must meet minimum standards before working; point of care fees should be avoided when possible; CHWs should go door to door and provide training on when to seek help; continuing training should be a requirement; CHWs should benefit from a dedicated supervisor and be paid and should be part of a strong local health system and data feedback loops.
Human Resources
In this study the authors explored the performance of by community health workers (CHWs) providing maternal and child health services at household level and the quality of the CHW-mother interaction using observations and in-depth interviews. Fifteen CHWs and 30 mothers/pregnant women were purposively selected in three rural districts of KwaZulu-Natal, South Africa. CHWs provided appropriate and correct health information but there were important gaps in the content provided. Mothers expressed satisfaction with CHW visits and appreciation that CHWs understood their life experiences and therefore provided advice and support that was relevant and accessible. CHWs expressed concern that they did not have the knowledge required to undertake all activities in the household, and requested training and support from supervisors during household visits. The authors assert that key building blocks for a successful CHW programme are in place to provide services for mothers and children in households but further training and supervision is required if the gaps in CHW knowledge and skills are to be filled.
A health system’s ability to deliver quality health care depends on the availability of motivated health workers, which are insufficient in many low income settings. Increasing policy and researcher attention is directed towards understanding what drives health worker motivation and how different policy interventions affect motivation, as motivation is key to performance and quality of care outcomes. As a result, there is growing interest among researchers in measuring motivation within health worker surveys. However, there is currently limited guidance on how to conceptualize and approach measurement and how to validate or analyse motivation data collected from health worker surveys, resulting in inconsistent and sometimes poor quality measures. This paper begins by discussing how motivation can be conceptualized, then sets out the steps in developing questions to measure motivation within health worker surveys and in ensuring data quality through validity and reliability tests. The paper also discusses analysis of the resulting motivation measure/s.
The authors examine the experiences of health workers through a gender lens, especially in fragile and post-conflict states. In these contexts, there may not only be opportunities to (re)shape occupational norms and responsibilities in the light of challenges in the health workforce, but also threats that put pressure on resources and undermine gender balance, diversity and gender responsive human resources for health (HRH). The authors used a mixed method for research in Sierra Leone, Zimbabwe, northern Uganda and Cambodia to understand how gender influences the health workforce. They applied a gender analysis framework to explore access to resources, occupations, values, and decision-making and draw largely on life histories with male and female health workers to explore their lived experiences, complemented by surveys, document reviews, key informant interviews, human resource data and stakeholder mapping. The findings shed light on patterns of employment: in all contexts women predominate in nursing and midwifery cadres, are under-represented in management positions and are clustered in lower paying positions. Gendered power relations shaped by caring responsibilities at the household level affect attitudes to rural deployment and women in all contexts face challenges in accessing both pre- and in-service training. Coping strategies within conflict emerged as a key theme, with experiences shaped by gender, poverty and household structure. Most health worker regulatory frameworks did not sufficiently address gender concerns. The authors argue that unless these are proactively addressed post-crisis, health workforces will remain too few, poorly distributed and unable to meet the health needs of vulnerable populations. Practical steps need to be taken to identify gender barriers proactively and engage staff and communities on best approaches for change.
This article is grounded in a research programme which set out to understand how to rebuild health systems post-conflict. Four countries were studied—Uganda, Sierra Leone, Zimbabwe and Cambodia—which were at different distances from conflict and crisis, as well as having unique conflict stories. The authors captured insights from 128 life histories and in-depth interviews with a variety of staff that had remained in service. This article aims to draw together lessons from these contexts which can provide lessons for enhancing staff and therefore health system resilience in future, especially in similarly fragile and conflict-affected contexts. The authors examine the reported effects, both personal and professional, of the three different types of shock (conflicts, epidemics and prolonged political-economic crises), and how staff coped. They find that the impact of shocks and coping strategies are similar between conflict/post-conflict and epidemic contexts—particularly in relation to physical threats and psychosocial threats—while all three contexts create challenges and staff responses for working conditions and remuneration. Health staff showed considerable inventiveness and resilience, and also benefited from external assistance of various kinds, but important gaps were found which point to ways in which they should be better protected and supported in the future.
This study seeks to understand how eye health services are delivered by primary health workers who have received training and what constraints remain to effective service provision. A qualitative investigation into the experiences of 20 primary health workers trained in primary eye care and eight key informants working within specialist eye health services or regional and district health management positions in two districts in Tanzania. Despite feeling confident in their own eye care skills, most primary health workers felt constrained in the services they could provide to their communities by insufficient resources needed for diagnosis and treatment, and by lack of systematic supportive supervision to their work. Specialist ophthalmic staff were aware of this issue, although for the most part they felt it was not within their capacity to remedy and that it fell within the remit of general health managers. Many participants discussed the low support to eye health from the national government, evidenced through the lack of dedicated funding to the area and traditional reliance on outside funds including international charities. The authors noted that although training of primary health workers is useful, it is not sufficient to address the burden of eye health disease present in rural communities in Tanzania. It is likely that broader engagement with the general health system, and most likely with the private sector, will be necessary to improve the coverage of eye health care to remote and poor communities such as those in Morogoro.
Care workers - who are largely migrant women, often working in informal home settings - make a considerable contribution to public health in many countries but are themselves exposed to health risks, face barriers to accessing care, and enjoy few labour and social protections. This WHO report, and its reflection on potential next steps, aims to foster debate about approaches to ensure that the global community meets its obligations in relation to these care workers. The report focuses on paid home-based care workers who attend to the varied needs of children, older people, people with disabilities and the disabled and ill people.It notes that a significant knowledge gap exists when it comes to how migrant care workers’ health is influenced – both positively and negatively – by the labour they perform and the contexts in which they undertake this work. The report highlights three key steps for all countries and regions to consider to improve the health and well-being of migrant care workers and their families:1. To generate evidence on the nature of migrant care work, the contributions to global health care and the terms and conditions of their employment. 2. To improve access to health services through specific measures to address non-discrimination, promote inclusion and participation of migrant care workers. 3. Promote and recognize care as a global public good that contributes to global health and well-being. The authors advocate for holistic, universal and person-centred health and social care systems.
This qualitative comparative study aimed at understanding similarities and differences in how relationships between community health workers, communities and the health sector were shaped in different Sub-Saharan African settings. The study demonstrates a complex interplay of influences on trust and community health workers’ relationships with their communities and actors in the health sector. Mechanisms influencing relationships were feelings of (dis)connectedness, (un)familiarity and serving the same goals, and perceptions of received support, respect, competence, honesty, fairness and recognition. Sometimes, constrained relationships between community health workers and the health sector resulted in weaker relationships between community health workers and communities. The broader context and programme context in which these mechanisms took place were identified. Policy-makers and programme managers should take into account the broader context and could adjust community health worker programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. This can contribute to enabling community health workers to perform well and responding to the opportunities offered by their unique intermediary position.
This qualitative formative research study aimed to inform the design of interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, the authors aimed to determine what leads to improved performance of CHWs. The CHW cadres studied were the rural health motivators, mothers-to-mothers mentors, HIV expert clients, and a community outreach team for HIV. Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: increased monetary compensation of CHWs, a more reliable supply of equipment and consumables, additional training, and an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as key factors.
From March to April 2014, a questionnaire asking about job satisfaction and turnover intentions was administered to all nurses at 36 public-sector health facilities offering antenatal and prevention of mother-to-child transmission services in Dar es Salaam, Tanzania. Slightly over half of the providers were dissatisfied with their current job, and 35% intended to leave it. Most providers were dissatisfied with low salaries and high workload, but satisfied with workplace harmony and being able to follow their moral values. The following factors were associated with providers’ intention to leave their current job: dissatisfaction at not being recognized by one’s superior, and poor feedback on the overall unit performance. Providing reasonable salaries and working hours, clearer job descriptions, appropriate safety measures, job stability, and improved supervision and feedback are argued to be key to retaining satisfied health workers for prevention of mother-to-child transmission providers.