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Table 4 Study characteristics

From: Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries

N o

1stAuthor/Year [Citations]

Country

Study type/ design

Type of CBHWs

Aim

Key issues/findings

Brazil specific studies

1

Svitone [46]

Brazil

Review

CHAs

To document primary health care lessons from the Northeast of Brazil following the implementation of CHAs Programme

Comprehensive information available, a decline in infant mortality, a rise in immunization, and timely interventions in times of crisis

2

Macinko [35]

Brazil

Program Evaluation

CHAs

To assess the effects of an integrated community-based primary care programme on microregional variations in infant mortality (IMR), neonatal mortality, and post-neonatal mortality rates from 1999 to 2004

Results show that infant mortality rate declined about 13 percent from 1999 to 2004, while Family Health Program coverage increased from an average of about 14 to nearly 60 percent

3

Aquino [16]

Brazil

Program Evaluation

CHAs

To evaluate the effects of the Family Health Programme (FHP) on infant mortality at a municipality level

The FHP had an important effect on reducing the infant mortality rate in Brazilian municipalities from 1996 to 2004. The FHP may also contribute toward reducing health inequalities

4

Zanchetta [40]

Brazil

Mixed methods

CHAs

To assessing the effectiveness of CHAs' actions in situations of social vulnerability

Barriers to CHAs' effectiveness included professional powerlessness, communication gaps, fragmented teamwork, organizational and structural barriers

Ethiopia Specific studies

5

Girma [40]

Ethiopia

Review

HEWs

To understand implications of strategies for human resource development (HRD) by 2015

The process to develop policy and strategy for managing human resource for health has been started

6

Negusse [26]

Ethiopia

Mixed methods

HEWs

To document the initial community perspectives on the Health Service Extension Programme in Welkait

HEWs are helpful, HEWs are more preferred over TBAs, HEWs provide good health services. Limitations: less visits, poor knowledge on major communicable diseases

7

Teklehaimanot [41]

Ethiopia

Qualitative

HEWs

To assess the working conditions of HEWs in Ethiopia and their job satisfaction

Health indicators have improved, performance in skilled delivery and postnatal care not satisfactory. Limited quality of service, utilization rate, access, referrals and programme evaluation

8

Admassie [47]

Ethiopia

Program Evaluation

HEWs

To evaluate the short-term and intermediate-term impacts of the HEW programme on child and maternal health indicators in the programme villages

The proportion of children and women using insecticide-treated bednets for malaria protection are significantly larger in programme villages than in non-programme villages

9

Koblinsky [52]

Ethiopia

Review

HEWs

To explore Ethiopia’s progress toward achieving MDG 5 through the Health Extension Programme

Achieving the set targets is a daunting task despite reaching the physical targets of two health extension workers per health post

10

Damtew [53]

Ethiopia

Qualitative (Case study)

HEWs

To examine conditions that may affect the quality of HEWs training in Ethiopia

Training inadequacies

11

Medhanyie [58]

Ethiopia

Mixed methods

HEWs

To investigate the Knowledge and performance of the HEWs on antenatal and delivery care as well as the barriers and facilitators to service provision

Poor knowledge of HEWs, poorly equipped health posts, and poor referral systems affected acceptability of services

12

Medhanyie [59]

Ethiopia

Program Evaluation

HEWs

To assess the role of HEWs in improving utilization of maternal health services in rural areas in Ethiopia

Better utilization of family planning, antenatal care etc. Limited contribution to health facility delivery, postnatal check-up etc.

13

Birhanu [61]

Ethiopia

Mixed methods

HEWs

To assess mothers’ experiences and satisfaction with health extension service

Most mothers had good relationships, were satisfied with and had positive attitude towards HEWs. Programme was however criticized for not including curative services and the less attention given to static services at health post

14

Teklehaimanot [42]

Ethiopia

Qualitative (Case study)

HEWs

To describe the strategies, human resource developments, service delivery modalities, progress in service coverage, and the challenges in implementing the HEP

Health system reformed to create a platform for integration/ institutionalization of the HEP with appropriate human capacity, infrastructure, and management structures

India specific studies

15

Scott [49]

India

Qualitative (Case study)

ASHAs

To investigate the contextual features hindering the ASHAs' capacity to increase quantitative health outcomes and act as cultural mediators and agents of social change

SHAs limited by: (1) the outcome-based remuneration structure; (2) poor institutional support; (3) the rigid hierarchical structure of the health system; and (4) a dearth of participation at the community level

16

Gopalan [60]

India

Mixed-methods

ASHAs

To examine the performance motivation of community health workers (CHWs) and its determinants on India's Accredited Social Health Activist (ASHA) programme

Performance motivation mainly influenced by the individual and the community level factors, while the health system factors scored the least

17

Kumar [43]

India

Program Evaluation

ASHAs

To study the factors influencing the work performance of ASHAs in community

Limitations included less knowledge, caste system, limited incentive practices and inadequate incentives

18

Shrivastava [54]

India

Mixed-methods

ASHAs

To evaluate the knowledge, attitudes and practices of ASHA workers in relation to child health

Gaps still exists in ASHAs’ knowledge regarding various aspects of child health morbidity

Pakistan specific studies

19

Afsar [50]

Pakistan

Program Evaluation

LHWs

To estimate the proportion of patient referral and to identify the factors associated with unsuccessful referral in Karachi, Pakistan

Limited communication and counselling skills of LHWs contributed to significant proportion of unsuccessful referrals

20

Afsar [51]

Pakistan

Qualitative

LHWs

To assess the strengths and weakness of the National Programme for Family Planning and Primary Health Care from the LHWs’ perspectives

Strengths: Some community members accepting LHWs. Weaknesses: contractual job, low salaries, irregular payment, no career development and poor logistical support

21

Douthwaite [38]

Pakistan

Mixed methods

LHWs

To evaluate the Lady Health Worker programme

The LHWP has succeeded in increasing modern contraceptive use among rural women

22

Haq [57]

Pakistan

Mixed methods

LHWs

To evaluate job stress among community health workers in Pakistan

Challenges: stress, low socio-economic status, long distances; inadequate, medical supplies, stipends, communication skills, lack of career structure

23

Haq [39]

Pakistan

Qualitative

LHWs

To document the perceptions of LHWs on their knowledge and communication needs, image building

Many respondents described their communication skills as moderately sufficient. Knowledge on emerging health issues was insufficient

24

Hafeez [37]

Pakistan

Mixed methods

LHWs

To review the LHW programme and explore various aspects of the process to extract tangible implications for other similar situations

Improved community links with first level care facilities, earned community trust. Limitations: poor support from sub-optimal health facilities, financial constraints and political interference

25

Mumtaz [55]

Pakistan

Mixed-methods

LHWs

To explore the impact of socio-cultural factors on LHWs' home-visit rates

Performance is constrained by both gender and biradari/caste-based hierarchies.

26

Wazir [17]

Pakistan

Review

LHWs

To conduct a SWOT analysis of the National Program for Family Planning and Primary Health Care in Pakistan

Strengths: comprehensive planning, implementation and supervision mechanisms, selection and recruitment processes. Weaknesses: slow progress, poor program integration, job insecurity and delayed salaries

Studies focusing on more than one country

27

Hermann [44]

Ethiopia and others

Review

HEWs

To investigate whether present CBHW programmes for ART are taking into account the lessons learnt from past experiences and analyse the extent to which they are seizing the new ART-specific opportunities

Adequate remuneration key to CBHW retention. Sufficient attention to be given to supervision, continuous training and health systems strengthening

28

Celletti [34]

Brazil, Ethiopia, etc.

Qualitative

CHAs HEWs

To evaluate the contribution of CHWs with a focus on identifying the critical elements of an enabling environment that can ensure that they provide quality services in a manner that is sustainable

Important requirements include adequate systems integration, political commitment; good planning, definition of scope of practice, selection, educational issues, career path, registration, licensure and certification; recruitment and deployment; adequate remuneration, supervision; referral system; supplies

29

Kane [19]

Brazil, Ethiopia, India, Pakistan, etc.

Realist synthesis (Review)

CHAs, HEWs, ASHAs, LHWs

To explore if randomised controlled trails could yield insight into the working of the interventions, when examined from a different perspective, a realist perspective

Positive mechanisms: anticipation of being valued; perceived improved social status; sense of relatedness with the health system; increased self esteem, sense of self efficacy, enactive mastery of tasks; sense of credibility, legitimacy

30

Lewin [20]

Brazil, Ethiopia, India, Pakistan, etc.

Systematic review

CHAs, HEWs, ASHAs, LHWs

To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases

LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care

31

Liu [6]

Brazil, Ethiopia, India, Pakistan, etc.

Review

CHAs, HEWs, ASHAs, LHWs

To explore CBHW programmes that have been deployed at national scale, as well as scalable innovations found in successful nongovernmental organization-run community health worker programmes

Ability by national CBWH programmes to reach scale is impressive, but quality and management challenging. If well managed programmes integrated into a well-functioning primary healthcare system can promote care and act as an effective link

32

Wouters [48]

Ethiopia and others

Synthetic review

HEWs

To review the impact of community-based support services on ART delivery and outcomes in resource-limited countries

CBHWs are not necessarily cheap or easy, a good investment to improve coverage of communities in need of health services

33

Jaskiewicz [56]

Ethiopia Pakistan and others

Review

HEWs LHWs

To review the influence of work environment in increasing community health worker productivity and effectiveness

Essential elements for improving productivity: defined workload, supportive supervision, supplies and equipment, and respect from the community and the health system

34

Balabanova [45]

Ethiopia, etc.

Review

HEWs, etc.

To discuss why some countries or regions achieve better health and social outcomes than others at a similar level of income and to show the role of political will and socially progressive policies

Attributes of success included good governance, political commitment, effective bureaucracies, ability to innovate and adapt to resource limitations, the capacity to respond to population needs and build resilience into health systems to face challenges. Transport infrastructure, female empowerment, and education also played a part

35

Glenton [2]

Brazil, Ethiopia, India, Pakistan, etc.

Systematic review

CHAs, HEWs, ASHAs, LHWs

To explore factors affecting the implementation of LHW programmes for maternal and child health

Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and health system constraints

36

Perry [3]

Brazil and others

Review

CHAs

To summarize the history, recent evolution, and current evidence of the effectiveness of CHWs around the world

CBHWs promote healthy behaviors, extend reach of health systems, help address health workforce resources shortage, and reduce health disparities