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Table 2 indicating how CHW interventions can overcome supply and demand side barriers to equity

From: How equitable are community health worker programmes and which programme features influence equity of community health worker services? A systematic review

Barrier How CHW intervention can overcome barrier Equity considerations for CHW programme planners
Supply side (CHW services)
Low number of health workers in hard-to-reach areas Local recruitment of CHWs, including recruitment of CHWs from marginalised groups Ensure CHWs are recruited locally, not centrally
Consider options to include illiterate CHWs in areas where education levels are low
Ensure CHW selection reflects community – inclusion of CHWs from marginalised groups
Time taken to reach service location Provision of services within the client’s home CHW intervention planning to consider geographic features – reduced household numbers per CHW where households are far apart/ difficult terrain
Cost of services Free service provision Payment for services can continue to present a barrier to service use, even if CHW services are provided within the home
Demand side (CHW services)
Demand for services and information about health care Developing improved client knowledge about CHW role as health care providers through home visits, sensitisation meetings and community mobilisation Consider comprehensive package of services, rather than single disease specific intervention
Weak sensitisation and community mobilisation around CHW intervention can lead to limited demand for services
Consider alternative approaches for certain groups – e.g. HTC provision by a non-resident CHW for youth and work based HTC (rather than home based) for migrant men
Waiting time for services, indirect costs (transport), opportunity costs Provision of curative services and provision of HTC within the home Ensure strong supply chain for commodities to all CHWs
Need for supportive supervision
Need for strong referral links between community and health facility
Education Reducing the knowledge/ behaviour gap between richest and poorest community members through one-to-one and group education Need to plan for behaviour change communication within CHW programme design
Household expectations and community and cultural preferences Provision of services within the home in cultural contexts where women are reluctant to seek care outside their home. Need for consideration of existing social relationships between clients and CHW
Demand side (Health facility services)
Demand for services and information about health care CHW led demand creation strategies, community engagement and action planning Consider the package of services provided at community level and whether this could reduce use of services by skilled provider at health facility (e.g. ANC)
CHW training in problem solving
Use of a household risk assessment by CHW to ensure high risk households receive more frequent home visits to advise about for clinic attendance
Waiting time for services, indirect costs (transport), opportunity costs Reimbursement for transportation Transport and opportunity costs will still exist, even where community is empowered and so community funds/ transport refunds are useful tools to overcome this barrier
Community funds
Education Reducing the influence of education on health facility service utilisation among those with limited formal education through one-to-one and group education Failure to develop community empowerment through support groups may hinder use of services at health facility level
Household expectations and community and cultural preferences CHW accompaniment during referrals Consider incentive for CHW to refer and accompany clients to health facility