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