By Maryse Kok

Over the past years, attention to the role of community health workers (CHWs) has been growing, so it was no surprise to me that the Global Symposium on Health Systems Research 2016 offered a considerable number of organized sessions, panels, presentations and posters around this subject in Vancouver last week.

UNICEF organized a session on “community health systems”, with a focus on CHWs. Evidence was shown on how several “hardware” elements of these systems (such as financing, monitoring and training and supervision) could be improved. For example, the Malaria Consortium developed m-health tools to support CHWs’ skills in prevention and diagnosis of diseases and provide a vehicle for data collection and supervision. The project shows good results in Uganda and Mozambique. World Vision has extensive experience in CHW programming and takes the lead in harmonizing CHW programmes in various countries, by developing clear job descriptions, tools for competency-based supportive supervision and training curricula. Management Sciences for Health has developed a tool for costing of CHW programmes, which can provide insight into needed resources to reach several specific health targets over time at national or district level. UNICEF will publish a study showing how CHWs are distributed at national and district level in Sierra Leone, Liberia, Niger and Malawi, and how close to their communities they are (in terms of distance). The evidence from these initiatives and studies provides important insights for policy makers, programme managers and implementers on what can be done to improve CHW and programme performance.

The realization that besides hardware, “software” elements (such as trust, values and relationships) are needed to reach optimal performance, was supported by various speakers during the symposium. Health systems are complex and social institutions, in which health worker performance is shaped by transactional processes between different actors. The intermediary position of CHWs makes this even more profound, as addressed in various presentations from the REACHOUT Consortium: CHWs continuously need to serve and link to communities and the health sector. Why do I refer to the “health sector” here, and not the “health system”? Because CHWs – and communities – are part of health systems. I think we should question ourselves when we talk about “community health systems”. We can keep it simple: we are talking about health systems.

The notion of health systems as complex, adaptive and social institutions affirms the attention to the role of CHWs. They are not only part of the health workforce supporting the achievement of disease related targets, but they also have the potential to facilitate relationships between different actors in the health system, and act as social change agents by triggering the raising of voices of communities. In other words, CHWs play an important role in bonding, bridging and linking – the pillars of social capital. We need to look at how hard- and software elements in health systems and in community health programmes interact with each other. For example, how can training or supervision interventions for CHWs be shaped in such a way that they trigger feelings of connectedness and serving the same goals, and create a sense of trust between various actors?

This is related to the call, in one of the plenary sessions, for intersectionality when analyzing and improving health systems. People are at the center of health systems, and the system’s functionality depends upon health workers, clients and communities. People can experience health status, phenomena affecting health and health care differently. If we had a better understanding about this in particular contexts, programmes could be optimized and health systems could become more equitable.

CHWs, as members of the communities they serve, have access to much needed context specific knowledge. They are said to have the ability to reach and include minority groups in health programmes. However, CHWs themselves, as every other health worker, share norms and values existing in communities; and their performance could be constrained by this. For example, female CHWs in Afghanistan are constrained in conducting certain tasks, as male involvement is no option in a society where females cannot speak to males outside their own households. It is important to reflect upon these issues, including reflexivity of how we as researchers are part of and influenced by the ideas and interest and norms and values of the communities we are part of.

We have seen that over the past decades and even now, CHW programmes do sometimes not perform in an optimal way, because of demotivation, mistrust, constrained communication and diverging expectations. Research on CHW programmes has much focused on hardware, but less on the software elements in health systems. The complex connection between the broader context and (the hard- and software elements of) health systems is recognized, but research related to this is scarce and translation of research findings to policy and programming options is even more challenging.

We need to look beyond researching how human resource management interventions can improve CHW performance, and expand on researching CHWs’ realities as intermediaries within health systems, embedded in specific social, political and economic contexts; and draw conclusions on what can be done to improve trusting relationships and address power between all actors involved. I believe if we do so, CHW programmes could be one step closer in contributing to resilient and response health systems, and therefore to health for all.

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