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By Kate Hawkins

Are close-to-community providers and community health workers (CHW) part of the health workforce? If so, what can governments and international agencies like the World Health Organization do to support them and ensure that their work is integrated into and supported by the wider health system? What does a human resources for health strategy that includes CHWs actually look like? These are some of the questions that we have been grappling with in REACHOUT as we read and responded to the recent World Health Organisation consultation on this issue.

A focus on community

One of the many positive elements of the draft strategy that is under consideration is that one of the principles explicitly mentions the role of communities in realising the right to health and states that communities should be empowered in order to work on the social determinants of illness.

“Support governments to build optimal health workforce models for the provision of people-centred integrated health services, responsive to patients’ sociocultural expectations, and empowering and engaging communities to be active participants in the health care production process.”

We believe that various types of close-to-community health care workers are vital human resources for health and that these cadres provide a critical interface between the community and the formal health system. We are concerned that this cadre of staff are not explicitly mentioned in the Global Strategy and that as a result they will not be factored into this holistic approach.

While there are certainly challenges in scaling up, and making the most of, close-to-community health programmes CHWs should be valued and nurtured in a similar manner to their formally employed peers who they work alongside often at considerable material and emotional cost to themselves.

We have gathered together some of the evidence in strengthening these programmes in our recent special supplement on the topic, “Supporting and strengthening the role of close-to-community (CTC) providers for health system development”. Further information on the costing of close-to-community programmes can be found in our WHO Bulletin article and this editorial “Maximizing the impact of community-based practitioners in the quest for universal health coverage”.

We would like to stress that we call for a greater emphasis in this area not to create special vertical programmes for CHWs, but rather to support the overall effectiveness and equity of national and sub-national health systems.

Political will

We note the focus in the draft strategy of the importance of political will in the scale up of well-functioning, appropriately supported health workforces. In recent months there has been a surge of support for close-to-community programmes. For example they have been being heralded as a ‘good buy’ for development in a high-level report released at the Financing for Development Conference. But how do we ensure that these programmes are effective and are run efficiently and equitably in ways that are owned by health care staff, CHWs and communities? From our REACHOUT analysis key areas of concern have emerged that have potential to undermine CHW programme effectiveness and equity: 1. supervision; 2. community engagement; 3. referrals; and 4. coordination between stakeholders. Scale-up of CHW programmes is seen as a way of reaching universal health coverage, but rapid scale-up that does not address these concerns poses a potential risk to service quality and equity.

Migration and health worker shortage

The overview of the draft strategy suggests that the out-migration of health workers from low- and middle-income countries and under-investment by governments in this area places a strain on the health system. We would also argue that it places more responsibility on under-supported close-to-community providers who are being expected to add new areas of work to their existing portfolios, despite limited capacity, barely any support and no complete picture of the quality of the services that are delivered. There is a danger that they are seen as a “magic bullet” which will ameliorate weaknesses in other areas of the system.

Improving the evidence base

We note that the draft strategy calls for stakeholders to draw on “evidence on what works in health workforce development across different aspects, ranging from assessment, planning and education, across management, retention, incentives and productivity, and refers to the tools and guidelines that can support policy development, implementation and evaluation in these various areas.” We feel that there should be mention of the local and community level in this paragraph. In REACHOUT we have been exploring quality improvement cycles in close-to-community programmes. We define quality improvement as a systematic approach to planning defining, monitoring, improving and evaluating community health programmes. Through our work we are embedding into CHW scale-up, tried and tested quality improvement methods that are easy to use, simple to do and where data are collected, analysed and used by communities and CHWs to improve things in their own contexts.

This is not without its challenges. Government standards and guidelines are not widely known or disseminated and few people in the health system and in the community are clear on what their roles in quality improvement for community health might be. There are far too many tools and documents that are not owned by communities and CHWs.

Furthermore, we note that there are few studies that capture or explicitly discuss the context in which CHW interventions take place. In our work contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were also prominent. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All these contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. Future health policy and systems research should better address the complexity of contextual influences on programmes.

Focus below the national level

Whilst increasing national and institutional capacity to govern programmes is a laudable aim we believe that attention should also be paid to the sub-national and community levels and management capacity. Our research has argued that a mix of financial and non-financial incentives, predictable for the CHWs, is an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.

We also feel that capacity for conducting community health research deserves special attention as the voices and perspectives of communities are not adequately represented and this requires developing strategic partnerships and using innovative methods.

We look forward to the next steps in the policy development process and hope that some of our desires and concerns are reflected in the document moving forwards.

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