Improving effectiveness of Community Health Workers in Low and Middle Income Countries through the provision of resources for their use: a systematic review

Problem

In low and middle-income countries, primary care services are limited by funding and lack of trained health workers. To address this, Community Health Workers (CHWs) are being deployed for tasks including monitoring patients with long term conditions and providing medication, follow up on mothers and babies, case finding for TB contact tracing. This allows trained health workers to focus on other tasks. Many CHW schemes have been successful, encouraging their use around the world. However, the most effective deployment of resources to support CHWs is not clear. Research question: What is the impact on CHW programmes of the provision of resources (e.g. airtime, small sums of money, transport) in Low and Middle Income Countries?

Approach

Systematic review of published evidence. We searched six search engines using search terms related to community health worker and low and middle income countries. We screened title and abstract with 20% screened independently by second researcher as quality check. Full papers were screened and appraised using Critical Appraisal Skills Programme checklists. Data was extracted and synthesised as a narrative.

Findings

1636 papers (without duplicates) were retrieved and screened, 2 papers found during full paper review were added giving final total of 32 papers. Of these two were RCTs with the remainder being observational studies.Where road infrastructure was poor and CHWs and patients had to walk long distances to a health facility, the provision of ambulances or motorbikes for transport made a difference but they were often poorly maintained and not available. Taxi drivers often transport people for free. A scheme to train them in first aid had the unintended consequence of reducing transport time to hospital. Two RCTs suggest mobile phones that provided CHWs with guidance/risk assessment tools are effective. Time was used more effectively, household consultations increased in length and quality, CHWs gained social legitimacy and CHWs used the phone to arrange transport for themselves or patients. Problems included network failure, lack of airtime, and broken phones.The provision of uniforms increased CHW motivation and was perceived by the CHWs as making them safer in the communityFor CHWs who already sold contraception provision of pregnancy test kits to give to patients increase provision of contraception. CHWs having diarrhoea packs to give to households reduced hospitalisation of children.

Consequences

The provision of resources such as transport, airtime for mobile phones and uniforms may solve practical problems for CHWs enabling them to undertake their work more effectively. Mobile phones that provide guidance/risk assessment tools improve CHW effectiveness. The results of this review have informed the design of an intervention to improve CHW effectiveness in the public health system of South Africa.