Stakeholders’ perceptions of policy options to support the integration of community health workers in health systems

The term ‘community health workers’ refers to diverse types of health workers that deliver elementary health services in communities [1]. While there is no universally agreed definition of community health workers (CHWs), the International Labour Organization (ILO) defines them as workers who ‘… provide health education and referrals for a wide range of services, and provide support and assistance to communities, families and individuals with preventive health measures and gaining access to appropriate curative health and social services...’ [2]. CHWs serve as a link between providers of health, social and community services and communities that may have difficulty in accessing these services.

Societies have used CHWs for a long time with varying levels of popularity and success. One of the earliest known example dates to the 1920s when Chinese ‘Farmer Scholars’, later known as the ‘Barefoot Doctors’, were trained for 3 months to work in rural communities [3]. Despite the long history of CHW programmes operating in diverse climes, health systems often have neglected this group of health workers and have failed to recognize them formally, especially by excluding them from the roster of health workers legally allowed to deliver services in health systems. This, coupled with inadequate monitoring and evaluation mechanisms, has resulted in a reduced ability to quantify CHW contributions to health system performance [3‐6].

In the 1970s, the World Health Organization (WHO) specifically recognized the contribution of CHWs to achieving primary health care (PHC) in countries. The Declaration of Alma-Ata states that ‘primary health care relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community’ [7]. The goal to enshrine integrated people-centred primary care through the concept of universal health coverage (UHC) is one that is still alive today. Consecutive biennial World health reports in 2006, 2008 and 2010 [8‐10] recognized the challenges affecting all health workers and argued for scaling up the health workforce as a critical measure to expand health services coverage.

To support capacity building of health workforce in countries, WHO, member states and partners developed the Global Strategy on Human Resources for Health: Workforce 2030 [11, 12]. The strategy encourages countries to adopt a diverse, sustainable skills mix that harnesses the potential of community health workers and mid-level health workers in inter-professional primary care teams. The ultimate aim is to achieve the third Sustainable Development Goal (SDG 3) to ‘ensure healthy lives and promote wellbeing for all, at all ages’. The contributions of community health workers are further highlighted by the report of the United Nations High-Level Commission on Health Employment and Economic Growth, which underscores their effectiveness and advocates for their recognition and support [13].

Despite potential added value of CHWs to health systems, policy guidance supporting the strengthening and scale-up of CHW programmes generally has been lacking, especially in developing countries where the programmes are most needed. To help countries address this gap, WHO developed a guideline to optimize community health worker programmes [14, 15, 16]. WHO guidelines typically follow the GRADE methodology as indicated in the WHO Handbook for Guideline Development [17]. The WHO guideline development process begins with a scoping proposal headed by a steering group. Submission of the guidelines scoping to the WHO Guidelines Review Committee (GRC) then follows for review and approval, before the setup of the Guideline Development Group (GDG) and the External Review Group (ERG). The GDG consists of international multidisciplinary experts and subject leaders (including CHWs themselves in this case) and is responsible for formulating the population, intervention, control, outcome (PICO) questions and making recommendations based on the evidence obtained from systematic reviews and other evidence gathered for the guideline development. The role of the ERG is to review the synthesis of the evidence gathered and to submit the findings to the GDG who then decide on the final recommendations before the approval by the WHO GRC. The success of implementing guidelines could depend on its acceptance and feasibility by end-users including policy makers/planners, decision makers and other implementers. The WHO guideline development process therefore allows for the input of stakeholders to be taken into account in addition to findings from the systematic evidence syntheses. Recently conducted studies have noted the significance of stakeholders’ views in the implementation of health care programmes [18, 19].

This paper reports findings from the assessment of stakeholders’ valuation of CHW outcomes of interest, and the perceived acceptability and feasibility of the policy options considered for developing the CHW guideline recommendations. It aims at ensuring greater relevancy, inclusiveness and ownership of the recommendations at policy implementation and practice levels.

This study was conducted using a cross-sectional mixed methods (quantitative and qualitative) design. It was conducted over a period of 6 months from February 2017 to July 2017. It targeted stakeholders, including community health workers, policy planners and government stakeholders involved directly or indirectly in country implementation of CHW programmes. The recruitment of respondents was done in a phased approach. The first selection of respondents was made among participants attending the 2017 Institutionalizing Community Health Conference held in Johannesburg, South Africa. Subsequently, respondents were identified from a wider audience including through the WHO Human Resources for Health contact list and the Health Information for All (HIFA) online platform to better target stakeholders from countries implementing CHW programmes. The WHO Human Resources for Health contact list and HIFA online forum enabled outreach to multisectoral groups including government representatives, health policy makers, academics, researchers, partner organizations, health professionals’ networks, publishers and librarians involved with CHWs. Participation was voluntary, and responses were made anonymous for privacy protection and to encourage openness, in line with WHO Research Ethics Review Committee (ERC) requirements.

The results of the study show that stakeholders rate the policy options to be generally acceptable and feasible. Participants deemed most of the outcomes of interest to be close to the ‘critical’ end of the scale with the highest-ranking outcomes being quality of CHW health services, health services coverage and access to care for patients. Participants also judged most of the policy options under consideration as ‘definitely acceptable’ and ‘definitely feasible’. They were uncertain regarding the acceptability or feasibility of few options, particularly the selection of CHWs on the basis of age and the selection of only those who completed a minimum secondary level of education. Adopting only CHWs who have completed a minimum of secondary education and the assessment of CHWs by service delivery supervision only were rated the most unacceptable (29%) for both policy options. It also follows that both policy options received the least percentage score for whether they are ‘definitely acceptable’ at 36% and 31% respectively.

Comparing the acceptability and feasibility of the policy options using the chi-square test, two are found to have statistically significant differences when p value < 0.05. These are assessing CHWs by service delivery supervision only and CHWs having a career ladder opportunity within the health and education systems. In the former, respondents found it more ‘definitely feasible’ (58%) than ‘definitely acceptable’ (31%). For the latter policy option, respondents judged it more ‘definitely acceptable’ (76%) than ‘definitely feasible’ (53%). Stakeholders and implementers may want to examine more contextual factors to determine setting-specific approaches regarding these policy options. For example, creating career ladder opportunities for CHWs may be acceptable but judging the required level of effort and resources needed to implement it will be important in this context. Similarly, though assessing CHWs by service delivery supervision only may be judged as feasible, the level of acceptance may require more caution and sensitivity if considered for application.

These study findings are important as they provide a useful signal from possible users on the relevance of the policy options, in addition to evidence obtained from systematic reviews in developing the guidelines. A systematic review of existing reviews on CHWs by Scott et al. documents the various ways in which CHWs have been deployed and the levers that helped ensure their success [20]. Findings of this study reveal that international/multilateral stakeholders were more represented (43%) in the survey compared to stakeholders representing governmental organizations (19%). Which stakeholders to engage and how to engage them will vary between settings. Integrating CHWs into health systems, however, is likely to ensure the sustainability of CHW programmes, and it is important for programme planners and decision makers to consider their approach according to health priorities and management and resource needs. An interesting observation narrated through the qualitative feedback highlights the importance of ensuring gender equality in selecting CHWs. In some contexts where female education is noted to be generally lower than that of males, it may be important to consider (while ensuring that quality and capacity are not undermined) that educational criteria or entry qualification standards for CHWs do not disadvantage women from selection in the first place.

The integration of CHWs in health systems is vital for them to thrive in countries. The results of the acceptability and feasibility of most of the described policy options above (though interpreted with caution due to the study limitations) indicate the prospect and willingness of stakeholders to support the integration of CHWs in health systems of countries.