Towards a framework for analyzing determinants of performance of community health workers in malaria prevention and control: a systematic review

Globally, malaria has declined in incidence by 37% and mortality rate by 60% between 2000 and 2015 [1]. Community interventions through Community Health Workers (CHWs), who are a link between the community and the health facility, have contributed to this reduction [2‐4]. The World Health Organization (WHO), in attempting to move toward elimination of malaria, has come up with a strategy that has three main building blocks which are to ensure universal access to malaria prevention, diagnosis, and treatment, to accelerate efforts toward elimination of malaria and attainment of malaria-free status, and to transform malaria surveillance into a core intervention [2]. These building blocks can be best achieved through Primary Health Care (PHC) using the CHW as key actors in the strategy, which most countries adopted after the 1978 Declaration of Alma-Ata [3, 4].

Community health workers are men and women with basic literacy and numeracy levels, chosen by the community and trained to deal with individual and community health problems while working in close relationship with the formal health care system [5‐7]. This review focused on trained CHWs who work as community malaria agents (CMAs) carrying out malaria prevention and control interventions in the community.

Studies have shown that CHW performance can help reduce morbidity and mortality in resource constrained settings [3, 7, 8]. The CHW performance is context-specific [7], and there is little evidence on what specific factors have contributed to effective implementation of the CHW strategy in malaria interventions. Community health workers provide cost-effective and sustainable ways of delivering malaria control interventions in the community. These interventions include conducting rapid diagnostic tests, malaria treatment, community sensitization for IRS, and distribution of insecticide treated nets (ITNs) [9]. Despite great efforts to combat it, the threat of resurgent malaria is present across different settings. Resurgence has in part been attributed to non-cooperation of communities in control initiatives [10]. Awareness of this threat and the development of systems to minimize resurgence are key to further progress in malaria control [10]. This systematic review was done to gather evidence of CHW performance evaluations in malaria and how they were measured, highlighting determinants of their performance in malaria prevention and control programs.

The search resulted in a total of N = 1692 results appearing on the databases of which n = 251 were from Google Scholar, n = 796 from Science Direct, n = 619 from PubMed, and n = 26 from reference lists of some articles. After title screening, n = 613 articles remained and n = 527 duplicates were removed leaving n = 86 articles for full abstract assessment. Abstracts not reporting the outcome of interest were n = 44, and n = 42 were considered for full text review. No full texts were found for n = 19 articles, and n = 7 were excluded as they were establishing use of CHW for an intervention while others were establishing efficacy of antimalarial drug given by CHWs. Some papers were excluded because they were not from sub-Saharan Africa and were published outside the review period. All the search results were managed in Endnote referencing software (Thomson Reuters, Philadelphia, USA) and the final 16 articles have been reported in this systematic review (Fig. 1).

This systematic review has found that CHW performance was evaluated differently in different malaria endemic settings without a standard evaluation tool. Most evaluations were competency based, focusing mainly on RDT, treatment, and referral services. This is similar to a study by Yasauko (2010) that assessed the quality of service of village malaria workers in Cambodia. In this study, village health workers (VHW) focused on diagnosis and treatment, ignoring other community malaria preventive roles. The study recommended the need to cover other aspects of malaria control in order to further strengthen community-based malaria control [29]. The roles need to include an integrated approach covering surveillance, communication, vector control, and environmental management including evaluating implementation of these instilled CHW skills in terms of quality and a measure of the intended purpose of the intervention to the community as CHW performance cannot only be evaluated through a skill but also by an outcome of the intervention [30].

Using evidence of determinants of performance in malaria interventions, we have proposed a performance framework which shows the elements that are vital for determining performance in community malaria programs. The major components are health system factors, CHW characteristics, and community factors (Fig. 2).

Our findings indicate that all elements of the WHO building blocks within the health system interlink in a complex manner and may not flow in a linear manner all the time. These have a significant influence on implementation of CHW programs in malaria interventions and their performance. The individual CHW characteristics are modified by the health system factors to create an enabling environment for individual CHWs, while community factors also play a role in shaping overall performance (Fig. 2). This means that CHWs cannot implement community malaria interventions without support from the formal health system. According to the findings, the malaria CHW strategy needs considerations for CHW characteristics like selecting at least more female CHWs, married CHWs, those with longer experience in community service, secondary level educational status, those with availability of support for household chores, and those with good sanitation practices. These characteristics should be taken into account when developing the selection criteria for CHW community-based malaria programs. The community leadership must be involved and consulted in selecting which CHWs may be engaged as this may assist in obtaining positive response from the community to the malaria interventions [7]. In addition, while WHO recommends that CHWs should receive remuneration, most CHWs are working on voluntary basis and their working terms are not made clear to them except for example the Malawian government that has salaried the health surveillance assistants including providing accommodation, a system that has led to improvement and scaling up of ICCM [23].

Improvement of CHW-professional staff relationship is important for improving CHW confidence, as it provides a level of motivation for a well-coordinated CHW program. Improved cognitive reflections exhibited in CHWs are part of performance measurements worth considering [30]. The CHW competencies in diagnosis, treatment, referral, and surveillance are a measure of individual CHW performance in malaria, but output is also dependent on training received, refresher courses, supervision, logistics, and supplies. Evidence indicates that competence evaluations through observations may have better results if evaluations are done within the CHW work environment [16]. A systematic review by Smith et al. 2014 on the effectiveness of strategies to improve community case management (CCM) of malaria reports that CHWs are able to provide good quality malaria care, including performing procedures such as rapid diagnostic tests with appropriate training, clear guidelines, and regular supportive supervision [31]. Evidence from a systematic review on the impact and implementation of supervision suggests that improving supervision quality has a greater impact than increasing frequency of supervision alone [32].

There is a need to strengthen CHW program coordination among stakeholders such as health ministries and nongovernmental organizations that play a big role in strategy or intervention implementation at district level. These stakeholders have a direct influence on the health system factors related to production of guidelines, registers, checklists, reporting tools, and evaluation tools of which studies revealed not to have had reporting or standard evaluation tools for malaria programs [11, 12, 15]. However, this review found that there are few or no reporting or standard evaluation tools for malaria programs though an innovation to improve the information system through use of phones for reporting has been effected in some countries like Zambia [33].

Motivated CHW may help encourage the community to adopt practices that promote health through witnessing visible changes in the community by CHW efforts as they are a link to the community [7]. Remuneration, availability of supplies, and relevant infrastructure have been found to be important demotivating factors for health workers [34]. To avoid demotivating CHW and health workers alike, sufficient remuneration; supplies of RDT, drugs, and ITNs; and job aids need to be consistent, including relevant infrastructure [23, 27, 34]. One study indicates that there is no serious attempt to globalize investment in CHWs as a strategy to combat malaria [35] hence funding allocation and remuneration for CHW programs should be increased if malaria elimination is to be achieved [20, 23, 35].

In this review, CHWs performed poorly due to increased workload as they have a large population coverage and perform multiple tasks. There is need for scaling up of these malaria CHW interventions and promoting continued use of CHWs in national programs as an important human resource that contributes to long-term impact of interventions [4, 35]. Integrating malaria control activities for CHWs as a holistic package is critical in the fight to eradicate malaria [27]. This entails continued recruitment and training to help reduce the workload and increase coverage. A systematic review assessing the most effective approach to delivering malaria treatment in developing countries recommended that CHWs roles should be recognized, integrated, and expanded as they were effective despite challenges met [35]. Adequate training and refresher courses are vital as knowledge on malaria epidemiology and vector ecology is essential in promoting integration and expansion of CHW practice [36]. This integrated approach may help foster the new WHO pillar strategy that has three main building blocks which are to ensure universal access to malaria prevention, diagnosis, and treatment, to accelerate efforts toward elimination of malaria and attainment of malaria-free status, and to transform malaria surveillance into a core intervention [2]. However, integrating and multitasking with other health programs needs total health system support as priority for CHWs to perform as an important cadre in delivery of primary health care services to the community [4].

The CHWs serve the community, and community feedback is therefore vital as this influences performance. Studies included in the review indicated poor utilization of CHW services [20] and that only the rural poor are utilizing their services [17]. Utilization of CHWs can be improved through engagement of community leadership who may influence the community to support the CHW malaria strategy through rewards [17] and adopting practices that prevent and control malaria. The CHW program is intended not only to improve intervention coverage but also to improve surveillance and reduce congestion in health facilities even in urban areas which are densely populated [3].

This review has shown that health system factors, community factors, and CHW characteristics were important factors that affect CHW performance with the health system factors being the most important. These CHWs are available and willing to serve the community but a workable environment for them has not been well established in many health systems. Factors affecting performance highlighted in this review should be taken into account by policymakers during designing, implementation, and adjusting of CHW programs with consideration that these factors interlink. Using evidence of performance determinants in malaria programs from various studies, we therefore suggest that a CHW performance framework developed from these studies could guide designing, implementation, and evaluation of community-based malaria prevention programs.