How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo.

BACKGROUND: Community health workers (CHWs) are critical players in fragile settings, where staff shortages are particularly acute, health indicators are poor and progress towards Universal Health Coverage is slow. Like other health workers, CHWs need support to contribute effectively to health programmes and promote health equity. Yet the evidence base of what kind of support works best is weak. We present evidence from three fragile settings-Sierra Leone, Liberia and Democratic Republic of Congo on managing CHWs, and synthesise recommendations for best approaches to support this critical cadre. METHODS: We used a qualitative study design to explore how CHWs are managed, the challenges they face and potential solutions. We conducted interviews with decision makers and managers (n = 37), life history interviews with CHWs (n = 15) and reviewed policy documents. RESULTS: Fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role. This has implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs' scope of work is varied and may change over time, requiring ongoing training. The modular, local and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is vital to retention and performance of CHWs. But there are challenges with supervision, scarcity of supplies, inadequate community recognition and unfulfilled promises about allowances. Clear communication about incentives with facility staff and communities is required as is their timely delivery. CONCLUSIONS: This is the first study that has explored the management of CHWs in fragile settings. CHWs' interface role between communities and health systems is critical because of their embedded positionality and the trusting relationships they (often) have. Their challenges are aligned to those generally faced by CHWs but chronic fragility exacerbates them and requires innovative problem solving to ensure that countries and communities are not left behind in reforming the way that CHWs are supported.

Using a human resource management approach to support community health workers: experiences from five African countries.

BACKGROUND: Like any other health worker, community health workers (CHWs) need to be supported to ensure that they are able to contribute effectively to health programmes. Management challenges, similar to those of managing any other health worker, relate to improving attraction, retention and performance. METHODS: Exploratory case studies of CHW programmes in the Democratic Republic of Congo, Ghana, Senegal, Uganda and Zimbabwe were conducted to provide an understanding of the practices for supporting and managing CHWs from a multi-actor perspective. Document reviews (n = 43), in-depth interviews with programme managers, supervisors and community members involved in managing CHWs (n = 31) and focus group discussions with CHWs (n = 13) were conducted across the five countries. Data were transcribed, translated and analysed using the framework approach. RESULTS: CHWs had many expectations of their role in healthcare, including serving the community, enhancing skills, receiving financial benefits and their role as a CHW fitting in with their other responsibilities. Many human resource management (HRM) practices are employed, but how well they are implemented, the degree to which they meet the expectations of the CHWs and their effects on human resource (HR) outcomes vary across contexts. Front-line supervisors, such as health centre nurses and senior CHWs, play a major role in the management of CHWs and are central to the implementation of HRM practices. On the other hand, community members and programme managers have little involvement with managing the CHWs. CONCLUSIONS: This study highlighted that CHW expectations are not always met through HRM practices. This paper calls for a coordinated HRM approach to support CHWs, whereby HRM practices are designed to not only address expectations but also ensure that the CHW programme meets its goals. There is a need to work with all three groups of management actors (front-line supervisors, programme managers and community members) to ensure the use of an effective HRM approach. A larger multi-country study is needed to test an HRM approach that integrates context-appropriate strategies and coordinates relevant management actors. Ensuring that CHWs are adequately supported is vital if CHWs are to fulfil the critical role that they can play in improving the health of their communities.

Raising the profile of participatory action research at the 2010 Global Symposium on Health Systems Research.

By involving citizens and health workers in producing evidence and learning, participatory action research has potential to organize community evidence, stimulate action, and challenge the marginalization that undermines achievement of universal health coverage. This paper summarizes and analyzes results of two sessions on this research model convened by the authors at the First Global Symposium on Health Systems Research in Montreux Switzerland, November 16-19, 2010. In so doing, it reviews case studies and experiences discussed, particularly their contribution to universal health coverage in different settings. The paper also reflects on challenges faced by participatory action research, and outlines recommendations from the two sessions, including creation of a learning network for participatory action research.