Community health workers at the dawn of a new era: 7. Recent advances in supervision.

BACKGROUND: Supervision is essential for optimizing performance and motivation of community health workers (CHWs). This paper, the seventh in our series, "Community health workers at the dawn of a new era", supplements the existing evidence on CHW supervision in low- and middle-income countries by reviewing what supervision approaches are employed in specific contexts, identifying potential facilitators of CHW supervision including mobile health (mHealth) interventions, and noting challenges of supervision including the relationship between supervision and other CHW programme elements. METHODS: For this exploratory research study on CHW supervision, we reviewed the supervisory interventions described in a compendium of 29 case studies of large-scale CHW programmes, performed an electronic search of multiple databases to identify articles related to CHW supervision published between 15 June 2017 and 1 December 2020, and from those articles followed additional references that appeared to be relevant for our results. RESULTS: We reviewed 55 case studies, academic articles, and grey literature resources as part of this exploratory research. A variety of supervision approaches have been adapted over time, which we grouped into five categories: external supervision, community supervision, group supervision, peer supervision, and dedicated supervision. These approaches are frequently used in combination. Digital (mHealth) technologies are being explored as potential facilitators of CHW supervision in both small- and large-scale programmes; however, evidence of their effectiveness remains limited to date. Inadequate support for supervisors is a major challenge, particularly given the numerous and varied roles they are expected to fulfil, spanning administrative, clinical, and supportive activities. Supervisors can help CHWs acquire other critical elements needed from the health system for them to perform more effectively: incentives to foster motivation, clarity of roles and tasks, adequate tools and supplies, appropriate knowledge and skills, and a safe work environment. CONCLUSION: In the absence of a universal "best approach" for CHW supervision, our recommendation is that countries and programmes prioritize homegrown evolution over time to suit the local context. In some cases, this may involve scaling up novel approaches that have proven effective at small scale or testing approaches that have worked in other countries.

Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes.

BACKGROUND: Community health worker (CHW) programmes are again receiving more attention in global health, as reflected in important recent WHO guidance. However, there is a risk that current CHW programme efforts may result in disappointing performance if those promoting and delivering them fail to learn from past efforts. This is the first of a series of 11 articles for a supplement entitled "Community Health Workers at the Dawn of a New Era". METHODS: Drawing on lessons from case studies of large well-established CHW programmes, published literature, and the authors' experience, the paper highlights major issues that need to be acknowledged to design and deliver effective CHW programmes at large scale. The paper also serves as an introduction to a set of articles addressing these issues in detail. RESULTS: The article highlights the diversity and complexity of CHW programmes, and offers insights to programme planners, policymakers, donors, and others to inform development of more effective programmes. The article proposes that be understood as actors within community health system(s) and examines five tensions confronting large-scale CHW programmes; the first two tensions concern the role of the CHW, and the remaining three, broader strategic issues: 1) What kind of an actor is the CHW? A lackey or a liberator? Provider of clinical services or health promoter? 2) Lay versus professional? 3) Government programme at scale or nongovernmental organization-led demonstration project? 4) Standardized versus tailored to context? 5) Vertical versus horizontal? CONCLUSION: CHWs can play a vital role in primary healthcare, but multiple conditions need to be met for them to reach their full potential.

Community health workers at the dawn of a new era: 10. Programme performance and its assessment.

BACKGROUND: While the evidence supporting the effectiveness of community health worker (CHW) programmes is substantial, there is also considerable evidence that many of these programmes have notable weaknesses that need to be addressed in order for them to reach their full potential. Thus, considerations about CHW programme performance and its assessment must be taken into account as the importance of these programmes is becoming more widely appreciated. In this paper, the tenth in our 11-paper series, "Community health workers at the dawn of a new era", we address CHW programme performance and how it is assessed from a systems perspective. METHODS: The paper builds on the 2014 CHW Reference Guide, a compendium of case studies of 29 national CHW programmes, the 2018 WHO guideline on health policy and system support to optimize CHW programmes, and scientific studies on CHW programme performance published in the past 5 years. RESULTS: The paper provides an overview of existing frameworks that are useful for assessing the performance of CHW programmes, with a specific focus on how individual CHW performance and community-level outcomes can be measured. The paper also reviews approaches that have been taken to assess CHW programme performance, from programme monitoring using the routine health information system to national assessments using quantitative and/or qualitative study designs and assessment checklists. The paper also discusses contextual factors that influence CHW programme performance, and reflects upon gaps and needs for the future with regard to assessment of CHW programme performance. CONCLUSION: Assessments of CHW programme performance can have various approaches and foci according to the programme and its context. Given the fact that CHW programmes are complex entities and part of health systems, their assessment ideally needs to be based on data derived from a mix of reliable sources. Assessments should be focused not only on effectiveness (what works) but also on contextual factors and enablers (how, for whom, under what circumstances). Investment in performance assessment is instrumental for continually innovating, upgrading, and improving CHW programmes at scale. Now is the time for new efforts in implementation research for strengthening CHW programming.

Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All".

BACKGROUND: This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era". METHODS: We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes. RESULTS: CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness. CONCLUSION: A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

A new resource for developing and strengthening large-scale community health worker programs.

Large-scale community health worker programs are now growing in importance around the world in response to the resurgence of interest and growing evidence of the importance of community-based primary health care for improving the health of populations in resource-constrained, high-mortality settings. These programs, because of their scale and operational challenges, merit special consideration by the global health community, national policy-makers, and program implementers. A new online resource is now available to assist in that effort: Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers ( http://www.mchip.net/CHWReferenceGuide ). This CHW Reference Guide is the product of 27 different collaborators who, collectively, have a formidable breadth and depth of experience and knowledge about CHW programming around the world. It provides a thoughtful discussion about the many operational issues that large-scale CHW programs need to address as they undergo the process of development, expansion or strengthening. Detailed case studies of 12 national CHW programs are included in the Appendix-the most current and complete cases studies as a group that are currently available. Future articles in this journal will highlight many of the themes in the CHW Reference Guide and provide an update of recent advances and experiences. These articles will serve, we hope, to (1) increase awareness about the CHW Reference Guide and its usefulness and (2) connect a broader audience to the critical importance of strengthening large-scale CHW programs for the health benefits that they can bring to underserved populations around the world.

Isolation of a mesenchymal cell population from murine dermis that contains progenitors of multiple cell lineages.

The skin contains two known subpopulations of stem cells/epidermal progenitors: a basal keratinocyte population found in the interfollicular epithelium and cells residing in the bulge region of the hair follicle. The major role of the interfollicular basal keratinocyte population may be epidermal renewal, whereas the bulge population may only be activated and recruited to form a cutaneous epithelium in case of trauma. Using 3-dimensional cultures of murine skin under stress conditions in which only reserve epithelial cells would be expected to survive and expand, we demonstrate that a mesenchymal population resident in neonatal murine dermis has the unique potential to develop an epidermis in vitro. In monolayer culture, this dermal subpopulation has long-term survival capabilities in restricted serum and an inducible capacity to evolve into multiple cell lineages, both epithelial and mesenchymal, depending on culture conditions. When grafted subcutaneously, this dermal subpopulation gave rise to fusiform structures, reminiscent of disorganized muscle, that stained positive for smooth muscle actin and desmin; on typical epidermal grafts, abundant melanocytes appeared throughout the dermis that were not associated with hair follicles. The multipotential cells can be repeatedly isolated from neonatal murine dermis by a sequence of differential centrifugation and selective culture conditions. These results suggest that progenitors capable of epidermal differentiation exist in the mesenchymal compartment of an abundant tissue source and may have a function in mesenchymal-epithelial transition upon insult. Moreover, these cells could be available in sufficient quantities for lineage determination or tissue engineering applications.

Human mesenchymal stem cell subpopulations express a variety of neuro-regulatory molecules and promote neuronal cell survival and neuritogenesis.

Mesenchymal stem cells (MSCs) transplanted at sites of nerve injury are thought to promote functional recovery by producing trophic factors that induce survival and regeneration of host neurons. To evaluate this phenomenon further, we quantified in human MSCs neurotrophin expression levels and their effects on neuronal cell survival and neuritogenesis. Screening a human MSC cDNA library revealed expressed transcripts encoding BDNF and beta-NGF but not NT-3 and NT-4. Immunostaining demonstrated that BDNF and beta-NGF proteins were restricted to specific MSC subpopulations, which was confirmed by ELISA analysis of 56 separate subclones. Using a co-culture assay, we also demonstrated that BDNF expression levels correlated with the ability of MSC populations or subclones to induce survival and neurite outgrowth in the SH-SY5Y neuroblastoma cell line. However, these MSC-induced effects were only partially inhibited by a neutralizing anti-BDNF antibody. MSCs were also shown to promote neurite outgrowth within dorsal root ganglion explants despite secreting 25-fold lower level of beta-NGF required exogenously to produce a similar effect. Interrogation of the human MSC transcriptome identified expressed mRNAs encoding various neurite-inducing factors, axon guidance and neural cell adhesion molecules. Moreover, a subset of these transcripts was shown to correlate with BDNF expression in MSC subclones. Collectively, these studies reveal the existence of MSC subpopulations that co-express neurotrophins and other potent neuro-regulatory molecules, which contribute to MSC-induced effects on neuronal cell survival and nerve regeneration. These subpopulations may represent more potent vectors for treating a variety of neurological disorders.