Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce.

BACKGROUND: Community health workers (CHWs) are widely recognized as essential to addressing disparities in health care delivery and outcomes in US vulnerable populations. In the state of Arizona, the sustainability of the workforce is threatened by low wages, poor job security, and limited opportunities for training and advancement within the profession. CHW voluntary certification offers an avenue to increase the recognition, compensation, training, and standardization of the workforce. However, passing voluntary certification legislation in an anti-regulatory state such as Arizona posed a major challenge that required a robust advocacy effort. CASE PRESENTATION: In this article, we describe the process of unifying the two major CHW workforces in Arizona, promotoras de salud in US-Mexico border communities and community health representatives (CHRs) serving American Indian communities. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and promotoras. In order to move forward as a collective workforce, it was imperative to integrate the perspectives of CHRs, who have a regular funding stream and work closely through the Indian Health Services, with those of promotoras, who are more likely to be grant-funded in community-based efforts. As a unified workforce, CHWs were better positioned to gain advocacy support from key health care providers and health insurance companies with policy influence. We seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the US and internationally. CONCLUSIONS: Legislated voluntary certification provides a pathway for further professionalization of the CHW workforce by establishing a standard definition and set of core competencies. Voluntary certification also provides guidance to organizations in developing appropriate training and job activities, as well as ongoing professional development opportunities. In developing certification with CHWs representing different populations, and in particular Tribal Nations, it is essential to assure that the CHW definition is in alignment with all groups and that the scope of practice reflects CHW roles in both clinic and community-based settings. The Arizona experience underscores the benefits of a flexible approach that leverages existing strengths in organizations and the population served.

Legislative landscape for traditional health practitioners in Southern African development community countries: a scoping review.

BACKGROUND AND OBJECTIVES: Globally, contemporary legislation surrounding traditional health practitioners (THPs) is limited. This is also true for the member states of the Southern African Development Community (SADC). The main aim of this study is to map and review THP-related legislation among SADC countries. In order to limit the scope of the review, the emphasis is on defining THPs in terms of legal documents. METHODS: This scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews methods. Two independent reviewers reviewed applicable legal definitions of THPs by searching the Southern African Legal Information Institute (SAFLII) database in April 2018 for legislation and bills. To identify additional legislation applicable in countries not listed on SAFLII and/or further relevant SADC legislation, the search engines, Google and PubMed, were used in August 2018 and results were reviewed by two independent reviewers. Full texts of available policy and legal documents were screened to identify policies and legislation relating to the regulation of THPs. Legislation was deemed relevant if it was a draft of or promulgated legislation relating to THPs. RESULTS: Four of 14 Southern African countries have legislation relating to THPs. Three countries, namely South Africa, Namibia and Zimbabwe, have acknowledged the roles and importance of THPs in healthcare delivery by creating a council to register and formalise practices, although they have not operationalised nor registered and defined THPs. In contrast, Tanzania has established a definition couched in terms that acknowledge the context-specific and situational knowledge of THPs, while also outlining methods and the importance of local recognition. Tanzanian legislation; thus, provides a definition of THP that specifically operationalises THPs, whereas legislation in South Africa, Namibia and Zimbabwe allocates the power to a council to decide or recognise who a THP is; this council can prescribe procedures to be followed for the registration of a THP. CONCLUSIONS: This review highlights the differences and similarities between the various policies and legislation pertaining to THPs in SADC countries. Legislation regarding THPs is available in four of the 14 SADC countries. While South Africa, Tanzania, Namibia and Zimbabwe have legislation that provides guidance as to THP recognition, registration and practices, THPs continue to be loosely defined in most of these countries. Not having an exact definition for THPs may hamper the promotion and inclusion of THPs in national health systems, but it may also be something that is unavoidable given the tensions between lived practices and rigid legalistic frameworks.

Discretion, power and the reproduction of inequality in health policy implementation: Practices, discursive styles and classifications of Brazil's community health workers.

This article explores the mobilization of power by health workers during policy implementation, showing how in a context of discretion and resource scarcity they can reproduce inequalities in access to health services. The argument innovates theoretically by supplementing the 'street-level bureaucracy' literature, which emphasizes frontline worker discretion, with a conceptualization of power as domination encompassing the shaping of behavior, the constitution of subjects and the reproduction of inequality. Empirically, the article focuses on Brazilian community health workers (agentes comunitários desaúde, CHWs). CHWs are a neglected but highly important segment of the health workforce that traditionally functions as a link between the health system and disadvantaged groups. The article examines how Brazilian CHWs act as street-level bureaucrats mobilizing power in their interactions with users. They operate within a severely under-resourced public health system, the Sistema Único de Saúde, which places constraints upon their action and forces them to make allocation decisions with little training and support. The article highlights the ways in which inequalities in access to health services are reproduced (inadvertently or not) through the practices, discursive styles and classifications of CHWs. Methodologically, the paper is based on ethnography with 24 CHWs and interviews with 77 other CHWs in Brazil.

Legislative Definitions of Community Health Workers: Examples from Other States to Inform Hawai'i.

Community health workers (CHWs) have been important contributors to the health and wellness of disenfranchised and minority communities for more than 50 years in the United States. Recently the Centers for Disease Control and Prevention (CDC) recommended several policy initiatives to support and advance the CHW workforce, including formalizing a state-level definition for CHWs. Such state-wide standards can lay the groundwork for health insurance reimbursement for CHW services, help establish a professional identity, and generate cohesion among CHWs. Some states have already adopted a formal definition of CHWs. Hawai'i has had grassroots and political movement in this direction, although no widespread, formal consensus has been reached. This paper reviews decisions in other states in formally defining CHWs in order to inform efforts in Hawai'i. As of February 2019, data has been collected on states which have formally defined CHWs. Two independent reviewers compared the definitions used in 15 states with formalized definitions using the American Public Health Association (APHA) CHW Section definition. We found that most states built upon the APHA definition to create working definitions that were codified into law, sometimes with minor modifications for relevance to their communities. Given the widespread use of the APHA definition, Hawai'i may also find benefit from using the APHA definition as a backbone for a state-level definition. Critically, following best practices, it will be important to take steps to ensure CHW self-determination in all aspects of the processes towards a state-level definition of and scope of care for CHWs.

The Governance of National Community Health Worker Programmes in Low- and Middle-Income Countries: An Empirically Based Framework of Governance Principles, Purposes and Tasks.

BACKGROUND: National community health worker (CHW) programmes are increasingly regarded as an integral component of primary healthcare (PHC) in low- and middle-income countries (LMICs). At the interface of the formal health system and communities, CHW programmes evolve in context specific ways, with unique cadres and a variety of vertical and horizontal relationships. These programmes need to be appropriately governed if they are to succeed, yet there is little evidence or guidance on what this entails in practice. Based on empirical observations of South Africa's community-based health sector and informed by theoretical insights on governance, this paper proposes a practical framework for the design and strengthening of CHW programme governance at scale. METHODS: Conceptually, the framework is based on multi-level governance thinking, that is, the distributed, negotiated and iterative nature of decision-making, and the rules, processes and relationships that support this in health systems. The specific purposes and tasks of CHW programme governance outlined in the framework draw from observations and published case study research on the formulation and early implementation of the Ward Based Outreach Team strategy in South Africa. RESULTS: The framework is presented as a set of principles and a matrix of 5 key governance purposes (or outputs). These purposes are: a negotiated fit between policy mandates and evidence, histories and strategies of community-based services; local organisational and accountability relationships that provide community-based actors with sufficient autonomy and power to act; aligned and integrated programme management systems; processes that enable system learning, adaptation and change; and sustained political support. These purposes are further elaborated into 17 specific tasks, distributed across levels of the health system (national, regional, and local). CONCLUSION: In systematising the governance functions in CHW programmes, the paper seeks to shed light on how best to support and strengthen these functions at scale.

"Contract to Volunteer": South African Community Health Worker Mobilization for Better Labor Protection.

In this paper, we explore the increasing activity around labor rights for South African community health workers (CHWs). Contextualizing this activity within broader policy and legal developments, we track the emergence of sporadic mobilizations for decent work (supported by local health activist organizations) and subsequently, the formation of a CHW union. The National Union of Care Workers of South Africa (NUCWOSA) was inaugurated in 2016, hoping to secure formal and secure employment through government and the consequent labor and occupational health protections. Various tensions were observed during fieldwork in the run up to NUCWOSA's formation and raise important questions about representation, legitimacy, and hierarchies of power. We close by offering suggestions for future research in this developing space.

Measuring work engagement among community health workers in Sierra Leone: validating the Utrecht Work Engagement Scale / La medición del compromiso con el trabajo en trabajadores sanitarios comunitarios de Sierra Leona: validación de la Escala Utrecht de Engagement

This study examines the concept of volunteer work engagement in a sample of 334 community health workers in Bonthe District, Sierra Leone. Structural equation modelling was used to validate both the 9-item and the 17-item Utrecht Work Engagement Scale (UWES-9 and UWES-17, respectively). Results assessing the UWES-17 invalidated the three-factor structure within this cohort of community health workers, as high correlations were found between latent factors. Findings for the validity of the UWES-9 were largely consistent with those of the UWES-17. Model fit for the UWES-9 were generally equivalent for the one-factor, three-factor, and bifactor solutions, however the three-factor model was once again rejected due to high factor correlations. Based on these results, the current sample provides evidence that work engagement is best represented as a unidimensional construct in this context. Findings are considered alongside previous research to offer support for the utilization of the shortened UWES-9 in this context, as it appears to provide a good representation of work engagement and possess a parsimonious unidimensional scoring scheme (AU)

Este estudio analiza el concepto de compromiso en el trabajo voluntario de una muestra de 224 trabajadores sanitarios comunitarios del distrito de Bonthe, Sierra Leona. Se utilizó el modelado de ecuaciones estructurales para validar la Escala Utrecht de Engagement, tanto la de 9 (UWES-9) como la de 17 (UWES-17) elementos. Los resultados de la evaluación de la UWES-17 invalidaron la estructura de tres factores en esta muestra de trabajadores sanitarios comunitarios, ya que se hallaron correlaciones elevadas entre los factores latentes. Los resultados de la validez de la UWES-9 mostraban gran congruencia con los de la UWES-17. El ajuste de modelo para la UWES-9 era en general equivalente para las soluciones de uno, tres y dos factores, aunque el modelo de tres factores fue una vez más rechazado por las elevadas correlaciones entre factores. A la vista de los resultados, esta muestra prueba que el compromiso con el trabajo se representa mejor como constructo unidimensional en este contexto. En la línea de la investigación precedente, se considera que estos resultados respaldan la utilización de la forma abreviada, UWES-9, en este contexto, dado que parece representar mejor el compromiso con el trabajo y dispone de un método unidimensional de puntuación parsimonioso (AU)

Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico.

Although it is known that the social determinants of health have a larger influence on health outcomes than health care, there currently is no structured way for primary care providers to identify and address nonmedical social needs experienced by patients seen in a clinic setting. We developed and piloted WellRx, an 11-question instrument used to screen 3048 patients for social determinants in 3 family medicine clinics over a 90-day period. Results showed that 46% of patients screened positive for at least 1 area of social need, and 63% of those had multiple needs. Most of these needs were previously unknown to the clinicians. Medical assistants and community health workers then offered to connect patients with appropriate services and resources to address the identified needs. The WellRx pilot demonstrated that it is feasible for a clinic to implement such an assessment system, that the assessment can reveal important information, and that having information about patients' social needs improves provider ease of practice. Demonstrated feasibility and favorable outcomes led to institutionalization of the WellRx process at a university teaching hospital and influenced the state department of health to require managed care organizations to have community health workers available to care for Medicaid patients.

Maternal healthcare in context: A qualitative study of women's tactics to improve their experience of public healthcare in rural Burkina Faso.

Improving the use of public maternal health facilities to prevent maternal death is a priority in developing countries. Accumulating evidence suggests that a key factor in choosing a facility-based delivery is the collaboration and the communication between healthcare providers and women. This article attempts to provide a fine-grained understanding of health system deficiencies, healthcare provider practices and women's experiences with maternal public healthcare. This article presents findings from ethnographic research conducted in the Central-East Region of Burkina Faso over a period of eight months (January-August 2013). It is based on monthly interviews with 14 women from village (10) and town (4) and on structured observations of clinical encounters in three primary healthcare facilities (two rural and one urban) (23 days). In addition, 13 health workers were interviewed and 11 focus groups with women from village (6) and town (5) were conducted (48 participants). Guided by an analytic focus on strategies and tactics and drawing on recent discussions on the notion of 'biomedical security', the article explores what tactics women employ in their efforts to maximize their chances of having a positive experience with public maternal healthcare. The synthesis of the cases shows that, in a context of poverty and social insecurity, women employ five tactics: establishing good relations with health workers, being mindful of their 'health booklet', attending prenatal care consultations, minimizing the waiting time at the maternity unit and using traditional medicines. In this way, women strive to achieve biomedical security for themselves and their child and to preserve their social reputation. The study reveals difficulty in the collaboration and communication between health workers and women and suggests that greater attention should be paid to social relations between healthcare providers and users.

Many Ingredients, One Sublime Dish: The Recipe for the Passage of Illinois HB5412 Into Law.

This article contextualizes the need for Illinois House Bill 5412 (HB5412), which calls for the establishment of a state board to create recommendations for the community health worker (CHW) field in Illinois, including a scope of practice, core competencies, training and certification standards, and sustainable funding and reimbursement mechanisms. Multisectorial partnerships and their outputs, coupled with frontline CHW interventions, created a synergistic climate conducive to the passing of this historic CHW legislation. This article provides a timeline and recipe for legislative success as described through processes and activities collaboratively undertaken, concentrating on a 5-year period (2009-2014).

Health governance in India: citizenship as situated practice.

Despite the impressive growth of the Indian economy over the past decades, the country struggles to deal with multiple and overlapping forms of inequality. One of the Indian government's main policy responses to this situation has been an increasing engagement with the 'rights regime', witnessed by the formulation of a plethora of rights-based laws as policy instruments. Important among these are the National Rural Health Mission (NRHM). Grounded in ethnographic research in Rajasthan focused on the management of maternal and child health under NRHM, this paper demonstrates how women, as mothers and health workers, organise themselves in relation to rights and identities. I argue that the rights of citizenship are not solely contingent upon the existence of legally guaranteed rights but also significantly on the social conditions that make their effective exercise possible. This implies that while citizenship is in one sense a membership status that entails a package of rights, duties, and obligations as well as equality, justice, and autonomy, its development and nature can only be understood through a careful consideration and analysis of contextually specific social conditions.

Health worker recruitment and deployment in remote areas of Indonesia.

CONTEXT: Providing health care in remote and very remote areas has long been a major concern in Indonesia. In order to improve access to quality health care for residents in these areas, various policies on recruitment and deployment of health workers have been implemented, among them compulsory service, contracted staff and the Special Assignment of strategic health workers. ISSUE: Indonesia's difficult geography presents great challenges to health service delivery and most health workers prefer to serve in urban areas, resulting in an uneven distribution of health workers and shortages in remote areas. Great efforts have been made to mobilize health human resources more equitably, including placement schemes for strategic health workers and contracted staff, combined with an incentive scheme. While these have partially addressed the severe shortage of health workers in remote areas, current government policies were reviewed in order to clarify the current situation in Indonesia. LESSONS LEARNED: The Contracted Staff and Special Assignment of Strategic Health Workers programs show have made a significant contribution to improving the availability of health workers in Indonesia's remote areas. As these two programs used financial incentives as the main intervention, other non-financial interventions should also be trialed. For example, incentives such as the promise of a civil servant appointment or the provision of continuing professional education, as well as the recruitment of rural-background health workers may increase the willingness of health staff to serve in the remote and very remote areas of Indonesia.

Developing lay health worker policy in South Africa: a qualitative study.

BACKGROUND: Over the past half decade South Africa has been developing, implementing and redeveloping its Lay Health Worker (LHW) policies. Research during this period has highlighted challenges with LHW programme implementation. These challenges have included an increased burden of care for female LHWs. The aim of this study was to explore contemporary LHW policy development processes and the extent to which issues of gender are taken up within this process. METHODS: The study adopted a qualitative approach to exploring policy development from the perspective of policy actors. Eleven policy actors (policy makers and policy commentators) were interviewed individually. Data from the interviews were analysed thematically. RESULTS: Considerations of LHW working conditions drove policy redevelopment. From the interviews it seems that gender as an issue never reached the policy making agenda. Although there was strong recognition that the working conditions of LHWs needed to be improved, poor working conditions were not necessarily seen as a gender concern. Our data suggests that in the process of defining the problem which the redeveloped policy had to address, gender was not included. There was no group or body who brought the issue of gender to the attention of policy developers. As such the issue of gender never entered the policy debates. These debates focused on whether it was appropriate to have LHWs, what LHW programme model should be adopted and whether or not LHWs should be incorporated into the formal health system. CONCLUSION: LHW policy redevelopment focused on resolving issues of LHW working conditions through an active process involving many actors and strong debates. Within this process the issue of gender had no champion and never reached the LHW policy agenda. Future research may consider how to incorporate the voices of ordinary women into the policy making process.

Winning policy change to promote community health workers: lessons from massachusetts in the health reform era.

There is a national movement among community health workers (CHWs) to improve compensation, working conditions, and recognition for the workforce through organizing for policy change. As some of the key advocates involved, we describe the development in Massachusetts of an authentic collaboration between strong CHW leaders of a growing statewide CHW association and their public health allies. Collaborators worked toward CHW workforce and public health objectives through alliance building and organizing, legislative advocacy, and education in the context of opportunities afforded by health care reform. This narrative of the path to policy achievements can inform other collaborative efforts attempting to promote a policy agenda for the CHW workforce across the nation.

Texas' community health workforce: from state health promotion policy to community-level practice.

BACKGROUND: Imagine yourself in Texas as a newly arrived immigrant who does not speak English. What would you do if your child became ill? How would you find a doctor? When you find one, will the doctor speak your native language or understand your culture? In a state of approximately 22 million people, many Texas residents, marginalized by poverty and cultural traditions, find themselves in this situation. To help them, some communities across Texas offer the services of promotores, or community health workers, who provide health education and assist with navigating the health care system. CONTEXT: In 1999, Texas became the first state in the nation to recognize these workers and their contributions to keeping Texans healthy. This paper examines a state health promotion policy that culminated in a training and certification program for promotores and the impact of this program on the lay health education workforce in Texas. METHODS: In 1999, the Texas legislature established the 15-member Promotor(a) Program Development Committee to study issues involved in developing a statewide training and certification program. During its 2-year term, the committee met all six of its objectives toward establishing and maintaining a promotor(a) certification program. CONSEQUENCES: By the end of December 2005, it is estimated that there will be more than 700 certified promotores in Texas. State certification brings community health workers into the public health mainstream as never before. INTERPRETATION: Promotores, a community health safety net and a natural extension of the health and human services agencies, improve health at the neighborhood level. Certification brings renewed commitment to serving others and a distinction to those who have been the unsung heroes of public health for decades.