Community health workers for maternal and newborn health: case studies from Africa and Asia

Mother holding newborn baby

Introduction:
Evidence suggests that Community Health Workers (CHWs) can play key roles in the achievement of health-related Sustainable Development Goals and Universal Health Coverage; particularly, provision of Maternal and Newborn Health (MNH) services in low-and middle-income countries. However, to harness the potential of CHWs in MNH, it is important to have a clear definition, a well-defined scope of practice and an enabling work environment.

Aim:
This study explored the characteristics and scope of practice of CHWs providing MNH services in sub-Saharan Africa and South Asia and documented the factors influencing CHWs’ service delivery.

Methods:
This qualitative study entailed multiple case studies exploring the characteristics, scope of practice and factors affecting CHWs providing MNH services in Bangladesh, India, Kenya, Malawi and Nigeria. It involved a review of policy documents, 36 focus group discussions and 131 key informant interviews with stakeholders within the formal health system and the community. A thematic analysis approach was used to synthesise the data from policy documents, focus group discussions and key informant interviews.

Findings:
The working definition and multiple cases describe CHWs as paraprofessionals or lay individuals with an in-depth understanding of a community’s culture and language. They have shorter training than health professionals and their primary goal is to provide culturally appropriate health services to the community. All CHWs in the study countries provide health education in relation to MNH care but therapeutic care, skilled antenatal care and birth attendance are exclusively within the remit of CHWs with longer training. Challenges of CHWs in the study countries include issues relating to trust when male CHWs provide services to female service recipients and the lack of clarity in the criteria used for inviting CHWs for in-service training. In contrast, mentoring and supervision by health professionals reinforce CHWs’ knowledge and skills, while the availability of supplies enables their application. Furthermore, CHWs in study countries are motivated by altruistic goals and prompt, regular, sustainable remuneration that is commensurate with effort.

Implications for policy, practice and research:
To the best of our knowledge, this is first multi-country case study exploring characteristics and scope of practice of CHWs providing MNH services. Stakeholders seeking to harness CHWs’ potential in multidisciplinary health teams may consider the CHW characteristics described in this study to guide selection of CHWs that are fit-for-purpose. They may also use these characteristics to differentiate between CHWs and other health workers when mapping health workforce data. This study highlights the inadequacy of guidelines recommending a common scope of practice for all CHWs without segmenting this common scope of practice to reflect the varied levels of education and duration of pre-service training. It notes a research opportunity in exploring the ideal gender mix of CHWs to address issues relating to trust between male CHWs and female recipients, encourage male involvement in MNH care and preserve the woman’s autonomy in making decisions relating to her health.

 

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