The Community Health Impact Coalition curates a fortnightly update on newly-released community health worker papers.

1. Effect of home-based childcare on childhood mortality in rural Maharashtra, India: a cluster randomised controlled trial

• Comments: Remarkable decline in under-5 mortality was achieved through routine systematic visitation of all homes by CHWs. The authors developed a cooperative partnership with local communities who set priorities and designed and implemented interventions that included regular planned home visits carried out by CHWs. Notably, home-based neonatal care was combined with integrated community case management (iCCM) for the post-neonatal period. Conclusion emphasizes need for broad institutional support & adequate remuneration for CHWs. Thank you to our long-time reader, Dr. Henry B. Perry, for flagging this study & its significance!
• Methods: Cluster RCT
• Takeaways: There was a decline of 65.8% in under-5 mortality while the U5MR actually increased by 16.6% in the control area during the same period (2004-2009); impact was sustained and ultimately replicated through the public sector. There was no strengthening of facility-based care in the Intervention Arm, showing that major gains in mortality reduction can be made without this.
• Implication: Major gains in mortality reduction can be achieved by investing in proactive, routine systematic home visitation by community health workers.

2. Examining the Gender Imbalance in the National Community Health Assistant Program in Liberia: A Qualitative Analysis of Policy and Program Implementation

• Comments: This article exploring the intersection of gender and community health is quite timely. Join us (and some of the authors’ institutions) for an in-depth look at gender and community health tomorrow, September 13th, at the UNGA Virtual Side Event From Gender Policy to Gender Parity: Lessons from the Community Health Workforce (Register).
• Methods: Qualitative – semi structured interviews with policymakers, CHAs, other members of the community health workforce, and community member
• Takeaways: Despite the Government of Liberia’s intention to prioritise women in the recruitment and selection of CHAs, the planning and implementation of the Liberia’s Revised National Community Health Services Policy were not gender responsive.  In particular, the education requirement for CHAs posed a significant barrier to women’s nomination and selection as CHAs, due to disparities in access to education for girls in Liberia.
• Implication: The inequitable gender balance of CHAs has impacted the accessibility, acceptability, and affordability of community healthcare services, particularly among women.

3. Not knowing enough, not having enough, not feeling wanted: Challenges of community health workers providing maternal and newborn services in Africa and Asia

• Comments: This article, the latest from CHIC collaborator Dr. Abimbola Olaniran and colleagues, sheds some light on the health systems support that is so often absent when programs are taken to scale.
• Methods: 36 focus group discussions and 131 key informant interviews in Bangladesh, India, Kenya, Malawi, and Nigeria
• Takeaways: Critical challenges facing CHWs fall into three buckets: (1) inadequate training, (2) low infrastructural support (e.g., supplies, transport for women in labor), (3) community acceptance of CHWs’ services (e.g., to local socio-cultural beliefs, CHW demographic characteristics such as sex, and time conflict between CHWs’ health activities and community members’ daily routine)
• Implication: Improving CHW performance depends on addressing training challenges, bolstering structural support, and meaningfully engaging the community to enhance acceptance of CHWs and their services.

4. “They are our eyes outside there in the community”: Implementing enhanced training, management and monitoring of South Africa’s ward-based primary healthcare outreach teams

• Comments: This in-depth look at a PEPFAR-supported program in South Africa uncovers a litany of challenges across several key CHW-related programmatic components. We can dream (and advocate!): What if every PEPFAR-supported program that includes CHWs had to go through a CHW AIM-based checklist as an annual reporting requirement?
• Methods: Mixed methods (surveys, key informant interviews, focus groups, health facility assessments, directly-observed time-motion studies; and review of program documents)
• Takeaways: Hiring and training more CHWs was a key implementation success. But…(1) gains in CHWs’ knowledge and skills were short-lived due to lack of ongoing training and mentoring; (2) there was insufficient integration of outreach teams into health facility management structures; (3) CHWs faced persistent shortages of equipment, supplies, transportation, and workspace; and (4) CHWs’ discontent with their salaries threatens program sustainability.
• Implication: To sustain improvements in training, supervision, and job satisfaction, CHWs must be equipped with needed resources, provided with ongoing supportive supervision, and strengthened by optimized program management, monitoring and processes.

5. “The More We Know, the More We’re Able to Help”: Participatory Development of an Evaluation Framework for Community Health Worker Programs

• Comments: The purpose of this study was to develop a flexible framework for evaluating components of CHW programs in community and clinical settings
• Methods: Semi-structured interviews plus survey with 23 CHWs and 19 CHW Supervisors across 18 federally qualified health centers and community-based organizations in Louisiana, Mississippi, Alabama, and Florida, USA
• Takeaways: The participant-informed evaluation framework for CHW programs specifies best practices across 7 evaluation categories: client relations, intraorganizational relations, interorganizational relations, capacity development, program effectiveness, cost-efficiency, and sustainability.
• Implication: Recommendations for CHW program evaluation include tailoring evaluation efforts and data collection methods to program context, using mixed-methods approaches for collecting evaluation data, and streamlining evaluation efforts with an organization’s existing evaluation systems.

6. Examining Roles, Support, and Experiences of Community Health Workers During the COVID-19 Pandemic in Bangladesh: A Mixed Methods Study

• Comments: Interesting look at the complex government-led, CHW-delivered response during COVID-19 in Bangladesh, including how support to CHWs varied by cadre and partner
• Methods: Mixed – phone-based survey of 370 government-employed CHWs +  28 in-depth interviews with policy makers, program managers, CHW supervisors, and CHWs + exploratory and regression analysis of survey data + qualitative analysis of interview data.
• Takeaways: Government-employed CHWs in Bangladesh continued to provide health education and routine services in their communities despite pandemic- and response-related challenges. CHWs reported slight decreases in routine work across all health areas early in the pandemic, and a majority reported added COVID-19-related responsibilities as the pandemic continued. Supportive mechanisms to CHWs (e.g., training, supplies, and supportive supervision) were not always uniformly distributed across cadres, leading to some discontent among CHWs.
• Implication: National stakeholders can strive to ensure equitable support, incentives, and supervision to family welfare assistants and health assistants working across all health areas as they undertake new COVID-19 responsibilities in their communities.

7. The family context of ASHA and Anganwadi work in rural Rajasthan: Gender and labour in CHW programmes

• Comments: #PayCHWs.  Women provide a $1 trillion subsidy to the global economy via their unpaid and underpaid health and care work. See article #6 in Issue 063 of our archive for more on why & how this manifests in India.
• Methods: Interviews with 20 ASHAs, Anganwadi Workers, and their families + participant observation in Anganwadi Centers, health centres, and family settings.
• Takeaways: ASHA and Anganwadi work is in high demand, despite being low paying, because of an overall lack of jobs for educated women. By providing honorable work, and keeping the idea of permanent employment in view but always just out of reach, the ASHA and Anganwadi programmes both exploit and strengthen gendered inequalities in the rural Rajasthani labour market.
• Implication: “Across the world, female community health labour is described as ‘volunteer’ labour, a move justified in part by the argument that holding unpaid positions empowers rural women to make change in their communities… The extent of the changes that might occur in rural Rajasthani households if ASHAs and Anganwadi Workers were receiving a living wage is a fascinating question.”