The Governance of National Community Health Worker Programmes in Low- and Middle-Income Countries: An Empirically Based Framework of Governance Principles, Purposes and Tasks (original) (raw)
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Community health workers at the dawn of a new era: 3. Programme governance
Health Research Policy and Systems
Background Community health workers (CHWs) can play a critical role in primary healthcare and are seen widely as important to achieving the health-related Sustainable Development Goals (SDGs). The COVID-19 pandemic has emphasized the key role of CHWs. Improving how CHW programmes are governed is increasingly recognized as important for achieving universal access to healthcare and other health-related goals. This paper, the third in a series on “Community Health Workers at the Dawn of a New Era”, aims to raise critical questions that decision-makers need to consider for governing CHW programmes, illustrate the options for governance using examples of national CHW programmes, and set out a research agenda for understanding how CHW programmes are governed and how this can be improved. Methods We draw from a review of the literature as well as from the knowledge and experience of those involved in the planning and management of CHW programmes. Results Governing comprises the processes a...
Health policy and planning, 2014
Health system governance has been recognized as a critical element of the health system strengthening agenda. To date, health governance research often focuses at national or global levels, adopting a macro-perspective that deals with governance structures, forms and principles. Little attention has been given to a micro-perspective which recognizes the role of health system actors in governance, or to considering the operational level of the health system. This article presents a South African case study of an intervention to address conflict in roles and responsibilities between multiple actors supporting service delivery at the local level, and explores the broader insights this experience generates about the nature of local health system governance. In an embedded case study, action learning and reflection theory were used to design and implement the intervention. Data in this article were drawn from minutes, observations and recorded reflections of the meetings and workshops th...
BMJ Global Health, 2019
IntroductionIn 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national policy proposed that teams of CHWs, called Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), supervised by a professional nurse were implemented. This paper explores WBPHCOTs’ and managers’ perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation guided by the Implementation Stages Framework.MethodsWe conducted a qualitative study consisting of five focus group discussions and 14 in-depth interviews with CHWs, team leaders and managers. A content analysis of data was conducted.ResultsThere were significant weaknesses in early implementation resulting from a vague national policy and a rushed implementation plan. During the installation stage, adaptations were made to address gaps including th...
Human Resources for Health
Health systems are social institutions, in which health worker performance is shaped by transactional processes between different actors. This analytical assessment unravels the complex web of factors that influence the performance of community health workers (CHWs) in low-and middle-income countries. It examines their unique intermediary position between the communities they serve and actors in the health sector, and the complexity of the health systems in which they operate. The assessment combines evidence from the international literature on CHW programmes with research outcomes from the 5-year REACHOUT consortium, undertaking implementation research to improve CHW performance in six contexts (two in Asia and four in Africa). A conceptual framework on CHW performance, which explicitly conceptualizes the interface role of CHWs, is presented. Various categories of factors influencing CHW performance are distinguished in the framework: the context, the health system and intervention hardware and the health system and intervention software. Hardware elements of CHW interventions comprise the supervision systems, training, accountability and communication structures, incentives, supplies and logistics. Software elements relate to the ideas, interests, relationships, power, values and norms of the health system actors. They influence CHWs' feelings of connectedness, familiarity, self-fulfilment and serving the same goals and CHWs' perceptions of support received, respect, competence, honesty, fairness and recognition. The framework shines a spotlight on the need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of CHWs, communities, health professionals and other actors in the health system, if CHW performance is to improve.
Working Paper 11: A framework to assess governance of health systems in low-income countries
Basel Institute on Governance Working Papers
As awareness of the role governance in the performance of health systems has increased, so has the need to come up with systematic means to evaluate governance shortcomings to develop adequate interventions. This working paper describes a framework to assess governance in the health systems of low-income countries that is intended to have empirical applicability with a problem-driven approach. The analysis is grounded on a re-categorization of governance dimensions for greater heuristic power, with an emphasis made on the importance of strategic systems design and accountability. The proposed methodology includes mapping of both formal and informal institutions, actors and networks. This underscores the idea that in order to properly address governance weaknesses it is of utmost importance to have an insight into whether the interplay of formal and informal norms facilitates or undermines system performance.
A Framework to Assess Governance of Health Systems in Low Income Countries
2011
The Basel Institute on Governance is an independent non-profit institution devoted to interdisciplinary research and policy advice in the areas of public, corporate and global governance, as well as international judicial cooperation and asset recovery. The Institute acts as a centre of competence by combining scientific methodology with hands-on practical experience to provide applied solutions to concrete problems. Based in Switzerland and associated with the University of Basel, the Institute is composed of internationally recognised academics as well as practitioners with longstanding experience in the field of anti-corruption. It further relies on a wide network of partners from around the world and works with all stakeholder groups concerned. Governance of Health Systems The concepts and methods described in this manuscript have been developed within the "Governance of Health Systems" research project that is currently being undertaken jointly by the Basel Institute on Governance and the Swiss Tropical and Public Health Institute. This project is funded by the Swiss National Science Foundation (grant number K-13K1-122277/1) and has the goal to contribute an analytical framework to assess governance in the health systems of low-income countries, with the view of proposing ideas for new and more effective governanceenhancing interventions. Working papers In this working paper series the Basel Institute on Governance publishes reports by staff members and invited international experts, covering critical issues of governance theory and practice. For a list of publications, please visit www.baselgovernance.org.
An approach to addressing governance from a health system framework perspective
BMC International Health and Human Rights, 2011
As countries strive to strengthen their health systems in resource constrained contexts, policy makers need to know how best to improve the performance of their health systems. To aid these decisions, health system stewards should have a good understanding of how health systems operate in order to govern them appropriately. While a number of frameworks for assessing governance in the health sector have been proposed, their application is often hindered by unrealistic indicators or they are overly complex resulting in limited empirical work on governance in health systems. This paper reviews contemporary health sector frameworks which have focused on defining and developing indicators to assess governance in the health sector. Based on these, we propose a simplified approach to look at governance within a common health system framework which encourages stewards to take a systematic perspective when assessing governance. Although systems thinking is not unique to health, examples of its application within health systems has been limited. We also provide an example of how this approach could be applied to illuminate areas of governance weaknesses which are potentially addressable by targeted interventions and policies. This approach is built largely on prior literature, but is original in that it is problem-driven and promotes an outward application taking into consideration the major health system building blocks at various levels in order to ensure a more complete assessment of a governance issue rather than a simple input-output approach. Based on an assessment of contemporary literature we propose a practical approach which we believe will facilitate a more comprehensive assessment of governance in health systems leading to the development of governance interventions to strengthen system performance and improve health as a basic human right.
Global Health Action, 2015
Background: Community health workers (CHWs) are used increasingly in the world to address shortages of health workers and the lack of a pervasive national health system. However, while their role is often described at a policy level, it is not clear how these ideals are instantiated in practice, how best to support this work, or how the work is interpreted by local actors. CHWs are often spoken about or spoken for, but there is little evidence of CHWs' own characterisation of their practice, which raises questions for global health advocates regarding power and participation in CHW programmes. This paper addresses this issue. Design: A case study approach was undertaken in a series of four steps. Firstly, groups of CHWs from two communities met and reported what their daily work consisted of. Secondly, individual CHWs were interviewed so that they could provide fuller, more detailed accounts of their work and experiences; in addition, community health extension workers and community health committee members were interviewed, to provide alternative perspectives. Thirdly, notes and observations were taken in community meetings and monthly meetings. The data were then analysed thematically, creating an account of how CHWs describe their own work, and the tensions and challenges that they face. Results: The thematic analysis of the interview data explored the structure of CHW's work, in terms of the frequency and range of visits, activities undertaken during visits (monitoring, referral, etc.) and the wider context of their work (links to the community and health service, limited training, coordination and mutual support through action and discussion days, etc.), and provided an opportunity for CHWs to explain their motivations, concerns and how they understood their role. The importance of these findings as a contribution to the field is evidenced by the depth and detail of their descriptive power. One important aspect of this is that CHWs' accounts of both successes and challenges involved material elements: leaky tins and dishracks evidenced successful health interventions, whilst bicycles, empty first aid kits and recruiting stretcher bearers evidenced the difficulties of resourcing and geography they are required to overcome. Conclusion: The way that these CHWs described their work was as healthcare generalists, working to serve their community and to integrate it with the official health system. Their work involves referrals, monitoring, reporting and educational interactions. Whilst they face problems with resources and training, their accounts show that they respond to this in creative ways, working within established systems of community power and formal authority to achieve their goals, rather than falling into a 'deficit' position that requires remedial external intervention. Their work is widely appreciated, although some households do resist their interventions, and figures of authority sometimes question their manner and expertise. The material challenges that they face have both practical and community aspects, since coping with scarcity brings community members together. The implication of this is that programmes co-designed with CHWs will be easier to implement because of their relevance to their practices and experiences, whereas those that assume a deficit model or seek to use CHWs as an instrument to implement external priorities are likely to disrupt their work.