The paper synthesizes the current understanding of how community-based health worker programs can best be designed and operated in health systems. The authors searched 11 databases for review articles published between January 2005 and June 2017. The authors identified 122 reviews, 83 from low- and middle-income countries, 29 from high income countries and 10 global. Community-based health worker programs included in these reviews are diverse in interventions provided, selection and training of community-based health workers, supervision, remuneration, and integration into the health system. Features that enable positive community-based health worker program outcomes include community embeddedness, supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of community-based health worker programs into health systems can bolster program sustainability and credibility, clarify community-based health worker roles, and foster collaboration between community-based health workers and higher-level health system actors. The authors found gaps in the review evidence, including on the rights and needs of community-based health workers, on effective approaches to training and supervision, on community-based health workers as community change agents, and on the influence of health system decentralization, social accountability, and governance.
Malawi faces severe staffing shortages in the health sector and high migration of health workers. This paper suggests that, like most countries in Sub-Saharan Africa, local training of medical personnel has neither plugged these capacities deficits nor increased retention rates. Given the economic realities in Sub-Saharan Africa and the allure of countries in the Organization for Economic Cooperation and Development, many locally trained physicians migrate. The paper concludes that, like much of Sub-Saharan Africa, Malawi is victim of regional developments. Owing to growth in migration of physicians from South Africa to Organization for Economic Cooperation and Development countries, the paper raises that Malawi has turned to recruiting doctors from other African countries, exacerbating capacity constraints elsewhere in the region.
This paper synthesises current evidence on gender and close-to-community providers and the services they deliver. The authors used a two-stage exploratory approach drawing upon qualitative research from six countries in the REACHOUT consortium in 2013 to 2014. This was followed by systematic review that took place in 2017, using critical interpretive synthesis methodology. This review included 58 papers. From this, the authors present the holistic conceptual framework to show how gender roles and relations shape close to community provider experience at the individual, community, and health system levels. The evidence presented highlights the importance of safety and mobility at the community level. At the individual level, inﬂuence of family and intra- household dynamics are of importance. Important at the health systems level, are career progression and remuneration. The authors present suggestions for how the role of a close to community provider can, with the right support, be an empowering experience. They argue for policymakers to promote gender equity in this cadre through safety and well-being, remuneration, and career progression opportunities.
This paper synthesises current evidence on gender and close-to-community (CTC) providers and the services they deliver. The review included 58 papers from literature to inform the development of a conceptual framework. The authors present a holistic conceptual framework to show how gender roles and relations shape CTC provider experience at the individual, community, and health system levels. The evidence presented highlights the importance of safety and mobility at the community level. At the individual level, family and intra-household dynamics are of importance. Important at the health systems level, are career progression and remuneration. The authors present suggestions for how the role of a CTC provider can, with the right support, be an empowering experience. Key priorities for policymakers to promote gender equity in this cadre include: safety and well-being, remuneration, and career progression opportunities.
This paper addressed the gaps in shortage of trained people and lack of national data on non-communicable diseases and their risk factors in Uganda. The authors developed and implemented a new track within an existing master of public health programme, aimed at developing graduate-level capacity and promoting research on key national priorities for trauma and injuries. They also offered training opportunities to a wider audience and set up a high-level national injury forum to foster national dialogue on addressing the burden of trauma, injuries and disability. Over the years 2012 to 2017 there were four cohorts of master’s students, with a total of 14 students. Over 1300 individuals participated in workshops and seminars of the short-term training component of the programme. The forum hosted three research symposia and two national injury forums. The authors note that institutional support and collaborative engagement is important for developing and implementing successful capacity development programmes, and that integration of training components within existing academic structures is key to sustainability and appropriate mentorship for motivated and talented students.
Representatives from the Democratic Nursing Organization of South Africa (Denosa), a trade union that represents nurses and professional midwives, say that nursing staff work under bad conditions. A Denosa spokesman said South African nurses and nursing staff were seeking work out of the country where they were appreciated and would get better salaries. “People who rely on the services of public healthcare workers are disadvantaged when public health workers are understaffed or strike due to unresolved grievances,” said Ashwell Jenneker of Statistics South Africa. In a dialogue, the South Africa Minister of Health, Aaron Motsoaledi said, “We will do our best to ensure that all health workers are given better working conditions. We will also work on making sure that the minimum service level of health workers is implemented.” Those attending the dialogue agreed that a formal investigation was needed into the working conditions of all health workers.
Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and as a means for improvement in health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from the authors’ deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. Several propositions were made for further conceptual development and research related to the question of CHWs and accountability.
This paper seeks to assess if targeted community-based medical education programme is associated with better prevention and treatment seeking behaviours in the management of malaria, a leading cause of morbidity and mortality of children under five in Uganda. A cross-sectional survey was done to compare communities around health facilities where medical students were placed at community-based education and Research Service (COBERS) sites with communities around similar health facilities where medical students were not placed (non-COBERS sites). The authors randomly selected two villages near each health facility and consecutively selected 10 households per village for interviews using nearest-neighbour method. The authors used a structured questionnaire to interview household heads on malaria prevention and treatment seeking behaviour for children under 5 years. The authors performed univariate analysis to determine site and demographic characteristics and performed a multivariate logistic regression to assess association between dependent and independent variables. Five hundred twenty-three of the children under 5 years in COBERS communities slept under insecticide treated nets the night before survey compared with 1451 in non-COBERS communities. 100 of children under 5 years in COBERS communities sought care for fever within 24 h of onset compared with 268 in non-COBERS communities. The presence of COBERS in communities is associated with improved malaria prevention and treatment-seeking behaviour for parents of children under 5 years. Further study needs to be done to determine the long-term impact of COBERS training program on malaria control and prevention in Uganda, along with its other effects.
Dixon Chibanda developed the Friendship Bench approach to mental health care in Zimbabwe. In this interview he tells Fiona Fleck how he is taking the innovative approach to other countries. The idea of the Friendship Bench arose when he lost a patient to suicide in 2005. After identifying a large burden of mental health conditions, Chibanda talked to the authorities, but they had no money, staff or facilities to offer. So in 2007 he worked with 14 grandmothers in Mbare, a suburb of Harare that was badly affected by the clearance operation of informally built suburbs in the city. The grandmothers were from the community and already doing community work and the friendship bench formalized their role. The first four years were focused on developing a culturally appropriate evidence-based intervention that they could deliver. They developed a problem-solving therapy in the local language drawing on familiar concepts in the local culture while incorporating elements of cognitive behavioural therapy. Together with the grandmothers, they came up with key terms – kuvhura pfungwa, which means opening the mind, kusimudzira, (uplifting), and kusimbisa(strengthening) – that formed the basis of the Friendship Bench approach. The benches are outside each health facility, initially they were set apart, but now they are quite public, because the programme is widely accepted in the communities. Harare has more than 53 primary health care facilities, each with one to four of these benches. When people come to these facilities seeking mental health services, they are screened with the Shona Symptoms Questionnaire 14 to determine the level of mental health disorders and referred to the grandmothers –lay health workers who have been trained and who are supervised by health professionals. Chibanda’s own grandmother lived in Mbare and – although she was not one the therapists – she was instrumental in coming up with the income generating component of the approach, which is an important part of the group peer support. After finishing sessions on the bench, the grandmothers sit in a circle and share the challenges they face with their colleagues, while crocheting bags with recycled plastic to sell. Now, after completing therapy, the grandmothers give their patients further support and show them how to make the bags, as a forum for problem solving and income generation. In Zimbabwe, the approach has been scaled up in more than 70 communities in Harare, Chitungwiza and Gweru and further roll out is taking place, with a component for adolescents under development. The approach is being rolled out in Tanzania, the USA, Canada, Australia and New Zealand.
As part of efforts to implement the human resources capacity building component of the African Regional Strategy on Disaster Risk Management (DRM) for the health sector, the African Regional Office of the World Health Organization, in collaboration with selected African public health training institutions, followed a multistage process to develop core competencies and curricula for training the African health workforce in public health DRM. In this article, we describe the methods used to develop the competencies, present the identified competencies and training curricula, and propose recommendations for their integration into the public health education curricula of African member states. The authors identified 14 core competencies and 45 sub-competencies/training units grouped into six thematic areas: 1) introduction to DRM; 2) operational effectiveness; 3) effective leadership; 4) preparedness and risk reduction; 5) emergency response and 6) post-disaster health system recovery. These were defined as the skills and knowledge that African health care workers should possess to effectively participate in health DRM activities. To suit the needs of various categories of African health care workers, three levels of training courses are proposed: basic, intermediate, and advanced.