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The Roles of Community Health Workers Who Provide Maternal and Newborn Health Services: Case Studies from Africa and Asia

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The Roles of Community Health Workers Who Provide Maternal and Newborn Health Services: Case Studies from Africa and Asia Research BMJ Glob Health: first published as 10.1136/bmjgh-2019-001388 on 10 August 2019. Downloaded from The roles of community health workers who provide maternal and newborn health services: case studies from Africa and Asia Abimbola Olaniran, Barbara Madaj, Sarah Bar-Zev, Nynke van den Broek To cite: Olaniran A, Madaj B, ABSTRACT Key questions Bar-Zev S, et al. The roles of Introduction A variety of community health workers community health workers (CHWs) provide maternal and newborn health (MNH) What is already known? who provide maternal and services in low-income and middle-income settings. newborn health services: There is a wide variety of community health workers However, there is a need for a better understanding of the ► case studies from Africa (CHWs) in low-income and middle-income settings; diversity in type of CHW in each setting and responsibility, and Asia. BMJ Global Health most are expected to provide one or more aspects of role, training duration and type of remuneration. 2019;4:e001388. doi:10.1136/ maternal and newborn health (MNH) care. bmjgh-2019-001388 Methods We identified CHWs providing MNH services in Bangladesh, India, Kenya, Malawi and Nigeria by What are the new findings? Handling editor Stephanie M reviewing 23 policy documents and conducting 36 focus ► The roles of CHWs in MNH care vary with duration of Topp group discussions and 131 key informant interviews. We training and whether they are community or facility analysed the data using thematic analysis. based. Received 2 January 2019 Results Irrespective of training duration (8 days to 3 ► CHWs are often expected to provide services that are Revised 25 April 2019 years), all CHWs identify pregnant women, provide health beyond their scope of practice during emergencies Accepted 25 May 2019 education and screen for health conditions that require where health professionals are unavailable and/or a referral to a higher level of care. Therapeutic care, referral may not be possible. antenatal care and skilled birth attendance, and provision ► Some CHW have limited roles in MNH care despite of long-acting reversible contraceptives are within the their training because health professionals may pre- exclusive remit of CHWs with training greater than 3 vent CHWs from providing those services which are months. In contrast, community mobilisation and patient viewed as the remit of health professionals. tracking are often done by CHWs with training shorter http://gh.bmj.com/ than 3 months. Challenges CHWs face include pressure What do the new findings imply? to provide MNH services beyond their scope of practice ► There is a need for policy-makers and programme during emergencies, and a tendency in some settings to planners to be clearer about the roles and respon- focus CHWs on facility-based roles at the expense of their sibilities of the different types of CHWs and revise traditional community-based roles. their scope of practice to reflect training duration Conclusion CHWs are well positioned geographically and while addressing challenges that prevent CHWs on September 29, 2021 by guest. Protected copyright. socially to deliver some aspects of MNH care. However, from providing MNH services stated in their scope there is a need to review and revise their scope of practice of practice. to reflect the varied duration of training and in-country legislation. on community health workers (CHWs) as an important cadre within multidisciplinary © Author(s) (or their 6 employer(s)) 2019. Re-use BACKGROUND primary healthcare teams. CHWs are increas- permitted under CC BY-NC. No Lessons learnt from the Millennium Devel- ingly expected to take on additional tasks commercial re-use. See rights opment Goals era show that a continued including in the area of MNH.7 and permissions. Published by BMJ. shortage of health professionals globally While there is relative clarity in the educa- tion and training duration of the different Centre for Maternal and remains a threat to achieving the health-re- Newborn Health, Liverpool lated Sustainable Development Goals and cadres of health professionals, CHWs are School of Tropical Medicine, Universal Health Coverage, especially goals often described in generic and non-specific Liverpool, Merseyside, UK relating to maternal and newborn health terms.2 8 Health professionals have been (MNH).1–5 There are recommendations described as individuals with a first degree Correspondence to Dr Abimbola Olaniran; to revise current health policies to reflect or higher qualification following 3–6 years Abimbola. Olaniran@ outlook. a sustainable and responsive skills mix of of health-related study in a higher educa- com available health professionals and refocus tional institution.9 10 In contrast, CHWs are Olaniran A, et al. BMJ Global Health 2019;4:e001388. doi:10.1136/bmjgh-2019-001388 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001388 on 10 August 2019. Downloaded from paraprofessionals or lay health workers with an in-depth health extension workers (CHEWs) and junior commu- understanding of a community’s culture and language. nity health extension workers (JCHEWs) in Nigeria. Additionally, the majority of CHWs have shorter training To understand and check if these were the main CHW than health professionals and their primary role is consid- cadres in each country, we purposively selected a sample ered to be the provision of culturally appropriate health of community and formal health system level stakeholders services to the community.11 as study participants and invited them to participate in This study aimed to explore the scope of practice of the study through email, phone calls and, where possible, different cadres of CHWs with regard to provision of face-to-face interview. Written consent was obtained from MNH care in different settings. It is anticipated that find- all study participants in English or in the relevant local ings from this study would guide local and global stake- language. holders recommending generic but expanded MNH roles for CHWs,12 13 without acknowledging the diversi- Data collection ties in their training duration. Data were collected across the study countries between August 2015 and March 2016. In each study country, we interviewed programme staff at the national and subna- tional levels and health professionals providing MNH METHOD care in primary healthcare facilities. Lastly, we conducted Study design, setting and population focus group discussions (FGDs) with CHWs, commu- We conducted a qualitative study using a multiple-case nity health committee members and service recipients study design to explore the training duration, charac- linked to the primary healthcare facilities. The principal teristics and scope of practice of CHWs providing MNH researcher (AO) conducted key informant interviews services in sub-Saharan Africa and South Asia. Five study (KIIs) and FGDs in English language while local research 14 15 countries were selected using multistage sampling. assistants conducted KIIs and FGDs in the relevant local The countries in each subcontinent constituted the first- language of each study setting. A total of 131 KIIs and stage sampling units. Subsequently, relevant WHO docu- 36 FGDs were conducted. The most recent versions of 16 17 ments were reviewed to identify countries known to 23 country policy documents were reviewed to explore have health workforce shortages, high maternal mortality and document CHW characteristics and scope of prac- 16 18 ratios and high neonatal mortality rates. These coun- tice with regard to MNH. Table 1 shows the study coun- tries made up the second-stage sampling units and tries, study locations, cadres of CHWs, policy documents included 42 countries in sub-Saharan Africa and five in reviewed and KIIs and FGDs conducted in each of the South Asia. The third stage entailed a comparison of these study countries. 47 countries with the 11 countries where the Centre for Maternal and Newborn Health at the Liverpool School Data analysis of Tropical Medicine (authors’ institution) was imple- To objectively compare 10 CHW cadres with diverse http://gh.bmj.com/ menting the ‘Making it Happen’ programme to reduce training durations, we grouped CHWs based on find- maternal and newborn mortality and morbidity. All 11 ings of a systematic review which categorised CHWs into programme countries were experiencing challenges lay health workers, and Levels 1 and 2 paraprofessional with health workforce crisis and maternal and neonatal CHWs.11 The systematic review described lay health mortality and were included in the third stage sampling workers as “individuals with little or no formal education unit. Using a limited literature review, countries with a who have undergone a few days to a few weeks of informal on September 29, 2021 by guest. Protected copyright. high density of CHWs providing MNH services were training” and Level 1 paraprofessionals as “individuals identified including Bangladesh and India (South Asia) with some form of secondary education and subsequent and Kenya, Malawi and Nigeria (sub-Saharan Africa). informal training lasting a few days to a few weeks”.11 Within each of these study countries, the location of Level 2 paraprofessionals were described as “individ- the Making it Happen programme offices informed the uals with some form of secondary education and subse- selection of the study districts, states or counties as these quent formal training lasting a few months to more than offices provided logistic support for the study.
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