Person:

Bossert, Thomas

Background: Community health workers (CHWs) are increasingly used to increase access to primary healthcare, and considered to be a key health worker cadre to achieve the UNAIDS 90-90-90 target. Despite the recent policy interest in effectively designing, implementing, and evaluating new CHW programs, there is limited evidence on how long-standing CHW programs are performing. Using the CHW Performance Logic model as an evaluation framework, this study aims to assess the performance of Swaziland’s long-standing national CHW program, called the rural health motivator (RHM) program. Methods: This study was carried out in the Manzini and Lubombo regions of Swaziland. We conducted a survey of 2,000 households selected through two-stage cluster random sampling and a survey among a stratified simple random sample of 306 RHMs. Additionally, semi-structured qualitative interviews were conducted with 25 RHMs. Results: While RHMs are instructed to visit every household assigned to them at least once a month, only 15.7% (95% CI: 11.4 – 20.4%) of RHMs self-reported to be meeting this target. Less than half (46.3%; 95% CI: 43.4 – 49.6%) of household survey respondents, who reported to have ever been visited by a RHM, rated their overall satisfaction with RHM services as eight or more points on a 10-point scale (ranging from “very dissatisfied” to “very satisfied”). A theme arising from the qualitative interviews was that community members only rarely seek care from RHMs, with care-seeking tending to be constrained to emergency situations. Conclusions: The RHM program does not meet some of its key performance objectives. Two opportunities to improve RHM performance identified by the evaluation were increasing RHM's stipend and improving the supply of equipment and material resources needed by RHMs to carry out their tasks.

Background: The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre. Methods: The CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance. Results: Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: i) increased monetary compensation of CHWs, ii) a more reliable supply of equipment and consumables, iii) additional training, and iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance. Conclusions: While this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.

Background: Community health worker (CHW) programs are believed to be poorly coordinated, poorly integrated into national health systems, and lacking long-term support. Duplication of services, fragmentation, and resource limitations may have impeded the potential impact of CHWs for achieving HIV goals. This study assesses mediators of a more harmonized approach to implementing large-scale CHW programs for HIV in the context of complex health systems and multiple donors. Methods and findings We undertook four country case studies in Lesotho, Mozambique, South Africa, and Swaziland between August 2015 and May 2016. We conducted 60 semistructured interviews with donors, government officials, and expert observers involved in CHW programs delivering HIV services. Interviews were triangulated with published literature, country reports, national health plans, and policies. Data were analyzed based on 3 priority areas of harmonization (coordination, integration, and sustainability) and 5 components of a conceptual framework (the health issue, intervention, stakeholders, health system, and context) to assess facilitators and barriers to harmonization of CHW programs. CHWs supporting HIV programs were found to be highly fragmented and poorly integrated into national health systems. Stakeholders generally supported increasing harmonization, although they recognized several challenges and disadvantages to harmonization. Key facilitators to harmonization included (i) a large existing national CHW program and recognition of nongovernmental CHW programs, (ii) use of common incentives and training processes for CHWs, (iii) existence of an organizational structure dedicated to community health initiatives, and (iv) involvement of community leaders in decision-making. Key barriers included a wide range of stakeholders and lack of ownership and accountability of non-governmental CHW programs. Limitations of our study include subjectively selected case studies, our focus on decision-makers, and limited generalizability beyond the countries analyzed. Conclusion: CHW programs for HIV in Southern Africa are fragmented, poorly integrated, and lack long-term support. We provide 5 policy recommendations to harmonize CHW programs in order to strengthen and sustain the role of CHWs in HIV service delivery.