CMPH Journal

Introduction

Primary Health Care (PHC) has remained a key approach for more than four decades to strengthen the health system and improve access to locally relevant essential health services for all [1] PHC as an approach to organize healthcare was agreed upon by the member states at the World Health Assembly in 1977 and the subsequent international conference in 1978 on PHC held in Alma Ata with the slogan of “Health for All” [2]. Most recent discourse such as the 2018 Astana Declaration has also reaffirmed the significance of PHC and its principles to strengthen health systems and achieve health-related Sustainable Development Goals (SDGs) [3]. As an approach to health system development, PHC has demonstrated links to better health outcomes, improved equity and increased health security [4-8].

Community Health Worker Programs (CHWPs) are an important ‘community-centered’ health systems strengthening strategy that supports the uptake of the PHC approach [7,9,10]. In Low-and Middle-Income Countries (LMICs) in particular, many CHWPs have been implemented as part of the PHC approach to enhance access to essential health care services close to community and as a means to achieve “Health for All” [11-13]. The 2015 SDGs recommended the expansion and institutionalization of CHWPs by national governments to achieve these updated goals [14]. This recommendation further enhanced the global interest in CHWPs as a strategy to increase access to basic health services, and to strengthen health systems [14-16].

CHWPs range from small-scale programs, which often implement specific interventions over a short period of time, through to large-scale programs implemented by non-government organizations to national level government-sponsored CHWPs [17,18]. Regardless of the size of the CHWPs, to be effective they need to incorporate PHC principles, including community participation, Universal Health Coverage (UHC), intersectoral collaboration and appropriateness and align their design, implementation and evaluation activities with those principles [5,19-22].

Considering the importance of CHWPs to strengthen health systems, there are a number of frameworks and indicators available to assess their performance [16]. Examples include the Community Health Worker (CHW) Common Indicators Project (CIP), CHW Assessment and Improvement Matrix (AIM) toolkit, Accompanimeter 1.0’ tool, 5-SPICE framework and Primary Health Care Performance Initiative (PHCPI) and WHO guideline on health policy and system support to optimize CHWPs [16,23-28]. These frameworks and indicators focus mainly on national level governance, strategies and funding and local level functionality and processes i.e. how to implement and monitor CHWPs. However, these frameworks do not explicitly assess the application of PHC principles in CHWPs.

Table 1: Indicator-activities from Delphi exercise to apply primary health care principles in community health worker programs.

Materials and Methods

Study Design

A systematic qualitative document analysis was conducted to assess the utility of PHC Indicator-Activities developed recently using Delphi method [29].

Study Setting

The study included two national level CHWPs from Ethiopia and Pakistan. The formal name of Ethiopian CHWP is National “Health Extension Program” and Pakistan’s CHWP is “National Program for Family Planning and Primary Health Care”, commonly known as the “Lady Health Worker Program”. The selection criteria for choosing these CHWPs included, (i) national coverage (ii) CHWPs as part of the well-established health infrastructure, (iii) contribution towards improvements in health outcomes such as maternal and child health, immunization, family planning and communicable diseases [30-33] and (iv) availability of documents informing planning, implementation and evaluation of these programs. The two CHWPs have been implemented differently; Pakistan’s program administration is devolved to provincial levels, whereas Ethiopian program is managed centrally at the national level.

Health Extension Program (HEP) of Ethiopia: This flagship program of the Government of Ethiopia, was launched by the Federal Ministry of Health in 2003 [34]. HEP aimed to improve access to healthcare services in rural areas in order to improve health outcomes by targeting households and communities [35]. The program focuses on health promotion, disease prevention including immunization, provision of family planning services, treatment of selected illnesses, documentation of community health status and mobilization of the community for health campaigns. The program also provides ongoing support to people with a chronic illness such as HIV/AIDS [36,37]. The HEP provides health services at the household, community and Health Post levels. CHWs are deployed in pairs, two for every village serving a population of 3000 to 5000 people and affiliated with each village’s health post [37].

Pakistan’s National Program for Family Planning and Primary Health Care (NPFPPHC): In 1994, Pakistan’s Ministry of Health launched its CHWP as part of a national strategy to improve health by bringing health services to the doorsteps of underserved communities. The program has been running for 24 years and during this time undergone various administrative changes ranging from federal management to post-devolution provincial management and regularization of CHWs as government employees. The program has a major role in the provision of primary care services and in the reduction of burden of disease via preventive strategies and health education for communities, especially in the rural areas [38]. The prime role of this program is to provide basic primary care services to the communities and organize community by developing women groups and health committees. Each CHW is responsible for approximately 1,000 people within a catchment area of 200 houses [39].

Data collection and analysis

Document analysis of the two CHWPs was conducted using publicly available documents since the inception of the CHWPs. We used READ approach as a stepwise guide for systematic and thorough review of documents [40]. The steps of this approach are (i) ready your materials, (ii) extract data, (iii) analyze data and (iv) distill the findings [40]. For the first step, all the relevant material was collected via searching grey literature using Google Search and by contacting CHWP officials in Pakistan and Ethiopia. The search terms consisted of programs, reports, case studies, evaluation, guidelines and planning documents combined with the name of each of the two CHWPs and countries included in the document analysis. Our search strategy was designed to be broad to minimize the possibility of missing relevant documents and included all types of descriptive, explanatory and evaluation evidence. The search was conducted during January and February 2022. The documents collated consisted of programmatic materials such as case studies, policy briefs, planning documents, evaluation reports and working papers produced outside of formal publication channels. The documents were then categorized based on their focus as either planning, implementation or evaluation. This document analysis did not include any peer-reviewed published articles as there has been a recent scoping review on published literature which informed that the application of PHC principles in national CHWPs is not uniform and in-depth review of program documents may provide more insights [29]. The second step consisted of data extraction into a Microsoft Excel spreadsheet where each row was a document and each column was the category of information such as document title, type of the document, author and date and evidence for each of the PHC Indicator-Activities. The data extraction form is provided as Appendix 1. As the third step, we followed a thematic content analysis approach for qualitative synthesis of information extracted from the documents [41]. The themes were developed apriori from the PHC principles and Indicator-Activities. The thematic content analysis approach is most appropriate to apply on descriptive data from program/ project documents for aggregate synthesis of information [41]. The level of evidence found for an Indicator-Activity in a CHWP was classified as ‘evidence available’ if it was found across two or more types of documents (planning, implementation or evaluation) of a CHWP. ‘Partial evidence available’ reflected that the information was found only in one type of document in a CHWP. ‘No evidence available’ means there was no information found in any type of document reviewed for that program in relation to an IndicatorActivity. The document review was continued until all available documents had been reviewed. At the fourth and last step of READ approach, the distillation process led to the synthesis of findings in tabular and narrative form, reported in the results section of this paper. The overall understanding about the utility of each particular PHC Indicator-Activity was developed by considering the collective evidence from the two CHWPs and classified as ‘overall level of evidence’ (Table 2).

Table 2: Classification of overall level of evidence for Indicator-Activities.

Results

In total, 20 documents were reviewed from both CHWPs. List of documents included in this analysis is provided as Appendix 2. The ‘overall level of evidence’ was strong for 22 of 29 Indicator-Activities, partial for four activities, while no evidence was found for two Indicator-Activities. The level of evidence found for each Indicator-Activity in and across the two CHWPs is presented in Table 3. Details of the evidence found in the documents for each Indicator-Activity is shown in Table 4. The ‘overall level of evidence’ is summarised in the following paragraphs.

Table 3: Summary of evidence for primary health care Indicator-Activities in the two community health worker programs.

Table 4: Example of evidence from Ethiopia and Pakistan’s Community Health Worker Programs.

Strong Evidence

Strong evidence was available for most of the IndicatorActivities (22/29) across both CHWPs. There are 13 IndicatorActivities for the principle of ‘Universal Health Coverage’ (UHC) and its sub-attributes; strong evidence was available for 12 of those 13 activities (Table 3). As an example, the Indicator-Activity of service provision and defined catchment area encompasses whether a program clearly defines a sub-set of population to which a CHW is tasked with to provide a set of locally relevant services. Both CHWPs stated distinct number of individuals to whom each CHW is responsible for providing a definitive set of health services such as maternal health, basic treatment, contraceptives and referrals (Table 4) [32,36,42].

There are two Indicator-Activities related to the principle of ‘Intersectoral Coordination’. Strong evidence was available for both of them. For example, evidence was available for ‘representation of non-health organizations on planning and governance structures’ in HEP where documents reported multisectoral, inter-ministerial partnership involving the ministries of health, finance, education and labour [34]. This program also showed evidence of collaborations with other subnational health authorities and finance bureaus for provision of training and salaries of CHWs via a payroll system. On the other hand, for NPFPPHC there was partial evidence identified for this IndicatorActivity under the principle of ‘Intersectoral Coordination’ (Table 4) [42]. Overall level of evidence was therefore classified as ‘strong evidence’ for this Indicator-Activity. Similarly, for the IndicatorActivity ‘public-private partnership’ the evidence was reported in two types of documents from HEP but was noted in only one of the planning documents of NPFPPHC (Table 3) [43,44].

Strong evidence was noted for the Indicator-Activity of ‘joint ownership and design of the CHWP’ under the principle of ‘Community Participation’ (Table 3). For example, community organization for health promotion activities and selection of CHW from within the area reflects this principle in NPFPPHC [38,39]. The HEP documents revealed a well-defined stepwise strategy for inclusion of community in all stages of program planning and implementation; from decision-making to evaluating the CHWP in Ethiopia (Table 4) [32,34].

Strong evidence was found for majority (9/12) of the IndicatorActivities related to the principle of ‘Appropriateness’ and its subattributes (effectiveness, cultural acceptability, affordability and manageability). For example, the evidence related to the IndicatorActivity ‘monitoring health outcomes’ reflecting effectiveness under the principle of ‘Appropriateness was identified across all types of documents of both CHWPs. Both programs have designed and implemented health information systems to improve continuous monitoring and evaluation of the CHWP (Table 4). On the other hand, the evidence for the Indicator-Activity ‘context specific program design and implementation’ was noted in only an evaluation report of NPFPPHC. The partial evidence for this Indicator activity points out that NPFPPHC focusses on the needs of marginalized population in general, but may not be specifically targeting subpopulation groups with specific concerns such as remoteness, nutritional deficiencies or relatively higher health education need [42]. Whereas, the evidence was found in two types of documents in HEP (strong evidence) [32,43]. Overall level of evidence was therefore classified as ‘strong evidence’ for this Indicator-Activity.

Partial Evidence

Partial evidence was noted for four Indicator-Activities (Table 3). The evidence was partial in both CHWPs for the IndicatorActivities ‘proportionate service provision’ and ‘CHWs role adjustment as the program evolves with respect to communities’ needs’ under the principle of appropriateness. Whereas, no information was found related to the Indicator-Activities ‘cost effective interventions’ and ‘addressing financial barriers to health care’ in NPFPPHC under the principle of appropriateness while there was partial evidence available for these activities in HEP. Overall level of evidence was therefore classified as ‘partial’ for these Indicator-Activities.

As an example, the evidence for ‘proportionate service provision’ was noted in only an implementation document of the HEP and only in an evaluation report of NPFPPHC [36,42]. The evidence for ‘CHWs role adjustment’ was noted only in an evaluation report of HEP indicating that the program incorporates additional services, which were not part of the original HEP packages and include high-impact curative services such as integrated community case management, community-based newborn care, and treatment of common childhood illnesses (Table 4). Similarly, the evidence for this activity was noted only in an evaluation report of NPFPPHC (Table 3).

No evidence

There was no evidence available in any type of documents for two Indicator-Activities ‘ensure privacy and confidentiality’ and ‘health literacy’ (Table 3).

The descriptors for the Indicator-Activities developed through Delphi research was refined by merging and appropriate placement of the Indicator-activities under a specific PHC principle or a sub-attribute of the principle based on the evidence found in this document analysis. The resultant list of Indicator-Activities with their description is provided in Table 5.

Table 5: Indicator-Activities reflecting the application of primary health care principles in a community health worker program.

Discussion

To the best of our knowledge, this is the first study that assessed the utility of a set of Indicator-Activities for the application of PHC principles by CHWPs in LMICs. Findings of this document analysis confirm that the PHC Indicator-Activities are applicable to the CHWPs as most (22/29) of these IndicatorActivities are evident in the two national level CHWPs. The results have also highlighted areas that CHWPs need to focus on to improve community engagement to increase program acceptance, access and utility.

CHWPs’ success is founded on PHC approach, and the Indicator-Activities can be used as descriptors to optimize the application of PHC principles by these programs. Evaluating CHWPs often proves to be difficult due to variability in their defining characteristics and because of their emphasis on certain particular roles and responsibilities of CHWs [45]. These roles and responsibilities of CHWs may also vary due to the national context (morbidity, national priorities, fiscal situation etc.); however, despite varying roles and responsibilities CHWPs should still focus on PHC principles.

As CHWPs are complex entities their assessment needs to be based on the data derived from a mix of reliable sources and obtained through the use of mix methods. There are numerous existing tools to measure performance of individual CHWs, programmatic determinants of CHW performance, community level outcomes and contextual factors that influence a CHWP [16]. However, these tools tend to focus more on governance, managerial, administration and fiscal aspects of the CHWPs. The set of Indicator-Activities identified through a Delphi process and assessed for its utility through this document analysis, is added to this toolbox and fills the gap in the method to assess application of PHC principles by CHWPs. Used in combination with the existing tools, Indicator-Activities can provide a complete picture of CHWP performance from PHC perspective. Therefore, these Indicator-Activities could be used to plan and monitor national level CHWPs in LMICs, track outcomes and assess whether these programs are meeting their intended objectives related to PHC principles.

The evidence for the Indicator-Activities ‘ensuring privacy and confidentiality of the clients’ for the principle of UHC and ‘health literacy’ for the principle of appropriateness could not be found in the documents reviewed in this study. However, we have not removed these Indicator-Activities out of the final list because of their relevance to improving access and cultural acceptability. Health literacy is the ability to engage with health information and services.46 It helps individuals to make effective use of available health services [47]. Low health literacy is a significant problem in many LMICs because of the low levels of general literacy and poorly resourced and functioning health systems with less than adequate investment in health education programs [48]. There is evidence on effective health literacy interventions improving health outcomes in LMICs [47,48]. With reference to ‘ensuring privacy and confidentiality’, CHWs have shown to be keen to observe ethical principles while carrying out their roles [49]. However, there is need to equip them with training and provision of relevant guidelines [49].

One of the limitations of this study is that the assessment of the utility of Indicator-Activities relied on program documents only. Assessment could be more rigorous if documents analysis is combined with discussions and interviews with CHWP staff and observation of the CHWP activities in the field. COVID-19 pandemic did not allow visits to program sites. Hence, a future study could be planned allowing that additional methodological rigor.

Secondly, this study has reported lack of evidence for the Indicator-Activities ‘ensuring privacy and confidentiality of the clients’ and ‘health literacy’. There is a possibility that these activities are part of CHWPs but were not described in the documents that were available for the review. This may be one of the limitations of this study as the evidence may be there in other documents we could not get hold.

Thirdly, the evidence is assessed by one reviewer and the individual subjective view may have affected the decision of whether a document has evidence related to a specific IndicatorActivity. This needs to be verified further by having two independent reviewers in future assessments of the IndicatorActivities. Moreover, we have not placed any weighting on the quality of evidence that was found for the Indicator-Activities assesses in this study. The Indicator-Activities need further validation through their application on a broader range of CHWPs in different countries and also through a more in-depth assessment of the quality of evidence.

Conclusion

The findings of this document analysis indicate that PHC Indicator-Activities are useful to the CHWPs across LMICs. These Indicator-Activities can be used to assess the application of PHC principles, which can inform planning, implementation, and evaluation of CHWPs. Future research may focus on assessing the Indicator-Activities in the field and applying them on a broad range of CHWPs.

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