39
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Taking stock of 10 years of published research on the ASHA programme: examining India’s national community health worker programme from a health systems perspective

      review-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background

          As India’s accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale.

          Methods

          We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW–health systems interface framework.

          Results

          A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results.

          Conclusion

          Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.

          Electronic supplementary material

          The online version of this article (10.1186/s12961-019-0427-0) contains supplementary material, which is available to authorized users.

          Related collections

          Most cited references159

          • Record: found
          • Abstract: found
          • Article: found
          Is Open Access

          Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review

          Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review. A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: found
            Is Open Access

            What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

            Objective To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems. Methods We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards. Findings We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance. Conclusion Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential. Electronic supplementary material The online version of this article (10.1186/s12960-018-0304-x) contains supplementary material, which is available to authorized users.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: found
              Is Open Access

              How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature

              Background Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs. Methods We searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized. Results Few studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. Conclusions Research on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance. Electronic supplementary material The online version of this article (doi:10.1186/s12961-015-0001-3) contains supplementary material, which is available to authorized users.
                Bookmark

                Author and article information

                Contributors
                kscott26@jhu.edu
                asgeorge@uwc.ac.za
                rajani.ved@gmail.com
                Journal
                Health Res Policy Syst
                Health Res Policy Syst
                Health Research Policy and Systems
                BioMed Central (London )
                1478-4505
                25 March 2019
                25 March 2019
                2019
                : 17
                : 29
                Affiliations
                [1 ]Independent consultant, Bangalore, India
                [2 ]ISNI 0000 0001 2156 8226, GRID grid.8974.2, School of Public Health, , University of the Western Cape, ; Robert Sobukwe Road, Bellville, Cape Town, 7535 South Africa
                [3 ]ISNI 0000 0004 5944 2073, GRID grid.502004.3, National Health Systems Resource Centre, ; New Delhi, India
                Author information
                http://orcid.org/0000-0003-3597-9637
                Article
                427
                10.1186/s12961-019-0427-0
                6434894
                30909926
                31679076-8c46-4b23-b9e4-08dba16fcc82
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 10 November 2018
                : 20 February 2019
                Funding
                Funded by: South African Research Chair's Initiative
                Award ID: 82769
                Funded by: FundRef http://dx.doi.org/10.13039/100000200, United States Agency for International Development;
                Award ID: AID-OAA-A-14-00028
                Categories
                Review
                Custom metadata
                © The Author(s) 2019

                Health & Social care
                community health worker,accredited social health activist,india,health policy and systems research,training and supervision,primary healthcare

                Comments

                Comment on this article