Application of Primary Health Care Principles in National or Large-Scale Community Health Worker Programs in Low- and Middle-Income Countries

Abstract

Introduction Primary health care (PHC) has led to improved health outcomes across a wide variety of settings in the past four decades. In low- and middle-income countries (LMICs), community health worker programs (CHWPs) are an essential aspect of the PHC strategy to achieve ‘Health for All’ and the Sustainable Development Goals. As part of the PHC approach, national CHWPs were envisioned as a strategy to implement the Alma-Ata Declaration in order to reach wider populations in LMICs and serve the unmet health care needs of village communities. Established under the PHC approach, national CHWPs were expected to encompass and promote the principles of PHC and, in doing so, achieve improvements in health outcomes. National CHWPs, as vehicles to incorporate PHC principles into health care provision, have contributed to reducing the under-five child mortality rate in various LMICs, including Brazil, Indonesia and Nepal. This demonstrates the clear link and need to incorporate PHC principles when implementing national CHWPs, and that the long-term success of these programs is rooted in the application of PHC principles. Therefore, the aim of this thesis is to investigate the application of PHC principles in national CHWPs and generate evidence to guide their application in these programs. This research maps the evidence of the application of PHC principles in national CHWPs in LMICs, identifies a core set of Indicator-Activities to reflect the implementation of PHC principles, and assesses the utility of these identified activities in CHWPs. Methods This thesis incorporates three studies, which are outlined below: Study 1: Although the PHC principles are evident in the program design and policies of the CHWPs in various countries, there is little evidence of the extent to which PHC principles are systematically applied across the national CHWPs beyond program design and policy. Therefore, the initial study—a systematic scoping review—aimed to review the application of four PHC principles (universal health coverage, community participation, intersectoral coordination and appropriateness) in the CHWPs’ objectives, implementation and stated outcomes, and to understand their contribution to the outcomes of those programs. Study 2: This study aimed to determine the relative importance of PHC principles and to identify a set of core Indicator-Activities that reflect the application of different PHC principles in national or large-scale CHWPs in LMICs. Through a Delphi survey involving a range of participants with experience and expertise in CHWP planning, implementation and evaluation in LMICs, a set of 29 Indicator-Activities was identified for the application of PHC principles in these programs. Study 3: Following on from the Delphi survey to identify Indicator-Activities, the third study aimed to assess the utility of these PHC Indicator-Activities for CHWPs in LMICs. The study included two national CHWPs from Pakistan and Ethiopia. A desk review of the CHWPs’ publicly available documents, including case studies, evaluation reports, program planning documents, policy briefs and working papers, was conducted using the READ approach. A data extraction form was developed using the PHC Indicator- Activities to collect information on each Indicator-Activity for the application of four PHC principles and their sub-attributes. Results Study 1, the scoping review, included 26 studies published between 1983 and 2019 and covered 14 CHWPs from 13 LMICs. ‘Universal health coverage’ and ‘community participation’ were the two commonly reported PHC principles. Similarly, the cultural acceptability aspect of the principle of ‘appropriateness’ was present in all CHWPs because these programs select CHWs from within the communities. Evidence for the principle of ‘intersectoral coordination’ was generally missing, along with effectiveness of CHWPs. The review found that the PHC principles were not uniformly applied in national CHWPs. For comprehensiveness and improved health outcomes, these programs need to incorporate all attributes of PHC principles. Future research may focus on how to incorporate more attributes of PHC principles while implementing national CHWPs in LMICs. Improved documentation of CHWP implementation in published peer-reviewed literature is also needed. In Study 2, 17 participants from 15 countries participated in the Delphi exercise. Based on participants’ responses for the activities that reached consensus, a set of 29 Indicator- Activities for the four PHC principles and their sub-attributes was developed with examples of types of activities for each Indicator-Activity. In the presence of other important and useful tools to measure the programmatic inputs and functionality of CHWPs, the Indicator-Activities developed can provide guidance on how PHC principles can be applied in the CHWPs. The next step will be to assess the utility of these Indicator- Activities. Study 3, the document analysis, included 20 documents from two national CHWPs. Strong evidence was found for 22 out of 29 Indicator-Activities, partial evidence was found for four Indicator-Activities and no evidence was found for two Indicator- Activities. One activity was found to be overlapping with the Indicator-Activity of ‘joint ownership and design of the CHWP’ so it was merged with it. The findings confirmed that the PHC Indicator-Activities identified are likely to be applicable to the CHWPs in LMICs. Future research may focus on assessing the Indicator-Activities in the field and applying them to a broader range of CHWPs. Conclusion Given the resurgence of interest in PHC in recent years, there is an opportunity to design, implement and evaluate CHWPs based on the principles of PHC. This thesis identified a lack of uniformity in the application of PHC principles in national CHWPs. While the PHC principles were found to still be important in improving CHWPs’ performance and contributing to better health outcomes, there was no tool to facilitate the application of these principles. The set of Indicator-Activities that was developed fills this gap and can be used to assess the application of PHC principles that can inform CHWP designing and monitoring in the context of LMICs. Strengths of the Research This thesis employed interrelated study designs with strong methodologies that add to the existing knowledge through a systematic review of the literature (scoping review), expert opinion (Delphi survey) and CHWP review (document analysis). The information was triangulated across these three studies to understand the application of PHC principles in CHWPs and develop a potential tool to facilitate the systematic application of these principles. Contributions of This Thesis to Existing Body of Knowledge The tool developed as an outcome of this research adds to the existing body of knowledge by providing a method to assess the application of PHC principles in CHWPs and strengthening the measures already available to assess CHWPs’ performance. In addition, this research reiterates the importance of PHC principles through a systematic approach and a set of comprehensive research methods.