Naimoli Joseph F, Perry Henry B, Townsend John W, Frymus Diana E, McCaffery James A
United States Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington, DC, 20523, USA.
Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD, 21205, USA.
Hum Resour Health. 2015 Sep 1;13:46. doi: 10.1186/s12960-015-0041-3.
There is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients' health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems - the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated.
We explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component.
We identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system.
We believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.
有充分证据表明，低收入和中等收入国家（LMIC）的社区卫生工作者（CHW）能够改善其服务对象的健康状况和福祉。然而，关于在大规模范围内提升和维持社区卫生工作者绩效的经证实策略的证据有限。尽管如此，社区卫生工作者的利益相关者需要指导和新思路，而这可以源于认识到社区卫生工作者在两个动态且相互重叠的系统——正规卫生系统和社区——的交叉点上发挥作用。虽然每个系统通常都会支持社区卫生工作者，但其支持不一定具有战略性、协作性或协调性。
我们探讨战略社区卫生系统伙伴关系，将其作为一种在已经开展或打算开展大规模社区卫生工作者项目的国家中改善社区卫生工作者项目规划和绩效的方法。为确定该方法的组成部分，我们利用了为期一年的关于社区卫生工作者绩效的证据综合分析、综合记录、作者咨询、综合分析之后发表的大规模社区卫生工作者项目的文档以及其他相关文献。我们还为所考虑的组成部分制定了纳入和排除标准。我们也研究了与实施每个组成部分相关的挑战和机遇。
我们确定了一个至少包含四项策略的组合，这些策略为社区与卫生系统之间加强合作提供了机会，解决了大规模社区卫生工作者项目中的传统弱点，并且在国家以下层面的广大地理区域以及最需要护理的弱势群体中实施是可行的。我们推测，同时实施所有四项策略所带来的社区卫生工作者绩效提升效益可能超过卫生系统或社区单独实施所能产生的效益。这些策略是：（1）社区卫生工作者项目的联合所有权和设计；（2）协作监督和建设性反馈；（3）一套平衡的激励措施；（4）一个纳入社区和卫生系统数据的实用监测系统。
我们认为，社区与卫生系统就一套同时实施的最低限度策略建立战略伙伴关系，有可能加速在大规模提升社区卫生工作者绩效方面取得进展。比较性、回顾性和前瞻性研究可以证实这些策略的潜力。更多关于战略伙伴关系的经验和证据有助于我们理解如何在公平的基础上实现卫生领域的可持续进展。
