De Neve Jan-Walter, Garrison-Desany Henri, Andrews Kathryn G, Sharara Nour, Boudreaux Chantelle, Gill Roopan, Geldsetzer Pascal, Vaikath Maria, Bärnighausen Till, Bossert Thomas J
Institute of Public Health, Heidelberg University, Heidelberg, Germany.
Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.
PLoS Med. 2017 Aug 8;14(8):e1002374. doi: 10.1371/journal.pmed.1002374. eCollection 2017 Aug.
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.
背景：社区卫生工作者（CHW）项目被认为协调不力，在国家卫生系统中的整合程度低，且缺乏长期支持。服务重复、碎片化以及资源限制可能阻碍了社区卫生工作者在实现艾滋病目标方面的潜在影响。本研究评估了在复杂卫生系统和多个捐助方背景下，以更协调一致的方式实施大规模艾滋病社区卫生工作者项目的调节因素。 方法与结果：2015年8月至2016年5月期间，我们在莱索托、莫桑比克、南非和斯威士兰进行了四个国家的案例研究。我们对参与提供艾滋病服务的社区卫生工作者项目的捐助方、政府官员和专家观察员进行了60次半结构化访谈。访谈与已发表的文献、国家报告、国家卫生计划和政策进行了三角验证。基于协调的3个优先领域（协调、整合和可持续性）以及概念框架的5个组成部分（健康问题、干预措施、利益相关者、卫生系统和背景）对数据进行分析，以评估社区卫生工作者项目协调的促进因素和障碍。发现支持艾滋病项目的社区卫生工作者高度分散，在国家卫生系统中的整合程度低。利益相关者普遍支持加强协调，尽管他们认识到协调存在一些挑战和不利之处。协调的关键促进因素包括：（i）现有的大型国家社区卫生工作者项目以及对非政府社区卫生工作者项目的认可；（ii）对社区卫生工作者采用共同的激励措施和培训流程；（iii）存在专门致力于社区卫生倡议的组织结构；（iv）社区领袖参与决策。关键障碍包括利益相关者众多以及非政府社区卫生工作者项目缺乏自主权和问责制。我们研究的局限性包括案例研究是主观选择的，我们关注的是决策者，并且在分析的国家之外的可推广性有限。 结论：南部非洲的艾滋病社区卫生工作者项目分散、整合程度低且缺乏长期支持。我们提供了5项政策建议，以协调社区卫生工作者项目，从而加强并维持社区卫生工作者在艾滋病服务提供中的作用。
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