Faculty of Medicine and Health, Sydney School of Public Health
Abstract
Non-Communicable Diseases (NCDs) such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes are the leading cause of premature death and disability worldwide, accounting for 60% of all deaths globally and 80% of NCD related mortality occurring in low and middle-income countries (LMICs). Health systems in LMICs have been oriented toward maternal and child health, and infectious illnesses as these were the main causes of morbidity and mortality until recently. Over the last decade, health systems in LMICs have recognized the need to address NCDs, and have restructured health services to include relevant prevention and control strategies. Health workforce is one of the key building blocks of health systems; however, most LMICs have a shortage of physicians. In addition, the available health care providers are unevenly distributed within countries with the majority concentrated in urban regions compared to rural regions where large proportions of the population reside. This poor distribution and shortage of physicians has led some countries to rely on task shifting, where tasks normally performed by qualified health professionals are transferred to other health providers with a lower level of education and professional training. In 1978, the Declaration of Alma-Ata included trained community health workers (CHWs) and traditional medical practitioners as part of the health team as a fundamental step towards comprehensive primary care. Since then, CHWs have been a cornerstone of health systems in several countries with over 26 different CHW programs identified in the literature across more than 24 LMICs. Traditionally, CHWs do not hold formal professional certification but receive job-related pre-service training. However, there is a lot of variation across countries where some countries require CHW certification before they can start performing their roles. CHWs reside in the community where they work, and are usually volunteers and sometimes receive financial compensation for receiving training and performance-based incentives for health related activities. CHWs can enable essential health care services to be provided in a cost-effective manner. They have been instrumental in reducing maternal and neonatal mortality rates through their presence for home births and making referrals for emergency obstetric care, and by promoting vaccination uptake, breastfeeding, and education about infectious disease. More recently, CHWs have been useful in HIV/AIDS prevention and control, educating communities and performing tasks such as screening, counselling and supplying antiretroviral drugs. With the increasing prevalence of NCDs and to meet changing community health needs, CHWs are sought to provide a similarly appropriate care for NCD risk factors control. While CHWs may not replace qualified health providers, they can play a considerable role in improving health outcomes by educating, screening, referring and following-up individuals at high risk of NCDs. CHWs have been trained in some settings to screen, educate and follow-up patients with NCDs or people at increased risk of NCDs. However, there is a need to better understand how to support CHW programs to be more effective and sustainable. There is knowledge gap in terms of the CHWs current capacity, working conditions, training provided for NCD prevention and control, remuneration, supervision and other upstream challenges facing CHWs and the health systems. The literature suggests that the there is a range of context-specific factors which can have an impact on the performance of CHWs and the quality of the care they provide. Some of these factors include the remuneration schemes employed, the workload, task complexity, lack of clarity in job description, and other essential factors such as interpersonal relationships between CHWs and other members of the primary health care team. CHW programs operate differently across and within countries. Evidence-based policy interventions are required to inform policy decision to ensure effective CHW program implementation. This thesis applies a mixed-methods approach to explore the capacity of the CHWs and the system support necessary to facilitate the CHW’s role in providing comprehensive, community-oriented, continuous primary health care which includes prevention and control strategies for NCDs. Part One provides an insight into the historical background of CHWs and how their role has evolved due to global health needs. With the expanding role of CHWs to incorporate NCDs, part two throws light on training of CHWs for NCDs in LMICs. Chapter two presents results of a systematic review about the effectiveness of training CHWs for cardiovascular disease prevention and management in LMICs. The chapter findings demonstrate the importance of having interactive and culturally adapted training sessions to make the training easier to follow and understand by the CHWs. The findings also highlight the need for evaluating the knowledge and skill-set of the CHWs to capture the training impact; and the necessity of scheduling refresher training at regular intervals to ensure knowledge retention. Chapter three demonstrates the importance of using an evaluation framework such as Kirkpatrick’s evaluation model to evaluate the effectiveness of training among CHWs. Using an evaluation framework, not only assesses the knowledge change but rather employs multiple measures to assess knowledge, skills and behaviour change of the CHWs. This allows for a more comprehensive interpretation of the training outcomes. The qualitative data involved in Chapter three provided insight on the low morale and discontent of the CHWs with their working conditions. In part three, I use a discrete choice experiment (DCE) to provide evidence of effective interventions that can keep the CHWs motivated and retain them in the workforce. Chapter Four explains the process of designing a DCE for Accredited Social Health Activists (ASHAs), who are CHWs in India. It also provides evidence of the feasibility of using Android computer tablets to display the DCE for the CHWs. In chapter five, I examine the relative importance of stated preferences of ASHAs to remain in service using a DCE survey. Career progression was found to be the main influencing factor for ASHAs in addition to fixed salary and other non-financial factors such as priority free family health-check and reduced workload. The findings demonstrated that the ASHAs sociodemographic characteristics such as their education level plays a key role in shaping their preference profile. These findings can inform future policy decisions of evidence-based recruitment and retention strategies that are applicable to the local context. CHWs have proven to be effective in providing a wide range of services including NCDs care. However to optimize the performance of CHW programs, we need to understand the system level support needed and the strategies necessary to be considered in the design and operation of CHWs’ programs. Part four, investigates the policy and implementation elements and system level support needed to enable the CHWs in rural India to provide comprehensive primary health care that incorporates NCDs. Chapter six uses policy review and qualitative research to understand the policy and implementation gaps, current capacity, working conditions and challenges faced by ASHAs in providing NCDs care to their community. It provides an overview of the perspectives of the key stakeholders of the ASHA program including ASHAs, ANMs, primary care doctors, community members, and district medical officers. Findings revealed that ASHAs are unrecognised as formal members of the NCDs delivery team, however they are overburdened with extensive NCDs tasks without receiving training or remuneration for these tasks. ASHAs remain to be volunteers that receive performance based remuneration and are not covered by any of the workers’ rights or laws. However, ASHAs remain enthusiastic about helping their communities and aspire to be recognised as formal employees of the health system with a potential career progression pathway. The concluding chapter summarises the key findings, discusses the main themes emerging from the thesis and outlines the future research directions and policy recommendations
