Community health workers (CHWs) have been recognized as a valuable resource for supplementing professional medical providers, particularly in resource-limited settings such as rural areas. These workers, who are members of their communities, have been shown to improve access to healthcare, increase health literacy, and enhance health outcomes. However, the effectiveness of CHWs in improving health outcomes has been highly variable in different contexts, and scaling up their impact nationally has been challenging.
As per a study published in PLOS Medicine, one area where CHWs can make a significant impact on maternal and child health, maternal and child mortality rates remain high in many low- and middle-income countries. The World Health Organization (WHO) has identified CHWs as a critical strategy for reducing these rates. However, the impact of CHWs on maternal and child health outcomes has to be more consistent, and more research is needed to understand how to maximize their effectiveness.
One possible way to enhance the effectiveness of CHWs is through ongoing supervision and monitoring. While supervision is joint in many CHW programs, it needs to be improved, with limited attention paid to the quality and frequency of supervision. This study aims to evaluate whether enhanced supervision and monitoring of existing government CHWs, perinatal home visitors, can improve child and maternal outcomes compared to standard care.
By examining the impact of enhanced supervision and monitoring on maternal and child health outcomes, this study can provide valuable insights into how to optimize the effectiveness of CHWs in resource-limited settings. If successful, this approach could be scaled up to improve the health of communities across the globe.
The study examined the effectiveness of supportive supervision and monitoring of community health workers (CHWs) in improving maternal and child health outcomes in rural South Africa. The study was conducted at eight clinics, where existing CHWs received enhanced training for a month and was randomized to receive ongoing monitoring and supervision over time or standard supervision. However, the study found no significant differences in maternal and child health outcomes between the two groups.
These findings are in contrast to earlier studies using a similar model of supervision and monitoring, which found a range of significant benefits. For example, the Philani model was shown to have significant improvements in PMTCT tasks, longer breastfeeding, less malnutrition, decreases in maternal alcohol use and problematic alcohol use, lower maternal depression, better early child growth, fewer low birth weight babies, and mothers who were more sensitive to their children’s needs compared to households without CHWs home visits. However, these benefits were absent in the current study.
One possible explanation for the null findings is the recruitment strategy and performance monitoring. In previous studies, the Philani program controlled all aspects of the intervention, including recruitment, training, and supervision. Philani created a recruitment system where communities put forward names of potential CHWs for their area, who were then interviewed by a panel, including organization representatives from all levels.
Philani narrowed the initial list to positive role models in their communities and mothers with similar adversities but raised healthy children. A pool of potential CHWs is selected, monitored repeatedly and unexpectedly over multiple probationary months, and certified. Final decisions about who is finally hired are made based on experiences during the training and over the first few months of conducting home visits.
In contrast, in the current study, all CHWs had already been hired by the Eastern Cape Department of Health, and most had been in their role for many years preceding the study. Before the study started, CHWs had predominantly been based in clinics and were reassigned from 2011 to 2015 to conduct home visits as part of the government’s plans for Re-engineering Health Care.
It took substantial prompting and oversight by the Philani team to get CHWs to conduct the home visits. This did not occur in the standard supervision group, and when asked, few mothers reported having received any home visits. This study suggests recruitment procedures and performance monitoring may be essential to effectively implement CHWs programs.
Surprisingly, mothers in the deeply rural areas of Zithulele had far fewer risk behaviors than in studies conducted in the Philani urban settings. One of the reasons there are few significant outcomes may be the low rates of depression and alcohol use and the relatively high existing breastfeeding rates, high rates of securing child grants, and adherence to PMTCT tasks.
This was not the case in any of the four previous studies evaluating the Philani program. The quality and coverage of HIV care in this subdistrict and South Africa, more broadly, has improved significantly in the last ten years. Before the study implementation, the researchers expected rates of risk that are about four times.