Description of the condition
The Millennium Development Goals 4, 5 and 6 aim to reduce child mortality, improve maternal health and combat HIV/AIDS, malaria and other diseases. A key obstacle to the achievement of these goals is the chronic shortage and poor distribution of health workers in many countries (WHO 2010). One important approach to this problem is the moving of tasks to health workers with less training, or “task-shifting” (sometimes referred to as “optimising”), for instance by transferring certain tasks from doctors to nurses, midwives, or lay health workers. By re-organising the health workforce in this way, policy makers hope to make more efficient use of the human resources already available and thereby expand and strengthen coverage of key health interventions (WHO/PEPFAR/UNAIDS 2007; WHO 2012).
Description of the intervention
Lay health workers (LHWs) perform diverse functions related to healthcare delivery. While LHWs are usually provided with job-related training, they have no formal professional or paraprofessional tertiary education and can be involved in either paid or voluntary care. The term LHW is thus necessarily broad in scope and includes, for example, community health workers, village health workers, treatment supporters and birth attendants.
The primary healthcare approach adopted by the World Health Organization (WHO) at Alma-Ata promoted the initiation and rapid expansion of LHW programmes in low and middle income country (LMIC) settings in the 1970s, including a number of large national programmes (Walt 1990). However, the effectiveness and cost of such programmes came to be questioned in the following decade, particularly at a national level in the LMICs. Several evaluations were conducted and these indicated difficulties in the scaling up of LHW programmes, as a consequence of a range of factors. Important constraints included inadequate training and ongoing supervision; insecure funding for incentives, equipment and drugs; failure to integrate LHW initiatives with the formal health system; poor planning; and opposition from health professionals (Frankel 1992; Walt 1990). These constraints led to poor quality care and difficulties in retaining trained LHWs in many of the programmes.
The 1990s saw renewed interest in community or LHW programmes in LMICs. This was prompted by a number of factors including the growing AIDS epidemic; the resurgence of other infectious diseases; and the failure of the formal health system to provide adequate care for people with chronic illnesses (Hadley 2000; Maher 1999). The growing emphasis on decentralisation and partnership with community-based organisations also contributed to this renewed interest. In high income country settings, a perceived need for mechanisms to deliver health care to minority communities and to support people with a wide range of health issues (Hesselink 2009; Witmer 1995) led to further growth in a variety of LHW interventions.
More recently, the growing focus on the human resource crisis in health care in many LMICs has re-energised debates regarding the roles that LHWs may play in extending services to 'hard to reach' groups and areas; and in substituting for health professionals for a range of tasks (Chopra 2008; WHO 2005; WHO 2006; WHO 2007). Task shifting is not a new concept; however, it has been given particular prominence and urgency in the face of the demands placed on health systems in a number of settings by the increased need for treatment of HIV/AIDS (Hermann 2009; Lehmann 2009; Schneider 2008; Zachariah 2009). Within this context, it is thought that LHWs may be able to play an important role in helping to achieve the Millennium Development Goals for health, particularly for child survival and treatment of tuberculosis (TB) and HIV/AIDS (Chen 2004; Filippi 2006; Haines 2007; Lewin 2008). For example, LHWs may be one route to expanding the coverage of effective neonatal and child health interventions, such as exclusive breastfeeding and community-based case management of pneumonia, which remains under 50% in many LMICs (Darmstadt 2005).
In contrast to earlier initiatives that tended to focus on generalist LHWs delivering a range of services within communities, more recent programmes have often been vertical in their approach. In these programmes LHWs deliver a single or a small number of focused interventions addressing a particular health issue, such as promotion of vaccination; or one aspect of treatment care, such as supporting treatment adherence for people with tuberculosis (TB) (Lehmann 2007; Schneider 2008).
Why it is important to do this review
The Cochrane review on the effectiveness of lay health worker programmes for maternal and child health and infectious diseases (Lewin 2010) identified a total of 82 randomised trials, representing a substantial body of evidence regarding the effectiveness of these types of programmes. In these trials, lay health workers received a small amount of training to perform a range of health services, often targeting common causes of childhood mortality and morbidity. The review concluded that these types of programmes can effectively deliver key maternal and child health interventions in primary and community healthcare, including interventions to increase childhood immunisation rates and breastfeeding rates.
While the review concluded that this approach is promising, the results of these trials were heterogeneous, which, given the complexity of these types of interventions, was not unexpected. In addition, the level of organisation and support used on these interventions may have been higher than in real-life settings. If these types of interventions are to be successfully implemented and scaled up, we need a fuller understanding of the factors that may influence their success and sustainability. These may include values and preferences of stakeholders and the feasibility and applicability of the intervention for particular settings and health care systems. While Cochrane reviews of effectiveness are not designed to answer these types of questions, there is growing acknowledgement that syntheses of qualitative research can address questions like those raised here.
It is also increasingly recognised that bringing together qualitative studies in one systematic review can add value by allowing us to see both similarities and differences that exist across various contexts. As with systematic reviews of effectiveness, reviews of qualitative data should be carried out in a systematic and transparent way. The last few years have seen strong development in systematic review methodology for summarising data from multiple qualitative studies, including within The Cochrane Collaboration (Noyes 2009), and the Cochrane Qualitative Research Methods Group has identified around 500 such reviews.
While high-quality systematic reviews of qualitative evidence can, on their own, prove valuable to researchers and policymakers, pairing qualitative reviews with systematic reviews of (quantitative) effectiveness data allows for even more comprehensive insights into single topic areas. At least one Cochrane review has previously prompted a “matching” review of qualitative data. The Cochrane review of directly observed therapy (DOT) versus self-administered treatment for adherence to TB treatment showed that DOT, despite its widespread use, does not achieve better outcomes (Volmink 2007). Two parallel reviews, both co-authored by members of the current research team (Munro 2007; Noyes 2007), searched for qualitative studies on factors explaining non-adherence to TB treatment. Together, these qualitative reviews not only provided supporting evidence regarding the intervention’s lack of effect but also helped explain this lack of effect and inform policy and the design of more appropriate interventions (Garner 2007). Qualitative evidence also helped to clarify the many, often context-specific barriers and facilitators to accessing and complying with complex interventions to promote medicines management and treatment.
Pairing reviews of effect with reviews of qualitative studies is equally relevant in the field of health workforce interventions and a large body of relevant qualitative research exists. This research has described barriers and facilitators to the success of interventions targeting different aspects of human resources for health. These factors include the attitudes and experience of the health workers themselves and also those of other stakeholders, such as the health professionals they work with or whose tasks they have taken over and the communities they serve. On the one hand, health workers taking on new tasks may appreciate the opportunity to be more useful as well as gaining increased salaries and public recognition (De Brouwere 2009). On the other hand, task shifting may not be accompanied by sufficient supervision or compensation and can create confusion, role conflicts and competition between health worker groups (De Brouwere 2009; Yakan 2009).
Previously, we had attempted to identify all qualitative studies that were carried out alongside the 82 trials included in the review of lay health worker programme effectiveness. Here, we contacted authors of all the included trials, checked papers for references to qualitative research, searched Pubmed for related studies, and carried out citation searches. However, we were only able to find qualitative research that had been done during or after the trial for only 14 (17%) of the trials (Glenton 2011). In addition, descriptions of qualitative methods and results were often sparse. Therefore, we decided to look for qualitative studies that explored lay health worker programmes in any context, either alongside or outside a trial context.
The current review is one of a series of reviews of qualitative research that aim to inform the World Health Organization's "Recommendations for Optimizing Health Worker Roles to Improve Access to key Maternal and Newborn Health Interventions through Task Shifting" (OPTIMIZEMNH) (WHO 2012).