Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice

Abstract

Background: The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve?

Methods: We searched six academic databases for recent (2014-2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis.

Results: One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps.

Conclusion: In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity.

Trial registration: PROSPERO registration number CRD42020177333 .

Keywords: Community health workers; Global health; Health equity; Low- and middle-income countries.

Fig. 1

PRISMA flow diagram

Fig. 2

Countries of eligible studies^a

Fig. 3

Quantitative findings on CHW service delivery

Fig. 4

Quantitative findings on CHW-promoted outcomes

Fig. 5

Meta-analysis of the association between facility delivery and distance between place of residence and health facility

Fig. 6

Meta-analysis of the associations of breastfeeding practices and utilisation of maternal health services with mothers’ SES

Fig. 7

Meta-analysis of the associations of breastfeeding practices and utilisation of maternal health services with mothers’ level of education

Fig. 8

Conventional thinking on CHW programme contributions to health equity

Fig. 9

Reconceptualizing CHW programme contributions to health equity

Fig. 10

Optimising equity impacts of CHW programmes: an integrated, evidence-based approach