Table 4.

Study characteristics

N o	1 stAuthor/Year [Citations]	Country	Study type/ design	Type of CBHWs	Aim	Key issues/findings
Brazil specific studies
1	Svitone [46]	Brazil	Review	CHAs	To document primary health care lessons from the Northeast of Brazil following the implementation of CHAs Programme	Comprehensive information available, a decline in infant mortality, a rise in immunization, and timely interventions in times of crisis
2	Macinko [35]	Brazil	Program Evaluation	CHAs	To assess the effects of an integrated community-based primary care programme on microregional variations in infant mortality (IMR), neonatal mortality, and post-neonatal mortality rates from 1999 to 2004	Results show that infant mortality rate declined about 13 percent from 1999 to 2004, while Family Health Program coverage increased from an average of about 14 to nearly 60 percent
3	Aquino [16]	Brazil	Program Evaluation	CHAs	To evaluate the effects of the Family Health Programme (FHP) on infant mortality at a municipality level	The FHP had an important effect on reducing the infant mortality rate in Brazilian municipalities from 1996 to 2004. The FHP may also contribute toward reducing health inequalities
4	Zanchetta [40]	Brazil	Mixed methods	CHAs	To assessing the effectiveness of CHAs' actions in situations of social vulnerability	Barriers to CHAs' effectiveness included professional powerlessness, communication gaps, fragmented teamwork, organizational and structural barriers
Ethiopia Specific studies
5	Girma [40]	Ethiopia	Review	HEWs	To understand implications of strategies for human resource development (HRD) by 2015	The process to develop policy and strategy for managing human resource for health has been started
6	Negusse [26]	Ethiopia	Mixed methods	HEWs	To document the initial community perspectives on the Health Service Extension Programme in Welkait	HEWs are helpful, HEWs are more preferred over TBAs, HEWs provide good health services. Limitations: less visits, poor knowledge on major communicable diseases
7	Teklehaimanot [41]	Ethiopia	Qualitative	HEWs	To assess the working conditions of HEWs in Ethiopia and their job satisfaction	Health indicators have improved, performance in skilled delivery and postnatal care not satisfactory. Limited quality of service, utilization rate, access, referrals and programme evaluation
8	Admassie [47]	Ethiopia	Program Evaluation	HEWs	To evaluate the short-term and intermediate-term impacts of the HEW programme on child and maternal health indicators in the programme villages	The proportion of children and women using insecticide-treated bednets for malaria protection are significantly larger in programme villages than in non-programme villages
9	Koblinsky [52]	Ethiopia	Review	HEWs	To explore Ethiopia’s progress toward achieving MDG 5 through the Health Extension Programme	Achieving the set targets is a daunting task despite reaching the physical targets of two health extension workers per health post
10	Damtew [53]	Ethiopia	Qualitative (Case study)	HEWs	To examine conditions that may affect the quality of HEWs training in Ethiopia	Training inadequacies
11	Medhanyie [58]	Ethiopia	Mixed methods	HEWs	To investigate the Knowledge and performance of the HEWs on antenatal and delivery care as well as the barriers and facilitators to service provision	Poor knowledge of HEWs, poorly equipped health posts, and poor referral systems affected acceptability of services
12	Medhanyie [59]	Ethiopia	Program Evaluation	HEWs	To assess the role of HEWs in improving utilization of maternal health services in rural areas in Ethiopia	Better utilization of family planning, antenatal care etc. Limited contribution to health facility delivery, postnatal check-up etc.
13	Birhanu [61]	Ethiopia	Mixed methods	HEWs	To assess mothers’ experiences and satisfaction with health extension service	Most mothers had good relationships, were satisfied with and had positive attitude towards HEWs. Programme was however criticized for not including curative services and the less attention given to static services at health post
14	Teklehaimanot [42]	Ethiopia	Qualitative (Case study)	HEWs	To describe the strategies, human resource developments, service delivery modalities, progress in service coverage, and the challenges in implementing the HEP	Health system reformed to create a platform for integration/ institutionalization of the HEP with appropriate human capacity, infrastructure, and management structures
India specific studies
15	Scott [49]	India	Qualitative (Case study)	ASHAs	To investigate the contextual features hindering the ASHAs' capacity to increase quantitative health outcomes and act as cultural mediators and agents of social change	SHAs limited by: (1) the outcome-based remuneration structure; (2) poor institutional support; (3) the rigid hierarchical structure of the health system; and (4) a dearth of participation at the community level
16	Gopalan [60]	India	Mixed-methods	ASHAs	To examine the performance motivation of community health workers (CHWs) and its determinants on India's Accredited Social Health Activist (ASHA) programme	Performance motivation mainly influenced by the individual and the community level factors, while the health system factors scored the least
17	Kumar [43]	India	Program Evaluation	ASHAs	To study the factors influencing the work performance of ASHAs in community	Limitations included less knowledge, caste system, limited incentive practices and inadequate incentives
18	Shrivastava [54]	India	Mixed-methods	ASHAs	To evaluate the knowledge, attitudes and practices of ASHA workers in relation to child health	Gaps still exists in ASHAs’ knowledge regarding various aspects of child health morbidity
Pakistan specific studies
19	Afsar [50]	Pakistan	Program Evaluation	LHWs	To estimate the proportion of patient referral and to identify the factors associated with unsuccessful referral in Karachi, Pakistan	Limited communication and counselling skills of LHWs contributed to significant proportion of unsuccessful referrals
20	Afsar [51]	Pakistan	Qualitative	LHWs	To assess the strengths and weakness of the National Programme for Family Planning and Primary Health Care from the LHWs’ perspectives	Strengths: Some community members accepting LHWs. Weaknesses: contractual job, low salaries, irregular payment, no career development and poor logistical support
21	Douthwaite [38]	Pakistan	Mixed methods	LHWs	To evaluate the Lady Health Worker programme	The LHWP has succeeded in increasing modern contraceptive use among rural women
22	Haq [57]	Pakistan	Mixed methods	LHWs	To evaluate job stress among community health workers in Pakistan	Challenges: stress, low socio-economic status, long distances; inadequate, medical supplies, stipends, communication skills, lack of career structure
23	Haq [39]	Pakistan	Qualitative	LHWs	To document the perceptions of LHWs on their knowledge and communication needs, image building	Many respondents described their communication skills as moderately sufficient. Knowledge on emerging health issues was insufficient
24	Hafeez [37]	Pakistan	Mixed methods	LHWs	To review the LHW programme and explore various aspects of the process to extract tangible implications for other similar situations	Improved community links with first level care facilities, earned community trust. Limitations: poor support from sub-optimal health facilities, financial constraints and political interference
25	Mumtaz [55]	Pakistan	Mixed-methods	LHWs	To explore the impact of socio-cultural factors on LHWs' home-visit rates	Performance is constrained by both gender and biradari/caste-based hierarchies.
26	Wazir [17]	Pakistan	Review	LHWs	To conduct a SWOT analysis of the National Program for Family Planning and Primary Health Care in Pakistan	Strengths: comprehensive planning, implementation and supervision mechanisms, selection and recruitment processes. Weaknesses: slow progress, poor program integration, job insecurity and delayed salaries
Studies focusing on more than one country
27	Hermann [44]	Ethiopia and others	Review	HEWs	To investigate whether present CBHW programmes for ART are taking into account the lessons learnt from past experiences and analyse the extent to which they are seizing the new ART-specific opportunities	Adequate remuneration key to CBHW retention. Sufficient attention to be given to supervision, continuous training and health systems strengthening
28	Celletti [34]	Brazil, Ethiopia, etc.	Qualitative	CHAs HEWs	To evaluate the contribution of CHWs with a focus on identifying the critical elements of an enabling environment that can ensure that they provide quality services in a manner that is sustainable	Important requirements include adequate systems integration, political commitment; good planning, definition of scope of practice, selection, educational issues, career path, registration, licensure and certification; recruitment and deployment; adequate remuneration, supervision; referral system; supplies
29	Kane [19]	Brazil, Ethiopia, India, Pakistan, etc.	Realist synthesis (Review)	CHAs, HEWs, ASHAs, LHWs	To explore if randomised controlled trails could yield insight into the working of the interventions, when examined from a different perspective, a realist perspective	Positive mechanisms: anticipation of being valued; perceived improved social status; sense of relatedness with the health system; increased self esteem, sense of self efficacy, enactive mastery of tasks; sense of credibility, legitimacy
30	Lewin [20]	Brazil, Ethiopia, India, Pakistan, etc.	Systematic review	CHAs, HEWs, ASHAs, LHWs	To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases	LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care
31	Liu [6]	Brazil, Ethiopia, India, Pakistan, etc.	Review	CHAs, HEWs, ASHAs, LHWs	To explore CBHW programmes that have been deployed at national scale, as well as scalable innovations found in successful nongovernmental organization-run community health worker programmes	Ability by national CBWH programmes to reach scale is impressive, but quality and management challenging. If well managed programmes integrated into a well-functioning primary healthcare system can promote care and act as an effective link
32	Wouters [48]	Ethiopia and others	Synthetic review	HEWs	To review the impact of community-based support services on ART delivery and outcomes in resource-limited countries	CBHWs are not necessarily cheap or easy, a good investment to improve coverage of communities in need of health services
33	Jaskiewicz [56]	Ethiopia Pakistan and others	Review	HEWs LHWs	To review the influence of work environment in increasing community health worker productivity and effectiveness	Essential elements for improving productivity: defined workload, supportive supervision, supplies and equipment, and respect from the community and the health system
34	Balabanova [45]	Ethiopia, etc.	Review	HEWs, etc.	To discuss why some countries or regions achieve better health and social outcomes than others at a similar level of income and to show the role of political will and socially progressive policies	Attributes of success included good governance, political commitment, effective bureaucracies, ability to innovate and adapt to resource limitations, the capacity to respond to population needs and build resilience into health systems to face challenges. Transport infrastructure, female empowerment, and education also played a part
35	Glenton [2]	Brazil, Ethiopia, India, Pakistan, etc.	Systematic review	CHAs, HEWs, ASHAs, LHWs	To explore factors affecting the implementation of LHW programmes for maternal and child health	Barriers and facilitators were mainly tied to programme acceptability, appropriateness and credibility; and health system constraints
36	Perry [3]	Brazil and others	Review	CHAs	To summarize the history, recent evolution, and current evidence of the effectiveness of CHWs around the world	CBHWs promote healthy behaviors, extend reach of health systems, help address health workforce resources shortage, and reduce health disparities