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1. Living and working in the same community
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When selecting LHWs, have you considered how they will be perceived by members of the community in which they will work, for instance in terms of their sociocultural or economic background or gender? For example, if male LHWs are included have you considered whether gender norms and safety issues may reduce mother’s trust of them? Do LHWs have ways of managing relationships with recipients and creating boundaries between work and personal lives when working and living in the same community? Are there routines and standards in place to ensure that LHWs do not share recipients’ personal information with others in the community, including if digital technologies (e.g., voice or video recorders) are used? Are LHWs and community members aware of these standards? LHWs working and living in the same community may be especially vulnerable to blame in instances of incidental death, disease, or other problems during care. Have you con-sidered how to offer help in these circumstances, for instance by providing visible support from the health system, or regular supervision and counselling? Have you considered how to foster community engagement and collaboration to help develop an enabling environment for LHWs? For example, how could the planning and implementation be done in a participatory approach with community members and community structures or organisations, for example, governmental, faith-or traditional-based, non-governmental, or civil society groups? Have you considered which community leaders or group have authority and respect in the community and in turn may be best placed to collaborate with? Or have you considered establishing appropriate bodies such as community health committees or forums to enable collaboration between community members and other role players?
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2. Work activities
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Are LHWs providing services that they see as relevant to the challenges they meet during their working day and in their interactions with community members? Have you provided LHWs with sufficient means of transportation, where necessary? Have you provided LHWs with the essential medical tools and equipment required for them to perform their tasks? Have you considered whether it might be possible for LHWs to incorporate digital devices as part of their health promotion and teaching tools? Have you put systems in place to ensure LHWs personal safety, for instance during travel or when visiting homes or neighbourhoods? Have you considered whether there is a reasonable balance between LHWs workloads and accumulation of new tasks? Have you considered whether mothers can discuss confidential information with LHWs without family members being present, and if not, how mothers’ privacy could be enhanced? Do cultural or social norms exist (e.g., gender) that could prevent some LHWs from mobilising within their community to fulfil their responsibilities? Have you considered whether community members are aware of the range of activities being performed by LHW programmes, and if not, how this awareness may be enhanced? For example, home visits may be perceived as providing only HIV/AIDS care or with a lack of knowledge regarding the broader range of functions they provide. Have you considered mobility of mothers in the area in which the programme is being implemented, and if so, how this could be accommodated?
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3. Working with other healthcare providers
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Have you considered how to ensure good working relationships between LHWs and other healthcare providers in primary care facilities (e.g., nurses or mid-level practitioners such as clinical officers, physician assistants, clinical associates)? For instance, are other healthcare providers encouraged to be respectful and responsive towards LHWs, to recognise their competencies and to accept their referrals? Has the use of LHWs added to the workload of other healthcare providers, as a result of additional tasks such as evaluation and supervision? Or do other healthcare providers perceive LHWs as lessening their workloads, and bringing com-plementary skills, knowledge, and experience?
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4. Referral systems
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Where LHWs are trained to refer patients with complications, are there sufficient health professionals to care for these patients? Are these health professionals willing and able to cooperate with LHWs when they receive these referrals? When referrals are necessary, do LHWs have access to functional phones to make this referral, means of transport for the patient, and funds to pay for this transport?
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5. Payment, incentives, and out-of-pocket expenses
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Are you offering LHWs sufficient salaries for their time and effort? Have you considered whether, and if so how, more secure and full-time contractual arrangements could be put in place for LHWs? Might it be possible for LHWs to receive benefits, incentives and/or opportunities for career progression? What other factors could be incorporated that could make a positive impact on the retention of LHWs? Is there a shared understanding between LHWs, programme managers and policy makers regarding how potential incentive systems reflects different tasks, different levels of responsibility or changes in skills because of further training? Have you provided LHWs with the necessary ‘work tools’, such as uniforms, mobile phones or identification (ID) badges? Have you ensured that they are reimbursed for out-of-pocket expenses? Are there systems in place whereby LHWs can voice their individual or collective concerns or complaints about incen-tives or other issues?
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6. Training, supervision and support
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Have you clarified what essential competencies LWHs require to fulfil their roles and perform the tasks they are required to perform? Are you offering LHWs sufficient training and supervision for them to fulfil these roles and tasks? This includes train-ing in communication and health promotion. These tasks are often central to the LHW role but are often neglected during training. It also includes ongoing and refresher training as opposed to once-off training. Have you ensured proper systems of supervision? Do supervisors have enough skills, sufficient time, and means of transportation to provide in-field supervision in addition to more remote supervision, for example, at clinics or on the phone. Do supervisors have a good understanding of LHWs working conditions and personal circumstances? Do they provide emotional, technical and clinical support on an ongoing basis? Do LHWs have the opportunity to share their experiences with other LHWs?
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7. Community Oriented Primary Care (COPC) and integration with other community- based care
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What community-based care is already present in the target area(s)? Which principles of COPC are present in this community-based care? For example, do they include a defined community, and if so, in what terms? Do they incorporate a multidisciplinary team, comprehensive and/or equitable approach to service delivery? Are they informed by analysis and prioritisation of local health needs and resources? Do they foster community engagement and participation, and if so, which community members or structure do they collaborate with? What other values or principles might inform existing community-oriented care? How does the existing community-oriented care respond to the previous questions and prompts in this table (#1–6 above?) How can existing LHW home visit programme/interventions for families with preterm and LBW infants strengthen and develop COPC? For example, have you considered how a multidisciplinary team of HCWs could be involved, for example, nurses, doctors along with LHWs? Have you considered how a comprehensive approach to care could be fostered, incorporating aspects of health promotion, disease prevention, treatment and rehabilitation? How can the LHW home visit programme/intervention for families with preterm and LBW infants collaborate with exiting community-oriented care activities and programmes to create synergy? For example, how could services across programmes be integrated or co-ordinated to enable person-centred and continuity of care over time in a continuous process?
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8. Governance and financing
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Have you ensured there is a clear directive from provincial governments? Have you considered how ongoing political commitment by relevant stakeholders and collaboration between different levels of government can be strengthened and developed? How might a sense of ownership amongst managers at local levels and decentralised decision-making be strengthened and developed? Have you considered how adequate resources will be allocated and ongoing financial commitment sustained?
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9. Monitoring, evaluation, data and health information
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Have you ensured systems are in place to monitor implementation and identify and respond to (changing) needs and effects? What mechanisms are there for checking and verifying this information to ensure the quality of this data? How might these monitoring and evaluation systems be integrated with existing primary health care information systems and data collection processes (e.g., from households, facilities, research and other sources)?
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