Table 3.

Enablers and barriers of community health workers’ effectiveness.

Author and date	Factors positively influencing effectiveness of CHWs in WBPHCOTs	Factors negatively influencing effectiveness of CHWs in WBPHCOTs	Results	Significance of the study	Conclusion/Recommendation
Adam, 2014	Training in skills practice.	Inadequate manpower (CHWS).	In each of the three separate areas where CHWs were trained, the number of women delivering with skilled attendance by CHWs was higher among those mothers who reported receiving at least one health message, compared to those who did not.	Knowledge of CHWs may promote delivery with skilled attendance by CHWs, which is essential.	The finding supported the Kenyan policy to promote health through a direct person-to-person trust-based spread of health messages. The ratio was 1 CHW to 20 patients, as recommended by the government.
Agrawal et al, 2011	Improving the knowledge level of CHWs through regular education and field-based refresher training programmes.	Poor knowledge.	The better the knowledge of CHWs or ANMs, the greater the number of women visited by them.	Better knowledge levels led to a greater number of patients seen for antenatal visits, and the women visited by this group showed adherence to essential newborn care practices at the household level.	Knowledge level of CHWs was an important factor.
Austin-Evelyn et al, 2017	Regular training programme, field-based supervision from the nurse team leader and availability of working tools in the field.	Overworked, insufficient supervision and CHWs struggled with their roles and scope of work.	Revealed the knowledge and perceptions of CHWs in PHC.	Misconceptions about CHWs’ roles and responsibilities by some community members.	Improving community health and well-being through programme management, supervision, scope and quality that challenged their ability to deliver on the potential of CHWs.
Brown et al, 2006	Training of community health workers.	Knowledge about health care needs and service provision in rural settings was lacking, with limited access to health care and geographical isolation of these indigenous people.	CHWs, although having limited education, were the most visible health care providers in the community.	Community health workers, with higher educational levels but also with higher drop-out rates.	The training of CHWs needed to incorporate culturally appropriate elements, as well as employ specific and simple educational techniques, to improve linkages between community health workers and health professionals.
Cordeiro and Soares, 2015	Training in health and technical health.	Difficulties related to the hierarchical structure and lack of credit from the technical team, among the other issues concerning the work process. Complex factor of work fragmentation in the process of the provision of health care diminished the role of workers. Low remuneration.	CHWs practiced a repetition of content taught to them in a hurried manner, drawn from clinical knowledge of the training of the nurses and physicians in universities.	Social abandonment of CHWs area and proposed complex practices. The role of the CHWs was not clearly defined.	High mortality rate of children due to lack of access and inadequate health services and shortage of manpower. To stimulate and facilitate access to health services.
de Moura Pontes et al, 2011	Follow-up visit.	There was no training of supervisors. Inadequate manpower.	CHAs in Angola perceived themselves as a ‘link’ between the community and health services.	CHWs should have a good relationship with the community and be acknowledged by the district coordinators and residents in the community.	Act on behalf of others. To implement health services.
Gauteng DoH, 2016	WBOT training for CHWs, in- service training.	Household members refused help. Clients gave wrong addresses, to health services who then could not trace them.	To identify the health needs of the people, especially the vulnerable.	Ward-based outreach team and social development.	Reduction in child mortality could be dramatically improved if there were more CHWs who were allowed to provide more health care.
Doherty et al, 2016	A higher CHW-to-population ratio than elsewhere. Expansion of the role of CHWs. An equity-focused strategy to train, supply and supervise CHWs to diagnose and treat diarrhoea, malaria and pneumonia in communities where access to health services was poor.	Low CHWs-to-population ratio, poor access to care.	Evidence showed that CHWs in sufficient numbers could have a rapid and positive impact on reducing neonatal and young child mortality, especially when they were allowed to treat common acute conditions.	The proposed role for CHWs in SA was extremely narrow, focusing primarily on counselling around prevention activities and adherence support. The role and scope of CHWs should be extended.	The creation of a period during work time dedicated to self-care and the practice of physical activities for the community health workers.
Florindo et al, 2014	Adequate information and knowledge on health issues.	Inadequate knowledge due to limited training given to CHWs.	The health workers developed a broader perspective of promoting physical activity in the context of health promotion and improvements in professionals’ perceptions regarding the benefits of physical activity for health. Better performance in terms of knowledge of physical activities for special cases, such as patients with cardiovascular, metabolic and bone diseases.	Although the health workers felt promoting physical activity was important, their approach was restricted to diseases and difficulties implementing actions that involved physical activity.	Community health workers needed to be integrated into the mainstream health care delivery system.
Javanparast et al, 2011	Building of lasting and sustainable relationships with communities, based on trust and recognition. Sound health knowledge and skills were the most important factors facilitating successful implementation of the CHW programme in Iran. The role of the CHW was to be clearly identified.	The heavy workload, lack of a support system, and poor supervisory mechanisms were the most common barriers.	CHWs were responsible for a wide range of activities because they had an in-depth understanding of health.	Training, programme enhancement and the forging of relationships with community members could be applicable to programmes in other countries seeking to improve the retention and performance of CHWs.	Supervision-related mechanisms (e.g., how supervisors could support CHWs to improve their performance).
Koyio et al, 2014	Training for building competence.	Lacked the appropriate knowledge required.	This probably indicated that the CHWs lacked the competence and skills needed for educating the community and mobilising it to seek oral health care services.	Development of a training course for increasing their knowledge.	CHWs needed to be educated about general oral and HIV-related oral diseases, early identification of (HIV-related) oral lesions and referral of community members suspected of being HIV-positive to the HFs.
Le Roux et al, 2015	Building relationships with health teams at different levels of the health care system, as well as having shared goals and supportive clinic and hospital leadership. Training on how to engage and establish a good relationship with a family.	Lack of a support system.	Commitment and excellence in health delivery by integrating care and training within the district.	Attitudes of families.	Integrating CHWs with PHC clinics and hospital health teams to improve maternal and child health that has had success in its early stages in a rural area.
Lightspeed, 2015	The imparting of basic knowledge to community health workers in the programmes (WBPHCOTs).	Population density; burden of disease in catchment population, and the distance from a primary health care facility.	The employment of CHWs.	It was important to involve lecturers in the implementation plan (IP) because most of the students (qualified) became the team leaders of the outreach teams.	To integrate CHWs into ward-based primary health care teams.
Lindblade et al, 2006	Training programme.	Inadequate knowledge and skill.	The prevalence of anaemia was not significantly different between the two groups of children recruited from the health facilities (P ¼ 0.25), but was significantly different between the children attending the health facility and children from the general population (sick children).	In areas of high anaemia prevalence, the HCS could increase the recognition and treatment.	According to the WHO, HCS was neither the best method for diagnosing anaemia, nor the least expensive, but could be the most economical method.
Mukherjee and Eustache, 2007	Trust, encouragement, better understanding of the disease.	Feelings of dissatisfaction with their salary.	The CHWs perceived that they had an important role in increasing access to care, particularly among vulnerable groups. They perceived their role as a strong promoter of the integration of the medical aspects of the disease with the spiritual components, particularly in providing emotional support and helping affected persons discuss and disclose their status to their families.	Understanding the importance of the CHWs in encouraging service utilisation. Nearly all of the patients attending the clinics were rural subsistence farmers. The average length of time a family walked to the Lascahobas clinic was three hours. Since the CHWs are themselves from the community, they often accompanied patients, families or even groups of patients from villages to the clinic.	The important factors of the CHWs’ work were psychosocial support and community solidarity; which should be given greater focus during training and supervision.
Negotiated Service Delivery Agreement, 2012	Skills competence development through an extensive orientation, training, mentorship and supervision programme. A team approach which included community health workers (CHWs).	Inadequate mentorship from professionals and from their training.	CHWs would also provide psycho-social support and manage interventions such as treatment, defaulter tracing and adherence support.	Implementation of policy and CHWs to facilitate access to health and other services.	Community assessments, community and group interventions.
Nxumalo et al, 2013	Training, supervision, and mentoring to assist CHWs, particularly in problem-solving skills and reporting.	The fragmentation and resultant lack of coordination within and between government departments at all levels was a common and significant constraint to improving access in all three communities. The lack of political accountability across all case studies had a detrimental effect on CHWs’ service.	Understanding social determinants as a cause of poor health was key to shaping the role and services of CHWs. This was conceptualised within the health sector and CHW activities that were confined to health issues.	The clients of CHWs often did not have identity documents and birth certificates which were required to obtain their social benefits.	The success and sustainability of CHW programmes required the ongoing commitment of resources, including investment in quality training, supervision, mentoring, and organisational support. In addition, resources were needed. The national programme of PHC outreach teams in South Africa was unlikely to achieve its expected outcomes unless there was sufficient capacity to support CHWs to operate effectively at the interface between the community and the health system.
Perez et al, 2009	Continuous training, having access to transport, adequate supervision and motivation of CHWs through the introduction of financial incentives and remuneration were among key factors to improving the work of CHWs in rural communities.	Inadequate resources, low coverage of the CHWs.	The study evaluated knowledge and practice concerning home management of fever and diarrhoea among infants and children under the age of 5 as a proxy indicator of the performance of CHWs at the household level. Results indicated that correct management of fever had been relatively good (40%). In contrast, management of diarrhoea was poor.	When compared to knowledge and practice, a positive influence of CHWs on specific essential family health practices by the households was found, namely knowledge of the management of childhood fever.	Reinforcing the role of CHWs could facilitate the improvement of child health when strategies such as upgrading existing lower-level facilities, improving and building referral systems, training and supervision were considered.
Perry, 2013	Training in integrated community case management (ICCM) and the diagnosis and treatment at the community level of childhood pneumonia, diarrhoea and malaria.	Role conflict between other health workers. Expansion in the LHWs’ roles and tasks had increased their workload.	Transformative agenda.	The effective functioning of large-scale CHW programmes offered one of the most important opportunities for improving the health of impoverished populations in low-income countries.	Decision-makers and programme implementers considered the initiation, expansion or strengthening of CHW programmes in their country.
Prinja et al, 2014	Human resource costs.	Delivery load excessive, inadequate manpower.	To provide health services through CHWs at sub-centre level. Cost of human resource alone accounted for 58%, followed by drugs (18%) and capital (13%). Almost half of the cost was incurred in the provision of services as part of an outreach programme, while 40% of the resources were spent on delivering services in an out-patient setting.	The tolerance value and VIF ranged between 0.535–0.845 and 1.18–1.86 respectively, indicating an absence of multicollinearity. Controlling for other determinants, we found that a 10% increase in human resource cost led to a 6% (p, 0.001) increase in the cost per person per year.	Our estimates would be useful in undertaking full economic evaluations or equity analysis of CHW programmes.
Rennert and Koop, 2009	Training, monitoring CHW performance, maintaining a high level of health worker training and providing continuous support to the CHWs.	Inappropriate case management was noted.	Follow-up visits by brigade evaluation teams documented a significant improvement in CHW patient assessment and prescribing behaviour over time.	The potential differences in the performance and community acceptance of male versus female CHWs, as well as problems and challenges around CHW reimbursement.	Ongoing evaluation, supervision, in-service training, and guidance were essential to maintain a successful health worker programme.
Roberton et al, 2015	The visits of their supervisor to their village. Support from facility-based supervisors.	Limiting the opportunities for one-on-one mentoring and individual feedback. Facility-based supervisors did not visit CHWs in their villages often, and supervision visits from district and regional staff were infrequent and scheduled with little advance notice.	The findings suggested that CHW supervision focused primarily on accountability and report checking. CHWs overwhelmingly said they felt positive about supervision and appreciated the support offered by facility-based supervisors. The supervisors themselves also spoke positively about supervision as an opportunity to provide feedback and support to CHWs.	Unrealistic expectations of what facility health workers were able to achieve, given human resource shortages and social constraints.	Supervision of CHWs could be strengthened by streamlining supervision protocols to focus less on report checking and more on problem-solving and skills development.
Signorelli et al, 2018	Appropriate training.	Inadequate training.	Public policies and their implementation in locally relevant PHC services and the potential key role of CHW in providing care for women experiencing domestic violence (DV). CHWs constantly visited people under their care, entering the domestic space so that dialogue could be established spontaneously and horizontally, though this was not always easily achieved.	Gaps in training/awareness with a lack of effective strategies for combating unequal gender relations.	This Brazilian experience could constitute a key strategy to support women affected by DV, both in chronic and acute situations. Listening to professionals and para-professionals, who were in direct contact with women victims of DV was essential to illuminate theory, policies and practices.
Sodo and Bosman, 2017	Openness to partnerships, co-operation between the various partners and sectors, and provision of consumables.	Resources such as stationery, equipment batteries and transport to conduct household visits. Poor planning and the lack of a budget for WBOTs. It affected the proper implementation of the programme and could result in poor outcomes.	The results of the assessment reported that 71 413 household visits were conducted in the financial year 2014/2015. The evidence showed that the programme contributed to strengthening linkages to other sectors and departments through a referral system. The results of the assessment reported that the professional nurses who worked full time in the facilities were delegated to perform the OTL’s duties, but they did not have enough time to go out and support the teams due to gross staff shortages in the facilities.	The use of delegated human resources was unrealistic because it affected the supervision of the programme.	The programme was achieving its set target, although there were still some problems in implementation, such as the dual roles played by the outreach team leaders and CHWs.
Sommanustweechai et al, 2016	Retraining, supervision and support would prevent them from becoming ‘quacks’ while maximising their potential contributions.	Inadequate support, in particular technical supervision, as well as the replenishment of CHW kits and financial support for their work and transportation.	CHWs were able to provide some of the services by themselves, such as the treatment of simple illnesses and they had provided services to 62 patients in the preceding 6 months. Their contributions to primary health care services were well accepted by the communities as they were geographically and culturally accessible.	The CHWs’ confidence in providing health services was positively associated with their age, education, and more recent training.	Given their contributions and easy access, policies to strengthen support to sustain their contributions and ensure the quality of services were recommended.
Suri et al, 2007	Training and support for CHWs.	Perceived lack of confidentiality; and inability to pay for transportation to the clinic.	Results suggested that CHWs recognised the need for HIV/AIDS- and TB-related interventions, but were unable to provide a response commensurate with this need. CHWs ranked HIV/AIDS as the highest priority among 8 pre-identified concerns facing the community.	Contradictory sentiments regarding the objectives and capability of the current CHW programme were expressed by the academic community.	In order to fully enable the existing CHWs’ programme to effectively fight the HIV/AIDS and TB co-epidemics, substantial improvements in supervision and collaboration had to be made in KwaZulu-Natal.
Tilahun et al, 2017	High motivation and willingness of HEWs to apply and maintain effort in their tasks; positive attitude. Improving competence and knowledge through training.	Inadequate training, poor knowledge and skills, negative attitudes, demotivation and institutional constraints.	Limited training in the mental health needs of children. The number of mental disorders among children in the community was considered high.	Opportunities mentioned included staff commitment, high levels of interest and a positive attitude toward providing the service.	If the key barriers to service provision were addressed and supported by policy guidance, community health workers could contribute substantially by addressing the treatment gap for children with mental health needs.
Van Ginneken et al, 2010	Good leadership and supervision, even though not always achieved, were essential to the success of programme.	High expectations of health services by the community.	The strong socio-political motivations of the late apartheid period projects were mostly not carried through into the post-apartheid period. The current struggle to redress the economic, health and racial inequalities had not been effective.	Poorly addressed issues, particularly in larger scale initiatives.	CHWs programmes within South Africa and globally, lessons learned from past programmes should play a stronger role in informing current policies.
Whyte, 2015	In-service training and support.	Lack of supervision, limited resources and poor knowledge and resources required to conduct household visits.	CHWs adhered to the guidelines regarding the follow-up of maternal clients with 85% of CHWs having conducted the required number of follow-up visits for pregnant and postnatal women; only 29% of children received follow-ups.	Both CHWs and supervisors needed ongoing training and supervision.	More resources should be available, CHWs’ supervision, capacity and training to improve the implementation process of future teams.
Wilford et al, 2018	Training and support from supervisors; provide services for mothers and children in the household.	Inadequate training and supervision of the gaps in CHWs’ knowledge and skills.	There were important gaps in the content provided by CHWs. Mothers expressed satisfaction with CHWs’ visits and appreciation that CHWs understood their life experiences and therefore provided advice and support that was relevant and accessible. CHWs expressed concern that they did not have the knowledge required to undertake all activities in the household and requested training and support from supervisors during household visits.	Training should include practical skills components, rather than only the classroom-based instruction currently available in South Africa. Although CHWs were well-accepted and appreciated by the mothers they visited, the care they provided was sub-optimal with many missed opportunities to provide important health information and to identify important health issues in the household.	A comprehensive and sustainable package of skills development, support and supervision of CHWs is required if this cadre is to reach their full potential and provide effective care for mothers and babies in the community.
Zulu, 2016	Regular feedback to the respondents and conducting performance reviews consistently.	Lack of management and supervisory support contributed to high rates of dissatisfaction amongst CCGs, as well as poor quality of work for community caregivers.	Ward-based outreach teams were crucial in the delivery of PHC services in rural municipal wards within the Operation Sukuma Sakhe programme. The lack of management and supervisory support contributed to high rates of dissatisfaction amongst CCGs, as well as poor quality of work by the community caregivers. There was a need for the Department of Health (DoH) to invest in the ward-based outreach teams (WBOTs) and allocate CCG budgets within the ward-based outreach teams.	The formulation of policies, programmes, methods and interventions which would enable the UThukela District Municipality to improve health outcomes.	The monitoring and evaluation policy should be reviewed to state clearly the tools, activities and benefits of the implementation of the M & E performance management systems. The use of point-of-care technology by the WBOTs should be strengthened, especially in deep rural wards.