Background

Despite the reduction of inequality in the last two decades in the area of Maternal and Child Health(MCH) outcome, the health system in sub-Saharan Africa, particularly the community based health system is still not equitable and resilient enough to respond to existing public health issues including MCH [1, 2]. Although Community Health Workers (CHWs) are increasingly being acknowledged as crucial members of the healthcare workforce in reducing health disparity, the countries in sub-Saharan Africa continue to have the highest maternal and under-five child death occurrences in the world. Hence, this has become a key health challenge in the region and persists as a global public health agenda for the new Sustainable Development Goals [3, 4]. Multiple evidence suggests that scaling up community health program and empowerment of CHWs can lead to better health outcomes [5, 6]. Over the past several years, increased attention has been given to CHWs led programs. However, challenges remain regarding ensuring adequate health systems support for CHWs [5].

World Health Organization (WHO) defined health system as all organizations, people and actions whose primary intent is to promote, restore, or maintain health [7]. Health manpower is among the essential component of a resilient health system [8]. However, in sub-Saharan Africa the health workforce remains four times below the recommended WHO standard [9] to ensure health equity. Health equity is the state in which all people are able to reach their full health potential and receive high quality care that is fair and appropriate from each person’s perspective, no matter where they live, who they are or what they have [10]. Health system resilience can be defined as the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganize if conditions require it [11]. Health coverage, quality of care and continuum of care are integral part of health equity and a resilient health system.

MCH inequality persist as an important agenda of the new Sustainable Development Goal [12]. Sustainable Development Goal 3 was aimed at reducing maternal mortality to less than 70 per 100,000 live births; reduce newborn mortality to at least as low as 12 per 1,000 live births in every country; and reducing under-five mortality to at least as low as 25 per 1,000 live births in every country [13, 14]. The Millennium Development Goal 5, which aimed to reduce maternal mortality rate by three-quarters, was not achieved in sub-Saharan Africa [13, 15]. In sub-Saharan Africa, a larger proportion of women give birth without any skilled attendants [13]. In rural areas, only 56 per cent of births were attended by skilled health personnel, compared with 87 per cent in urban areas [13]. In low and middle income countries, many of which are in sub-Sahara Africa, the coverage of institutional delivery is as low as 50 per cent but accounts for 99 percent of global maternal mortality [2]. In addition, about 80% of morbidity and death in children under the age of five occur before reaching health institution and health care providers [11]. This makes sub-Sahara Africa the riskiest region for maternal and under- five child death occurrences in the world. Understandably, this has become a key health challenge in the region.

In sub-Sahara Africa the unacceptable health outcomes including MCH are associated with health system challenge [16]. There is a shortage of 3.7 million healthcare workers to respond to the continued health crises [17]. For example, the region accounts 25% of the world’s disease burden, however spends less than 1% from Gross Domestic Product on health and has only 3% of the world’s health manpower [18]. Particularly, the empowerment and availability of CHWs is not comparable to the demand, which poses a real challenge to the already fragile health system. Thereby, reducing the capacity of the health system to respond to the exceptional high maternal and child mortality rates in the region. The situation is worse in rural and remote areas where the provision of services is difficult because of limited health budgets and scattered populations living in isolated villages or islands [19]. We argue that context based effective CHWs empowerment could be a useful strategy to address the health workers challenge to ensure MCH equity and a resilient health system. Empowerment has become a dynamic mainstream action-oriented concept with a focus on removal of barriers and enhancement effective development of policy and practice [20, 21].

Community Health Workers led programs have contributed significantly to improving public health outcomes in sub-Saharan Africa [5, 22]. The WHO has noted CHWs, as a key resource to providing basic health services for underserved areas because they help to fill the shortage of primary health service provider at the community level. Since 1978, Alma Ata’s call there have been multiple efforts towards building community health [17, 18] to play major role in undeserved countries including countries in sub-Saharan Africa [19]. According to the WHO, CHWs are members of the communities where they work, who should be selected by the communities, be supported by the health system and have shorter training than professional workers [15, 16]. They are more accessible and they provide the platform that ensure health equity [23]. CHWs provide non-heretical community-based services. This is because they are well positioned in connecting grass-root communities to the public health system and thereby making the health system more people-centered to promote, prevent, detect and respond to primary health needs including MCH [24]. The promising outcomes of CHWs in providing equitable MCH services is noticeable in many countries such as Brazil, Bangladesh, and Nepal which have effectively executed CHWs led programmes [5, 18, 22–24]. However, while community health programs are conceptually and operationally related to specific community setting, there is limited evidence on context-based community health system building. Health system approach aligned to or based on the context is crucial to plan, implement and sustain a resilient community health system.

Although there is an increasing body of literature on effectiveness (What works) of empowerment of CHWs program from the intervention outputs and outcome measures, and health policy and beneficiary community, there is limited evidence on the process of how CHWs programs work (how it work)from the lived or practical experience and perspective of CHWs [5]. Existing studies have focused on effectiveness of CHWs program intervention result and target from the perspective of beneficiary community [25–28]. Furthermore, some of these studies are in the context of global to low- and middle-income countries [29, 30] and they are not specifically in the context of sub-Sahara Africa. Additionally, these studies have reported the barriers of effectiveness of the empowerment of CHWs based on quantitative measurement such as output and outcome measures [17, 25].

We argue that evidence based on result measures cannot tell how the empowerment strategy facilitated or disrupted the power of CHWs on their work environment, ensuring MCH equity and a resilient community health system. Hence, it would be difficult to identify and address where and when CHWs feel powerlessness and frustrated about how organizational and relational arrangements hindered them from achieving the desired impact, particularly in reducing MCH inequality and building a resilient community health system. Also, measurement of output and outcome indicator metrics do not fully capture process and quality of care and continuum of care and are limited to measuring contact with a health provider. Measuring outcomes alone does not provide insight into the causal link between the process and outcome. Hence it is insufficient in capturing whether people receive quality care or how it works [2, 31]. For example, the work by Stiglitz-Sen-Fitoussi on going “Beyond GDP”, indicates that a singular focus on outcomes is insufficient to show “how the pie was sliced” [32].

According to the WHO there is a research gap in understanding how to ensure the sustainability of CHWs program, previous research experience on the role of community-based health workers represents a mix of varying degrees of quality [33]. The existing reviews highlight a lack of robust evidence on contextual factors from the perspective of community health workers. Thus, to the best of our knowledge there is no systematic review that has provided in-depth insight into the individual and contextual barriers to and enablers of the effectiveness of CHWs from the perspective of front line CHWs. In addition, to the best of our knowledge no systematic review has been performed to unravel the contextual factors like how, for whom and under what circumstances the CHWs’ programs work.

The objective of this protocol is to outline the methodological process of a systematic review that will gather qualitative data to examine determinants of community health workers effectiveness for delivery of maternal and child health in Sub Saharan Africa.

This systematic review will be guided by the following question: What are the CHWs’ perceived barriers to and facilitators of effectiveness of community health workers to ensure MCH equity and a resilient community health system in sub-Saharan Africa?

Methods

Discussion

This protocol outlines the methodological process of a systematic review that will gather data to examine the determinants of CHWs effectiveness for equitable maternal and child health, and a resilient community health system in Sub Saharan Africa.

Such an evidence base has the potential to provide an opportunity to better plan and implement MCH. Hence, this review will be of value to decision makers, policy makers, practitioners, and members of the community with interest in supporting the MCH equity and a resilient community health system. Additionally, this review will contribute to the campaign for effective empowerment of CHWs. However, some limitations are anticipated when planning the methodology for this systematic review. Because of the exclusion of studies not published in English language, important data may be missed. This may result in publication bias. The resulting manuscript will be disseminated in a peer-reviewed journal and at international and national conferences.

Supporting information