Policy options for improving the performance of community health workers (CHWs) in maternal and child health in Brazil: analysis of barriers and facilitators to CHW national programme and evaluation of a community-based trial in Recife

Background and objectives. Studies and international agencies’ policy documents, while acknowledging the potential of Community Health Worker (CHW) programs in improving reproductive maternal newborn and child health (RMNCH) outcomes, underline the scarcity of strong evidence of effectiveness and solicit more in-depth investigations on the implementation process of such programs. Recent developments about how to improve service quality in RMNCH emphasize the need of a system approach, according to which any attempt to evaluate and improve the overall system, or part of it, should take into account the overall complexity and interdependency across actors and components. Moving from the intersection between the current debate on CHWs, the emphasis on quality improvement and system approaches to health systems, the research is aimed at developing analytical and policy tools that may be used to improve the performance of CHWs in Brazil, a country whose CHW program is considered among the most valuable models globally. Methods. A three step process has been envisaged. The first step, through a systematic review of qualitative studies conducted in Brazil on CHWs and building on concepts driven from the international literature, develops a logic model to describe factors influencing CHWs’ performance in Brazil and their underlying mechanisms. The second step, moving from a case study built around the impact evaluation of an intervention trial targeting CHWs in the city of Recife and aimed at supporting quality home visits to pregnant women and mothers, is aimed at providing further insights on barriers and facilitators to interventions designed to improve CHWs’ performance, and at further validating the model. The third step uses the logic model to identify and systematize policy options, contextualized to the Brazilian system, to improve the performance of CHWs across all their attributions and tasks as well as in a specific area such as RMNCH. Results. The systematic review, confirming the findings of international literature, showed that, although the main factors influencing CHWs’ performance reside in the formal health system components and in the sub-system elements of the CHW program, the community system is a powerful source of complex interactions that may act either as facilitators or as barriers of CHWs’ performance. A logic model was developed to facilitate the identification, analysis and visualization of these factors and their dynamics. The case study confirmed the validity of the model for analyzing and interpreting the results of the intervention and, by explaining the reasons for its partial failure, provided hints about how interventions and policies aimed at improving CHWs’ performances should be conceived. Using the model as the reference framework, policy options were systematized according to the health and community system components and proposed as a comprehensive compendium and as policy packages according to the various levels of responsibility regarding CHW program in the Brazilian health system. A model for prioritization criteria was also proposed. Conclusions. The analytical and policy tools that were developed may be useful for a more systematic and evidence-based approach to improving the performance of CHWs in Brazil. The systematization of influencers of CHWs’ performance and their mediators can be used to describe the institutional and stakeholders’ response to CHW program. The logical model, populated with institutional and behavioral facilitators and barriers, can serve to identify areas that requires action for program strengthening. The policy compendium can facilitate, at various levels of the system, the development and prioritization of policy packages aimed at improving RMNCH-related tasks of CHWs in a broader systemic perspective, recognizing that most factors influencing specific tasks of CHWs are cross-cutting and need to be addressed as such.