Optimizing the role and functions of CHWs in service of a people-centred community health system in sub-Saharan Africa. A realist synthesis

Introduction

The role of Community Health Workers (CHWs) in sub-Saharan Africa is critical to achieve people-centred health systems. Despite a large evidence base, there is a dearth of knowledge regarding the contextual factors and mechanisms that shape CHW performance in providing people-centred care. This study aims to map out conditions that enable people-centred care by CHWs in sub-Saharan Africa by identifying the key mechanisms and contextual factors.

Methodology

A realist synthesis approach was employed to explore how, why, and under what conditions CHW interventions lead to desired outcomes for people-centred care. A systematic review of the literature was undertaken from 2014 to 2024, focusing on studies conducted in sub-Saharan Africa. The review followed a six-phase process, including the development of the initial programme theory, search for evidence, evidence review and quality appraisal, data extraction, data synthesis and analysis, and refinement of the programme theory, followed by formulation of context-mechanism-outcome (CMO) configurations.

Results

This synthesis included 36 studies from 14 sub-Saharan African countries. In total, 101 CMO configurations were identified and condensed into 17 preliminary configurations. Specific contexts and mechanisms emerged that influence outcomes related to CHW programmes. The study identified trust, motivation, and adaptive leadership as fundamental meta-mechanisms that challenge the siloed structure of the IPCHS framework, emphasizing the need for greater flexibility to capture interactions across different strategies of the framework.

Conclusion

This study demonstrates that integrating CHWs into formal systems, aligning CHW-specific interventions with community-based initiatives, establishing intersectoral partnerships, and updating the IPCHS framework to incorporate adaptive leadership and feedback mechanisms can enhance the delivery of people-centred care.