Marco referencial

Figure 6 represents the resulting logic thematic model of this review. The upper (health system inputs, mediators, CHWs’ performance and health impact) and lower (health system and community system) boxes describe the captions to the framework, which summarizes the links between the health and community system inputs, CHWs’

performance, health impact at population level. The framework, in accordance with the findings of our review, identifies CHWs’ KAP, other FHTs health professionals’ KAP and team work as key mediators of the effect of health system inputs on CHWs’ performance and at the same time recognizes that this performance is also affected by the community system, including issues related to access to services and health beliefs and behaviors. For the sake of clarity, only main categories generated by the review are displayed in the model, which implies the function of all categories at a lower hierarchical level.

CHWs’ performance, the core analytical focus of this review, is placed in the third column, between health and community systems’ inputs (first column and second to last row), mediators of effects (second column) and health outcomes at population level, including access and use of services and health behaviors and practices (fourth column). Arrows represent the logic connections found through the analysis of the literature between all elements of the framework. They can be unidirectional, or bidirectional. As described in the narrative synthesis, CHWs’ performance is influenced either directly or indirectly by systemic issues, mediators of effects, but also by the effects they have on health outcomes within their population (changes in access to services or behaviors), which feedback on their performance and on elements included in the community system.

Figure 6 Logic thematic model for CHW program implementation and CHWs’ performance in Brazil

4. Discussion

Our qualitative literature review of studies carried out in Brazil showed that CHWs’ performance is influenced, through complex and non-linear connections, by a wide range of systemic inputs, and mainly by CHW specific and non-specific components of the health system and the community system.

Among the variety of factors involved and their complex interactions, two factors emerged from the review as key for the quality of CHWs’ performance: the policies regarding the human resources and their management on one side and the community views towards health on the other.

Within the former, the evidence reported highlighted the key role played by the lack , or inadequacy, of training, CPD, support and supervision provided to CHWs, all of which were reported as profoundly affecting attitudes, knowledge and practice of CHWs. The role played by health professionals working in team with CHWs, their leadership, attitude and supervisory skills were also identified as playing an important role in shaping the ultimate functioning of CHW programme.

Within the latter, two elements were found to be highly influential for CHWs’ attitudes, knowledge and practice, and therefore for their performance: the communities’

individual and collective knowledge, attitudes and expectations in relation to health and health services, including CHWs’ role and tasks, and the existing level of social cohesion and attitude to collective problem solving.

Our review confirm the main findings of extensive reviews and studies addressing barriers and facilitators of CHWs’ performance (Glenton et al., 2013; Naimoli et al., 2014; Kok et al. 2014; Kok et al. 2015; Schneider et al., 2016) in recognizing that the formal health system, through its various components, and the community system, through its economic social and cultural features, should be seen as the two main system players in shaping the performance of CHWs as well as the effectiveness of CHW programs. Mechanisms of reciprocal influence between factors seems also similar to those described by Kok et al. (2014, 2015) and Glenton et al. (2013). Also, similarly to what shown by Kok et al. (2014; 2015), Naimoli et al. (2014) and Glenton et al. (2013), CHWs’ KAP seem to be the key mediators between the inputs from the various components of the two systems and CHWs’ performance.

Our findings are aligned with the reviews by Kok (2014, 2015) and Glenton et al. (2013) in identifying the appropriate management of human resource aspect as crucial to facilitate CHWs’ performance. This includes interactive training methods and action- oriented contents, with priority given to communication skills, and guidance for support and supervision to be provided to CHWs, including recognition of their role and collaborative team work (Glenton et al., 2013).

While our findings confirm the role attributed to the various factors in influencing CHWs’ performance, they somewhat differ in assessing the direction of this influence and the main mechanisms through which this influence is exerted.

For example, from the review by Kok et al. (2014) financial incentives emerge as factors which can increase motivation and adherence to standards and at the same time can shift the performance based on the type of incentives. In the review by Glenton et al. (2013), salary is portrayed as an aspiration for volunteers and as a source of frustration for those CHWs who are entitled to it but feel it is too low. The concern that its introduction would shape differently CHWs’ role and its relationships with both the health system and the community is also mentioned. While we confirmed the contradictory role of financial incentives, their role emerged mainly as negative. This is not surprising in a system where CHWs are fully integrated in the health system. In such

a system, where the salary is given for granted, although a source of complaint because too low, financial incentives which are based on quantitative outputs, are unanimously seen as a cause of distortion of CHWs’ role, professional identity, and a cause of daily conflict between the quality content of the activities and their number. Clearly, financial benefits where CHWs are not integrated into the formal health system and therefore are not paid or receive extremely low salaries may be seen much more favorably. Brazilian CHWs are able to conceive in principle the potential value of incentives, particularly the non financial ones, such as opportunities for professional development and career progression, but complain that financial incentive mechanisms are not focusing on what CHWs perceive as their core tasks. The different, on average higher, educational level of CHWs in Brazil and the motivation that the older CHWs still maintain as servants to their communities may be explanations of these differences. Similarly, the role, and therefore the lack, of leadership and governance capacity of managers and coordinators and of user-friendly and relevant information system were found more important in the Brazilian system where CHWs are integral part of the formal health sector and therefore suffer from the inadequacy of what they perceive as essential system elements. Expanded tasks and longer time spent for service delivery were found by Kok et al. (2014) as positive factors for CHWs performance, while in our review the extension of task attribution was usually negatively perceived. This might be due to the fact that Kok et al. (2014) included many studies where CHWs programs were not integrated with the health system, thus feeling part of a health program was felt as a professional reward, and expanding tasks as a way to get a higher salary, while in our review are mainly seen as a burden.

Our findings also confirm the important role of social recognition of CHWs’ role by the community, of the views about health and health services of community members and of their relations with health professionals in shaping CHWs’ motivation and consequently their performance emerging from both reviews. We have also confirmed the contradictory role played by requiring CHWs to be resident in the community they work for described by Glenton et al. (2013). The mix of trust, expectations, personal ties, ability to read the context, responsibility, blame that being a resident brings about may lead to a variety of possible favorable and unfavorable influences on CHWs’ performances.

Finally, the degree of community participation and cohesion, the prevailing cultural beliefs and the presence of social and economic hardships have been recognized by our review as strong influencers of CHWs’ performance, in alignment with Kok’s and Glenton’s reviews (Glenton et al., 2013; Kok et al. 2014; Kok et al. 2015). This is a particularly interesting finding. While it is widely recognized that social determinants impact directly and indirectly on health outcomes (WHO, 2008), it is not so widely acknowledged that they may have a direct influence of the way that health professionals and services working in those communities perform. Interactions between CHWs and community members emerge as largely bidirectional.