AI Insight
This cross-sectional study analyzed health survey data from 68,019 women across Ghana, Kenya, Tanzania, and Malawi to assess equity in community health worker (CHW) program reach. The study found that CHW contact rates varied seven-fold between countries (3.1% to 22.8%), with adolescent women aged 15-19 consistently having half the odds of CHW contact compared to women aged 25-29 across all four countries. Wealth-based equity varied by country, with Ghana achieving equal reach across all income levels while Kenya and Malawi showed pro-poor targeting, and rural areas had higher contact rates in Kenya and Malawi.
Why it matters
The findings reveal a systematic gap in CHW program reach to adolescent women across sub-Saharan Africa, suggesting that current universal health coverage strategies may be missing a critical demographic group. The research demonstrates that equitable reach across wealth levels is achievable at scale, as shown by Ghana's program, and highlights the need for targeted interventions such as school-based outreach to improve adolescent access.
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⚠️ Preprint – Noch nicht peer-reviewed
Dieser Artikel wurde noch nicht von unabhängigen Experten begutachtet. Die Ergebnisse sind vorläufig und sollten mit Vorsicht interpretiert werden.
Background Community health workers (CHWs) are central to universal health coverage strategies across sub-Saharan Africa. Yet whether CHW programs equitably reach women across socioeconomic and demographic groups remains poorly characterized at the multi-country level. Methods A cross-sectional secondary analysis of Standard DHS-8 data from Ghana (2022), Kenya (2022), Tanzania (2022), and Malawi (2024) was conducted (N = 68,019 women aged 15-49). The primary outcome was self-reported contact with a CHW or fieldworker in the prior 12 months. Survey-weighted logistic regression was performed using Taylor series linearization to account for complex survey design, both individually per country and pooled. The RE-AIM framework guided the evaluation of program reach. Results National CHW coverage varied 7-fold, from 3.1% in Tanzania to 22.8% in Malawi. The most consistent cross-country equity finding was by age: women aged 15-19 had approximately half the adjusted odds of CHW contact compared to women aged 25-29 in every country (pooled aOR = 0.47, 95% CI [0.42, 0.52], p < .001). Pro-poor wealth gradients were significant in Kenya and Malawi, whereas Ghana achieved equitable reach across all wealth quintiles (p = .685). Rural residence was independently associated with higher CHW contact in Kenya (aOR = 1.48) and Malawi (aOR = 1.91). Conclusions Adolescent women aged 15-19 are systematically underserved by CHW programs across sub-Saharan Africa, a finding consistent across four countries with widely different program scales. This adolescent gap is the most consistent equity finding across the dataset, persisting across all four countries regardless of program scale, wealth distribution, or governance structure. Ghana’s Community-based Health Planning and Services (CHPS) program demonstrates that equitable CHW reach across wealth quintiles is achievable at scale. Kenya’s extreme within-county variation indicates that sub-national governance quality is a dominant driver of equity. Targeted strategies, including CHW protocol redesign and school-based outreach, are urgently needed to close the adolescent reach gap.