Table 2 An assessment of the local applicability of a systematic review on lay health worker interventions (from the perspective of a South African policymaker)

1. Were the studies included in the systematic review conducted in the same setting or were the findings consistent across settings or time periods?

   • 48 studies were included in the review

◦ 25 from the Unites States (US)

◦ 3 from the United Kingdom (UK)

◦ 2 each from Brazil, South Africa and Tanzania

◦ 1 each from Bangladesh, Canada, Ethiopia, Ghana, India, Ireland, Mexico, Nepal, New Zealand, Pakistan, Philippines, Thailand, Turkey, and Vietnam

   • Findings were not always consistent across settings

   • Most studies were published from 1995 onwards although one study was published in 1980. It is not clear from the review whether the findings were consistent over time periods

2. Are there important differences in on-the-ground realities and constraints that might substantially alter the feasibility and acceptability of an option?

   • In South Africa, concerns have been expressed about the capacity of the health system and non-government organisations (NGOs) to provide clinical and managerial support for a very large scale-up of LHW programmes, particularly in currently under-resourced areas where, it could be argued, they are most needed. Capacity may be different from the high-income settings (US, UK) in which many of the studies were conducted

   • In South Africa, there is some resistance among nurses, and within nursing professional associations, to extending the scope of practice of LHWs. This may restrict the range of tasks that LHWs are able to take on. While the acceptability of LHWs to consumers seems reasonable, based on observations from existing programmes, this is likely to vary across settings in the country and for different tasks (e.g. immunisation, breastfeeding promotion)

   • In South Africa, most LHWs are currently involved in providing home-based care to people living with HIV/AIDS and treatment support to this group and to people with TB. It is not clear how feasible it would be to extend their roles to include the areas shown to be effective in the review (immunisation promotion, treatment of childhood infections, breastfeeding promotion). Furthermore, the LHW interventions shown to be effective in the review were focused on very specific health issues, such as the promotion of breastfeeding or immunisation uptake. Little evidence was identified regarding the effectiveness of more 'generalist' LHWs who are given responsibility for delivering a range of primary healthcare interventions

   • In South Africa, norms and traditions regarding breastfeeding as well as differing baseline levels of breastfeeding and high rates of HIV/AIDS among mothers may alter the applicability of the review findings on LHWs for breastfeeding promotion

3. Are there important differences in health system arrangements that may mean an option could not work in the same way?

   • In South Africa, LHWs are not licensed to dispense antibiotics for the treatment of acute respiratory infections in children or to dispense anti-malarial drugs. It may therefore be difficult in the short- to medium-term to extend their scope of practice in this way, even if shown to be effective in a review

   • In South Africa, most LHWs are employed by NGOs, who receive funding from the government for the LHWs' salaries. It is not clear how secure this funding mechanism is

4. Are there important differences in the baseline conditions that might yield different absolute effects - even if relative effectiveness were the same?

   • Baseline immunisation rates may be lower in South Africa than in some of the settings where the studies on LHWs for immunisation were conducted (Ireland, USA). Higher absolute effects might therefore be anticipated in South Africa

5. What insights can be drawn about options, implementation, and monitoring and evaluation?

   • Most of the LHW interventions shown to be effective were focused on single tasks. The effectiveness of 'generalist' LHWs who deliver a range of primary healthcare interventions needs evaluation.