Community health workers as ‘boundary spanners' in Sub-Saharan Africa: a qualitative systematic review

Davids, Lydia

Community health workers as ‘boundary spanners' in Sub-Saharan Africa: a qualitative systematic review

Thesis / Dissertation

2026

Publisher

University of Cape Town

Department

Department of Public Health and Family Medicine

Faculty

Faculty of Health Sciences

Abstract

Community health workers (CHWs) play an essential role in bridging health systems and communities in sub-Saharan Africa (SSA). However, their ability to serve as effective boundary spanners is shaped by multiple, interrelated factors. Understanding these influences is essential for supporting CHWs and enhancing their contributions to health systems. This qualitative systematic review explores the factors influencing the boundary-spanning roles of CHWs in SSA. The study was conducted in two phases. First, a scoping review mapped the factors affecting CHWs' roles as boundary spanners between communities and health systems in low- and middle-income settings. This mapping led to an analytical framework for the systematic review. The second phase, a qualitative systematic review, aligned with the analytical framework and key terms defined in the scoping phase, delved deeper into understanding the factors influencing CHWs' boundary-spanning roles within the SSA context. The search strategy included English-language peer-reviewed literature and institutional-reviewed reports published from 2013 to 2024. Of the 1,244 records identified, 43 studies representing 18 countries in SSA were included in the review. Direct references to the intermediary role of CHWs appeared in 36 of the studies while all 43 studies highlighted at least one boundary-spanning role of CHWs—categorized into several groups that emphasize their work in bridging communities and health systems. The findings were synthesized into five thematic areas that highlight the interplay between systems hardware and software influencing CHWs' boundary-spanning roles. The review highlights the importance of fostering collaborative relationships between CHWs, health systems, and communities, and the impact of underlying power dynamics on health systems' hardware and software, necessitating policies that enhance CHW involvement in decision-making, build trust, and recognize their contributions. These insights are valuable for policymakers, programme managers, and health system leaders aiming to address barriers and optimize CHWs' roles as effective intermediaries in SSA.

Keywords

Community health workers

sub-Saharan Africa

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