This article draws on literature searches done by several of the authors for several publications that reviewed topics of relevance to community health workers.12, 14, 16, 17, 18, 50, 72, 73 The Cochrane Library was searched for additional systematic reviews using the terms “community health workers”, “lay health workers”, “mid level health workers”, and “primary health care”. Additional references were provided by individuals listed in the acknowledgments section and by some of the
ReviewAchieving child survival goals: potential contribution of community health workers
Introduction
Progress towards the United Nations' Millennium Development Goals, including those on maternal and child mortality, is off track, particularly in sub-Saharan Africa. The Millennium Development Goal on child mortality aims for a two-thirds reduction from 1990 to 2015, but at current progress this may not be attained until 2165 in sub-Saharan Africa.1, 2 It is estimated that over 60% of deaths in children under age 5 years (currently >10 million per year) could be prevented by various existing interventions.3 Recent analysis indicates that 41–72% of newborn deaths can be prevented by available interventions, if provided at high coverage, and around half of this reduction is possible with community-based interventions.4
However, the health systems in many countries are too weak and fragmented to enable the scaling-up of essential interventions for maternal, newborn, and child health.5 One key challenge is the need to develop and strengthen human resources to deliver essential interventions.6, 7 The density of health workers (doctors, nurses, midwives) is inversely associated with maternal, infant, and under-5 mortality,8 and is more than ten times higher in Europe and North America than in sub-Saharan Africa. Various factors are responsible for inadequate human resources in many countries, including inadequate supply, migration, poor morale, and the effects of HIV/AIDS.6, 7, 9
These factors, together with the high cost of training doctors and nurses and the low use of services based in health facilities in many areas, have rekindled interest in the possibility of substantial health gains from the use of community health workers and mid-level health workers such as clinical assistants. Several African and south Asian countries are currently investing in new cadres of community health workers as a major part of strategies to reach the Millennium Development Goals, in some cases arguing that they preferentially reach the poor who are less likely to use health facilities. For example, Ethiopia is training 30 000 community-based health extension workers (women) to focus on maternal, newborn, and child health, malaria, and HIV. India, Kenya, Uganda, Ghana, and South Africa are also considering national programmes for community health workers. Therefore, it is now timely to assess the evidence that such health workers can perform the necessary tasks and function as part of a sustainable workforce.
In the 1970s and 1980s, community health workers were a cornerstone of primary health care as envisaged by the Alma Ata declaration. However by the early 1990s, enthusiasm for community health workers had diminished for several reasons, including the challenges of scaling-up programmes in a sustainable fashion while maintaining effectiveness, and the perceived success of some vertical programmes.10
Historically, programmes for community health workers have emerged in very different political and societal contexts. There are philosophical and political differences between the promotion of community health workers as community advocates and agents that change behaviour and the view that they are essentially an extension of formal health care.11
In this Review we focus on child survival, although many of the issues are also relevant to other priority areas encompassed by the Millennium Development Goals. Child survival is most effectively addressed with the provision of care during the lifecourse (figure 1), an approach that emphasises the intergenerational gains of improved health (eg, improved nutrition in young girls, delayed age of first pregnancy, and death of the mother affects the survival and health of the next generation12, 13). Although we acknowledge the importance of a lifecourse approach, in this Review we primarily consider interventions that directly improve child health (panel 1,14, 15 figure 1).
Section snippets
Who are community health workers and mid-level workers?
Complex and sometimes confusing terminology is used to describe various types of non- professional health workers.16 A statement from a WHO Study Group suggests that,17 “Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers”.
Which interventions can be delivered in community settings?
A growing array of effective interventions can be delivered in the community (figure 1).18, 19 These encompass behavioural interventions to promote healthy behaviour, such as hand washing and breastfeeding, preventive interventions, such as insecticide-treated nets for malaria and micronutrients, and more complex tasks, such as prevention of mother to child transmission of HIV, case management of childhood illnesses such as malaria, pneumonia, and neonatal sepsis. In addition, the active
Why should interventions be delivered in community settings?
Currently the coverage of many effective interventions is low3, 4—well under 50% in many cases—and the quality of care is deficient in many communities.20 Care for neonatal disorders has received little emphasis in public health programmes, and only 3–12% of children born at home in five south Asian and sub-Saharan African countries received a visit from a trained health worker within 3 days of birth.2
Improvement in health facilities alone is not sufficient to avert a large proportion of child
Impact and cost-effectiveness of community health workers
Most assessments are process associated and many address disease-specific programmes26, 27—eg, increasing coverage of insecticide-treated nets or measles vaccines. South Asia has contributed to most of the studies on mortality impact; however, most of these were relatively small-scale programmes. There are few publications that address process assessment of breastfeeding and nutrition promotion,28 integrated child health, or programmes for maternal, newborn, and child health. For example,
Determinants of the success of community health worker programmes
Research has commonly been limited to relatively short-term studies in selected populations, and more work is needed to describe the key factors involved in sustaining performance over years and decades at scale. This requires institutionalisation of change, and one of the challenges from an assessment standpoint is the ability to capture and place a value on such change.51 The determinants of success can be seen as comprising four main interacting categories (figure 2). The relative importance
The need for new knowledge to improve health systems
A Task Force convened by WHO suggested a wide ranging research agenda covering 12 topic areas, which, if addressed, could provide the knowledge to improve health system functioning.79 Human resources in general and the role of community health workers and mid-level cadres in the delivery of effective interventions constitute key topics for such research. This research agenda must be addressed as a matter of urgency by embedding evaluative research in initiatives to promote child survival. Such
Conclusions
Given the challenges, especially in Africa, as a result of political or natural crisis, structural adjustment, health sector reform, HIV/AIDS, as well as the loss of professional skills, consideration of a renewed role for community health workers is relevant and timely.85 Tasks need to be focused; community workers cannot provide comprehensive care for all community health needs. Supportive management, including appropriate supervision and availability of infrastructural support are critical
Search strategy and selection criteria
References (87)
- et al.
How many child deaths can we prevent this year?
Lancet
(2003) - et al.
Evidence-based, cost effective interventions: how many newborn babies can we save?
Lancet
(2005) - et al.
Overcoming health-systems constraints to achieve the Millennium Development Goals
Lancet
(2004) - et al.
Human resources for health: overcoming the crisis
Lancet
(2004) - et al.
Human resources and health outcomes
Lancet
(2004) - et al.
4 million neonatal deaths: When? Where? Why?
Lancet
(2005) - et al.
Can the world afford to save the lives of 6 million children each year?
Lancet
(2005) - et al.
Systematic scaling up of neonatal care in countries
Lancet
(2005) - et al.
Inequities among the very poor: health care for children in rural southern Tanzania
Lancet
(2003) - et al.
Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials
Lancet Infect Dis
(2003)
Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial
Lancet
Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India
Lancet
Economic evaluation in primary health care: the case of Western Kenya community based health care project
Soc Sci Med
The effects and costs of expanding the coverage of immunisation services in developing countries: systematic literature review
Vaccine
Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomized controlled trial
Lancet
Economic evaluation of a women's group intervention to improve birth outcomes in rural Nepal
Lancet
Are large-scale volunteer community health worker programs feasible? The case of Sri Lanka
Soc Sci Med
Low utilization of community health workers: results of a household interview survey in Burkina Faso
Soc Sci Med
Community-based health workers: head start or false start towards health for all?
Soc Sci Med
Can community health workers and caretakers recognise pneumonia in children? Experiences from Western Uganda
Trans R Soc Med Hyg
How can we achieve and maintain high-quality performance among health workers and managers in low-resource settings?
Lancet
Reducing attrition among village health worker programs in rural Nigeria
Soc Econ Plan Sci
Human Development Report 2003 Millennium Development Goals: a compact to end human poverty
The Millennium Development Goals for health: rising to the challenges
Working together for Health: World Health Report 2006
How nurses in Cape Town clinics experience the HIV epidemic
AIDS Bulletin
World Development Report: Investing in Health
The village health worker: lackey or liberator?
HIV and mortality of mothers and children: evidence from cohort studies in Uganda, Tanzania, and Malawi
Epidemiology
Lady Health Worker Programme
Implementating community-based perinatal care: results from a pilot study in rural Pakistan
Lancet
A joint learning initiative: human resources for health and development: review of the utilization and effectiveness of community-based health workers in Africa. JLI Working Paper 4–1, 2004
Strengthening the performance of community health workers in primary health care: report of a WHO study group
Community-based interventions perinatal health outcomes in developing countries: a review of the evidence
Pediatrics
Programmatic pathways to child survival: results of a multi-country evaluation of integrated management of childhood illness
Health Policy Plan
Rectal artemether versus intravenous quinine for the treatment of cerebral malaria in children in Uganda: randomised clinical trial
BMJ
Impact of integrated management of childhood illness on inequalities in child health in rural Tanzania
Health Policy Plan
Mosquito nets and the poor: can social marketing redress inequities in access?
Trop Med Int Health
Integrating insecticide-treated bednets into a measles vaccination campaign achieves high, rapid and equitable coverage with direct and voucher-based methods
Trop Med Int Health
Distributing insecticide-treated bednets during measles vaccination: a low-cost means of achieving high and equitable coverage
Bull World Health Organ
Improving breastfeeding practices on a broad scale at the community level: success stories from Africa and Latin America
J Hum Lact
Evidence from community-based and outreach approaches in Africa. Countdown Conference, London, December 2005
Intervention models for the management of children with signs of pneumonia or malaria by community health workers
Health Policy Plan
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