Elsevier

The Lancet

Volume 369, Issue 9579, 23–29 June 2007, Pages 2121-2131
The Lancet

Review
Achieving child survival goals: potential contribution of community health workers

https://doi.org/10.1016/S0140-6736(07)60325-0Get rights and content

Summary

There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability.

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

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

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