The 2013–2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security. Chronically fragile and under-resourced health systems enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11 310 deaths (as of 5 May 2016) in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating. Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public’s lack of access to health services. Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilisation of communities when an outbreak has been identified. In this paper the authors make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems.
Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and as a means for improvement in health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from the authors’ deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. Several propositions were made for further conceptual development and research related to the question of CHWs and accountability.
Community Health Workers feel unrecognised and undervalued by community leaders and health professionals. This was the central message from a major thematic discussion held on the HIFA forums and sponsored by The Lancet, Reachout Project/Liverpool School of Tropical Medicine, World Vision International and USAID Assist Project. More than 60 HIFA members contributed their experience and expertise to the discussion, including CHW programme managers, researchers and policymakers, as well as a large number of CHWs and ASHAs from India and Uganda. Countries represented included Burundi, Cameroon, Canada, Ethiopia, France, Ghana, India, Iran, Japan, Kenya, Malaysia, Netherlands, New Zealand, Nigeria, Pakistan, Rwanda, Switzerland, Tanzania, Uganda, UK, and USA. Other major concerns were lack of training and supervision; access to healthcare information; remuneration; equipment, medicines, and need for mobile phones/computers. CHWs said they are asked to carry out a wide range and ever increasing number of tasks, but often without the appropriate facilities to enable this. CHWs feel unrecognised and undervalued by official health care providers which not only reduces morale but also creates a disjoint between perceived influence by community, and their actual influence, reducing their respect from the community. Furthermore, this lack of respect is reflected in their lack of training and supervision, and results in a paucity of avenues for them to voice their needs and concerns.
This article investigates whether present community health worker programmes for antiretroviral treatment are taking into account the lessons learnt from past experiences with community health worker programmes in primary health care and to what extent they are seizing the new antiretroviral treatment-specific opportunities. It is based on a desk review of multi-purpose community health worker programmes for primary health care and of recent experiences with antiretroviral treatment-related community health workers. The renewed attention to community health workers is very welcome, but the scale-up of community health worker programmes runs a high risk of neglecting the necessary quality criteria if it is not aligned with broader health systems strengthening. To achieve universal access to antiretroviral treatment, this is of paramount importance and should receive urgent attention.
The Community Health Workers (CHWs) Programme was launched in Luanda, Angola, in 2007 as an initiative of the provincial government. The aim of this study was to assess its implementation process. This is a case study using document analysis, CHWs reports, individual interviews and focal groups. Until June 2009, the programme had placed in the community 2548 trained CHWs, providing potential coverage for 261 357 families. Analysis of qualitative data suggested an association of CHWs with improvements in maternal and child access to health care, as well as an increase in the demand for health services, generating further need to improve service capacity. Nevertheless, critical points for programme sustainability were identified. For continuity and scaling up, the programme needs medium- and long-term technical, political and financial support.
This paper, prepared for the International Consortium for Research on Equitable Health Systems, provides an overview of the concepts and practice of Community Health Workers (CHWs) in several developing and developed countries. In doing so it identifies critical factors that influence the overall performance of CHWs including gender, the nature of employment, career prospects and incentives, educational status and training. It finds that the selection of CHWs from the communities that they serve, population coverage and the range of services offered at the community levels are vital in the design of effective CHW schemes. The smaller the population coverage, the more integrated and intensive the service offered by CHWs.
The provision of health services to rural and remote communities has been the source of much concern and debate in recent times. One aspect of this is the universal problem of insufficient medical practitioners in rural areas and the associated issues of recruitment and retention. Rural communities can play an important role in the recruitment and retention of health professionals, particularly in terms of aiding the integration of health professionals and their families into the community.
This paper seeks to assess if targeted community-based medical education programme is associated with better prevention and treatment seeking behaviours in the management of malaria, a leading cause of morbidity and mortality of children under five in Uganda. A cross-sectional survey was done to compare communities around health facilities where medical students were placed at community-based education and Research Service (COBERS) sites with communities around similar health facilities where medical students were not placed (non-COBERS sites). The authors randomly selected two villages near each health facility and consecutively selected 10 households per village for interviews using nearest-neighbour method. The authors used a structured questionnaire to interview household heads on malaria prevention and treatment seeking behaviour for children under 5 years. The authors performed univariate analysis to determine site and demographic characteristics and performed a multivariate logistic regression to assess association between dependent and independent variables. Five hundred twenty-three of the children under 5 years in COBERS communities slept under insecticide treated nets the night before survey compared with 1451 in non-COBERS communities. 100 of children under 5 years in COBERS communities sought care for fever within 24 h of onset compared with 268 in non-COBERS communities. The presence of COBERS in communities is associated with improved malaria prevention and treatment-seeking behaviour for parents of children under 5 years. Further study needs to be done to determine the long-term impact of COBERS training program on malaria control and prevention in Uganda, along with its other effects.
In January, 2009, the World Health Organization’s (WHO) Executive Board considered the adoption of a global code of practice to address the movement of health workers from developing countries, the ‘WHO Draft Code of Practice for the International Recruitment of Health Workers’. This attention to brain drain is welcome, but the initiative does not begin to adequately address the consequences or roots of health-worker migration from sub-Saharan Africa to the rich developed world, especially to the United Kingdom, United States and Canada. The movement of skilled health workers constitutes a major transfer of riches from poor societies to the affluent, and the only appropriate redress is a bilaterally managed scheme of direct reimbursement of the value lost, along the lines proposed by Mensah and colleagues in 2005.
Although the Human Resources for Health (HRH) crisis is apparently not new in the public health agenda of many countries, not many low and middle income countries are using Primary Health Care (PHC) as a tool for planning and addressing the crisis in a comprehensive manner. The aim of this paper is to appraise the inadequacies of the existing planning approaches in addressing the growing HRH crisis in resource limited settings. A descriptive literature review of selected case studies in middle and low income countries reinforced with the evidence from Tanzania was used. Consultations with experts in the field were also made. In this review, we propose a conceptual framework that describes planning may only be effective if it is structured to embrace the fundamental principles of PHC. We place the core principles of PHC at the centre of HRH planning as we acknowledge its major perspective that the effectiveness of any public health policy depends on the degree to which it envisages to address public health problems multi-dimensionally and comprehensively. The proponents of PHC approach in planning have identified inter-sectoral action and collaboration and comprehensive approach as the two basic principles that policies and plans should accentuate in order to make them effective in realizing their pre-determined goals. Two conclusions are made: Firstly, comprehensive health workforce planning is not widely known and thus not frequently used in HRH planning or analysis of health workforce issues; Secondly, comprehensiveness in HRH planning is important but not sufficient in ensuring that all the ingredients of HRH crisis are eliminated. In order to be effective and sustainable, the approach need to evoke three basic values namely effectiveness, efficiency and equity.