Henry Perry

Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness

Over the past half-century, community health workers (CHWs) have been a growing force for extending health care and improving the health of populations. Following their introduction in the 1970s, many large-scale CHW programs declined during the 1980s, but CHW programs throughout the world more recently have seen marked growth. Research and evaluations conducted predominantly during the past two decades offer compelling evidence that CHWs are critical for helping health systems achieve their potential, regardless of a countrys level of development. In low-income countries, CHWs can make major improvements in health priority areas, including reducing childhood undernutrition, improving maternal and child health, expanding access to family-planning services, and contributing to the control of HIV, malaria, and tuberculosis infections. In many middle-income countries, most notably Brazil, CHWs are key members of the health team and essential for the provision of primary health care and health promotion. In the United States, evidence indicates that CHWs can contribute to reducing the disease burden by participating in the management of hypertension, in the reduction of cardiovascular risk factors, in diabetes control, in the management of HIV infection, and in cancer screening, particularly with hard-to-reach subpopulations. This review highlights the history of CHW programs around the world and their growing importance in achieving health for all.

Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh

In Bangladesh, rapid advancements in coverage of many health interventions have coincided with impressive reductions in fertility and rates of maternal, infant, and childhood mortality. These advances, which have taken place despite such challenges as widespread poverty, political instability, and frequent natural disasters, warrant careful analysis of Bangladeshs approach to health-service delivery in the past four decades. With reference to success stories, we explore strategies in health-service delivery that have maximised reach and improved health outcomes. We identify three distinctive features that have enabled Bangladesh to improve health-service coverage and health outcomes: (1) experimentation with, and widespread application of, large-scale community-based approaches, especially investment in community health workers using a doorstep delivery approach; (2) experimentation with informal and contractual partnership arrangements that capitalise on the ability of non-governmental organisations to generate community trust, reach the most deprived populations, and address service gaps; and (3) rapid adoption of context-specific innovative technologies and policies that identify country-specific systems and mechanisms. Continued development of innovative, community-based strategies of health-service delivery, and adaptation of new technologies, are needed to address neglected and emerging health challenges, such as increasing access to skilled birth attendance, improvement of coverage of antenatal care and of nutritional status, the effects of climate change, and chronic disease. Past experience should guide future efforts to address rising public health concerns for Bangladesh and other underdeveloped countries.

Evidence on feasibility and effective use of mHealth strategies by frontline health workers in developing countries: systematic review

Given the large‐scale adoption and deployment of mobile phones by health services and frontline health workers (FHW), we aimed to review and synthesise the evidence on the feasibility and effectiveness of mobile‐based services for healthcare delivery.

Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool

Objectives  To survey infrastructure characteristics, personnel, equipment and procedures of surgical, obstetric and anaesthesia care in 17 hospitals in Ghana.

Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews

BACKGROUND For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.

Low-cost mesh for inguinal hernia repair in resource-limited settings

IntroductionHernia repair is one of the most frequently performed surgical procedures worldwide, yet more than half of hernias may be untreated in African countries that lack adequate and affordable surgical care. Although this disease burden can be effectively reduced by surgical repair, public health efforts to promote repair have been sparse because of the presumed high cost of surgery.ObjectiveTo review the epidemiology and treatment of hernias in African countries and to assess the efficacy and safety of using low-cost mesh for repair in resource-limited settings.MethodsAn extensive literature search was performed using PubMed and the Cochrane Library to locate pertinent background information and studies that used low-cost alternatives to commercial mesh.ResultsMost hernia repairs in Africa are performed as high-risk emergency procedures. When treatment is provided, fewer than 5% are repaired using implanted mesh because of its high cost, despite the demonstrated improvement in clinical outcomes with tension-free repair. A total of four studies using low-cost mesh were reviewed. Three of the studies compared postoperative outcomes for repairs using sterile mosquito nets with those using commercial surgical mesh. The fourth study randomized patients to receive either an indigenous bilayer device or the Prolene Hernia System. No significant differences in recurrence or in incidence of wound complications between repairs using low-cost and commercial mesh were observed. The price of low-cost mesh was generally less than 1/1,000 the price of commercial mesh.ConclusionsThere were no significant differences in outcomes between repairs using low-cost and commercial mesh. While the size of the study populations and the limited time for follow-up preclude conclusive measures of effectiveness, recurrence, and long-term complications, these studies demonstrate that providing an improved standard of surgical care need not be prohibitively expensive.

Insights from Community Case Management Data in Six Sub-Saharan African Countries

There is strong research evidence that community case management (CCM) programs can significantly reduce mortality. There is less evidence, however, on how to implement CCM effectively either from research or regular program data. We analyzed monitoring data from CCM programs supported by the International Rescue Committee (IRC), covering over 2 million treatments provided from 2004 to 2011 in six countries by 12,181 community health workers (CHWs). Our analysis yielded several findings of direct relevance to planners and managers. CCM programs seem to increase access to treatment, although diarrhea coverage remains low. In one country, the size of the catchment area was correlated with use, and increased supervision was temporally and strongly associated with improved quality. Planners should use routine data to guide CCM program planning. Programs should treat all three conditions from the outset. Other priorities should include use of diarrhea treatment and insurance of adequate supervision.

Comparing estimates of child mortality reduction modelled in LiST with pregnancy history survey data for a community-based NGO project in Mozambique

BackgroundThere is a growing body of evidence that integrated packages of community-based interventions, a form of programming often implemented by NGOs, can have substantial child mortality impact. More countries may be able to meet Millennium Development Goal (MDG) 4 targets by leveraging such programming. Analysis of the mortality effect of this type of programming is hampered by the cost and complexity of direct mortality measurement. The Lives Saved Tool (LiST) produces an estimate of mortality reduction by modelling the mortality effect of changes in population coverage of individual child health interventions. However, few studies to date have compared the LiST estimates of mortality reduction with those produced by direct measurement.MethodsUsing results of a recent review of evidence for community-based child health programming, a search was conducted for NGO child health projects implementing community-based interventions that had independently verified child mortality reduction estimates, as well as population coverage data for modelling in LiST. One child survival project fit inclusion criteria. Subsequent searches of the USAID Development Experience Clearinghouse and Child Survival Grants databases and interviews of staff from NGOs identified no additional projects. Eight coverage indicators, covering all the project’s technical interventions were modelled in LiST, along with indicator values for most other non-project interventions in LiST, mainly from DHS data from 1997 and 2003.ResultsThe project studied was implemented by World Relief from 1999 to 2003 in Gaza Province, Mozambique. An independent evaluation collecting pregnancy history data estimated that under-five mortality declined 37% and infant mortality 48%. Using project-collected coverage data, LiST produced estimates of 39% and 34% decline, respectively.ConclusionsLiST gives reasonably accurate estimates of infant and child mortality decline in an area where a package of community-based interventions was implemented. This and other validation exercises support use of LiST as an aid for program planning to tailor packages of community-based interventions to the epidemiological context and for project evaluation. Such targeted planning and assessments will be useful to accelerate progress in reaching MDG4 targets.

Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach.

BackgroundThere is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients’ health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems – the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated.MethodsWe explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component.ResultsWe identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system.ConclusionsWe believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.

Reducing child global undernutrition at scale in Sofala Province Mozambique using Care Group Volunteers to communicate health messages to mothers.

Care Group peer-to-peer behavior change communication improved child undernutrition at scale in rural Mozambique and has the potential to substantially reduce under-5 mortality in priority countries at very low cost. Care Group peer-to-peer behavior change communication improved child undernutrition at scale in rural Mozambique and has the potential to substantially reduce under-5 mortality in priority countries at very low cost. Background: Undernutrition contributes to one-third of under-5 child mortality globally. Progress in achieving the Millennium Development Goal of reducing under-5 mortality is lagging in many countries, particularly in Africa. This paper shares evidence and insights from a low-cost behavior-change innovation in a rural area of Mozambique. Intervention: About 50,000 households with pregnant women or children under 2 years old were organized into blocks of 12 households. One volunteer peer educator (Care Group Volunteer, or CGV) was selected for each block. Approximately 12 CGVs met together as a group every 2 weeks with a paid project promoter to learn a new child-survival health or nutrition message or skill. Then the CGVs shared the new message with mothers in their assigned blocks. Methods of evaluation: Household surveys were conducted at baseline and endline to measure nutrition-related behaviors and childhood nutritional status. Findings: More than 90% of beneficiary mothers reported that they had been contacted by CGVs during the previous 2 weeks. In the early implementation project area, the percentage of children 0–23 months old with global undernutrition (weight-for-age with z-score of less than 2 standard deviations below the international standard mean) declined by 8.1 percentage points (P<0.001), from 25.9% (95% confidence interval [CI] = 22.2%–29.6%) at baseline to 17.8% at endline (95% CI = 14.6%–20.9%). In the delayed implementation area, global undernutrition declined by 11.5 percentage points (P<0.001), from 27.1% (95% CI = 23.6%–30.6%) to 15.6% (95% CI = 12.6%–18.6%). Total project costs were US