How Effective Are Community Health Workers?

"The purpose of this review is to assess the effectiveness of CHW programs, with particular emphasis on how they have or how they might assist countries in achieving the health-related MDGs."

In recognition of the needs for achieving the Millennium Development Goals (MDGs) for health and the" massive shortage and inequitable distribution" of health workers in Africa and Asia, this document, prepared for the MDG Health Alliance, serves to provide an update and supplement to a 2010 review of community health workers (CHWs) done by the World Health Organization (WHO) and the Global Health Workforce Alliance.  The review describes, within a framework of the MDGs, the kinds of: face-to-face, interpersonal, and group public health education; personal empowerment and efficacy; and direct treatment and treatment access addressed by CHW programmes. [Footnotes have been removed throughout by the editor.]

This review includes an overview of research that addresses the complexity of measuring health in a population and the relationship of the work of CHWs to those measurements, based upon MDG targets. Below are examples of the kinds of information and the organisation of information in this review:

Addressing world hunger:

• "The promotion of exclusive breastfeeding by CHWs through community-based interventions has been shown to be highly effective. According to one recent systematic review and meta-analysis of randomized controlled trials, the odds of exclusive breastfeeding was 5.6 times greater in the group exposed to the CHW intervention compared to the group that was not."
• "The effectiveness of CHWs in promoting appropriate feeding after 6 months of age... is minimal at best according to current evidence..."
• "There is extensive experience in small-scale projects and limited experience in large-scale projects of CHWs" helping mothers through using the Positive-Deviance (PD) Hearth Model to learn local knowledge on successful feeding and childcare practices. "The most significant example of the effectiveness of PD Hearth is from Vietnam, where early success in reducing the percentage of children with severe malnutrition (from 23% to 6%) led to a scaling up of the program to two districts with a population of 1.2 million people and a reduction in the prevalence of severe malnutrition for 19% to 4%."

Addressing the under-five mortality rate:

•  "The effectiveness of CHW interventions in expanding immunization coverage and especially in reaching priority, hard-to-reach groups is well-documented in numerous reviews. These studies complement numerous other studies that demonstrate that in rural or marginalized populations, face-to-face one-one interpersonal communication through CHWs is the most effective means of promoting immunization uptake."
• CHWs can provide pregnant women with basic education on healthy and hygienic pregnancy, birth, and newborn care during prenatal home visits. "An analysis of combined results of eight studies [in Bangladesh, India, Nepal, and Pakistan] of home-based newborn care provided by CHWs indicates that newborn mortality can be reduced by 24% using this approach." Participatory learning and action groups that build self-awareness, such as the Care Group model, have shown statistically significant reductions in neonatal mortality, with a 30% reduction in Nepal and a 32% reduction in India. Child health days and family interventions that package immunisations with other family planning and birth-related care are also shown to be effective.

Addressing maternal mortality:

• Trained birth attendants and family planning services educators are roles for CHWs that have reduced maternal mortality rates in some areas. These programmes need to: use strategies guided by community opinion and build political and bureaucratic support, among other sound management priorities for sustainability.

Halting and reversing the spread of HIV/AIDS and increasing access to treatment:

• "Initially, CHW home-based care programs were used to support primary care givers....CHWs fill diverse roles in HIV prevention and care, including provision of home-based, palliative care, voluntary HIV counseling and testing services, treatment preparation and support services, community mobilization and HIV prevention/ health promotion. In South Africa, these prevention services include condom provision and promotion, community-based HIV education and mobilization for HIV testing and treatment." CHWs, some of whom are HIV positive, can provide peer-to-peer support. "Studies in Haiti and inner-city Boston found that CHWs effectively monitored treatment, provided psychosocial support, and were associated with reduced stigma and improved ART adherence. Additionally, access to community support in the form of CHWs, treatment buddies and/or HIV/AIDS support groups, was the strongest predictor of treatment success in the public sector ART program in one South African province..."

The studies reviewed include integrated approaches such as an approach called Community-Directed Interventions (CDI), in which communities are given responsibilities for the planning and delivery of medications for certain diseases. Studies show that communities can partner with CHW programmes to enhance care.

As stated here, "there is substantial evidence on common challenges faced by large-scale CHW programs, but less clear evidence on best practices in CHW program design and implementation." However, known best practices include:

• a country-wide comprehensive policy framework that is friendly to CHW programmes.
• communities as partners in CHW programmes, including participation in programme design, in the selection of CHWs, and in providing oversight to CHW performance at the community level.
• financial support and engagement in planning, training, and deployment from the national to the local level.
• a well-designed and clearly defined job description for the CHW, along with: sufficient numbers of workers for the tasks required; appropriate pre- and in-service education and training; linkage to the formal health system for supervision, referrals, and supplies; both financial and non-financial incentives; and advancement opportunities.
• access to mobile health technology.
• monitoring and evaluation.