1 million community health workers in sub-Saharan Africa by 2015

During the past 10 years, community health workers (CHWs) have emerged as a focal point of international discussions of primary health-care systems. Although lay community-based health workers have been active for at least 60 years, the Millennium Development Goals (MDGs) in 2000 prompted new discussion of how these workers can help to extend primary health care from facilities to communities. CHWs have since been part of an international attempt to revise primary health-care delivery in low-income settings, and CHW programmes have been changed accordingly. Instead of being regarded as unpaid, lightly trained members of the community who focus mainly on health education and provide basic treatments, CHWs are increasingly envisioned as a trained and paid corps who give advice and treatments, and implement preventive measures. Many national governments, including those of Brazil, Pakistan, Ethiopia, and India, are making CHWs a cornerstone of the scaling up of community health delivery. A key diff erence between the old and new CHW models is that workers are now viewed as an integral and formal part of the health system, with reporting lines, training, supervision, and feedback. Several develop ments have stimulated eff orts to develop a more substantial role for CHWs in primary health care; new mobile health technologies, household-administered rapid diagnostic tests, and expert support systems based on information and communications technologies (ICTs) are greatly enlarging the range of services that CHWs can eff ectively provide. New ICTs are also enabling improved training and supervision methods, and make the eff ectiveness of evidence-based com munity-based protocols delivered by CHWs easier to measure and show. On the basis of the new and expanded idea of CHWs as a subsystem within the formal health-care system, the Earth Institute at Columbia University convened a Technical Taskforce in June, 2011, to examine the best practices for scaling up and integrating CHWs into health systems. The Taskforce agreed that to achieve the MDGs, roughly 1 million CHWs should be trained and deployed in sub-Saharan Africa by 2015. The Taskforce’s fi ndings also showed the fairly small cost of scaling up a modern CHW subsystem, estimating that the CHW subsystem costs roughly US$6∙56 per head per year for the covered (rural) population. Finally, the report underscored the importance of integrating CHW subsystems into the next generation of primary health-care delivery. The UN’s Broadband Commission, UNAIDS, Roll Back Malaria, and the MDG advocates are among the groups calling for a massive scaling up of CHWs in sub-Saharan Africa. Before 2000, and in many places until today, CHWs in sub-Saharan Africa were mainly regarded as volunteers who provide a few simple services, mostly in community awareness and disease prevention. However, evidence supports an expanded role of CHWs in communitybased case management, and several reviews and guidelines from WHO now recommend the expansion of CHW activities. In December, 2011, WHO released a 3-year study highlighting the importance of CHWs at the household level. The report builds on other synthesis studies fi nding that when deployed at scale, CHW activities can have a profound eff ect on achieve ment of MDGs 4, 5, and 6. The new integral role for CHWs uses advances in diagnostic and treatment technologies in the management of malaria, pneumonia, malnutrition, and diarrhoea, which con stitute the most preventable common causes of death of children younger than 5 years in sub-Saharan Africa. The CHW subsystem should be regarded as an integral part of WHO’s six health system building blocks: service delivery, health workforce, information, medicines, fi nancing, and governance. As identifi ed by the CHW Technical Taskforce, the critical inputs for a CHW subsystem include: service delivery clarity and capability; health workforce management; information systems and data use; medical products, point-of-care diagnostics, and technology; fi nancing for CHWs; and leadership and governance of system quality. Each of these elements corresponds to one of WHO’s building blocks. In the CHW system deployed in the Millennium Villages outlined in the Technical Taskforce Report, there is a minimum ratio of one CHW for 150 households (about 650 people). CHWs systematically circulate through out their catchment zone, prioritising visits to pregnant women, children younger than 5 years, and sick community members. In the Millenium Villages, CHWs provide health education, pre-approved clinical services, and coordinated referral to health facilities. The CHWs are supported by ICT systems built around mobile telephony, and, increasingly, around smartphones. CHWs are managed in groups of six by senior CHWs, who are experienced CHWs trained in support ive supervision, and who in turn report to CHW managers based at the primary care health centre and trained in management techniques. Since a typical Millennium Village site (cluster) has between 30 000 and 80 000 residents, a site’s CHW manager regularly interacts with eight to 20 senior CHWs. This management system is best regarded as an integrated training and supervisory system in which new CHWs can be closely supported as they gain experience in providing Published Online March 29, 2013 http://dx.doi.org/10.1016/ S0140-6736(12)62002-9