Executive Summary Community health workers (CHWs) are increasingly shown to have the potential to improve the health status of the population, in particular that of the more disadvantaged or those living in hard to reach areas. Their involvement in mother and child programmes, HIV/AIDs and TB programmes as well as chronic diseases and palliative care has been documented across many countries. Many studies have documented impressive impacts due to better prevention through health education, to significantly higher case-finding than in standard care, better support for treatment adherence and increased control or cure rate, to better support for palliative care allowing patients to remain with their families at the end of their lives. However, in many low income countries the CHW platform has been very patchy with inadequate training, inadequate support and supervision, uncertain funding and low morale amongst CHWs. This weak system then leads to underperformance and disappointing results. In South Africa in 2012 the government launched the PHC re-engineering approach which placed the WBOTs system (Ward-based outreach teams) firmly in the continuum of PHC services with strong linkages with PHC facilities and district hospitals to improve access, detection and support in the community. The roll-out of WBOTs has been uneven and this platform is generally under-resourced. A new study on WBOTs in 2 provinces, with more developed WBOTs system, showed that expenditure on WBOTs represented under 4% of their respective PHC expenditures. The purpose of this investment case commissioned by the National Department of Health is to assess the return on investment of a strong CHW platform in Africa. This report reflects the potential of a high performing CHW platform based on findings from South African or international literature. The first part focusses on the impact of CHWs on the health sector. It follows a life course model and focusses on mother and child health, HIV/AIDs, TB, Hypertension, Diabetes and Palliative care. It estimates deaths averted, DALYs averted, cost per additional DALY averted and whether the intervention is cost-effective or even cost-saving.
Evidence for CHW/lay worker-related interventions for diabetes care The intervention consisted of four 60-min sessions of education that focused on understanding diabetes, living a healthy lifestyle, understanding the medication and avoiding complications. Although the training manual antic- ipated the sessions would last up to 120 min, in reality the sessions lasted up to 60 min. Health promoters recruited from the district health services were trained over a total of 6 days to deliver each session within the facility, using a guiding style of communication on motivational interviewing principles and skills A Systematic Review() of the role of CHWs in diabetes care and management is summarized below. Unique Contributions to Literature Source Population and Setting Study Design and Key Elements of Intervention Outcomes participatory research (CBPR) and description of behavioral theories of intervention Spencer M; Rosland AM; et al. 164 and Latino adults with type 2 diabetes in southwest and east Detroit, MI 6-month RCT to test effectiveness of a CBPR intervention for improving glycemic control. Decrease in HBA1C from 8.6% at baseline to 7.8% at follow up and improved self-reported diabetes understanding CBPR methods to deliver Diabetes Prevention Program(DPP) lifestyle intervention Ruggiero L; Castillo A; et al. 3 Latino populations in southwest Chicago at risk of type 2 diabetes 12-month prospective study of a DPP, intervention Improved physical activity and dietary scores and improved BMI (< .91 kg/m2) and circumference (<1.56 in.) at 6 months study solely utilizing CHWs with dietitian oversight Katula JA: Vitolins MZ; et al. Sample in Forsyth County, NC with fasting glucose from 95–125 mg/dL, and a BMI ≥25 and ≤39.9 kg/m2 RCT testing a CHW-led weight loss intervention based on the Diabetes Prevention Program Improved fasting glucoses (−4.3 vs −0.4 mg/dL) and weight loss (−7.1 vs 1.4kg) compared to control Examination of long-term Brown HS; Wilson KJ; et al. 46 Hispanic 18-month Cost-effective ($33,319/QALY gained) on based based
of CHW intervention using QALYs adults from Laredo, Texas with type 2 diabetes study of of CHW-led lifestyle intervention the conventional $50,000 cutoff per QALY in patients with diabetes Successful implementation of CHWs into team-based care model Hargraves JL; Ferguson WJ; et al. 1415 patients from 12 community health centers in MA (494 patient from 6 centers in intervention) 24-month RCT incorporating CHWs into health care teams Intervention group was more likely to set goals Team-based chronic care management incorporating CHWs Allen JK; CR; et al. 525 patients with CVD or type 2 diabetes from 2 community health centers in Baltimore, MD. 12-month RCT using NP-CHW integrated team model for CVD risk reduction Significant improvement in total cholesterol (difference, −19.7 mg/dL), LDL-C (−15.9 mg/dL), triglycerides (−16.3mg/dL), systolic blood pressure (−6.2 mmHg), HbA1c (−0.5%) and perception of quality of care approach that also provided detailed description of recruitment and training Walton JW; Snead CA; et al. 100 uninsured or underinsured adult patients with type 2 diabetes from 5 charity clinics at 5-year study using CHWs supported by nurse care managers to provide diabetes 18-month results showed improved HbA1c (8.7% to 7.4%) and high levels of satisfaction with the program randomized
Baylor Health Care System in Dallas TX. education Description of a diabetes CHW certificate course Ferguson WJ; Lemay CA; et al. 10 CHWs from 6 community health centers in MA (part of Hargraves et. al study above) study of certificate course with follow-up trainings for CHWs Improved knowledge and skills in diabetes and recommendations for CHW training programs Development of an onsite and based training program Colleran K, Harding E; et al. 23 diverse CHWs from across New Mexico study training program for CHWs New knowledge, skills and confidence for participants. The distance learning strategy allowed for extended training of a diverse group of participants Study of CHWs by role (educator-only or educator + bridge) Ayala GX; Vaz L; et al. 61 CHW programs in Latino communities Systematic review of the roles of CHWs in Latino communities Educator-only programs reached more participants and employed nearly all CHWs as staff; increased contact in educator + bridge. Consensus on CHW scope of practice between CHWs and employers Findley SE; Matos S; et al. 226 CHWs and 44 employers from New York study surveying CHWs and employers on the CHW Nearly all CHWs willing to complete additional training; 93% of employers agreed standardized