Access to healthcare through community health workers in East and Southern Africa

Abstract

Executive Summary
In the last decade, there has been an unprecedented investment in health care to accelerate the reduction of under-five child mortality. However, one of the main barriers to proven and affordable health care has been limited access to high-impact child survival interventions for pneumonia, diarrhoea and malaria in remote areas and marginalized communities. The deployment of well-supervised Community Health Workers (CHWs) is a strategy that aims to increase access to health care for millions of children across Africa. All 20 countries in the East and Southern Africa Region (ESAR) surveyed have CHWs serving in some capacity.
Policies supportive of CHWs are regularly incorporated into general health policy and strategy documents at a national level, although policy status was not reported for all countries surveyed. CHWs are allowed to provide a wide range of services, as per policy. Indeed, many countries have multiple CHW cadres with differing levels of training, responsibility, and professional status. They provide a spectrum of health-related counselling, as well as preventive and curative health services outside of formal health facilities, bringing services closer to families who previously had limited contact with trained health workers.
Most of the CHW programs described here have multiple external funders and are at least partially funded by donors. Only two countries, Angola and Lesotho, reported supporting their CHW programs fully through domestic funding. However, about half of the cadres listed were at least partially funded through domestic resources. Most of the donor funding is time-bound, which means that there is a need for improved transition planning with respect to implementation. CHW programs can be thrown into crisis at the conclusion of an external grant – governments may attempt to retain the CHWs for some time, but the programs are not sustainable without the financing for incentives and further training.
The approach of using CHWs to identify, treat, and refer complicated cases of pneumonia, diarrhoea or malaria (the leading causes of under-five mortality) is known as integrated community case management (iCCM). At policy and implementation levels, iCCM is often a later stage addition to training and responsibilities in existing CHW programs. Since 2010, at least one cadre of CHWs in about half of ESAR countries conduct iCCM in targeted areas, evaluating patients at home or in the community at the onset of symptoms, and providing immediate treatment or referral.
The main objective of this report is to elucidate the current state of community provision of health services beyond public facilities, through the vehicle of CHWs. Understanding the role of each CHW cadre in the ESAR countries is intended to clarify the current and potential roles of CHWs in contributing to national healthcare systems.
In addition to a comprehensive literature review, the study used a cross-sectional survey with close- and open-ended questions administered to UNICEF Country Offices and other key informants to investigate and map CHW characteristics and activities throughout the region. Responses were received from 20 of the 21 UNICEF Country Offices in the UNICEF East and Southern Africa region in May–June 2013. Data on 37 cadres from across the 20 countries made up of nearly 266,000 CHWs form the basis of this report. This report catalogues the types and characteristics of CHWs, their relationship to the broader health system, the health services they provide and geographic coverage of their work.
Eligibility for candidacy in CHW programs is an area of significant variability among countries and even among cadres within countries. The criteria for eligibility can be subdivided into the following categories: qualifications (academic or skills), age, gender, and geography. The most common qualification-related prerequisites are a minimum level of education (18 cadres) or literacy (17). The level of education required varies from completion of primary school to high school diploma; the latter is often for more responsible cadres, such as in Ethiopia, Namibia, Tanzania, Zambia, and Zimbabwe. For the largest number of programs (13), the age requirement is simply having reached 18 years old or the age of maturity; eight require a minimum age of 20 or 21; and four require an age of 25 or more. No cadre has a strict gender requirement, although four programs in Kenya,
vi
Mozambique, Ethiopia, and Somalia prefer females. All cadres but two (Community Health Assistants - CHAs - of Tanzania and Zambia and Health Surveillance Assistants – HSAs - of Malawi) require CHW candidates to be a resident in and/or elected by the local community.
Pre-service training regimens vary between cadres and countries based on the availability and skills of trainers, training budgets, and the responsibilities of the CHWs being trained. Beyond pre-service training, many countries also provide in-service trainings to extend or refresh the skills of the CHWs. Of the 20 cadres receiving pre-service training in iCCM, the iCCM component generally takes place in less than a week (only five cadres receive more). Both Ethiopia (HEWs) and Zambia (CHAs) provide pre-service training for one year on a range of promotive, preventative and curative services, including a component on iCCM.
CHWs also receive a wide range of incentives for their work, varying from complete voluntary workers (Botswana, South Africa) to what are increasingly called Health Extension Workers (HEWs) or CHAs that are formally employed and paid using domestic funds (Ethiopia, Kenya, Zambia). Along this continuum lie a number of different CHW sustainability strategies from “subsidies” (Mozambique) to performance-based incentives at co-operatives (Rwanda). Zambia has a strategy of having both voluntary CHWs and paid CHAs. About two-fifths of CHWs are full-time and about the same fraction are salaried. Beyond salaries, few financial incentives are available to CHW program managers. These are primarily transportation allowances, bicycles, per diem payments and/or lunch vouchers during training and monthly meetings. Program managers use some non-financial incentives (e.g. t-shirts, badges) as cost-saving methods to keep CHWs engaged, and also to promote awareness of CHW services in the community.
CHWs perform a broad range of activities related to health including preventive counselling, health education, behaviour change communication and health promotion, as well as screening, treatment and referral for a range of diseases (malaria, tuberculosis, HIV, among others). In addition, they help mobilize communities for vaccinations and other community health activities. They often even assist in areas tangentially related to health, such as following up with school dropouts. However, any single CHW cadre only performs a subset of these activities. About half (11) of the countries in the region are utilizing iCCM as a tool to reduce childhood illness and mortality. Because of the community-based nature of iCCM, it is usually conducted via the lowest level of primary care facilities or through CHW programs. Whether facility-based care may be considered iCCM depends on the health system design and if facilities are serving one or multiple communities.
A single CHW provides health care to a catchment population ranging from 200 to 2,500 people. Populations greater than this are generally seen to fall under a Health Centre. Effective supervision of CHWs by public sector staff in health centres is viewed as an important means of integrating CHWs with the public health system. Despite reportedly detailed supervision strategies, a lack of sufficient, supportive supervision was one of the most mentioned challenges across cadres. It appears that these strategies are not being fully executed as designed.
Although the training, incentives, and activities of the CHW cadres vary greatly among countries, the challenges faced by CHW programs are similar: providing incentives for motivating and retaining CHWs, conducting supervision, coordinating CHW activities with the health system, and maintaining the supply chain for services provided by CHWs. Addressing these challenges must be prioritized if efforts to increase the scope and quality of CHW services are to be successful.
At the global level, CHWs have largely been considered to be a homogeneous class of healthcare worker. A more nuanced differentiation would be helpful to improve policy coordination, strategic planning and implementation of community-based health care. Based on results of the present survey, a post-hoc classification identified four distinct types of CHWs in ESAR countries:
vii
Summary Table: CHW classification model
CHW model name Services offered Level of effort Paid? Total CHW cadres in classification Curative Preventive Reproductive & family planning Case Manager iCCM Yes Maybe Most Full-time Usually 17 Community Liaison Disease Management Yes Maybe Part-time Mixed 9 Health Promoter No Yes Usually Part-time Rarely 10 Traditional Birth Attendant (TBA)-plus No Maybe Yes Part-time Rarely 1
There was only one TBA-plus CHW cadre reported in this study. However, this may be due to the under-reporting of traditional birth attendants, as these are often considered a separate class of healthcare worker rather than a subset of CHWs. Having TBAs engaged in a slightly broader range of reproductive health activities beyond maternal delivery (including family planning) is likely more widespread and would be a low-cost model for expanding CHW care given the high geographic coverage of TBAs in many countries.
In summary, this research documents that CHWs provide a variety of services with a broad range of potential tools. The report presents current training, responsibilities, and the scale of CHW programs in 20 ESAR countries. It also puts forward a potential CHW classification model to improve advocacy for and targeting of appropriate community health interventions (see Summary Table, Table 3 and Annex 5).