P-186 Differentiated and simplified PrEP delivery in Italy: alignment with WHO guidance is needed

ABSTRACTCommunity health programs are gaining relevance within national health systems and becoming inherently more complex. To ensure that community health programs lead to equitable geographic access to care, the WHO recommends adapting the target population and workload of community health workers (CHWs) according to the local geographic context and population size of the communities they serve. Geographic optimization could be particularly beneficial for those activities that require CHWs to visit households door-to-door for last mile delivery of care. The goal of this study was to demonstrate the feasibility and utility of geographic optimization in the context of community health programs in rural areas of the developing world. We developed a decision-making tool based on participatory mapping and route optimization algorithms in order to inform the micro-planning and implementation of two kinds of community health interventions requiring door-to-door delivery: mass distribution campaigns and proactive community case management (proCCM) programs. We applied the Vehicle Routing Problem with Time Windows (VRPTW) algorithm to optimize the on-foot routes that CHWs take to visit households in their catchment, using a geographic dataset obtained from participatory mapping onOpenStreetMapcomprising over 100,000 buildings and 20,000 km of footpaths in the rural district of Ifanadiana, Madagascar. We found that personnel-day requirements ranged from less than 15 to over 60 per CHW catchment for mass distribution campaigns, and from less than 5 to over 20 for proCCM programs, assuming 1 visit per month. To facilitate local use of VRPTW algorithms by operational teams, we developed an “e-health” platform to visualize resource requirements, CHW optimal schedules and itineraries according to customizable intervention designs and hypotheses. Further development and scale-up of these tools could help optimize community health programs and other last mile delivery activities, in line with WHO recommendations, linking a new era of big data analytics with the most basic forms of frontline care in resource poor areas.

Community health programs are gaining relevance within national health systems and becoming inherently more complex. To ensure that community health programs lead to equitable geographic access to care, the WHO recommends adapting the target population and workload of community health workers (CHWs) according to the local geographic context and population size of the communities they serve. Geographic optimization could be particularly beneficial for those activities that require CHWs to visit households door-to-door for last mile delivery of care. The goal of this study was to demonstrate how geographic optimization can be applied to inform community health programs in rural areas of the developing world. We developed a decision-making tool based on OpenStreetMap mapping and route optimization algorithms in order to inform the micro-planning and implementation of two kinds of community health interventions requiring door-to-door delivery: mass distribution campaigns and proactive community case management (proCCM) programs. We applied the Vehicle Routing Problem with Time Windows (VRPTW) algorithm to optimize the on-foot routes that CHWs take to visit households in their catchment, using a geographic dataset obtained from mapping on OpenStreetMap comprising over 100,000 buildings and 20,000 km of footpaths in the rural district of Ifanadiana, Madagascar. We found that personnel-day requirements ranged from less than 15 to over 60 per CHW catchment for mass distribution campaigns, and from less than 5 to over 20 for proCCM programs, assuming 1 visit per month. To illustrate how these VRPTW algorithms can be used by operational teams, we developed an "e-health" platform to visualize resource requirements, CHW optimal schedules and itineraries according to customizable intervention designs and hypotheses. Further development and scale-up of these tools could help optimize community health programs and other last mile delivery activities, in line with WHO recommendations, linking a new era of big data analytics with the most basic forms of frontline care in resource poor areas.

Community health programs are gaining relevance within national health systems and becoming inherently more complex. To ensure that community health programs lead to equitable geographic access to care, the WHO recommends adapting the target population and workload of community health workers (CHWs) according to the local geographic context and population size of the communities they serve. Geographic optimization could be particularly beneficial for those activities that require CHWs to visit households door-to-door for last mile delivery of care. The goal of this study was to demonstrate how geographic optimization can be applied to inform community health programs in rural areas of the developing world. We developed a decision-making tool based on OpenStreetMap mapping and route optimization algorithms in order to inform the micro-planning and implementation of two kinds of community health interventions requiring door-to-door delivery: mass distribution campaigns and proactive community case management (proCCM) programs. We applied the Vehicle Routing Problem with Time Windows (VRPTW) algorithm to optimize the on-foot routes that CHWs take to visit households in their catchment, using a geographic dataset obtained from mapping on OpenStreetMap comprising over 100,000 buildings and 20,000 km of footpaths in the rural district of Ifanadiana, Madagascar. We found that personnel-day requirements ranged from less than 15 to over 60 per CHW catchment for mass distribution campaigns, and from less than 5 to over 20 for proCCM programs, assuming 1 visit per month. To illustrate how these VRPTW algorithms can be used by operational teams, we developed an "e-health" platform to visualize resource requirements, CHW optimal schedules and itineraries according to customizable intervention designs and hypotheses. Further development and scale-up of these tools could help optimize community health programs and other last mile delivery activities, in line with WHO recommendations, linking a new era of big data analytics with the most basic forms of frontline care in resource poor areas.

Debt crisis strains Greece's ailing health system

BackgroundThe effectiveness of community health workers (CHWs) in delivering community-based preventive services is often curtailed by inadequate or complete lack of integration of the CHW programmes into national health systems. Although literature has defined the context and guidelines for integrating CHW programmes into health systems, indicators to quantitatively assess the extent of integration are inadequately addressed.AimThis article presents an integration scale – CHW Programme Integration Scorecard Metrics (CHWP-ISM) – for measuring the extent of CHW programme integration into national health systems.SettingLiterature review and policy documents were focused on sub-Saharan Africa, while interview participants were drawn from six African countries.MethodsA deductive–inductive approach to item and measurement scale development was employed. Information obtained from a combination of diverse literature sources, subject matter expert (SME) interviews and documentary abstraction from publicly available policy documents advised item generation for the proposed CHWP-ISM. The study qualitatively captured the sectoral CHW integration, thematically analysed the data and culminated in the quantitative integration metrics.ResultsAnalysis of the responses from six SMEs and abstraction from policy documents resulted in the compilation of metrics with a total of 100 indicators for the CHWP-ISM scale that could be used to assess the level of CHW programmes integration into national health systems. The indicators were categorised along the six World Health Organization’s (WHO) health systems building blocks. Subject matter expert responses corresponded well with abstracted results from the 18 country CHW programmes, indicating content validity.ConclusionThe proposed scorecard metrics can be used to quantitatively rate the extent of CHW programmes integration into health systems, in an attempt to strengthen health systems to improve health outcomes.

Background/Introduction:Research was conducted to identify needs for policy and legislation changes aimed at creating enabling environment for the implementation of the Emergency Medical Teams (EMT) Regional Action Plan 2024-2030 (RAP) to be facilitated by the WHO Regional European EMT Capability Hub (REECH).Objectives:Establishing commonalities and differences in EMT-related policy and legislation in countries representing different subregions of the WHO/Europe.Informing the RAP policy and legislation framework development.Method/Description:An analysis of the legal and normative frameworks governing EMTs in the selected countries – Spain, the UK, Georgia, Kyrgyzstan. The study involves reviewing legislative documents, policy frameworks, and operational guidelines that regulate EMTs’ integration into national health systems and emergency response coordination mechanisms.Results/Outcomes:Common characteristics of national legislation and policy frameworks include clear legal mandates, integration with national health systems, and alignment with national health policies. Differences identified: EMT governance and subordination (e.g., health sector in Georgia and UK, civil protection domain in Spain and Kyrgyzstan); patterns of international collaboration (e.g., stronger engagement with EUCPM for Spain, WHO guidance and support for Kyrgyzstan and Georgia).Conclusion:The WHO European region’s diversity informs different approaches to policies and legislation aimed at supporting RAP. Enablers include clear EMT mandates and their integration with national health systems and international mechanisms. However, routes to these enablers vary due to differences in policies, health system design, and legislation adoption procedures. Future research will include more countries and a detailed list of research questions to identify patterns in legislation and policy enablers for achievement of the Global EMT goals.

Subsequent to the demonstrated potential of community health workers (CHWs) in strengthening health systems to improve health outcomes, recent literature has defined context and guidelines for integrating CHW programs into mainstream health systems. However, quantitative measures for assessing the extent of CHW program integration into national health systems need to be developed. The purpose of this study was to validate a newly developed scale, Community Health Worker Program Integration Scorecard Metrics (CHWP-ISM), for assessing the degree of integration of CHW programs into national health systems in Sub-Saharan Africa (SSA). Data obtained through a pilot study involving a purposively selected sample of 41 participants selected from populations involved in CHW programs work in selected countries of SSA formed the basis of a 31-item bifactor model. Data were collected between June and December 2019. By applying a latent variable approach implemented with structural equation modeling, data analysis was mainly done using the R statistical environment, applying factor analysis procedures. Dimensionality, construct validity, and the CHWP-ISM scale's internal consistency were assessed. Confirmatory factor analysis of the CHW-ISM bifactor model supported a co-occurring CHW integration general factor and six unique domain-specific factors. Both the comparative fit index (CFI) and Tucker-Lewis Index (TLI) fit indices were above 0.9, while the root mean square of the residuals (RMSR) was 0.02. Cronbach's alpha (α), Guttman 6 (Lambda 6), and Omega total (ωt) were above 0.8, indicating good scale reliability. Statistical significance of the bifactor model suggests that CHW integration has to be examined using factors that reflect a single common underlying integration construct, as well as factors that reflect unique variances for the identified six subject-specific domains. The validated CHWP-ISM could be useful to inform policy advisers, health systems, donors, non-governmental organizations, and other CHW program stakeholders with guidance on how to quantitatively assess the integration status of different components of CHW programs into respective critical functions of the health system. Improved integration could increase CHW program functionality, which could in turn strengthen the healthcare systems to improve health outcomes in the region.

BackgroundThe paucity of Human Resources for Health (HRH) is a major global healthchallenge. The World Health Organization (WHO) recognizes the potentialsthat Community Health Workers (CHWs) have in closing the gap of aninadequate supply of human resources for health (HRH). However, weak CHWintegration into national health systems curtails effective implementationof CHW delivered high impact interventions in resource constrained settings.This study assessed the extent of integration of the CHW Recruitment,Education, and Certification (REC) component into the national healthsystem’s HRH building block, using Botswana’s CHW program as a casestudy.MethodsThe study used mixed methods. Data collated from CHW training programdocumentary abstraction, five key informant interviews were analyzedthematically. Data collected through the survey with 123 CHWs were analyzedquantitatively. A recently developed Community Health Workers ProgramIntegration Scorecard Metrics (CHWP-ISM) that comprises of the WHO buildingblocks and corresponding CHW integration metrics, with process, evidence,and status of integration parameters, was used to determine the extent ofintegration.ResultsAn analysis of Botswana’s CHW REC component using the CHWP-ISM scale showedthat the component was 80% integrated into the national HS. Whereas the CHWtraining program was fully government sponsored and accredited, some aspectsof the program’s selection and recruitment criteria and training modalitieswere lacking integration. Although CHW training was exclusively offered at alocal private training institute, findings from documentation reviews,interviewed KIIs and the survey show that the training accreditation,regulation and funding was the responsibility of the central government.ConclusionThe application of the CHWP-ISM scale to assess extent of CHW programintegration into HS identified important CHW human resource integration gapsin CHW selection criteria and recruitment process as well non-inclusion ofCHWs post-training accreditation by national accreditation board ingovernment policy documents.

Purpose: This study aims to explore the role of midwifery practices in promoting maternal and neonatal health, emphasizing the impact of midwifery-led care models, cultural competence, and the integration of midwifery into national health systems. Research Design and Methodology: The research employs a qualitative design, utilizing semi-structured interviews and focus group discussions with midwives, healthcare providers, policymakers, and community health workers in low-resource settings. Thematic analysis was used to identify key themes and patterns within the data. Findings and Discussion: The findings indicate that midwifery-led care models significantly improve maternal and neonatal outcomes by providing continuous, personalized support, which reduces unnecessary medical interventions and enhances maternal satisfaction and emotional well-being. The study also underscores the importance of cultural competence in midwifery, as culturally sensitive care builds trust and improves health outcomes. Integrating midwifery into national health systems, supported by appropriate policies and resources, is crucial for achieving better maternal and neonatal health outcomes. The research highlights the need to address socio-economic barriers that hinder effective midwifery care in low-resource settings. Implications: The study provides valuable insights for policymakers and healthcare providers, emphasizing the need for supportive policies, adequate resources, and continuous professional development for midwives. Countries can enhance maternal and neonatal health outcomes by integrating midwifery services into national health systems and fostering cultural competence. The findings also suggest areas for future research, including the need for more diverse settings and mixed method approaches to provide a comprehensive understanding of midwifery practices.

Although Colombia has a health system based on market and neoliberal principles, in 2004, the government of the capital-Bogota-took the decision to formulate a health policy that included the implementation of a comprehensive primary health care (PHC) strategy. This study aims to identify the enablers and barriers to the PHC implementation in Bogota. The study used a qualitative multiple case study methodology. Seven Bogota's localities were included. Eighteen semi-structured interviews with key informants (decision-makers at each locality and members of the District Health Secretariat) and fourteen FGDs (one focus group with staff members and one with community members) were carried out. Data were analysed using a thematic analysis approach. The main enablers found across the district and local levels showed a similar pattern, all were related to the good will and commitment of actors at different levels. Barriers included the approach of the national policies and a health system based on neoliberal principles, the lack of a stable funding source, the confusing and rigid guidelines, the high turnover of human resources, the lack of competencies among health workers regarding family focus and community orientation, and the limited involvement of institutions outside the health sector in generating intersectoral responses and promoting community participation. Significant efforts are required to overcome the market approach of the national health system. Interventions must be designed to include well-trained and motivated human resources, as well as to establish available and stable financial resources for the PHC strategy.

In May 2006, the Ministers of Health of all the countries on the African continent, at a special session of the African Union, undertook to institutionalise efficiency monitoring within their respective national health information management systems. The specific objectives of this study were: (i) to assess the technical efficiency of National Health Systems (NHSs) of African countries for measuring male and female life expectancies, and (ii) to assess changes in health productivity over time with a view to analysing changes in efficiency and changes in technology. The analysis was based on a five-year panel data (1999-2003) from all the 53 countries of continental Africa. Data Envelopment Analysis (DEA) − a non-parametric linear programming approach − was employed to assess the technical efficiency. Malmquist Total Factor Productivity (MTFP) was used to analyse efficiency and productivity change over time among the 53 countries' national health systems. The data consisted of two outputs (male and female life expectancies) and two inputs (per capital total health expenditure and adult literacy). The DEA revealed that 49 (92.5%) countries' NHSs were run inefficiently in 1999 and 2000; 50 (94.3%), 48 (90.6%) and 47 (88.7%) operated inefficiently in 2001, 2002, and 2003 respectively. All the 53 countries' national health systems registered improvements in total factor productivity attributable mainly to technical progress. Fifty-two countries did not experience any change in scale efficiency, while thirty (56.6%) countries' national health systems had a Pure Efficiency Change (PEFFCH) index of less than one, signifying that those countries' NHSs pure efficiency contributed negatively to productivity change. All the 53 countries' national health systems registered improvements in total factor productivity, attributable mainly to technical progress. Over half of the countries' national health systems had a pure efficiency index of less than one, signifying that those countries' NHSs pure efficiency contributed negatively to productivity change. African countries may need to critically evaluate the utility of institutionalising Malmquist TFP type of analyses to monitor changes in health systems economic efficiency and productivity over time.

At the international level, further reflection on the role of community health workers is in progress. The objective of this work is to develop a model of the integration of community health workers in the National Health System. The study was conducted in Benin and Togo. It was a cluster survey that involved 385Community Health Workers (CHW), 238village heads, 92health care managers selected responsibly, and 6150households selected in a probabilistic manner. The analysis of the strengths, weaknesses, opportunities and threats of interventions under Community directives has contributed to the development of the model.Results: In both countries, community health reference materials existed, and 98.4% community health workers were trained before the beginning of the activities, and all have an intrinsic motivation for the work they do. Only 31.3% of households participated in the selection of community health workers in their locality. The absence of laws recognizing the work of the CHW is a threat to their integration into the healthcare system. The main elements proposed in the model are, the development of the status of community health workers, their remuneration on a budget managed by the health district and fed by several sources. Community Health Workers should not be a health care alternative, but an integral part of the national health system.

Sierra Leone has faced numerous devastating health crises over the past decade, including the Ebola epidemic (2014–2016), the COVID-19 pandemic (2020–2022), and the ongoing mpox outbreak declared on January 10, 2025. These emergencies have exposed the fragility of the healthcare system. Community Health Workers (CHWs) have become indispensable in addressing these challenges, particularly in underserved and remote areas. This commentary highlights the crucial role played by CHWs in bridging healthcare gaps during public health emergencies, and challenges encountered. It also proposes recommendations to enhance their impact in bolstering the Sierra Leone healthcare system. Since Sierra Leone established CHW as a health workforce in 2012, they have played vital roles in outbreak response, including contact tracing, public awareness campaigns, disease surveillance, and ensuring the continuity of care for non-emergency services. Their contributions during health crises, such as breaking disease transmission chains during the COVID-19 pandemic and promoting social mobilization during the mpox outbreak, underscore their central role in building a resilient health system. Despite their importance, CHWs face significant challenges that hinder their effectiveness. These include insufficient training opportunities, inadequate resources such as protective equipment and medical supplies, lack of formal integration into national health systems, and irregular or insufficient remuneration. Addressing these barriers is essential to optimize their impact and sustain their contributions to health system resilience. Key strategies include providing regular training and mentorship, equipping CHWs with essential resources, integrating them into national emergency response plans, and ensuring timely and equitable compensation. The role of CHWs in Sierra Leone offers critical lessons for low- and middle-income countries struggling with healthcare worker shortages. Investing in CHWs enhances emergency preparedness and also strengthens health systems, improves healthcare accessibility, and advances progress toward Sustainable Development Goal 3. Recognizing CHWs as a cornerstone of outbreak response is essential to building resilient and equitable healthcare systems worldwide.

BackgroundBased in part on the success of India’s early community health worker (CHW) programs, the Government of India launched in 1977 a national CHW scheme—the Village Health Guides (VHGs)—to provide preventive, promotive, and basic curative care to rural populations. Although this program had promising origins in smaller demonstration projects, it failed to deliver the hoped-for impact at scale and was abandoned. Based on extensive evidence and experience, the World Health Organization and the World Health Assembly have strongly endorsed the value of national CHW programs and their integration into national health systems. Surprisingly, given the scale and importance of the VHG program and its pioneering nature as a national CHW program, little has been published describing this experience. This article is the second in a series that focuses on critical issues that face the effectiveness of large-scale CHW programs.Case presentationSeveral systemic factors emerge as main contributors to the failure of the VHG Scheme, namely, a lack of support from the formal health sector, an overly hasty implementation of the scheme, and poor communication between the government and health centers about the role of the VHGs. The remuneration structure and the VHG selection process were at the root of the program’s shortcomings at the implementation level.ConclusionNational CHW schemes are an increasingly important tool for achieving universal health coverage and ending maternal and child deaths by 2030. Although the VHG Scheme was initiated over 40 years ago, the lessons described in this case highlight important considerations to help both current and future large-scale CHW programs avoid the same pitfalls.

BackgroundThe World Health Organization’s health systems guidance and the normative standards about health systems endorsed in World Health Assembly (WHA) have the potential to better support national and subnational health...