Abstract
BackgroundOver thirty years have passed since the Alma-Ata Declaration on primary health care in 1978. Many governments in the first decade following the declaration responded by developing national programmes of community health workers (CHWs), but evaluations of these often demonstrated poor outcomes. As many CHW programmes have responded to the HIV/AIDS pandemic, international interest in them has returned and their role in the response to other diseases should be examined carefully so that lessons can be applied to their new roles. Over half of the deaths in African children under five years of age are due to malaria, diarrhoea and pneumonia - a situation which could be addressed through the use of cheap and effective interventions delivered by CHWs. However, to date there is very little evidence from randomised controlled trials of the impacts of CHW programmes on child mortality in Africa. Evidence from non-randomised controlled studies has not previously been reviewed systematically.MethodsWe searched databases of published and unpublished studies for RCTs and non-randomised studies evaluating CHW programmes delivering curative treatments, with or without preventive components, for malaria, diarrhoea or pneumonia, in children in sub-Saharan Africa from 1987 to 2007. The impact of these programmes on morbidity or mortality in children under six years of age was reviewed. A descriptive analysis of interventional and contextual factors associated with these impacts was attempted.ResultsThe review identified seven studies evaluating CHWs, delivering a range of interventions. Limited descriptive data on programmes, contexts or process outcomes for these CHW programmes were available. CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions.ConclusionsCHW programmes could potentially achieve large gains in child survival in sub-Saharan Africa if these programmes were implemented at scale. Large-scale rigorous studies, including RCTs, are urgently needed to provide policymakers with more evidence on the effects of CHWs delivering these interventions.
Highlights
Over thirty years have passed since the Alma-Ata Declaration on primary health care in 1978
It has been argued that where national community health workers (CHWs) programmes have failed, this has not been due to a failure of the concept of CHWs or Primary Health Care (PHC) but because the support and supervision necessary to make them effective were too often missing
This paper reports how we conducted the systematic review, an analysis of the studies identified by the review with descriptions of the CHW programmes they evaluated, and the observations and conclusions we have made
Summary
Over thirty years have passed since the Alma-Ata Declaration on primary health care in 1978. Many governments in the first decade following the declaration responded by developing national programmes of community health workers (CHWs), but evaluations of these often demonstrated poor outcomes. In 1978, the Declaration of Alma-Ata presented Primary Health Care (PHC) as the means of achieving Health for All and community or lay health workers (CHWs) became a distinguishing feature of PHC implementation as it was rolled out. Recent developments confirm the growing recognition of the importance of PHC It was the main subject of the 2008 WHO World Health Report, has the endorsement of WHO Director-General Margaret Chan [5], and was the topic of a themed issue of the Lancet [6]
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