1 Million Community Health Workers by 2015—Is Family Planning the Missing Ingredient?
As resource-constrained countries struggle with the brain drain of medical workers, overcrowding of hospitals, weak health systems, and the reluctance of trained health personnel to work in rural areas, a New Solutions Initiative of the United Nations Sustainable Development Solutions Network is underway to put in place 1 million community health workers (CHWs) by 2015.
In rural areas of sub-Saharan Africa, CHWs have for many years provided selected rural populations with basic medical care, contraceptive supplies, and information that they otherwise would not be able to access. But these efforts have not been widespread and have often run out of funding after the initial investment. In other countries such as Brazil, Bangladesh, China, and Nepal, CHW efforts have been more successful, according to a recent report, (PDF), “How Effective Are Community Health Workers?” by Henry Perry and Rose Zulliger from the Johns Hopkins Bloomberg School of Public Health.
Answering their own question, Perry and Zulliger conclude that “CHWs provide the world’s most promising health workforce resource for accelerating progress in achieving the health related MDGs (Millennium Development Goals).”
I was therefore surprised to see that apart from HIV prevention on the About page of the new 1 Million Community Health Workers website, there was no mention of family planning counseling or contraceptive distribution, much of which has and is being done by community health workers. A clue to this omission can be found in a Technical Task Force Report (PDF) posted on the site. In a note about costs, it says that the estimated calculated cost of US$6.56/person covered by CHW services (at a ratio of one generalist CHW for every 650 rural Africans and one childbirth-specialist CHW for every 3,500 Africans) does not include “two potential Community Health Worker services: offering family planning services and providing HIV screening for the general population. Since there is no consensus among public health specialists on whether CHWs should be tasked with these services, we separate them...” The report goes on to say that “studies have found that the average cost of family planning per user is around $20 per woman per year, including the cost of contraceptives. Having generalist CHWs extend family planning services at this cost per woman in her reproductive years (ages 15-49) averages $1.6 billion per year, or $5.38 [more] per person serviced by the CHW program.”
Perry and Zulliger, on the other hand, indicate in their report that these programs (originally known as Community Based Distribution) have increased utilization of family planning services and decreased costs for clients (and increased convenience) when compared to facility-based services, particularly in rural areas. They cite the example of Bangladesh—considered to have had one of the world’s most successful family planning programs in a setting where there was not concurrent rapid economic development. “This program’s ‘backbone’ was the community-based distribution of pills and condoms by Family Welfare Agents who visited the homes of women every two months throughout the country.”
I was pleased to see that the new 1 Million Community Health Workers website’s blog page did post an article on March 1 about Perry and Zulliger’s report saying that services delivered by CHWs that hold the most promise for reducing maternal and child mortality are: “family planning, distributing misoprostol (for reducing the risk of post-partum hemorrhage in women who give birth at home), essential neonatal care at home, promoting exclusive breastfeeding during the first six months of life, integrated community case management of childhood illnesses (pneumonia, diarrhea and malaria), and promoting and providing immunizations.”
According to Perry and Zulliger, “The cost-effectiveness of these programs becomes even greater as CBD programs are linked to other interventions such as immunizations.” They write that a recent review showed that CHWs can safely provide a number of contraceptive methods, including oral contraceptive pills, condoms, emergency contraception, injectables, the Standard Days Method, and the Lactational Amenorrhea Method. They can also effectively refer patients for long-acting and permanent forms of family planning.
Many countries including Afghanistan, Ethiopia, and Uganda have successfully used CHWs to provide family planning and increase the percentage of couples using a modern method.
Perry and Zulliger caution, however, that “In spite of the growing enthusiasm for expanding CHW programs, as evidenced by a recent high-level call by a global Technical Task Force to train one million CHWs in Africa, it remains the case that...our knowledge of the effectiveness of large-scale CHW programs remains limited, and the challenges faced by early large-scale CHW programs appear to still be present.” They note that some earlier failures of CBD of contraceptives in Africa provide important clues as to why similar CHW programs also failed:
- Failure to give adequate attention to sound management and quality assurance, especially as programs scale up
- Failure to test and develop pilot approaches and scaling up without making adjustment to large-scale operations
- Failure to use strategies that are guided by community opinion
- Failure to build political and administrative/bureaucratic support for the program
- Premature focus on sustainability and cost recovery
Let us hope that this new initiative will not only take note of these lessons, but also build on the successful record of community-based distribution of contraceptives as a major ingredient in the effort to bring health services to rural populations in Africa over the next few years.