HOW EFFECTIVE ARE COMMUNITY HEALTH WORKERS? An Overview of Current Evidence with Recommendations for Strengthening Community Health Worker Programs to Accelerate Progress in Achieving the Health-related Millennium Development Goals September 2012 Henry Perry, Senior Associate Department of International Health Johns Hopkins Bloomberg School of Public Health and Rose Zulliger, PhD Doctoral Candidate Department of Health Behavior and Society Johns Hopkins Bloomberg School of Public Health Acknowledgements This report was prepared for the MDG Health Alliance. Funding was provided by the Alliance and the Rockefeller Philanthropy Advisors, Inc. We are grateful for the assistance of Sara Ju, master’s student in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health, for her assistance in collecting information used in this review and in editing this document. We are also grateful for the assistance of Ingrid Friberg, Assistant Scientist in the Department of International Health, with the LiST calculations. How Effective Are Community Health Workers? | i Table of Contents Acknowledgements .......................................................................................................................... i Glossary ........................................................................................................................................... iv I. Introduction ............................................................................................................................. 1 II. Who Are Community Health Workers? ................................................................................... 1 III. History of Community Health Worker Programs .................................................................... 2 A. National Examples of Large-Scale CHW Programs ................................................................ 4 B. CHW Programs that Have Emerged Since the 1990s ............................................................ 5 IV. Assessing the Evidence on Community Health Worker Effectiveness .................................... 7 V. Evidence of Effectiveness of CHWs in Achieving the Millennium Development Goals for Health ...................................................................................................................................... 8 A. Target 1C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger .................................................................................................................................. 8 B. Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate 10 Immunizations ....................................................................................................................... 10 Community Case Management of Serious Childhood Illness................................................ 11 Malaria ................................................................................................................................... 14 Interventions to Reduce Neonatal Mortality ........................................................................ 15 Impact of Integrated Interventions Provided by CHWs on Under-Five Mortality ................ 16 Modeling the Potential Impact of CHWs on Under-Five Mortality ....................................... 19 C. Target 5A: Reduce by three-quarters the maternal mortality ratio .................................... 21 Training of Traditional Birth Attendants ............................................................................... 21 Prevention of Post-Partum Hemorrhage ............................................................................... 21 D. Target 5B: Achieve universal access to reproductive health services ................................. 22 E. Target 6A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS ................. 24 F. Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it ................................................................................................................................. 25 G. Target 6C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases .................................................................................................................... 26 How Effective Are Community Health Workers? | ii Malaria ................................................................................................................................... 26 Tuberculosis ........................................................................................................................... 27 H. CHW approaches and interventions that have effectiveness in achieving combinations of MDG goals .......................................................................................................................... 28 VI. National Examples of CHW Contributions to Progress in Achieving MDG Goals .................. 29 A. Brazil ..................................................................................................................................... 30 B. Bangladesh ........................................................................................................................... 31 C. Nepal .................................................................................................................................... 32 VII. Evidence Regarding the Effectiveness of Scaling Up Community Health Worker Programs 33 VIII. Equity Considerations ............................................................................................................ 34 IX. Cost-Effectiveness of Interventions and Services Provided by Community Health Workers 35 X. Interpreting the Evidence and Identifying the Knowledge Gaps .......................................... 42 XI. Drivers of Community Health Worker Performance ............................................................. 43 XII. Conclusions ............................................................................................................................ 61 XIII. Recommendations ................................................................................................................. 62 XIV. References ............................................................................................................................. 63 How Effective Are Community Health Workers? | iii Glossary AIDS Acquired immune-deficiency syndrome AIM Assessment and improvement matrix APOC African Program for Onchocerciasis Control ART Anti-retroviral therapy ASHA Accredited Social Health Activist (India) BRAC Building Resources across Communities (formerly Bangladesh Rural Advancement Committee) CBIO Census-based, impact-oriented CCM Community case management CBD Community-based distribution CDI Community-directed intervention CHA Community Health Agent (Brazil) CHD Child Health Day CHW Community health worker CMAM Community-based management of severe acute malnutrition CPR Contraceptive prevalence rate DALY Disability-adjusted life year DOTS Directly observed therapy, short course (for tuberculosis) DMPA Depot-medroxyprogesterone acetate EPI Expanded Program on Immunizations FCHV Female Community Health Volunteer (Nepal) FP Family planning HAS Hospital Albert Schweitzer (Haiti) HIV Human immunodeficiency virus icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh (formerly) IPTc Intermittent preventive therapy to all children ITN Insecticide-treated bed net LiST Lives Saved Tool MCH Maternal and child health MCH-FP Matlab Maternal Child Health-Family Planning MDG Millennium Development Goal MOH Ministry of Health NGO Non-governmental Organization PD Positive deviant ORS Oral rehydration solution How Effective Are Community Health Workers? | iv ORT Oral rehydration therapy RDT Rapid diagnostic test RUTF Ready-to-use therapeutic food SEARCH Society for Action, Education and Research in Community Health (India) TB Tuberculosis TBA Traditional birth attendant TTBA Trained traditional birth attendant UNICEF United Nations Children’s Fund WHO World Health Organization How Effective Are Community Health Workers? | v I. Introduction Community Health Workers (CHWs) provide a critical and essential link with health systems and are a powerful force for promoting healthy behaviors in resource-constrained settings. During the past decade, there has been an explosion of evidence and interest concerning community health workers and their potential for improving the health of populations where health workforce resources are limited. Given the massive shortage of health workers in Africa and Asia – recently estimated to be 4.25 million workers1 – the inequitable distribution of health workers within countries, and the need to accelerate progress in achieving the MDGS for health, it is essential to take stock of the current body of evidence. This document serves to provide an update and supplement to the extensive review carried out by Bhutta and colleagues under the auspices of the World Health Organization and the Global Health Workforce Alliance in 2010.2 II. Who Are Community Health Workers? Viewed from the global perspective, CHWs are a diverse category of health workers who have many specific names that may be unique to the context in which they work (such as ASHA or Angwanwadi workers in India, Promotores in Latin America, Lady Health Workers in Pakistan, or Health Extension Workers in Ethiopia). These