A timely examination of the potential of lay health workers

The Third Global Forum on Human Resources for Health, held recently in Brazil, put the spotlight on the potential of lay health workers to help address global health workforce shortages. (You can see some of the Twitter reporting from the event at #3GFHRH).

The event is timely given that national health workforce issues will be up for discussion this week at a Health Workforce Australia conference in Adelaide.

A recent Cochrane review examined the role of lay health workers, including traditional birth attendants. In most of the studies reviewed, lay health workers provided care to people who were on low incomes living in wealthy countries or to people living in poor countries.

In wealthy countries, they provided health promotion, counselling and support, and in poor countries they also distributed food supplements, contraceptives and other products, treated children with common childhood diseases, and managed women in uncomplicated labour.

“Rather than being seen as a lesser trained health worker, lay health workers represent a different and sometimes preferred type of health worker. The often close relationship between lay health workers and their recipients is a strength of such programmes,” the review found.

Thanks to Helen Morton, head of communications and external affairs at Cochrane, for the article below which examines how governments can facilitate the uptake of lay health workers. It was first published on the Guardian Global Development platform.

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Just how do you get health services to every woman and every child?

Helen Morton writes:

Community recruits can plug the shortage of qualified health workers and help the UN deliver on its promise to save 16 million women and children by 2015.

The political profile of health workers is now higher than ever. At the UN general assembly in September, world leaders renewed their commitment to deliver for ‘Every Woman Every Child‘, a global movement aiming to save the lives of 16 million women and children.

The third Global Forum on Human Resources for Health that was held recently in Brazil focused on how this rhetoric can be translated into reality.

The forum promised to “kick start a decade of action for human resources for health,” and with the World Health Organization anticipating a global shortfall of 4.2 million health workers by 2015, that action is long overdue.

But it’s not just a numbers game. Yes, more health workers are needed – and rapidly. More finance is required – committed over the long term to address health crises in sustainable ways.

But if health workers are to deliver for ‘Every Woman Every Child’, governments, agencies and NGOs also need to think hard about how and where that money is spent.

‘Task shifting’ is being positioned as part of the solution, with the WHO recently releasing a guideline on shifting tasks to health workers with lower levels of formal education.

Community health workers could increasingly be encouraged to take on tasks despite lacking experience and expertise. For some, this represents a move to second-class care for poor people.

For others, community health workers are a culturally appropriate and cost-effective way of providing access to health care. Reviews of the evidence, however, make clear that community health worker programmes can lead to better health for mothers and children, including increasing rates of breastfeeding and immunisation.

The UN’s ability to deliver on its promise rests, in part then, on the shoulders of the many millions of women working in often-remote communities with little training or support.

So, what can governments do to ensure that the impacts of community health workers can be maximised within, and beyond, the homes and communities in which they deliver health care?

A new review from Cochrane, analysing evidence from over 50 qualitative studies of community health worker programmes globally, has identified eight key factors that could help facilitate success:

1. Community connection: Selecting community health workers with local knowledge and from similar backgrounds to their patients.

2. Incentives: Introducing incentives that community health workers see as fair, consistent and appropriate.

3. Participation: Enabling families and communities to engage in deciding which health services will best meet their needs.

4. Training: Providing sufficient, high-quality and relevant training, including counselling and communication skills.

5. Working conditions: Ensuring a reasonable workload, manageable distances to cover and adequate supplies.

6. Integration: Encouraging clinics and the broader health system to recognise and engage community health workers, and nurses and other health professionals to develop better working relationships with them.

7. Low/no cost services: Delivering health care that is affordable for all.

8. Communication and support: Providing opportunities for community health workers to provide mutual support to one another and building channels for them to voice grievances.

So, the evidence points to key factors that could help increase community health workers’ ability and appetite to deliver. But what does experience tell us?

Patients, policy-makers, programme managers, and community health workers themselves feel there are significant barriers to success.

Alongside questions around credibility, confidentiality and social recognition, the relevance and sufficiency of services represents a real challenge.

Some countries, such as Ghana and Nicaragua, report that community health workers are providing basic curative care, but the majority are focused solely on health promotion activities.

With community health workers regularly reporting being approached about issues outside of their training and an enhanced global commitment to task-shifting, it’s time to stop talking about what community health workers can and cannot do and start actually testing it.

If they are to be valued as different, and sometimes preferred, rather than lesser-trained alternatives, their lack of integration in the broader health system is a barrier to be acknowledged.

Some health professionals see workers’ over-confidence, for example in birth attendance, as a problem. Other doctors and nurses feel that they represent a reduction in their authority and an increase in their workload.

Relationships, between community health workers and their more qualified counterparts, and the communities that they serve, are therefore central to the success of any community health worker programme.

Community health workers don’t represent a ‘silver bullet’ for global health care. They do, however, deliver services that will be central to meeting health and development targets in the decades to come.

As global, national and local leaders move from commitment to concrete activity for ‘Every Woman Every Child’, the evidence of what works must inform action – the recent forum in Brazil being a good place to start.

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Jennifer Doggett will cover the #HWA2013 conference for the Croakey Conference Reporting Service, and you can track the stories here.