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Can the deployment of community health workers for the delivery of HIV services represent an effective and sustainable response to health workforce shortages? Results of a multicountry study

Celletti, Francescaa; Wright, Annaa; Palen, Johnb; Frehywot, Sebleb; Markus, Anneb; Greenberg, Alanb; de Aguiar, Rafael Augusto Teixeirac; Campos, Franciscod; Buch, Erice; Samb, Badaraa

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doi: 10.1097/01.aids.0000366082.68321.d6
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Abstract

Introduction

The shortage of qualified medical staff in low and middle-resource countries has reached a crisis point and represents a major barrier to scaling up HIV services. A 2006 report from the World Health Organization (WHO) on antiretroviral therapy (ART) coverage and a subsequent report released by the Joint United Nations Programme on HIV/AIDS (UNAIDS) on the barriers to scaling up HIV services both show that a shortage of human resources for health is one of the major bottlenecks [1]. It follows, therefore, that rapid strengthening of human resources for health is a vital part of any effort to increase the coverage of HIV services [2–13].

Several countries have begun to formalize the practice of task shifting for HIV services as one of a range of emergency strategies designed to address the human resources for health crises [14,15]. Task shifting involves extending the scope of practice of existing cadres of health workers to allow for the rational redistribution of tasks among the health workforce in order to make better use of human resources and ease bottlenecks in the service delivery system [2,7,16–19]. For example, in a number of high-income countries, such as Australia, the United Kingdom and Northern Ireland and the United States, as well as in low-income countries such as Malawi, the role of nurses has been extended in some settings to include the prescription of routine medication including ART [16,17,20–23].

When necessary, task shifting can also involve the creation of new cadres to extend the workforce capacity. These new cadres can be trained and deployed much faster than traditional medical doctors and nurses because they receive specific, competency-based training that is designed to equip them to perform clearly delineated tasks [24]. New cadres, created under the task shifting approach, can be mid-level (for example, clinical officers who, in the right circumstances, have successfully delivered many of the services traditionally reserved for doctors). The task shifting approach has also been used to deploy community health workers (CHW) – non-professional cadres of health workers who undertake short course training and work within their own communities to complement and support the services provided by other health workers [25]. For example, in Malawi and Uganda, the basic care package for people living with HIV/AIDS has been designed to be delivered by non-specialist doctors or nurses supported by CHW and people living with HIV/AIDS [26]. Similarly, Ethiopia has implemented a plan to hire CHW to expand the current workforce delivering HIV services [27].

The experiences of countries that have deployed CHW in response to the AIDS epidemic have, in many cases, included benefits that extend beyond HIV services and that imply potential for further extending the role of CHW in the delivery of a wider range of health services. Despite many good examples of the successful employment of CHW [28], however, there is still debate about the relative merits and most appropriate role for CHW and a shortage of evidence to show precisely what factors are associated with their successful and sustainable deployment [29]. Our study aimed to evaluate the involvement and contribution of CHW to the HIV response with a focus on identifying the tasks that CHW can deliver successfully and the critical elements of a enabling environment that can ensure that CHW provide quality services in a manner that is sustainable.

Methods

To analyze whether CHW increase coverage of HIV services and to investigate the factors for success, the following two areas of investigation were identified: the reorganization of clinical services under a task shifting model including CHW, and the regulatory and policy framework needed to support such a model. In each area of investigation, different themes were identified, as described in Table 1.

Table 1
Table 1:
Areas of investigation and themes analysed in the country studies.

The method of work included a collection of primary data in five countries: Brazil, Ethiopia, Malawi, Namibia and Uganda. In each area of investigation, the work included desk review, the development of survey tools and data gathering tools, country visits and analysis of findings.

For the analysis of the regulatory and policy framework, the desk review focused on country-specific documents including national strategic plans, policies and guidelines, constitutions and all other legal statutes and regulations that regulate healthcare workers. In Ethiopia, Malawi, Namibia and Uganda, face-to-face interviews were conducted with senior government officials (e.g. Minister of Health, Minister of Education, Minister of Capacity Building), with representatives from national healthcare provider associations, with non-governmental organizations (NGO) providing HIV prevention, care and treatment, with associations representing people living with HIV/AIDS and with other stakeholders in the country. Materials were collected to document the policies (e.g. regulations) and practices found during the site visits. A total of approximately 50 key informants was interviewed in each country, making a total of approximately 200 interviews. In Brazil, national records were reviewed.

For the study of the reorganization of clinical services, a desk review and analysis of human resources plans, and specifically HIV service scale-up plans, was undertaken and included interviews with key informants. In Ethiopia, Malawi, Namibia and Uganda, a total of 73 facilities was selected across the four countries to provide a cross-sectional view of the existing delivery model for HIV services. Information was collected by direct observation of patient–provider encounters using observational checklists (n = 152) and semistructured interviews (n = 389) on the tasks performed by CHW, health outcomes when possible, and service users' satisfaction. The opinions and involvement of people living with HIV/AIDS were collected via standard interviews with key informants and focus group discussion. In Brazil, a review of national data records was performed.

Results

Analysis of regulatory framework for task shifting to community health workers

The research conducted in Brazil, Ethiopia, Malawi, Namibia and Uganda found that all five countries had performed some regulatory assessment to determine the adequacy of the existing norms to support task shifting to CHW, either in the delivery of HIV services or of other services. The assessment typically focused on areas such as: scope of practice; standards of care; pre-service and in-service training; labour issues; working conditions; and supervision and monitoring.

Cross-country findings are presented below in the following categories: collaborative planning; education and training; recruitment procedures; employment conditions; sustainability of financing for the services rendered; and informal constitution of health workers. Promising examples of the creation of CHW cadres are described in Boxes 1–3.

Box. 1
Box. 1
Box. 2
Box. 2
Box. 3
Box. 3

Collaborative planning

Country visits showed that collaborative planning with all relevant stakeholders at the initiation of the design process of any CHW programme, whether for HIV or other services delivery, is a key factor for the success of the programme's development as well as its implementation. For example, for the health extension workers in Ethiopia, the key players include (but are not limited to) Ministry of Health, Ministry of Education and all other line ministries and agencies that have jurisdiction over some aspect of the practice of CHW (e.g. Ministry of Labour, Ministry of Local Government and Rural Development, Ministry of Human Resources Management and Development), medical councils and associations, nurse and midwives councils and associations, and pharmacy, medicine and poison boards and related associations. In Brazil, the family health programme was designed through collaboration between the Ministry of Health, municipal state and managers and Pan American Health Organization (PAHO).

Education and training

Country findings highlighted the need for standardized and nationally endorsed training, which also includes continuing education. Education requirements, training programmes, and certification processes currently vary within and across countries. In Brazil, the Ministry of Health is in charge and offers training through regional health schools. In other countries, the Ministry of Health (specifically the HIV programme) and NGO typically train and ‘certify’ CHW who have undergone a short period of training, with more or less interaction between the ministry and the NGO concerned, as in Malawi and Ethiopia. In some instances, the Ministry of Health will provide the training of NGO-based CHW. In others, such as Uganda, the Ministry of Health will sponsor the training, and in others the ministry will simply approve the curriculum or not intervene at all, as in Namibia.

Recruitment procedures

Recruitment varies significantly within and among countries. In Ethiopia, for example, the Federal Ministry of Health, with regard to the health extension programme (see Box 1) uses as selection criteria people who have been innovators in the community. In contrast, the Community Counsellors in Ethiopia (a NGO programme), must have a high school diploma, be a resident of the town where they will work, should have been involved in HIV-related activities and be willing to serve the area where they live for at least one year. In Brazil, CHW are hired by the municipalities. In Uganda, NGO recruit CHW with diverse backgrounds; some cadres must have a university degree or diploma, whereas others have no previous medical experience.

Employment conditions

Country findings highlighted the need for defined career structures and promotion opportunities, which ideally are incorporated into the creation of a CHW programme and the broader civil servant system already in existence in the country. This was found to have been the case in Brazil and Ethiopia. The findings also pointed to an evolution over time, whereby CHW typically take on additional responsibilities and skills, which are learned on-site and are thus not a part of a standardized training programme with other CHW. Concerns were raised regarding the expansion of the role of CHW based on the local needs of the facility or community and how it may conflict with other professionals who have been trained and certified to provide these services.

Sustainable financing for services rendered

Sustainable payment and financing for services rendered is a key factor in recruiting and retaining CHW. In many cases they are either day or contractual workers with unreliable payment systems for the services that they provide, or they are paid in a non-monetary form. Country experiences support a solution whereby CHW are part of a civil/public service structure. In countries where this integration is not possible, an alternative and reliable source of funding for payments and salaries should be identified and established at the inception of the programme so as to be able to recruit and most importantly retain these CHW in the places that they are most needed to work. In addition to the health extension workers in Ethiopia, another good example of this is the creation of 8000 community nutrition and HIV/AIDS workers by the Office of the President and Cabinet of Malawi. This particular cadre of CHW is the result of combining two cadres that existed under two distinct ministries (the home craft workers under the Ministry of Gender and the farm home assistants under the Ministry of Agriculture). These CHW are civil servants with an established salary payment structure.

Informal constitution of health workers

In each of the countries studied, many CHW are not trained by the Ministry of Education, nor recognized by the Ministry of Public Services or any of the professional councils or associations. Rather, they tend to originate from and be trained through the NGO sector. Often, they receive a small allowance or salary, non-financial incentives, or work on a volunteer basis (particularly at district level health centres). In Uganda, the high level of government support for ‘task shifting’ in the NGO sector has resulted in a large number of cadres providing HIV and non-HIV clinical services in the field. Although this is essential in meeting the needs of communities, it has raised concerns about the level of standard training that is competency based and the extent of the supervision provided to these cadres. Similarly, in Namibia, training is conducted by NGO that support the community volunteers. More than one-third of volunteers undergo a week-long training, whereas other training programmes range from as little as 1–3 days up to 2 weeks. Training programmes vary depending on the type of volunteer, and a clear certification process does not exist. For many, there is no follow-up continuous education system. Creating standards of practice and oversight for CHW was identified as an important step to ensure the safety and quality of services.

Table 2 summarizes the necessary conditions for the successful implementation of the task shifting approach, including CHW, as found in the five study countries.

Table 2
Table 2:
Analysis of regulatory framework: summary of country findings.

Analysis of reorganization of clinical services

Cross-country findings are presented below in the following categories: competencies and scope of practice; coverage and quality of services; mentoring and supervision; service users' satisfaction and CHW views and opinions.

Competencies and scope of practice

The results from the country studies show that CHW contribute significantly to the delivery of HIV services. The tasks that CHW were undertaking were similar between the study countries. In general, they included the identification and referral of people living with HIV/AIDS, counselling and support, the execution and interpretation of rapid HIV testing, follow-up of stable clients on first-line ART, dispensing of drugs prescribed by a qualified provider, tasks related to the prevention of mother-to-child transmission and monitoring and support of adherence. CHW also provided supportive services for HIV care, including as pharmacy assistants, data clerks, X-ray technicians and laboratory assistants. CHW often played other numerous roles and had responsibilities that included providing community level education programming and outreach beyond HIV service delivery, as in Brazil. A complete list of tasks performed in any of the five countries is provided in Table 3.

Table 3
Table 3:
HIV clinical tasks performed by community health workers in the countries studied.

Coverage of services and quality

Observation of the involvement of CHW led to the conclusion that this had a positive impact on both the coverage and quality of services.

First, the study showed that the first contact with the health system for people living with HIV is with CHW in 39% of cases, with doctors in only 24% of cases and with social workers in 15% of cases. With regard to specific country examples, in Ethiopia, people receiving HIV testing and counselling rose from 500 000 to 1 600 000 from 2006 to 2007 after CHW were trained to deliver these services, among other interventions. In Namibia, the facilities with CHW providing adherence counselling and other forms of support witnessed 91% of patients ever started on ART still on first-line therapy. In other facilities in Namibia, the ART initiation rate increased significantly after CHW were appointed to deliver HIV testing and counselling; from having little more than 2000 patients on ART since 2002, the number of patients starting ART increased to 160 per month after the CHW intervention. In Uganda, in the facilities where CHW were assigned to data management, records appeared to be more completed. Furthermore, the facilities applying a task shifting approach that also included CHW had a better default rate than others that were using a more traditional service delivery model (5.8% versus 8.5%). In Brazil, coverage for immunization and prenatal consultancies increased significantly and infant mortality decreased after the deployment of CHW in the family health teams.

Mentoring and supervision

Better outcomes were observed when CHW were offered sustained and supportive supervision within the structure and functions of the health team. When it occurs continuously, this type of supervision becomes a routine part of a health worker's job. Such supervision can have a motivating effect on health workers and is an opportune time to provide follow-up training, improve performance and solve other systemic problems. It is also important to underline that certain tasks can be safely delegated only if supervision is provided on a constant basis. It was observed that supportive supervision requires motivation on the part of supervisors and staff to adopt new behaviour, locally appropriate tools and the investment of time and resources. In Brazil, for example, 30 CHW are under the supervision of one nurse and, in the family health teams, four to six are supervised by a nurse. Also of importance was the commitment of the top management and the integration of the programme into existing human resource management systems.

Services users' satisfaction

People living with HIV reported a high level of satisfaction with the services they received from CHW. In a survey of 200 people living with HIV, more than 90% were satisfied or extremely satisfied with their assigned CHW.

Community health workers' views and opinions

The study also included focus groups and qualitative interviews with over 400 CHW to understand their expectations and to assess their understanding of their contribution to the health care of the community they service. CHW stated their willingness to assume more extended tasks. In some cases, professional health workers, such as nurses and doctors, supported the role of CHW and recognized that their services allowed them to concentrate on more complicated tasks. In other cases, however, senior cadres felt threatened by CHW. Focus group discussions with people living with HIV/AIDS concluded that they can make an important contribution in the role of trained CHW. Starting from their personal experience, CHW who are themselves living with HIV can make a crucial contribution to addressing issues such as prevention, disclosure, adherence, self-care and stigma and discrimination. People living with HIV/AIDS often show a preference for CHW who are also living with HIV/AIDS.

Discussion

Learning the lessons of the past

CHW of one kind or another have been involved throughout the history of organized health services [25]. Following the Alma Ata conference in 1978, the Health Care For All movement saw many countries experimenting with different approaches to the mobilization of cadres of health workers with only little formal training in order to expand general health promotion and disease-specific services [28]. Indeed, it was the WHO Alma Ata declaration on Primary Health Care in 1978 that established CHW as a generic title and defined their role internationally [28]. Over time, and under pressure of fiscal reform, however, the commitment of governments to these programmes faltered and, in many cases, their management and funding shifted to the non-state sector [16]. As a result, programmes of varying types, qualities, aims and standards proliferated, and doubts were raised about the potential of CHW to deliver quality care [16].

In the current era, CHW are again being promoted as a key to scaling up health services in the face of both scarce human resources for health and limited financial resources. Bearing in mind the lessons from the past, issues about quality of care, standardization of services and training and certification have now assumed greater importance [16,29]. Also the factors associated with success and sustainability still need to be more fully elucidated [29].

The contribution to the expansion of the health workforce

Our findings show that the deployment of CHW further extends the rational redistribution of tasks under the task shifting approach and can help quickly expand the health workforce both at the facility and the community level. For example, in Ethiopia, 24 500 health extension workers have been trained in 3 years and deployed to their respective communities, and in Brazil the number of CHW increased from 29 000 in 1994 to 229 600 in 2009. Task shifting to CHW can make a major contribution to the decentralization of HIV and other services to rural areas where the shortages of human resources for health are most acute, and so bring health services closer to people in need. CHW can more easily be responsive to marginalized and underserved communities and so contribute to making health services more widely available. Their membership of the communities they serve makes them a vital link to the network of comprehensive public health services. Strong planning and monitoring is, however, needed to ensure an efficient system as a new cadre, or an old cadre with new roles, poses challenges for acceptance, coordination and sustainability. The review of the evidence is also showing that, as of today, CHW are widely distributed around the globe and have a greater presence in rural areas compared with more qualified cadres (Fig. 1).

Fig. 1
Fig. 1:
Percentage of doctors, nurses and non-professional workers in rural areas. Source: World Health Report, 2006.

Improvements in coverage and quality of care

Based on the results of the study, the involvement of CHW is seen to produce good health outcomes and high levels of service user satisfaction at the tertiary level (specialized hospital and facility), the secondary level (district hospital or district outpatient facility) and at the primary level (health centre or at the community level). The inclusion of CHW in health teams allows frequent service–user interaction at the community level, which improves adherence, patient follow-up and psychosocial support. They thus contribute to better outcomes than can be achieved through services delivered only by doctors and nurses.

A review of the recent literature also finds that there is a broad consensus that delegation to cadres of health workers with no formal clinical training can increase access to health care and improve the quality of care. There is quantitative evidence that CHW can have a positive impact on health outcomes. HIV programmes with the involvement of CHW have resulted in better adherence rates and better outcomes on ART [30–32]. A number of studies has found that CHW play an important contributory role in countries that are scaling up HIV services and concluded that overall CHW remain underutilized [33–35]. Some of the most robust evidence of the safety and effectiveness of task shifting to CHW in well-designed programmes comes from rural Haiti, where community-based care of people living with HIV/AIDS has been highly effective [33,34].

There is also evidence that CHW can improve the quality of health care in non-HIV services. In 1983, a primary healthcare programme in the Gambia trained CHW in birthing techniques. After 3 years, maternal and neonatal mortality halved compared with levels before the introduction of the programme [36]. An extensive field trial conducted from 1996 to 2003 in the Gadchiroli district of India trained CHW to deliver primary neonatal care. This trial reported significant improvements in health outcomes and showed that trained CHW are highly effective at reducing mortality among children [37]. Malaria prevention and treatment programmes have also benefited from the use of CHW. A trial of malaria prophylaxis in the Gambia provided by traditional birth attendants significantly reduced the frequency of low-weight births [38]. A study in Zaire published in 1996 introduced CHW to treat malaria in 12 villages in one area while retaining only a health centre in a close ecologically comparable area. After only 2 years, 65% of malaria cases were being treated by these CHW in the 12 villages and morbidity had fallen by 50% compared with the control area [39]. CHW are also playing an increasingly important role in high-income countries such as the United States. It has been shown that they have contributed in increasing access to health care for vulnerable and underserved groups [40–42]. A number of studies exist that have systematically compared services delivered by CHW with the traditional medical model. One review of 43 studies found that CHW programmes showed greater efficiency in certain interventions, such as immunization uptake, but not in others such as the treatment of fever [43]. Other studies have also concluded that CHW interventions can result in better outcomes at some cost saving in comparison with clinic-based care [44–47].

Key factors for success

The results from the country studies consistently show that certain conditions should be observed if CHW are to contribute to well-functioning and sustainable service delivery and to broader human resources for health strengthening. The crucial conditions for success can be clustered around eleven broad areas: (1) political will and commitment; (2) collaborative planning; (3) definition of scope of practice; (4) selection and educational requirements; (5) registration and licensure and certification; (6) recruitment and deployment; (7) systems integration including adequate and sustainable remuneration; (8) mentoring and supervision including referral system; (9) career path and continuous education; (10) performance evaluation; and (11) regular supply of equipment and commodities.

These factors should be addressed when creating and scaling up CHW programmes, and the development and implementation of these conditions should ideally involve a collaboration or partnership among all relevant stakeholders. These are likely to include representatives both of governmental line ministries and of non-governmental stakeholders, such as national and international NGO, international donors and donor countries and international organizations from the United Nations and professional associations. Countries that have implemented successful CHW programmes have benefited from the leadership of their Ministry of Health and noted the shepherding role it had in initiating a collaborative planning process and in inviting all of the relevant stakeholders to the table.

The review of the literature also showed that the provision of some sort of governmental support for task shifting to CHW is critical [48–51], including as key to successful implementation criteria such as standardized training protocol, effective selection and recruitment processes, retention incentives, continuous education and wages or other appropriate and commensurate incentives [52–56]. On this last issue, there is a strong body of evidence indicating that if CHW are to be properly integrated into health systems, they must be sustained through a variety of measures including adequate remuneration [52,54,57]. There is virtually no evidence that volunteerism can be sustained for long periods of time [58].

Barriers to implementation

The study consistently found that cadres that belong to the CHW category are typically not regulated by either the medical or nursing councils or other entities with regulatory authority (e.g. Ministry of Health). In some countries task shifting involving CHW takes place at a local level, but in these cases the country has little control over the process including training, enrolment, retention and quality of the services provided. The lack of regulation can undermine all necessary pre-conditions identified in the study and outlined in the paragraph above, such as the quality of services, adequate remuneration and retention of the cadre in the formal or informal service delivery system. Other additional barriers to the implementation of a task shifting approach that includes CHW were found to be resistance from higher level cadres who may feel threatened by their skills (although it has been observed that these cadres can develop an appreciation for the work of CHW over time as this relieves them of certain duties and allows them to perform higher-level tasks), weakness of the referral systems and finally lack of commodities and supplies.

Conclusion

The multicountry study found consistent evidence that access to quality HIV services can benefit from a task shifting approach employing CHW. This is supported in the findings of other published data. The successful and sustainable deployment of CHW is, however, dependent on the existence of an enabling environment that includes a supportive regulatory framework, functioning referral systems, robust quality assurance mechanisms (such as standardized training and supportive supervision), adequate remuneration of health workers and sufficient resources for health service delivery.

The deployment of CHW, under a task shifting approach, is already being undertaken in many countries to address health workforce shortages, particularly as an emergency response to the HIV epidemic. The tasks that have been safely and efficiently undertaken by CHW are numerous, and cover prevention, treatment and care, as described in Table 3.

There is sufficient evidence to convince policy makers that CHW can make a significant contribution to reinforcing an overstretched health workforce. Unless certain conditions are met, however, the value of the intervention cannot be assured as doubts remain as to the quality and sustainability of the services that can be provided by CHW. If the positive outcomes that have resulted from the deployment of CHW for the delivery of HIV services are to be sustained and extended to a wider range of health interventions, then countries must heed the evidence on the need for an appropriate regulatory environment and for the other enabling conditions. With the necessary support, the valuable addition that CHW can make to the urgent expansion of human resources for health and to universal coverage can be optimized.

Acknowledgements

This study formed part of a more comprehensive research project, ‘The WHO-commissioned Study on Task Shifting’, supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), UNAIDS and Cooperazione Generale allo Sviluppo, Ministry of Foreign Affairs, Rome, Italy. The authors were responsible for conceptualizing the paper, undertaking country visits and personally collecting some of the data. The authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The authors are grateful to the countries that allowed them to gather information; to all those who helped in the collection of the data in countries and to all members of the WHO Task Shifting working group as listed in the WHO guidelines and recommendations on Task Shifting (see http://www.who.int/healthsystems/TTR-TaskShifting.pdf). The WHO guidelines and recommendations on Task Shifting were developed by the Human Resources for Health Department directed by Dr Manuel Dayrit.

Conflicts of interest: None.

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