Community health workers and
midwifery workforce: reflections
on evidence and future agenda
AMREF Health Africa International Conference
Nairobi
25 November 2014
Dr Giorgio Cometto,
Global Health Workforce Alliance
World Health Organization
Human resources for health:
global challenges, global opportunities
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Source: Campbell et al, GHWA and WHO, 2013
Community health workers: an opportunity
for maternal and child health, HIV, TB …
"Lay health workers provide promising benefits in promoting immunisation
uptake and breastfeeding, improving TB treatment outcomes, and reducing
child morbidity and mortality when compared to usual care" Lewin et al, Cochrane Rev,
2010
"Community health workers …were found to be especially effective in
promoting mother-performed strategies (skin to skin care and exclusive
breastfeeding)." Gilmore and McAuliffe, BMC Public Health 2013
"Community health workers were reported to enhance the reach, uptake and
quality of HIV services, as well as the dignity, quality of life and retention in
care of people living with HIV. The presence of CHWs in clinics was reported
to reduce waiting times, streamline patient flow and reduce the workload
of health workers. Clinical outcomes appeared not to be compromised." Mwai et
al J Int AIDS Soc 2013
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… and more
"Non-specialist health workers have some promising benefits in improving
people's outcomes for general and perinatal depression, post-traumatic
stress disorder and alcohol-use disorders, and patient- and carer-outcomes
for dementia" van Ginneken et al, Cochrane Rev, 2013
"Overall, the studies consistently identified positive outcomes associated with
CHW-delivered interventions, including decreased asthma symptoms,
daytime activity limitations, and emergency and urgent care use." Postma et al J
Asthma 2013
"CHW programmes can have large impacts on the control of Buruli ulcer in
sub-Saharan Africa." Vouking et al, Pan Afr Med J 2013
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Midwifery scale-up could avert 83% of all
maternal and neonatal deaths, stillbirths
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Source: Homer C, Friberg I et al, Lancet, 2014
Success in reducing maternal mortality hinges
on facility births and midwifery scale-up
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Source: Van Lerberghe W, Matthews Z et al, Lancet, 2014
Midwifery-led services can have better
outcomes than standard care models
Lower use of intra-partum regional anaesthesia and episiotomies in
midwifery-led care compared to traditional physician-led care
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Source: Lassi Z, Cometto G et al, WHO Bulletin, 2013
Value for money of CHWs investments
"Using country GDP per capita as the WHO reference threshold for costeffectiveness, all three CHW programmes found to be cost-effective.
Incremental cost per life year gained was estimated to vary between $82 and
$3,396. ... the CHW-led approach has a high likelihood to be a cost-effective
approach to delivery of some essential health interventions." McPake B, Edoka I et
al, GHWA and WHO, 2014 (Health Systems Research Symposium abstract; forthcoming publication)
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Value for money of midwifery investment
16-fold Return on
investment in terms of
lives saved and costs of
Caesarean sections
avoided
through investments in
midwifery education and
deployment to communitybased services.
(State of the World’s Midwifery, 2014)
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The next frontier: CHWs in health systems
• Clear/ transparent
selection system
involving communities
• Curriculum to include
scientific knowledge
on basic preventive
and curative care
• Adapt contents to
health system needs
• Include CHWs in HRH
planning
• Have a budget line /
resource allocation
• Ensure supplies/
equipment
• Effective referral
systems
• Regular monitoring &
supervision
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Planning
Production/
Education
Performance
Deployment
/ retention
Source: Bhutta et al, GHWA, 2010
•
Community
preparedness
• Regular and sustainable
remuneration package
• Opportunities for
professional
development
The next frontier (2)!
Effective coverage of midwifery care
EFFECTIVE
COVERAGE
CRUDE COVERAGE
AVAILABILITY
workforce is
AVAILABLE?
ACCESIBILITY
workforce is
ACCESSIBLE?
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QUALITY
workforce is
ACCEPTABLE?
workforce
provides QUALITY CARE?
• A midwife is available
in or close to the
community
• Woman attends
• Woman attends
• A midwife is available
• A midwife is available
• As part of an integrated
team of professionals,
lay workers and
community health
services
• As and where needed
• Financial protection
ensures no barriers to
access
Source: SoWMy 2014
|
ACCEPTABILITY
• As and where needed
• Providing respectful
care
•
•
•
•
•
Woman attends
A midwife is available
As and where needed
Providing respectful care
Competent and
enabled to provide
quality care.
Global shifts in causes of DALYs (1990-2010)
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Source: IHME, 2013
Pregnancies in 73 SoWMy countries (19502100)
Source: SoWMy 2014
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Remember the future!
Consider long-term vision for CHW integration
• CHWs often seen as short-term stop-gap measure
• But increasing and evolving needs on the horizon, i.e. "0"
targets, growing NCD burden, demand for quality
• Fiscal space improvements will allow greater investment in skilled
HRH
• Role of CHWs to evolve over next decades: less diagnostic/
curative, more health promotion, chronic care management,
treatment compliance
• Plan for CHWs with the country's long-term needs and vision in
mind
• Envisage evolving role for CHWs in health systems
• Tailor selection, education, career pathways accordingly
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Remember the future (2)!
Enable midwifery scale-up and practice
Enabling policy
environment
Enabling
practice
environment
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-align job titles, roles and responsibilities
-allow to practice within full scope of
profession
-strong linkages education/ employment
-licensing/ re-licensing systems
-improve salaries
-incentive for rural deployment/ retention
-access to effective referral
-professional development opportunities
Further information
Health Workforce Department, WHO &
Global Health Workforce Alliance
World Health Organization
Avenue Appia 20 CH-1211 Geneva 27 Switzerland
Email: ghwa@who.int
http://www.who.int/workforcealliance/en/
http://unfpa.org/public/home/pid/16021
http://www.thelancet.com/series/midwifery
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