Defining Skilled Care: Assessing the Effectiveness of Community Health Workers

The 2005 World Health Report estimated that an additional 700,000 skilled birth attendants are needed to provide universal coverage of maternal and newborn services in the 75 countries where maternal and neonatal mortality is highest. The shortage of skilled health workers is particularly salient as the interventions which have the greatest effect on neonatal deaths are most dependent on skilled assistance, rather than technology and products. Global actors advocate for a woman’s right to choose to deliver with a skilled attendant present, as well as for a reserved right to access safe professional care in case of emergencies or complications for either her or her baby. However, this right is greatly unfulfilled in developing countries. In south Asia and sub-Saharan Africa, where two-thirds of neonatal and maternal deaths occur, only about a third of women deliver in the presence of a skilled attendant. These disparities persist within developing countries as well, as the richest women have six-times higher skilled attendance coverage than the poorest women.

In response to these huge shortages—and their implications for equitable access for the poorest—the use of community health workers has long been championed as cornerstone of PHC. Surrounding Alma-Ata in the 1970s and 1980s mass training of community health workers and traditional birth attendants was promoted by the WHO and others. As conceived within the principles of CBPHC, the CHW combines promotional, preventative and curative service functions for comprehensive health and wellbeing, including intersections with agricultural and economic needs of the community. CHWs were viewed as a much-needed link between formal health services and poor and marginalized communities. Indeed, several studies show that CHWs may be the only feasible and acceptable link to improve health in the near term. And, these bridging activities can close gaps in preventative and curative care for greater effectiveness of services in the long term as well.

A village health worker in Gadchiroli, India monitors newborns' growth. 

CHWs are also less susceptible to brain-drain and co-option into vertical programs. This is because their skills are specific to their community, and less transferrable than the skills of nurses or physicians. Additionally, CHWs often work to increase community management and ownership of health-related programs, and thus are accountable to their own communities, rather than an external organization. This, and the great sense of pride CHWs feel for their work, as well as the elevated status and respect they receive, further contribute to their desire to remain within their communities over time.

While there is robust evidence that CHWs have been effective in improving health—especially child health—implementation of CHW programs has been variable. Overall, CHW programs have been faulted for insufficient focus on training and supervision, and inadequate links with the health system, e.g. via referral systems. This has severely limited CHWs impact on neonatal health. A meta-analysis of mainly observational studies notes a small decrease in perinatal mortality (8%) and birth asphyxia-specific neonatal mortality (11%) in those cared for by trained traditional birth attendants. While positive, this impact suffers from the inadequate implementation constraints mentioned above.

Due to differential quality of care in CHW programs, the 1990s witnessed a major reversal in policy, with the WHO and other UN agencies strongly discouraging the use of traditional birth attendants and exclusively promoting facility births with skilled attendants. This remains the preferred option today, with calls for major investments in scaling-up midwifery, nursing and physician programs.

While the need for quality, skilled care with linkages to the health system is crucial, the current global strategy creates a vacuum for poor communities currently experiencing the highest neonatal and maternal mortality rates. Training of midwives will take decades, and in the meantime communities will suffer.

CHW programs are still relevant; as CHWs have a role to play that can be fulfilled neither by formal health services nor by communities alone. Furthermore, unlike the purely technical functions of midwives, CHWs are much-needed advocates for social change in the systemic causes of ill-health. However, better tools for measuring progress on these goals are needed to inform and support CHWs’ work.

We can learn from failed CHW programs in the past, and develop new innovative approaches to link the role of CHWs with a strong continuum between community and facility care. This sort of linking of care has been demonstrated as much more effective in reducing maternal and newborn deaths than focusing on either the community or facility alone. For example, evidence shows that bringing traditional birth attendants into facilities for training has been effective in promoting emergency obstetric referrals. Additionally, skills of various cadres of workers can be combined into collaborative teams, with nurse-midwives supervising CHWs in community-based delivery, to raise access to skilled care over time. This “frontline health worker” team approach can also ensure focus on both maternal and neonatal health needs. For example, tasking traditional birth attendants with primary responsibility for mothers, and village health workers with the health of the newborn. The creation of new cadres of community-based health workers for more comprehensive care across the lifecycle has also been undertaken; for example multipurpose health extension workers in Ethiopia.

WHO has recently held talks revisiting the role of traditional birth attendants and other community-level health workers. How can we continue to learn from the past, and find new ways of strengthening health workforce for the future?