C

Can the deployment of com

munity health workers forthe delivery of HIV services represent an effective andsustainable response to health workforce shortages?

Results of a multicountry study

Francesca Cellettia, Anna Wrighta, John Palenb, Seble Frehywotb,

Anne Markusb, Alan Greenbergb, Rafael Augusto Teixeira de Aguiarc,

Francisco Camposd, Eric Buche and Badara Samba

opyright © L

aWorld Health OrFederal de MinasPretoria, South Af

Correspondence t

Tel: +4122791440

ISS

In countries severely affected by HIV/AIDS, shortages of health workers present a majorobstacle to scaling up HIV services. Adopting a task shifting approach for the deploy-ment of community health workers (CHWs) represents one strategy for rapid expansionof the health workforce. This study aimed to evaluate the contribution of CHWs with afocus on identifying the critical elements of an enabling environment that can ensurethey provide quality services in a manner that is sustainable.

The method of work included a collection of primary data in five countries: Brazil,Ethiopia, Malawi, Namibia, and Uganda.

The findings show that delegation of specific tasks to cadres of CHWs with limitedtraining can increase access to HIV services, particularly in rural areas and amongunderserved communities, and can improve the quality of care for HIV. There is alsoevidence that CHWs can make a significant contribution to the delivery of a wide rangeof other health services.

The findings also show that certain conditions must be observed if CHWs are tocontribute to well-functioning and sustainable service delivery. These conditionsinvolve adequate systems integration with significant attention to: political will andcommitment; collaborative planning; definition of scope of practice; selection andeducational requirements; registration, licensure and certification; recruitment anddeployment; adequate and sustainable remuneration; mentoring and supervisionincluding referral system; career path and continuous education; performance evalu-ation; supply of equipment and commodities.

The study concludes that, where there is the necessary support, the potential contri-bution of CHWs can be optimized and represents a valuable addition to the urgentexpansion of human resources for health, and to universal coverage of HIV services.

� 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

AIDS 2010, 24 (suppl 1):S45–S57

Introduction

The shortage of qualified medical staff in low and middle-resource countries has reached a crisis point andrepresents a major barrier to scaling up HIV services.

ippincott Williams & Wilkins. Unauth

ganization, Geneva, Switzerland, bGeorge WasGerais, Belo Horizonte, Mina Gerais, Brazil, dMrica.

o Francesca Celletti, MD, World Health Organi

3; fax: +41227914747; e-mail: cellettif@who.in

N 0269-9370 Q 2010 Wolters Kluwer He

A 2006 report from the World Health Organization(WHO) on antiretroviral therapy (ART) coverage and asubsequent report released by the Joint United NationsProgramme on HIV/AIDS (UNAIDS) on the barriers toscaling up HIV services both show that a shortage of

orized reproduction of this article is prohibited.

hington University, Washington, DC, USA, cUniversidadeinistry of Health, Brazilia, Brazil, and eUniversity of Pretoria,

zation, 20 Avenue Appia, Geneva, Switzerland.

t

alth | Lippincott Williams & Wilkins S45

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S46 AIDS 2010, Vol 24 (suppl 1)

human resources for health is one of the majorbottlenecks [1]. It follows, therefore, that rapid strength-ening of human resources for health is a vital part of anyeffort to increase the coverage of HIV services [2–13].

Several countries have begun to formalize the practice oftask shifting for HIV services as one of a range ofemergency strategies designed to address the humanresources for health crises [14,15]. Task shifting involvesextending the scope of practice of existing cadres of healthworkers to allow for the rational redistribution of tasksamong the health workforce in order to make better useof human resources and ease bottlenecks in the servicedelivery system [2,7,16–19]. For example, in a number ofhigh-income countries, such as Australia, the UnitedKingdom and Northern Ireland and the United States, aswell as in low-income countries such as Malawi, the roleof nurses has been extended in some settings to includethe prescription of routine medication including ART[16,17,20–23].

When necessary, task shifting can also involve the creationof new cadres to extend the workforce capacity. Thesenew cadres can be trained and deployed much faster thantraditional medical doctors and nurses because theyreceive specific, competency-based training that isdesigned to equip them to perform clearly delineatedtasks [24]. New cadres, created under the task shiftingapproach, can be mid-level (for example, clinical officerswho, in the right circumstances, have successfullydelivered many of the services traditionally reserved fordoctors). The task shifting approach has also been used todeploy community health workers (CHW) – non-professional cadres of health workers who undertake shortcourse training and work within their own communitiesto complement and support the services provided byother health workers [25]. For example, in Malawi andUganda, the basic care package for people living withHIV/AIDS has been designed to be delivered by non-specialist doctors or nurses supported by CHW andpeople living with HIV/AIDS [26]. Similarly, Ethiopiahas implemented a plan to hire CHW to expand thecurrent workforce delivering HIV services [27].

The experiences of countries that have deployed CHW inresponse to the AIDS epidemic have, in many cases,included benefits that extend beyond HIV services andthat imply potential for further extending the role ofCHW in the delivery of a wider range of health services.Despite many good examples of the successful employ-ment of CHW [28], however, there is still debate aboutthe relative merits and most appropriate role for CHWand a shortage of evidence to show precisely what factorsare associated with their successful and sustainabledeployment [29]. Our study aimed to evaluate theinvolvement and contribution of CHW to the HIVresponse with a focus on identifying the tasks that CHWcan deliver successfully and the critical elements of a

pyright © Lippincott Williams & Wilkins. Unauthor

enabling environment that can ensure that CHW providequality services in a manner that is sustainable.

Methods

To analyze whether CHW increase coverage of HIVservices and to investigate the factors for success, thefollowing two areas of investigation were identified: thereorganization of clinical services under a task shiftingmodel including CHW, and the regulatory and policyframework needed to support such a model. In each areaof investigation, different themes were identified, asdescribed in Table 1.

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

For the analysis of the regulatory and policy framework,the desk review focused on country-specific documentsincluding national strategic plans, policies and guidelines,constitutions and all other legal statutes and regulationsthat regulate healthcare workers. In Ethiopia, Malawi,Namibia and Uganda, face-to-face interviews wereconducted with senior government officials (e.g. Ministerof Health, Minister of Education, Minister of CapacityBuilding), with representatives from national healthcareprovider associations, with non-governmental organiz-ations (NGO) providing HIV prevention, care andtreatment, with associations representing people livingwith HIV/AIDS and with other stakeholders in thecountry. Materials were collected to document thepolicies (e.g. regulations) and practices found duringthe site visits. A total of approximately 50 key informantswas interviewed in each country, making a total ofapproximately 200 interviews. In Brazil, national recordswere reviewed.

For the study of the reorganization of clinical services, adesk review and analysis of human resources plans, andspecifically HIV service scale-up plans, was undertakenand included interviews with key informants. InEthiopia, Malawi, Namibia and Uganda, a total of 73facilities was selected across the four countries to provide across-sectional view of the existing delivery model forHIV services. Information was collected by directobservation of patient–provider encounters using obser-vational checklists (n¼ 152) and semistructured inter-views (n¼ 389) on the tasks performed by CHW, healthoutcomes when possible, and service users’ satisfaction.The opinions and involvement of people living withHIV/AIDS were collected via standard interviews withkey informants and focus group discussion. In Brazil, areview of national data records was performed.

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Deployment of community health workers in response to health workforce shortages Celletti et al. S47

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

Analysis of regulatory framework for CHW Analysis of reorganization of clinical services including CHW

Collaborative planning Competencies and scope of practicesEducation and training Access to services and qualityRecruitment procedures Mentoring and supervisionEmployment conditions Service users’ satisfactionSustainability CHW views and opinionsInformal constitution of CHW

CHW, Community health worker.

Results

Analysis of regulatory framework for task shiftingto community health workersThe research conducted in Brazil, Ethiopia, Malawi,Namibia and Uganda found that all five countries hadperformed some regulatory assessment to determine theadequacy of the existing norms to support task shifting toCHW, either in the delivery of HIV services or of otherservices. The assessment typically focused on areas suchas: scope of practice; standards of care; pre-service and in-service training; labour issues; working conditions; andsupervision and monitoring.

Cross-country findings are presented below in thefollowing categories: collaborative planning; educationand training; recruitment procedures; employmentconditions; sustainability of financing for the servicesrendered; and informal constitution of health workers.Promising examples of the creation of CHW cadres aredescribed in Boxes 1–3.

Collaborative planningCountry visits showed that collaborative planning with allrelevant stakeholders at the initiation of the design processof any CHW programme, whether for HIV or otherservices delivery, is a key factor for the success of theprogramme’s development as well as its implementation.For example, for the health extension workers inEthiopia, the key players include (but are not limitedto) Ministry of Health, Ministry of Education and allother line ministries and agencies that have jurisdictionover some aspect of the practice of CHW (e.g. Ministry ofLabour, Ministry of Local Government and RuralDevelopment, Ministry of Human Resources Manage-ment and Development), medical councils and associ-ations, nurse and midwives councils and associations, andpharmacy, medicine and poison boards and relatedassociations. In Brazil, the family health programmewas designed through collaboration between the Ministryof Health, municipal state and managers and PanAmerican Health Organization (PAHO).

Education and trainingCountry findings highlighted the need for standardizedand nationally endorsed training, which also includescontinuing education. Education requirements, trainingprogrammes, and certification processes currently vary

opyright © Lippincott Williams & Wilkins. Unauth

within and across countries. In Brazil, the Ministry ofHealth is in charge and offers training through regionalhealth schools. In other countries, the Ministry of Health(specifically the HIV programme) and NGO typicallytrain and ‘certify’ CHW who have undergone a shortperiod of training, with more or less interaction betweenthe ministry and the NGO concerned, as in Malawi andEthiopia. In some instances, the Ministry of Health willprovide the training of NGO-based CHW. In others,such as Uganda, the Ministry of Health will sponsor thetraining, and in others the ministry will simply approvethe curriculum or not intervene at all, as in Namibia.

Recruitment proceduresRecruitment varies significantly within and amongcountries. In Ethiopia, for example, the Federal Ministryof Health, with regard to the health extension programme(see Box 1) uses as selection criteria people who havebeen innovators in the community. In contrast, theCommunity Counsellors in Ethiopia (a NGO pro-gramme), must have a high school diploma, be a residentof the town where they will work, should have beeninvolved in HIV-related activities and be willing to servethe area where they live for at least one year. In Brazil,CHW are hired by the municipalities. In Uganda, NGOrecruit CHW with diverse backgrounds; some cadresmust have a university degree or diploma, whereas othershave no previous medical experience.

Employment conditionsCountry findings highlighted the need for defined careerstructures and promotion opportunities, which ideally areincorporated into the creation of a CHW programme andthe broader civil servant system already in existence in thecountry. This was found to have been the case in Braziland Ethiopia. The findings also pointed to an evolutionover time, whereby CHW typically take on additionalresponsibilities and skills, which are learned on-site andare thus not a part of a standardized training programmewith other CHW. Concerns were raised regarding theexpansion of the role of CHW based on the local needs ofthe facility or community and how it may conflict withother professionals who have been trained and certified toprovide these services.

Sustainable financing for services renderedSustainable payment and financing for services rendered is akey factor in recruiting and retaining CHW. In many cases

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S48 AIDS 2010, Vol 24 (suppl 1)

Box 1.In Ethiopia, the largest cadre of CHW is the health extension worker, assigned both at the health post and communitylevel. The health extension worker programme in Ethiopia is the country’s flagship programme that addresses theprevention of diseases and promotion of health at the community level. The programme started after seeing the greatwork done in agriculture by agricultural extension workers. It is based on Ethiopia’s health sector developmentprogramme and was introduced as a vehicle to attain the millennium development goals. The programme is aninnovative health service delivery programme that aims at universal coverage of primary health care. It gives priorityto the prevention and control of communicable disease such as HIV, tuberculosis and malaria, with the goal ofproviding equitable access to health services. The model was developed over a 2-year period beginning in 2003 afterextensive consultation of the Federal Ministry of Health with all pertinent stakeholders, including the FederalMinistry of Education, Federal Ministry of Labour and Social Affairs, Federal Ministry of Finance, Federal Ministry ofCapacity Building, Council of Ministers, Civil Services Commission, technical vocational training schools, regionalhealth bureaus and regional education bureaus. As a result of such broad consultation, the Federal Ministry ofCapacity Building approved civil service structure, the Civil Service Commission approved minimum jobrequirements and grading, and the Federal Ministry of Health proposed the key intervention areas, duties andresponsibilities, recruitment criteria and the training. Defined career structure and promotion as well continuoustraining was incorporated into the programme. The students are selected in the community from the community andneed to have middle school education. The training is a one-year training that includes both in-class and practicalsessions and the health extension programme includes training in hygiene and environmental sanitation, family healthservices, disease prevention and control including HIV, tuberculosis and malaria and health education andcommunication. After completion they are certified by the Federal Ministry of Health. After graduation, they work75% outreach in the community and 25% at a health post. The government decided to accelerate the implementationof the health extension programme in order to cover the whole country by 2009, i.e. 30 000 health extension workerswill be deployed.

Box 2In Malawi the CHW cadres called health surveillance assistants, developed over an extended time and in response tonumerous public health emergencies, are trained for over a 10-week period by the Ministry of Health for a wide rangeof primary prevention and clinical care areas. At the completion of the training, the health surveillance assistantsreceive a certificate of ‘attendance’, which allows them to provide some level of primary care. The key playersinvolved in planning or implementing the scale-up of this cadre included the Nursing and Midwives Council,Medical Council of Malawi, Ministry of Health and Population, Nurses and Midwife Association, Ministry ofEducation, Ministry of Labour, Health Services Commission, the College of Health Sciences, Ministry of LocalGovernment and Rural Development, Department of Human Resources Management and Development, MedicalCouncil of Malawi and the Pharmacy, Medicine and Poison Board. To date, the health surveillance assistants have notbeen recognized as a healthcare provider group by any of the regulatory councils or provider associations. They aremanaged by the Ministry of Health and provided salary and remuneration as other low-skilled labourers. Nationalstrategic planning documents have recently targeted the health surveillance assistants for rapid scale-up and expansionto meet the ever growing demand for clinical care in the rural areas. Regarding HIV services, the health surveillanceassistants are used for HIV testing and counselling services and home-based services such as adherence monitoringand dispensing ART. In general, the country has used its existing regulatory structures (formal and informal) toaccomplish a significant level of ‘task shifting’ in a relatively short period of time.

they are either day or contractual workers with unreliablepayment systems for the services that they provide, or theyare paid in a non-monetary form. Country experiencessupport a solution whereby CHWare part of a civil/publicservice structure. In countries where this integration is notpossible, an alternative and reliable source of funding forpayments and salaries should be identified and established atthe inception of the programme so as to be able to recruitand most importantly retain these CHW in the places thatthey are most needed to work. In addition to the healthextension workers in Ethiopia, another good example ofthis is the creation of 8000 community nutrition and HIV/AIDS workers by the Office of the President and Cabinetof Malawi. This particular cadre of CHW is the result of

pyright © Lippincott Williams & Wilkins. Unauthor

combining two cadres that existed under two distinctministries (the home craft workers under the Ministry ofGender and the farm home assistants under the Ministry ofAgriculture). These CHW are civil servants with anestablished salary payment structure.

Informal constitution of health workersIn each of the countries studied, many CHW are nottrained by the Ministry of Education, nor recognized bythe Ministry of Public Services or any of the professionalcouncils or associations. Rather, they tend to originatefrom and be trained through the NGO sector. Often,they receive a small allowance or salary, non-financialincentives, or work on a volunteer basis (particularly at

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Deployment of community health workers in response to health workforce shortages Celletti et al. S49

Box 3In Brazil the community health agents’ programme and the family health programme, both launched by the Ministryof Health, have deployed CHW since the early 1990s. The number of CHW has risen rapidly from 29 000 in 1994 to229 000 in 2009, and this growth has been accompanied by a significant expansion of family health teams – each ofwhich includes between four and six CHW.CHW were officially integrated into the civil service structure in 1991 and the cadre was recognized as a profession in2002. All CHW receive a salary, whereas minimum recruitment requirements, training requirements and the scope ofpractice for CHW are defined under federal law. CHW take compulsory introductory courses offered by regionalhealth schools and technical schools and receive in-service supervision.The competencies and scope of practice of the CHW involved in these programmes do not involve the performanceof any medical or nursing procedures. They focus on disease prevention and health promotion, including counsellingactivities. CHW support individuals, families or neighbourhoods, and their activities include regular home visits,record keeping and data inputing and promotion of grass-roots participation in health policies and engagement inlocal intersectoral actions.The reported impacts include improvements in coverage of immunization and prenatal services and some studies haveshown improvements in health outcomes including decreases in infant mortality, cardiovascular morbidity andimproving oral care.

district level health centres). In Uganda, the high level ofgovernment support for ‘task shifting’ in the NGO sectorhas resulted in a large number of cadres providing HIVandnon-HIV clinical services in the field. Although this isessential in meeting the needs of communities, it hasraised concerns about the level of standard training that iscompetency based and the extent of the supervisionprovided to these cadres. Similarly, in Namibia, training isconducted by NGO that support the communityvolunteers. More than one-third of volunteers undergoa week-long training, whereas other training programmesrange from as little as 1–3 days up to 2 weeks. Trainingprogrammes 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 CHWwas identified as an important step to ensure the safety andquality of services.

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

Analysis of reorganization of clinical servicesCross-country findings are presented below in thefollowing categories: competencies and scope of practice;coverage and quality of services; mentoring and super-vision; service users’ satisfaction and CHW views andopinions.

Competencies and scope of practiceThe results from the country studies show that CHWcontribute significantly to the delivery of HIV services.The tasks that CHW were undertaking were similarbetween the study countries. In general, they includedthe identification and referral of people living withHIV/AIDS, counselling and support, the execution andinterpretation of rapid HIV testing, follow-up of stableclients on first-line ART, dispensing of drugs prescribed by

opyright © Lippincott Williams & Wilkins. Unauth

a qualified provider, tasks related to the prevention ofmother-to-child transmission and monitoring and supportof adherence. CHW also provided supportive services forHIV care, including as pharmacy assistants, data clerks,X-ray technicians and laboratory assistants. CHW oftenplayed other numerous roles and had responsibilities thatincluded providing community level education program-ming and outreach beyond HIV service delivery, as inBrazil. A complete list of tasks performed in any of the fivecountries is provided in Table 3.

Coverage of services and qualityObservation of the involvement of CHW led to theconclusion that this had a positive impact on both thecoverage and quality of services.

First, the study showed that the first contact with thehealth system for people living with HIV is with CHW in39% of cases, with doctors in only 24% of cases and withsocial workers in 15% of cases. With regard to specificcountry examples, in Ethiopia, people receiving HIVtesting and counselling rose from 500 000 to 1 600 000from 2006 to 2007 after CHW were trained to deliverthese services, among other interventions. In Namibia,the facilities with CHW providing adherence counsellingand other forms of support witnessed 91% of patients everstarted on ART still on first-line therapy. In other facilitiesin Namibia, the ART initiation rate increased signifi-cantly after CHW were appointed to deliver HIV testingand counselling; from having little more than 2000patients on ART since 2002, the number of patientsstarting ART increased to 160 per month after the CHWintervention. In Uganda, in the facilities where CHWwere assigned to data management, records appeared tobe more completed. Furthermore, the facilities applying atask shifting approach that also included CHW had abetter default rate than others that were using a moretraditional service delivery model (5.8% versus 8.5%). InBrazil, coverage for immunization and prenatal con-

orized reproduction of this article is prohibited.

Co

S50 AIDS 2010, Vol 24 (suppl 1)

Tab

le2.

Anal

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of

regu

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sultancies increased significantly and infant mortalitydecreased after the deployment of CHW in the familyhealth teams.

Mentoring and supervisionBetter outcomes were observed when CHW were offeredsustained and supportive supervision within the structureand functions of the health team. When it occurscontinuously, this type of supervision becomes a routinepart of a health worker’s job. Such supervision can have amotivating effect on health workers and is an opportunetime to provide follow-up training, improve performanceand solve other systemic problems. It is also important tounderline that certain tasks can be safely delegated only ifsupervision is provided on a constant basis. It wasobserved that supportive supervision requires motivationon the part of supervisors and staff to adopt newbehaviour, locally appropriate tools and the investment oftime and resources. In Brazil, for example, 30 CHW areunder the supervision of one nurse and, in the familyhealth teams, four to six are supervised by a nurse. Also ofimportance was the commitment of the top managementand the integration of the programme into existinghuman resource management systems.

Services users’ satisfactionPeople living with HIV reported a high level of satisfactionwith the services they received from CHW. In a survey of200 people living with HIV, more than 90% were satisfiedor extremely satisfied with their assigned CHW.

Community health workers’ views and opinionsThe study also included focus groups and qualitativeinterviews with over 400 CHW to understand theirexpectations and to assess their understanding of theircontribution to the health care of the community theyservice. CHW stated their willingness to assume moreextended tasks. In some cases, professional health workers,such as nurses and doctors, supported the role of CHWandrecognized that their services allowed them to concentrateon more complicated tasks. In other cases, however, seniorcadres felt threatened by CHW. Focus group discussionswith people living with HIV/AIDS concluded that theycan make an important contribution in the role of trainedCHW. Starting from their personal experience, CHWwho are themselves living with HIV can make a crucialcontribution to addressing issues such as prevention,disclosure, adherence, self-care and stigma and discrimi-nation. People living with HIV/AIDS often show apreference for CHW who are also living with HIV/AIDS.

Discussion

Learning the lessons of the pastCHW of one kind or another have been involvedthroughout the history of organized health services [25].

orized reproduction of this article is prohibited.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

S52 AIDS 2010, Vol 24 (suppl 1)

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

1. HIV sensitization, literacy, education, counsellingCommunity-based educationFacility-based education

2. Testing and counselling in facility and communityRecognize HIV-related illnesses and refer a patient for HIV testingOffer HIV testing and counselling (including TB patients and TB suspects)Conduct pre-test counsellingExecute and interpret HIV test (rapid test or ELISA)Conduct post-test counselling

3. Preventive interventionsBasic interventions:Provide key information on HIV, safer sex and condom use and distribute condoms and educational materials when availableEducate and counsel on STIManage STIAssess family status including pregnancy, family planning, partner and children statusAdvise on prevention for IDU and harm reductionPrevention of mother-to-child-transmission:Offer HIV counselling and testing to pregnant womenExecute and interpret HIV test (rapid test or ELISA)Counsel mother on interventions to reduce the risk of transmitting HIV to her infantAdvise and counsel on safer sex, partner and children testingAssess the acceptability of the proposed interventionsEducate on basic preventive measures: malaria, TB, wormsIntroduce information regarding infant feeding optionsDiscuss plans for delivery, the likely delivery location and the birth attendant, review strategies to decrease the risk of transmission

at the time of deliveryDiscuss where the prophylactic antiretroviral drugs will be kept until needed and how the woman will access the ART at the correct timeAdvise and counsel on family planningPEP:Recognize exposure that could place HCW at risk for HIV infectionManage self-limited side effects of antiretroviral drugs in PEP regimensManage severe toxicities of antiretroviral drugs in PEP regimensExecute and interpret post-exposure HIV testProvide counselling and support, and refer to formal psychological counselling as neededProvide facility and community-based education regarding health worker safety and PEP, as part of general HIV education and stigma

reductionCircumcision:Provide sexual and reproductive health counsellingConduct presurgical counsellingPositive preventionEducate and counsel on preventing sexual and non-sexual transmission of HIVCounsel on reproductive choices and family planningAdvise on how to prevent other infectionsEncourage physical activityAdvise on nutrition, clean water, and other sanitation measures

4. Clinical management of HIVTriageDecide which patient needs to be seen by which health workerPatient visit and clinical reviewRegisterFind medical record and return it to filesTake weightTake vital signsTake heightAssess clinical signs and symptomsAssess pregnancy status, family planning and HIV status of partners and childrenDetermine functional statusReview TB statusRegister results/fill in laboratory result formAdminister intramuscular or subcutaneous injectionsProvide wound care or change dressingsProvide psychological supportComplete medical record (paper/electronic)Manage TB co-infectionIdentify an HIV-positive patient with symptoms such as chronic cough and/or chronic fever and/or weight loss as a TB suspect and

encourage/assist clinic visit5. ART

Preparation for ARTExplain goal, benefits and risks of ARTCounsel patient on the importance of adherence and explore options to maintain long-term adherence

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Deployment of community health workers in response to health workforce shortages Celletti et al. S53

Prepare the individual patient and/or patient’s caregiver to initiate ARTEstablish readiness of the patient to start ARTExplain food/other diet restriction when needed

6. Early follow-up (up to 3 months from starting ART)Clinical monitoringTake weightTake vital signsDetermine functional statusMonitor and support adherenceRespond to new signs and symptoms and possible side effectsRecognize/manage self-limiting antiretroviral drug side effects and encourage/assist consultation or clinic visit when necessaryManage TB co-infectionIdentify symptoms such as chronic cough and/or chronic fever and/or weight loss as a TB symptoms suspect in the first three months

of ART and encourage/assist clinic visitProvide combined TB/ART directly observed treatment if necessaryRecognize side effects of TB and/or HIV medications and encourage/assist consultation or clinic visit when necessaryDispensing and arranging follow-upDispense antiretroviral and other drugsArrange follow-up visit

7. Long-term follow-up (3 months after initiation of ART)Clinical monitoringMonitor and support ART adherenceTake weightTake vital signsDetermine functional statusRequest CD4 cell count test and viral load (if available and indicated)Recognize/manage self-limiting antiretroviral side effectsAfter decision for initiation of TB treatment, provide TB treatment to patients other than sputum-positive pulmonary TB patientsRecognize side effects of TB and/or HIV medications and encourage/assist consultation or clinic visit when necessaryProvide combined TB/ART directly observed treatment if necessary in a patient who is on ART for more than 3 monthsDispensing and arranging follow-up visitsDispense antiretroviral and other drugsArrange follow-up visits

8. Clinical management of HIV-positive pregnant womenClinical managementDescribe the benefits and risks of ART in the first trimester and during pregnancy in general, and general health for pregnant womenExplain when to start ART; adherence and monitoring; management of mild side effectsEducate on basic preventive measures: malaria, TB, worms

9. Clinical management of newborns, including prevention of mother-to-child transmissionClinical managementExplain timing for HIV test of the child to parentsCounsel HIV-positive mothers with a child of unknown HIV status on feeding options

10. Clinical management of HIV-positive childrenNutritionEducate and counsel on proper local foodsEducate and counsel on clean water and sanitation

11. Psychosocial support for HIV-positive children and for other children in household, including orphansEducate and counsel caregiverSupport and counsel the childSupport child and caregiver for disclosureSupport child and caregiver for appropriate developmentSupport child and caregiver for illness and deathSupport for orphans and vulnerable children and their caregiversInitiation of ARTEducate and counsel child and/or caregiver to adherenceDetermine any barriers to adhering to ARTOffer assistance in disclosure if necessaryAssist the family in incorporating ART into daily lifeExplain the management and planning for an uninterrupted supply of medication for children

12. Palliative carePain managementConduct pain assessment(s)Teach the patient and caregiver how to give pain medicineTeach the patient and caregiver how to give oral morphineAdvise on non-pharmacological methods for controlling painSymptom managementManage common symptoms (weigh loss, nausea, fever, diarrhoea, trouble sleeping, anxiety, etc.)Psychosocial support and end-of-life careCounselling, psychosocial and spiritual supportSupport at end of lifeSupport for caregivers, family members and children

ART, Antiretroviral therapy; ELISA, enzyme-linked immunosorbent assay; IDU, injection drug user; PEP, post-exposure prophylaxis; TB,tuberculosis.

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S54 AIDS 2010, Vol 24 (suppl 1)

23%

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Doctors Nurses Others

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

Following the Alma Ata conference in 1978, the HealthCare For All movement saw many countries experi-menting with different approaches to the mobilization ofcadres of health workers with only little formal training inorder to expand general health promotion and disease-specific services [28]. Indeed, it was the WHO Alma Atadeclaration on Primary Health Care in 1978 thatestablished CHW as a generic title and defined theirrole internationally [28]. Over time, and under pressureof fiscal reform, however, the commitment of govern-ments to these programmes faltered and, in many cases,their management and funding shifted to the non-statesector [16]. As a result, programmes of varying types,qualities, aims and standards proliferated, and doubts wereraised about the potential of CHW to deliver quality care[16].

In the current era, CHW are again being promoted as akey to scaling up health services in the face of both scarcehuman resources for health and limited financialresources. Bearing in mind the lessons from the past,issues about quality of care, standardization of services andtraining and certification have now assumed greaterimportance [16,29]. Also the factors associated withsuccess and sustainability still need to be more fullyelucidated [29].

The contribution to the expansion of the healthworkforceOur findings show that the deployment of CHW furtherextends the rational redistribution of tasks under the taskshifting approach and can help quickly expand the healthworkforce both at the facility and the community level.For example, in Ethiopia, 24 500 health extensionworkers have been trained in 3 years and deployed totheir respective communities, and in Brazil the number ofCHW increased from 29 000 in 1994 to 229 600 in 2009.Task shifting to CHW can make a major contribution tothe decentralization of HIV and other services to ruralareas where the shortages of human resources for healthare most acute, and so bring health services closer topeople in need. CHW can more easily be responsive tomarginalized and underserved communities and socontribute to making health services more widelyavailable. Their membership of the communities theyserve makes them a vital link to the network ofcomprehensive public health services. Strong planningand monitoring is, however, needed to ensure an efficientsystem as a new cadre, or an old cadre with new roles,poses challenges for acceptance, coordination andsustainability. The review of the evidence is also showingthat, as of today, CHWare widely distributed around theglobe and have a greater presence in rural areas comparedwith more qualified cadres (Fig. 1).

Improvements in coverage and quality of careBased on the results of the study, the involvement ofCHW is seen to produce good health outcomes and high

pyright © Lippincott Williams & Wilkins. Unauthor

levels of service user satisfaction at the tertiary level(specialized hospital and facility), the secondary level(district hospital or district outpatient facility) and at theprimary level (health centre or at the community level).The inclusion of CHW in health teams allows frequentservice–user interaction at the community level, whichimproves adherence, patient follow-up and psychosocialsupport. They thus contribute to better outcomes thancan be achieved through services delivered only bydoctors and nurses.

A review of the recent literature also finds that there is abroad consensus that delegation to cadres of healthworkers with no formal clinical training can increaseaccess to health care and improve the quality of care.There is quantitative evidence that CHW can have apositive impact on health outcomes. HIV programmeswith the involvement of CHW have resulted in betteradherence rates and better outcomes on ART [30–32]. Anumber of studies has found that CHW play an importantcontributory role in countries that are scaling up HIVservices and concluded that overall CHW remainunderutilized [33–35]. Some of the most robust evidenceof the safety and effectiveness of task shifting to CHW inwell-designed programmes comes from rural Haiti,where community-based care of people living withHIV/AIDS has been highly effective [33,34].

There is also evidence that CHW can improve the qualityof health care in non-HIV services. In 1983, a primaryhealthcare programme in the Gambia trained CHW inbirthing techniques. After 3 years, maternal and neonatalmortality halved compared with levels before theintroduction of the programme [36]. An extensive fieldtrial conducted from 1996 to 2003 in the Gadchirolidistrict of India trained CHW to deliver primary neonatalcare. This trial reported significant improvements inhealth outcomes and showed that trained CHW arehighly effective at reducing mortality among children[37]. Malaria prevention and treatment programmes havealso benefited from the use of CHW. A trial of malariaprophylaxis in the Gambia provided by traditionalbirth attendants significantly reduced the frequency of

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Deployment of community health workers in response to health workforce shortages Celletti et al. S55

low-weight births [38]. A study in Zaire published in 1996introduced CHW to treat malaria in 12 villages in one areawhile retaining only a health centre in a close ecologicallycomparable area. After only 2 years, 65% of malaria caseswere being treated by these CHW in the 12 villages andmorbidity had fallen by 50% compared with the controlarea [39]. CHWare also playing an increasingly importantrole in high-income countries such as the United States. Ithas been shown that they have contributed in increasingaccess to health care for vulnerable and underserved groups[40–42]. A number of studies exist that have systematicallycompared services delivered by CHW with the traditionalmedical model. One reviewof 43 studies found that CHWprogrammes showed greater efficiency in certain inter-ventions, such as immunization uptake, but not in otherssuch as the treatment of fever [43]. Other studies have alsoconcluded that CHW interventions can result in betteroutcomes at some cost saving in comparison with clinic-based care [44–47].

Key factors for successThe results from the country studies consistently showthat certain conditions should be observed if CHWare tocontribute to well-functioning and sustainable servicedelivery and to broader human resources for healthstrengthening. The crucial conditions for success can beclustered around eleven broad areas: (1) political will andcommitment; (2) collaborative planning; (3) definition ofscope of practice; (4) selection and educational require-ments; (5) registration and licensure and certification;(6) recruitment and deployment; (7) systems integrationincluding adequate and sustainable remuneration;(8) mentoring and supervision including referral system;(9) career path and continuous education; (10) perform-ance evaluation; and (11) regular supply of equipment andcommodities.

These factors should be addressed when creating andscaling up CHW programmes, and the developmentand implementation of these conditions should ideallyinvolve a collaboration or partnership among all relevantstakeholders. These are likely to include representativesboth of governmental line ministries and of non-governmental stakeholders, such as national and inter-national NGO, international donors and donor countriesand international organizations from the United Nationsand professional associations. Countries that haveimplemented successful CHW programmes have bene-fited from the leadership of their Ministry of Health andnoted the shepherding role it had in initiating acollaborative planning process and in inviting all of therelevant stakeholders to the table.

The review of the literature also showed that the provisionof some sort of governmental support for task shifting toCHW is critical [48–51], including as key to successfulimplementation criteria such as standardized trainingprotocol, effective selection and recruitment processes,

opyright © Lippincott Williams & Wilkins. Unauth

retention incentives, continuous education and wages orother appropriate and commensurate incentives [52–56].On this last issue, there is a strong body of evidenceindicating that if CHWare to be properly integrated intohealth systems, they must be sustained through a variety ofmeasures including adequate remuneration [52,54,57].There is virtually no evidence that volunteerism can besustained for long periods of time [58].

Barriers to implementationThe study consistently found that cadres that belong tothe CHW category are typically not regulated by eitherthe medical or nursing councils or other entities withregulatory authority (e.g. Ministry of Health). In somecountries task shifting involving CHW takes place at alocal level, but in these cases the country has little controlover the process including training, enrolment, retentionand quality of the services provided. The lack ofregulation can undermine all necessary pre-conditionsidentified in the study and outlined in the paragraphabove, such as the quality of services, adequateremuneration and retention of the cadre in the formalor informal service delivery system. Other additionalbarriers to the implementation of a task shifting approachthat includes CHW were found to be resistance fromhigher level cadres who may feel threatened by their skills(although it has been observed that these cadres candevelop an appreciation for the work of CHWover timeas this relieves them of certain duties and allows them toperform higher-level tasks), weakness of the referralsystems and finally lack of commodities and supplies.

Conclusion

The multicountry study found consistent evidence thataccess to quality HIV services can benefit from a taskshifting approach employing CHW. This is supported inthe findings of other published data. The successful andsustainable deployment of CHW is, however, dependenton the existence of an enabling environment that includesa supportive regulatory framework, functioning referralsystems, robust quality assurance mechanisms (such asstandardized training and supportive supervision), ade-quate remuneration of health workers and sufficientresources for health service delivery.

The deployment of CHW, under a task shifting approach,is already being undertaken in many countries to addresshealth workforce shortages, particularly as an emergencyresponse to the HIV epidemic. The tasks that have beensafely and efficiently undertaken by CHWare numerous,and cover prevention, treatment and care, as described inTable 3.

There is sufficient evidence to convince policy makersthat CHW can make a significant contribution toreinforcing an overstretched health workforce. Unless

orized reproduction of this article is prohibited.

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S56 AIDS 2010, Vol 24 (suppl 1)

certain conditions are met, however, the value of theintervention cannot be assured as doubts remain as tothe quality and sustainability of the services that can beprovided by CHW. If the positive outcomes that haveresulted from the deployment of CHW for the delivery ofHIV services are to be sustained and extended to a widerrange of health interventions, then countries must heedthe evidence on the need for an appropriate regulatoryenvironment and for the other enabling conditions. Withthe necessary support, the valuable addition that CHWcan make to the urgent expansion of human resources forhealth and to universal coverage can be optimized.

Acknowledgements

This study formed part of a more comprehensive researchproject, ‘The WHO-commissioned Study on TaskShifting’, supported by the U.S. President’s EmergencyPlan for AIDS Relief (PEPFAR), UNAIDS and Coop-erazione Generale allo Sviluppo, Ministry of ForeignAffairs, Rome, Italy. The authors were responsible forconceptualizing the paper, undertaking country visits andpersonally collecting some of the data. The authors had fullaccess to all of the data in the study and take responsibilityfor the integrity of the data and the accuracy of the dataanalysis. The authors are grateful to the countries thatallowed them to gather information; to all those whohelped in the collection of the data in countries and to allmembers of the WHO Task Shifting working group aslisted in the WHO guidelines and recommendations onTask Shifting (see http://www.who.int/healthsystems/TTR-TaskShifting.pdf). The WHO guidelines andrecommendations on Task Shifting were developed bythe Human Resources for Health Department directed byDr Manuel Dayrit.

Conflicts of interest: None.

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