Moving towards universal health coverage (UHC) requires an affordable service platform that enables under-served, vulnerable communities to access care. Vulnerable people often fail to access care, feel unsupported so that they miss appointments, or fail to adhere to treatment schedules. An accessible and affordable service platform requires sufficient numbers of appropriately trained health workers to provide comprehensive primary health care. Supervised shifting of tasks from expensive, trained staff to others who can perform tasks requiring less specialized knowledge, is one approach to address this need. Programmes that train and deploy community health workers (CHWs; lay people with minimal training), are well placed to support people from vulnerable communities to negotiate access to facility-based care. Research has shown that CHW programmes are successful if there is good programme design and management, integration with the health system, and the programme is designed to be able to meet the community’s needs. However, there is insufficient evidence on how to put these characteristics into practice. Policy makers and service providers want to know:
how many CHWs are needed and at what cost
what constitutes a manageable workload and travelling distances
is it more effective to have two cadres (one responsible for comprehensive preventative and promotive care and another for the physical care of house-bound patients) to allow the health system to draw on the services of people with lower education levels who are able to provide physical care.
Whether CHWs should operate from a clinic at some distance from the community they serve, or a basic health post located within the community?
Does reporting to a clinic-based nurse facilitate the CHW team’s access to medication & supplies, as well as allow engagement with clinic staff about patients who have been referred?
Does the benefit of having a health post as a base in the community, with a full-time nurse who can do home visits, outweigh these advantages?
With limited numbers of nurses able to supervise CHWs, what strategies might ensure efficient use of these trained individuals?
Could a nurse supervise several teams, if each team had a senior CHW as an immediate supervisor?