Review www.thelancet.com Vol 369 June 23, 2007 2121 Lancet 2007; 369: 2121–31 Published Online March 6, 2007 DOI:10.1016/ S0140-6736(07)60325-0 See Editorial page 2052 See Comment page 2058 Director’s office, London School of Hygiene and Tropical Medicine, UK (A Haines MD); School of Public Health, University of the Western Cape, Bellville, South Africa (D Sanders MRCP, U Lehmann PhD); Malaria Branch, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, USA (A K Rowe MD); Saving Newborn Lives/Save the Children-US, and Health Systems Research Unit, Medical Research Council, Cape Town, South Africa (J Lawn MRCP); Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK (S Jan PhD, D Sanders, D Walker PhD); The George Institute for International Health, Sydney, Australia (S Jan); International Health Department, Bloomberg School of Public Health, Johns Hopkins University, USA (D Walker); Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan (Z Bhutta PhD) Correspondence to: Prof Andrew Haines, Director’s office, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK andy.haines@lshtm.ac.uk Achieving child survival goals: potential contribution of community health workers Andy Haines, David Sanders, Uta Lehmann, Alexander K Rowe, Joy E Lawn, Steve Jan, Damian G Walker, Zulfiqar Bhutta There is renewed interest in the potential contribution of community health workers to child survival. Community health workers can undertake various tasks, including case management of childhood illnesses (eg, pneumonia, malaria, and neonatal sepsis) and delivery of preventive interventions such as immunisation, promotion of healthy behaviour, and mobilisation of communities. Several trials show substantial reductions in child mortality, particularly through case management of ill children by these types of community interventions. However, community health workers are not a panacea for weak health systems and will need focussed tasks, adequate remuneration, training, supervision, and the active involvement of the communities in which they work. The introduction of large-scale programmes for community health workers requires evaluation to document the impact on child survival and cost effectiveness and to elucidate factors associated with success and sustainability. Introduction Progress towards the United Nations’ Millennium Development Goals, including those on maternal and child mortality, is off track, particularly in sub-Saharan Africa. The Millennium Development Goal on child mortality aims for a two-thirds reduction from 1990 to 2015, but at current progress this may not be attained until 2165 in sub-Saharan Africa. 1,2 It is estimated that over 60% of deaths in children under age 5 years (currently >10 million per year) could be prevented by various existing interventions. 3 Recent analysis indicates that 41–72% of newborn deaths can be prevented by available interventions, if provided at high coverage, and around half of this reduction is possible with community- based interventions. 4 However, the health systems in many countries are too weak and fragmented to enable the scaling-up of essential interventions for maternal, newborn, and child health. 5 One key challenge is the need to develop and strengthen human resources to deliver essential interventions. 6,7 The density of health workers (doctors, nurses, midwives) is inversely associated with maternal, infant, and under-5 mortality, 8 and is more than ten times higher in Europe and North America than in sub-Saharan Africa. Various factors are responsible for inadequate human resources in many countries, including inadequate supply, migration, poor morale, and the effects of HIV/AIDS. 6,7,9 These factors, together with the high cost of training doctors and nurses and the low use of services based in health facilities in many areas, have rekindled interest in the possibility of substantial health gains from the use of community health workers and mid-level health workers such as clinical assistants. Several African and south Asian countries are currently investing in new cadres of community health workers as a major part of strategies to reach the Millennium Development Goals, in some cases arguing that they preferentially reach the poor who are less likely to use health facilities. For example, Ethiopia is training 30 000 community-based health extension workers (women) to focus on maternal, newborn, and child health, malaria, and HIV. India, Kenya, Uganda, Ghana, and South Africa are also considering national programmes for community health workers. Therefore, it is now timely to assess the evidence that such health workers can perform the necessary tasks and function as part of a sustainable workforce. In the 1970s and 1980s, community health workers were a cornerstone of primary health care as envisaged by the Alma Ata declaration. However by the early 1990s, enthu- siasm for community health workers had diminished for several reasons, including the challenges of scaling-up programmes in a sustainable fashion while maintaining effectiveness, and the perceived success of some vertical programmes. 10 Search strategy and selection criteria This article draws on literature searches done by several of the authors for several publications that reviewed topics of relevance to community health workers. 12,14,16–18,50,72,73 The Cochrane Library was searched for additional systematic reviews using the terms “community health workers”, “lay health workers”, “mid level health workers”, and “primary health care”. Additional references were provided by individuals listed in the acknowledgments section and by some of the reviewers. Some examples of programmes for community health workers referred to were presented at the Countdown to 2015 Child Survival Conference, sponsored by The Lancet and other organisations, which took place at the University of London in December 2005. We have also included some references to grey literature sources, which may not have been peer-reviewed, that provided contextual information about the factors conducive to scaling up and sustainability of programmes for community health workers. To address questions of impact and cost effectiveness, we focused on the conclusions of randomised trials and systematic reviews of such trials where these were available, but other designs, such as case studies, were drawn upon to provide evidence about factors that determine the performance and sustainability of programmes for community health workers. For more information on the health extension progamme in Ethiopia see http://cnhde. ei.columbia.edu/programs/hep