The last decade has highlighted major gaps in the availability, accessibility, acceptability and quality of the health workforce in many countries. ⁽¹1 Campbell J, Dussault G, Buchan J, Pozo-Martin F, Guerra Arias M, Leone C, et al. A universal truth: no health without a workforce. Forum report, third global forum on human resources for health, Recife, Brazil. Geneva: World Health Organization; 2013. Available from:Available from:http://www.who.int/workforcealliance/knowledge/resources/hrhreport2013/en/ [cited 2015 August 4].
http://www.who.int/workforcealliance/kno... The quantity, skills and geographic distribution of the health workforce have long been recognized as factors that limit population health outcomes and progress towards the related Millennium Development Goals. ⁽²2 Working together for health: the world health report 2006; Geneva: World Health Organization 2006. Available from:Available from:http://www.who.int/whr/2006 [cited 2015 August 4].
http://www.who.int/whr/2006... Similarly, the even more ambitious health targets included in the Sustainable Development Goals - scheduled for adoption by the United Nations General Assembly later this month - may be undermined by the same factors.

Recognizing this reality, there have been calls for a paradigm shift in health workforce development efforts, moving towards a more diverse range of skills supporting primary health care. ⁽³3 Cometto G, Boerma T, Campbell J, Dare L, Evans T. The third global forum: framing the health workforce agenda for universal health coverage. Lancet Glob Health. 2013;6:e324-5.http://dx.doi.org/10.1016/S2214-109X(13)70082-2
http://dx.doi.org/10.1016/S2214-109X(13)... This has catalysed growing interest in, and attention to, the potential of various types of community-based practitioners in expanding access to essential health services, particularly in under-served communities in low- and middle-income countries. ⁽⁴4 Singh P, Sachs JD. 1 million community health workers in sub-Saharan Africa by 2015. Lancet. 2013 Jul 27;382(9889):363-5.http://dx.doi.org/10.1016/S0140-6736(12)62002-9PMID 23541538
http://dx.doi.org/10.1016/S0140-6736(12)... Several studies have demonstrated the potential of various types of community-based practitioner in delivering a range of health services. ⁽⁵5 Gilmore B, McAuliffe E. Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review. BMC Public Health. 2013;13:847.PMID 24034792

6 Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010; (3):CD004015.PMID 20238326^-77 Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health. 2014;35(1):399-421.http://dx.doi.org/10.1146/annurev-publhealth-032013-182354PMID 24387091
http://dx.doi.org/10.1146/annurev-publhe... The new analysis by McPake and colleagues⁸8 McPake B, Edoka I, Witter S, Kielmann K, Taegtmeyer M, Dieleman M et al Are community-based practitioners cost-effective in LMICs? Insights from a multi-country study in Kenya, Indonesia, and Ethiopia. Bull World Health Organ. 2015;vol:ppin this issue of the Bulletin adds an important dimension to this debate, by providing an empirical foundation to the argument. McPake et al. report that investment in these types of health workers can be a cost-effective approach, in certain contexts and under certain circumstances.

However, it is critical to take a broader health system perspective. As noted by the authors of this new analysis, the terms "frontline health workers" and "community health workers" are often used in a non-specific way and can confuse the evidence base. The term "frontline" is not a classification recognized by the World Health Organization (WHO) or the International Labour Organization (ILO). Even the official classification of community health workers can refer to a diverse typology of lay and educated, formal and informal, regulated and unregulated, paid and unpaid health workers. Different policies relating to individual cadres, their scope of practice, education and relation to the health system undermine efforts to strengthen service delivery at community level. ⁽⁹9 Tulenko K, Møgedal S, Afzal MM, Frymus D, Oshin A, Pate M, et al. Community health workers for universal health-care coverage: from fragmentation to synergy.. Bull World Health Organ 2013 Nov 1;91(11):847-52.http://dx.doi.org/10.2471/BLT.13.118745PMID24347709
http://dx.doi.org/10.2471/BLT.13.118745... Large-scale studies that have analysed the policy and health systems features of community-based practitioner programmes have identified major gaps relating to the inclusion of these cadres in national health systems and in the adoption of appropriate education, deployment, performance management and retention strategies. ⁽¹⁰10 Global Health Workforce Alliance. Global experience of community health workers for delivery of health related millennium development goals - a systematic review, country case studies, and recommendations for integration into national health systems.; Geneva: World Health Organization 2013. Available from:Available from:http://www.who.int/workforcealliance/knowledge/themes/community/en/ [cited 2015 August 4].
http://www.who.int/workforcealliance/kno...

Fortunately, the elements needed for successful integration of community-based practitioners in health systems have been mapped. ⁽¹¹11 Møgedal S, Wynd S, Afzal M. Community health workers and universal health coverage: a framework for partners' harmonized support. Working paper commissioned by the Global Health Workforce Alliance.; Geneva: World Health Organization 2013. Available from:Available from:http://www.who.int/workforcealliance/knowledge/resources/Framework_partenrs_harmonised_support.pdf [cited 2015 August 4].
http://www.who.int/workforcealliance/kno... An extensive, global consultation on evidence relevant to the attainment of universal health coverage has been completed¹²12 Health workforce 2030: towards a global strategy on human resources for health.; Geneva: World Health Organization 2015. Available from:Available from:http://www.who.int/hrh/documents/synthesis_paper_them2015/en/ [cited 2015 August 4].
http://www.who.int/hrh/documents/synthes... and the results translated into a draft of WHO's Global strategy on human resources for health: workforce 2030. ⁽¹³13 Global strategy on human resources for health: workforce 2030. Draft for consultation.; Geneva: World Health Organization 2015. Available from:Available from:http://www.who.int/hrh/resources/globstrathrh-2030/en/ [cited 2015 August 4].
http://www.who.int/hrh/resources/globstr... After consultations in all WHO Regions, the final version of this strategy will be considered by the World Health Assembly in 2016. The global strategy recognizes the potential of involving community-based, mid-level and advanced practitioners as part of a multi-disciplinary health workforce that offers people-centred, integrated primary health services.

Translating this vision into reality and leveraging the potential efficiency gains that McPake et al. have identified requires, among other things, that: (i) national policy-makers move towards the full integration of community-based practitioners in public health strategies, allowing these cadres to benefit from formal employment, education, health system support, regulation, supervision, remuneration and career advancement opportunities; (ii) development partners and funding agencies see the value of investing in these cadres and contribute to the capital and recurrent costs incurred when expanding this workforce; (iii) normative agencies such as WHO and ILO address the evidence and classification gaps by developing more precise definitions and categories for these cadres.

To make the most of the investment opportunities that community-based, mid-level and advanced practitioners represent, policy-makers need to jointly support this agenda. Guidelines on the role, education and integration of community-based practitioners are being prepared by WHO for publication in 2017. These guidelines will provide governments and development partners with evidence-based recommendations on community-based practitioners, including potential returns on investment. These guidelines are intended to support universal health coverage and the achievement of the Sustainable Development Goals.

References

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