Community Health Workers’ Integration Models and Health System Integration Effectiveness for Universal Health Coverage in Sub Saharan Africa: A Systematic Review
Abstract:
In sub-Saharan Africa (SSA), evidence suggests that many low and middle-income
countries face severe shortages and uneven distribution of health workers,
medicines and infrastructure, resulting in poor quality services and serious
gaps in coverage for essential health care. In addressing the human resources
gaps of trained health professionals, Community Health Workers (CHWs) were
recruited and integrated in the health system and they are increasingly
regarded as central actors in achieving Universal Health Coverage (UHC) and
strengthening primary health care (PHC) in SSA. Evidence from existing studies
shows that community health workers have the greatest impact when they are well
integrated across the main health system building blocks. Estimates of
Community Health Worker (CHW) density vary widely across Sub-Saharan Africa,
ranging from about 11.2 to 59.5 CHWs for every 10,000 people. These differences
depend largely on how many hours CHWs work and the scope of services they
provide. However, integration models differ widely across nations with mixed
outcomes in service provision, equity, and sustainability. Three models of
integration dominated: government-driven, hybrid, and Non-Governmental Organisation-driven
(NGO). Government-driven models have 40% higher levels of sustainability than
donor-based models and cost-effectiveness ratios of $1.20 per capita per annum,
for example in Ethiopia and Ghana, among others. Successful CHW integration is
context-dependent model selection, with no single model likely to be optimal
for every situation; success depends on close adaptation to the local health
system and community context.
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