Noncommunicable diseases (NCDs) are major contributors to the disease burden and deaths globally. In the Asia Pacific and South Asia region too, rapid economic growth, demographic and societal transition in many countries have been accompanied by an epidemiological shift towards NCDs. Countries in South and South-East Asia have seen a 37.7% increase in deaths related to NCDs between the years 2000-2017, and those in the Western Pacific region a 10.2% increase. NCDs are expected to account for 72.5% and 87.2% of total deaths in the two regions respectively by the year 2030. Conversely, the health-care systems of many countries in the region are unprepared to address the needs of the growing burden of NCDs. Strengthening primary health services and the health workforce are two ways to prevent and manage NCDs.
Nearly half of the world’s people do not have access to essential health services. Health system limitations, particularly the chronic shortage of health workers make the need to identify sustainable and effective solutions to manage NCDs even more urgent. The WHO estimates a global shortfall of 18 million health workers by 2030, with the largest deficiency of health workers in South-East Asia (6.9 million in 2013).
Community Health Workers (CHWs) present a possible solution. One way to address health worker shortages has been to train members of the community to serve as CHWs to deliver essential health services. Early examples of CHWs include the Chinese ‘barefoot doctors’ – illiterate farmers trained to deliver first-aid, maintain vital registries, and even provide smallpox vaccinations. Even before the barefoot doctors were the Russian Feldshers who were literate, but given 3-years of formal training to provide primary care in remote areas. The role of CHWs in the delivery of primary care gained further prominence in the 1970s following the Alma Ata Declaration. More recently, primary care has witnessed renewed attention as indispensable to achieving universal health coverage and meeting the targets set under the Sustainable Development Goals, and CHWs as critical components of PHC.
CHWs for PHC: savings in terms of costs and time of medical professionals without compromising on quality of care, or health outcomes
Traditionally, CHWs in LMICs have played a role in the delivery of maternal, newborn and child health services, and communicable diseases. Their contributions extend from increasing the demand for health services as in Liberia, to effectively identifying severe diseases in newborns, facilitating patient referrals, improving health information, awareness and communication. Engaging CHWs in the delivery of primary health care services has demonstrated potential savings in terms of costs and time of medical professionals without compromising on quality of care, or health outcomes. Results from a systematic review of economic evaluations of CHW interventions aimed at improving child health outcomes, indicate prevention of severe anemia and malaria in infants to be cost-effective compared to standard case management. in Bangladesh community case management of severe acute malnutrition costs US$26 per DALY averted, as compared to US$1344 per DALY averted for inpatient treatment. In their review on costs and cost-effectiveness of community health workers, Vaughan et al. find community groups facilitate by lay health workers and traditional birth attendants to be cost-effective in reducing neonatal deaths. The evidence supports cost effectiveness of CHW interventions to improve health outcomes in maternal, newborn and child health. This also bears relevance towards engaging CHWs, as part of health system strengthening efforts to meet the needs of preventing and managing NCDs, particularly in LMICs
In a pilot study in India, home visits by trained CHWs to inform households on NCDs, and screening for NCDs enabled them to detect high blood pressure among 32.6% of participants and screen for HPV via self-swabs (HPV tested positive in 8.6% of the women). Results indicated both feasibility and acceptability of the CHWs in the delivery of screening services. In China, the increase in NCDs led to a focus on the integrated delivery systems for NCDs as central to reforms around 2015, and strengthening PHC, particularly community-based services to manage NCDs. CHWs in the country have been used to screen for glucose levels, blood pressure and weight to identify high-risk individuals, as well as management of case records and adherence to medication. CHWs have also been used for psychosocial counselling to improve adherence to treatment and outcomes among those with chronic conditions such as diabetes.
Way forward: supportive policies, multisectoral approaches and integrated management of NCD-related services
Community health workers offer one way to strengthen primary care, and support health systems faced with the challenge of addressing the growing burden of NCDs, particularly in low resource settings. Supportive policies, use of information communication technologies, multisectoral collaboration, and aligning community-based and primary care are ways to support CHWs in undertaking NCD-related activities. The country experiences of Bangladesh, China, Nepal and Viet Nam (See Table1 ) presented in the policy brief, Use of community health workers to manage and prevent noncommunicable diseases, highlight the range of activities, from data collection, screening and management of NCDs, health education and counselling to prevent NCDs which CHWs have undertaken in these countries.
There is a growing body of evidence supporting the role of CHWs in the prevention, screening and management of NCDs. Current evidence indicates that CHWs play an effective role in the prevention and management of NCDs compared with standard care. The brief emphasizes the need for policies and programs to support and strengthen the role of CHWs, including efforts to involve CHWs as members of physician-led PHC teams; use of participatory methods to identify types of NCDs to be managed by CHWs, as well as enhancing the technical capacity and skills, and supervision of CHWs to deliver primary and NCD-related health services.
Strengthening supply side factors such as improving the availability and access to essential equipment, skills and guidelines for CHWs can support capacity building, strengthening professional confidence. Existing experiences can serve to inform context-specific policies and programs to support CHWs in the provision of NCD-related services and support them in their function as providers of community-based primary health services. Read the full policy brief here.