Labour conditions in dual-cadre community health worker programmes: a systematic review.

BACKGROUND: Health care delivered by community health workers reduces morbidity and mortality while providing a considerable return on investment. Despite growing consensus that community health workers, a predominantly female workforce, should receive a salary, many community health worker programmes take the form of dual-cadre systems, where a salaried cadre of community health workers works alongside a cadre of unsalaried community health workers. We aimed to determine the presence, prevalence, and magnitude of exploitation in national dual-cadre programmes. METHODS: We did a systematic review of available evidence from peer-reviewed databases and grey literature from database inception to Aug 2, 2021, for studies on unsalaried community health worker cadres in dual-cadre systems. Editorials, protocols, guidelines, or conference reports were excluded in addition to studies about single-tier community health worker programmes and those reporting on only salaried cadres of community health workers in a dual-cadre system. We extracted data on remuneration, workload, task complexity, and self-reported experiences of community health workers. Three models were created: a minimum model with the shortest time and frequency per task documented in the literature, a maximum model with the longest time, and a median model. Labour exploitation was defined as being engaged in work below the country's minimum wage together with excessive work hours or complex tasks. The study was registered with PROSPERO, CRD42021271500. FINDINGS: We included 117 reports from 112 studies describing community health workers in dual-cadre programmes across 19 countries. The majority of community health workers were female. 13 (59%) of 22 unsalaried community health worker cadres and one (10%) of ten salaried cadres experienced labour exploitation. Three (17%) of 18 unsalaried community health workers would need to work more than 40 h per week to fulfil their assigned responsibilities. Unsalaried community health worker cadres frequently reported non-payment, inadequate or inconsistent payment of incentives, and an overburdensome workload. INTERPRETATION: Unsalaried community health workers in dual-cadre programmes often face labour exploitation, potentially leading to inadequate health-care provision. Labour laws must be upheld and the creation of professional community health worker cadres with fair contracts prioritised, international funding allocated to programmes that rely on unsalaried workers should be transparently reported, the workloads of community health workers should be modelled a priori and actual time use routinely assessed, community health workers should have input in policies that affect them, and volunteers should not be responsible for the delivery of essential health services. FUNDING: None.

Lessons from an eight-country community health data harmonization collaborative.

BACKGROUND: Community health workers (CHWs) are individuals who are trained and equipped to provide essential health services to their neighbors and have increased access to healthcare in communities worldwide for more than a century. However, the World Health Organization (WHO) Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes reveals important gaps in the evidentiary certainty about which health system design practices lead to quality care. Routine data collection across countries represents an important, yet often untapped, opportunity for exploratory data analysis and comparative implementation science. However, epidemiological indicators must be harmonized and data pooled to better leverage and learn from routine data collection. METHODS: This article describes a data harmonization and pooling Collaborative led by the organizations of the Community Health Impact Coalition, a network of health practitioners delivering community-based healthcare in dozens of countries across four WHO regions. OBJECTIVES: The goals of the Collaborative project are to; (i) enable new opportunities for cross-site learning; (ii) use positive and negative outlier analysis to identify, test, and (if helpful) propagate design practices that lead to quality care; and (iii) create a multi-country 'brain trust' to reinforce data and health information systems across sites. RESULTS: This article outlines the rationale and methods used to establish a data harmonization and pooling Collaborative, early findings, lessons learned, and directions for future research.

Burden of disease in francophone Africa, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

BACKGROUND: Peer-reviewed literature on health is almost exclusively published in English, limiting the uptake of research for decision making in francophone African countries. We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to assess the burden of disease in francophone Africa and inform health professionals and their partners in the region. METHODS: We assessed the burden of disease in the 21 francophone African countries and compared the results with those for their non-francophone counterparts in three economic communities: the Economic Community of West African States, the Economic Community of Central African States, and the Southern African Development Community. GBD 2017 employed a variety of statistical models to determine the number of deaths from each cause, through the Cause of Death Ensemble model algorithm, using CoDCorrect to ensure that the number of deaths per cause did not exceed the total number of estimated deaths. After producing estimates for the number of deaths from each of the 282 fatal outcomes included in the GBD 2017 list of causes, the years of life lost (YLLs) due to premature death were calculated. Years lived with disability (YLDs) were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae. Disability-adjusted life-years (DALYs) were calculated as the sum of YLLs and YLDs. All calculations are presented with 95% uncertainty intervals (UIs). A sample of 1000 draws was taken from the posterior distribution of each estimation step; aggregation of uncertainty across age, sex, and location was done on each draw, assuming independence of uncertainty. The lower and upper UIs represent the ordinal 25th and 975th draws of each quantity and attempt to describe modelling as well as sampling error. FINDINGS: In 2017, 779 deaths (95% UI 750-809) per 100 000 population occurred in francophone Africa, a decrease of 45·3% since 1990. Malaria, lower respiratory infections, neonatal disorders, diarrhoeal diseases, and tuberculosis were the top five Level 3 causes of death. These five causes were found among the six leading causes of death in most francophone countries. In 2017, francophone Africa experienced 53 570 DALYs (50 164-57 361) per 100 000 population, distributed between 43 708 YLLs (41 673-45 742) and 9862 YLDs (7331-12 749) per 100 000 population. In 2017, YLLs constituted the majority of DALYs in the 21 countries of francophone Africa. Age-specific and cause-specific mortality and population ageing were responsible for most of the reductions in disease burden, whereas population growth was responsible for most of the increases. INTERPRETATION: Francophone Africa still carries a high burden of communicable and neonatal diseases, probably due to the weakness of health-care systems and services, as evidenced by the almost complete attribution of DALYs to YLLs. To cope with this burden of disease, francophone Africa should define its priorities and invest more resources in health-system strengthening and in the quality and quantity of health-care services, especially in rural and remote areas. The region could also be prioritised in terms of technical and financial assistance focused on achieving these goals, as much as on demographic investments including education and family planning. FUNDING: Bill & Melinda Gates Foundation.

Data needed to respond appropriately to anemia when it is a public health problem.

Although the proportion of anemia amenable to change varies by population, the World Health Organization (WHO) criteria used to describe the public health severity of anemia are based on population prevalences. We describe the importance of measuring iron and other etiologic indicators to better understand what proportion of anemia could be responsive to interventions. We discuss the necessity of measuring inflammation to interpret iron biomarkers and documenting anemia of inflammation. Finally, we suggest assessing nonmodifiable genetic blood disorders associated with anemia. Using aggregated results from the Global Burden of Disease 2016, we compare population prevalence of anemia with years lived with disability (YLD) estimates, and the relative contributions of mild, moderate, and severe anemia to YLD. Anemia prevalences correlated with YLD and the relative proportion of moderate or severe anemia increased with anemia prevalence. However, individual-level survey data revealed irregular patterns between anemia prevalence, the prevalence of moderate or severe anemia, and the prevalence of iron deficiency anemia (IDA). We conclude that although the WHO population prevalence criteria used to describe the public health severity of anemia are important for policymaking, etiologic-specific metrics that take into account IDA and other causes will be necessary for effective anemia control policies.

Diseases, Injuries, and Risk Factors in Child and Adolescent Health, 1990 to 2017: Findings From the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.

Importance: Understanding causes and correlates of health loss among children and adolescents can identify areas of success, stagnation, and emerging threats and thereby facilitate effective improvement strategies. Objective: To estimate mortality and morbidity in children and adolescents from 1990 to 2017 by age and sex in 195 countries and territories. Design, Setting, and Participants: This study examined levels, trends, and spatiotemporal patterns of cause-specific mortality and nonfatal health outcomes using standardized approaches to data processing and statistical analysis. It also describes epidemiologic transitions by evaluating historical associations between disease indicators and the Socio-Demographic Index (SDI), a composite indicator of income, educational attainment, and fertility. Data collected from 1990 to 2017 on children and adolescents from birth through 19 years of age in 195 countries and territories were assessed. Data analysis occurred from January 2018 to August 2018. Exposures: Being under the age of 20 years between 1990 and 2017. Main Outcomes and Measures: Death and disability. All-cause and cause-specific deaths, disability-adjusted life years, years of life lost, and years of life lived with disability. Results: Child and adolescent deaths decreased 51.7% from 13.77 million (95% uncertainty interval [UI], 13.60-13.93 million) in 1990 to 6.64 million (95% UI, 6.44-6.87 million) in 2017, but in 2017, aggregate disability increased 4.7% to a total of 145 million (95% UI, 107-190 million) years lived with disability globally. Progress was uneven, and inequity increased, with low-SDI and low-middle-SDI locations experiencing 82.2% (95% UI, 81.6%-82.9%) of deaths, up from 70.9% (95% UI, 70.4%-71.4%) in 1990. The leading disaggregated causes of disability-adjusted life years in 2017 in the low-SDI quintile were neonatal disorders, lower respiratory infections, diarrhea, malaria, and congenital birth defects, whereas neonatal disorders, congenital birth defects, headache, dermatitis, and anxiety were highest-ranked in the high-SDI quintile. Conclusions and Relevance: Mortality reductions over this 27-year period mean that children are more likely than ever to reach their 20th birthdays. The concomitant expansion of nonfatal health loss and epidemiological transition in children and adolescents, especially in low-SDI and middle-SDI countries, has the potential to increase already overburdened health systems, will affect the human capital potential of societies, and may influence the trajectory of socioeconomic development. Continued monitoring of child and adolescent health loss is crucial to sustain the progress of the past 27 years.

Child and Adolescent Health From 1990 to 2015: Findings From the Global Burden of Diseases, Injuries, and Risk Factors 2015 Study.

Importance: Comprehensive and timely monitoring of disease burden in all age groups, including children and adolescents, is essential for improving population health. Objective: To quantify and describe levels and trends of mortality and nonfatal health outcomes among children and adolescents from 1990 to 2015 to provide a framework for policy discussion. Evidence Review: Cause-specific mortality and nonfatal health outcomes were analyzed for 195 countries and territories by age group, sex, and year from 1990 to 2015 using standardized approaches for data processing and statistical modeling, with subsequent analysis of the findings to describe levels and trends across geography and time among children and adolescents 19 years or younger. A composite indicator of income, education, and fertility was developed (Socio-demographic Index [SDI]) for each geographic unit and year, which evaluates the historical association between SDI and health loss. Findings: Global child and adolescent mortality decreased from 14.18 million (95% uncertainty interval [UI], 14.09 million to 14.28 million) deaths in 1990 to 7.26 million (95% UI, 7.14 million to 7.39 million) deaths in 2015, but progress has been unevenly distributed. Countries with a lower SDI had a larger proportion of mortality burden (75%) in 2015 than was the case in 1990 (61%). Most deaths in 2015 occurred in South Asia and sub-Saharan Africa. Global trends were driven by reductions in mortality owing to infectious, nutritional, and neonatal disorders, which in the aggregate led to a relative increase in the importance of noncommunicable diseases and injuries in explaining global disease burden. The absolute burden of disability in children and adolescents increased 4.3% (95% UI, 3.1%-5.6%) from 1990 to 2015, with much of the increase owing to population growth and improved survival for children and adolescents to older ages. Other than infectious conditions, many top causes of disability are associated with long-term sequelae of conditions present at birth (eg, neonatal disorders, congenital birth defects, and hemoglobinopathies) and complications of a variety of infections and nutritional deficiencies. Anemia, developmental intellectual disability, hearing loss, epilepsy, and vision loss are important contributors to childhood disability that can arise from multiple causes. Maternal and reproductive health remains a key cause of disease burden in adolescent females, especially in lower-SDI countries. In low-SDI countries, mortality is the primary driver of health loss for children and adolescents, whereas disability predominates in higher-SDI locations; the specific pattern of epidemiological transition varies across diseases and injuries. Conclusions and Relevance: Consistent international attention and investment have led to sustained improvements in causes of health loss among children and adolescents in many countries, although progress has been uneven. The persistence of infectious diseases in some countries, coupled with ongoing epidemiologic transition to injuries and noncommunicable diseases, require all countries to carefully evaluate and implement appropriate strategies to maximize the health of their children and adolescents and for the international community to carefully consider which elements of child and adolescent health should be monitored.