Community health workers for universal health-care coverage: from fragmentation to synergy.

To achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access. Since Alma-Ata, inconsistent support of community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs' contribution. The current drive towards universal health coverage (UHC) presents an opportunity to enhance people's access to health services and their trust, demand and use of such services through CHWs. For their potential to be fully realized, however, CHWs will need to be better integrated into national health-care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability. In moving towards UHC, much can be gained by investing in building CHWs' skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to progress.

Pour parvenir à une couverture sanitaire universelle, les systèmes de santé devront étendre leur portée à toutes les communautés, y compris celles qui sont les plus pauvres et les plus difficiles d'accès. Depuis la Déclaration de Alma-Ata, le soutien inégal des agents sanitaires des collectivités et l'échec de leur intégration dans les systèmes de santé ont empêché la pleine réalisation de leur contribution potentielle dans le contexte des soins de santé primaires. Le développement et le maintien des programmes des agents sanitaires des collectivités se heurtent à une multitude de défis à relever: mauvaise planification; multitude d'acteurs concurrents avec peu de coordination; formation fragmentée et spécifique aux maladies; gestion et financement à l'initiative des donateurs; lien ténu avec le système de santé; coordination, supervision et soutien de mauvaise qualité, et sous-reconnaissance de la contribution des agents sanitaires des collectivités.La campagne actuelle vers une couverture sanitaire universelle offre une opportunité d'améliorer l'accès des personnes à des services de santé, ainsi que leur confiance, demande et utilisation de tels services par le biais des agents sanitaires des collectivités. Pour que leur potentiel puisse être pleinement réalisé, les agents sanitaires des collectivités devront toutefois être mieux intégrés dans les systèmes nationaux de soins de santé en termes d'embauche, de supervision, de soutien et d'évolution de carrière. Les partenaires au niveau du monde, du pays et du district devront harmoniser et synchroniser leurs engagements dans le soutien aux agents sanitaires des collectivités tout en maintenant suffisamment de flexibilité pour permettre aux programmes d'innover et de répondre aux besoins locaux. Un leadership fort du secteur public sera nécessaire pour faciliter l'alignement avec les cadres politiques nationaux et la coordination dirigée par le pays et pour réaliser des synergies et des responsabilités, la couverture universelle et la durabilité. En avançant vers la couverture sanitaire universelle, il y a beaucoup à gagner en investissant dans l'acquisition de compétences des agents sanitaires des collectivités et en les soutenant en tant que membres à part entière des équipes de santé. Les investissements autonomes au bénéfice des agents sanitaires des collectivités ne sont pas des raccourcis vers le progrès.

A fin de lograr la cobertura universal de la salud, los sistemas sanitarios deben llegar a todas las comunidades, incluidas las más pobres y de difícil acceso. Desde la conferencia de Alma-Ata, el apoyo inconstante de los trabajadores comunitarios de salud (TCS) y la falta de integración de estos en el sistema sanitario han impedido la plena realización de su contribución potencial en el contexto de la atención primaria de la salud. La ampliación y el mantenimiento de los programas de trabajadores comunitarios de salud suponen muchos desafíos: la mala planificación, los agentes múltiples que compiten con insuficiente coordinación, la fragmentación en los programas de capacitación orientados a combatir enfermedades específicas, la gestión y la financiación impulsadas por los donantes, la escasa unión con el sistema sanitario, la falta de coordinación, supervisión y apoyo, y la infravaloración de la contribución de los trabajadores comunitarios de la salud.El avance actual hacia la cobertura universal de la salud (CUS) ofrece una oportunidad para mejorar el acceso de la población a los servicios de salud, así como para aumentar la confianza, la demanda y el uso de dichos servicios a través de los trabajadores comunitarios de salud. Sin embargo, es necesario integrar mejor a los trabajadores comunitarios de salud, en términos de empleo, supervisión, apoyo y desarrollo profesional, en los sistemas nacionales sanitarios para aprovechar plenamente su potencial. Los socios a nivel mundial, nacional y local deben armonizar y sincronizar su compromiso a favor de los trabajadores comunitarios de salud, manteniendo la flexibilidad suficiente para que los programas tengan capacidad de innovación y respuesta frente a las necesidades locales. Se requiere un fuerte liderazgo por parte del sector público para facilitar la alineación con los marcos de las políticas nacionales y la coordinación dirigida por el país, y para lograr sinergias y la rendición de cuentas, la cobertura universal y la sostenibilidad. En la consecución de la cobertura universal de la salud, pueden obtenerse grandes beneficios si se invierte en el desarrollo de competencias de los trabajadores comunitarios de salud, y se les apoya como miembros valiosos del equipo sanitario. Por el contrario, las inversiones aisladas en trabajadores comunitarios de salud no son atajos hacia el progreso.

Socio-cultural insights and lymphatic filariasis control--lessons from the Pacific.

BACKGROUND: Sustainable and equitable health programmes require a grounded understanding of the context in which they are being implemented. This socio-cultural understanding is pivotal for effective delivery of elimination programmes. Standardised valid methods are needed for gathering authentic socio-cultural insights. The currently recommended protocol for collecting Lymphatic Filariasis (LF) related socio-cultural data, while moving in the right direction, is inadequate. To collect data which provides an understanding of local health beliefs and practices, and communities' understanding of LF, techniques must be developed that are both valid and time efficient. An approach developed in the Pacific provides a basic snapshot of socio-cultural insights which are crucial to the development of relevant and sustainable health education and elimination programmes. SUMMARY: The increasing interest in socio-cultural LF research presents a unique opportunity for coupling socio-cultural and bio-medical understandings of LF. To address the backlog in the socio-cultural sphere will require investment of time and effort to integrate valid qualitative approaches into current data collection methodologies.

Qualitative analysis of the impact of a lymphatic filariasis elimination programme using mass drug administration on Misima Island, Papua New Guinea.

BACKGROUND: Papua New Guinea is the only endemic country in the Western Pacific Region that has not yet introduced a countrywide programme to eliminate lymphatic filariasis. However, on Misima Island in Milne Bay Province, government and private sectors have collaborated to implement a pilot elimination programme. Although interim evaluation indicated that the programme has been parasitologically successful, an appreciation that sustainable health gains depend on understanding and accommodating local beliefs prompted this qualitative study. METHODS: We investigated Misima community members knowledge and attitudes about lymphatic filariasis and the elimination programme. A combination of focus groups and key informant interviews were used to explore participants perceptions of health; knowledge of the aetiology and symptoms of filariasis, elephantiasis and hydrocele; attitudes towards the disease and mass drug distribution; and the social structure and decision-making protocols within the villages. RESULTS: Focus group discussions proved inferior to key informant interviews for gathering rich data. Study participants did not consider lymphatic filariasis ("pom") a major health problem but were generally positive about mass drug administration campaigns. A variety of conditions were frequently and incorrectly attributed to filariasis. Participants expressed the belief that individuals infected with filariasis always had visible manifestations of disease. A common misconception was that taking drugs during campaigns provided long-term immunity against disease. The role of mosquito vectors in transmission was not generally appreciated and certain clinical presentations, particularly hydrocele, were associated with supernatural forces. Multiple adverse events were associated with mass drug administration campaigns and most study participants mentioned community members who did not participate in campaigns. CONCLUSION: Important issues requiring educational intervention and elimination activity modification in the Misima region were identified during this study. Research outcomes should assist Papua New Guinea in developing and implementing a national elimination strategy and inform discussions regarding the appropriateness of current elimination strategies.

Increasing trends in HIV prevalence among people aged 50 years and older: evidence from estimates and survey data.

OBJECTIVE: To present the most recent 2013 UNAIDS estimates of HIV prevalence among people aged 50 years and older, and to validate these estimates using data from national household surveys. DESIGN: Modelled estimates of HIV prevalence were validated against nationally representative household survey measures of HIV prevalence. METHODS: The UNAIDS 2013 HIV estimates were used to compute HIV prevalence and number of people living with HIV aged 50 years and older. Sex-specific HIV-prevalence rates by the 5-year age group were calculated from nationally representative household surveys conducted between 2003 and 2013, and were compared to prevalence rates from the modelled estimates. The ratios (Spectrum/Survey) of the prevalence rates from the two sources were analysed. RESULTS: In 2013, an estimated 4.2 million (4.0-4.5 million) people aged 50 years and older were living with HIV. The global HIV prevalence among older individuals more than doubled in almost all the 5-year age groups since 1995. There was a relatively good agreement between the modelled HIV-prevalence rates and the survey-based rates among men and women aged 50-54 years (0.90 and 1.00 median ratio, respectively), whereas for 55-59 year-olds, the differences were more notable (ratios of 0.63 for men and 0.90 for women). CONCLUSION: Both data sources suggest HIV-prevalence rates among people aged over 50 have increased steadily in the recent years. Care and treatment services need to address the specific needs of older people living with HIV. Action is needed to incorporate older age groups into HIV surveillance systems.

Understanding the community impact of lymphatic filariasis: a review of the sociocultural literature.

Lymphatic filariasis (LF) is endemic in approximately 80 tropical and subtropical countries. About 120 million people are infected with the parasite and a billion are estimated to be at risk of infection. The main focus of the LF elimination programme to date has been to interrupt transmission by means of annual community-wide treatment campaigns with diethylcarbamazine and albendazole, or albendazole and ivermectin, for a period of four to six years. Although substantial progress has been recorded wherever the strategy has been successfully implemented, initial gains have been accompanied by a realization that this strategy alone will not ensure a permanent solution in all settings. The fairly extensive LF literature is dominated by laboratory research and quantitative field measurement of the impact of LF, particularly local prevalence studies of parasite-infected humans and vectors. As the global elimination programme expands, the absence of sociocultural understanding is being recognized as a critical flaw in ensuring that programmes are appropriate and responsive to local needs and understanding. This paper assesses the current state of sociocultural understanding pertaining to LF. It concludes that, at present, there is insufficient understanding of the sociocultural factors associated with the presence and treatment of the disease, and that appropriate social science methods should be used to address this deficiency and ensure community partnership in delivering and sustaining the success of LF elimination programmes.

Getting the balance right? GPs who chose to stay in rural practice.

BACKGROUND: Despite major challenges to the retention of rural GPs in Australia, little is known about why some rural GPs stay long-term within their communities. METHOD: A group of rural GPs interviewed as part of another study about 10 years ago were re-interviewed to explore their attitudes to their reasons for staying. RESULTS: Eighteen of the original group of 23 could be contacted and 13 were interviewed. Factors that appeared to promote staying in rural practice were: strong attachment to the community; and practice arrangements that allow for adequate time off-call and for holidays. However, several GPs were stressed and some had considered leaving. The stressors were similar to those identified in earlier research, including overwork and having to send children to boarding school. CONCLUSION: Personal and professional support arrangements within the community appear to be associated with decisions by rural GPs to remain in practice for substantial periods of time. Retention strategies should focus on facilitation of local integration. WHAT IS ALREADY KNOWN: Some doctors stay for prolonged periods of time in rural practice, although most leave after a few months or years. The reasons why rural doctors stay have until now not been explored. WHAT THIS STUDY ADDS: Rural doctors who stay for prolonged periods of time, defined in this study as 10 or more years, have established personal and professional support networks that have provided protection from the more negative aspects of rural professional life.