Maximizing the impact of community-based practitioners in the quest for universal health coverage

Editorials 590 The last decade has highlighted major gaps in the availability, accessibility, acceptability and quality of the health workforce in many countries. 1 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. 2 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. 3 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. 4 Several studies have demonstrated the potential of various types of community-based practitioner in delivering a range of health services. The new analysis by McPake and colleagues 8 in 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. 9 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. 10 Fortunately, the elements needed for successful integration of …