Academic journal article Bulletin of the World Health Organization

Lay Health Worker Attrition: Important but Often ignored/Attrition Du Personnel Non Medical: Importante, Mais Souvent ignoree/Rotacion del Personal Sanitario No Cualificado: Una Cuestion Importante, Aunque Frecuentemente Ignorada

Academic journal article Bulletin of the World Health Organization

Lay Health Worker Attrition: Important but Often ignored/Attrition Du Personnel Non Medical: Importante, Mais Souvent ignoree/Rotacion del Personal Sanitario No Cualificado: Una Cuestion Importante, Aunque Frecuentemente Ignorada

Article excerpt

Introduction

A community or lay health worker is a member of the community who has received some training to promote health or to carry out some health-care services, but is not a health-care professional. Community or lay health worker programmes were promoted in many countries in the 1970s and 1980s, but many were abandoned as they failed to realize the potential demonstrated in several initiatives led by nongovernmental organizations and in national programmes such as China's "barefoot doctors." With recent evidence of their effectiveness, and in the context of the health workforce crisis, interest in lay health workers has increased and many countries are again investing in national programmes. (1,2) However, sustainability of these programmes is threatened by high rates of attrition.

Measuring attrition and identifying its determinants should be an integral part of managing any lay health worker programme, but it is often ignored in favour of reporting health outcomes and process indicators such as the number of workers recruited and trained. The emphasis on reporting health outcomes is appropriate, since the main purpose of lay health worker programmes is to bring health services closer to communities so as to improve health outcomes. Thus, evidence on improvement of health outcomes is necessary to justify the introduction or continued use of lay health workers in any context. However, attrition that leads to disruption in the continuity of care and retraining costs can undermine the ultimate goal of these programmes.

Searches of key databases and interrogation of published reviews of lay health worker programmes find that high turnover is widely recognized as a challenge. Several researchers acknowledge this as an area that requires further research but this recognition has not translated into empirical research on this topic. (3-5)

Contribution to health

Several reviews have reported that lay health workers carry out a variety of health tasks and are referred to using about 60 different names around the world. (1,2,6-9) Lay health workers deliver a wide range of interventions in such areas as nutrition, maternal and child health, primary health care, malaria, tuberculosis and HIV/AIDS prevention and control, mental health and non-communicable diseases. A review of randomized controlled trials found that these workers can be effective in increasing immunization coverage, improving breastfeeding rates, reducing infant mortality and improving tuberculosis treatment. (9) They contribute to the prevention and management of communicable and noncommunicable diseases, and maternal and child health.

It is difficult to state the number of lay health workers worldwide, because many programmes exist as small-scale projects. Furthermore, as pointed out by Lehmann and Sanders, (1) when they are not owned and firmly embedded in communities, the programmes are vulnerable. They often exist on the physical and organizational periphery of health systems and thus may be fragile and unsustainable. Nonetheless, some countries have implemented national programmes (Table 1).

Lack of data

There are very few published studies on lay health worker attrition, particularly quantitative studies with a primary outcome of attrition or retention. We found 11 reviews that summarize the evidence on various subtopics of lay health worker programmes, including attrition or retention. (1,2,5-12) However, most published peer-reviewed studies are largely of lessons learnt from evaluations of lay health worker programmes. (13-18) We found only one quantitative study that had "attrition" as a primary outcome. (17)

Attrition

Attrition has been identified as one of the key challenges of lay health worker programmes'. (8) Attrition levels were reported between 3.2% and 77% in the 1980s). (11,18) The problem persists in current programmes: a lay health worker programme in the Plurinational State of Bolivia noted a 43% attrition rate, (19) in South Africa a tuberculosis intervention programme lost 11 out of 12 lay health workers in less than a year (20) and, in Bangladesh, implementation of an intervention aimed at improving newborn care lost 32 out of 43 lay health workers over a four-year period. …

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