For the past two decades, evidence has been accumulating that community health workers (CHWs) and community-based programming could be effective to deliver essential, evidence-based maternal, neonatal, and child health (MNCH) interventions to populations in resource-limited settings. Questions linger about the potential impact of scaling-up community-based platforms when these platforms continue to be under-resourced and unable to reach their full potential while global health funding focuses on narrowly targeted interventions.
Our recent analysis published in the open-access Journal of Global Health examined the impact of truly investing in and expanding community-based primary health care (CBPHC) to reach coverage targets set as 50%, 70% and 90% in a sample of 73 low- and middle-income countries. Using the Lives Saved Tool (LiST), we created country-specific models. Mortality change was estimated if coverage of 30 key MNCH interventions could be increased at scale through a community-based platform of service delivery.
The estimated impact was an overall reduction of 14%, 23%, and 32% fewer deaths compared to a scenario assuming coverage of these critical interventions remained unchanged and no progress was made toward the goals of 50%, 70%, and 90% respectively. Although all regions of the world would benefit considerably, the African region would receive the greatest benefit: 58% of the lives saved globally at 90% coverage would be in Africa. Specific interventions which contributed to the number of stillbirths prevented and maternal, neonatal, and child lives saved varied across countries* depending on baseline levels of mortality and coverage and as well as the presence of contextual risk factors (e.g., levels of stunting and wasting prevalence), but the individual interventions that would save the most lives on a global level at 90% coverage were: nutritional support during pregnancy, malaria treatment with artemisinin compounds, oral rehydration solution to treat diarrhea, handwashing with soap, and oral antibiotics to treat childhood pneumonia.
The benefits of delivering these critical health interventions to women and their children is unequivocal, but the findings from our paper underscore the importance of strengthening community-based platforms of service delivery. This is especially needed in settings where current coverage of these evidence-based interventions remains low. The coverage levels will need to be expanded to accelerate mortality reductions for the global goal of ending preventable child and maternal mortality by the year 2030 as called for by the global Sustainable Development Goals (SDGs).
Applying a systematic approach that incorporates recent and available data sources is valuable for the Healthy Newborn Network to quantify the anticipated gains and guide evidence-based
decision-making. Realizing the untapped potential of community-based platforms to expand population-level coverage will require not only strategic allocation of resources but informed and thoughtful planning to build and sustain a cadre of skilled and effective CHWs. Building robust community platforms for service delivery will be needed to incorporate the new evidence-based interventions that will most certainly become available during the next two decades. The platforms will need the capability to visit all homes on a regular basis to identify pregnant woman, assure that they receive proper education, risk screening, and nutritional support, and provide in-home support to women at the time of delivery and support for newborns during the first critical days of life. Evidence regarding the effectiveness of nutritional support during pregnancy in reducing stillbirths is robust, but platforms and programs to deliver these interventions are just now being developed.
* Country-specific estimates presenting the potential impact (i.e. stillbirths prevented, maternal, neonatal, and child lives saved) if target levels of 50%, 70%, and 90% for the 30 interventions are achieved in the final year are available as Supplementary Material.
