Many thanks for stimulating this open discussion on CHWs – a critical cadre in resolving the health workforce crisis in Africa… and beyond.

In IAPB (the International Agency for the Prevention of Blindness) we have been making use of various cadres of CHWs for many years, most notably, Community Directed Distributors (CDDs) of Zithromax for trachoma control and Ivermectin for oncho/river blindness.  

Last year, as part of our comprehensive response to the  workforce crisis (ophthalmologists, optometrists, allied eye health professionals, Primary Eye Care Workers and CHWs), we undertook a situation analysis, in 23 countries in Africa, of the  role of CHWs in eye health.

The results were quite staggering as we discovered 59 different cadres playing a role, in one way or another, in promoting eye health at the community level.

The report, which has just been finalised, is attached [*] along with 2 of the most relevant appendices – on classifications and  a Ghana case study. The Report, along with all the appendices will be available in the next 2 weeks on the IAPB Africa website.  

Alongside this work,  one of  our cadre-specific Working Groups has also completed a provisional set of core competencies for the eye health component of the CHW workforce, which we are currently validating with expert groups in WHO-Afro.

In a  sense, all this is by way of background to our response to the discussion of the week – What are the most pressing challenges in the scale-up of CHW programmes today ?

Our Response = 6 Key issues:

1.       Fragmentation: Even within a hitherto vertical programme such as eye health we are constantly striving, as IAPB, to coordinate the activities of our many member agencies and to align a collective  response with existing CHW initiatives.  

2.       Comprehensiveness: According to 3 recent studies in Kenya, Cameroon and Nigeria, ocular morbidities (particularly conjunctivitis and presbyopia) account for 15-20% of all health problems faced by communities in addition to  blindness at 1%, low vision at 1% and uncorrected refractive error at 4%. In other words, eye health is a major challenge at the community level and we all need to work to ensure that any new curriculum for CHWs includes the component of eye health.  

3.       Data: While we have excellent figures for the number of CDDs due to the long-running oncho and trachoma control programmes, much less is known about the numbers, distribution, retention, training, and impact of CHWs who have been trained to deliver eye health services, as our report makes clear. Our response has been to develop a database (the IADb) of over 300  eye health indictors, aligned with DHIS2 and the African Health Observatories, to capture basic data at the community and primary levels.

4.       Funding: Various  approaches  to scaling-up the CHW workforce are being implemented but the capacity to take them to scale remains elusive.  IAPB, with 40 active members  in Africa, can play a part  in scaling-up but cannot  take on the job on its own. We need to see a greater government commitment to a comprehensive process, which must include all causes of mortality and morbidity.

5.       Disability: In eye health we would also be looking at the role of the community worker in disability  eg finding the blind child, inclusive education  of the irreversibly blind child and rehabilitation of the blind adult.

6.       Inter-sectoral collaboration: This is critical at community level with respect, in particular, to water and sanitation in trachoma control.

I do hope this contribution to the discussion is useful and we look forward to comments, constructive criticism and guidance as we move forward together.

As always

Ronnie Graham

Director, HReH,

IAPB Africa    

HIFA profile: Ronnie Graham is Director, Human Resources for Eye Health, IAPB Africa, and is based in Durban, South Africa. Professional interests: Human resources for eye health in Africa, advocacy, HMIS, research, primary health care, mHealth, Francophone and Lusophone Africa, faculty and training programmes, the GHWA-HWAI (Global Health Workforce Alliance – Health Workers Advocacy Initiative) and health economics. rgraham AT iapb.org

[*Note from HIFA moderator: HIFA does not carry attachments. Please contact Ronnie direct. Thanks, Neil PW]