Toward a geography of community health workers in Niger: a geospatial analysis

BackgroundLittle is known about the geography of community health workers (CHWs), their contribution to geographical accessibility of primary health care (PHC) services, and strategies for optimizing efficiency of CHW deployment in the context of universal health coverage (UHC). MethodsUsing a complete georeferenced census of front-line health facilities and CHWs in Niger and other high resolution spatial datasets, we modelled travel times to front-line health facilities and CHWs between 2000-2013, accounting for training, essential commodities, and maximum population capacity. We estimated additional CHWs needed to maximize geographical accessibility of the population beyond the reach of existing front-line health facilities and CHWs. We assessed the efficiency of geographical targeting of the existing CHW network compared to modelled CHW networks designed to optimize geographical targeting of the estimated population, under-five deaths, and plasmodium falciparum malaria cases. ResultsThe percent of the population within 60 minutes walking to the nearest CHW increased from 0{middle dot}0% to 17{middle dot}5% between 2000-2013, with 15{middle dot}5% within 60 minutes walking to the nearest CHW trained on integrated community case management (iCCM) - making PHC services and iCCM, specifically, geographically accessible for an estimated 2{middle dot}3 million and 2{middle dot}0 million additional people, respectively. An estimated 10{middle dot}4 million people (59{middle dot}0%) remained beyond a 60-minute catchment of front-line health facilities and CHWs. Optimal deployment of 8064 additional CHWs could increase geographic coverage of the estimated total population from 41{middle dot}5% to 73{middle dot}6%. Geographical targeting of the existing CHW network was inefficient but optimized CHW networks could improve efficiency by 55{middle dot}0%-81{middle dot}9%, depending on targeting metric. InterpretationsWe provide the first high-resolution maps and estimates of geographical accessibility to CHWs at national scale, highlighting improvements between 2000-2013 in Niger, geographies where gaps remained, approaches for improving targeting, and the importance of putting CHWs on the map to inform planning in the context of UHC. O_TEXTBOXKEY QUESTIONSO_ST_ABSWhat is already known?C_ST_ABSO_LIPrevious studies have estimated geographical accessibility (as travel time) to CHWs for subnational areas only1-4 and have assessed efficiency of the distribution of hospitals in low and middle-income countries.5 C_LI What are the new findings?O_LIThe percent of the population within 60 minutes walking to the nearest CHW increased from 0{middle dot}0% to 17{middle dot}5% between 2000-2013, with 15{middle dot}5% within 60 minutes walking to the nearest CHW trained on integrated community case management (iCCM) - making PHC services and iCCM, specifically, geographically accessible for an estimated 2{middle dot}3 million and 2{middle dot}0 million additional people, respectively. C_LIO_LIAn estimated 10{middle dot}4 million people (59{middle dot}0%) remained beyond a 60-minute catchment of front-line health facilities and CHWs in 2013, with important variation across subnational geographies, training of CHWs, and availability of essential commodities. C_LIO_LIOptimal deployment of 8064 additional CHWs could increase geographic coverage of the estimated total population from 41{middle dot}5% to 73{middle dot}6%, providing physical access to PHC services for an additional 5{middle dot}7 million people not covered in 2013. C_LIO_LIOptimized CHW networks increased efficiency of geographical targeting compared to the existing CHW network by 55{middle dot}0%-81{middle dot}9%, depending on targeting metric. C_LI What do the new findings imply?O_LIGeographical accessibility to primary health care services, including iCCM, improved in Niger between 2000-2013 with important contributions by CHWs. C_LIO_LIGaps in geographical accessibility remained as of 2013 but scale-up of the CHW network, using the scale-up approach described in this study, could substantially increase geographical accessibility of PHC services. C_LIO_LIThe efficiency of geographical targeting of the existing network of CHWs was suboptimal. The approach for optimizing efficiency of geographical targeting described in this study could be used to improve geographical targeting of CHW deployment in Niger and other countries. C_LIO_LIThis work is a first step toward establishing a geography of CHWs in Niger and is a call to action to put CHWs on the map globally to inform health system planning and maximize geographical accessibility, efficiency, and impact of investments in the context of UHC. C_LI C_TEXTBOX