Thirty years after Alma-Ata: a systematic review of the impact of community health workers delivering curative interventions against malaria, pneumonia and diarrhoea on child mortality and morbidity in sub-Saharan Africa

We searched databases of published and unpublished studies for RCTs and non-randomised studies evaluating CHW programmes delivering curative treatments, with or without preventive components, for malaria, diarrhoea or pneumonia, in children in sub-Saharan Africa from 1987 to 2007. The impact of these programmes on morbidity or mortality in children under six years of age was reviewed. A descriptive analysis of interventional and contextual factors associated with these impacts was attempted.The review identified seven studies evaluating CHWs, delivering a range of interventions. Limited descriptive data on programmes, contexts or process outcomes for these CHW programmes were available. CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions.CHW programmes could potentially achieve large gains in child survival in sub-Saharan Africa if these programmes were implemented at scale. Large-scale rigorous studies, including RCTs, are urgently needed to provide policymakers with more evidence on the effects of CHWs delivering these interventions.In 1978, the Declaration of Alma-Ata presented Primary Health Care (PHC) as the means of achieving Health for All and community or lay health workers (CHWs) became a distinguishing feature of PHC implementation as it was rolled out. Several reviews of national CHW programmes in the late 1980s and early 1990s came to similar conclusions: quality of care from large-scale programmes was poor, generally because of a lack of ongoing training and supervision and poor logistical and financial support [1-3]. It has been argued that where national CHW programmes have failed, this has not been due to a failure of the concept of CHWs or PHC but because the support and supervision necessary to make them effective were too often missing. With the HIV/AIDS pandemic, and increasing acknowledge