Intended for healthcare professionals

Analysis Health in South Asia

Rethinking community based strategies to tackle health inequities in South Asia

BMJ 2018; 363 doi: (Published 29 November 2018) Cite this as: BMJ 2018;363:k4884
  1. Zulfiqar A Bhutta, founding director, co-director12,
  2. Abhay Bang, director3,
  3. Kaosar Afsana, professor4,
  4. Bishal Gyawali, PhD fellow5,
  5. Shafiq Mirzazada, director6,
  6. Renuka Jayatissa, head7
  1. 1Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
  2. 2Centre for Global Child Health, the Hospital for Sick Children, Toronto, Canada
  3. 3SEARCH, Gadchiroli, Maharashtra, India
  4. 4James Grant School of Public Health, BRAC University, Dhaka, Bangladesh
  5. 5Department of Public Health, Aarhus University, Aarhus, Denmark
  6. 6Academic Projects Afghanistan, Aga Khan University, Kabul, Afghanistan
  7. 7Department of Nutrition, Medical Research Institute, Ministry of Health, Colombo, Sri Lanka
  1. Correspondence to: ZA Bhutta zulfiqar.bhutta{at}

A long term strategy is vital to build on the impact of community health workers in achieving universal health coverage, say Zulfiqar Bhutta and colleagues

The world recently celebrated the 40th anniversary of the Alma Ata declaration in 1978 to provide “health for all by the year 2000.” That remarkable call for action was not followed by concerted action, however, with much debate on the need for selective or universal primary care.1 To accelerate progress in reducing poverty and improving health outcomes, 189 countries signed up to the Millennium Development Goals (MDGs) in September 2000 with two major goals (goal 4 and 5) focused on reducing child and maternal mortality by 2015.2

South Asia (comprising Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) accounts for a disproportionate number of maternal and under 5 deaths.3 Of 2.5 million neonatal deaths in 2017, 43% occurred in South Asia. An estimated 35% and 31% respectively of all global under 5 deaths and deaths among children between 5 and 14 years of age also occurred in South Asia.34 The corresponding proportion of maternal deaths in 2015 in South Asia was 20%.5 A recent review indicates that Afghanistan, India, and Pakistan have not yet achieved the MDG 4 goals of reducing child mortality.34

A major policy response to improve access to healthcare in the region—specifically maternal, newborn, and child health (MNCH) services—has been shifting tasks to community health workers (CHWs) and community based volunteers67 in rural and remote areas. Here, we review the impact of community based strategies and the role of community health workers, and explore opportunities for their long term engagement to tackle health inequities in South Asia.

Health disparities in South Asia

Progress in child survival within South Asia varies greatly (table 1).3 …

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