By Kingsley Chikaphupha and David Musoke, Co-Chairs of the HSG Thematic Working Group on Supporting and Strengthening the Role of Community Health Workers in Health System Development
The 2nd International Symposium on Community Health Workers brought together over 500 participants from 35 countries to explore the theme: ‘Potentials of CHWs in the prevention and control of Non-Communicable Diseases (NCDs) in the context of Universal Health Coverage (UHC).’ The symposium took place in Dhaka, Bangladesh from the 22nd to 24th November, 2019 and was hosted by icddr, b.
Building off the success of the first symposium held in Kampala, Uganda in 2017, the symposium brought together public health practitioners, policy-makers, researchers, implementers, CHWs, students, funders, civil society, and other stakeholders to share learning on community health systems, and program innovations, in a variety of settings including resource-constrained environments such as conflict areas and urban slums. In addition, the symposium explored how health system challenges can be addressed to facilitate program scale-up. The Dhaka Symposium, as with that held in 2017 in Kampala, is part of the Supporting and Strengthening the Role of Community Health Workers in Health System Development Thematic Working Group (TWG) of Health Systems Global (HSG). In this blog, we discuss 2 key themes that emerged from the Bangladesh symposium: CHWs addressing non-communicable diseases and CHWs in special situations.
CHWs and the global burden of non-communicable diseases
As previously noted, the main theme of the conference was ‘Potentials of CHWs in the prevention and control of Non-Communicable Diseases (NCDs) in the context of Universal Health Coverage (UHC)’. Throughout the conference, delegates deliberated on four key sub-themes: CHW programming in low-and middle-income countries (LMICs); CHWs and UHC; CHWs in special situations; and CHW programmes and prevention and control of NCDs.
Access to, and use of, health services are limited by insufficient numbers of qualified health providers, increased workload among existing health professionals, delayed health seeking behavior, and lack of awareness about routine care. This is especially true in resource-poor settings. Symposium participants agreed that CHWs are a major solution to reducing the NCD burden, particularly in LMICs. For example, delegates presented evidence on the role CHWs can play as health educators, advisors, rehabilitation workers and support-group facilitators to address NCDs in communities. Engagement of CHWs in NCD control can help mitigate the global health human resources crisis. CHWs can also strengthen the link between health services and communities and increase awareness about prevention and control of NCDs. Several presentations highlighted the contributions CHWs are making to NCD control in Kenya, Thailand, Bangladesh, India and China. Some of the interventions CHWs implement to help improve NCD service delivery include:
Advocating for individual and community needs: CHWs articulate and advocate for the needs of individuals and communities and provide guidance for access to health services. CHWs involve communities in advocacy and map communities to locate and support services.
Providing wellness services: CHWs promote wellness, educate local communities on disease prevention, provide individual social and health care support, organise and facilitate support groups, and conduct health screenings.
Building individual and community capacity: CHWs act as a bridge between individuals and communities to access need-based health and human services and provide direct services such as informal counselling, social support, and care coordination.
Navigating the health and human services system: CHWs work to increase access to primary care, enhance health literacy, and facilitate continuity of care by providing follow-up care especially for NCDs.
Bridging the gap between communities and health and social service systems: CHWs enhance the quality of care, educate community members, and establish better communication processes in communities.
The opening ceremony session at the symposium
CHWs in special situations
The symposium had several presentations and deliberations on the role of CHWs in special situations. Special situations encompassed rapidly urbanizing contexts, urban slums, and fragile and conflict settings. Gaps identified on the work done by CHWs in special situations included: CHWs are not well positioned for social action; there are no specific adaptations to urban work; and CHWs working in urban areas have the potential, but lack needed innovations, to enhance their service delivery capacities.
It must be mentioned that symposium participants said many CHWs feel undertrained and not adequately resourced. In most countries, it was mentioned that district health management teams (DHMTs) perceive urban facilities and CHWs to be well resourced due to higher presence of non-governmental organisations (NGOs). Urban CHWs seem to possess higher education than rural CHWs. However, the competencies of all CHWs are not different as they universally depend on the availability of resources to function well. CHWs are involved in referral of gender-based violence (GBV) cases despite being beyond their remit in many instances. Understanding what motivates CHWs to work in special situations can help retain CHWs and address sustainability issues to support programmes. There is need for high investment in CHWs to improve their capacity. Evidence shows CHWs often receive lots of information on technical issues but little to none on social action.
The symposium also presented a lot of learning about CHWs experiences in fragile and conflict-affected setting; of great importance was the issue of resilience in CHWs. Participants called for a recognition of the vulnerabilities and challenges that CHWs face, and for policymakers, activists and governments to work towards developing policies and interventions that will build strong and responsive support systems for CHWs including during post-conflict recovery. This strategy will ensure sustenance of CHW motivation and a sense of security, as well as improved work performance. Lessons learned included:
Fragility’s consequences can bring mistrust: This comes from the fact that the community is mostly not involved in the design of interventions. We need to start seeing beyond the CHWs and engage other stakeholders like community-based organizations and community leaders.
Resilience is lies in the community: Recognise that the community has something to offer if interventions are to register higher levels of positive impact.
Strike a balance in the gender norms of CHWs: A good example was given from India where ASHAs are all female, and as a result, are not able to adequately bring male members of households into discussion of reproductive health or other services. Pairing ASHAs with husbands or men could address the gap.
Psychological trainings of CHWs can equip them to handle stressful encounters: CHWs face difficult situations every day, supporting women who have suffered abuse or combating violence against children, and they need to be adequately trained and supported to manage these stressful situations.
End the continued provision of inadequate incentives: CHWs are putting their lives in danger by working in these conflict settings. Dr. Mushtaque Chowdhury, former Executive Director of BRAC, put it well: “Expecting CHWs to work on a voluntary basis is just not a practical thing to do.” It also is not ethically sound in many contexts.
The issues of CHW remuneration and improved training were also highlighted during the symposium. Delegates argued that it is time to do away with the argument that paying CHWs will strain already constrained ministry of health budgets in resource-constrained settings. Countries have adopted / adapted task-shifting strategies and profound evidence points to success when CHWs are trained and deployed. Not paying CHWs is unethical and unsustainable. Symposium delegates also emphasized the need for improved training packages for CHWs to maximise on their potentials. For example, Dr. Maryse Kok from the Royal Tropical Institute (KIT), Netherlands said: “We need more efforts in the training and broader capacity building for CHWs to achieve optimal impact of their work.”
Some very eye-opening research questions were posed for continued interventions in fragile and conflict affected settings, which will be explored further in 2020 when the HSG CHW TWG co-hosts a webinar with the HSG TWG on fragile and conflict-affected settings. Look out for promotion activities for the webinar in the first quarter of 2020.
All in all, by tackling a diverse range of topics and the very healthy discussions that ensued during the symposium, the 2nd global symposium on CHWs lived up to its billing. The conference statement shows that the symposium managed to facilitate development of better strategic pathways for creating community-based programmes for NCDs, as it demonstrated that CHWs are part of the solution to attain reduction of the NCD burden. Involvement of CHWs in prevention and control of NCDs will help to reach the SDG target of 25% reduction in the risk of premature mortality from NCDs by 2025 and one-third reduction in premature deaths from NCDs by 2030. The symposium demonstrated that CHWs are critical to attainment of the ‘right to health’. Well-trained CHWs who provide timely, affordable, appropriate, quality care are a means to achieving universal health coverage.