By Laura Hoemeke, Director of Health Policy & Systems, IntraHealth International and HSG Member
The global health community first made widescale investments in community health workers (CHWs) more than 40 years ago. But last month, I left the 71st World Health Assembly wondering whether we had learned anything from CHW experiences over the last several decades.
The 1978 Declaration of Alma-Ata underscored the central role of bringing health care “as close as possible to where people live and work” as part of achieving universal primary health care. The declaration, which is being revamped for its 40th anniversary later this year, defined primary health care (PHC) as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.”
Starting in the 1960s, several countries tried, to varying degrees of success, to introduce national CHW programs. After the Alma-Ata conference, even more countries invested in scaling up CHW programs. Experience shows, though, that the scaled-up programs were not, for the most part, successful — not well-resourced and not integrated with community systems or national health systems. Ministries of health, funding agencies, communities — and CHWs themselves — lost their enthusiasm.
Yet at panel presentations and discussions during this year’s WHA, many speakers still focused on CHWs as the solution without focusing on what hasn’t worked in the past, and what it will take to create sustainable and scalable CHW programs this time.
(1) Community health workers need to be an integral part of functional health systems — not (another) NGO pilot program
During the WHA, I heard brilliant ideas about what CHWs could do. In addition to diagnosing and treating basic childhood illnesses, they could administer a range of contraceptive methods. And promote handwashing. And active lifestyles. And conduct initial screening for both infectious and non-communicable diseases. Oh, and sell products house-to-house, too.
And then what? Moderators and other panellists often responded that CHWs can refer cases they don’t have the skills to manage up to the next level of care. Rarely discussed, however, was that next level of care. Are treatment or advanced diagnostics available at a secondary or even tertiary level? What really happens when a disease — or risk of one — is detected?
In additional to strong referral levels of care, we know from experience that CHWs need ongoing training and high-frequency supervision. In general, that supervision needs to be provided by health workers with both clinical and managerial skills, ideally health workers that are part of a country’s formal health system. In adding NCD prevention and diagnostics, among other tasks, to CHWs’ workloads, we are adding entire new skill sets and need to prepare CHWs and their supervisors for that.
A 2017 CHW reference guide examined national CHW programs, but did not “address specific technical issues related to specific interventions [such as the range of interventions that CHW can provide, the training and logistical support required for specific interventions, and so forth].” These are make-or-break elements, however, in developing effective and sustainable programs.
The Alma-Ata declaration recognized — 40 years ago — that CHWs need to function as key members of teams of providers. Primary health care, it said, “relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries, and community workers as applicable, as well as traditional practitioners as needed,suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.”
(2) Community health workers need a mutually trusting relationship with the communities they serve, as well as the health system
The WHO’s 13th General Program of Work, adopted unanimously during this year’s WHA, states, “To respond effectively and appropriately to needs and expectations, health services need to be organized around close-to-community networks of people-centred primary care, with due attention to effectiveness, safety and efficiency, as well as to continuity, integration and coordination of care and respectful and compassionate relations between people and their health care workers.”
The Alma-Ata declaration also recognized “people have a right and duty to participate individually and collectively in the planning and implementation of their health care.” This includes having a voice in determining how close-to-community services will operate and how CHWs will interact with communities. Study after study has shown that communities will not access the services of CHWs unless they trust them implicitly. Let’s hope that a new generation of CHW programs will be developed through processes that include the voices of communities themselves.
(3) Community health workers need motivation — and that’s more than t-shirts
Long gone, we hope, are the days when CHWs were expected to wake in the early hours, visit 100 houses before attending to their own families and fields — and be (seemingly) happy to be rewarded with a NGO t-shirt or bar of soap. If we place the lives of children and families in the hands of dedicated CHWs, we certainly need to dedicate resources to reward their time and effort.
Countries need to develop appropriate policies and strategies to compensate CHWs. In many countries, this includes formalizing CHWs as government employees. As experience shows, sustainability takes long-term commitment, not just a three-year project-linked grant. Countries have devised a variety of ways of compensating CHWs, including payment-for-performance or results-based financing, but these experiences have had mixed results, due primarily to the complexity of measuring performance at the community level.
Efforts have included training CHWs in income-generating activities to generate funds to support their activities. Many of these efforts have failed because they don’t take into account the time CHWs spend serving their communities (and supporting their own families) without the added burden of income-generating activities.
Promising efforts, which have worked in several countries, include systems in which CHWs are paid small fees for treatment or medicines and other products by the people they serve. The premise is that community members save resources, especially transport and time, and are willing to pay for “house calls.” But ensuring that these schemes equitably serve the poorest of the poor is challenging. And incorporating them into national health systems — with clinically trained salaried supervisors — is difficult.
Research has shown that investment in CHWs in Sub-Saharan Africa can yield a return on investment of up to 10:1 — and even greater long-term returns considering their potential impact of the health and productivity of populations. We know, however, due to the large numbers of CHWs required to provide basic coverage to a country’s population, CHW programs are not a cheap substitute for other cadres of health workers. Many countries, unfortunately, cannot afford basic CHW programmes without an influx of foreign investments.
After participating in a week of discussions and debates about the role of CHWs during the WHA, I often felt that the weight of universal health care is being put squarely on the shoulders of CHWs. To play a key role in advancing PHC and universal health care, though, CHWs need support. And resources. Let’s take some of the weight off hardworking CHWs and share it among the broad shoulders of all actors in the global health community. And let’s remember that a national CHW program is only as strong as the health system that supports it.