Trauma training and starting small: How to build strong CHW programs in times of war

With the world facing a shortage of 10 million health workers by 2030 and at least half of the world's population not receiving the full range of essential health services, community health workers are crucial to bringing health care to people that formal health systems can't reach.

Study after study shows community health workers (CHWs) have helped improve health outcomes in numerous low- and middle-income countries (LMICs). They ensure people take their medication and keep up with treatments, identify environmental or lifestyle factors that make people sick, and boost health-seeking behavior – all of which eases the burden on primary health care systems.

In conflict settings, CHWs are even more vital to delivering essential and urgent health care. They work in areas where people might be caught in active fighting, where accessing facility-based health services is impossible, where sourcing medicines, medical equipment, food and clean water is a struggle, and where government presence is minimal or non- existent.

In these scenarios, optimizing CHW systems can help efficiently and effectively deliver health services to people in need. But while various global health organizations have developed frameworks for CHW optimization, few have been designed for fragile settings, let alone conflict zones. After seeing how difficult it was to recruit and motivate CHWs during his fieldwork in Turkey and Syria, community health specialist Dr. Ahmad Habboush teamed up with health system consultant Dr. Abdulkarim Ekzayez and Brynne Gilmore, an expert in public health and primary care, to research the problem for the Research for Health Systems Strengthening in Northwest of Syria (R4HSSS) project.

For their case study, they chose the rebel-held region of northwest Syria, where the concept of CHWs is relatively new. Rudimentary CHW programs were brought in by international NGOs in 2013, two years after civil war broke out in the country, and have been gradually growing since then. The researchers collected on-the-ground interviews with CHWs, NGOs, and other stakeholders to develop a framework for optimizing CHW programs in conflict settings, which was published in BMJ Global Health in July 2023.

Exemplars News spoke with Dr. Habboush and Dr. Ekzayez about how to get the most out of CHW programs in places where danger, uncertainty, and trauma are part of daily life.

Why are community health workers particularly important in conflict settings?

Dr. Habboush: Community health workers are known for being able to increase [health care] access to people living in hard-to-reach areas and being able to identify health issues early, which is essential for early intervention. There's a huge problem globally in human resources for health, and this problem is exacerbated in conflict settings like Syria, in terms of numbers and capacity and specialization. The current available health services are overwhelmed – they are not able to meet the demand. And you have a community which is more susceptible to disease because of the war conditions and destroyed infrastructure and WASH problems. When we don't invest in community health workers in such settings, we put existing human resources at risk by putting all this stress on facility-based interventions, because they have limited capability.

Dr. Ekzayez: Specifically in conflict settings, we have two issues that are different from fragile or development settings. One is the typology of morbidity and diseases – the emergence of some health threats that traditional fixed-facility health systems cannot deal with. Take, for example, the polio outbreak in Syria in 2017. Without a door-to-door campaign in the community, we would not have been able to control it. So the first issue is about emerging health threats.

The second issue is about utilization of health services. In terms of accessibility or health-seeking behavior, conflict settings are different from other settings. Syria has about 6.8 million internally displaced people who face multiple intersecting challenges that can impact their access to health care, including discrimination, barriers to entering the workforce, and lack of a permanent address. To see those people, especially those who have been displaced multiple times, you need to go and visit them, and community health workers are best placed to do that. During our research for a different project, we compared CHWs to mobile clinics and found that CHWs are much more mobile and have more knowledge in terms of how to keep track of displaced people, where they came from, and where they are going.

Nearly 90% of CHWs you interviewed said they strongly believed in the value of their work, but only 50% said they were confident the community believed the same. You stress the need to address the integration and perception of CHWs in conflict settings. Why are those two factors so important?

Dr. Habboush: One of our findings is that the perceptions of key stakeholders and funders is the main challenge for the integration of CHWs into the official health system. It's perceived as either/or – health care is delivered either through the facility or through CHWs. But that's not the case, both have to be integrated and work together to complete the cycle of treatment and ensure the wellbeing of patients who live in hard-to-reach areas.

CHWs are not replacing the facility-based system, they are complementing and supporting it. In conflict settings, the demand is huge and the resources are limited. Without integration of CHWs, facility-based staff will not be able to follow up with patients at home, they will not be able to identify problems early or change behavior, and that will lead to more health problems and consequently increase the burden on doctors.

CHWS can do this. They can understand why a particular behavior is not being changed, because they live with the people in their camps, in their towns, and they understand their daily struggles.

What is your guidance for recruiting and retaining CHWs, which can be especially difficult in conflict situations?

Dr. Habboush: Recruitment comes under the institutional elements of our framework – it has a strong connection with sustainability and integration. It's important to consider communication skills as core when recruiting CHWs, because that's vital to facilitating their collaboration with specialized health providers. Also, selecting CHWs from their own communities is crucial for service demand and acceptance among the served community. These factors are important in other settings, but they are more critical in conflict settings as they heavily influence the relevance and effectiveness of the program.

In terms of payment, we should clarify that CHW programs in northwest Syria have been making progress. Internationally, the debate is whether we should pay CHWs or consider them volunteers. In Syria, in general, the NGOs that hire CHWs consider them staff. Their salaries are not very glamorous, but they are paid relatively fairly. However, NGOs are not unifying their CHW salaries, so you have CHWs who are paid more by international NGOs than local NGOs, so that leads to CHWs quitting local NGOs to work at international NGOs.

Another issue is short-term funding from donors, who would rather fund a six-month project rather than a two-year project. And that makes for a very insecure job for CHWs. Even if they love CHW work, they also have to put food on the table. And this is a big problem in terms of retaining CHWs and having them produce meaningful health outcomes. To change a patient's behavior, you need time, at least one year, and you need to systematically measure the impact of those CHWs to produce the evidence to convince donors to fund a longer-term project. And there is very little evidence measuring the impacts of CHW programs in conflict scenarios.

We also suggest that long-term projects consider salary enhancement – even incrementally – which is linked to a sense of career development and consequently retention. In our study, 19% of CHWs surveyed said career development was critical for them.

There has been a move toward the localization of health programs over the past decade, mainly since the issue was included as a commitment at the 2016 World Humanitarian Summit. Why is the emerging trend of localization a promising sign for CHW systems in conflict zones?

Dr. Ekzayez: For CHWs, the issue of localization in conflict settings is really important because there are some sensitivities specific to conflict. Localization is not only about having local people in the driving seat, it's also about the processes of priority setting and feedback communication channels with local communities. All of these elements should be designed in a way that address the specificities of each context, and this cannot be possible without having, first, local people involved in the leadership and, second, equal multidisciplinary partnerships between the different stakeholders.

In northwest Syria, most of the cross-border humanitarian response has been remote. This has pushed a lot of international actors to rely on local actors to deliver the response, and it has given more space for local actors to lead the response. While most CHW programs in Syria are vertically led by the NGOs, who run them remotely, they are locally coordinated and implemented in the field.

But there is still that lack of integration between these programs and the locally led health system structures, such as health committees of the local councils and health directorates. That's because the vertical management of these programs by NGOs does not allow enough flexibility for further integration with local health systems.

What are the main differences between your framework and other available CHW optimization frameworks?

Dr. Habboush: Ours speaks to two different levels of optimization within humanitarian settings. First, on a small scale within one or two NGOs, and then at a more scaled-up national or sub-national level. In northwest Syria, it's not possible to scale up a program because the region has no governing body to provide oversight of any programs. This should not be an excuse for individual NGOs to not get the most out of their CHW programs, even on a small scale.

Our framework tells NGOs, 'You don't have to wait until all the other NGOs work like you do.' They can start with a few particular institutional factors, like how to recruit CHWs. Once you have one successful program, the lessons for effectiveness can be extracted and replicated in other small-scale programs, which can then lead to a cascade toward a feasible large-scale program.

Dr. Ekzayez: We acknowledge that there's a lack of governance of community health workers, which is the case in most conflict settings, and that's why the framework tries to direct specific elements of the optimization role to different stakeholders with the hope that this will be integrated.

And that's why there's a focus on integration. Because neither of the systems are perfect – the health facilities system is usually overloaded, stretched, and sometimes collapsed, which is why we need something at the community level to complement it. This complementarity element is a necessity rather than an additional component.

Dr. Habboush: We also look at the importance of training on topics like psychosocial health. In conflict settings, you have very serious mental health issues within the community and among CHWs themselves, who are in direct contact with people going through trauma. So CHWs have to be trained on how to deal with mental health issues, how to take care of their own mental health, so they don't quit their jobs after two or three months.

You also have to train them in first aid, because at any point a bombing can happen, and they have to respond, they have to help pull people from under the rubble. Sometimes, they have to be the first responders, and to do so effectively, they have to be trained. This is not very common in other settings because this is usually the responsibility of other health staff. In northwest Syria, since they are in the field all the time, they must respond. Otherwise, if the community perceives them as ineffective in difficult times, like bombings, then they will not listen to them after the bombing is over.