‘Research, advocate and activate’: How CHIC's strategy is paying dividends for CHWs

As community health worker (CHW) advocates point out, CHWs are workers. Millions of CHWs around the world are a cornerstone of primary health care and research shows that for every dollar a government invests in them, they can generate a return of up to $10 in terms of increased employment and productivity and fewer health crises.

It's one of the great paradoxes of global health that the majority of CHWs – who are overwhelmingly women and deliver a wide range of promotive, preventative, diagnostic, and treatment services – are either unpaid or barely paid. They also often lack the professional training, supervision, and supplies they need to succeed.

Advocates of professional CHWs say that ensuring they are properly equipped, trained and compensated would help address the projected shortfall of 10 million health workers by the year 2030 and save some two million lives annually. They also say the professional CHW (proCHW) movement is a matter of gender and economic justice for the workers themselves.

Community Health Impact Coalition (CHIC) has been at the forefront of this movement. The coalition, which includes thousands of CHWs and dozens of global health organizations in more than 60 countries, collects evidence to help international bodies create professional CHW guidelines, lobbies global financing institutions to increase professional CHW funding, and helps organize in-country networks to forward national professional CHW policies.

The coalition has had some notable successes: it’s helped ensure professional CHW best practices have been enshrined in the WHO's inaugural CHW guidelines and 39 countries now have policies that support professional CHWs. It’s also helped propel international funding for CHWs, including working with Last Mile Health, the Financing Alliance for Health and former Liberian President Ellen Johnson Sirleaf to launch Africa Frontline First, which has mobilized more than US$100 million in funding for the professionalization of CHWs across the continent.

Exemplars News spoke with the CEO of CHIC, Dr. Madeleine Ballard, who is also Assistant Professor at the Arnhold Institute for Global Health and the Department of Global Health and Health System Design at the Icahn School of Medicine at Mount Sinai, and Chisomo Boxer, a CHW advocate in Malawi, about their shared work.

Could you please introduce yourselves and describe what you're currently working on?

Dr. Ballard: I'm the CEO of Community Health Impact Coalition and this is my colleague, CHW advocate extraordinaire Chisomo Boxer.

Boxer: I am the acting senior disease control surveillance assistant with Wandikweza, which trains, equips, supports and supervises community health workers. I supervise 130 community health workers who are salaried and over 200 who are not on payroll yet.

Could you describe the problem CHIC is trying to address and what's at stake?

Dr. Ballard: There are millions of community health workers globally who have been a cornerstone of primary health care for a century and 70% of them are women. There are mountains of indisputable evidence from randomized trials that CHWs improve health outcomes. They reduce the amount of sickness in the population. They reduce the number of deaths, particularly for children under five. They also deliver big equity and economic dividends, but only if they're set up to thrive.

Yet millions of community health workers are not salaried. They're not skilled. They're not supervised. They're not supplied.

If we look at low and middle-income countries, half of CHWs are unpaid or unsalaried. That number is 86% in Africa. What we see is this dual-sided human rights issue where community health workers are exploited and they're less effective for patients. The kicker is that they are people who are not going to get care. We believe in quality care for all, including those who are providing it.

Boxer: Just to add to what Madeleine said – I think we as community health workers globally are exploited and less effective for patients than we could be. When we have a very conducive environment, our productivity is high. Who benefits most are the patients we serve. But if you're exploited in a workplace, things don't go as well, especially for the patients. CHIC is trying to make sure there's provision of care and reduce the hurdles and hindrances we face when we're working in different settings so we can serve our clients and communities. More often than not, we're exploited financially, physically, economically, and psychologically, and that doesn't sit well with us. We really appreciate the role that CHIC is playing to address these challenges and create a conducive environment so community health workers can work to the best of their potential.

CHIC describes professional CHWs as salaried, skilled, supervised, and supplied. Could you explain what you mean by each of these?

Boxer: When we first came together as a coalition, we did so to address the gaps in terms of knowledge around the key ingredients of a successful community health worker program. We compared and contrasted operational approaches across recruitment, tasks, supervision, supply chain integration, and much more. The outcome was a coherent set of eight best practices. These included being accredited, accessible, proactive, and continuously trained, supported, and paid. We live in a world where you can't live without money so for us to deliver services effectively on the ground, we need at least to be paid. We also wish to be integrated into robust health systems.

CHIC describes its strategy as 'research, advocate and activate.' How does your research help international and national CHW organizations create professional community health worker guidelines, and could you give us an example of how that has succeeded?

Dr. Ballard: We're making professional CHWs the norm by changing guidelines, funding, and policy, using the three tactics you just articulated. We conduct research to equip international norm setters with evidence. We advocate to increase global financing for community health and then we activate in-country CHW networks to win national policies.

There are a couple of key policy documents that drive investments and shape policy worldwide. CHIC comes together to generate new multi-country insights that no single organization could and then get them baked into these global guidelines.

And it’s working. Here are some of our big wins to date. First, global guidelines that are shaping investment decisions and national policy in 190+ countries. Before CHIC started, there was no World Health Organization guideline on community health, which is notable because community health workers have existed for over a century. CHIC ensured seven out of eight proCHW best practices, including CHW payment, were included in the guidelines.

We've also seen our research cited in the first-ever guidance from UNICEF and The Global Fund on counting CHWs, in USAID's flagship tool for CHW evaluation, and in the Africa CDC's forthcoming community health strategy. At this point, our peer-reviewed articles have been viewed 150,000 times – most academic articles get viewed fewer than 10 times.

There's now a whole bunch of guidance architecture that didn't previously exist that helps CHWs and ministries of health go to ministries of finance and make appeals. It also guides funders when they're thinking about investments and puts the best evidence at everyone's fingertips.

In terms of advocacy, could you walk us through how CHIC influences global financing institutions to increase professional community health worker funding and could you give us an example of how you’ve been successful with that?

Dr. Ballard: CHW financing is both insufficient and inefficient. As a coalition, we create a global surround sound to change global financing institutions – how they measure success and ultimately how they invest. The context is that global financing institutions are often trying to redress an injustice like lack of health care – and then, inadvertently, creating other injustices from a labor or gender perspective – and, simultaneously, not getting the biggest bang for their buck in terms of health and equity and economic returns.

We're also driving the uptake of these professional CHW best practices in the bilateral and multilateral sector by tracking actual global investments and monitoring changes to this figure over time to evaluate how close we are to closing the financing gap. One example of a win is that about 80% of the overseas development aid for community health comes from three sources: the US government, the Canadian government, and The Global Fund. We recently worked to secure a commitment from The Global Fund to become the first donor to make professional CHWs a board-level priority. What that means is that our evidence-based recommendations shaped a new key performance indicator mandating that the 126 countries eligible for Global Fund funding increase the number of professional CHWs in their ranks. Rather than saying, ‘Hey, we're delivering all these HIV, TB, and malaria commodities on the backs of – maybe – unpaid women, The Global Fund has said, 'This is a board-level consideration, we want to know that we're actually building resilient health systems with integrated professional and paid, protected, contracted CHWs going forward.' That's a big shift towards health system strengthening and towards supporting CHWs to thrive in the long term.

In terms of activation, how do you mobilize in-country networks to influence national professional community health workers policies, and could you walk us through an example of a successful campaign?

Boxer: Our research and advocacy work creates an enabling environment for systems change. But that is not enough. Health is not just technical, it's political. Currently, power belongs to the politicians. At the same time, you also have to understand that those facing high stakes typically have low power, so there is a need for us to build power within communities together with those who have power.

Every time CHWs are being discussed, we believe it is important for a community health worker to be in the room. We say nothing for us without us. We are unleashing the power of community health workers to translate our research and advocacy work into country-level practice change.

Through our networks of community health workers and partners in ministries of health, we are fostering the uptake of evidence-based policies at the national level. We also want to develop an international association of community health workers so that we can form a global network and speak with one voice.

You’ve described your big hairy audacious goal as a critical mass of 95 countries having adopted professional community health worker policies. What’s the pathway to achieving that goal?

Boxer: Our goal is to see 95 low and medium-income countries adopt professional community health worker policies. So far, we're at 39. To track progress and accelerate policy change, we operate a dashboard on proCHW policies, which helps us to track potential openings for policy changes and provides a picture of how the entire field is moving. There is no other coalition like us. We are policy-focused, top-down and bottom-up, and field catalysts. We exist to amplify others and achieve system change – and to win.

Dr. Ballard: The only thing I'd add is that, yes, we're at 39, but we're able to track policies across nearly 100 countries, so we're able to see not only where we've won, but where we can win next. The good thing about CHW policies or community health policies is they're usually five, 10, or 15 years long, so with this dashboard, we can see which ones are coming up for renewal or expiring. So, we pick from that list and say, ‘Boom, that's where we're mobilizing next.’ That way allied NGOs and national CHW associations can participate as a block during that window. We're just running that playbook over and over. And it’s working.