Perspectives

The Covid-19 pandemic has set the world back 25 years in 25 weeks, as Bill and Melinda Gates said in their 2020 Goalkeepers Report in September.

In particular, the pandemic is threatening hard-won progress in healthcare. A recent WHO survey, based on reports from 105 countries, found that 90 percent of countries experienced disruption to its health services this year between March and June. Such impact of disruption of healthcare can be devastating – as we saw during the West African Ebola outbreak – and in the case of the coronavirus, could become a bigger killer than the virus itself. Experts estimate that deaths from HIV, tuberculosis, and malaria could double in the next year, and vaccine coverage could drop to levels last seen in the 1990s.

As countries grapple with how to respond to the pandemic and rebuild health systems, they must prioritize investment in community health workers as one of the most efficient and equitable ways to expand access to primary healthcare.

Community health workers are not a new concept – the idea began with the “barefoot doctors” of China in the 1950s, and today, an estimated 7.2 million community health workers serve their neighbors worldwide. While no program is exactly the same, community health workers are typically recruited directly from their own communities to provide primary health services to their neighbors, thereby extending the health system to reach communities that are often left behind.

In the United States, 64,900 community health workers are actively working in their communities to treat diseases like diabetes, HIV/AIDS, tuberculosis, or cancer, and provide prevention services ranging from sexual and reproductive health, behavioral health, cardiovascular health, and chronic disease. During the pandemic, they have also played an important role. In major cities like Boston, Philadelphia, and San Francisco, contact tracing, testing and education efforts have happened partly because of the tireless efforts of community health workers on the ground. But because community health workers can have over 100 different job titles, they are not always properly identified or recognized as a key part of the health workforce.

Recently, our two respective organizations, Last Mile Health and Gates Ventures, teamed up with local academic institutions and partners on the ground to launch Exemplars in Global Health – a program to identify the success factors in global health and provide decision-support services to leaders who, by adapting lessons from Exemplar countries to new contexts, can help identify efficiencies.

One of the areas we studied was community health workers, and what sustains high-performing networks. We found that Bangladesh, Brazil, Ethiopia, and Liberia are among the countries that have built impressive community health worker programs that are steadily increasing access to primary healthcare for their citizens. They also play a critical role when crises hit by supporting the response and providing consistent access to care.

Well-trained community health workers could help identify cases earlier, reducing treatment costs and changing the course on preventable deaths.

As member states consider the future of their efforts to respond and rebuild, they should look to countries like Liberia to consider how countries can leverage a moment of crisis into long-term health system strengthening. During the 2014-2015 Ebola outbreak, community health workers were on the frontlines of the response, case-finding and contact-tracing. Shortly after the outbreak, the Government of Liberia scaled up this workforce, hiring at least one community health worker for every rural and remote community, a huge step for a country that previously had only 50 doctors for its population of 4.3 million. Today, these first responders have conducted three million patient visits to provide routine primary healthcare and treated over one million cases of childhood disease. And, much like they did during the Ebola outbreak, they are now fully engaged in the fight against the coronavirus.

Another crucial takeaway we uncovered is the importance of designing systems that address specific problems faced by a given population. Brazil’s Family Health Strategy, for example, has deployed community health workers to stop patients dropping out of treatment for diabetes and hypertension. Its network of 265,500 community health workers covers two-thirds of the population and has driven a 3x increase in primary healthcare visits from 1994 to 2014. For countries facing a similar burden of non-communicable diseases, well-trained community health workers could help identify cases earlier, reducing treatment costs and changing the course on preventable deaths.

With the prospect of rising poverty levels post-coronavirus, training tens of thousands as community health workers would also reduce unemployment and provide a living wage. This, however, could not happen without paying them a salary – as recommended by the WHO. Payment not only motivates community health workers, ensuring they stay committed to the work over the long-term, but it also delivers an impressive return on investment. Community health workers can yield an economic return of up to 10:1 due to increased productivity, reduced risk of epidemics, and increased employment opportunities.

Studying these countries and the progress they’ve achieved across multiple areas has made it clear that Covid-19 reveals a vital lesson: investment in resilient health systems is non-negotiable. Community health workers allow us to better serve the daily health needs of our communities, while preparing for the next emergency. In our work, we have seen time and again that this critical workforce can be one of the strongest foundations of strong primary health systems.

It is our hope that decision makers will consider how to adopt and adapt the lessons we’ve uncovered in many of their member states. But it is our even bigger hope that the urgency of this moment is met with investment in community health workers as the foundation of a resilient health system that can not only help us end the current pandemic but reimagine health for all in the future.

Raj Panjabi is the CEO of Last Mile Health and Assistant Professor at Harvard Medical School and the Division of Global Health Equity at Brigham & Women’s Hospital.

Niranjan Bose is Managing Director of Exemplars in Global Health.

At long last, national CHW programs are garnering the attention, recognition, and scrutiny they deserve as an integral component of – or perhaps even the foundation for – achieving universal access to primary health care.¹ In 2018, the World Health Organization adopted the evidence-based Guideline on health policy and system support to optimize community health worker programmes.^2,3 In 2019, the World Health Assembly passed a historic resolution on CHWs, highlighting their role “to assure that universal health coverage and comprehensive health services reach difficult-to-access areas and vulnerable populations,” and their role in “advancing equitable access to safe, comprehensive health services.”

There is a large body of research demonstrating that smaller scale CHW programs can significantly improve health outcomes across multiple diseases and in diverse geographical and cultural settings.^4,5 The national CHW programs in Bangladesh, Brazil, Ethiopia and Liberia examined by the EGH program show that these contributions to improved health can be achieved at scale. Below, I’ve provided background on each of the programs and some of the most important areas of impact.

Bangladesh has a long history, since independence in 1971, of productive collaboration between the government and NGOs on CHW programs, as well as a history of strong community engagement in development programs. In addition to the government’s three CHW cadres (Family Welfare Assistants, Health Assistants, and Community Health Care Providers), there are many NGOs with their own CHWs, most notable by far is BRAC’s CHW program of national scope that consists of two CHW cadres (Shasthya Shebikas and Shasthya Kormis). Altogether, Bangladesh has slightly more than 1 CHW per 1,000 population.

CHWs have been an integral part of the country’s health care system for more than three decades now and are widely seen as having made key contributions to Bangladesh’s remarkable achievements in reducing maternal and child mortality and control of tuberculosis. Bangladesh was one of the few countries to achieve the Millennium Goals for health, which included a two-thirds decline in the mortality of children younger than five years of age between 1990 and 2015, and it has achieved a remarkably high contraceptive prevalence rate of 62% (and a fertility rate which at present is at replacement level, only 2.1 births per woman), to which CHWs have made major contributions.

Brazil, like Bangladesh, has a long history of strong CHW programming that dates back now three decades. Community Health Agents (CHAs) are full-time government employees who visit every house monthly for health promotion, surveillance, and linkage to the facility-based health system. CHAs each serve fewer than 1,000 people and serve on Family Health Teams composed of other CHAs, nurses, and a physician based at a nearby health center.

Brazil’s health status is one of the best in the world for an upper middle-income country, and it is one of the few countries in the world that has completely eliminated socioeconomic disparities in the nutritional status of children. The country’s CHWs are seen as critical to this achievement through their promotion of maternal and child health by educating families on appropriate household behaviors (including good nutrition) and linking families to needed health services. These have been fundamental elements of the CHAs’ work for four decades now.

Ethiopia began its current CHW program only 15 years ago, though the country’s experimentation with CHW models dates back to the 1950s. It’s dual cadre CHW program consists of professionalized Health Extension Workers (HEWs) and Women’s Development Army (WDA) volunteers. HEWs have one year of training, are salaried government employees with the same benefits as all government employees and serve a catchment of approximately 2,500 people. The WDA volunteers each serve 5-10 households.

Despite the more recent implementation, Ethiopia’s advances in reproductive, maternal, and child health have been remarkable. Ethiopia’s CHWs have been the foundation for these advances, leading to a rapid expansion of the contraceptive prevalence rate from only 5% when the HEWs were introduced to 40% at present. Ethiopia’s CHWs contributed, in no small way, to a two-thirds decline in the mortality of children younger than five years of age between 1990 and 2015. Ethiopia is also remarkable for the role of HEWs and WDA volunteers in the control of HIV/AIDS, malaria, and tuberculosis, all of which have improved remarkably since the introduction of HEWs.

Liberia’s CHW program is the newest of the four, with its cadre of Community Health Assistants introduced in 2016, partly as a response to the devastating 2014-15 Ebola epidemic. Now, its more than 3,000 Community Health Assistants are located in communities more than 5 kilometers from the nearest health facility and have a catchment area of about 350 people.

The country’s CHWs make more than one million home visits each year. One-quarter of all the malaria diagnoses and treatments are made by these Community Health Assistants. Since their introduction, they have managed more than 700,000 cases of childhood malaria, pneumonia, diarrhea, and malnutrition. The program has learned from the weaknesses of many other national CHW programs and built from the outset a strong supervisory program with one full-time Community Health Service Supervisor for every 10 Community Health Assistants. These specially trained supervisors spend 80% of their time out in the communities working directly with their Community Health Assistants. They are also responsible for ensuring that the supplies and medicines needed by the Community Health Assistants are restocked as needed.

Widespread recognition of the importance of CHWs has been slow in coming. This category of health worker has struggled to achieve a well-defined and consistent role in public health and in health systems. As a result, these programs are too often underfunded afterthoughts. Despite nearly a century of experience – as the earliest CHW program was launched in the 1930s in China – health programs still struggle to incorporate, define, employ, support, and leverage this critical cadre of health worker. However, as the evidence from these four Exemplar CHW programs demonstrate, Frankel’s conclusion in 1992 is still relevant today: “There is no longer any place for discussion of whether CHWs can be key actors in achieving adequate health care. The question is how to achieve their potential.”^{6, p. 1}

Authored by: Dr. Henry Perry, Senior Scientist, Johns Hopkins University Link to Bio

References:
1. Schneider H, Okello D, Lehmann U. The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. Human resources for health 2016; 14(1): 65.
2. WHO. WHO guideline on health policy and system support to optimize community health worker programmes. 2018. apps.who.int/.../9789241550369-eng.pdf (accessed 12 May 2020).
3. Cometto G, Ford N, Pfaffman-Zambruni J, et al. Health policy and system support to optimise community health worker programmes: an abridged WHO guideline. The Lancet Global health 2018; 6(12): e1397-e404.
4. Perry HB, editor. Engaging Communities for Improving Mothers' and Children's Health: Reviewing the Evidence of Effectiveness in Resource-Constrained Settings. Edinburgh, Scotland, UK: Edinburgh University Global Health Society; 2017.
5. Black RE, Taylor CE, Arole S, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel. Journal of global health 2017; 7(1): 010908.
6. Frankel S. Overview. In: Frankel S, ed. The Community Health Worker: Effective Programmes for Developing Countries. Oxford, England: Oxford University Press; 1992: 1-61.

All of the countries with Exemplar CHW programs—Bangladesh, Brazil, Ethiopia and Liberia—have established programs in which CHWs are paid and/or incentivized. The WHO strongly recommends that practicing CHWs be remunerated with a financial package commensurate with the demands of the job and their training. Research indicates that investing in community health as a key component of the primary health care system can be a very cost-effective strategy for achieving health goals.

Low income countries, including Liberia, have debated the benefits of paying community health workers. In this case, Liberia decided to pay CHWs based on evidence from other countries and in-country pilots demonstrating the benefits of a well-paid and professionalized CHW cohort. Liberia’s decision was also informed by the poor performance of its earlier community health volunteers. Liberian officials understood that serving as a health worker can be dangerous, given the national experience with Ebola. As a result, officials have been sensitive to demands that health workers should be paid in a manner that reflects the risks they take and the value of their work. For more information about the discussion within Liberia on if and how to pay CHWs, please refer to Liberia Context.

The question remains, how to balance paying CHWs in a context of limited resources. How can low income countries keep professional CHW programs financially sustainable? Countries can follow a four-step process to develop a financial pathway to support CHW programs: determine the program scale, create an annual cost estimate for the plan, set annual financial targets by funding source, and identify financing mechanisms to fulfill these targets.

In Liberia, the Ministry of Health did a fiscal analysis during the development of its CHW program. It revealed that paying CHWs provided a good value for money. The Liberian government discovered that hiring, training and equipping CHWs and community nurse supervisors would only amount to 3-6% of total health expenditures and would help extend primary health care to over 60% of the rural population that was previously out of reach of health care. Further, paying CHWs can reduce CHW turnover. This is critical for keeping training expenses down and ensuring quality care by experienced CHWs.

Other exemplar countries have found innovative financing structures that help maximize resources. Ethiopia uses a “One Budget” approach to maximize efficiency, reduce duplication and avoid off-budget spending. The government pools donor funds for community health and allocates those funds through one centralized budget under the government’s control. Bangladesh leverages NGO partner resources to fill service area gaps. Brazil established threshold spending requirements on health care for its state and municipal governments, with incentives for implementing the CHW program and improving quality. Successful national financing strategies require government coordination of partners, donors, and stakeholders to capitalize on available internal and external resources.

Exemplar countries have also shown that healthcare financing is not a zero-sum game: paying CHWs does not take jobs from nurses and other healthcare providers. In fact, integrating CHWs into a team-based approach to extending primary health care services can create job opportunities for other health workers, for instance as supervisors. As an example, in Liberia 10% of the community health workforce is nurses, midwives and other frontline clinicians. Investing in CHWs creates incentives to improve overall workforce systems that can be leveraged by other cadres of health workers, a benefit that is likely not costed when calculating the return on investment of the community health system.

Finally, exemplar successes reveal that the challenge of CHW financing is equal parts technical and political/advocacy. Successful programs combine the technical evidence, plans, and investment cases with advocacy aimed at building champions and coalitions to secure financial support.

Other Resources:

• WHO provides guidance to countries on developing an affordable CHW program.
• For additional tailored support contact Exemplars in Global Health, Financing Alliance for Health, AMP Health or Last Mile Health.

Authored by: Dr. Raj Panjabi, CEO of Last Mile Health Link to Bio