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