FERESO, Ghana — It was Rebecca Sutenga's seventh pregnancy, but it was the first time anyone from the government health system had ever come to check on her.
In early April, when she was only a few months along, a community health worker, or CHW, stopped by her home in Fereso in rural central Ghana during an initial health survey of the area. Throughout 2016, the Ghanaian government recruited, trained, and deployed 20,000 CHWs in a bid to shore up the country's fledgling health services. The program focused on remote regions such as Fereso, where about 45 percent of the country's 28 million people live, but health facilities are scarce.
Sutenga said the young CHW "had a nice way of talking to me. She explained the importance of visiting the health facility during my pregnancy and ensure I don't have any complications." The 25-year-old mother followed the advice and began attending regular antenatal visits. During one such visit, a CHW — a nurse trained in community-based medicine, who also oversees the CHWs — determined that Sutenga was slightly anemic. She explained this might lead to future complications, including early delivery, and gave the expectant mother a list of foods to eat to help address the problem.
"If there was not the CHW, I would have come to the health center, but not this early," Sutenga said. "I might never have known."
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Ghana is at the cutting edge of a global push to introduce CHWs in a bid to achieve universal health coverage. The model has been around for decades, but health officials here say there is much to learn from previous attempts — especially better integration into existing health systems — to ensure these new efforts will actually help deliver better health coverage.
The World Health Organization estimates there are more than 400 million people worldwide without access to even basic health care. CHWs might be key to helping them get it, according to Dr. Alexis Nang-Beifubah, the director of health services in Ghana’s Ashanti Region, which includes Fereso.
"This is the last mile we want to go," he said. "They strengthen the surveillance system. They report on time. They see somebody with a symptom and quickly they do a report."
Building up the base
Ghana's CHWs are secondary school graduates recruited from the communities where they work. They were interviewed, selected and then put through a weeks-long training process to prepare them for a range of responsibilities — everything from preparing vaccination campaigns to providing first aid services.
Their first task, though, was to visit the roughly 100 homes they had each been assigned, meet the people living there and gather an initial impression of their medical conditions. For people with potential medical needs — diabetics, HIV patients and pregnant women, for instance — the CHWs were trained to offer advice that could stave off possible problems and to highlight symptoms that should lead the patients to seek quick care at the closest health facility.
Deploying well-trained CHWs to rural settings is both cheaper and easier than constructing and staffing full health facilities. If they are from the communities where they are deployed, Ghanaian officials said CHWs find it easier to gain the trust of the people living there. If those CHWs actually live in the area, they are also well positioned to monitor people with chronic conditions and gauge how a community's overall health evolves.
CHWs also focus on preventive health care, such as Sutenga's possible pregnancy complications, which authorities hope can ease some of the pressure on health facilities. Spotting concerns early can avert future emergencies while still guiding patients who do need critical health services toward them.
With its low costs and potential payoffs, CHW models have caught the attention of a number of nations in Africa and beyond. Countries such as South Africa are shoring up national-level programs to replace an existing piecemeal approach. Even developed countries, including communities in the United States, are looking at replicating some of the lessons from the CHW models.
"It's going to be a century before we have enough facilities and physicians and nurses that can provide these services in poorer countries," said Dr. Henry Perry, an expert in international health at Johns Hopkins University, who has done extensive research on CHWs. "Or we can move ahead with creating a stronger community-based system that provides high-quality services down to the household level by community-based practitioners."
The CHW idea has been around for decades, falling in and out of political favor as health needs have changed. China's large-scale "barefoot doctors" program in the 1920s was one of the best-known early models. Illiterate community members were trained to record births and deaths, provide vaccinations and offer basic primary health care. Communities around the world began to adopt similar models, tailoring the CHWs' responsibilities to individual settings.
But national models fell out of favor in the 1980s and 1990s, experts said, because governments were not willing to dedicate the resources needed to fully integrate the programs into their national health care systems and ensure the CHWs succeeded. While more affordable than building brick and mortar facilities, CHWs still have to be trained and — in many models — paid. The Ghanaian government, which is paying its CHWs roughly $100 per month, budgeted $25 million for salaries alone for the program's first two years.
As national programs collapsed, many nongovernmental organizations and aid agencies continued to deploy CHWs or similar types of lay health workers to help facilitate specific projects. CHWs have been instrumental in efforts to eradicate Guinea worm and polio, for instance. But without the consistency that comes with a standardized system, experts said this approach has also created problems, especially where CHWs are paid better than government health workers.
"In the past, CHWs have been effective in Ghana," said Dr. John Ganle, who works in the University of Ghana's department of population, family and reproductive health. "But I think the operations got into conflict with the mainstream health care system. There's a lot of struggle and sometimes problems with mainstream health care workers."
CHWs also took on a stigma, at times “seen as second-class providers for second-class citizens," according to Perry. That perception is now starting to shift, he said. "It's obvious community health workers provide the opportunity for making universal health coverage available, providing high-quality service to everyone."
The handful of countries that have stuck with CHWs have seen impressive results — an important factor in boosting their popularity among policymakers once again. Perry highlighted Brazil, where since the late 1980s the government has built a network of more than 250,000 Agentes Comunitários de Saúde covering more than half the population. The outcomes have included significant reductions in infant mortality and hospitalizations, and upticks in areas such as antenatal care and immunization.
They are the kind of results that caused countries such as Ghana, under pressure to reach UHC and improve their medical outcomes, to take a second look at CHW programs.
A new generation
For new CHW programs to succeed where previous iterations have failed, policy architects need to ensure they have learned the lessons from those earlier efforts, experts told Devex. That begins with government commitments to support the system and define exactly how the CHWs fit within the health structure.
Critical to that strategy will be answering questions such as whether CHWs will be paid or not. Ghana opted for a paid model after surveys showed that earlier iterations of volunteer CHWs lost interest in the work over time. Still, without any major donors yet to get behind the global push for CHWs, some countries question whether the cost of paying the health workers is tenable in the long term.
Whatever the outcome of the internal policy debate, experts agree that some form of remuneration is critical. Dr. Simon Lewin, a health systems researcher at the Norwegian Knowledge Center for the Health Services, said there are also multiple examples of successful, national-level volunteer programs. He pointed to Nepal, where the decades-old Female Community Health Volunteer program rewards participants with public recognition.
"Some people are happy to volunteer a small amount of time in specific settings," he said.
Other program elements appear more straightforward. Participants at the first-ever international symposium on CHWs, which took place in Kampala, Uganda, in February 2017, underscored that while programs should vary depending on a country's needs, "institutionalization and integration of community health workers into the formal health system structure is crucial." That means formalized trainings and clear command structures to emphasize to communities that the CHWs are representatives of the health system and their advice should be taken seriously.
CHWs must also feel protected and recognized by the government, which can help guard against possible conflicts when individual CHW-driven projects offer different salaries and opportunities.
What CHWs do not do, policy experts said, is relieve the government and donors of the continuing task to invest in other areas of the health system. Local health workers can flag potential pregnancy complications, for instance, but they cannot diagnose the problem.
"Without a strong health system and social care system, those targets will not be reached," Lewin said, "regardless of what cadre is emphasized or what program is put in place."
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