Opinion: Digital health solutions need to consider the health worker

The term “community health worker,” or CHW, refers to a variety of community health aides that are selected, trained, and work in the communities from which they come. To great success, they are agents of social change, working to improve conditions that impact people’s health and playing roles beyond traditional medicine.

Indeed, a recent study showed that CHWs’ ability to improve population health is “incontrovertible.” But while this umbrella term may be helpful in capturing the sheer breadth and value that CHWs play across the globe, it is indicative of their ever-expanding duties.

As we look to the future of health care, there is renewed urgency to create and implement solutions that intentionally put CHWs at the heart of the development of new interventions and meet the growing responsibilities of CHWs.

The expansion of CHWs’ scope

In 1978, the World Health Organization’s Alma Ata Declaration named CHWs as a cornerstone of comprehensive primary health care. CHW guidelines developed by WHO in 1987 listed 23 activities and tasks that CHWs may be responsible for. The consensus today is that no one person can perform all the activities laid out in the declaration. And yet, the role of CHWs continues to grow.

In 2018, WHO guidelines to optimize CHW programs were released, describing eight primary health care services that CHWs could support. This does not mean CHWs are doing less. Quite the opposite, in fact. Below we highlight three reasons why CHWs are doing so much more:

1. They are tasked with tackling noncommunicable diseases. In the 1970s, CHWs were tasked with improving maternal and child health, and the management of common infectious diseases. Today, they also take on medical care, referrals guidance, health education, and behavior change support, encompassing NCDs such as cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes. This has created a massive responsibility, as NCDs account for 41 million deaths each year, of which 77% occur in low- and middle-income countries.

2. They work on crisis care. CHWs are set up to be change agents in communities while also functioning as extensions of formal health services. In recent years, CHWs have taken on responses to epidemics — including the 2014 Ebola, the 2015 Zika epidemics — and COVID-19. During a field visit conducted by Dimagi in March 2020 in Madhya Pradesh, India, CHWs reported working long hours; monitoring check posts to screen migrant workers returning to their villages; conducting door-to-door screenings; and spreading awareness about COVID-19. All of these are in addition to their existing responsibilities.

3. They offer psychosocial support. CHWs are increasingly relied upon to address both psychological and social needs of individuals, families, and communities by forming support groups and providing one-to-one counseling. Demand for such services is particularly high during times of crisis, placing additional pressure on CHWs to fill this service gap. The concept of “task-shifting” may indeed reduce strain on the health system but is problematic when tasks are only shifted in one direction — toward CHWs with no plans to shift tasks away from them.  

These all beg the question: How can we support CHWs with the tools to support their community, and also themselves?

The role of digital implementers

As more and more CHWs are equipped with smartphones, there is notable excitement about the potential of digital interventions to strengthen health systems. When designed well, digital systems can amplify the existing impact of CHWs and provide much-needed support to workforces.

However, digital implementers must be mindful that their initiatives work to reduce the overall burden on CHWs while addressing the emerging health needs of the communities they serve. So, what should we be mindful of when designing digital health interventions?

1. Don’t collect data that you don’t need. As digital systems make it easier to collect and analyze data, there is a temptation to collect more and more data. This can eat into the time CHWs have for other important activities.

2. The goal of digital systems should be to replace paper systems altogether. When new digital systems are implemented, it is common for CHWs to continue maintaining paper forms in parallel. We should treat this double data entry as a failure of the digital system. Digital implementers should be proactive in understanding whether paper systems are still in use and work toward a digital system.

3. Acknowledge that increasing responsibility should be met with appropriate support. CHWs should receive adequate supportive supervision, mentorship, training, and compensation for their work. Digital implementers should strive for forward-looking solutions that meet these needs. For example, solutions can enable training and certification of new skills for front-line workers, orchestrate payment for services, bolster performance and program management, and provide psychosocial support to CHWs.

4. Invest in the usability of digital tools. Digital implementers should prioritize the usability of their products. This means understanding CHWs’ perception of them, how they impact CHWs’ work and the context in which they are used. Solutions should be locally adapted, consistent with existing workflows, and address the pain points of CHWs.

Call to action

With these considerations in mind, digital health implementers will be better positioned to support CHWs and improve community health. This work cannot happen in isolation, that is why we are members of The Resilience Collaborative, a learning community that brings together stakeholders across sectors to advance evidence-based strategies for health worker resilience, particularly in LMICs. And this is why Dimagi is creating a working group as part of The Resilience Collaborative that's open for any organization to apply to. In this group, Dimagi will guide participants through the process of adapting a mobile message program — which was developed with each of the above considerations for digital implementers in mind — for specific contexts.

As we move forward, these types of collaboratives will be essential to draw stakeholders, alongside CHWs, into the conversation to address barriers that health workers face. But while the issues CHWs face may vary, the key first step to each is recognizing the weight of responsibilities that CHWs take on and working toward making their load lighter.