Opinion: Prioritize community health workers to unlock health for all

As the global community gathers this September in New York for the first in-person United Nations General Assembly in two years, it might feel like a return to “business as usual.” Handshakes and hugs may be exchanged, events will be abuzz with attendees. However, the glaring and unacceptable health inequities exposed by the COVID-19 pandemic continue to threaten and devastate the lives of millions.

Across the African continent, more than half of its people — around 615 million — are still not accessing the health care they need. One in two children living with HIV across East and Southern Africa still do not have access to life-saving antiretrovirals. And 2 out of 3 mothers who die during pregnancy live in sub-Saharan Africa.

Going back to “business as usual” would not only mean ignoring this reality — it would be an unforgivable missed opportunity and tacit agreement that preventable infections, poor health, and deaths are acceptable, especially in vulnerable and marginalized communities.

As an African NGO operating across 10 countries, the scale and complexity of the challenge to achieve Sustainable Development Goal 3 of good health and well-being for all by 2030 is not lost on us. But there is good news — the HIV and COVID-19 responses have shown us what it will take.

Only by investing in community-led, integrated primary health care solutions, can we turn this lofty policy ambition into a reality.

Not only is this accepted as international best practice — the World Health Organization argues that universal health coverage “should be based on strong, people-centered primary health care.” This has also been mothers2mothers’, or m2m’s, experience.

Reimagine health delivery

By shifting power to communities, and training and employing women living with HIV as community health workers, or CHWs, known as “Mentor Mothers,” we have seen grassroots female leadership transform the health and well-being of communities.

Since 2001, almost 12,000 m2m Mentor Mothers have reached nearly 15 million women, children, adolescents, and families with life-saving health services and education. We have virtually eliminated the transmission of HIV from mother-to-child for people enrolled in our services for eight consecutive years, and helped to keep over two million at-risk mothers and children alive.

It is clear to us that the journey to “Health for All” must be led by the people who know their communities best. CHWs like m2m Mentor Mothers use their lived experience and understanding of local realities to connect with their peers and provide the health services they need. They ensure no one is left behind or lost to care, while also relieving pressures on health systems. They are trusted providers of critically needed health services —including during COVID-19 when they provided continuous support to their communities after being designated as essential workers.

In addition to the “how” of service delivery, to achieve Health for All we must reimagine the range of services being delivered. We need to ensure stronger alignment of health systems and services with local needs — making it easier for people to get a greater range of health services, from one provider, in a place that suits them.

Delivering such a one-stop service will be essential to get, and keep, people in care. Evidence shows that CHWs are a critical resource in ending preventable child and maternal deaths, and are helping turn the tide on HIV, tuberculosis, malaria, and noncommunicable diseases. It is beyond time to trust CHWs to do more, and to train and support them to provide more integrated services, including clinical services such as testing and drug dispensing.

For m2m, this has meant evolving from an organization focused on the prevention of mother-to-child transmission of HIV, into an integrated primary health care organization. We are taking the next step in this journey this month as we release our new strategic plan, which will see our frontline team address an increased number of interrelated health challenges at health facilities, in communities, and through digital channels.

And yet with only eight years left to achieve the Sustainable Development Goals, or SDGs, the world is still only paying lip service to CHWs, and failing to invest in their potential to deliver integrated primary health care services. According to Africa Frontline First, the African continent is currently facing an annual financing gap toward community health of around $4.4 billion. Meanwhile, up to 85% of CHWs in sub-Saharan Africa receive no salary for their work.

This is unacceptable.

At m2m, we have purposefully invested in the training, employment, and ongoing support of Mentor Mothers. Because that is the right thing to do — and it unlocks impact. Adequate compensation, increased financing, training, and tools, and better recognition and qualifications for those at the front line: this, collectively, is what will help us build the health care systems that we need to build a healthier, fairer tomorrow.

Prioritize investment and trust communities

Community health is a community effort. So, what can we, as a global community, do?

First, governments, funders, and policymakers must use UNGA to voice their unequivocal political and financial commitment to CHWs. With every $1 invested in CHWs generating $10 social and economic return, it is high time that we back the political rhetoric with tangible investments. Countries such as Bangladesh, Ethiopia, and Nepal, which have been leaders in improving the health of their populations and prioritized large-scale CHWs programs, have done just that. 

Second, we must stop thinking in silos, and commit to prioritizing integrated health solutions. Key to this will be trusting communities to lead the way to health for all, through the creation of a professional, paid, cadre of CHWs delivering services their communities need and deserve. Local leadership is essential to achieve this.

Rather than ignoring the COVID-19 pandemic, and the fault lines it exposed, we can turn the recent crisis into an opportunity. If we recognize the need for better, integrated health care and invest in CHWs as the foundation of effective health systems, we just might be the generation that makes health for all a reality.