“Community health workers are able to lighten the load on the health system to deliver certain services closer to home.” This viewpoint shared by Paurvi Bhatt, president at the Medtronic Foundation, might be central to addressing the global health crisis we currently face. With the World Health Organization predicting a potential shortage of 18 million health workers by 2030 — and the global burden of noncommunicable diseases expected to increase by 17 percent by 2025 — new ways need to be found to get care to those that need it.
Given the shortage of physicians, Bhatt, whose organization focuses on improving health for the underserved, believes one answer is investing in trusted people from communities. Boosting the role of community health workers, or CHWs, could save 2.5 million lives or more per year.
“We are experiencing the world’s greatest health worker shortage in history, and that’s only likely to grow if nothing changes.”— Raj Panjabi, CEO, Last Mile Health
CHW-based initiatives have shown how this can help. The government of Liberia, in partnership with organizations such as Last Mile Health, provides training, supervision, and cash incentives to CHWs in order to provide primary health services in rural and remote areas as part of the country’s National Community Health Assistant Program.
This initiative showed considerable improvements in childhood illness treatment for diarrhea, fever, and acute respiratory infection, with an increase of 40-60 percentage points in access to care. The aim is that by 2021, all 1.2 million Liberians living over an hour’s walk from the nearest health facility will have access to a professional CHW.
“We need to shift from thinking that care only happens in the space of a hospital or clinic, as it really happens in the home and the community as well,” said Raj Panjabi, CEO at Last Mile Health. “I think if we really want to speed this train up, then putting the last mile first is going to be a mental shift that needs to happen. We are experiencing the world’s greatest health worker shortage in history, and that’s only likely to grow if nothing changes.”
During a CHW pilot initiative in Liberia’s remote Konobo district, which then informed the scale-up of the National Community Health Assistant Program, 100 percent access to a CHW in the region was achieved. Meanwhile, a study run in rural Mexico observed a twofold increase in the odds of disease control when a CHW-led intervention was used for diabetes and hypertension.
A global gap
There has been considerably less focus by CHW programs on NCDs as opposed to communicable diseases — something the Mexican study notes by citing the lack of data on CHWs in improving outcomes among patients.
Over the past five years, Medtronic Foundation has partnered with governments and nonprofit organizations across Brazil, India, South Africa, and the United States to improve diagnosis, management, and control of diabetes and hypertension. A key strategy was to strengthen the capacity of CHWs and other frontline providers — including community paramedics in the U.S. — to bring care closer to patients and communities. The foundation built CHW capacity to screen, refer, and follow up chronic patients to clinical and nonclinical services and used digital information systems to improve communication between patients and providers.
Yet, this focus is key in terms of treating both chronic and acute conditions, given that NCDs are responsible for over 70 percent of deaths worldwide each year — equating to 41 million people. Of these deaths, almost 4 in 5 are in low- and middle-income countries.
Bhatt highlighted that infectious diseases have often captured the limelight and funding has not been as readily geared towards longer-term campaigns often needed for NCDs.
“We respond to the urgency and crisis of the moment,” she said. “But we are in a moment in time where we can change that.”
Bhatt said the common denominator in successes seen in the program was ensuring that people affected and their frontline care teams were part of the solution and involved in decision-making processes.
People are recognizing that such programs are actually able to save money in the long run, said Bhatt, adding that even though there are still not enough public sector financial flows for NCD care, things have improved considerably since the work started.
She said there are more partners in this area, with public-private partnerships and a multisectoral approach that is necessary to move forward because coordination from many different parts of society is required to truly impact health outcomes.
Bhatt highlighted that there is much more room for CHWs to be involved in the decision-making process, while also influencing gender and youth employment opportunities. Given that CHWs are predominantly women, an intentional focus on gender and investing in their training and career pathways to employment, she explained, could help spur on progress in several SDG areas such as gender, health, education, and employment.
However, Bhatt stressed that CHW programs are not just about technology.
“Many people are jumping to a technological solution as the tool that will solve all of this,” she said. “Technology is a critical enabler to solve many issues in health care, but it’s not the magic bullet that will solve it all.”
Whether a disease is infectious or noninfectious, CHWs are key to getting the optimum results, Panjabi added.
“The programs with the best hypertensive outcomes, the best diabetic outcomes, and those with the better chances of controlling Ebola or HIV — every single one of those has a well-supported community health worker as part of that medical team,” he said.
One way to do this is to “decentralize” technology-enabled systems to shift the power of health care to the periphery, Panjabi said, with more companies creating easy-to-use “off-road, off-network, off-grid, palm-of-your-hand diagnostics and therapeutics” and shifting tasks from medical specialists to CHWs.
Last Mile Health itself, along with partners, is setting up a series of online courses and digital tools on a platform called the Community Health Academy. It works by connecting ministries of health to a suite of leadership courses and equips CHWs with mobile phones, training, and other diagnostic and tracking tools to collect patient data.
Jim Campbell, director at the Health Workforce Department at WHO, referred to a “second generation” of CHW programs that will see further improvements in access to services, promotion of prevention and referral to appropriate care services supported by better mobile and point-of-care technologies to make all health workers far more engaged.
“There’s a much greater awareness of how people in the community can make a significant impact not only on community and national health, but also on global health security,” said Campbell.
“What we’re seeing is that across Africa, Asia, and Latin America, where there has been an integrated approach to making community health workers part of the primary health care team and providing them with education and a salary, the impact and return on investment are ever greater and greater,” he added.
CHW programs are having an impact in communities around the world, including the U.S. Rosaura Polanco is a Bronx-based community health worker on the Promotoras team at nonprofit organization Grameen PrimaCare, which focuses on promoting nonclinical care — partly through the use of weekly workshops — for immigrant women who may lack access to health information and resources available, on top of a language barrier.
Like many of the Grameen Promotoras team that hail from other countries, Polanco originally came from the Dominican Republic to the U.S. and faced the same issues as others in getting health care. “Part of my strength as a community health worker is that
these women know that I do not speak down to them. I am on their level. I can explain everything because I am one of them and am empathic with their situations,” she said.
She added: “With something as simple as providing vulnerable people with the most basic knowledge of healthy behaviors and disease prevention, delivered by trusted people within their own communities, I think major improvements in disease outcomes can be made in developing countries.”
To aid recognition of the importance of CHWs, WHO will consider a resolution at this year’s World Health Assembly to be introduced by the governments of Ethiopia and Ecuador on opportunities for these workers in delivering primary health care.
“This really consolidates the evidence base,” said Campbell, adding that it shows countries want to see greater investment and focus on CHWs.
There is also an increasing recognition for an NCD focus. In the past three years, countries such as Liberia, Ethiopia, and Malawi have established poverty commissions for NCDs and injuries.
Liberia’s ministry of health highlighted in its recent report that only 18 percent of health resources went towards NCDs and injuries. Alongside its focus on CHWs, there is therefore a chance to address this, with the ministry deploying almost 3,000 CHWs to aid early referrals to clinics and for follow-up care for chronic conditions.
Panjabi emphasized that CHWs are not a panacea, but they can certainly help link up those without access.
“You need an army of workers that can bring people within reach of the health system,” he said. “We still have a lot of work to accelerate this … and include packages of care on NCDs; the burden is not simply infectious.”
Bhatt said: “I think we’re really at the precipice of an incredible opportunity if we’re willing to be creative and bring the right players around the table … I hope that if we are connecting all these dots, we can enable CHWs to engage and develop the full range of services needed on the ground to serve and improve the lives of people living with NCDs.”