Opinion: More equitable health systems? Empower frontline health workers

Though the United States and the world have been galvanized to action by visceral images of acute police brutality, we know that systemic racism can be far more subtle, insidious, and deep-seated. Racism within health care is no exception.

For years, this has been evident through reduced life expectancy and increased maternal and infant mortality among people of color, but it comes into sharper focus during pandemics — from HIV/AIDS to COVID-19 — as inhospitable health services, skewed or missing data, economic vulnerability, and other social determinants of health compound into a crisis of injustice and inequity.

As a result, it is no surprise that there is massive distrust of the formal health system, creating a vicious cycle where the system’s history of discouraging and denying care has made communities afraid to access care.

Take, for example, this U.S. poll about willingness to receive a future COVID-19 vaccine: only 54% of Black adults said they would consider receiving a vaccine, compared to 74% of white adults. Elsewhere, a mistrust of white or Western medicine, stemming from racist colonial policies and practices, has challenged polio eradication campaigns in Nigeria and Pakistan, hampered Ebola control efforts in Guinea, and sparked demand for an untested Madagascan COVID-19 remedy, despite concerns from the World Health Organization.

How then, can we begin to dismantle such established systems of exclusion and discrimination?

Our approach at the Johnson & Johnson Center for Health Worker Innovation is to focus on those at the very heart of delivering primary and community-based care, frontline health workers — particularly nurses, midwives, and community health workers. There is robust evidence to show that nurses and midwives bring people-centered care closer to the communities where they are needed most. Nurses are more likely to be located in areas of low socioeconomic and health status than physicians, and are often the first health workers that community members meet, playing a vital role as the gateway to the formal health system.

In addition, CHWs are a cadre that is receiving renewed attention as part of the drive for universal health coverage. CHWs are very deliberately recruited from within the communities they serve to establish a critical bridge between communities and care.

For example, in Jordan, the Johnson & Johnson Foundation has partnered with the International Rescue Committee to recruit CHWs from both the local and Syrian refugee population for training and support. Steeped in the same cultural and contextual environment, they are a trusted source of support across the life course to help communities manage their own health and navigate access to services. This approach helps build trust and mutual understanding and increases access to the formal health system by connecting community members to community health centers.

Importantly, CHWs are tasked with the pursuit of health in and for communities — not just the detection and treatment of disease in hospitals — and can identify social determinants of health that exist far outside of traditional brick and mortar health facilities. To tackle inequities in health and provide health for all, investing in community health and frontline health workers must be a core part of the solution. But this also isn’t enough.

Frontline health workers are an overwhelmingly female workforce around the globe, with a particular concentration of non-white women in caregiving, rather than diagnostic, roles.

Community health workers can experience many of the same educational, linguistic, and cultural barriers that their clients face when engaging with formal systems of power and privilege. It’s no coincidence that global health decision-makers too often ignore health worker voices, and women are grossly underrepresented in positions of leadership, making up 70% of the health workforce but only 25% of senior roles. About 50% of women’s work in the health and social sectors is unrecognized and unpaid. This existing disadvantage intersects with, and is multiplied by, other identities, such as race and class.

This is one important reason why CHWI continues to invest in education and capacity building for nurses, midwives, and CHWs, including leadership and management training as well as platforms for them to raise their collective voices, such as CHW Advocates and Women in Global Health. Through our 20-year partnership with the Aga Khan School of Nursing and Midwifery in East Africa, we have strengthened 10 nursing and midwifery professional associations by providing organizational development, governance, and marketing support. This enabled them to provide health workers with ongoing professional development while fostering an active nursing and midwifery community across the region. We have also provided scholarships to nurses and midwives to undertake part-time advanced nursing certificates with an emphasis on leadership and management. More than 2,500 nurses have graduated and over 100 have since moved into leadership roles.

Our stance at CHWI is clear: by solving the problems of frontline health workers, we improve health care for everyone. With a seat at the table, they can be leaders, innovators, and agents of change to help us face the historic inequities of our sector and to rebuild equitable health systems so urgently needed now and into the future.