Q&A: How to overhaul community health for improved global outcomes

A community health worker delivers malaria treatment to a child in Mali. Photo by: PMI

Government-owned community health systems, free from silos, are key to not just improving community health, but also global health outcomes, according to Anthony Gitau, director of global community impact sub-Saharan Africa at Johnson & Johnson.

“Governments need to own community health workers at the regional or national level. There needs to be one plan for community health services which all stakeholders buy into and contribute to based on their strengths, expertise, and areas of interest,” he said, explaining that this could improve understanding, prevention, early diagnosis of disease, and appropriate access to treatment and quality care.

Currently, there is a deficit of 18 million health workers globally. According to the World Health Organization, education and employment of health personnel will account for 80% of the investment required to achieve universal health coverage by 2030.

“Although the ministries and everyone in the health care system refers to community health as the foundation of the health care system, it's very fragmented and very few governments have actually committed resources to community health.”

— Anthony Gitau, director of global community impact sub-Saharan Africa, Johnson & Johnson

“My call is: Can we work together to first establish a community health system that is agnostic to any intervention area? Once this is in place, can we add on the supporting systems in a cohesive way within one plan in every country that we work in? That is what will lead to the success of community health and for the health system in general,” said Gitau, adding that formal integration of community health workers into the health system would be at the center of the solution.

Speaking to Devex, he explained how J&J is taking steps toward such a system in Kenya through its community health units for universal health coverage, or CHU4UHC, platform — the first initiative of their new Center for Health Worker Innovation — and what more the global health sector can do to improve the community health workforce.

This conversation has been edited for length and clarity.

What are the biggest challenges you believe community health workers face today?

Although the ministries and everyone in the health care system refers to community health as the foundation of the health care system, it's very fragmented and very few governments have actually committed resources to community health. What has happened then is that different partners and different entities — all required to deliver programs at the community level — will go ahead and engage community health workers in a very fragmented way that then leads to implementation that cannot be properly tracked.

This creates a fundamental gap in understanding what the cost of community health work is and what it can deliver because there is no homogeneous implementation of community health services. It has also been difficult to truly understand the resources available for community health programming.

How do you think that particular challenge can be overcome?

The most commonly cited barrier by governments is the issue of paying community health workers. For Kenya, it's estimated that there are approximately 100,000 community health workers, and when you say you're going to pay them a salary, it becomes a very complex situation.

What we, alongside many of our partners, are advocating for is that whatever you do — whether you can give an incentive or a stipend or a salary— let it be formalized, let it be provided for in the health budget either at the national or regional level, and let it be given in a regular way. Therefore, the government then owns and recognizes the community health worker as a formal cadre of the national health system.

They become a force that can be leveraged by stakeholders and the ministry within one fixed plan, ultimately improving in recognition and confidence in their role in the broader health system.

Can you explain to us what the CHU4UHC platform is?

The community health units for universal health coverage, or CHU4UHC, platform is a coalition of all stakeholders interested and invested in community health at the country level. We are collaborating closely with the Kenyan government to launch by the end of 2019.

At its most basic level, it is a country-led and -owned platform that brings together stakeholders across sectors to identify and address obstacles in the implementation of homogeneous community health programs. The way we set the program up is that the starting point is a co-creation, aimed to understand what the current situation of the country is in terms of community health.

We leverage the benchmarks of newly released WHO guidelines for community health to compare and identify where the gaps are. Finally, we design with stakeholders what the ideal interventions could be, openly discussing as a coalition how to address these deep needs in community health and who would be the best partner to deliver what’s missing.

All of this is led by the ministry of health so that there is total ownership and commitment for the work that is going to be done. Our hope is that if it is successful in Kenya, this is a model we could deploy with community health systems in other countries as we scale up.

Many community health coalitions that have led great advancements in care have had a sharp focus on putting community needs first and bringing together stakeholders at a global level. This balance of local and global pushes for the privatization of community resourcing and commitment, but what’s often missing is the national level buy-in, translating those commitments into country-level implementation.

If the initiative is successful, what impact will it likely have on health in general?

We look at success from the role of a community health worker. It's really the preventive and promotional aspects of their work that are most important. We will have better awareness on disease, lower disease burdens due to knowledge on prevention, earlier disease detection, and proper linkages and referrals to health care systems.

For those diseases that can be managed at the community level — for example, malaria — an empowered and properly resourced community health worker can test at the household level and provide treatment. We can then reduce the burden of treatment-seeking and transition to preventive and promotive quality primary care.

What more can the sector be doing to improve the community health workforce?

I think, as a whole, part of the fragmentation we've seen is due to disjointed funding. If I'm managing an HIV program, for example, I'll train the community health workers on HIV and you'll see great results in that area. Somebody else will come and do something on maternal health, another on malaria, and another on nutrition.

What happens then is you have a very fragmented approach, from training through measurement, and utilization of resources. If we could work together and collaborate, and say, “Let's have a competent, remunerated, engaged community health worker who is well-trained on everything,” then we'd have much better results truly changing how people live healthier lives.

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