Investing in the training and capacity building of community health workers is a fundamental pillar to creating strong health systems — and to achieving universal health coverage by 2030, according to global health experts.
A 2015 World Health Organization report states that 3 million deaths per year could be prevented by expanding access to key interventions provided by community health workers. To support this, WHO released a set of guidelines in 2018 to help identify what is required to facilitate the integration of health workers into health systems and local communities.
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“Investing in community health workers represents good value for money. And yet, they are often operating at the margins of health systems, without being duly recognized, integrated, supported, and rewarded for the crucial role they play,” wrote WHO Director-General Dr. Tedros Adhanom Ghebreyesus in the guidelines’ foreword.
The 2015 report also highlighted additional potential economic benefits. For example, investment in community health in sub-Saharan Africa could result in an economic return of up to 10:1 by supporting increased productivity from a healthier population, and potentially reducing the risk of epidemics such as Ebola.
But this kind of long-term investment is not always a top priority. For former Ecuadorian health minister Verónica Espinosa, one of the biggest challenges she faced was to convince the government that health is a good investment.
“This budget is not an expenditure, but an investment that has saved thousands of lives,” Espinosa said. In 2016, during her time in office, Ecuador’s health expenditure amounted to 8.4% of gross domestic product, close to the Organization for Economic Co-operation and Development average of 8.8%.
Expanding primary care in local communities
From security guard to community health worker
Kanahiya Singh was working as a security guard at the Smile Train partner hospital Sant Parmanand in Delhi, India, before he was contacted by Dr. S.C. Sood, a plastic surgeon performing the free corrective surgeries, to help him identify children with cleft lip and palate.
After receiving guidance and mentorship from Sood, Singh started biking around the informal settlements of Delhi to help identify cleft patients and bring them back to the hospital for surgery — he’s now been doing it for 12 years, he told Devex through a translator.
Twice per week, he drives around in a hospital-provided vehicle to identify new cleft patients. On Wednesdays and Thursdays — when surgeries take place — he makes sure that the blood work and prerequisites are completed before the doctor sees the patient, and schedules the free surgeries. He has become the main point of contact for many patients and their families, as he often sees them throughout their entire journey — from their first encounter to the surgery.
Access to health care is essential to achieve UHC, particularly improved access to primary health care, Espinosa said, adding that community health workers are key to breaking down existing barriers in health systems.
A change in Ecuador’s constitution in 2008 included declaring health care a right and also made the role of the state explicit in terms of its responsibility to provide UHC. This led to the launch of a new model of health care, based on community workers and primary health care, she explained.
“What we needed to have is the doctors, nurses, and community workers that belonged to those communities, but also had all the knowledge, capacity, and the training to actually take care of that community,” Espinosa said.
In 2014, Ecuador began recruiting health workers to undergo a two-year technical training program across 17 formally recognized institutes. The main requirements were to represent a community — particularly vulnerable groups such as sex workers and indigenous peoples — and to secure the support of the health worker’s local community to join the program. Engaging the communities in the selection of workers also made implementation easier, she said.
The training has a dual component, including both technical training at a recognized institution and many hours of practical experience.
“Part of their curricula was to be in the community, learning with the health system, with the doctors, the nurses,” Espinosa said.
Following the training there were immediate noticeable differences in community health care. For example, the program’s alumni began to take pregnant women showing signs of potential complications to health facilities earlier, which could help reduce the associated risks during pregnancy or childbirth, or even maternal mortality, she said.
Reaching local communities, via the community
One of the benefits of community health workers and volunteers is their direct contact with local communities, for example, those working with Smile Train — an NGO providing free corrective surgery for cleft lip and palate, a condition that causes difficulties eating, breathing, and speaking, and affects 1 in every 700 children. A 2017 study found that community members can help strengthen community-based interventions if given the right training, support, and supervision.
“We are able to get everyone to know about cleft lip and palate through [community health volunteers] … Communities trust them because they have been doing a lot of work in the community already,” said Jane Ngige, program director for Smile Train in East Africa.
This results in better access to the organization’s programs and more people identified that could be in need of surgery, Ngige said. “In Uganda, our treatment program actually grew by about 12% because of the community health volunteers workshops that we ran in 2016,” she said.
Through the organization’s partner hospital model — which works with hospitals in low- and middle-income countries — local surgeons and staff receive training to deliver effective cleft care in their communities. This helps to keep costs down and eliminates potential cultural and language barriers.
The training programs have shown positive results. Volunteers were given a pre-test before undergoing training around a specific kind of cleft lip and palate, and took another test following training to measure knowledge acquisition.
“The impact was really good. Even during the training they started referring patients,” Ngige said.
Receiving adequate training can also empower community health workers and volunteers to pass on the knowledge to others in their communities. In Nyeri County, Kenya, financial constraints meant Smile Train was unable to train the county’s estimated 2,000 volunteers, so representatives were selected from each of the sub-counties to provide the training themselves.
“We trained about 400 community health volunteers in that particular county, and they would in turn go back to their sub-county and help in training others,” Ngige said.
Using m-health to reach the last mile
Health Access: A series for achieving UHC
While training for community health workers and volunteers is crucial, new digital tools can also enable workers to provide better and more timely care by supporting decision-making and helping identify at-risk patients more quickly. Such tools can be particularly useful when community health workers are located in rural areas.
“Sometimes the community health worker [is] very far [away] and they’re met with a situation that needs immediate support for them to make a decision,” said Basimenye Nhlema, director of community health for Partners in Health, a nonprofit health care organization that operates in Malawi’s rural, south-western region of Neno.
The organization is currently piloting a mobile application co-designed with Medic Mobile to help empower 228 local health workers to effectively screen, treat, and refer patients for a range of conditions. By using smartphones equipped with the application, health workers can ask for immediate support from their supervisor, a member of the technical team, or a clinician.
For example, the app can help indicate the recommended course of action based on the response from the patient and a set of screening questions. This helps the health worker to identify patients that might be in need of immediate referral or who need to be accompanied to a facility.
The pilot includes a week-long training for community health workers — many of whom have never used a smartphone — on how to use the device, its functions, and the app.
M-health is just a tool, however, not the solution to every challenge in the health sector, said Nhlema.
“You already need to have a robust and tested system on the ground, so that when this tool, or this technology, is coming in, it’s coming in to enhance the existing work or success,” she added.
Local ownership is also crucial for building strong and sustainable health systems.
“Sustainability is not just for us training the local medical professionals to do their work, but also the fact that the county or [national] government are able to own that particular program,” said Smile Train’s Ngige.
Making the case to ‘professionalize’ health workers
Adequate training of community health care workers is essential. However, there is often a misconception that community health workers can’t provide quality care, according to Jenny Schechter, co-founder and executive director of Integrate Health, an organization working to end preventable deaths in remote communities.
“We actually see quite the opposite. We see that our community workers consistently maintain correct case management rates above 90%,” she said, achieved through clinical mentorship, continued training, and coaching programs for health workers. In Togo, the organization currently has 96 community health workers deployed, serving a population of about 140,000 people.
“The clinics fill up pretty quickly, if we don’t have community health workers providing that triage function — treating the simple cases that they are trained to treat in the home — then we won’t be able to accommodate the need given the existing facility infrastructure,” said Schechter. She added that the movement of care out of hospitals and clinics and into the home is the future of primary health care.
She hopes the U.N. High-level Meeting on UHC, taking place in New York on September 23, will shed light on the strong investment case that is professionalizing community health workers. Organizations such as these — successfully investing time and energy in training community health workers — could help ministries of health make the case to their ministries of finance in order to support the case for increased investments.
Update, Sept. 17, 2019: The story was updated to note that Integrate Health's community workers consistently maintain correct case management rates above 90%.
For a closer look at the innovative solutions designed to push for progress on universal health coverage around the globe, visit the Healthy Access series.