KIGALI, Rwanda — For most people living in rural Africa, the first point of contact for health care is with community health workers. Serving as the link between structured health facilities and communities, these workers provide a range of essential health services from prenatal consultations to malaria screenings.
For more than 40 years, community health workers, or CHWs, have been globally recognized by the World Health Organization as a vital element of primary health care coverage, and consequently, a significant component to achieving universal health coverage.
“It echoes and reinforces prevailing discourse around CHWs ... and provides more specificity on best practices.”— Giorgio Cometto, guideline lead author and human resources coordinator for health policies, norms, and standards, WHO
Yet decades later, these roles remain mostly voluntary, with limited training options or financial incentive needed to encourage delivery of quality health services.
“I want to ask the honorable minister and all policymakers, in most African countries, community health workers are not paid, so … how can you make them accountable … and what are you doing to educate them?” Senait Fiseha Alemu, an Ethiopian community health worker asked the Rwandan minister of health during a panel last week at the Africa Health Agenda International Conference in Kigali, Rwanda.
Serving 9,000 families in her district can be difficult, Alemu explained in Amharic, noting that she walks one to two hours by foot some days to visit patients. However, she said she plans to continue her education and that she “remains committed to staying” in her community and “serving them with the health services they need.”
Last week during AHAIC, WHO launched a new guideline on health policy and system support to optimize community health worker programs in alignment with the organization’s Workforce 2030 global strategy on human resources for health, which includes goals such as halving current inequalities to health worker access and improving completion rates in medical and professional health training courses.
“It echoes and reinforces prevailing discourse around CHWs ... and provides more specificity on best practices,” explained Giorgio Cometto, lead author and WHO human resources coordinator for health policies, norms, and standards.
The guideline lists 15 policy and effective workforce strategy recommendations ranging from CHW selection, training, management, and integration, to implementation and evaluation considerations at policy and local levels.
When selecting community health workers, for example, the guideline suggests using certain selection criteria such as community membership and appropriate education level to the tasks considered but warns against selection based on age or marital status. Regarding pay, the guideline makes a “strong” recommendation for a financial package based on number of hours worked and job demands, and suggests countries shy away from performance-based incentives.
“WHO took a bold position supporting a financial package commensurate to the complexity, the workload, and a number of other factors, and that based on evidence … this is best for the performance of CHWs, the retention, and labor rights argument,” Cometto said during the guideline launch in Kigali.
The guideline makes a similar “strong” recommendation to provide paid CHWs with a written agreement specifying roles and responsibilities, working conditions, pay and workers’ rights.
The report suggests a general services training with an emphasis on practical experience, using e-learning where relevant.
Also critical, Cometto noted, is a competency-based formal certification following preservice training to reinsure the quality of care provided, as well as to guarantee continued employability, official entry into national health care systems, and potential for progression of CHWs.
In March 2017, Africa’s largest health NGO, Amref Health Africa, began a five-year campaign to help solve the global shortage of 17.4 million health workers required to deliver primary health care to the more than 400 million people who lack essential health services — which helped to provide evidence for the new WHO guideline. The campaign currently runs in Kenya, Uganda, Zambia, Malawi, Tanzania, and has been instrumental in pushing inclusive CHW policies in these countries.
In Kenya, Amref advocacy efforts have focused on the passage of a CHW Act in the national assembly that would recognize and provide salaries to CHWs in Kenya. In Uganda, the organization has pushed the ministry of finance to fully finance its own national Community Health Extension Worker strategy by fiscal year 2020. Amref was also key in helping the country launch its national training strategy for CHWs there.
“In terms of financing, we know that the health system is built from the top, not the bottom,” Amref CEO Githinji Gitahi stated. Most health systems are structured with 30 to 40 percent of the health budget spent on primary care and the rest spent on tertiary care: doctors, hospitals, [with] many governments investing in MRIs and cancer centers. This means the money remains at the top, he argued. Because of this, community health systems which are a component of primary health care suffer from a lower availability of resources.
While the guideline is not meant to instruct governments on what to do, Gitahi said, it is meant to give recommendations.
Rural populations in remote areas have the right to information on how to stay healthy, something that CHWs can provide regularly, he added. “We know that [in] our villages … the people live very far from their health facility and therefore, the question of whether the people may need a link between the health facility and themselves is undeniable.”