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Community Health Workers: A Priority for Universal Health Coverage?

This guest post was written by Colin Gilmartin, Senior Technical Officer at Management Sciences for Health (MSH), a nonprofit global health organization and GHC member organization. Gilmartin specializes in health care financing and the planning and costing of community-based services. He can be followed on Twitter, @colingilmartin. MSH’s mission is saving lives and improving the health of the world’s poorest and most vulnerable people by closing the gap between knowledge and action in public health.

Community Health Volunteer in a remote village of Tulear, Madagascar, giving instructions to a client on the use of pregnancy tests. Image by Samy Rakotoniaina/MSH

How countries can move toward building sustainable community health programs.

Universal health coverage (UHC) is increasingly recognized as the best way to achieve the Sustainable Development Goal targets on health. But with 400 million people lacking access to essential health services and a projected shortage of 18 million health workers, it will take unprecedented effort and funding. Community health workers (CHWs) could be an important part of the solution—but without effective investments and sound planning, we will fall short of achieving UHC.

Many low- and middle-income countries rely on a robust community health workforce, but few are self-sustaining and many rely heavily on external donors. CHWs fill critical gaps while delivering quality, affordable services closer to underserved patients. Even during crises, such as West Africa’s Ebola outbreak, CHWs can ensure the continuity of services while helping to stop epidemics.

As a 2015 report shows, CHWs can also yield a sound 10-to-1 return on investment, when accounting for a healthier population’s increased productivity and formal employment and the prevention of costly health crises. Expanding access to community services could prevent up to 3 million deaths annually while substantially reducing patients’ out-of-pocket costs.

Recognizing these benefits, low- and high-income countries alike are developing and expanding CHW programs. In Ethiopia, Community Health Extension Workers (CHEWs) proved instrumental in reducing maternal and child deaths and in meeting nearly all of the country’s 2015 Millennium Development Goals on health. Countries including Ghana and Sierra Leone are training and deploying a combined 35,000 CHWs to bridge gaps. Even in American cities like Philadelphia, CHWs are delivering evidence-based health interventions to high-risk patients while reducing overall health care costs.

While CHWs are not a new concept, the recent momentum for scaling CHWs raises an important question: will they be a long-term investment or simply a palliative solution to achieve short-term results?

Amid competing funding priorities and uncertainty around foreign assistance, countries show reluctance to invest in community health systems. CHWs are often unpaid volunteers, lack a career path, and are rarely considered part of the formal health workforce. These factors, combined with growing demand for their time, contribute to high rates of attrition. Further, in the absence of proper planning, frequently there is no funding for ongoing training, program support, and supervision of CHWs. This can lead to low-quality services or, worse, a complete stoppage of services in the most challenged communities.

To achieve UHC and the health SDG targets, long-term community health planning is essential—and along with helping countries identify solutions to meet health goals, it provides an opportunity to evaluate progress and make improvements. Planning can also help countries identify the costs and resource needs to sustain CHWs, including medicines and supplies; equipment; incentives; training; as well as program management, supervision, and reporting. It also cuts down on duplicative efforts among partners.

To facilitate this process, the NGO where I work, Management Sciences for Health, partnered with UNICEF to create a Community Health Planning and Costing Tool that helps calculate the costs of delivering comprehensive community health services for up to 10 years. To-date, the tool has helped plan the long-term implementation of national community health programs in Madagascar, Malawi, and Sierra Leone.

Understanding the costs and required financing for large-scale community health programs helps governments more effectively advocate for domestic and external funding sources, including the private sector. Plus, identifying funding gaps can help countries pool different sources to ensure that health programs operate fully and consistently.

As countries move toward building and sustaining national community health programs, they should consider a few key takeaways.

First, long-term financing plans should be developed to support continuous services and funding for all elements of a community health program. While domestically-financed programs may prove unrealistic for many countries, there are opportunities to leverage existing initiatives and donor funding. For example, in Rwanda, CHWs are integrated into the country’s national performance-based financing scheme, which provides incentives to fund income-generating activities. Other countries leveraged multi-year Global Fund support to cover antimalarial medicines, rapid diagnostic tests, training, and incentives.

Community health program funding should work to strengthen health systems overall. Embedded in weak health systems, CHWs programs will be ineffective and investments will fall flat. CHWs will only succeed when all building blocks are performing. For example, programs must reinforce strong supply chains, a dynamic supervisory and management workforce, and an effective flow of health information.

As frontline health workers, the CHW role should also be institutionalized in national health systems. Along with clearly defined responsibilities, they should receive ample recognition, incentives, and professional development opportunities. By doing so, countries can improve the quality of service delivery, ensure greater accountability to their communities, and increase CHW retention.

Lastly, we must continue to demonstrate the impact of CHWs and draw lessons. To strengthen the investment case for CHWs, we must go beyond demonstrating achievements of process indicators and coverage metrics and document how effectively CHWs improve patient outcomes, reduce costs to health systems and patients, and contribute to health milestones and targets. By sharing experiences and lessons-learned, other countries might avoid shortcomings and adapt program successes to address their health priorities.

This article was originally published in Global Health NOW. Join the thousands of subscribers who rely on Global Health NOW summaries and exclusive articles for the latest public health news. Sign up for the free weekday e-newsletter, and please share the link with friends and colleagues:

Home by Home: Liliane’s Tireless Fight Against Malaria

This guest post has been provided by GHC member Jhpiego. It originally appeared as a photo essay on Jhpiego’s medium blog. 

Photo credit is Jhpiego/Karen Kasmauski

Olivia Mboli, a single mom of five children, works on a palm oil plantation in west Cameroon, earning $32 to $42 per month.

“It’s difficult to meet my children’s needs,” she says, particularly when they get sick.

Three years ago, Olivia was pregnant with twins when a tree fell on her husband and killed him as he walked to work. Today, twins Norbert and Albert are just small enough to still be held, and Princess — Olivia’s only daughter — is 9 years old. Olivia also has two older sons. Keeping the five of them on a path to thrive and succeed is a constant struggle for Olivia. But community health worker Liliane Mbom is her strong ally, helping Olivia and her family to stay healthy and malaria-free.

In Cameroon, malaria accounts for 43 percent of deaths and more than half of illnesses of children under age 5. Pregnant women are particularly vulnerable; malaria can have significant health consequences for both the expectant mother and her unborn child. Community health workers like Liliane serve as the first line of defense against malaria in so many areas of the country.

Liliane Mbom is a teacher by training, but when the chief officer at the local health center visited her village looking for help educating residents about malaria prevention and providing basic care, she was nominated by her peers.

“The people designated me. I initially refused…but they convinced me and I accepted,” Liliane says.

Liliane’s work — from community education to home visits — has a dramatic impact on families like Olivia’s.

“I book an appointment beforehand with the head of the family and I go to [the] house on the designated date. We discuss malaria prevention, what to do when a child or an adult has a fever, and we talk about the right way to use a mosquito net,” Liliane says, describing a typical home visit.

Through a Jhpiego-led initiative funded by ExxonMobil in April 2014, Liliane learned how to diagnose malaria using rapid diagnostic tests. She learned how to manage cases of uncomplicated malaria with common malaria medicines — artemisinin-based combination therapy — and when to refer severe cases to health facilities. Through educational talks and home visits, Liliane is raising public awareness of malaria.

She is a touchpoint for families on the best practices to prevent malaria and the first point of care for many palm oil workers.

For Olivia and her children, Liliane is a key component of a healthy, malaria-free life. This World Malaria Day, we celebrate Liliane and the thousands of community health workers like her who fight tirelessly for a malaria-free future!

Community Health Worker Nutrition Advocacy Tool

Community health workers (CHW) play a critical role in delivering evidence-based, cost-effective interventions that can improve nutrition outcomes in the communities they serve. In collaboration with the USAID-funded Advancing Partners and Communities (APC) project, SPRING has gathered data around key nutrition responsibilities for Community Health Workers in 9 countries that can be used to advocate for increased commitment to nutrition in community health programs. The data identifies gaps in nutrition service delivery and helps program planners take action. Access tool.

The Future of Health Financing

This blog was cross-posted from IntraHealth, and written by Pape Amadou Gaye

If you had asked me back when I started my career what I found most exciting about the future of global health, I would have told you about my dream that primary health care would someday be available to all.

But today, my answer to that question is a bit different. Global health has radically improved since those days, and I believe more than ever that universal access to primary health care is within our reach. Now when I look to the future—to the day when we’ve achieved our Sustainable Development Goals and made health coverage truly universal—I dream of an even healthier global population with unprecedented options for care.

I see a robust global middle class with greater purchasing power than ever. I see domestically financed health systems and mixed markets where the public and private sectors offer multiple points of access to an array of comprehensive health services. And I see communities educated and able to focus on self-care, while health workers provide high-quality, sustainable, patient-centered services to all those in need.

But how will we reach this future? And how can we afford it?

Before we even set foot on this path, politicians and policymakers must first accept that spending on health is not merely a cost—it’s an investment. For every dollar invested in community health workers, for example, we see returns as high as $10.

The first step will be investing today in the health workforce, where huge funding gaps remain. Take community health workers—80 percent of populations rely on them for primary health care, and yet many in the global health and development community continue to see them as volunteers. Governments, donor agencies and others don’t budget and plan for their integration into the formal health system.

We can expand and leverage our investments in health systems and the workforce for sustainable returns by:

1. Reforming preservice education for health workers.

Too often, health education focuses on specialized, hospital-based care. Shifting the focus to primary health care and adding health system leadership and governance to the curricula will help countries build fit-for-purpose workforces.

2. Investing in youth.

The health sector is a huge employer. By ensuring young people who are interested in becoming health workers have access to education, and by focusing on employment and job creation for young people, we will yield sustainable returns.

3. Advocating for more favorable health policies.

This includes those that support frontline teams of health workers, demedicalize care by promoting task-sharing, and expand education for self-care.

4. Bringing more voices and partnerships to the table.

Governments must become more open to outsourcing and contracting certain functions to the private sector—and to bringing economists, financiers and other new stakeholders into the fold.

Africa in particular has great potential for new market solutions. And there are some excellent domestic health financing models now being tried in low- and middle-income countries that could be expanded.

In Namibia, for example, IntraHealth International has been working with the government to update staffing norms for health facilities by implementing the first-ever national application of the World Health Organization’s Workload Indicators of Staffing Need method. This is helping the government pinpoint staff shortages and misalignments down to the individual facility—and then make budgeting and deployment decisions accordingly.

Other great examples include the entrepreneurial and door-to-door approaches of Living Goods and the HealthKeepers Network, and the Abraaj Group’s investments in networks of private-sector health facilities linked with frontline health workers.

We also know it’s possible to raise revenue for the health sector through so-called sin taxes, such as on alcohol and tobacco. According to the WHO, raising the tax on cigarettes by one “international dollar” per pack would raise cigarette excise revenue worldwide by about $141 billion and decrease global cigarette consumption by about 18 percent.

The Evolving Role of International Donors and Partners

International donors and development partners must change the way we work and the value we provide as we move toward more LMICs financing their own health sectors.

How will we get there?

First, we will have to advocate for stellar global and national governance, holding global agencies and countries accountable for developing, financing, and implementing evidence-based policies and programs. Secondly, we should liaise with the private sector to identify innovative solutions and investments that make health care more accessible and affordable to all. And thirdly, we must provide state-of-the-art technical assistance, helping countries translate academic research into sound, context-specific policy and practice.

The global health of tomorrow relies on investments made today. If we start by collaborating to lay the groundwork for strong health systems and workforces around the world, we’ll be on our way to a future of better health and prosperity for all.

This piece originally appeared in Devex as part of its Making Markets Work series.