SEATTLE, Washington — According to a report from the World Health Organization and the World Bank in 2017, at least half of the world faces a lack of basic health services. When they do have access, many are pushed into poverty because they have to pay for them out of pocket. One solution to this growing issue has been the integration of community health workers (CHWs) to strengthen the ability of countries to provide basic health services.
What to Know About CHWs
Many low- and middle-income countries have considered integrating community health workers into health systems. Not only is it useful but necessary due to the lack of basic health services and clinicians for an ever-growing population. For more than 50 years, community health workers have provided services where there is a lack of infrastructure or an adequate number of doctors. A comprehensive review of 122 community health worker programs, 83 of which were from low- and middle-income countries, concluded that CHWs make significant contributions when serving underserved groups and can handle complex counseling and biomedical related tasks. CHWs perform a wide range of tasks that vary in roles. These include preventative, developmental and, in very specific cases, defined roles for particular interventions.
In 2007, Geneva’s Department of Human Resources for Health and the World Health Organization, produced a report called “Community health workers: what do we know about them?” The report found five basic themes about community health workers and how they are being utilized in low- to middle-income countries. CHWs have proven to have a valuable contribution to community health, especially in the area of child health. For CHWs to be successful, they must be adequately trained and carefully selected. They also must be continually supported, which translates to the need for continuous training, management and supervision.
CHWs are not a cure-all for weak health systems nor a less expensive option to “fix” the lack of basic health services for underserved populations. CHW programs are at risk of failure unless they are situated in the communities of the people in need. Finally, it remains controversial whether CHWs should be volunteers or paid. As volunteers, it is virtually impossible to have a sustainable program, so CHWs usually have some income.
Brazil’s Family Health Strategy
Brazil’s Family Health Strategy (FHS) was authorized through the Alma-Ata Declaration in 1978 and the 1988 constitution in Brazil, which determined healthcare as a human right. Since the 1990s, CHWs have been essential to meeting the country’s primary healthcare needs. Brazil started the FHS in 1994. It aims to provide care with multidisciplinary teams. Teams include “a physician, a nurse and about six CHWs.” Each group can also include psychologists, physiotherapists, community pharmacists and a dental team. Each team covers 3,000 to 4,000 people with each CHW covering at most 150 families.
Today, CHWs fill the gap of the lack of access to basic health services for about 67% of the population. FHS is entirely publicly funded and, despite the recent economic downturn, federal law prevents budget cuts. More coverage results in more accurate mortality data, improvements in breastfeeding rates, a decrease in inequity in healthcare utilization, uptake in immunization and a substantial reduction in hospitalizations for acute symptoms of chronic illnesses.
Indian Accredited Social Health Activists
The Indian Accredited Social Health Activists (ASHAs) is another example of a successful CHW program. In India, community health workers are known as ASHAs. ASHAs contribute to significant improvements in maternal, child and overall reproductive health. Since 2005, India has trained 750,000 ASHAs, investing more than $1,000 in each ASHA per year.
Also, launched in 2005, the National Rural Health Mission (NRHM) uses ASHAs to strengthen the health system for some of the poorest people in the country. A local committee elects the women who become ASHAs. From 2005 to 2010, each program had a budget between $1.2 million and $15.5 million per state.
India accounts for one-third of all global maternal deaths. Between 1990 and 2016, pregnancy-related deaths decreased by 77%. Increasing ASHAs capacity in aiding in preventative education, reproductive health, family planning, linking families to appropriate care and directing patients to the correct services at each stage of pregnancy has been a key component in the success of decreasing pregnancy-related deaths
Although there has been a countrywide success in addressing maternal and child health, challenges remain. The ASHA program had some of the highest reaches with the poorest populations but did not manage to reach women in different socioeconomic and caste groups. For example, only 18% of the scheduled tribes utilized deliver facilities versus 51% of the forward castes. The program also faces operational challenges, such as paying the ASHAs on time. This decreased their motivation to provide quality services.
Evaluation of Successes of CHWs
Unlike Brazil and India, many countries have included community health workers in their public health strategies, but have encountered countless challenges due to lack of funding for professional development, managerial supervision and government support of programs. As a warning, some evaluations of CHW-based programs caution against using their successes as a sign of a cure to the issues health systems encounter. Countries need to develop Long-term solutions to create robust health systems that can provide basic health services seamlessly.
Using community health workers to support the work of national health systems has substantially impacted the populations of both Brazil and India. As seen in both countries, community health workers can be successful in reducing the lack of basic health services with continuous training, state support and the quick upscaling of programs.
– Danielle Barnes