Community health workers for universal health-care coverage: from fragmentation to synergy
Kate Tulenko a, Sigrun Møgedal b, Muhammad Mahmood Afzal c, Diana Frymus d, Adetokunbo Oshin e, Muhammad Pate e, Estelle Quain d, Arletty Pinel f, Shona Wynd g & Sanjay Zodpey h
a. CapacityPlus, IntraHealth, 1776 I St, NW, Washington, DC 20006, United States of America (USA).
b. Norwegian Knowledge Center for the Health Services, Oslo, Norway.
c. Global Health Workforce Alliance, Geneva, Switzerland.
d. United States Agency for International Development, Washington, USA.
e. Federal Ministry of Health, Abuja, Nigeria.
f. Genos Global, Panama City, Panama.
g. Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland.
h. Public Health Foundation of India, New Delhi, India.
Correspondence to Kate Tulenko (e-mail: firstname.lastname@example.org).
(Submitted: 10 March 2013 – Revised version received: 24 May 2013 – Accepted: 01 July 2013.)
Bulletin of the World Health Organization 2013;91:847-852. doi: http://dx.doi.org/10.2471/BLT.13.118745
From Alma-Ata to universal health coverage
From the early years of primary health care, community-based health workers and volunteers (henceforth referred to as community health workers [CHWs]) have played a key role in satisfying the need and demand for essential health services. The Alma-Ata Declaration states that primary health care “relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community”.1
The values and principles set down at Alma-Ata continue to be relevant today, even though the primary-health-care movement has encountered difficulties in many countries and at many levels when seeking to put them into practice. With the growing momentum for making universal health coverage (UHC) a core strategy for shaping the post-2015 global health agenda, known barriers to coverage and access must be overcome.2 This also applies to factors that undermine the role of CHWs in the health system.
The path-finding pilots for community-based primary health care and CHW models took place in nongovernmental settings in the beginning of the 1970s. The Christian Medical Commission of the World Council of Churches, in proactive engagement with the World Health Organization (WHO),3 was instrumental in making the case for this paradigm shift in health care by joining efforts with lead projects in Guatemala, India, Indonesia and elsewhere, among them the Comprehensive Rural Health Programme in Jamkhed, India, established in 1970,4 which continues today. After the Commission’s pioneering work, hundreds of other faith-based groups and nongovernmental organizations (NGOs) have continued to refine community-based health-care models and CHW programmes.
After Alma-Ata, the eagerness of public health authorities to produce national blueprints for the rapid scale-up of primary health care did, however, generally miss out on creating ample space for community participation. The comprehensiveness and continuity of care – so basic to the model – were soon replaced by selective interventions for focused results, including selected maternal and child health interventions and family planning. Well-intended, top down national planning and external support created wave after wave of CHWs in the making and reshaping, under different names and with different roles. Many countries and many communities can recall a history of training, deployment and failure of several repeating initiatives, such as that in the United Republic of Tanzania in the 1980s.5 Caught between the formal health system and the community and often in a “grey zone” between public, nongovernmental and private health systems, CHWs were for a long time seen as a stopgap measure and did not receive the adequate support needed for sustainability.
When the epidemic of HIV infection set in, community-based care models found new expressions. The need to act grew organically out of the affected communities in the early days of the epidemic. People living with HIV infection had no choice but to help one another. What evolved was a system rooted in the local context and born out of friendship and a shared experience: mothers supported mothers, gay men supported gay men and grandmothers helped grandmothers. When the early antiretrovirals became available, projects and programmes funded by governments, donors and NGOs spotted the opportunity to utilize existing community HIV support networks and began funding training and development for CHW programmes specific to the needs of HIV programmes, yet largely without being part of the local health services and clinics. What started out as community-based responses began to evolve into multiple, stand-alone CHW programmes focused on HIV care with varying degrees of formality, sustainability, success, support and reporting.6
The use of CHWs for childhood development and maternal, neonatal and child health care has a long history, as illustrated in India. The Accredited Social Health Activists (ASHA) model for the follow-up of women during pregnancy, delivery and the postnatal period has been relatively successful in overcoming barriers to service delivery and increasing institutional deliveries.7 The ASHA programme has attained roughly 70% coverage of both mothers and neonates in participating areas.8
Lady health workers in Pakistan, behvarz in the Islamic Republic of Iran, agentes communitários de saúde in Brazil, BRAC community health workers in Bangladesh, village health volunteers in Thailand, and health extension workers in Ethiopia all represent different successful CHW models.9 Zambia agreed on a national CHW strategy in 2010 and implemented a community health assistant programme in 2012. In August 2011 Nigeria held its very first national meeting on human resources for health, which brought together various partners and representatives of all levels of government. Similar national meetings have taken place in Kenya in 2011 and in 2013 the United Republic of Tanzania. These programmes and processes have, in different ways, brought in the voices of the CHWs and their communities and seek to optimize the potential contribution of skilled and supported CHWs to primary health care (Box 1).
Box 1. Commonly noted contributions of community health workers (CHWs)
- CHWs who are properly trained, equipped and supported can take on a range of tasks that otherwise depend on mid-level health workers.
- CHWs extend care to underserved communities, where they enhance access to health services and promote people’s trust, demand and use of such services.
- CHWs who speak the local language and identify with the local community convey health messages more effectively.
- CHW training and service contribute to capacity for community leadership.
- CHWs recruited from the communities they serve are less likely to go elsewhere because of difficult living conditions.
- CHWs can help service users avoid trips to health facilities, which translates into saved transportation costs and time.
- CHWs can meet some of the needs of homebound patients.
Scale-up and sustainability
Although some sustainable national CHW programmes exist, such programmes have not achieved the scale-up and sustainability envisioned at Alma-Ata. CHWs have traditionally been recruited, trained, employed and supervised at the periphery of health ministry structures. Donors have generally supported CHW programmes to achieve goals linked to disease-specific vertical programmes or for the performance of specific tasks such as family planning, nutrition and immunization. Moreover, CHWs often lack a career ladder or professional associations. Although such vertical approaches may have resulted in short-term gains, programme fragmentation, ownership and sustainability have been major concerns.
The impact of CHWs can no longer be taken on faith; rigorous effectiveness and cost-effectiveness data are needed. Systematic reviews of studies comparing CHWs with usual practices have shown the effectiveness of CHWs in promoting immunization and breastfeeding, improving tuberculosis treatment outcomes and reducing child morbidity and mortality. The importance of integrating CHWs into the health system on the basis of a core set of skills defined at the national level and with appropriate supervision and support cannot be sufficiently underscored. In this process, due attention must be paid to the need for diverse training in keeping with the various roles and tasks performed by CHWs on the ground.10,11
In 2012, several initiatives were implemented to engage the services of CHWs and other health workers at the front line in providing improved access to life-saving care. Together, these initiatives brought to light a dearth of operational research and a need for better synergies in knowledge management and operations. They also revealed that CHW programmes are still fragmented, with many different programmes of different origins having evolved over time, and that this fragmentation can be linked in part to the way programmes and initiatives are funded by external partners and coordinated at the country level.12,13 The Global Health Workforce Alliance synthesized the findings from these consultations and has initiated work to improve synergies across initiatives and partners.
The experience with CHW programmes points to six key challenges in terms of policy and practice, with implications for scale-up and sustainability. These are discussed in the following sections.
Neglect of CHWs in health workforce planning
In most countries’ health workforce strategies, district and local authorities are responsible for hiring, managing and supporting CHWs at the front-line facility and community levels without strong guidance from the national level. The creation of CHW programmes in multiple “waves” throughout the past 30 years has contributed to severe fragmentation on the ground. There is a need for explicit principles and guidance from the national level on ways of integrating and aligning these efforts to optimize synergies and build sustainable platforms for the scale-up of CHW programmes towards achieving UHC.
Multiple actors without coordination
United Nations partners working in the sphere of health have direct or indirect engagement with CHW programmes and other community-based health initiatives – often in diverging ways within the same country. Partners engaged in supporting CHW and community-based programmes are seldom present at the district or lower level but work through contractors and implementers without national or local mechanisms for coordination. Faith-based and NGO-related private or community-based CHW programmes have their own contracts and arrangements for health workers and barriers to communication between public and NGO providers are not uncommon.
Fragmented, disease-specific focus
Differences in the way interventions – in family planning, nutrition, malaria, immunization, HIV-related care and maternal and child health – are structured and supported add to the complexity of the situation. Training, management and incentive structures differ widely. Results and accountability frameworks for these programmes are not structured to drive synergies across initiatives. Be they local and free-standing or part of nationwide efforts, programmes and initiatives often stimulate piloting and innovation. Yet because resulting innovations are not coordinated, they do not spread and programmes are not scaled up.
Unclear link to the health system
There is an urgent need for supervision and support for CHWs at the level of programme implementation. The role of the district and subdistrict levels in facilitating coordination and ensuring synergy among multiple stakeholders and initiatives is often unclear. This is also true of the accountability of CHW programmes to the district and community governance structures for health and development. This lack of clarity in the link of CHW programmes to the health system undermines overall commitment to and capacity for supervision and support.
Competing nongovernmental organizations
The “NGO challenge” acts as a further barrier to synergy across CHW initiatives and partners. Although competition for funding among international, regional and national NGOs fosters creativity and momentum, it makes competing NGOs disinterested in cooperating with one another. When NGOs bid for contracts they feel compelled to offer a product that is different from what other NGOs offer. It therefore behoves donors to incentivize cooperation among NGOs or to make it mandatory.
CHWs often operate in an environment in which it is not clear whether they represent the community, an NGO, the health system or a combination of these. This can lead to confused responsibilities and accountabilities among the various actors and deprives CHWs of the support they need. CHWs interface between their communities and formal health systems and their roles and expectations must therefore be clarified and understood by all parties. CHWs also face opposition from more established health professionals, such as physicians and nurses, who may see them as a potential threat to their job security and salaries. In most countries, CHWs have never been integrated into the established, salaried team of health system workers, have never been professionalized and have never been given a voice in the affairs of the health system or the non-state health sector.14
Synergy, integration and sustainability
The challenges identified in this paper stem from the “going it alone” approach applied by most funders and implementers of CHW programmes, which has left us with a legacy of parallel initiatives funded separately, delivering separately and reporting separately. If the isolated health gains that have been achieved through CHW programmes are to be sustained and scaled up to meet UHC targets, a clear strategy for optimizing synergies and integration is needed.
Major steps have been taken at the national level, through a variety of collaborative frameworks, plans and strategies, to harmonize and coordinate the actions of multiple entities in support of health system development and service delivery. Examples include sector-wide support platforms, the International Health Partnership and the Global Health Workforce Alliance’s programme of Country Coordination and Facilitation for Human Resources for Health. However, these coordination mechanisms seldom cover programmes implemented under district-level authority at the health facility and community levels, including CHW programmes.
With the growing focus on scaling up CHW programmes of differing scope and fit within the formal health system, decisive steps to ensure operational synergies are essential. Such steps must be taken through agreed national policies and with guidance and alignment by all partners and they must allow for flexibility and innovation. The aim must be to optimize a health team approach at the front line of the health system, fit for the local context, with facility-based and community-based health workers working together. This approach may result in slower progress at the outset but will ensure long-term results and sustainability.
It is the responsibility of every national government to establish guidelines for scaling up CHW programmes that respond to local needs and realities. A national inventory of ongoing programmes and community-based CHW initiatives is key to alignment among different programmes. The policy framework for integration and alignment of the tasks performed by different types of CHWs across different vertical initiatives must be agreed on by both funders and implementers. Specifically, the question of incorporating CHWs into the formal health system and the greater health workforce must be addressed, together with the mechanisms for regulating their performance – i.e. setting standards for training, licencing, scope of work, career ladders and supervision.
District health management teams and local governments need to be given the authority to bring together the implementing partners to enhance synergies and programme alignment in accordance with national guidance, make full use of the space for innovation, and facilitate mutual learning. District health managers will need to work with their community counterparts as appropriate to track and act on CHW-related service data, keep coverage maps, ensure the necessary supervision and guidance, and track performance.
Key to engaging CHWs to attain UHC is the readiness of global and national partners and implementers to (i) value collaboration; (ii) comply with national- and district-level guidance on synergies and integration; (iii) share information; (iv) ensure sufficient local flexibility and (v) monitor established indicators. As an alliance of key stakeholders, the Global Health Workforce Alliance is well placed to promote a health system approach, with coordination across CHW initiatives, when seeking programme scale-up at the global, national and district levels. In this context, new initiatives such as the One Million Community Health Workers Campaign, hosted by the United Nations Sustainable Development Solutions Network and the Earth Institute, represent important opportunities for aligned action. Multilateral partners, global initiatives, donors and international NGOs need to closely examine programming, funding and reporting to minimize fragmentation and duplication and ensure the scale-up of CHW programmes in the context of a trained, equipped and supported health team.
As was made clear in the Alma-Ata Declaration and as is valid today, CHWs, whether hired by the formal health system or selected and supported by communities, cannot be left to serve on their own.15 CHW programmes need be comprehensive rather than vertical and they should rely on both the community and the formal health system for supplies, communications and referrals. Isolated investment in CHWs is no shortcut to progress.
CHWs can be effective, integral members of the health team. They can go beyond the provision of care and foster community-based action. As the MDG era comes to an end and a new era focused on UHC begins, the global health community has a unique opportunity to work with CHWs to create lasting health improvements everywhere.
The views expressed in this publication are solely the authors’; they do not necessarily reflect the views of the United States Agency for International Development or the Government of the United States.
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