Working for Community Health

Recently I attended a consultation on Community Health Workers (CHWs) organised by the Global Health Workforce Alliance. The consultation brought together policy makers, practitioners, academics and other experts from the world of public health in an attempt to look at how CHW programmes can be scaled up, particularly in countries off-track in terms of the Millennium Development Goals (MDGs).

Many people in developing countries are unable to access health services. There may be many deterrents – cost, quality of care and distance to the nearest health facility for example. Working in Mozambique a couple of years ago I met a woman who, every month, walked overnight in order to receive her antiretroviral medication at the district hospital – a remarkable endeavour, albeit not that exceptional for people in remote communities in many parts of the developing world.

In a lot more cases, distance can have deadly consequences – quite literally for a woman in labour requiring emergency obstetric care but with no means of reaching the health facility 5 miles away, or the newborn baby delivered at home and suffering postnatal complications. Community Health Workers are seen as a potentially effective solution, extending the reach of the ‘formal’ health system into the communities whose health needs are enormous yet so often neglected.

However, a potentially effective solution isn’t necessarily a straightforward one. “Community health worker” is something of an umbrella term, and a particularly big umbrella at that. The function – and the specific responsibilities attached to it – can vary significantly from one country to another.

Depending on the context, their role may be primarily promotive, or preventive, or therapeutic. Different emphases requiring quite different skills. Wherever they are employed, CHWs need to be recruited, trained, equipped with the necessary tools and supplies, supervised and of course financed.

Crucially, CHWs also need to work within a functioning health system. If they arrange for the pregnant woman to be transported to the nearest labour ward only for her to be asked to pay for a delivery she can’t afford, or refer a sick child to a health centre which has no medical staff, then their usefulness will be limited. Scratch the surface and a great idea can quickly become an operational headache.

The CHW consultation looked at some of the critical implementation issues, including: production and deployment, attraction and retention, teamwork, and CHW performance,
and the further evidence needed to support national implementation. There was an emphasis on practical recommendations for countries wishing to introduce or develop a cadre of CHWs, building on the findings of the CHW review commissioned by the Global Health Workforce Alliance prior to the meeting.

There was of course no expectation that a two day consultation would come up with all the answers, it was just one step in an ongoing process. A lot of subsequent work will need to be done with national Ministries of Health and other counterparts. Save the Children will hopefully be able to make a useful contribution here.

If CHWs do become an integral part of the health system in an increasing number of developing countries, the cherished principles of the seminal 1978 Alma-Ata declaration will be a step closer to being realised.