Stop!

Put your shoes back on!

We don’t need to urgently send them to doctors in Africa!

(Plus, your feet smell)

I was actually referring to the campaign run by Colombia University’s Earth Institute called “One Million Community Health Workers” (1mCHW). Supported by many large organisations, it aims to achieve universal health care in rural-Sub Saharan Africa by 2020 by providing 1 Community Health Worker (CHW) for every 650 rural inhabitants. Since its launch in January 2013 at the World Economic Forum, the campaign’s main agenda has been to provide access to quality and affordable health services to those who do not currently have access to them.

“The Campaign believes that the best way to close this gap is by supporting governments, global partners, and national stakeholders dedicated to CHW scale-up in the context of health systems strengthening.”

– 1mCHW website

Since the year 2000, there has been a big global push to use similar CHW interventions in order to achieve the Millennium Development Goals 4 and 5. Moving forward, we need to consider the effectiveness of these programs and to assess them in the context of the development of their country and its health system – to avoid providing “band-aid” fixes (see Myth 5).

But I guess you’re still wondering… What are Community Health Workers?

What do they have to do with achieving universal health care in Africa?

And… Why aren’t they wearing any shoes?!?!

What are “CHWs” and what do they do?

I guess I could answer those questions… Or maybe you could just watch this short video by the Malaria Consortium:

So, now we know that Community Health Workers (CHWs) are given basic primary healthcare training in order to care for their respective communities. They perform basic yet extremely important tasks such as providing health education to pregnant mothers, providing Malaria medication, promoting hygienic behaviours and even testing for diabetes and high blood pressure. We need CHWs to perform these tasks as there is a massive shortage of doctors, nurses and health clinics in many rural and remote areas. They have been key in delivering primary health care services to these areas over the last 70 or so years.

«The single intervention that “would do the most to improve the health of those living on less than $1 per day” would be to “hire community health workers to serve them.”

– Paul Farmer, Harvard Medical School
  (in this Plos Medicine blog)

The battle to combat preventable diseases in the undeveloped world heavily centres on the use of CHWs. Many organisations truly believe that creating, training and providing resources to more CHWs is the best chance we have to eliminate Malaria, HIV Aids and malnutrition, and also to improve child and maternal health measures for good.

“An estimated 10.6 million children under five years of age still die each year from preventable or treatable diseases… A large proportion of these deaths could be prevented through early, appropriate and low-cost treatment of sick children in the home or community, with antibiotics, antimalarials or oral rehydration therapy.»

– UNICEF, in this report from 2006

History of CHW programs:

Still unsure about the whole “Barefoot” thing? Well…

…that all started back in the 1950s in the People’s Republic of China, where one of the early CHW programs was implemented. There, they trained illiterate farmers to record births and deaths, perform vaccinations and provide other health promotion services to rural communities (read more here). This program expanded at such a pace that in the 1970s that there were said to have been about 1 million of these CHWs caring for China’s 800 million strong population at the time. And…

…can you guess what they were called?

That’s right! Barefoot Doctors!

And guess what else? Our shoeless friends became the new (medical) craze of the 1960s as similar programs started popping up across the globe! * This was seen as the new approach to covering the massive gaps in access to health services in undeveloped countries. In the wake of this, all of the 134 countries present at the 1978 Alma-Ata conference agreed 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.”  

CHWs Programs around the world – success stories:

The CHW movement has been responsible for improving the health outcomes and increasing the access to primary health care of millions of people worldwide, including in the following countries:

In the 1980s in Brazil we saw the “Programa Agente Comunitário de Sáude” employ and train 7,300 people as CHWs in order to assist their communities with vaccinations and, breastfeeding and diarrhea information. This program led to increased breastfeeding rates, reduced infant mortality and hospitalization rates, and also provision of coverage to 40% of population by the year 2000. Find specific information here, here and here.

There are also successful CHW interventions run in Bangladesh and Nepal. In Bangladesh, roughly 100,000 CHWs are currently used to provide home-based family planning services to over 110 million people! Nearby in Nepal, 40,000 CHWs also provide family planning, immunizations and treatment of common childhood problems. Read more here.

These three examples have been some of the most effective interventions in reducing under-five mortality rate in the last 25 years. You can see a video of the BRAC intervention in Bangladesh here and a video of a successful intervention in one region in Uganda here.

Currently there are around 1.3 million CHWs worldwide according to the WHO, and as you can see in the map below (source), they also exist in developed countries such as the USA, where there are large differences in health outcomes between different population groups.

Ensuring the effectiveness of future CHW interventions:

During the 80s and 90s, the economic crisis meant that we saw many of the large scale CHW programs collapse due to a lack of available funding. This lead to a lack of training, supervision, medical support and integration of programs with health systems. That is why we need CHW interventions to be well monitored in terms of their function, spending and impact.

It is important to note that CHW programs can be highly politicised and that they can be present without making real, sustainable changes to a country’s health system. It is therefore essential they form a part of a larger scale social, political and health care reform. This ensures that the development of the country is not limited by vertical health programs that provide care as a temporary solution. An important part of this is to ensure that CHWs are paid, well supported and that they campaign for social equity for their communities. Here are some more considerations published by the WHO.

Conclusion:

History has shown us the powerful impacts that CHW programs can have on the health of the world’s most vulnerable and hard to reach people. It is now time to use them in conjunction with the development of the country and its health system. Unless we want to have to find 5 million CHWs by 2030, let’s get it right now!

Footnotes:

* They probably wore shoes