Rallying for UHC (III): Community Health Workers Can Accelerate Progress towards Universal Health Coverage in Sub-Saharan Africa

Rallying for UHC (III): Community Health Workers Can Accelerate Progress towards Universal Health Coverage in Sub-Saharan Africa

 {Photo credit: Todd Shapera}Emanuel Bizimungu, a community health worker in eastern Rwanda, examines a girl.Photo credit: Todd Shapera

As the United Nations General Assembly kicks off general debate on the post-2015 development agenda this week, advocates of a universal health coverage (UHC) target are rallying other organizations to build and showcase support around UHC. These efforts include high-profile events on Monday and Tuesday, both hosted by the Rockefeller Foundation with partner support. On Wednesday, Johnson & Johnson hosted an event on the key role of frontline health workers to efforts like these. This post, which originally appeared on The Lancet Global Health Blog, is part of a "Rallying for UHC" series: MSH bloggers expanding on the themes raised by these events and considering the road ahead for UHC in post-2015 discussions. Readers can participate by adding comments on the blog posts, or joining the conversation on Twitter with the hashtag.  

[Biodun Awosusi talking with a patient in Lagos.] Biodun Awosusi talking with a patient in Lagos.

In January this year, a team of doctors, community health workers (CHWs), and volunteers took part in medical outreach in poor neighbourhoods in Lagos, Nigeria. The CHWs helped to mobilize the people, provided basic health education, and screened participants for diabetes mellitus and hypertension. Almost a quarter of participants had either diabetes mellitus or hypertension. One out of ten needed urgent medical attention; they were referred to nearby general hospital for further care. It was a rewarding experience for me to see how much CHWs can contribute in taking health care to the doorsteps of those who need it most but could not afford it.

Poverty is predominantly a rural phenomenon in sub-Saharan Africa, where more than 60 percent of the population lives in rural areas. The cost of illness drives many people to deeper levels of poverty. More than 200 million people live in extreme poverty in the region and are in dire need of affordable quality health services. Poverty drives many people away from hospitals to seek care from quacks and traditional healers when they could get affordable, life-saving health care from health workers, particularly CHWs who are close to them. As the rhetoric for universal health coverage (UHC) rises, I strongly believe CHWs have a key role to play to accelerate progress towards UHC in the region.

Is there any evidence to assert that CHWs can deliver? Of course there is. CHWs provide life-saving, culturally acceptable health-care services that reduce preventable causes of maternal and child mortality. They are increasingly seen as inevitable change agents in community-based primary health-care reforms. WHO and UNICEF state that CHWs deliver integrated community case management of malaria, pneumonia, diarrhoea, and malnutrition which are leading killers of children younger than 5 years. CHWs also provide a vital link between communities and health facilities.

According to WHO, we face a global shortage of 4.3 million health workers. Out of 57 countries with critical shortages of health workers, 36 are in sub-Saharan Africa. Although the region has 25 percent of the global burden of disease, it has only 3 percent of the world’s health workers. This is unacceptable. CHWs can help to address this challenge in order to improve access to health care. Interestingly, there is a progressive move in this direction in some countries in the region.

With more than 45,000 CHWs and less than 1000 doctors, Rwanda has recorded revolutionary improvement in health outcomes facilitated by strong leadership. The maternal mortality ratio dropped by 60 percent over the past decade and deaths from HIV, tuberculosis, and malaria have each dropped by about 80 percent over the same period. Under-5 mortality has been cut by 70 percent since 2000. Rwandan President Paul Kagame says, “Use of community health workers is something we have had experience with and we have seen good results.”

In Ethiopia, CHWs are also making impact. At the Abuja+12 Special Summit of Heads of State, Ethiopian Prime Minister and African Union Chairperson Hailemariam Desalegn asserted that the flagship health extension programme in his country involving 38,000 health extension workers has led to a significant reduction in HIV infections and the number of women dying in childbirth, and has also increased the number of children immunized.

These achievements suggest that CHWs could be key to achieving the Millennium Development Goals (MDGs). They can also speed up progress towards UHC. UHC has gained huge momentum at national and global levels with strong endorsements from the World Bank, WHO and the UN General Assembly. The UN Secretary General Ban Ki Moon recently recognized UHC as a plausible target in the post 2015 development agenda.  Despite this overwhelming support, the global health community has failed to realize the connection between CHWs and UHC.

Let’s examine this link.

UHC is a goal to ensure people everywhere have access to the essential health services they need without incurring financial hardship. CHWs contribute to meeting this goal by providing affordable culturally acceptable health-care services to people in settings where they need them most. They ensure mothers and children can receive care for common ailments within the community. When necessary, they refer patients to health facilities.

Although UHC contributes to sustainable development, it is limited by financial and physical barriers. Is there any role for CHWs here? Rwandan Health Minister, Agnes Binagwaho has an answer. She asserts, “Access to care in resource-constrained countries face financial, infrastructural and geographical barriers. Community health workers are a solution for overcoming those and improve access to healthcare in rural communities.”

UHC guarantees equitable access to preventive, curative, rehabilitative, and palliative care. CHWs contribute to this by providing basic health education and family planning services. They ensure children are immunized and women deliver in the presence of skilled birth attendants. They treat common ailments and also provide a link to health facilities to facilitate the continuum of care.

This link has great implications as policy makers design UHC programmes in countries with a large informal sector. It shows that CHWs can make vital inputs. Such programmes should not focus solely on risk pooling mechanisms but also on developing a viable CHW subsytem which recognizes that CHWs provide many basic life-saving health services in a highly cost-effective and culturally acceptable way. This subsytem will emphasize how CHWs at the community level can also help to garner social and political support for community-based risk pooling mechanisms, as seen in Rwanda.

A good CHW subsystem in a country (eg, Rwanda) would have an adequate number of well trained, highly motivated CHWs, equitably distributed across the country. They must receive adequate training from clinical experts and be properly supervised to ensure they provide quality services to the populace. They should also have a consistent supply of diagnostic testing materials, essential drugs, and user-friendly treatment guidelines to facilitate delivery of quality services.

These elements are captured in the 1 million community workers campaign launched by the Earth Institute. The campaign offers a golden opportunity to deploy a million CHWs in sub-Saharan Africa to achieve “systematic rural healthcare coverage across rural sub-Saharan Africa” to fast-track achievement of the MDGs. By supporting relevant stakeholders committed to “CHW scale-up in the context of primary healthcare systems”, the campaign can significantly improve access to essential health services for the rural dwellers in Africa. It is expected that this will significantly cut down the burden of disease in the region.

However, we must resist the temptation to create a monster vertical programme that neglects broader human resource for health reform and focuses solely on CHWs. We know such programmes do not last and waste scarce resources. Any CHW subsystem in any country should be implemented within broader strengthening of human resources for health that emphasizes effective collaboration among all cadres of health workers. CHWs cannot replace highly skilled health workers but can complement them in order to make quality healthcare available to people everywhere.  

With this, UHC stands as a realizable health target in Africa.