Beyond the Facility Walls: Community Health Workers Need Support

Beyond the Facility Walls: Community Health Workers Need Support

 {Photo credit: Katy Doyle/MSH}A health worker in Togo counsels a woman on reproductive health.Photo credit: Katy Doyle/MSH

Many years ago I began my public health career in Ciudad Nezahualcoyotl, then a squatter settlement of 1.8 million people, bordering Mexico City in the State of Mexico. Lack of land and unaffordable rents forced poor migrants, streaming in from the country side in search of employment and a better life in the city, to settle in the surrounding peri-urban areas. This large municipality, with few paved streets, was difficult to navigate in the rainy season. During the dry season, the wind would kick up dust storms that made it hard to see a block ahead. Nezahualcoyotl means hungry coyote in the Nahuatl language  and too many families in Neza, as people sometimes called it, were poor and hungry.

As I worked in the Mexican Ministry of Health (MoH) to build a primary health care system in Neza, I witnessed both the struggle and resilience of the residents, often against tremendous odds. The tallest building in Neza at that time was the four story Ministry of Health general hospital. On occasion I would go to the roof to look out at the sprawling community. I saw resilience in rods sticking out of some first floor roofs, indicating a plan to build a second floor—and a future.  I  saw resilience in people caring for their families and in the community’s involvement in health: people volunteering in immunization campaigns, advising their neighbors in this often hostile setting about the closest health center, organizing to clean the streets, warning against the dangers of rabies (Neza was called the rabies capital of Latin America at that time), and attending “charlas” (chats) on health topics in people’s homes. The community health system extended far beyond the four walls of the seven MOH health centers and the  general hospital in Neza, and, as I would occasionally argue with the surgeons at the hospital, was as important as the health work inside the facilities.

Although Neza was a peri-urban area, people often were disconnected from the formal health system. They were unaware of services, or wary of them, or they postponed addressing health issues because of larger daily priorities or for a myriad of other reasons. You had to go to the people to reach them. The community health volunteers that we trained and supported, walked through mud, often with a stick in their hands to chase away street dogs , following up on people in their homes, checking on pregnant women and newborns, imparting information about healthy behaviors, referring people to services, lobbying the municipal government to pick up the garbage strewn in empty lots, among other things.

Later, we worked throughout the State of Mexico, a state of several million inhabitants  to strengthen  primary care and a cadre of community health workers—volunteers as well as the country’s first Ministry of Health-salaried workers—and build the connections with the formal health system. We developed a public health residency program recognized by the ministry, to attract doctors, nurses, dentists, and nutritionists to work in rural areas and peri-urban areas, like Neza.

Strengthen and Support Community Health

In the last three decades, community-based health promotion, education and advocacy activities—organized and sustained by community actors—have increased exponentially. In 1978, nations came together to examine and emphasize a continuum of care: health from the households and community to facilities at the Alma Ata Primary Health Care conference. Since then, the World Health Organization, The Global Fund, US Agency for International Development (USAID), and other key stakeholders continue to draw attention to the critical role of community health, community health workers, and community involvement. 

From Neza to Nigeria, community health workers, health extension workers, outreach workers, community advocates, peer educators drawn from high risk populations, as well as members of community-based health committees and task forces, community support groups, and coalitions are reaching underserved and vulnerable populations and saving lives. Take, for example, the progress on HIV and AIDS through the work of community health workers, peer educators, community support groups for people living with HIV and orphans and vulnerable children, outreach workers and adherence counselors, those advocating for and supporting at- risk populations, human rights for health, and demand-side accountability mechanisms. The impact of communities taking actions to support their members, although often unquantified, is huge  

However, even today, the work outside the walls of health facilities remains insufficiently organized, funded, supported, recognized, and integrated with the work of the more formal health system. Work is often piled on community health workers, often more than they can humanly achieve, despite their commitment. Systematic data on activities implemented in the community, and information on the impact of these activities, are rare. 

Community health saves lives. If we are to achieve the Sustainable Development Goal targets on maternal, newborn, child and adolescent health, family planning and reproductive health, HIV and AIDS, TB, malaria, chronic diseases, epidemics prevention, and other areas of health—outcomes that are pinned to work at the community level—we must do more to support community health workers and other community-based agents for health.