From Afghanistan to Zimbabwe, Community Health Worker (CHW) programmes that are connecting people with various needs to the health services they require, close to where they live, are being implemented – combining trust, expertise, action, and impact.
Throughout the four-day (April 19 – 22, 2021) second Institutionalising Community Health Conference (ICHC 2021), four heads of global health agencies (UNICEF, WHO, UNAIDS, and USAID), various Ministers of Health, several panellists and participants overwhelming agreed that Community Health (CH) is the foundation for primary care/primary health care and the main pathway towards achieving universal health coverage (UHC).
As Dr Shannon Hader, Deputy Executive Director of UNAIDS said at the opening plenary: “This has to be a new model of systems for health…it can’t just be adding on community health workers and community-led components, after the formal or facility health is perfected or funded”.
The vital role of CHWs in emergency situations was also highlighted as COVID-19 disrupted essential health services and continues to cast a dark shadow on health systems, unravelling their inherent weaknesses.
During the pandemic, CHWs helped to sustain treatment in the homes of those with HIV, Tuberculosis, and Malaria; and kept primary health care services like immunisation and pre-natal care going. They assisted people to wear masks and maintain hand hygiene, and now mobilising them to get vaccinated against the virus.
“They’ve carried out case-finding, contact tracing and help hunt down the virus in an attempt to stop it in its tracks”, observed Raj Panjabi, US Global Malaria Coordinator for the President’s Malaria Initiative.
Furthermore, ICHC 2021 was informed that Health Ministers from over 190 countries came together at the 2019 World Health Assembly (WHA) to adopt a historic resolution on CHWs. This resolution called for greater investments, not just in community health services, but in community health systems, including systems to strengthen skills, supervision, supplies and salaries.
And later that year Heads of States committed to community-based health care, at the first UN high-level declaration on UHC. However, such paper proclamations and verbal rhetoric are not enough.
Notwithstanding, based on reports from the pre-conference scorecards, many countries have made tremendous progress in investing in systems to strengthen PHC in communities since the previous ICHC in 2017. Community clinics have been built, CHWs, Nurses and Midwives have been trained, they have been equipped with point-of-care tests, medicines and smartphones, systems to strengthen the quality of data and quality of care have been enhanced.
What has been the impetus instigating countries to develop roadmaps in order to optimise CHW programmes?
For Ethiopia, the revitalisation of the health extension programme that has already shown big impact in reducing maternal and child mortality, was a major driver in configuring the CH roadmap. Besides, with a huge population (117 million), addressing the huge burden of communicable diseases, along with maternal and child health, will not be possible without a strong disease prevention and health promotion programme.
Moreover, there has been a shift in epidemiology arising from non-communicable diseases, as the needs of communities have also increased requiring more packages of health intervention at the community level. Furthermore, “the need to engage communities more….and the lessons learnt during the pandemic of COVID and the role health extension workers played …has also contributed to a stronger roadmap design that we are now having”, Dr Liya Tadesse Gebremedhin, the Ethiopian Minister of Health stated.
In Afghanistan, improving services at community level and developing the systems for CH on a sustainable basis, remain central to the country’s community health policy and strategy. Other than putting in place systems for strong supervision and monitoring, data quality, reporting and feedback and multisectoral coordination, as well as increasing the number of CHWs in urban areas; the main concern of the Ministry of Public Health is on incentivising about 30,000 CHWs currently working as volunteers.
At the cost of $63 million over 5 years, this war-torn country is looking up to donors to foot the bill. Though Afghan government officials are not unaware that reliance on external support to pay CHWs salaries is not a viable option in the long-term, the reality on ground is dire, as domestic funding for health has been an ongoing issue. “…we have a lot of challenges…health is in competition with other sectors”, noted one of them.
Besides developing and maintaining the community health workforce and strengthening systems for community-based health care, some countries have also engaged communities and expanding their collective or group roles in addressing issues that affect their lives.
Zambia has revamped the Neighbourhood Health Committees (NHCs) that previously existed and now prioritised by the National Strategic Health Development Plan. These are non-partisan, multisectoral bodies composed of local residents in a certain catchment area. Apart from local planning and selection of community-based volunteers, they are also the platforms for multisectoral action and accountability at the community level. Dr Slvia Chila, Assistant Director, Community Health at the Ministry of Health reports that NHCs also take the lead in community health budgeting and financing, which has been integrated into the health sector, where at least 10% of national budget goes into community activities.
Ghana has introduced the ‘community scorecard’, aimed at empowering communities, strengthening accountability and improving healthcare quality at PHC level. It consists of two components: a scoring session during which community members provide feedback on 9 indicators related to quality of health services; and the development of Community Health Action Plans (CHAPS) to address the issues identified during the scoring session. There are reports that through the community scorecard, critical challenges deterring health facilities from providing quality services, including inadequate power and water supplies have been resolved.
“I think the community scorecard has come to stay; we don’t have a choice. it is a crucial tool if we truly want to make sure that the voice of the patient, the communities and our families are actually at the center of health care, which is what the national health care quality strategy launched in 2016 seeks to achieve”. ~ Dr Mary Eyram Ashinyo, Deputy Director Quality Assurance, Ghana Health Service
Using disease-specific and/or programme-specific resources, Haiti has been able to strengthen organised community groups to be more involved in addressing root causes of ill health, including poverty. This approach has not only helped CHWs to connect community members to many different types of essential health services, but also improved the general health and well-being of community members.
Along the same lines, Dr Jocelyne B. Pierre-Louis, Haiti’s Director responsible for the Directorate of Health Promotion and Environmental Protection (La Direction de la Promotion de la Santé et de la Protection de l’Environnement – DPSPE) at the Ministry of Public Health and Population (Ministère de la Santé Publique et de la Population – MSPP) ; mentioned that the country is experimenting with digitisation of the community health information system and linking it to the District Health Information System version 2 (DHIS2) platform.
Talking about Improving access to and use of community health data:
Liberia adheres to “a clear decentralisation policy that outlines how data should be shared and used for decision making from the community to the national level”, said Olasford Wiah, Director, National Community Health Programme at the Ministry of Health.
As reported, Liberia’s community-based information system has service-based tools to optimise workflow management for Community Health Assistants (CHAs) – used in a logical format starting with case detection, classification, treatment and referral. While these tools are kept at the community level to maintain an accurate record of CHAs’ work in their communities, this information can later be used by the CHAs and their supervisors, as well as community health committees for decision-making around health education and interventions, as needed.
Uganda, which currently pays a monthly allowance to community health workers who are called Village Health Teams (VHTs) are being provided with the right tools and supervision to collect good quality data that creates accountability. With a vision for a digitally empowered community health workforce, one of the community health reporting tools is being reviewed to facilitate a more streamlined process of data collection, and data transfer (following VHT home visits) into the national health information management system.
Remarking, Dr Upenytho George DuGuMm, Commissioner Health Services, Community Health in the Ministry of Health: “We embrace innovation in Uganda… rural connectivity is a challenge…we are using smart-paper technology to augment our data…we believe in a digitally enabled village health team…we will deploy a digital solution to coordinate care and household data that will feed into our national information system”.
Malawi has developed and rolling out the community health register, which is an integrated community health data collection tool for all community health interventions. Used in monitoring of essential care package, access and coverage, it supports the delivery of integrated community health services and serves as an accountability tool – as all sectors now accept the community health register as data for decision-making.
The importance of understanding community engagement for this process was emphasised. “We started with development of the community health indicators through engagement meetings with all our stakeholders “, Doreen Namagetsi Ali – Deputy Director for Preventive Health Services (Community Health) – recalled. In addition to harmonising the framework for community health information management system, Malawi’s Ministry of Health has identified some community health indicators that has now been integrated into the DHIS2.
In terms of financing community health services, ICHC 2021 was informed that beyond doing the math, financing community health is a political choice and requires political will, planning, and coordination.
However, costing countries’ community health strategy proved useful in providing evidence for engaging governments and other stakeholders, including the private sector – as an investment case for funding national community health services.
Using the ‘Community Health Planning and Costing Tool’, experiences from Burkina Faso, Zimbabwe and Afghanistandemonstrated that expanded access to community health services have direct impact in reducing maternal and under five mortality rates. Other than providing evidence for knowing the cost to achieve population coverage and impact, community health costing exercises also provided useful information on how efficiencies could be implemented.
Moreover, costing data also revealed that financing community health is not limited to financial incentives (allowances and salaries) of CHWs and supplies and equipment for service delivery. Fiscal resources for capacity building and other operational and recurring costs need to be considered also. As such, innovative funding (catalytic and coordinated investments) needed to support and sustain these other fundamental cost drivers is critical.
And as the ‘community’ becomes the central unit for health planning, tactical shift around financing is needed.
At the ICHC 2021, the call for multi-sectoral engagement at the community level was very loud. As Dr Wilson Were of WHO mentioned, “health is made from home and community and not from hospitals and clinics”. Therefore, the community must be the unit for intersection – multisectoral action: service provision across various domains (healthcare, education, agriculture, livelihood etc.), accountability and learning.
However, multi-sectoral action requires multi-sectoral planning and financing. Though many countries lay claim to understanding community-level multisectoral action, there is a sense that there is a huge know-do gap. This may not be unrelated to the ways and means of undertaking multisectoral action but also the capacity of doing so. If one may then ask: What are the competencies required to undertake multi-sectoral approaches at the community level?