Community Health Workers: Forgotten No More

They crisscross the villages, urban settlements, hills, valleys and planes, sometimes on foot, sometimes on bicycles.

They wear T-shirts with health messages. They carry a bag containing tablets, syrups and health information materials. They mobilize communities to go for vaccination. They distribute mosquito nets. They supply contraceptives. They accompany women to ante-natal clinics and delivery rooms and ensure that they deliver safely.

They go by various names such as Community Health Workers (CHWs), Community Health Volunteers, madaktari wa kijiji (village “doctors”), and so on.

For a long time they have never been a priority agenda for the public health sector and they are rarely recognized or paid for the work they do. This is, however, bound to change. Key players in health including WHO, Amref Health Africa and IntraHealth International have teamed up to launch a global-wide campaign to have CHWs formally employed and given benefits as any other civil servants. As a result, there were mentions and discussions on CHWs in several sessions of the 70th World Health Assembly.

The incoming WHO Director-General, Dr Tedros Adhanom Ghebreyesus, a former Minister of Health in Ethiopia, promised to strengthen primary health care which includes revamping the CHW agenda. Ethiopia has led the way in showing how best CHWs can be used by the health system.

If CHWs were to do their work as expected, there would be tremendous improvement in prevention of common diseases such as diarrhea, malaria and pneumonia which are still the main killers of children. They would also help a lot in preventing deaths of women from pregnancy-related causes. HIV prevention and care would reach millions through the work of their hands. In fact, it is now acknowledged internationally that Ebola would not have had the toll it did in West Africa if the community health workers were available to do their work.

As it is now, however, these important workers are not available to everyone who needs their services and as such the many benefits they bring to healthcare are not being realized. But note that the lack of community health workers is not caused by a deficit of those who want to be trained to do the work. In fact, many people have been trained to be CHWs.

The problem is attrition of those who have been recruited and trained. Attrition rates for CHWs are highest compared to any other cadre of health workers. The rate is as high as 77% in some communities – meaning that out of every 10 people recruited and trained, only two remain to do the work.

Although there may be other minor reasons for attrition of CHWs, the greatest reason is that they are not paid for the work they do. The issue of remuneration of CHWs remains largely unresolved among key players. On the one extreme there are stakeholders who believe that CHWs should be purely volunteers and that their motivation should come from personal satisfaction and that they should be happy for making their communities better places to live.

They believe that by volunteering, CHWs pay allegiance to no other institution but their communities and that this makes them achieve better results for the community. It is extrapolated that in such communities individuals will in return appreciate CHWs including providing them material support.

On the other extreme, there are stakeholders who believe that CHWs play a key role in health and that the functions must be structured, supervised, monitored and remunerated by Ministries of Health with a package commensurate to their efforts. They believe that CHWs should be formally employed and the jobs should come with benefits. In addition, they believe that CHWs must be provided with the means to do their work including supplies and travel logistics.

In the middle ground are organisations and governments that believe in a mixture of volunteerism and self-sustaining financing for CHWs. In this model, the CHW may sell family planning and other commodities to raise funds for their work. Further, CHW groups can be supported to form cooperatives and have access to loans to start income generating activities to support their work. Reimbursement of CHWs for expenses incurred in the course of doing their work is also encouraged and where possible stipends are recommended.

Despite the convictions of these various players, scientific studies show that the better model is the one for hiring and paying CHWs a salary like any other civil servant. This scientific fact is not in dispute. Studies show that volunteer CHWs have twice the attrition rates as those who receive some form of remuneration.

Remuneration as a key factor in attrition of CHWs is well demonstrated when unmarried people are recruited and trained as volunteer CHWs. As soon as they marry, such CHWs abandon their duties and look for paid employment to support their families. Where volunteer CHWs choose to continue to play their roles, they do it as part-time engagement, giving more time to paid employment. Many times their families disapprove of these extra voluntary duties and within no time they drop out. In instances where CHWs are supported to generate their own resources from enterprises, many fail for lack of entrepreneurial skills. Those who succeed may become more interested in the business than in providing voluntary services.
In reality, attrition of CHWs means a lack of continuity in the relationships established among a CHW, community, and health system. This destabilizes progress in achieving health outcomes. Further, considerable investments are made in identifying, screening, selecting, and training the CHW and costs for this rise with high attrition rates. When CHWs leave, the opportunity is lost to build on their experiences and make community work more effective.

It is these evidence-based realities that have made organizations such as Amref Health Africa, WHO and IntraHealth International embark on a campaign to integrate and remunerate CHWs like the other health workers. Governments will have to develop CHW strategies that take this approach into account. Where necessary, laws will need to be changed to accommodate CHW civil servants. It is also hoped that the donor community, other NGOs and the private sector will support this agenda since it could be the shortcut to achieving global health security and universal health coverage.
Dr Joachim Osur is the Director of Regional Offices and Field Offices, Amref Health Africa