Community Health Workers Are Here – And They’re Ready for Change

Community health workers (CHWs) are on the frontline of any health system. From the United States, where navigators help people find health insurance, to Ethiopia where Community Health Extension Workers provide a full package of community health options during home visits, CHWs extend the reach of health services to marginalized, rural, or impoverished communities.

About ten years ago, I visited a group of CHWs in rural Madagascar, where less than 40 percent of households are within 5 kilometers of a health facility. I was in awe of these volunteers who walked for hours to secure supplies for their communities and took even longer zebu cart rides to help transport women to and from maternity care. These CHWs bravely faced challenges under difficult circumstances: paper records, limited training and supervision, and few commodities.

In March, I had the privilege of attending the Third International CHW Symposium in Monrovia, Liberia. The community health workers I met those many years ago would be amazed at the range of new financing, training, mentoring, data collection, diagnostic, and treatment options that are now available at the community level. At the same time, many challenges remain.

The Liberian Minister of Finance outlined the major issue succinctly in his keynote address, noting that “Hiring [government] staff…civil servants…is a difficult case to make. It requires significant commitment from the government and it’s critical to understand the return on investment from those new staff”– an understandable statement from the person whose job is to maintain Liberia’s fiscal health. While some studies have shown that every $1 in investment in CHWs provides a $10 return, we still have a way to go to build the evidence and work with ministries of health to make the case for CHWs in low- and middle-income countries.

In another conference session, we also heard that the debate has moved beyond whether to pay CHWs and on to determining which models are most appropriate for professionalization and compensating CHWs. We heard several proposals to do just this, including paying salaries and providing standardized training as they do in Ethiopia; robust monitoring, evaluation, compensation, and integrated training programs, as with Liberia; or even developing income-generating activities for CHWs such as in Kenya and Bangladesh.

Supporting the goal of professionalizing CHWs, of course, means following the evidence that CHWs are most effective when they have the tools necessary to upgrade their skills, the supervision to maintain high-quality services, and the data reporting tools to ensure high-quality monitoring of community health. In sessions throughout the week, presenters discussed many new digital tools to accomplish these goals, from smartphone app-based checklists, to remote supervision, to apps, such as CommCare, that support reporting to national health information systems, such as DHIS2. 

While these digital tools can provide support to workers in remote areas who may not have regular contact with the formal health system, connecting CHWs to, and integrating them with, the health system was also a major topic of conversation. Even Rwanda, which long maintained CHWs for specific health focus areas geared toward immunization or an infectious disease, presented their work to create what they call “polyvalent CHWs” that can provide a full community health integrated package, including basic family planning, malaria, maternal and child health, and health promotion services, in line with WHO guidelines.    

Integration also means including community perspectives in CHW activities; options include connecting CHWs to facilities through supervision from trained health workers and health committees that provide feedback from the community to the facility and provide guidance on outreach to CHWs.

In support of these new approaches, we heard a powerful call-and-response from the Liberian CHWs in attendance. It goes something like this:

Community Health Workers!

We Are Here!

For What?

For Change!

With new commitments from governments, partners, and civil society to compensate, professionalize, formalize, and connect CHWs, change is possible – change that improves health and wellbeing for millions of people who currently cannot access health services. I’m proud to support this change through RTI International’s partnerships with National Ministries of Health and local organizations in Senegal, Guinea, and the Philippines to bring health information and services to underserved communities.

Read more about our work in Global Health.