National Community Health Worker Programs: Descriptions from Afghanistan to Zimbabwe

By: Henry B. Perry

Understanding country community health worker (CHW) programs has never been more important. Existing efforts to expand health services are insufficient and may leave one-third of the world’s population without universal health care (UHC) in 2030.¹ In 2019, the United Nations General Assembly passed a resolution noting that a “measurable acceleration is urgently needed” to reach the health-related targets of the SDGs by 2030.¹ A major expansion of commitment to nationwide CHW programs throughout the world, is necessary for such an acceleration to be achieved.

The Director-General of the World Health Organization, Dr. Tedros Adhanom Gebreyesus, has declared that “[T]here will be no UHC without PHC [primary health care].”³ Similarly, it is fair to say that in resource-constrained, high-mortality settings, there can be no PHC without CHWs. CHWs should be a pillar, if not the foundation, of PHC in rural and low-income settings.

My colleagues and I put together National Community Health Worker Programs: Descriptions from Afghanistan to Zimbabwe² to provide evidence on which to build and expand stronger community health worker programs. The case studies provide insights into details of existing national CHW programs – their structure, their achievements, and the challenges they face. The publication is timely given the rapidly growing interest not only in CHWs but in community health more broadly, in engaging communities for improving their own health, and in community-based surveillance for priority infectious disease outbreaks, especially now that we are in the midst of the COVID-19 pandemic and are highly likely to face similar pandemics in the future.

At long last, national CHW programs are garnering the attention, recognition, and scrutiny they deserve as an integral component of – or perhaps even the foundation for – primary health care.⁵ In 2018, the World Health Organization adopted the evidence-based Guideline on health policy and system support to optimize community health worker programmes.^6,7 In 2019, the World Health Assembly passed a historic, first-ever resolution on CHWs highlighting their role “to assure that universal health coverage and comprehensive health services reach difficult-to-access areas and vulnerable populations,” and their role in “advancing equitable access to safe, comprehensive health services.” The Assembly called upon Member States to “optimize community health worker programmes” as part of the global strategy to achieve universal health coverage by 2030 and to attain Sustainable Development Goal 3 (Ensure healthy lives and promote well-being for all at all ages).⁸

Yet, despite the overwhelming evidence of the effectiveness of CHW programs, country investments in national CHW programs are only a small fraction of what is being spent on PHC more broadly, and greater investment in PHC is needed.⁴ Furthermore, only 2.5% of global health donor assistance over the past decade has been devoted specifically to CHW programs, and two-thirds of this was for vertical programs related to HIV/AIDS, malaria, tuberculosis, reproductive health or family planning.

Although CHW programs have continued to expand, current information about national CHW programs is sparse and not easily accessed. In 2010, the Global Health Workforce Alliance and the World Health Organization released a comprehensive report on the global experience with national CHW programs, including a systematic review of literature on this topic.⁹ In 2014, a group of experts, including myself, produced a guide for developing and strengthening CHW programs at scale that drew heavily on previous experiences with CHW programs.¹⁰ In 2017, this same group of experts produced 13 case studies of national CHW programs.¹¹ National Community Health Worker Programs: Descriptions from Afghanistan to Zimbabwe updates and expands the 2017 case studies of national CHW programs. Each case study has at least one author who has personal in-country experience with the program being described. This compendium contains 29 case studies from the following countries: Afghanistan, Bangladesh, Brazil, Ethiopia, Ghana, Guatemala, India, Indonesia, Iran, Kenya, Liberia, Madagascar, Malawi, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Rwanda, Sierra Leone, South Africa, Tanzania, Thailand, Uganda, Zambia, and Zimbabwe.

Each case study follows a similar format: a one-page summary followed by detailed sections on historical context, health needs, health system structure, CHW program features, CHW scope of work, selection and training, support and supervision, incentives and remuneration, community role, linkages with the formal health system, program scale-up, monitoring and data use, financing, impact and challenges.

In addition to the case studies, an introductory chapter provides a history of national CHW programs and an overview of published literature on this topic. The concluding chapter includes observations about the case studies, commonly shared challenges, notable trends and achievements, a review of the push and pull factors affecting CHW program expansion and strengthening, new frontiers, the case for CHW program expansion and strengthening, and thoughts on the way forward.

Over the coming months, CHW Central will feature summaries of these country case studies with links to the fuller country descriptions included in the complete document. For those wanting to download the full resource, it can be accessed here at any time.

The new-found recognition of the importance of CHWs has been slow in coming. This often unsung category of health worker has struggled to achieve a coherent and consistent role in public health and in health systems. As a result, these programs have ended up too often as an underfunded afterthought. Despite nearly a century of experience – as the earliest CHW program was begun in the 1930s in China – health programs still struggle to define, employ, support, and marshal this critical cadre of health worker. However, as the compendium helps us to realize, Frankel’s prescient declaration in 1992 is even truer today:

There is no longer any place for discussion of whether CHWs can be key actors in achieving adequate health care. The question is how to achieve their potential.^{12, p. 1}

This newly released compendium is overdue and can contribute to the development of stronger and more effective programs all over the world. It makes information about what these programs have achieved available and it will help provide a fuller sense of their potential. Now is the time to prioritize the strengthening of national CHW programs so that there are adequate numbers of well-trained and well-supported CHWs. Millions of lives are at stake.

References

1.     UNGA. Resolution adopted by the General Assembly on 10 October 2019: Political declaration of the high-level meeting on universal health coverage. 2019. https://undocs.org/en/A/RES/74/2 (accessed 21 April 2020).

2.     Perry H, editor. National Community Health Programs: Descriptions from Afghanistan to Zimbabwe. Washington, DC, USA: United States Agency for International Development/Jhpiego; 2020.

3.     Gebreyesus T. Address by Dr. Tedros Adhanom Ghebreyesus, Director-General. 2019. http://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_3-en.pdf (accessed 20 April 2020).

4.     WHO. Countries must invest at least 1% more of GDP on primary health care to eliminate glaring coverage gaps. 2019. https://www.who.int/news-room/detail/22-09-2019-countries-must-invest-at-least-1-more-of-gdp-on-primary-health-care-to-eliminate-glaring-coverage-gaps (accessed 27 March 2020).

5.     Schneider H, Okello D, Lehmann U. The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014. Human resources for health 2016; 14(1): 65.

6.     WHO. WHO guideline on health policy and system support to optimize community health worker programmes. 2018. https://apps.who.int/iris/bitstream/handle/10665/275474/9789241550369-eng.pdf?ua=1 (accessed 21 April 2020).

7.     Cometto G, Ford N, Pfaffman-Zambruni J, et al. Health policy and system support to optimise community health worker programmes: an abridged WHO guideline. The Lancet Global Health 2018; 6(12): e1397-e404.

8.     World Health Assembly. Community health workers delivering primary health care: opportunities and challenges. 2019. https://apps.who.int/gb/ebwha/pdf_files/EB144/B144_R4-en.pdf (accessed 17 April 2020).

9.     Bhutta ZA, Lassi ZS, Pariyo G, Huicho L. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendation for Integration into National Health Systems. Geneva: World Health Organization and the Global Health Workforce Alliance; 2010.

10.  Perry H, Crigler L, Hodgins S. Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policy Makers. 2014. http://www.mchip.net/sites/default/files/mchipfiles/CHW_ReferenceGuide_sm.pdf (accessed 21 April 2020).

11.  Perry H, Zulliger R, Scott K, et al. Case Studies of Large-Scale Community Health Worker Programs: Examples from Afghanistan, Bangladesh, Brazil, Ethiopia, India, Indonesia, Iran, Nepal, Niger, Pakistan, Rwanda, Zambia, and Zimbabwe. 2017. https://www.mcsprogram.org/resource/case-studies-large-scale-community-health-worker-programs-2/?_sfm_resource_topic=community-health (accessed 17 April 2020).

12.  Frankel S. Overview. In: Frankel S, ed. The Community Health Worker: Effective Programmes for Developing Countries. Oxford, England: Oxford University Press; 1992: 1-61.

Author Affiliation

Henry B. Perry is a Senior Scientist at Johns Hopkins School of Public Health.