How Collective Action Will Amplify Impact of Community Health Worker Models

We know that large-scale social change is a team sport—no one social entrepreneur can create a new status quo on her own. This reality is evident in the global effort to achieve universal health coverage, a promise of Sustainable Development Goal 3 to, “ensure healthy lives and promote well-being for all at all ages”. Health for all will only be achieved through collective action, so today we celebrate one collaborative effort. Recently six entrepreneurial community health organizations—Hope Through Health, Possible, Muso, Last Mile Health, Partners in Health, and Living Goods—have reviewed research from the past and opened up their own practices to synthesize what works best in community health worker models.

Community health workers are not new. Since at least the 1950s, the potential of community health workers has been evident, with different models flourishing in different contexts—from “barefoot doctors” of the Chinese Cultural Revolution, to the Last Mile Health-trained frontline health workers who work in remote villages of Liberia today.

Large-scale and national CHW programs though have rarely duplicated the success of smaller, targeted community-based interventions. With the African Union calling for 2 million more CHW employed by 2020 to close Africa’s healthcare gap, now is the time to take a close look at what works in the field. Twenty-three countries have adopted principles for institutionalizing community health, and CHWs are highlighted as a key strategy by the World Health Organization. Practitioner Expertise to Optimize Community Health Systems is no blueprint for a one-size-fits-all approach. “Implementation of high-performing CHW programs requires that design principles and operational guidelines be approached as a series of flexible tools,” write the authors.

This collective process of reflection has resulted in a set of 8 “design principles that drive programmatic quality and are debated or not commonly found in programs across the globe.”

• Accredited: CHWs must prove their competency before carrying out there work.
• Accessible: point of care user fees should be avoided when possible.
• Proactive: For active disease surveillance, CHWs go door-to-door looking for sick patients and providing training on how to identify danger signs and quickly contact a CHW.
• Continuously Trained: Continuing medical education is not only available to but required of CHWs.
• Supported by a Dedicated Supervisor: CHWs benefit from regular assessment of patient experience and one-on-one coaching.
• Paid: CHWs are compensated competitively.
• Part of a Strong Health System: CHW deployment is accompanied by investments to increase the capacity, accessibility, and quality of the primary care facilities.
• Part of Data Feedback Loops: CHWs report all data to public-sector monitoring and evaluation systems which improves programs and CHW performance.

“Further articulating and universalizing an operationally specific quality standard demands a broader coalition,” write the authors. The impact of community health workers has been uneven over the course of several decades, and capturing the shared experience of a network of doers is a great expression of what we may see with the forthcoming Community Health Academy. Universal global health coverage is a lofty goal, and it demands radical cooperation. We celebrate this remarkable effort to co-learn, sharing best practice and admitting mistakes, in order to advance health for all.