Quote of the month: “We are convinced that the truth stops at what we have learned in our schools; we are afraid to empower communities and lose importance… we just prefer to study the community approach and talk about it. But we do not want to implement it.”
Simon Kabore (HIFA Member, Directeur Exécutif du Réseau Accès aux Médicaments Essentiels, Burkina Faso), translated from a posting on the HIFA-French forum
Earlier this year, HIFA hosted a sponsored thematic discussion on Community Health Workers (CHWs) to identify their needs and how they could be better supported. The findings painted a stark picture of a workforce unsupported and under-served in almost every respect: training and supervision, access to healthcare information; remuneration; equipment, medicines, mobile phones/computers. In addition, CHWs are often asked to carry out a wide range and ever-increasing number of tasks, but often without the appropriate facilities to hand.
Respect, recognition, empowerment
Perhaps unsurprisingly, the thematic discussion found that CHWs’ most pressing need concerns something much more fundamental, and which resonates with our ‘Quote of the Month’: respect and recognition from community leaders and health professionals. As Simon Kabore argues, a step-change is needed in the relationship between CHWs and health leaders. The empowerment of CHWs to manage healthcare within their communities and call on their governments to develop policies that recognize and support the health needs of communities is long overdue.
For HIFA members Armand Nkwescheu and Kavita Bhatia, the road to respect and recognition starts with listening. Armand, a public health consultant in Cameroon, felt that there had been a failure to learn from the community, adding, “health professionals always behave like communities are not knowledgeable enough to make choices or take decisions”. Kavita, an India-based independent researcher, also emphasised the importance not only to listen to CHWs but also to ‘formalise’ their perspectives within research. She was in no doubt: CHWs “deserve a hefty dose of respect from us for navigating unknown territories of language, knowledge and activity while living in the poorest communities”.
Connecting ASHAs and CHWs with the global HIFA community
As someone who has worked with CHWs and their communities for over three decades, Kavita also felt that the implications of empowering CHWs went far beyond influencing government policy. Responding to Simon Kabore’s message, she envisaged a future where, “community-based control over health care and policy, will extend to control over national and global economics, politics, environment and gender equations”. She may also have laid some of the groundwork, having helped to establish an active link between HIFA members and the WhatsApp group of CHWs/ASHAs [Accredited Social Health Activists] in India, the first example of regular cross-communication between HIFA and an external community. This was announced in July along with another WhatsApp-HIFA link for CHWs in Uganda by HIFA Member, Carol Namata, an environmental health officer at Uganda’s Makerere University. According to Carol, “coordinators, mobilisers and health workers have been using the group as one of the ways to conduct mobilization of CHWs to participate in different activities such as training sessions organised in the different communities”. A third WhatsApp group of ASHAs and CHWs, again in India, has been started by HIFA member Sunanda Reddy. Connecting CHWs with the wider global HIFA community is now a strategic priority for the HIFA Project on Community Health Workers.
Kavita has offered to support any HIFA members wishing to set up a CHW WhatsApp group and, looking ahead, other low- and middle-income countries (LMICs) now have the opportunity to build upon this innovative model to evolve a global network of CHWs/ASHAs, enhancing their collective voice. As Kavita noted in her response to Simon Kabore’s message, “We cannot cap the lid once we set free the genie of ‘community management of health policies’. Is the world ready?”
Towards Universal Health Coverage
Hopefully, the answer to that question is ‘yes’ because CHWs certainly are ready. During July, the HIFA forum reported on CHWs in Burkina Faso, diagnosing and treating malaria in children, “demonstrating excellent adherence to test results and treatment guidelines, suggesting they can be deployed for screen and treat approaches of malaria in pregnancy.” Progress towards the elimination of lymphatic filariasis was attributed in part to “community health volunteers (CHV) or community drug distributors (CDD) [who] play a major role in delivering MDA [mass drug administration] medicines and achieve maximum treatment coverage” (HIFA member, Chandrakant R Revankar, USA). July also saw the publication by CHW Central of ‘CHW Reference Guide Summary’, which provides an overview of the vital contribution which CHWs make to healthcare delivery across a range of settings worldwide.
Yet CHWs remain an unsupported and underserved workforce. Given the workplan which the WHO has evolved to meet the Sustainable Development Goals, it’s more important than ever that health leaders listen, learn, respect, recognize and, most importantly, empower CHWs. As HIFA member Armand Nkwescheu stated in July, "Communities want health professionals (community health workers) who have time to sit down and help them…not just promote solutions ill adapted to their environment as the only way of doing things." Armand’s words directly reflect the thinking behind the proposed healthcare provider-patient relationship at the heart of the WHO framework for Integrated People-Centred Healthcare Services (IPCHS). Implementing IPCHS will be a key driver for delivering Universal Health Coverage (UHC) by 2030, a priority for the recently-elected WHO-DG. Yet In 2016, WHO reported a projected shortage of 18 million health workers mostly in low- and lower-middle-income countries, between now and 2030. Reducing the shortfall alone won’t be sufficient to deliver UHC – but an empowered community health workforce, “navigating unknown territories of language, knowledge and activity while living in the poorest communities” will determine success or failure.
Note 1: In July 2017 we exchanged 267 messages from 104 members in 35 countries (Bangladesh, Cameroon, Canada, Congo-Brazzaville, Croatia, Denmark, France, Germany, Ghana, Honduras, Hong Kong, India, Iran, Ireland, Kenya, Liberia, Malawi, Mali, Mongolia, Myanmar, Nepal, New Zealand, Nigeria, Pakistan, Philippines, Rwanda, Singapore, South Africa, Sudan, Switzerland, Tanzania, Uganda, USA, Venezuela, Zambia).
Note 2: As this month's blog shows, increasing and strengthening the links between Community Health Workers (CHWs) can make a huge difference. It also helps HIFA to build a detailed picture of CHWs' needs. If you are a Community Health Worker (CHW), work with or support CHWs, please join HIFA today. Link up with your colleagues, share your experiences and help us to meet CHWs'needs and improve health in communities across the world.
Martin Carroll was previously Head of the International Department at the British Medical Association, London UK, and has worked on issues affecting health in LMICs since 2003. He represented the BMA on the HIFA Steering Group from 2008-16 and is now an independent adviser to the group. Martin is a member of two HIFA working groups: Multilingualism and Evaluating Impact of Healthcare Information.