"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
VISIONS OF THE FUTURE: Building Tomorrow's Community Health Workforce
As part of the ‘Symposium on CHWs and Their Contribution Towards the Sustainable Development Goals’ Makerere University (Uganda), CHW Central, Nottingham Trent University (UK), and World Vision are supporting a series of interviews with academic leaders and experts in international health development and delivery fields to provide their vision of the future of CHWs in a new light.
We will explore: How can CHWs create lasting impacts in the era of the Sustainable Development Goals? What steps need to be taken to scale up, empower, and create changes within in our global workforce?
The interviews will be posted on CHW Central over the next weeks as part of the preparation for the Symposium taking place from February 21st-23rd in Uganda
Read our second interview with Saul Guerrero below.
Saul Guerrero is the Director of International Nutrition Initiatives at Action Against Hunger USA. He has previously served as Director of Nutrition at Action Against Hunger UK. Prior to joining ACF he worked for Valid International supporting UN agencies, NGOs and national governments in the design, implementation and evaluation of community-based management of acute malnutrition interventions in over 16 countries in Africa and Asia. In 2012 he created the Coverage Monitoring Network (CMN), an inter-agency initiative to evaluate the reach of nutrition services worldwide. In 2015, he co-founded the No Wasted Lives initiative, a collaboration between UNICEF, the Children’s Investment Fund Foundation, ECHO, the UK’s Department for International Development and Action Against Hunger to accelerate the scale up of treatment for acute malnutrition. He is a founder of the Nutrition Subgroup of the CCM Task Force and currently serves as its co-chair.
Follow Saul on Twitter: @sauliguerrero
What is your vision of how ‘tomorrow’s CHWs’ will contribute to ending hunger in the SDGs era?
I think that the biggest challenges in achieving SDG2 on hunger will be similar to the challenges of achieving SDG3 on child mortality: equity and access. Children suffering from the most extreme form of malnutrition today are unlikely to be in a position to access care. Even in areas where treatment services are available, we know that only 1 in 3 use them, and we know it’s the same old barriers that get in the way (e.g. opportunity costs, distance, awareness, etc.). CHWs offer a unique opportunity to deliver services to prevent and treat the effects of hunger in a more accessible, truly community-based manner. And we are starting to see credible evidence that when nutrition services that have traditionally been delivered at health facilities are delivered by CHWs, the treatment coverage can double. So I see CHWs as the best opportunity that we have to offer credible, viable and sustainable answers to the question of universal coverage of hunger eradication or malnutrition management services.
What specific actions can CHWs undertake to contribute to this ambitious goal, and what do they need to achieve that?
I feel like there is two sets of things that CHWs can do better than anyone in terms of delivering SDG2: the first is taking nutrition counseling further into the communities. I feel that CHWs not only have the capacity to reach further geographically, but also socially, and this combination makes me more optimistic about what can be achieved by working with CHWs in terms of hunger reduction. The second is dealing with the consequences of hunger. CHWs already play a critical role in detecting malnutrition, but I believe that we can and should empower them to go further, in the way that we have done so with other conditions. If we succeed in empowering CHWs to treat malnutrition, they can not only become a critical part of achieving SDG2 – they can increase their already significant contribution to SDG3.
Should CHWs have a role in assessing/ensuring food security at family and community levels?
I think that CHWs already indirectly do so by monitoring the nutritional status of children, which we know acts as a proxy of a number of things including the food security status of the households in which they live. The question is, could they do more? I would say yes, but with a caveat; I think that CHWs can continue to help in supplying early warning mechanisms and other periodic food security assessments with critical data about communities that perhaps wouldn’t be included in these types of assessments. But the caveat is that if they are to do so we need to simplify the way in which they measure and report this information, to enable this additional activity to be added to their workload without compromising their overall performance and motivation.
What is the role of CHWs in ending hunger and especially severe acute malnutrition?
Their role in dealing with severe acute malnutrition is critical. In theory, CHWs are already expected to identify cases of severe acute malnutrition and refer them to nearby services. Although the evidence to demonstrate the impact of their contribution is limited, I think that there is sufficient anecdotal evidence to say that they are playing a role in many countries. The problem is that such referrals are only effective if people can act on the referral, if the services they are referred to are truly accessible to users. And I don’t think that is the case in most countries, which is why for other key child survival interventions CHWs go beyond just diagnosing and referring. There are a number of ongoing initiatives in Mali, Pakistan, Kenya and other countries that are assessing the effectiveness, cost-effectiveness and quality of care when severe acute malnutrition is treated by CHWs. And the results so far are incredibly positive: in Mali, they have doubled the coverage of treatment whilst delivering comparable results in every other area. At a time when the nutrition community is looking for ways of significantly improving the coverage of services, CHWs present some of the strongest alternatives available.
Given the future, climate change and increasing food market instability, how do you think that will influence CHWs work (scope, competencies, needs) in preventing and treating extreme hunger?
It safe to assume that two things are going to happen: the first is that extreme hunger and severe malnutrition is not going to go away, and is likely to increase, and the second is that more and more many of these cases will be found in growing urban areas. So more and more it will become virtually impossible for CHWs to address childhood illnesses effectively without addressing the nutritional status of children, in particular acute malnutrition. It will also mean that we will increasingly need to think of ways of delivering these services in urban environments. How we empower and support CHWs to deal with malnutrition, how do we train them to detect it and diagnose its severity, how we supply them in sparsely populated rural areas or heavily populated urban centres, these are all questions that are going to continue to be critical in years to come.
In what contexts do you see SAM treatment by CHWs as being of critical importance?
I would say that in the same contexts in which they are already critically important for other childhood services. In hard to reach areas, away from the usual catchment area of health facilities, in areas where women might find it more difficult to travel on their own. I think that the same lessons that have been learned already by other sectors about the complementary role that CHWs can play are only now starting to be fully understood by those dealing with the treatment of severe acute malnutrition, and the more we see CHWs taking on this task the more we are likely to see measurable change in terms of the impact on both nutrition and other childhood illnesses.
Any final thoughts and comments?
We need more evidence, more people exploring the contributions that CHWs can make in the treatment of acute malnutrition, not just for nutrition’s sake but as a critical part of also accelerating progress in child survival as a whole. We know that a child that is severely malnourished is 9 times more likely to die from infections, so if our CHWs are able to treat acute malnutrition they would immediately improve the chances of survival of the children they are already treating. But we need to pursue this more aggressively, and we need frontline service providers to show that this is both possible and desirable. We are reaching a tipping point in the discovery of what CHWs can do for hunger and malnutrition, but we need more people to see this potential and help generate the experiences necessary for things to really pivot.
All CHW Visions interviews have been conducted and compiled by Polly Walker.