A conversation with: Kingsley Chikaphupha, Reach Trust (Malawi) and co-chair of the TWG on CHWs, and Maryse Kok, KIT Royal Tropical Institute (The Netherlands)
Forty years after Alma Ata, 2018 was a remarkable year regarding the promotion of health for all. The Global Conference on Primary Health Care, co-hosted by the government of Kazakhstan, WHO and UNICEF, was held in Astana, Kazakhstan on October 25 and 26. A new declaration on primary health care, aligned with the sustainable developments goals, was made. During the same conference, WHO launched a new guideline on health policy and system support to optimize community health workers programmes. Health Systems Global (HSG) also held its 5th Global Symposium on Health Systems Research in Liverpool, UK in October 2018. Common across all these events was the call that the provision of universal primary health care should be at the heart of sustainable health systems.
During the 5th HSG symposium, the network’s thematic working group on supporting and strengthening the role of community health workers in health system development (in short, the HSG CHW TWG) organized a participatory session to share experiences from CHW research and practice, to strengthen leadership and management of CHW programmes across the globe.
Multi-sectoral action, quality and fragility in CHW programming
Discussions centered around five themes: 1) CHWs’ roles in responding to new health challenges – aging and non-communicable diseases; 2) the optimization of CHWs’ intermediary role between health systems and communities; 3) challenges in supporting CHWs to promote quality services; 4) CHWs in fragile or conflict-affected contexts; and 5) knowledge transmission and scale-up of CHW pilot studies and programmes.
The discussions of these five themes, which took place through the world café format, highlighted the importance of multi-sectoral action to improve and scale up CHW programmes. Governments – not only ministries of health, but also ministries of finance, education, local government, and public service – civil society, and private sector are often involved in CHW programming, but programme designs are seldom harmonized among stakeholders; more collaboration would contribute to a better situation for CHWs and their clients. Ministries of health could take the lead in multi-sectoral collaboration, and communities and CHWs should have a voice in policy development and priority setting. These are ambitious, process-related, recommendations, which come on top of challenging decisions to be made regarding selecting, training, and certifying CHWs; managing and supervising CHWs; and integration of CHWs into and support by health systems and communities, which are the main foci of the WHO CHW guideline. The WHO also recognizes the importance of linking CHW initiatives and programmes to national education, labour and community development sectoral or sub-sectoral policies and frameworks (page 17, 71), and mentions the private sector as employers of CHWs.
Another major theme in the discussions during the HSG conference was quality of community health services. Currently, in many countries, programming and research initiatives are looking at how to improve quality, which is broader (and thus even more complex) than individual CHW performance. The new WHO CHW guideline provides a welcome contribution here. Improving quality is not only about having the systems in place for the selection, training, certification, supervision and incentivising CHWs, it is also about considering the role of CHWs in relation to other health workers, the general health system, and existing community structures in an appropriate manner (page 12), and the values, relationships and power of these different actors. Yes, another ambitious recommendation!
Lastly, we would like to highlight the emerging interest and need to know more about how CHWs could be best supported in fragile settings. It is known that CHWs play a critical role in serving populations in settings affected by conflict, natural disaster, disease outbreak and other emergencies, but practical insights are needed that could be useful for policy makers and programme managers who need to rapidly respond in those situations. While the WHO rightly points to the importance of safe and decent working conditions of CHWs in conflict-affected settings and chronic complex emergencies, more evidence is needed on how CHW programmes can optimally contribute to health for all in those settings.
We want to join the WHO, governments, development partners, civil society organisations, private sector and donors in their commitment to strengthen primary health care and community health systems. Hereby, we should commit to consider the question that was raised during our session in the HSG symposium: How can we work to move from asking what CHWs can do for the health system, to engage them with the unique perspectives they bring and also ask how can we support CHWs? This question is relevant in gaining further evidence on how CHW programmes can be most effective as well as using the existing evidence for building and sustaining integrated CHW programmes at country level.