A conversation with: Ateeb Ahmad Parray¹⁻², David Musoke²⁻³, and Kingsley Chikaphupha²⁻⁴
“One of the primary themes that emerged from the symposium was the importance of quality of care over coverage.”
The 3rd International Community Health Workers (CHW) Symposium was held in Monrovia, Liberia from March 20-24, 2023, under the theme “Advancing Community Health Worker Programs to Build Resilient and Reputable Health Systems that Would Accelerate Primary Health Care for Universal Health Coverage.” It brought together over 700 participants from over 46 countries including CHWs, policymakers, practitioners, researchers, and advocates to share experiences, learn from each other, and strategize about what steps can be taken to improve the performance and impact of community health workers.
One of the primary themes that emerged from the symposium was the importance of quality of care over coverage. This sentiment was echoed by CHW participants and is supported by a growing body of scientific evidence, with studies showing that quality of care is crucial for improving health outcomes. Improving the quality of primary healthcare services could save millions of lives globally, making CHW programs that prioritize quality of care over quantity of services provided more likely to be successful in improving health outcomes.
Inadequate funding at every level was identified as a major challenge facing CHW programs. This lack of funding can lead to a range of issues, including decreased motivation and performance among CHWs. Inadequate funding is one of the primary barriers to scaling up CHW programs in low- and middle-income countries. Investment in CHW programs is critical for their success and for improving health outcomes in these countries. In response to this, during the symposium, the Government of Liberia committed $1.8 million USD to their national CHW program.
In addition, the paradox of the “payment for performance model” (P4P) was discussed, wherein CHW programs are often expected to show performance to receive compensation, but they cannot perform without adequate funds. This underscores the importance of ensuring that CHW programs are well-funded and supported.
Supportive supervision was also identified as a challenge in hard-to-reach areas. Scientific evidence supports the importance of supportive supervision for improving CHW performance and ensuring the quality of care provided. The lack of adequate supervision in hard-to-reach areas can lead to absenteeism and decreased motivation among CHWs, negatively impacting the quality of care provided.
“CHW programs should be included in the planning, prioritization and operationalization of such national pillars as the HRH strategy, the digital health plans and many more.”
Several country-specific case studies were presented during the symposium. For example, the South Sudan context revealed that the trainings of CHWs are often too short, which can affect the ability of CHWs to provide high-quality care. Lack of universal CHW policies was also identified as a challenge, with some CHWs suggesting that policies should be harmonized and made universal to ensure consistency and quality of care across different programs and partners. This augurs well and is in line with observations by the World Health Organisation in 2018, which noted; “Across and within nations, there are disparities in the assistance given to CHWs and in how they are integrated into communities and health systems; Good-practice examples are not always imitated, and policy choices with stronger evidence of efficacy are not always chosen.”
In line with this, institutionalization of CHW programs emerged as a big theme during the symposium. A need for governments to ensure that CHW systems are owned and adequately financed i.e., ensuring that governments’ visions are clear and that CHW programs should be integrated into policies was emphasized. For example, CHW programs should be included in the planning, prioritization and operationalization of such national pillars as the human resources for health (HRH) strategy, the digital health plans and many more. Speakers echoed sentiments that CHW programs MUST be tabled at the budget and policy level, reminding policymakers and politicians that leadership and political will are key to achieve institutionalization of CHW programs.
Based on the priorities outlined in the Post-Ebola Investment Plan for Building a Resilient Health System, the Government of Liberia created a roadmap for rebuilding a resilient health system. The aim of the roadmap is to provide health security to all people, reduce risks due to epidemics and other health threats, accelerate progress towards universal health coverage, and create the National Community Health Assistant (CHA) Program as part of a “fit for purpose” health workforce and contribution towards sustained community engagement. Thus, with support from partners, the Vice President of Liberia, Jewel Cianeh Taylor, introduced the new ten-year CHW strategic policy 2023-2032. The vision of this new policy is to expand access and delivery of high-quality services to all communities through a government-managed community health workforce. This workforce will contribute to the reduction of morbidity and mortality through the provision of a high-quality, cost-effective standardized essential package of community health services and to mitigate potential public health risks in all communities.
“Measurement should be locally driven, which can inform and empower communities.”
The symposium also emphasized the importance of community engagement and feedback. Scientific evidence supports the importance of community engagement for improving health outcomes, particularly for maternal and child health. As one Liberian CHW mentioned, “Measurement should be locally driven, which can inform and empower communities.” This means that CHWs should work closely with communities to identify health priorities and develop appropriate interventions. Community feedback should also be incorporated into program planning, and investment in monitoring and evaluation is crucial. Involving communities in program planning and evaluation can help to ensure that CHW programs are effective and meet the needs of the communities they serve.
The symposium was marked by in-depth discourse on the pressing need to bolster health information systems and adopt data-driven methodologies to monitor and evaluate CHW programs. Eminent speakers, policymakers, and practitioners alike unanimously emphasized the criticality of integrating CHWs more robustly into existing healthcare ecosystems – particularly in contexts where these professionals function informally or are not formally recognized. The nuanced discussions dove deep into strategies for aligning disparate stakeholders towards this common goal while also factoring in resource constraints, cultural nuances, and ethical considerations amongst other pertinent factors that play a crucial role in determining programmatic effectiveness.
“…our health systems are often focused on solving disease rather than achieving ‘health.’”
Another interesting point that emerged from the symposium was that our health systems are often focused on solving disease rather than achieving “health.” This underscores the importance of a holistic approach to healthcare that considers social determinants of health, such as poverty, education, and access to clean water and sanitation. CHWs can play a crucial role in addressing these broader health issues by working closely with communities to identify and address the root causes of health problems.
These lessons can be applied globally to improve the performance and impact of community health workers, especially in low-resource settings where they play a critical role in improving access to primary healthcare services and reducing health disparities in marginalized communities. The event culminated in the Liberian Minister of Health launching the “Monrovia Call To Action,” an evidence-based mutual commitment to fund, scale, and strengthen community health programs as an integral part of primary health care for realizing universal health coverage.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, U.S.A.
- Community Health Workers Thematic Working Group of Health Systems Global
- Makerere University School of Public Health, Makerere University, Kampala, Uganda
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi