By: Emily Bensen, Integrate Health
October 31, 2018
Last week, I attended the Global Conference on Primary Health Care in Astana, Kazakhstan. I was there to represent my colleagues who work in the small West African nation of Togo to strengthen primary health care systems. Our model integrates professional community health workers (CHWs) with improved care in public clinics, providing high-quality and cost-effective care to neglected populations. The conference provided a unique opportunity to connect with and learn from many other organizations and governments working to achieve health for all. At Integrate Health, we collaborate with others to constantly improve the care we provide to patients. We rely on adopting successful solutions from other places, and adapting them to our setting.
CHW programs have existed for decades, and yet although the promise of CHWs has been well documented, high-impact programs are scarce, and often left un-replicated. This dilemma requires recommendations that governments and civil society around the world can refer to when building community health systems, to effectively “adopt” best practices and “adapt” to their setting.
Back in Astana at the Global Conference on Primary Health Care, the World Health Organization (WHO), UNICEF, and AFRO Health Systems and Services Department, unveiled these long-awaited recommendations: the WHO guideline on policy and system support for optimizing community health worker programmes. Stakeholders from civil society, governments, and the private sector participated in the panel discussion. WHO first introduced the guidelines, then participants heard diverse perspectives from government, civil society, and importantly, a community health worker herself, on the potential impact of the guidelines in achieving the newly adopted Astana Declaration and health for all.
The goal of the WHO guidelines is to provide member states with a policy guide to strengthen the design and ultimately the results of CHW programs, by both reinforcing evidence that has been long-known, as well as breaking ground in the political discourse. The guideline creation process was a joint effort of over 100 collaborators who participated in literature reviews, stakeholder surveys, and document drafting.
The guideline contains 15 policy recommendations centering around three main categories. The first category, selecting, training and certifying CHWs, reinforces the evidence that CHWs should be nominated by their community and meet minimum educational requirements. It also speaks to a competency-based formal certificate upon training completion, among other training recommendations. The second category relates to the management and supervision of CHWs, indicating that CHWs require ongoing supervision from a dedicated supervisor, a financial package commensurate with their job demands, and potential for career pathways. Finally, the third category speaks to the integration of CHW programs into the broader health system, including target population size and supply chain recommendations.
While listening to Dr. Giorgio Cometto, WHO Heath Workforce Department Coordinator, present the guidelines, my mind traveled back to Togo. Integrate Health and the Government of Togo are already replicating some of the guidelines, for example, ensuring dedicated supervision of CHWs. In this case, the guidelines provide us with affirmation and further evidence that this practice is effective. Integrate Health employs one full-time supervisor for every 25-30 CHWs, who receive at least one supervision visit per month.
In other cases, such as the potential for career pathways, Integrate Health has room to grow. In these cases, the guidelines provide further motivation and direction to continue strengthening our programs. We currently have strategies for recognizing high performance by CHWs, such as promoting them to lead the CHW team in their community, or be a trainer for new cohorts of CHWs. We continue to plan for job development over the long term for our CHWs, to ensure that they are motivated and properly compensated after five years, ten years, and beyond.
During the discussion, a special emphasis was made on the financial resources necessary for a CHW program. “Do not implement them under the false pretense that you can do it with a shoestring budget,” said Dr. Cometto. “We need to plan the resources necessary.”
After the guidelines were revealed, a diverse panel responded to them, and engaged the participants in a lively discussion around what opportunities are presented by the guidelines. Ruth Tarr, a Community Health Assistant in the Liberian National Community Health Assistant program, gave a moving, first-hand testimony of the importance of the 15 recommendations. “The government understands the importance of my work, and makes sure I’m trained, supplied, supervised, and paid,” she said. “Because I am paid, I feel proud. I’m saving for my daughter’s education and my own education.”
We heard from UNICEF’s David Hipgrade on why UNICEF values CHWs and supports the guidelines: “Health starts at home. The hospital is just for repairs. CHWs empower communities to produce health.” USAID Deputy Assistant Administrator Kerry Pelzman shared that the guidelines would help USAID better collaborate with partners following a standardized yet adaptable platform. Professor Mengesha Admassu, Executive Director of the International Institute for Primary Health Care in Ethiopia, shared lessons from Ethiopia’s national CHW program, and announced improvements they are initiating such as career advancement for their cadre of CHWs. Finally, Raj Panjabi, CEO of Last Mile Health, discussed the national community health extension worker program in Liberia that Ruth Tarr is part of and encouraged country governments to join the movement. “If you want to modernize your community health workforce, you are not alone,” he explained. “And, the guidelines are a great resource.”
As Dr. Tedros, WHO Director General, said earlier in the Astana conference, these guidelines are just the beginning of the journey. We, collectively, need as much energy and commitment as possible from all partners to harness this momentum and continue with our collective agenda to ensure high-quality, equitable healthcare for all.
Emily Bensen is the Deputy Director at Integrate Health (www.integratehealth.org), a growing global health non-profit whose mission is to end preventable deaths in neglected communities. IH partners with the government to integrate professional community health workers with improved care in public clinics to transform the health of thousands of people in Togo, West Africa.