By: Henry B. Perry
Henry B. Perry, III, MD, PhD, MPH is a Senior Associate in the Health Systems Program of the Department of International Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. He joined Hopkins in 2009; his career prior to that has included stints working with Future Generations, Curamericas Global, ICDDR,B, the BASICS Project in Bangladesh, and Hôpital Albert Schweitzer in Haiti. Dr. Perry has a formal background in medicine (including general surgery), public health, sociology and anthropology. He conducts research on community-based primary health care.
This feature was originally shared via email on December 6, 2024.
The Lancet Commission Global Health 2050
There has been one major notable publication that I am aware of that seems worthy of calling your attention to, that gives new insights into the importance of primary health care (PHC) and community health. This is The Lancet Commission Paper published on 14 October 2024 entitled “Global Health 2050: the path to halving premature death by mid-century” (linked). This is a follow-on to their seminal 2013 Lancet Commission Paper entitled “Global Health 2035: a world converging within a generation.”
I want to take this opportunity to comment on this important major piece of work – 54 pages long, featuring 310 references and an accompanying website containing an appendix of 108 pages together with briefings and a video of the launch of the report at the 2024 World Health Assembly in Berlin in October. The Commission was led by Lawrence Summers and Dean Jamison along with a host of eminent global health leaders.
This paper identifies 15 priority conditions — eight infection and maternal/child health (MCH) conditions and seven non-communicable disease (NCD) and injury-related conditions – that countries should give priority to in order to reduce by 50 percent the probability of a premature death (a death before the age of 70) compared to 2019 levels.
Here are the 15 priority conditions affecting premature mortality:
| Infection and MCH priority conditions | NCD and injury-related conditions |
| ● Childhood cluster diseases: comprising four vaccine-preventable illnesses (whooping cough, diphtheria, measles, and tetanus). ● Diarrheal diseases ● HIV/AIDS ● Lower respiratory tract infections ● Malaria ● Maternal conditions ● Neonatal conditions ● Tuberculosis |
● Atherosclerotic cardiovascular diseases ● Diabetes ● Hemorrhagic stroke ● Infection-related NCDs (stomach cancer, liver cancer, cervical cancer, rheumatic heart disease, and cirrhosis secondary to hepatitis virus) ● Road injury ● Suicide ● Tobacco-related NCDs (chronic obstructive pulmonary disease and cancers of the mouth and oropharynx, larynx, trachea, bronchus and lung) |
Importantly, the Commission included other conditions in their analysis that need attention, but which fall outside of the above 15 conditions because addressing them would not lower mortality – in essence conditions with long-term morbidity consequences or conditions that need and deserve care even though addressing them will not have any consequences on mortality rates. Here are other priority conditions that need addressing that do not prevent premature mortality:
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The paper is written from a health economics perspective – making the case for why individual countries and the global community writ large should give priority to investing the funds needed to address the priority conditions and how such funds might be obtained.
Of particular importance to me is the limited attention that the Commission gives to how countries might actually go about addressing these conditions. Nonetheless, in Table 8 they state that community-based primary health care teams would be able to address all the infection and MCH priority conditions, some of the NCD and injury-related conditions (basic drug therapy for hypertension and diabetes as well as management of chronic obstructive lung disease), along with the other important conditions shown above that do not have the same impact on mortality (mental health conditions, family planning, school-aged child and adolescent development, custodial and palliative care, public health functions, and primary care functions).
These recommendations are extremely important provided how little emphasis is given to the importance of community-based primary health care and the need to strengthen it for accelerating improvements in global health.
The term “community health worker” is not used specifically – but the Commission does highlight the importance of “empanelment (ie, assignment of patients to clinics based on geographical proximity), provision of a manageable set of preventive, chronic, and acute services across the lifespan at little or no out-of-pocket cost to patients, and use of community outreach workers who are in regular contact with local households to assess priority health needs and connect individuals to services.” p. 22
The Commission estimates that low-income countries would need to expand their health spending by one percent of GDP to scale up these interventions to full coverage, and lower-middle-income countries would need to expand their health spending by two percent of their GDP.
The paper presents a detailed discussion on the fiscal policies that countries would need to undertake in order to come up with the needed funds. Of course, one of many changes that would be needed would be limiting government expenditures on “high-cost, low-value-for money health interventions,” including “high-cost technologies (e.g., chronic hemodialysis, novel cancer drugs)” [p. 26]. The Commission strategically avoids using the term higher-level hospitals and other forms of tertiary care, but that is obviously what they are referring to.
A good deal of attention is given to issues arising from the COVID-19 pandemic and the need to prepare for the next global pandemic. They report the current status of research about the risk of a future pandemic, and state that there is a greater than 20 percent probability of a pandemic in the next 20 years that will kill at least 25 million people [p. 32]. Therefore, the potential contribution of community-based primary health care and community health workers to detection and control of infectious disease outbreaks is critically important.
From my standpoint, as a passionate promoter of community health workers, community engagement, and primary health care, this paper is a resounding affirmation of the value of investing in community-based primary health care.
The Community Health Delivery Partnership (CHDP)
The need for the global health community to give more focused attention to communities and community-based service delivery has resulted in a dialogue among all the major actors in global health over the past several years. This led to the global launch in October 2023 at the World Health Summit in Berlin of what is now called the Community Health Delivery Partnership. The CHDP is comprised of national, regional, and global partners, including ministries of health and other relevant ministries, civil society organizations, community health workers from designated CHDP countries, regional bodies such as the African Union, Africa CDC, and donors and multilateral initiatives including the Bill and Melinda Gates Foundation, CORE Group, Gavi, the Vaccine Alliance, Global Financing Facility, The Global Fund to Fight AIDS, Tuberculosis and Malaria, International Federation of Red Cross and Red Crescent Societies, United States Agency for International Development, U.S. President’s Malaria Initiative, UNICEF, UNAIDS, World Bank, World Health Organization, and philanthropic organizations.
Vision of the CHDP
Increased access to equitable, high-quality essential health services through community-based primary health care.
Mission of the CHDP
The CHDP champions a country-led, data-driven approach to identify policy and program actions to advance national priorities, with the aim of supporting countries to strengthen the health system at the community level, including community health workers’ status, rights and protections.
As part of this process, UNICEF has spearheaded a process to estimate, once again, the return on investment (ROI) in community health workers. A widely cited report released in 2015 concluded that for every dollar invested in CHWs, there would be a $10 return in terms of the economic value of children’s lives saved, the economic spin offs of giving CHWs a salary, and reduced likelihood of a pandemic. Over the past year, I have been working with a team from Johns Hopkins, an expert panel, and UNICEF colleagues to estimate what the return on investment in CHWs would be over the next 20 years in which these CHWs provide a broader array of services as mentioned above in the 2024 Lancet Commission Report. We look forward to this coming out before too long in the peer reviewed literature. Again, the findings indicate that the ROI will be quite favorable.
The investment case for investing in primary health care and community health workers
I call your attention to a paper that Professor Jeffrey Sachs and I published recently in the Oxford Research Encyclopedia on precisely this topic (attached) and available online here.
Wider availability of publications on community health workers
I am pleased to let you know that our highly regarded 468-page book of case studies of 29 national CHW programs is now available on Amazon, as shown below and can be accessed here. The chapters can also be read at CHW Central.
Course on Coursera: Health for All through Primary Health Care
This short, free online course, running every month for a decade now, has had almost 100,000 enrollees and the monthly enrollment rates now are quite strong. It involves four hours of work per week for four weeks. You might want to consider taking this yourself or offering it to colleagues and/or students. Registration is available here.
Journal supplement on Community Health Workers at the Dawn of a New Era
Some of you may not be aware of the journal supplement that my colleagues and I published recently. This can be downloaded here. Hard copies can be purchased here.
Henry B. Perry, MD, PhD, MPH
Senior Associate, Health Systems Program
Department of International Health
Johns Hopkins Bloomberg School of Public Health
Baltimore, MD, USA 21205
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