The Frontline Health project, implemented by Population Council, is examining effective ways of measuring performance for community health workers (CHWs) so ministries of health (MoH) can develop new, or adapt existing, policies that maximize their impact and move toward universal health coverage.
By Amy Dempsey

Version française ici.

In the beginning of May, the project convened a meeting in Johannesburg, South Africa. With integrating community health (ICH) partners – funded by the United States Agency for International Development (USAID) – and MoH representatives, USAID, UNICEF, and the Bill & Melinda Gates Foundation in attendance, the discussion focused on the status of respective community health programs.

During a panel discussion, MoH representatives answered one primary question: What are the challenges in institutionalizing community health programs? This blog summarizes the highlights from their responses. 

Dr. Moïse Kanyere Kakule, Democratic Republic of the Congo: The DRC has a long history in community participation, dating back to the 1970s with small scale pilots inspired by the Alma Atta Declaration in 1978. Since then, the country has organized its strategies with community participation in mind, but in the roll out it was difficult to retain community health workers. That led to an effort to rethink the community health model and get engaged beyond service delivery points by going into the wider system and “repositioning the community from being a target to being an actor, partner, and someone who will benefit from the services.” An element of this approach are village committees – or the unit that operationalizes the strategy – but scale up and dissemination are challenging. The challenge with this is making sure there is buy-in for this vision among communities, which means there is a need for more communication and empowerment.

The entire health workforce is 500,000 people and the challenge is paying them. “How can we increase the number of the paid community health workforce if we are already challenged in paying those who currently work for us?”

Dr. Christopher Oleke, Uganda: Uganda is strengthening community health systems through formation of village health teams – a minimum of two in every village – with 180,000 CHWs trained and employed throughout the country. They work purely on a voluntary basis, and in order to become a village health team member, they receive one week of basic training and their responsibilities are simple: They mobilize communities, link them to service points, disseminate health information, and provide health commodities.

For the last 18 years, this has been the strategy, and two years ago there was a comprehensive review that examined its effectiveness. From the review, there were several clear issues with institutionalizing the village health workforce.

Similar to the DRC, Uganda struggles to pay, motivate, and retain its village health workers.

The second challenge is the bureaucratic requirements of streamlining this strategy into the system. “There are regulatory requirements that impact institutionalization. When you formalize [CHWs], which party or institution is then responsible for regulating their services?”

Policy makers in Uganda also need data showing results from investments into village health programs, specifically data that addresses the achievement of village health workers.

“Despite the challenges, there is a general positive attitude that village health teams contribute to the improvement of community health in our country.”

Daniel Kavoo, Kenya: Community health in Kenya started in 2006 with the development of structural documents for training CHWs and community health units, which are meant to serve 5,000 people. At the time, funding came from the MoH, but in 2014 the government system changed.

That came as a blessing and a challenge. While leadership and governance is an issue, the counties accept community health as a part of life, but it is not always a priority. Currently, there are units in every county, but there are supposed 9,500 CHWs throughout the country, but the MoH is adding 5,360 more.

What has helped is the President’s commitment to health. “Everyone is talking about [universal health coverage]…We are fighting for institutionalized community health.”

Jerome Korvah, Liberia: In 2013, UNICEF and the MoH assessed the community health program and workforce policy and the Ebola outbreak. The assessment showed facilities are not reaching their health targets, and there has been an increase in maternal and neonatal mortality.

The findings encouraged the MoH to review the entire health system and the policy for building resilience for health. The MoH could see the access gap between urban and rural communities – in urban settings, facilities were closer to meeting indicators than those in rural settings, where communities can be up to 10 kilometers from a health facility.   

This led to the question: Can there be a program that focuses on rural areas? “Currently we have 2,900 CHWs trained and deployed. It is our expectation that in the next three years we can bridge the gap [between urban and rural].”

The goal in Liberia is to have 4,000 CHWs. However, rolling out the program is difficult – the MoH’s initiative to increase access to free services has led to stockouts. As a result, the formal government and districts are trying to require fees for services, but it is difficult to implement that policy, as well.

Dr. Frantz Gerald Nerette, Haiti: The community health strategy started in 2012, after two big catastrophes – the earthquake in 2010 and the cholera outbreak in 2011. The government saw how important it was to increase access to health services within the population.

“There are 1,900 doctors in the country and they are more attracted to private sector. Sixty percent of our public health workforce is concentrated in the capital…The MoH decided more needs to be done to increase access to health services for all.”

To ensure community acceptance and participation, the CHWs come from the communities they serve. They match the criteria and the profile of the region, and receive training in, and are tested on, five areas. But before training and deploying CHWs, a minimum of two years of program financing is needed and the MoH must validate the training curriculum and exams.

Dr. Plea Boureima, Mali: Before the 1990s there were community health workers as part of primary health care, but there was a gap in coverage. There was no national strategy with its own vision and objectives, so the government organized a forum for community care and starting implementing community health in five regions. Despite positive results, there is insufficient human resources, and 100 percent of the financing is from donors.

“Another issue is scaling up in the northern region, where communities feel like they have been left behind in the community health strategy. The northern region is also where they have conflict.”

Additionally, there is a lot required of a person becoming a CHW. They must have nine years of primary care education, plus a certificate and a diploma, which leads to nurses and doctors becoming CHWs. And that creates a challenge. They have more skills and do not always stick to the package of interventions.

Despite being different stages of institutionalization, this panel discussion illustrated that ministries of health face many of the same challenges with bringing community health programs to scale. Compensation and retention of CHWs, determining appropriate regulation and accountability measures, and ensuring buy-in from the served communities continue to raise questions.

In collaboration with integrating community health partners, ministries of health, USAID, and the foundation, the Frontline Health project seeks to inform policymakers to understand the best mechanisms for institutionalizing frontline health workers within health systems and ultimately support improved access to healthcare among hard-to-reach communities.