Harnessing the world’s greatest healthcare resource
In every phase of the Covid-19 pandemic, community health workers have been indispensable. They made diagnoses, carried out contact tracing, cared for the sick and administered vaccines. And they accomplished all of these tasks with minimal funding, oversight, and assistance.
The use of community health workers in rural health care has a long history of success. In the 1960s, Chinese “barefoot doctors” helped the country eradicate smallpox and double life expectancy. A decade later, Bangladesh partly emulated the Chinese initiative when it launched its community health worker program, which has helped the country achieve the majority of the health-related Millennium Development Goals, such as increasing the immunization rate against diphtheria, tetanus and pertussis for rural children from near zero in the 1980s to over 90% today.
Community health workers are neither doctors nor nurses. They are local residents with basic medical training who help bridge the gap between health care facilities and underserved populations. Usually they are trained by NGOs and receive little or no compensation from their governments. In fact, few governments around the world maintain registries of community health workers or have a way to communicate with them.
These committed people can form the backbone of the resilient health systems needed to manage the next pandemic. But for that, they need more support.
The challenges faced by community health workers around the world are considerable. Many, like Nepal’s 50,000 female community health volunteers, are unpaid, even though the value of the free treatment and labor these workers provide around the world is estimated at $1.5 trillion.
But money is only a problem. In Brazil, some community health workers receive only one or two weeks of training before starting unsupervised work. Community health workers in Ethiopia spend more time traveling than caring for patients due to the rural and remote nature of the communities they serve. A survey in Liberia in 2018 and 2019 found that less than half of community health workers had stocks of life-saving zinc or amoxicillin. And just over half had oral rehydration solution and malaria medication, crucial tools in a country where thousands of people die of diarrhea and malaria each year.
It’s no wonder that many community health worker programs experience high levels of attrition and vacancies. In Bangladesh, 15% of positions are vacant at any given time. Staff turnover increases costs as replacements must be recruited, trained and deployed. It also reduces the quality of care, as new workers generally have less hands-on experience in providing health services.
The pandemic has revealed the need for strong and adaptable health systems, especially in underserved communities. To build these systems, we must find a way to properly recruit, train, equip, supervise and compensate frontline workers.
To begin with, groups running community health worker programs should review and strive to follow the World Health Organization’s recommendations on supporting community health workers. Additionally, governments should develop and maintain geo-referenced national registries of community health workers, which can be used to communicate public health messages, improve linkages between rural communities and health centers, and manage crises. Monitoring community health workers can also help ensure that they are properly trained and equipped.
Finally, governments and funding partners should explore other ways to support community health workers. An unrecognized and inexpensive tool is a sturdy bicycle. World Bicycle Relief, in collaboration with civil society organizations such as the Catholic Medical Mission Board and ministries of health in seven countries, has distributed nearly 175,000 of its specially designed Buffalo bicycles, enabling community health workers to spend less time in transit and more time with patients.
Bicycles have improved health outcomes in several African countries. In Kenya, community health workers on bicycles saw 88% more patients and referred 50% more patients for TB screening at a local clinic. Community health workers equipped with bicycles in Zambia quadrupled the frequency of visits to their patients. And in Malawi, they doubled the number of patients they could visit. Surveys show that community health workers who have bicycles are less likely to quit. Similarly, if program supervisors have bicycles, they can provide more guidance to community health workers, leading to better care for patients and greater job satisfaction for caregivers.
When the acute phase of the Covid-19 pandemic ends, it will be largely thanks to the tireless work of community health workers. The best thing the world can do to maximize their effectiveness in future crises is to ensure they are properly trained, equipped, empowered and even compensated.
Powers is CEO of Catholic Medical Mission Council. Neiswander is CEO of World Bicycle Relief.