One Million Community Health Workers

Three years ago I was working as a medical doctor in one of the poorest states in Northern Nigeria, with sky-high maternal and child death rates, and even higher rates of preventable disease. My pediatric clinic was the only source of formal and free health care for thousands of indigent children in the city and several villages. So their mothers trudged endless kilometers to bring them in.  I was frantically working to see 100 to 200 children daily, often for viral fever, diarrhea, or malaria, conditions which someone with less specialized skills and knowledge could have addressed.

It was about this time that the National Primary Health Care Development Agency launched the Midwives Service Scheme. This renewed debates in health circles within the state and the rest of the country surrounding the performance of the community health worker (CHW) scheme that Nigeria had launched in the 1970s. The pertinent question became: how could Nigerian health systems mobilize human resources to anticipate and respond more compassionately and efficiently to the health needs of our people in rural and remote areas? After witnessing the deterioration and death of child after child following the long trudge to my clinic, this discussion took on a new level of importance for me.

Since 1990 the death rate globally of children below the age of five has plummeted by nearly half, and maternal deaths have fallen by at least 40 percent. Despite these gains, there is still a significant amount of work to be done. We have the means to address persistent, needless suffering in families from the violence-affected regions of Northern Nigeria to the slums of Andhra Pradesh.  Yet every two minutes, a woman dies in pregnancy or childbirth. Approximately 20,000 children still die daily from preventable causes. It is no coincidence that the 57 countries within sub-Saharan Africa (SSA) and South Asia with severe health workforce shortages record the highest numbers of preventable deaths. I believe that a global commitment towards prioritizing the training, deployment, and motivation of CHWs for disadvantaged communities would be a leap in the right direction.

Being an evidence junkie myself, let me start by highlighting evidence from CHW programs around the globe. In Nepal, female CHWs have for decades worked in communities providing treatment for common childhood diseases, distributing oral contraceptives, and promoting available health services.  Bangladesh has a similar CHW program that provides home-based family planning services. Both countries have experienced some of the most rapid declines in deaths among children below five in the world since 1990. Finally, in Ethiopia, the efforts of CHWs have helped double the number of children receiving immunization vaccines, pneumonia treatments, and vitamin A, resulting in a decrease in child death rates by almost 50%.

So this seems to work, but will the costs be prohibitive? The Earth Institute at Columbia University calculates that the yearly cost for a phased roll-out across rural low-income SSA by 2015 would be about US$6.58 per person served with a grand total CHW program cost of approximately US$2 .3 billion per year.  This amounts to only a quarter of the FY 2008 global health allocation from the US Federal Budget, according to the Kaiser Family Foundation. Seems like an obvious solution, right? However, because the United States funding for global health is focused on disease-specific objectives—such as addressing HIV/AIDS rather than more horizontal initiatives like strengthening human resource for health, even though the latter can be used to achieve the former—CHW programs do not stand a chance. The total expenditure on population health globally is an even larger figure, and is largely allocated to vertical programs and other “quick wins.” Considering that CHWs bring essential care to the doorsteps of millions and present us with early response systems to the population health threats of the future, it is difficult to understand why investments in national CHW systems have yet to be made a global priority.

So it works and we can afford the cost, but why should you care? Well, there is the fact that no one should be denied access to health care when they truly need it.  Plus the 2010 United States National Security Strategy recommends strengthening health systems and investing in global health as key components towards countering national security threats. We now know that countries with poor population health are more prone to instability, conflict and extremism, and an ensuing vicious cycle of unrest and ill-health. In an interconnected world, instability in one region of the world portends potential economic and security crises in that the next: Trouble spreads fast.

Hence a month ago, when I sat in the Shubert Theater and listened to Dr. Sonia Sachs’ compelling argument for The One Million Community Health Worker Campaign, I was already a believer. In brief, the Earth Institute, Columbia University convened a Technical Taskforce in June 2011, to examine best practices for scaling up and integrating CHWs into health systems. The experts calculated that, to achieve the Millennium Development Goals, roughly 1 million CHWs should be deployed in sub-Saharan Africa (SSA) by 2015. In CHW programs we are presented with the opportunity to provide disadvantaged rural and remote communities with access to a wide range of simple, evidence-based, cost-effective and life-saving health care services. By the end of 2015, with concerted global action, we could bring quality health care to the doorsteps of 650 million Africans, many of whom would be excluded otherwise. Now that’s a no-brainer.

Guest Author: Adanna Chukwuma, Health Policy Fellow, Global Health Corps.