One Million Community Health Workers

Worldwide, there are severe shortfalls in the health workforce—not just in the quantity of doctors, nurses and other health workers, but in their management, performance and geographical distribution. These shortfalls are particularly glaring in light of the global movement for universal health coverage (UHC), progress towards which will require a high-functioning workforce.

This month’s 3^rd Global Forum on Human Resources for Health (HRH), which convened global health policymakers in Recife, Brazil, trumpeted the need for political commitment to health workforce strengthening. With UHC a top priority of conference sponsors like the World Health Organization (WHO), conference discussions were framed as seeking HRH solutions “towards UHC.” Improving retention and performance towards UHC. Health workers’ advocacy towards UHC.

Indeed, it’s an opportune moment for the HRH movement to latch onto the movement towards UHC. UHC holds a privileged position in the post-2015 development agenda as a favorite of the WHO and World Bank and—more importantly—as a strategy for low- and middle-income countries to improve health equity, reduce health system fragmentation and reinforce economic development. Since human resources are an essential UHC input, the HRH community can both ride the UHC momentum and help drive the agenda.

But the HRH community needs a clearer picture of what UHC means in the development context. Today’s UHC movement is guided by two complementary concepts: (1) the aspirational vision of a world in which everyone receives all the health services he or she needs, without suffering financial hardship and (2) a roadmap charting the right course towards better overall coverage, focused on equity and reducing preventable mortality. Discussions in Recife seemed to have picked up only on the aspirational vision of UHC—and while “everything for everyone” is an important touchstone for the UHC movement, it’s the more practical conception of UHC that should guide HRH policy and advocacy moving forward.

UHC’s Top Priorities

For developing countries, the UHC agenda is increasingly understood as a specific set of strategies that target health inequities in settings with weak coverage—where healthcare access is limited, families have to scrape together money when somebody gets sick, and people die needlessly. There, UHC reforms come down to this decision: to organize resources around ensuring that the poorest people can at least get cheap, lifesaving health interventions, and building from there.

This agenda entails real tradeoffs. Shiny new urban hospitals may have to wait. It’s also a deliberate turn away from the vertically-organized, disease-specific health programs of the 2000’s, which scaled up key services but left health systems fragmented. In contrast to the aspirational vision of everything for everyone, this conception of UHC can be achieved in any setting, relatively quickly, as key building blocks move into place.

Following the UHC Roadmap

HRH is one of those building blocks. Early progress towards UHC doesn’t require the massive, specialized workforce of a rich country, but it does require a workforce well-suited to the highest priority tasks, like health promotion and primary care.

In Recife, however, the HRH community invoked UHC as if it were just the aspiration of an optimally functioning health system. Quantity of nurses needed for UHC? Same as the number we need for an effective health system. Skills mix? Work towards one that could eventually provide everything to everybody. Same agenda, new terminology.

UHC isn’t just a placeholder for better systems. It’s a roadmap focused on equitable access to basic services. In HRH, the real UHC agenda would dictate:

• A commitment to scale up the community health workforce in the near term. CHWs are usually drawn from the communities they serve, including the poor, rural areas that experience the worst health coverage. They’re culturally competent and more likely to stay in those communities than urban recruits. They can provide a range of basic primary care services around safe motherhood, childhood illness and family planning, while referring tougher cases to health facilities.

As discussed in Recife, CHW programs are active in most countries, but they’re often overlooked by government health planners. Run by donors or NGOs, the lack of coordination makes these programs less efficient and equitable than they should be. Unlike in Ethiopia, which has formalized and managed the role of its 30,000 health extension workers, CHWs often operate in a gray zone of health policy.

Governments should take the lead from host Brazil, who implemented a primary care-focused strategy by dramatically scaling up community level services in the 1990s and 2000s. Instead of building hospitals, Brazil built outpatient facilities. To perform outreach and health promotion, Brazil deployed thousands of Family Health Teams with CHWs performing outreach alongside doctors and nurses. The approach raised coverage of core interventions to nearly 100%, driving remarkable reductions in preventable mortality and erasing geographical inequalities.

• Evidence-based task shifting for expanded primary care. In the near term, clinical training and deployment should prioritize primary care. Physicians can provide this care but they aren’t the only option. We heard substantial evidence in Recife that mid-level health workers, such as nurses, can effectively deliver certain interventions traditionally provided by doctors.
• Progressively increasing specialty physicians and other staff, commensurate with financing. As the UHC financing transition boosts funding for health, reforms should budget for more specialized care. The health workforce must keep up. The right mix will vary by country. In Mexico, for example, the Seguro Popular reforms of 2003 initially provided beneficiaries with a core group of public health interventions and immunizations; a package of essential health services; and a few benefits around catastrophic illness, such as HIV medicines. Year after year, as financing has grown, Seguro Popular has layered on additional benefits, including breast cancer treatment and more than 50 other benefits around catastrophic illness. Mexico has worked to evolve human resources accordingly.
• Meaningful coordination with the private sector. In many countries, half of service delivery happens in the private sector; for patients and providers, public facilities aren’t the only game in town. Effective UHC reforms have managed the public/private split, and so must HRH initiatives. At the same time, the private sector is increasingly recognizing its interest in a healthy population and starting to contribute accordingly. It’s a fertile moment for public-private partnerships to boost financial sustainability.

A Clear Path for HRH

Just as HRH facilitates UHC, UHC can facilitate HRH by mobilizing political and financial capital. There was consensus in Recife that HRH improvements require buy-in from the highest levels of government: on their own, health ministers lack the necessary influence over HRH financing, medical education and public sector hiring and compensation. They can’t necessarily deliver the human resource management systems required for retention and high performance. HRH governance requires high-level commitment to energize and coordinate across sectors and agencies.

UHC represents a rare opportunity to rally an entire government around health reforms. There’s a strong demand for health insurance and healthcare access among those who don’t have them—often a winning political cause, particularly in countries with a strong sense of social solidarity. Behind the promise of UHC (for example, a new or expanded pro-poor health insurance mechanism), we’ve seen low- and middle-income countries develop new taxes or other funding schemes, using the money to train more health workers and reshape service delivery for better outcomes. HRH gains traction in the context of a broader social movement for health equality. (Not just locally but globally: can you imagine a post-2015 HRH target outside the context of a UHC target?)

For the HRH community, the status quo hasn’t worked. Health workforce gaps have only gotten worse. To make Recife count, this community must recognize UHC for what it is: not just another demand on already short-staffed health workers, but a transformative agenda that could refocus attention on the HRH cause.

Guest Blogger:  Jonathan Jay, JD MA