Calling for More Community Health Workers: A Conversation with Abiodun Awosusi

Abiodun Awosusi.

Endorsed by global stakeholders like the World Health Organization (WHO), World Bank, UN General Assembly, and African Ministers of Health and Finance, universal health coverage (UHC) is gathering momentum in the post-2015 health development agenda. As countries and international organizations consider how to address maternal and child mortality, unmet need for family planning, and other poor health indicators and outcomes, UHC is seen as a way to help countries have the mechanisms needed to increase access to lifesaving, quality care.

Abiodun Awosusi, MD, a public health physician, is a campaign coordinator for the Health for All Campaign for Universal Health Coverage in Nigeria, led by MSH.

A recent report from a joint commission side session at the Third Global Forum on Human Resources for Health identified community health workers and other frontline health workers as key to achieving universal health coverage. Why are community health workers so important to achieving universal health coverage (UHC)?

Without frontline health workers, universal health coverage cannot be achieved. Universal health coverage, UHC, offers an opportunity to strengthen the health system to improve access to care. Its goal is to ensure everyone can receive the healthcare they need without suffering financial hardship in paying for it. Community health workers, CHWs, help to overcome the financial, physical and infrastructural barriers to healthcare for the poor. This is particularly important in rural areas of sub-Saharan Africa where there is a high poverty level and shortage of health workers.

In sub-Saharan Africa, poverty is predominantly a rural phenomenon--more than 60 percent of the population lives in rural areas. The cost of illness--and paying out of pocket for care--drives many people to deeper levels of poverty. More than 200 million people live in extreme poverty in the region and are in dire need of affordable quality health services.

Because of the costs, many people shy away from hospitals and seek uncertain and sometimes inappropriate care from unqualified medical practitioners and traditional healers. Skilled health workers, particularly community health workers could provide affordable, life-saving health care to the people in communities where they live.

But many communities do not have access to skilled health workers. Out of 57 countries with critical shortages of health workers, 36 are in sub-Saharan Africa. Although the region has 25 percent of the global burden of disease, it has only 3 percent of the world’s health workers. Massive exodus of health workers from Africa to developed countries annually worsens this shortage. Community health workers, working in tandem with available highly skilled professionals, can fill the gap.

What types of quality, appropriate services can community health workers -- often volunteers -- provide?

Community health workers are invaluable service providers in resource-poor settings with limited access to facility-based healthcare. One area is in providing integrated community case management of childhood illnesses, known as iCCM. Despite efforts to reduce child mortality, many children still die from preventable causes such as pneumonia, diarrhea, malaria and malnutrition. The number of children dying worldwide is reducing, but in some African countries, the decline is slow or non-existent. 

A recent WHO/UNICEF joint statement on integrated community case management provides compelling evidence that CHWs can improve access to essential health services for children. It says appropriately trained and properly supervised CHWs who consistently receive essential medicines such as oral antibiotics, oral rehydration salts (ORS) and zinc, oral antibiotics and artemisinin-based combination therapy (ACT), and necessary equipment such as malaria rapid diagnostic test kits (RDTs), contribute to significant reduction in child mortality. In Ghana and Zambia, more than two-thirds of sick children diagnosed with pneumonia and malaria received early treatment by these frontline health workers.

Another area CHWs have proven useful is in maternal health. More than half of maternal deaths in the world occur in sub-Saharan Africa, usually from leading causes such as severe bleeding, postpartum infections, pre-eclampsia and unsafe abortions. Poor women who live in rural areas with limited access to health facility and skilled health workers are most affected. This is unacceptable. In a number of country programs, CHWs are trained to identify danger signs of pregnancy and refer women to health centres. They also encourage women to give birth in a health facility in the presence of a skilled attendant.

Can you provide more examples of how CHWs are improving health and saving lives?

Definitely. With more than 45,000 CHWs and less than 1000 doctors, Rwanda has recorded revolutionary improvement in health outcomes facilitated by strong leadership. The maternal mortality ratio dropped by 60 percent over the past decade and deaths from HIV, tuberculosis, and malaria have each dropped by about 80 percent over the same period. Under-five mortality has been cut by 70 percent since 2000.

In Ethiopia, CHWs are also making impact. At the Abuja+12 Special Summit of Heads of State, Ethiopian Prime Minister and African Union Chairperson Hailemariam Desalegn asserted that the flagship health extension program in his country involving 38,000 health extension workers has led to a significant reduction in HIV infections and the number of women dying in childbirth, and has also increased the number of children immunized.

What about family planning and reproductive health? What role can CHWs play?

There is huge unmet need for family planning in Africa, a continent which will double its population by 2050. About a quarter of couples who would like to space births by 2 years do not use a contraceptive method. This need could be met by providing timely family planning information and services to families at health facilities and within communities. Community-based health workers can help women get contraceptives and also ensure men are involved in family planning.

CHWs can also help to reduce cultural barriers to families using family planning services in rural areas. They understand the social dynamics of their communities and can effectively carry out counseling and distribution of condoms and birth control pills with limited resistance from members of the community. In Afghanistan and Northern Nigeria, female community health workers help to facilitate uptake of family planning and reproductive health services by women. In Uganda, properly trained and supervised CHWs deliver quality family planning services, including distribution of injectables, which have become increasingly popular among women. They are regarded as the “best buy” in global health as they promote community acceptance of contraceptives and use.

I strongly believe -- and these achievements suggest -- that CHWs are key to providing quality care for women and children most in need, and speeding up progress toward UHC.

Portions of this interview originally appeared on The Lancet Global Health Blog here and here.