The Rising Tide of Community Health Workers

In the past few weeks, there has been an steady rise in news about Community Health Workers (CHWs), domestically and abroad.  Tina Rosenberg has written a wonderful 3-part series that introduces the concept of community health workers to the broader readership of the New York Times.  Late last year, I gave a TEDx talk (below) about how the Millennium Villages Project (MVP) has studied the best of national and NGO programs to develop a CHW system that has promise for country scale-up, including relatively rich countries like the US!  In fact, The WHO has recently recognized our approach.  The reason for enthusiasm is obvious: without replacing doctors and nurses, regular people can take an active role in the health of their community.

Ok, so regular people might be a bit misleading.  Anyone who is selected for a process, undergoes dedicated training and is paid for their work begins the process of professionalization.  But what sets CHWs apart is that they are selected from their community, live in their community and work in their community.  The bottom line is that they know the people and place.  This makes it particularly important to undergo some sort of professional transformation; there is a balance struck between maintaining a familiarity with neighbors and developing a professional presence.

A couple weeks ago, a group of 30 or so of us who are dedicated to community based health systems met at a place called Still Harbor in Boston.  Still Harbor was started by Tom White and Ed Cardoza, two people who were instrumental in starting Partners in Health (PIH) — PIH is a fellow pioneer in developing the new generation of CHW systems (called accompagnatures in their parlance).  It was an impressive group, representing organizations like PIH (Haiti, Malawi, Rwanda, Peru, Mexico), Nyaya Health (Nepal), Village Health Works (Burundi), Tiyatien Health (Liberia), Global Action (Sierra Leone), MVP (10 countries in Sub-Saharan Africa) and others.  The discussion focused upon how to maintain the high quality of interactions, relationships and impact represented in each effort when expanded at a national scale, which is currently being done in conjunction with many of these groups.  We came to 5 key “operating principles”:

• A Formal Approach for Rapid Deployment of CHWs – training 50 CHWs, much less 1000 or 10,000 is a feat.  We’re in the process of  gathering the best methods from countries like Ethiopia, Malawi, India, China and Pakistan, who have had experience with the logistics of large-scale deployments.
• Tight Linkages with Local Primary Health Care (PHC) Systems – multiple generations of national CHW programs have fallen short of expectations because they were deployed in a vacuum of health system support.  They simply weren’t there.  CHWs are an integral part of PHC systems and they have a maximal impact in that context.
• Continuous Improvement through Active Organizational Management – This basically means that information should drive the development of a CHW management system and guide organizational growth.  This is being made possible with tools like ChildCount+, which allows managers to track the performance of CHWs via the accuracy of their SMS text messages about household visits.
• Support for Remote Case Management – When CHWs get to households, they’re pretty much on their own.  We can extend a knowledge environment with decision support systems like CommCare, that prompt CHWs through a range of scenarios they may encounter like how to identify pregnant mothers at high risk for complications in delivery.
• Sustainable Financing Mechanisms – There are a range of ways to finance CHW systems, such as government support, community based financing and a mix of private sector partnerships.  Depending on the environment, ranging from an urban city in the US to a village in Malawi, the approach can vary so long as the most vulnerable populations have access to care.  Planned approaches and creative solutions will facilitate the broad presence of CHWs in our communities throughout the world.

In short, the world of CHW systems is heating up and there will continue to be a lot to discuss as more people find out how important they are to health in their communities.  I think what will amaze people is how CHW-like approaches have relevance in “high performing health systems” as much as they do in places like the MVP.  In posts to come, I’ll talk about how CHWs can be part of the solution to address challenging health issues like obesity, mental health and long-term care.  Can you imagine someone in your neighborhood being a resource for your health?  It’s a leap, I know.  Under what conditions would it be ok? @prabhjotsinghNY

In the meantime, here’s the talk I gave at TEDx:

Prabhjot Singh is the director of the Program for Health Systems and Community Health Worker Advisor to the MVP, at the Center for Global Health and Economic Development. He is also an assistant professor at the School of International Public Affairs.

The Center for Global Health and Economic Development (CGHED) mobilizes health research and programs that enable low-resource countries to develop quality health systems for the poor, promote sustainable economic development and achieve the Millennium Development Goals (MDGs) – global targets for reducing extreme poverty and hunger and improving education, health, gender equality and environmental sustainability.  For more information about CGHED’s work, please visit  our website”