Community health workers and their promise for Liberia’s remote villages

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Few physicians and a decimated health care system remained in the aftermath of Liberia’s recent fourteen year civil war. Only 51 physicians remained to serve the nation’s four million people. This shortage is felt most acutely in rural Liberia, where more than 1.5 million people live beyond the reaches of health facilities.

Similar gaps in rural health access exist throughout the world. Despite tremendous progress in global health over the past decade, more than one billion people will go their entire lives without seeing a health worker.

Globally, community health workers (CHWs) have been proposed as a key tool for bridging the rural delivery gap. Policy initiatives, such as the One Million Community Health Workers Campaign, are advocating for a paraprofessional community health worker that is properly trained and equipped to provide home-based care for common diseases. In Liberia, organizations like Last Mile Health have worked alongside the Liberian government to successfully deploy CHWs who are both trained and paid a living wage in the country’s most remote corner.

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While CHWs have been demonstrated as an effective intervention, debate still exists on the appropriateness of remuneration. CHWs seek to be paid for their work, especially given that many work full-time hours in place of other paid jobs. Remuneration is also critical for retaining workers — an economically important factor when governments are investing time and money in large-scale trainings. Yet, at scale, thousands of new paid community health workers would significantly impact national health budgets.

Similar cost concerns were raised during global fights for HIV, tuberculosis, and malaria, but large-scale treatment was made possible with the advent of PEPFAR and the Global Fund to Fight AIDS, TB, and Malaria. Just as people needlessly die in the absence of antiretroviral treatment, so too do citizens suffer when health workers are inaccessible. The global public health community must rally together to promote new funding mechanisms to promote the widespread adoption of paid community health workers.

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7 Responses to “Community health workers and their promise for Liberia’s remote villages”

  1. euhunmwangho Says:

    I am an active supporter of using Community Health Workers to improve access to health care and bridge disparities in access. But it is interesting to observe how over the years, they are being given larger roles to play in health care delivery. Community Health Workers are also called Community Health Volunteers or Village Health Workers. And the concept of their work is to provide supportive health care services to their community voluntarily. Back then, Community Health Workers weren’t required to be paid and most took on this duty for personal reasons including to help their fellow community members or because they had suffered a disease condition that now affected their community. At most, if the Community Health Worker worked full time, they were compensated by their Community through in-kind or non-monetary donations such as food or offering domestic help. These are also incentives but they are less costly than adding them onto the pay scale. This article ” Community Health Worker Incentives and Disincentives: How They Affect Motivation, Retention and Sustainability” written by Karabi et al, is a must read as it provides further insight into this topic. In developing countries with tight health budgets, adopting paid Community Health Workers would be a costly endeavor. i am not sure how cost effective it would be as Community Health Workers are not substitutes to doctors or nurses. Community Health Workers play more of a complementary/supportive role in the health system. Therefore countries with low numbers of human resources and infrastructure in the healthcare field would still need actively rebuild their system.

    On the flip side, it is interesting to observe how through reversed innovation, developed countries are currently becoming increasingly involved in the use of Community Health Workers to promote access to health care

  2. euhunmwangho Says:

    Here is the weblink to the article i referred to: https://www.ghdonline.org/uploads/Community_Health_Workers_-_how_they_affect_motivation_retention_and_sustainability.pdf

  3. gomezkar Says:

    What I found most interesting in the article that you shared is that the most important factor they identified in relation to the effectiveness of a CHW’s work is the relationship they have with the community, a factor that is often not acknowledged. I think my initial thought is that financial incentive would be high on the priority list but reading this article it appears to be more complex than that. Fostering these relationships would be key in strengthening the effectiveness of the CHW’s work. I think many of the concepts we learned in this class can be applied in this situation. In order to plan the program many layers and factors must be analyzed to identify the incentives that would be most effective based on the community’s own unique characteristics.

  4. hdroppert Says:

    CHW’s have become increasingly popular over the past decade. It seems curious that Africa (and the world in general) has to date been unable to cobble together best practices to create effective systems of CHWs for countries engaging in these programs anew.
    Furthermore, very little research on the quality of CHW work has been done. Last term, I sat in on a recent PhD dissertation that evaluated the quality of CHW work in Rwanda (a country that is often lauded for its CHW program) and found that often the quality is poor or insufficient. This research finding was particularly disappointing to me since I have personally witnessed CHWs successfully and efficiently working in the field to achieve better health outcomes for their people.

  5. cberkley2 Says:

    I enjoyed reading your post. The statistic about how many people in developed countries never see a doctor – ever — is startling. Community health workers can, as you said, play an important role in filling the gap. It is only natural that they would expect payment for their services. It is an opportunity cost if they work for free. Hopefully there will be additional consideration and advocacy for budget considerations for additional health workers with funders. The basis for their usefulness has been shown time and time again. I agree with hdroppert that there will have to be some consistency, however, in that the health workers are trained in such a way that there is consistent value add wherever they are installed.

  6. kavitadharamraj Says:

    Kavita Dharamraj: Community Health Workers and their promise for Liberia’s remote villages:
    The opening statistics of this article were quite horrifying- 51 physicians to 1.5 million people! This literally means that one physician is being allocated to 29,412 persons. If anything, this clearly screams out for the dire need for more health workers. However, the sad truth is that many governments do see human health and human lives (especially in rural areas) as expendable and are not willing to channel funds into improving either.
    Rural Liberia has been described as being so remote that health care is difficult to access. If this is true for residents, then it is also true for assigned Community Health Workers (CHW). These workers are being asked to work in remote areas, away from town conveniences and away from medical attention in the event that they too fall ill. This is quite a lot to ask from a person. While it may seem an act of great kindness and goodwill from these workers, the truth is that the poor sanitation and living conditions can take a toll on them. Adequate financial remuneration should be mandatory, and governments need to find a way to allocate these funds.
    In cases where payment of Community Health Workers is not being honored, global attention needs to be sought. The internet and social networking sites can be used to attract international attention to the plight of the CHW and rural residents alike. Governments’ inaction and lack of concern for their people’s health will be made public and much criticism will be received. In this way, they will be more motivated to find the money needed to pay the CHW (whether garnered from foreign aid or otherwise) and thus improve the health of their people.

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