Why community health workers can lead to more respectful care for women and girls

Most evidence shows access to quality maternal health services — even the most basic services — requires many personal sacrifices for women and girls around the world, especially in poor or remote communities where there may not be doctors or primary health facilities.

Getting to a health facility may take several days of travel and is often compounded by lost wages and leaving children behind. Upon arrival at a health facility, women may not receive the services they need. Research from the Heshima project shows that when they do make it to a health facility, they may experience disrespect and/or abuse during delivery, ranging from medical procedures performed without their consent, discrimination, non-confidential care, abandonment or denial of care, detention, and physical and verbal abuse. As suggested by a woman in Kenya:

“I was young when I went to deliver my first baby. Instead of being assisted, the nurses kept insulting me, ‘you enjoyed doing it, why are you screaming now? Don’t try and scream here.’ I can never go back to that facility. The nurses are just there not helping; you wonder if it’s a hospital you were brought to?” (FGD, Women).[1]

All these challenges further disincentivize women and their families from seeking care, or lead them to prioritizing healthcare only at the time of acute need — such as right at the time of childbirth — which prevents the timely detection of pregnancy-related complications that could harm them and their babies.

While many research and program initiatives focus on new innovations for advancing improvements in maternal and newborn health, the truth is that even today, basic access to health services can save lives and reduce mortality and morbidity in women and children. This is where community health workers (CHW) come in.

CHWs have been around since the 1940s, first in China as “barefoot doctors” — farmers who received basic medical training and brought primary care services to rural communities, where urban-trained doctors were unavailable. The model was later refined by a number of integrated community-based programs in Asia and Africa, and demonstrated dramatic declines in maternal, infant, and child deaths. In 1978, the Alma Atta Declaration proclaimed that quality primary healthcare is a human right — not a privilege just for the wealthy — and advocated for bringing healthcare as close as possible to where people live and work. This incentivized large-scale CHW programs in some of the poorest countries around the world. However, these programs were severely resource-constrained and in practice, ‘Health for All’ was translated into “poor care for poor people.” There was not enough emphasis on training the CHWs, ensuring they were respected within their communities, providing them with institutional support from health facilities, or providing them with a consistent stipend for the services they provided. With the advent of HIV/AIDS in the 1980s and increased emphasis on vertical disease-specific programs, these integrated programs in communities lost favor.

Now, we see a second wave of enthusiasm, and renewed hope for integrated primary health care programs. In 2008, the World Health Organization emphasized “Primary Health Care (Now More Than Ever)” and advocated, once again, for putting communities at the center of their health. We now have nearly four decades of evidence showing that when CHW programs are properly supported, they can improve uptake of childhood immunization services, promote initiation of early and exclusive breastfeeding, improve pulmonary tuberculosis cure rates, and reduce infant and child morbidity and mortality. Despite this evidence, we still do not know exactly what made these programs successful. In the early models, they were led by charismatic community leaders with personal connections to individual families and households, but we have not understood what it takes for programs like this to work at the national level. What we do know is that quality care for all women and girls is critical for a healthier, more prosperous world.

With a renewed interest in community health, the Frontline Health project is examining not just whether these programs are effective, but what factors make them effective. We hope to reach out to the broader community that have worked with CHWs in various contexts to identify critical areas of research that would help us strengthen these program globally.

[1] Warren, Charlotte E., et al. “Manifestations and drivers of mistreatment of women during childbirth in Kenya: implications for measurement and developing interventions.” BMC pregnancy and childbirth 17.1 (2017): 102.