A community health worker speaks with a client. (Photo by Jeroen van Loon for Amref)

Universal Health Coverage Begins in the Community

Why reaching the last mile should be our first priority

by Katey Linskey

As the global community prepares for the upcoming High-Level Meeting on Universal Health Coverage, world leaders and health experts have the opportunity to come together to renew commitments for primary health care to deliver universal health coverage and the Sustainable Development Goals. Following the October 2018 Primary Health Care Conference in Astana and the recent 72nd World Health Assembly, the momentum heading into the High-Level Meeting is indeed historic. However, in order to spark real and lasting change, this momentum needs to be translated into country commitments that will impact the lives of health workers themselves.

Community members and health workers — most of whom are women — will be responsible for translating declarations into frontline service delivery. As Professor Miriam Were, Kenya’s Goodwill Ambassador of Community Health Strategy, said, “If change doesn’t happen in the community, nothing changes and we keep talking. If change happens in the community — in the household — a nation changes!”

Achieving universal health coverage must be done in an equitable manner; this means making good on the promise to secure health access for all, particularly hard-to-reach populations. When the global movement pledges to leave no one behind, it is a pledge to ensure that those who need care most receive it first. Vulnerable populations and communities must be prioritized, particularly women and girls who need to access a strong continuum of care throughout their lives. Investing in community health workers ensures that health care is delivered on the doorsteps of those who need it most.

Albertha Freeman, a community health nurse supervisor from Liberia, attended the 72nd World Health Assembly in May 2019 and testified to the improvements she’s seen in her community since Liberia enacted a national program. Community health workers bridge the gap between their communities and the formal health system, bringing health care as close as possible to where people live and work. For most people living in rural and hard-to-reach areas, the first point of contact for health care is with community health workers. In order to reach their full potential, they must be integrated and supported within the larger system. When speaking about what motivates her work, Freeman said, “I refuse to accept poor care for poor people.”

Fortunately, decades of evidence have provided us with direction on how to best develop and implement community health worker programs. The World Health Organization guidelines for community health outline key program elements that support optimal performance for community health programs. The key quality metrics are outlined below:

Skills proficiency — Local members of the community who are recruited as community health workers need to be trained in the clinical and management skills required to perform their roles. This could range from assessing and treating illnesses to collecting and reporting data on service provision. An important element of community health programs is to measure and reinforce skills proficiency of the community health workforce.

Supervision — Supporting community health workers requires access to regular supportive, clinical supervision services. Clinical supervisors are trained to coach and monitor community health workers and provide refresher trainings as needed. Supervision is a key factor contributing to performance and job satisfaction. Supervision also provides a critical link between the community and the primary health care system, thus ensuring a strong continuum of care. Further, supervision is key to a functioning health system, particularly for data collection and monitoring. At the World Health Assembly, Freeman promised to continue supervising community health workers and serving her people if governments continue to invest in health workers.

Salaries — The World Health Organization recommends contracting community health workers — ideally through government — and “remunerating practicing [community health workers] for their work with a financial package commensurate with the job demands, complexity, number of hours, training and roles that they undertake” (WHO, 2018). Remuneration is not only an evidence-based method for improving satisfaction, motivation, retention and performance but also a recognition of the moral obligation to provide the right to work for rural populations and an opportunity for female economic empowerment.

Selection — Community health workers must be selected from the communities they serve. Basic literacy, skills and personality tests are utilized to strengthen selection and support optimal performance. Further, there should be preferential recruitment for female community health workers given cultural acceptability that strengthens quality of service delivery and demand for services.

Supplies — In order to provide life-saving health services to their communities, community health workers must have the requisite medications and supplies. Therefore, the design of community health programs needs to be paired with investments that strengthen and extend supply chains to provide last-mile distribution of these materials.

Strategies — In order to be effective and sustained over the long term, community health programs must be part of costed country strategies, policies and plans, and supported by key stakeholders such as funders and implementing partners. This helps to ensure that systems are put in place to support all community health functions, to embed community health workers in the formal health system and to mobilize sustained funding for community health worker programs. Often, these programs strengthen the economy and employment opportunities as the largest formal employment opportunity for rural women and youth.

Governments must confirm their commitments to reach their most vulnerable populations by making community health a clear and funded universal health coverage priority. They also need to utilize the World Health Organization’s guidelines to realize these priorities in a meaningful way for communities. Supporting best practices, coupled with frontline perspectives and political will, can drive lasting impact in health outcomes. We encourage governments to make good on the promise to leave no one behind and elevate the requests of Freeman and health workers like her around the world for better health outcomes.

Katey Linskey is policy and public partnerships officer with Last Mile Health.

Last Mile Health works with Amref Health Africa, Aspen Management Partnership for Health, Financing Alliance for Health, the International Rescue Committee and Living Goods to elevate the visibility of community health within the UHC space through the Communities at the Heart of UHC campaign.

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