Starting From the Bottom to Get There: Are Community Health Workers the Key to Achieving Universal Health Coverage?

By Udochisom Anaba, Quantitative Researcher (Maternal & Newborn Health), Population Council

“History is made by our achievements. We have come a long way to make the impossible possible: from the control of fire, to life-saving vaccines to landing on the moon. Our next historic achievement is right in front of us: health for all humankind.” April 7th, 2018, World Health Day celebration

These were the words used by the World Health Organization, calling on government and partners to ensure access to essential quality health services for everyone — whoever they are, and wherever they live — by 2030, while ensuring that they do not suffer financial hardship when accessing services.

The ambitious vision is achievable with investment in the primary healthcare workforce as a key strategy to providing cost-effective and equitable access to essential healthcare services, especially for the poor and those living in remote, rural areas. However, there is a growing concern within the global health community that health systems may not have the human resources to achieve Universal Health Coverage (UHC). Which is why there has been a resurgence of interest in community health and recruiting and training community health workers (CHW) in low- and middle-income countries (LMICs) to mitigate the projected shortage of 18 million health workers by 2030.

Community Health Workers are widely recognized as key to making progress on this agenda. This was evident at the recent primary health conference in Astana, Kazakhstan, the Astana Declaration, where world leaders reaffirmed the importance of community health systems and CHWs in strengthening primary health care. In addition, the WHO also unveiled the first-ever guidelines for community health workers to guide policy and programming.

This is just the beginning. For efforts to be sustainable, we need to pay adequate attention to understanding the factors that keep CHWs active and committed to the welfare of their communities. We need to understand what motivates them and how we can improve their performance. Incentives are key, but most ministries of health in LMICs do not have adequate resources allocated to commit to a regular salary for the large cadres of CHWs, and this gives credence to a “package” of incentives for CHWs. Research from different settings shows that the retention and motivation of CHWs can improve with a combination of financial incentives, such as regular salaries, performance-based monetary incentives, and non-financial incentives like trainings, adequate access to supplies, supportive supervision, respect, and trust.

Now is the time to take these into consideration and examine a grassroots approach to UHC. While skilled healthcare professionals are crucial to a functioning health system, we need to consider a bottom-up approach to UHC, starting with CHWs. Recruiting and training is not enough, we also need ways to retain them; we need to get their perspectives on UHC and to ask them what would incentivize them to improve their performance and be better able to serve their communities.

This will not only put equity back at the heart of UHC, it will also embody the concept of Universal Health Coverage: leaving no one behind because when the voices of CHWs are heard, the voices of the poor and vulnerable families and marginalized populations whom they serve are also heard.