Community health workers: An essential tool in the fight against cancer
By: Varsha Ranjit, MPH (Spark Engagement Committee)
In 2014, the World Health Organization [WHO] declared India as Polio-free: a remarkable achievement for this socially and culturally diverse country with high population density, extreme poverty and high birth rates. In a BBC report describing the pathways that led to this successful Polio-eradication in India, Nicole Deutsch, head of Polio Operations for UNICEF in India, emphasized that one of the two main factors that contributed to this success was the millions of front-line and community health workers (CHWs) who were involved in reaching the most vulnerable communities and in providing a range of essential services. The backbone of this mass immunization campaign was the community-based approach, which galvanized the support of community members to produce positive health outcomes for their communities.
Community Health Workers
Partners in Health [PIH] defines community-health workers (CHWs) as those living in the communities where they work, and are trusted and welcomed into homes. CHWs provide high-quality services for a wide range of health problems. PIH’s mission of providing preferential options for the poor in health care and ensuring access to good quality care in areas with the greatest need, is supported by their community-based approach, which uses CHWs as the central resource for providing access to healthcare.
CHWs are often community members who are volunteers or who receive an allowance, and who receive an informal training but have in-depth knowledge of their communities, culture and language. PIH views CHWs as a core part of their work and as Dr Farmer emphasizes in the quote below, for CHWs to have the maximum impact it is important that they are well-trained and properly compensated. Ultimately, CHWs link remote, isolated communities and the health system; providing a strong connection between the people who cannot access health care and a government’s health care system. They have become an important delivery strategy in underdeveloped and underserved communities.
In 2007, when Dr. Paul Farmer, co-founder of Partners in Health was asked by PLOS Medicine to describe ‘a single intervention that he thinks would improve the health of those living in poverty’, he emphasized the major impact that CHWs have on healthcare delivery and communities:
“Hire community health workers [CHWs] to serve them. In my experience in the rural reaches of Africa and Haiti, and among the urban poor too, the problem with so many funded health programs is that they never go the extra mile: resources (money, people, plans, services) get hung up in cities and towns. If we train village health workers, and make sure they’re compensated, then the resources intended for the world’s poorest — from vaccines, to bed nets, to prenatal care, and to care for chronic diseases like AIDS and tuberculosis — would reach the intended beneficiaries. Training and paying village health workers also creates jobs among the very poorest.”
CHWs in Developing Countries: The Solution to Two Problems
Problem 1: The Rise of Non-Communicable Diseases
Today, non-communicable diseases [NCDs] such as cardiovascular diseases, cancer, and diabetes are the leading cause of death and disability globally. In 2015, 70% of deaths were due to NCDs, with over 75% occurring in low and middle-income countries [LMICs] (Daniels et al., 2014). Due to poverty and lack of stable health and regulatory systems in developing countries undergoing epidemiological transitions, the prevalence of NCDs is associated with premature death and disability. NCDS that can be prevented and even treated often lead to death in LMICs when compared to developed regions due to the lack of affordable and inaccessible diagnostic, preventative and curative care in LMICs.
Cancer
In 2015, there were 30.7 million deaths related to NCDs in LMICs, and the leading cause was cardiovascular disease accounting for 45% of all deaths and the 2nd leading cause was cancer, causing 8.8 million deaths in LMICs alone. The types of cancer in LMICs include lung cancer, cervical cancer, breast cancer, leukemia and liver cancer.
Cervical cancer can be prevented with the use of the human papillomavirus [HPV] vaccine and by regular Papanicolaou [PAP] tests. Despite the largely preventable nature of this cancer, it is the leading cause of death from cancer among women in sub-Saharan Africa and South Asia (Daniels et al., 2014). Depending on the stage of cancer, breast cancer can be successfully treated when diagnosed early. Screening techniques such as mammograms and usage of economical diagnostic techniques in developing countries are important.
Problem 2: The Shortage of Skilled Health Professionals
A 2013 report on the analysis of human resources for health in 36 countries noted that the threshold ratio of population to skilled health professionals in 2008 was 23.2 million health workers for a world population of 6.7 billion (Skilled health professionals in the report included midwives, nurses and physicians.) And among the countries that were below the threshold; there were 8.9 million health workers for a population of 4.9 billion; indicating a deficit of 7.2 million health workers. The health worker shortage crisis is predicted to worsen by 2035, with the global deficit growing to 12.9 million.
The Solution:
With the global rise in NCDs, especially in developing regions and the increasing shortage of skilled health professionals, the gap between these two growing problems can be bridged efficiently by CHWs.
PIH’s community-based approach of integrating CHWs to improve health outcomes was started in Haiti, with their pioneering initiative of using CHWs to deliver health care to people living with chronic diseases and to increase community awareness of cancer.
Most recently, PIH implemented an initiative for early-detection of breast cancer in Rwanda and emphasized on the role that CHWs play in strengthening the health care system and improving care for breast-cancer patients.
Breast cancer has a high mortality-to-incidence ratio in low-resource settings because of late diagnosis and limited access to essential treatment such as radiation and chemotherapy. For example, in approximately twenty years since 1990, premature death from breast cancer in LMICs reached 90% (Daniels et al., 2014). To increase the chances of survival and provide equitable health care, PIH assisted in a training program in rural Rwanda in 2015 to evaluate whether the provision of education, training and mentorship to CHWs and nurses can enhance breast cancer detection. Analysis of results showed that CHWs’ knowledge about breast cancer risk factors, symptoms, and treatability showed a significant 18.8% increase after the training (Pace et al., 2018). Further, about 77% of the CHWs had no formal primary school education and after training, an average of 98% of the CHWs led education sessions with their communities and talked to their clients about breast health and breast cancer (Pace et al., 2018).
Increasing control of cervical cancer in developing regions includes increasing the access to the HPV vaccine and implementation of screening programs within the regions; taking into consideration the cultural factors and shortage of resources.
CHWs are and will continue to play an integral role in educating, identifying, referring, screening and testing women for the prevention of cervical cancer. And there is proof that integrating the control of cervical cancer with communities, health clinics, local leaders, civil society, district hospitals and national governments is working. A study conducted in the region of Jujuy, Argentina — an area which had the highest mortality rate for cervical cancer, revealed that training CHWs to educate women, provide self-collection kits and deliver the used kits to health centers not only increased coverage of women but led to the quadrupling of screening among women (Saraiya & Senkomago, 2015).
Therefore, community members can be trained to become the center of health systems in developing and rural areas. They can fill the gap in the shortage of skilled health workers, strengthen heath systems, and be the bridge between remote, rural and poor communities and the public health sector. In addition, they can assist in the treatment and prevention of both communicable and NCDs.
Dr. Farmer’s comment on the single intervention of hiring and training CHWs that will improve the health outcomes of those living in poverty echoes the reality that when communities are actively involved in defining their own needs, prevalent health issues can be treated and problems prevented, often by the people themselves and with little education and minimal assistance.
PIH continuously recognizes the importance of CHWs in ensuring that critical resources reach the intended beneficiaries, and has collaborations with several partners to fulfil their mission. Partners in Health has over 12,000 CHWs who perform diverse functions across the globe and form the foundation of the organization’s community-based approach to overcoming barriers to heath care.
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