We have a global health worker shortage of 4.5 million, and unsurprisingly, the shortage is most acute in low- and middle-income countries. Sub-Saharan Africa has 11% of the world’s population, 24% of its disease burden and 3% of its health workers (PDF). If you want a good visual of this, head back to Cynthia’s post from last May. Rural areas are worse off, and “brain drain” has exacerbated the issue, all while medical interventions and treatments are becoming more complex and multi-step. For example, the WHO Guidelines for prevention of mother-to-child-transmission of HIV (PMTCT) were updated in 2010 to reflect the newest knowledge around prophylactic antiretroviral treatment, infant feeding, and other issues. The guidelines certainly are an improved approach to PMTCT–but they also add on to the many tasks already assigned to a nurse offering support, education, and treatment to a pregnant woman or new mother living with HIV. The shortage has existed for a good long while–but the crisis is getting worse.
Apart from training new doctors (six years), nurses (three to four), and midwives (four), one of the most popular solutions to the global health workforce deficit has been to use community health workers (CHWs), local people trained to do basic medical tasks and treatments, bring patients from their communities to clinics for care, and a host of other activities. CHWs address three key issues:
The history of the modern CHW goes back at least as far as the barefoot doctor program in China in the 1950s and 60s. Barefoot doctors were farmers trained in basic hygiene and health to provide care in rural areas, where doctors refused to work. Various incarnations of the CHW began to multiply in resource-constrained settings, but most programs were wiped out or significantly curtailed following the economic recession and the subsequent (disastrous) development interventions of the 1980s. More recently, however, they’ve been making a comeback as “task shifting,” “health systems strengthening,” and other terms have gained significant buzz status.
The continuing trend, however, is to keep CHWs as volunteers. This, of course, is cheaper for governments and organizations. Often there are problems in the health worker hierarchy around paying CHWs. Although CHWs (and patients) may see the role as a vital part of the health system, other health workers may not. However, a common sentiment is that “financial incentives can destroy the spirit of volunteerism and work against the volunteer philosophy of a sense of community.” My feeling is that it’s one thing to ask a college student in the United States to spend some volunteering at the soup kitchen between classes. Asking a mother of five living in a mud house with no water or electricity and struggling by on subsistence farming is something else. It’s certainly not sustainable (and neither, by the way, is it possible to retain the college student as a volunteer in the long-term–though no one pretends that it is).
One of the biggest champions of paid community health work is Partners in Health (PIH), which has CHW and peer educator programs from Haiti to Boston. Not only does the organization argue that fair compensation is a moral imperative (and a jump-starter for economic activity), PIH claims that during the 2004 Haitian coup d’état, not a single HIV/AIDS client missed a dose of antiretroviral treatment. My own organization has also maintained its commitment to paying its trained “Mentor Mothers,” mothers living with HIV who help other HIV-positive pregnant women and new mothers navigate the PMTCT cascade.
Even the WHO has gotten on board. In a 2007 booklet (PDF), the WHO also stressed that “task shifting should generally be promoted for its potential for improving services–not saving money.” In 2008, it recommended:
Countries should recognize that essential health services cannot be provided by people working on a voluntary basis if they are to be sustainable. While volunteers can make a valuable contribution on a short term or part time basis, trained health workers who are providing essential health services, including community health workers, should receive adequate wages and/or other appropriate and commensurate incentives.
However, donor and host governments and NGOs haven’t caught on, for the most part. The fact is, however, that volunteer CHW programs tend to see higher rates of attrition. And, even if a program is cheaper because it’s using volunteers, it has to invest more time and money into recruiting and training new volunteers–not to mention that it will have a harder time measuring their impact. There are, of course, a host of issues to address down the road, for example, establishing paths for upward mobility comes to mind as a problem. But what’s clear is that, for now, CHWs work and they work best when they’re paid.
This is a difficult thing to say in a time of global economic recession, and I know that development and public health types are always crying out for more funding for their specific projects and issues, but health systems strengthening must be addressed now–and bigger investments in HSS must be made now. This insistence on volunteers instead of fairly compensated peer health workers flies in the face of logic, further divests local people from ownership of their health systems, and deepens inequalities. Volunteerism should be seen through the lens of the privilege of choice (much like, for example, non-religious vegetarianism), not the lens of requirement. It is unfair to deny local people paid jobs because donors don’t like the idea of a higher salary percentage on a budget.
Although CHWs will not fully replace doctors and nurses, they can help relieve the task burdens under which current health care workers struggle. We will not be able to fill the gaps left by too few doctors and nurses in resource-constrained settings. Not any time soon, anyway. CHWs, if recognized as part of the health system and fairly compensated for their work, are given skills, professionalized, and empowered to contribute to their communities’ right to health. This has always seemed like such a no-brainer. Pay people for their work.
