Time to boost community-based health worker programs in low-income countries

As we all work together to overcome the current global COVID-19 pandemic and be better prepared for future ones, it is important to embrace the opportunity afforded by this crisis to “build back better,” as President Biden says, — not only for global health security but also for accelerating health improvements and socio-economic development for the poorest of the poor around the world.

Now is the time for the United States to provide financial and technical leadership in reducing the “evidence-practice” gap in expanding the coverage of the broad range of low-cost basic and essential preventive and curative interventions that communities and community health workers (CHWs) in low-income countries can provide. A conservative estimate is that CHW programs provide a 10-to-1 return on investment — including the benefits they can provide by early detection of disease outbreaks and control of future pandemics. And the return on investment is not only in economic terms, but also in equity terms. The poorest of the poor are the ones who will receive the greatest health benefits from such programs. And by providing women from poor families a living wage as a CHW, the benefits in terms of empowerment and reduced gender inequity will be substantial not only for them but for their children as well.

The countries of the world came together in 2015 through the United Nations and adopted the Sustainable Development Goals to be achieved by the year 2030. These include, among other things, ending preventable child and maternal deaths as well as making basic and essential health care available to all. At present, 7.5 million mothers as well as their babies and young offspring are dying each year, mostly from conditions that are readily preventable or treatable. Another 4 million deaths are occurring each year from TB, HIV, malaria and lack of essential surgical care, also conditions that are readily preventable or treatable. At least half of the world’s population lacks access to essential health services. At least half of the world’s population lacks access to essential health services.

We are almost at the half-way point of the 15-year timeline for achieving these goals, but without a marked acceleration in progress we will miss the mark. Now is the time for concerted and renewed additional action, and now is the time for the United States to provide moral and financial leadership.

The moral and financial leadership provided by the United States in 2013 and since through its funding of the President’s Emergency Plan for AIDS Relief (PEPFAR) has saved some 20 million lives and has reaffirmed to people throughout the world that the United States cares about them. We can save even more lives through accountable, transparent and cost-effective investments in CHWs and community health.

Currently, more than one-half of the populations in low-income countries do not have access to many evidence-based life-saving interventions that communities and CHWs can provide, and these people are less educated and poorer, further away from health facilities, and at greater risk of death.

A truly exciting opportunity now awaits the world to reverse this chronic “silent” pandemic that dwarfs the current COVID-19 pandemic in severity by an order of magnitude. Science and rigorous programmatic evidence accumulated over the past two decades tell us millions of lives can be saved each year by stronger community-based programs that can be implemented by community health workers (CHWs) and the community itself.

Properly trained and supported CHWs can provide doorstep advice and support to adopt healthy household behaviors. CHWs can provide critical services such as the management of serious childhood illness — including pneumonia, the leading cause of child death in the world today. Additionally, CHWs can offer family planning services, which save the lives of mothers by preventing maternal deaths among women who did not want to become pregnant and save the lives of children as a result of the many proven benefits of birth spacing. CHWs can also  identify and treat of high blood pressure, which is the leading modifiable risk factor for disease and death in the world today, promotion of better maternal and child nutrition, and can assist with many more life-saving interventions.

The world has been tragically slow in applying this evidence. Since 2007, only 2.5 percent of donor assistance for health in low-income countries has been focused on CHW programs, and most of this support has been for specialized CHWs to work in vertical programs focused on a few priority diseases rather than strengthening CHW programs to more effectively address a broader range of priority conditions for today and tomorrow.

The vast evidence-practice gap is no longer morally or ethically acceptable. By building stronger CHW programs and guiding the community in actions that they can take, this gap can be narrowed, saving millions of lives.

The world has been slow to recognize that so many lives can be saved by building strong CHW programs and by engaging communities in improving their own health. Training more doctors and nurses will be important, but this takes time. CHWs can be trained quickly and can be effective in preventing and managing most common diseases and conditions, and they can also do what clinic-based providers cannot do — reach out to the homes of families, the most important place arguably for addressing the source of where diseases start and where they can best be addressed early on.

The COVID-19 pandemic aside, readily preventable or treatable diseases and other conditions will cause millions of deaths in low-income countries in 2021, and millions more will likely die each year thereafter. Is this the legacy we want to leave our children and the world? Without concerted actions from all of us, future generations will ask, just as so many of us ask now about the moral stain of slavery and subsequent racism, why didn’t we do more and do it earlier to prevent this tragedy — especially when the remedy is so quick and easy to implement at a cost to save a life that is only a tiny fraction of what we spend in the United States to save a life? Now is the time to launch a PEPFAR-like program for Universal Health Coverage that is focused on strengthening health systems that have as their foundation strong CHW and community health programs.

Henry B. Perry, MD, PhD, MPH, is a senior associate at Johns Hopkins Bloomberg School of Public Health’s Department of International Health and an expert in community-based primary health care, child survival interventions and NGO-led field programs.