Strengthening and sustaining community support for community health workers: A conversation with Dr. Ram Shrestha
(Dr. Shrestha at the marketplace during ICHC 2017. Photo by Shayanne Martin, USAID)
Shayanne Martin: In the last few years, we’ve seen a number of global health events that have increased our reliance on community health workers (CHWs). Now that Test & Start HIV treatment guidelines call for all people living with HIV to begin treatment once diagnosed, CHWs are critical to bringing HIV services--such as testing, counseling and medication delivery--to the community. CHWs have also proven their value in overcoming recent global health threats.
During the Ebola crisis, CHWs played a critical role tracking the spread of the virus and teaching communities about proper quarantine and safe burial practices.
CHWs have also been integral in the Zika response, educating communities about how Zika is spread, effects of the virus, prevention methods and what to do if infected. Even more, out in the community, CHWs are on the frontline responding to health emergencies and improving access to care. However, CHWs can get caught working between the community and health facilities without full integration or connection into either environment, making performing their job extremely challenging.
In a 2014 World Health Worker Week interview, Ram Shrestha and Rhea Bright discussed using a community health system strengthening approach which engages existing community groups to support the community health workforce. The USAID ASSIST project, through support from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), has applied this approach to improve service delivery needs across health areas, including HIV. As we celebrate World Health Worker Week this year, it’s an opportune time to examine what progress has been made over the last three years to support CHWs.
In this interview, Rhea and I follow up with Ram to learn more about his efforts supported by the USAID ASSIST project to strengthen linkages between communities and health facilities and reduce the workload of CHWs.
Rhea Bright: As we reflect on remaining challenges, can you describe some areas in need of improvement that still affect the community health workforce?
Ram Shrestha: There are still weak linkages between communities and health facilities and CHWs are not always integrated into the community system. CHWs may have to go door to door to reach people, which can be difficult without transportation or the community's support for their work. As a result, CHWs may be poorly motivated and there could be low uptake of services by community members. This is especially challenging for HIV programs that need to reach a lot of people for testing and treatment. If a CHW is only going door to door, the CHW does not have enough time to deliver proper counseling and client support to all households in need. However, if the CHW can access community groups that can encourage members to get tested for HIV and to stay on treatment, the program is able serve more people living with HIV.
Another challenge is the reliance on non-governmental organizations to deliver services. In instances where donors and non-governmental organizations start implementing activities without building onto the existing system, results are achieved. However, I have often witnessed that after a program ends, the problem returns because it was only temporarily addressed through ad hoc interventions.
The community health system strengthening approach strengthens the linkage between the community and health facility by utilizing existing community groups, so that if a program ends, community members can maintain a pathway to care. More research is needed to understand how this community system approach can be used to bring even more people for testing, as well as increase male partner involvement, adherence and retain more people on treatment.
Shayanne: In light of those challenges, what progress and successes have you observed using the community health system strengthening approach over the past three years?
Ram: We continue to see progress in countries that are using USAID ASSIST’s community health system strengthening approach. For example, in villages in Botswana, we see health workers being supported by existing traditional structures, community groups and social networks. A community improvement team (CIT) in Palla Road village includes representatives from existing formal and informal community groups, a local chief and health facility staff. The team has been working to improve retention of people living with HIV in care and treatment. During a quality improvement team meeting in the village, the team worked with health facility staff to identify gaps in care. It became apparent that some people were not returning to care for antiretroviral treatment. CIT members brainstormed ways to maintain confidentiality and protect patient identity when locating and referring patients back to the facility. This was a sensitive area because of the confidential nature of patients’ HIV status. The teams came up with the idea of healthcare workers visiting those patients, while other CIT members conducted health education talks in the village. Out of 23 patients who had not returned for care, within a month 14 were located; one had passed away and 13 returned to care. Using the CIT, the health system was able to expand the reach of health workers and increase utilization of HIV treatment.
Rhea: Sustainability is a fundamental component of USAID’s work. We believe that sustainability has been achieved when host country partners and beneficiaries are empowered to take ownership of development processes, including financing and maintaining project results and impacts beyond the life of a USAID project. Seeing how the community health system strengthening approach builds on the existing community system, are there country examples where sustainability has been achieved?
Ram: In Mali, the USAID ASSIST project implemented the community health system strengthening approach to address anemia in pregnancy. The original activity focused on identifying pregnant women in the community and referring them to antenatal care to receive iron tablets. We started the project in a few villages, but we are finding that the approach is spreading to other villages without additional donor support. Women’s groups in neighboring villages initiated a process to replicate the antenatal care improvement activities. They reached out to the villages to learn how to implement the community health system strengthening approach and to set up quality improvement committees. Without external technical assistance or financial support, community groups in non-intervention villages are independently participating in monthly village committee meetings and are identifying and referring pregnant women to the community health center.
Rhea: Hand in hand with sustainability, USAID also aims for communities to be responsive and resilient. In the context of emergency situations, such as Zika or Ebola outbreaks, what are the benefits of focusing on strengthening community health systems?
Ram: All of the groups that are included in the community health system strengthening approach meet monthly on their own. All the while, the health quality improvement committee, which is comprised of one member of each participating community group, also meets regularly to discuss health issues affecting the community and the messages they should disseminate through their network. This community engagement creates strong links between households, the community and the health system.
When natural disasters or health emergencies happen, the quality improvement committee members are well-positioned to understand the community's needs and link community members to health services.
Community groups can absorb the shock of disasters and emergencies and increase community resiliency. For example, when Nepal suffered the massive earthquake in April 2015, local groups organized to identify and recover people buried under the rubble before any military or international groups could activate a response. External help was needed because of the scale of the disaster, but the community system strengthening approach strengthened the response.
Similarly, strong health systems and facilities connected to households by CHWs are better prepared to handle emerging pandemic threats like Ebola and Zika. ASSIST is beginning to apply the community health system strengthening approach to improve community resilience in the face of Zika in the Latin America and Caribbean regions.
Shayanne: Similarly, thinking ahead, how else can this model of community system strengthening be applied to achieve greater impact beyond the health sector?
Ram: Implementing partners often support Civil Society Organizations (CSOs) to implement programs, creating a project community structure. If CSOs are linked to the existing community system, CSOs and community groups can collaborate to rapidly provide services to more people and strengthen the connection between villages and health facilities.
In Lesotho, with funding from PEPFAR, ASSIST is expanding the community health system strengthening approach to orphans and vulnerable children (OVC) and social services. CSOs implementing the OVC program have joined the community quality improvement committee to ensure that OVC receive healthcare, education and legal services. Community groups identify OVC not linked to health facilities, not in school or not receiving appropriate legal support and protection and refer them to the CSOs. Before this approach, the OVC program was considered separate from the health system. However, now it has become apparent that it is ideal for social services to be integrated into the health system.
Using the community health system strengthening approach, we expect that the number of children reached by the OVC program will increase without any increase in costs.
It is a great model for maximizing investments across development priorities and building community responsiveness to challenges beyond health.