It’s mid-morning in the Tiby Millennium Village in Mali. Winds from the desert are gusting across the parched landscape. Rokia, a community health worker in the village, sits with a young mother in a spare courtyard of the household. Gently she asks the key questions: “How are your children today?” “Are the bed nets in good shape?” “Are you getting enough to eat?” She playfully coaxes the three-year-old daughter to put out her arm to have it measured. The results are excellent: in the “green” on the tape measure. No signs of acute under-nutrition.
This household is fortunate on this day. The children are healthy; the bed nets are in place and being used; and the young mother is on time with her antenatal visits. Rokia often faces an urgent condition: a bout of malaria needing a quick confirmed diagnosis using one of her rapid-diagnostic tests, an undernourished child, a pregnant woman who has not yet gone for an antenatal visit. Rokia will be ready. She carries a backpack with diagnostics, oral rehydration solution and zinc, oral antibiotics, flip charts, and a handbook. Her mobile phone is already at hand, to call the ambulance or clinic, or to text the expert server to get information on dosages and other recommendations.
Rokia is a proud and capable member of the new generation of community health workers (or CHWs) who are increasingly on the frontlines of disease control in rural Africa. Doctors and nurses are still few and far between. The United States, Western Europe, and the Middle East are giant vacuum cleaners that suck up Africa’s doctors and nurses (and skilled health workers from other low-income regions) with enticements of vastly higher salaries. Africa loses twice by this brain drain, incurring a chronic shortage of doctors and nurses while also incurring the financial loss of all of the training the government has invested in them.
CHWs are different. They come from within the rural communities, typically young people with around eight to twelve years of schooling. They don’t qualify for medical positions abroad and are therefore not subject to the brain drain. Yet when properly trained and supported as part of an organized local primary health system, CHWs save lives on par with the doctors and nurses. They are warmly embraced by the community, and bring trust and cultural knowledge and sensitivity to topics such as childbirth, contraceptives, and family planning. And of special importance, they reach vulnerable individuals (the very poor, remote, elderly disabled) and groups (such as ethnic minority groups) that otherwise would not reach out to clinics for help.
My colleagues and I at the Earth Institute at Columbia University have been working with African public health specialists in Africa to strengthen the capacity of the CHW system. When we began the work in the Millennium Villages in 2006, Africa’s community health workers were generally unpaid, untrained, unsupervised volunteers with no diagnostic or therapeutic capabilities. They took great pride in their work but had very little capacity to save lives and improve community health.
Their role then was mainly to spot sick individuals in the community and to help them find their way to the nearest clinic and to encourage preventative care (such as vaccinations and antenatal visits). Even these limited tasks were often fruitless, since the nearest clinic might be 15 km away, without ambulance or phone connection. The clinic might charge an unaffordable user fee, and often was bereft of basic laboratory equipment such as a microscope to diagnose malaria, or drug supplies to treat presumed illnesses.
All of this has changed dramatically in just a few years thanks to the lessons learned in the Millennium Villages and other studies and programs. Now the CHWs are seen to be a key part of a functioning primary health system. This system should include a clinic within short walking distance, with supplies, a skilled birth attendant and other staff, electricity, and safe water; an ambulance for emergency transport; an emergency “911″ number; a policy of free care at the point of service (so as not to turn away the indigent); and trained and remunerated CHWs, taught also to treat diseases and save lives in the community.
Mobile phones have become the new “virtual stethoscopes” of the CHWs. The phones provide link the CHWs to the entire health system, including an expert automated system that informs the CHWs about drug doses, test results, and dates for repeat antenatal visits and vaccinations. The Millennium Villages deploy a powerful mobile system called ChildCount+ that can guide the CHW through malaria treatments, nutrition advice, how to pick up danger signs and refer patients to clinic, and other aspects of health care.
Last spring, the Earth Institute hosted around two-dozen leading organizations in a Technical Task Force on Community Health Workers to describe the cutting-edge “best practices.” The report not only described the breakthrough areas for CHW activities but also described the costs of deploying such a system (around $6 per person in a community covered by CHWs). The Task Force called on the world community to help low-income countries to scale up the mass training and deployment of CHWs.
Specifically, the One Million Community Health Workers Report called for 1 community health worker per hundred households throughout rural Africa, roughly 1 CHW per 500 people (since there is an average of five persons per household). With around 500 million people in rural sub-Saharan Africa, that suggests a total of 1 million CHWs to cover all of rural Africa, and a continent-wide modest cost of around $3 billion per year. It’s thrilling that now many leading health organizations are also now calling for a mass scale up of CHWs.
The Global Fund to Fight AIDS, TB, and Malaria can easily cover much of the costs of deploying CHWs throughout Africa. Leading pharmaceutical companies including Glaxo Smith Kline, Novartis and Merck are also taking leadership. The benefits of deploying 1 million CHWs will be huge. Africa’s rural population will gain access to life-saving health care. The rural economy, especially agribusiness, will benefit as malaria, TB, AIDS, and other killer diseases recede. And the world will gain greater security. Today’s violent conflicts occur in fragile states, often those gravely weakened by disease. Healthier societies can more easily get back on their feet
The campaign for 1 million CHWs has begun. Become part of the effort. Join the ONE Campaign. Contribute to the Global Fund. Follow the Millennium Villages Project. Study public health. Volunteer. In countless ways, you can be part of the great global effort to ensure health for all.
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