Tuesday, October 9, 2012

Kiva Innovations: Funding community health workers on the front lines of global health

Since the 1980s, “Health for All” has been a rallying call in the global health community to make health care available and affordable to everyone.

More recently, the United Nations' Millennium Development Goals called for universal access to treatment for HIV/AIDS and reproductive health, and reductions in the under-five mortality rate, the maternal mortality ratio and global malaria rates.

Unfortunately, as we're all too aware in the United States, equitable access to healthcare is a mammoth challenge.

Recruiting community health workers

One solution, particularly in developing countries, is to train community health workers. These individuals have come to play a crucial role in addressing the shortage of health services, especially in remote areas where medical access is limited or nonexistent.

According to the World Health Organization (WHO), the term “community health worker” encompasses a broad spectrum of individuals in terms of training, age and literacy. That said, a key requirement across all community health workers is that they're trained to work specifically in the communities where they live. 

Community health workers are often (and ideally) selected by communities themselves and undergo shorter training sessions than professional health workers. Because they have such strong links to their local communities, they're able to respond to local norms and customs and help facilitate community acceptance of health interventions.

China’s barefoot doctor movement

The strategy to employ community health workers was largely popularized by China’s barefoot doctor movement, which began in the 1950s. At the time, China had only 40,000 physicians trained in Western medicine to serve a population of 540 million people. That’s one doctor for every 13,500 people. By comparison, in the U.S. today, there’s one doctor for every 320 people (and that’s high compared to countries like Israel, Italy and Belgium). China's physicians were also concentrated in urban areas even though the population was 80% rural at the time.

In response, Mao Zedong began to train community health workers to treat patients and organize sanitation campaigns in rural areas. This program proved so successful, they started to cure schistosomiasis (a disease caused by parasitic worms) at high rates. These health workers were selected and paid for by their own villages and underwent an intensive 3 to 6 month training program. With limited instruction, most were able to provide basic health care, teach hygiene and sanitation and know when to refer more serious cases to physicians at health centers.

In the 1970s, the WHO began to look to China’s program as a model for delivering health care to rural populations, and it's become the inspiration for the community health worker phenomenon.

Community health worker programs today 

Community health worker programs are not a silver bullet. They're not necessarily cheap or easy to implement, and it's difficult to guarantee quality of service. But there is evidence that -- when undertaken thoughtfully with proper selection and training -- they can improve health outcomes in remote areas, particularly when the alternative is no care at all. This is especially true when it comes to child health.

For example, one of the most successful community health worker programs, Programa Agente Comunitário de Sáude, is in Brazil. It began in the state of Ceará, where health workers served 65% of the population for about $1.50 for each person served. The program is linked to a 32% drop in infant mortality within five years.

The program consisted of community health agents who would train for three months before being assigned to make monthly visits to 50 to 250 households. They provided services like prenatal care, vaccinations and checkups. The government has since adopted the program on a national level, and community health agents currently provide services to 60% of the population. Since then, the program has continued to be associated with improvements in health outcomes, particularly in infant mortality.

Community health worker-staffed “health houses” in Iran have also been very successful. These houses are designed to provide aid to 1,500 people within an hour’s walking distance, and are responsible for providing basic preventative health care and referring more serious cases to rural health centers and district hospitals. In fact, as highlighted in a recent article in The New York Times, the success of Iran’s health houses inspired the founding of HealthConnect, a program that serves the Mississippi Delta population through door-to-door community health workers.

There has also been a great deal of success outside of government-run programs. One highly-lauded health organization, Partners in Health (PIH), attributes its effectiveness to its 8,000 community health workers. These employees are responsible for providing basic child and maternal health care, and for ensuring that patients with demanding drug regimens adhere to their schedules. PIH has found that community health workers play a key role in their retention of patients with HIV/AIDS.

The financing challenge

One major hurdle for these programs, highlighted in this opinion piece, is financing. Many community health worker programs fail because they depend on funding from outside donors and can't sustain themselves otherwise.

Kiva is interested in exploring how our lenders could support community health worker programs that are in need of small-scale financing. While any loan intervention would have to be demand-driven, some potential fits could include loans to health workers for start-up kits, or for smartphones and other information technology products that are used by health workers when they visit patients.

If you're interested in partnering with Kiva in this area, please contact our community support team at contactus@kiva.org. Also stay tuned for future posts on how Kiva is exploring engagement in health access across the globe!

Rebekah Chang is an intern for Kiva’s Strategic Initiatives team, looking for new partners and loan products to extend opportunities and access to more people around the world. Rebekah has an M.A. in Development Economics and Conflict Management from Johns Hopkins University School of Advanced International Studies. Send her your feedback on this blog series at blog@kiva.org.

This is part of a larger series on Kiva’s strategic initiatives and innovative loan products that are designed to expand opportunities for more borrowers around the world.

Image courtesy of IamEmpowered.