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The Frontline Warriors of Global Health – Community Health Workers

By Lotta Velin and Elizabeth Miranda

“They do the work we can’t do; they are our eyes and our hands.”

Rose-Marie from Haiti is speaking about the frontline heroes of global health: the community health workers. This is a voice far removed from the echo chamber that global health conferences can easily become. During the Women Leaders in Global Health Conference in Kigali, in early November, we had the privilege of listening to an eye-opening panel consisting of five Community Health Workers (CHWs): Florence Mukantaganda from Rwanda, Featha K. Reeves Kolubah from Liberia, Adey Tilahun Techane from Ethiopia, Pushpa Rathod from India and Rose-Marie Renaty from Haiti. Over the prior three months, we also had the opportunity to collaborate with seven CHWs on a large, prospective study being done in the rural Kirehe district of Rwanda, looking at ways to combat surgical site infections in women after cesarean section deliveries. And between these two experiences, the value and importance of CHWs in global health has never been clearer.

The direct clinical benefits of having a strong CHW network is often talked about and is indisputable. Even in regions where adequate infrastructure is in place, many people are unable to access care when needed due to financial reasons. Every year, hundreds of millions of people are driven below the poverty line due to catastrophic health care expenditures. This is a fact even in countries such as Rwanda where, despite efforts to provide universal health coverage with the impressive national health insurance Mutuelle de Santé, the cost of transport to the nearest health center or hospital is more than many can afford. In ensuring effective distribution of currently available services, CHWs may be our best ally. They undergo training to acquire key skills for health maintenance and disease prevention, and they play an especially important role in maternal care delivery. In fact, the minister of health in Rwanda has also credited CHWs for the eradication of cerebral malaria and reduced infant mortality due to diarrheal disease.

But the value of CHWs extends beyond the clinical sphere – they are also essential when it comes to developing new global health research and national and international health policies. As Adey from Ethiopia described, CHWs are key in collecting data from those hard-to-find patients and communities and turning it into information that can be reviewed by governments and non-governmental organizations (NGOs). We have seen it time and time again with our CHW team in Rwanda – these women know which patients will be hard to find, which roads would be best to take, which local CHWs or community members they should contact to find those patients. They have inside information that raises the quality of the project data. Adey also described the monthly reports the CHWs compile based on their work and experiences to share with the ministry of health or community leadership. These reports are then used to frame new health policies and to fund new public health interventions.

CHWs are also helping with the global push towards the fifth UN sustainable development goal: achieving gender equality and empowering women. The majority of CHWs worldwide are women and this can be an asset when delivering healthcare. Featha from Liberia suggested that male CHWs may face cultural barriers when, for example, coaching women on breastfeeding. She also described that, in many cases, men do not want their wives to be cared for by other men, and in these cases, having a female CHW available is essential. The majority of women do this work for a very small stipend or, in some cases, completely pro bono, since the few paid CHW positions that exist are largely held by male CHWs. This work requires long hours and keeps CHWs from performing other income-generating activities, and yet they continue to volunteer, all for the sake of the health of their neighbors. Female CHWs take on these physical and economic barriers while facing social challenges that their male counterparts might not. As Featha described, CHWs often face resistance from their husbands regarding the long hours their roles require, and this tension can put them at higher risk of experiencing gender-based violence in their own homes. Despite all of these obstacles, women continue to step up and take on the responsibility of serving their communities’ health. Female CHWs not only improve and maintain the health of their fellow women, but they also serve as role models to the women and girls in their communities, proving that they are just as capable of performing these duties as their male counterparts, if not more so.

In the words of Pushpa from India, CHWs can act as “the bridge between the government and the health system and vulnerable people”. They have knowledge and experiences that many working in the global health sphere do not - knowledge that cannot be read in a book or taught in a classroom. And their value lies not just in the clinical care delivery, but also in the fields of research, policy making, and advocacy for health equity and gender equality. Because of this, it is essential that they are included in all conversations regarding strengthening of their countries’ healthcare delivery systems. Additionally, CHWs must be supported, both financially and socially, for the crucial work that they do. Mobilizing funds and providing educational and social resources for CHWs needs to be prioritized. Women like Florence, Featha, Adey, Pushpa, and Rose-Marie have proven time and time again that they are strong, dedicated, determined, and essential to defending the health of their countries. It is high time to recognize their value and reward them accordingly.

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