As the Save the Children 4-wheel drive struggles to tackle the slick, red mud of the main road to a health centre in Lomami province in the Democratic Republic of Congo, we pass burned-out villages amid the undulating green countryside of rainy season.
It takes two hours to travel just 30 km. For the community health workers operating in this area, providing health services to families in nearby villages, who are often displaced and difficult to reach (even by bicycle), is a daily challenge – and a key part of their role.
Community health workers are members of a community, chosen by the community to provide basic health care services – such as identifying and treating common childhood illnesses like pneumonia, diarrhoea and malaria.
I’m here in DRC to conduct research into what keeps community health workers motivated and willing to stay in the job despite the challenges they face. Given the physical and political obstacles to working in the area, it feels like our research couldn’t be more relevant.
A critical part of the health system
We know that community health workers are one of the most effective ways to bring healthcare to poor people, particularly in rural, remote communities, and for maternal and child health. They help overcome the ‘last mile’ challenge, bridging the gap between health centres – which can be few and far between – and children in need.
Some governments have been stepping up their efforts to support community health workers – Sierra Leone, for instance, launched a new community health worker policy earlier this year, recognising their critical role in the health system, and the enormous contributions they made during the Ebola crisis.
However, big challenges remain – particularly at the operational level. How should community health workers be embedded in the health care system in ways that are adapted to local context, effective, and sustainable?
Our research into community health workers looks at their impact, the challenges they face and what Save the Children, our partners, and other NGOs can do to address them.
“One of our own”
As part of our partnership with GSK, Save the Children is training community health workers in 16 countries, mainly in West Africa. We’ve done a lot of work to ensure the effectiveness of our training and supportive supervision to health workers, so that they have as much impact as possible during the life of the project.
That impact comes across clearly from talking to local communities. In Lomami, the community sees a community health worker as “one of our own”. Earlier this year, as violence spread through Kasai, Lomami and Kasai-Oriental provinces, the value of this was enormous. During the conflict, community health workers fled with their own communities – and were able to continue to provide health services and advice even while families were hiding in the bush.
The community members that we meet in Lomami are fiercely protective of their community health workers, raising examples of when their health workers have been unfairly overlooked or excluded from a health activity. Clearly, community ownership of community health workers is key to their success.
The perennial question of sustainability
But what happens after the project finishes? Although we design and implement our projects in a collaborative way with governments and communities, and include advocacy on health worker financing as part of our work, the retention of health workers over time remains a significant concern. What’s the secret to retention and motivation?
In October, we talked to community health workers in Côte d’Ivoire. Many spoke of the opportunity to fulfil a childhood dream of being a health professional. Others noted the importance of their interactions with the village nurse to their personal enjoyment of the job.
Conversely, some community health workers we heard from in DRC felt they were not recognised as having a formalised role in the health system. They have no ID badges. They’re not always included in local health activities. And they’re sometimes required to pay for other children’s health care from their own pocket when they refer them. These were the key drivers to some community health workers leaving the job.
This suggests that formal recognition of the cadre of community health workers within the health system (through reimbursement of work-related expenses and issuing formal IDs or uniforms, for example) can make or break their motivation – and therefore retention.
What needs to be done?
What does this mean for Save the Children, our partners, and other NGOs as we work to support community health workers?
It suggests we should be acknowledging that their effectiveness within the health system relies on shared ownership between local communities and the Ministry of Health. Both of them need to trust and recognise the value of community health workers in order for them to deliver high-quality health services.
The role of Save the Children and other NGOs – and a core component of our project activities – should be to facilitate and strengthen those relationships in order to improve the sustainability of community health worker programmes. The role of the Ministry of Health should be to provide effective stewardship, governance and policy frameworks, and allocate adequate and sustainable financing to scale-up coverage of community health worker programmes.
I’ll be travelling to two more countries later in the year to collect similar information, and we’ll use the findings, together with GSK, to inform and strengthen the design and implementation of our programme in West and Central Africa, and influence national policies around human resources for health. Watch this space for further insights!