Economic, social and geographical barriers prevent at least half of the world’s population from accessing the essential health services they need.

On the African continent, dispersed populations are often separated by great distances from their nearest health care facilities, with 83% of people living in rural communities having no access to primary health care services at all.[1] These emerging economies also have far fewer medical resources to begin with. The continent averages one doctor per 3,324 people, compared to one per 293 in Europe.[2] Compounding these issues is expenditure. Over 800 million people spend at least 10% of their household budgets on health expenses for themselves, families and communities, sending 100 million of those people into extreme poverty.[3] Ultimately, these barriers significantly deter health seeking behaviours, which are linked to worse health outcomes, increased morbidity and mortality and poorer health statistics.

Community Health Workers (CHWs) across Africa are helping to counter these challenges by plugging shortage gaps, strengthening health systems and supporting the achievement of universal health coverage. According to the WHO’s definition, CHWs are ‘health care workers that are members of the communities in which they work. They are supported by their country’s health system but not necessarily a part of its organisation and have shorter training than professional workers.’

The Boma Health Initiative (BHI) in South Sudan 

CHWs are particularly instrumental in enabling citizens to access primary health care in low-income and fragile contexts where populations are spread out in remote, rural areas. No more so than in South Sudan, where Crown Agents is managing the Health Pooled Fund (HPF) programme. With 90% of the population living in rural areas, and with over 56% of the population living more than 5km from a health facility, accessing health services is challenging. The rainy season and insecurity further exacerbate access by restricting the movement of people.

The Boma Health Initiative (BHI) is the country’s flagship community health policy, which is operationalised with support from HPF, and plays a critical role in ensuring marginalised communities can access basic medical services. Boma Health Workers (BHW) are trained on a standardised package of health services to support to their communities. This includes safe motherhood, family planning, sexual and gender-based violence, and identification and treatment of simple illnesses such as pneumonia, diarrhoea, and malaria in children. Having a trained BHW embedded in the community means that care is available on their doorstep. This cuts down travel time and provides ease of access to basic services. On average, this initiative enables over 150,000 children a month in South Sudan to be treated for illnesses such as malaria, pneumonia and diarrhoea.

Addressing key health issues in communities

CHWs can also support in addressing key health issues in their communities, including non-communicable diseases. CHWs have been key in Crown Agents’ work to control and eradicate Neglected Tropical Diseases (NTDs). These diseases are often water-born, and therefore education on WASH and sanitation habits are vital for achieving eradication. Over 18 months, we delivered training on the prevention of NTDs to 10,000 CHWs across Ethiopia, Kenya and South Sudan. This enabled them to deliver public health messages on the importance of hand and face hygiene. 251,000 Community Drug Distributors were also upskilled to distribute critical drugs during Mass Drug Administrations to prevent NTDs and to provide educational information on the medicines. This upskilling of CHWs provided them with an additional tool that they can continuously use to improve the health of their communities.

A trusted partner

CHWs are often selected by their communities as a trusted individual. They are therefore able to provide the best understanding of local nuances and where there are cultural barriers to health seeking behaviours, CHWs can sensitively address those issues taking into consideration traditional customs and norms. In Zimbabwe, CHWs have been vital for helping to combat vaccine hesitancy in rural communities. Through our Results Based Financing Programme, we have trained over 20,000 CHWs to disseminate vaccine information materials in two vernacular languages, Shona and Ndebele. These interactive sessions often include drama and role plays as well as opportunities for community members to ask questions. This interaction between CHW and community member has a bi-directional benefit. It upskills the health literacy of a community as well as providing communities with health services where they reside.

Surveillance, prevention and treatment of COVID-19

The Covid-19 pandemic has also highlighted the important role CHWs play in disease surveillance, prevention and treatment of symptoms as well as educating communities. CHWs have helped to rapidly spread awareness of Covid-19, support the management of moderate symptoms at homes and track clusters of infection.  In the last quarter of 2021 alone, Crown Agents trained 522 CHWs through the RBF programme in Zimbabwe to identify COVID-19 symptoms and refer unvaccinated people to their nearest health facility. In South Sudan, all 4,400 BHWs and 220 supervisors operating nationally were trained on the prevention and control of the COVID-19 transmission and demand creation for the Covid-19 vaccine. Our teams also worked with the CHWs to adapt how they conducted their work to comply with COVID-19 control regulations. E-training materials were developed for health workers so that they could access them on their phones in their homes or workplaces rather than face to face gatherings. Data was also automated to eliminate the unnecessary handling of papers and documents.

Achieving Sustainable Development Goal 3, health and wellbeing for all is an uphill battle with numerous challenges. In meeting this Goal, Community Health Workers have a unique role to play, particularly in ensuring those in remote and rural settings can access primary health care, despite global health care worker shortages. These workers help to bridge a link between communities and the health sector, distilling health information and knowledge in a manner that is understandable and accepted by locals. There is robust evidence indicating actions taken by CHWs directly lead to improved health outcomes, particularly in tackling key regional issues, such as child mortality and non-communicable diseases. Looking ahead, Crown Agents is committed to carefully selecting, appropriately training and continuously supporting CHWs. We also seek to continue to work hand in hand with Ministries of Health, so that the programmes that CHWs support can continue producing results well into the future.

[1] https://www.globalcitizen.org/en/content/barriers-global-health-care-access-covid-19/

[2] https://www.social-protection.org/gimi/gess/RessourcePDF.action?ressource.ressourceId=51297

[3] https://www.who.int/news/item/13-12-2017-world-bank-and-who-half-the-world-lacks-access-to-essential-health-services-100-million-still-pushed-into-extreme-poverty-because-of-health-expenses