From the 2nd Global Community Health Workers Symposium, Dhaka, Bangladesh 22-24 November 2019 : Lessons and next steps towards UHC and SDG 2030.
Members will remember that in my previous posting about the 2019 Technical Advisory Group (TAG) meeting of the Population Council’s meeting in Dhaka Bangladesh on 20th November 2019, which preceded the 2nd Global CHW Symposium, I highlighted our pleasant surprise at the publication of the seminal work done by the Frontline Health project since is 2018 inaugural meeting in Washington. Neil and I co-represent HIFA on the TAG. The work is titled ‘A conceptual framework for measuring community health workforce performance within primary health care systems’. If you missed it, I repeat the reference below:
CITATION: Smisha Agarwal, Pooja Sripad, Caroline Johnson, Karen Kirk, Ben Bellows, Joseph Ana, Vince Blaser, Meghan Bruce Kumar, Kathleen Buchholz, Alain Casseus, Nan ChenHannah, Sarah Faich Dini, Rachel Hoy Deussom, David Jacobstein, Richard Kintuet al. A conceptual framework for measuring community health workforce performance within primary health care systems. Hum Resour Health (2019) 17: 86. https://doi.org/10.1186/s12960-019-0422-
The 2nd Global CHW Symposium proper:
It was a hugely successful meeting with participants from many countries (rich and not so rich) and groups: about 35 countries, The WHO, UNICEF, DFID, ILO, Save The Children, UNFPA, development partners (USAID, etc), non governmental organisations ( e.g. Population Council’s Frontline Health Project, Bill and Melinda Gates Foundation, Last Mile Health, etc), civil societies organisations, health professional associations, private health sector, individuals, others. Especially significant was the participation of representatives of CHWs from Bangladesh in particular, whose efforts have placed the host country at the centre of the Global effort to advance the positive contributions of CHWs, and to steer the world to understand that given the present structure of health systems in most countries including the LMICs, it is safe to say that without CHWs PHC will be difficult (if not impossible) to achieve and without PHC the global aspirations of UHC (with no one left behind) and SDGs by 2030 are not attainable.
For me the climax of the three day symposium was the launching of the Bangladesh Strategy for Community Health Workers (2019-2030) document. Apparently, the first country to do so. It is a 33-page document in which the Minister of Health and Family Welfare (MOHFW) of Bangladesh declared in the Foreword, that 'Bangladesh has achieved immense success in the health sector. The Prime Minister received an award for achieving the MDG in health and very recently (November 2019) received the VACCINE HERO award from GAVI for our achievement in vaccination programme. I believe that the national action plan will follow this strategy document launching.’
The Secretary, Health Services Division of the MOHFW emphasised the role of CHWs in his own message by stating that 'the current (Bangladesh) health system and workforce is gaining momentum to go for UHC. In particular in this crucial journey community health workers are very vital and essential ------'. The Director General of MOHFW went further to say in his own message in the strategy document that 'Bangladesh has been one of the first countries to develop national scale cadres of CHWs beginning in 1960s with its smallpox and malaria assistants followed by the deployment of oral rehydration solution (ORS) workers by BRAC in the 1970s. Even though Bangladesh is a country with shortage of public sector health workers, it has made unprecedented and rapid progress in several health indicators and outcomes with sincere and relentless contributions from the community health workers (CHWs)'. He went on. 'The strategy gives special importance to e-record keeping and reporting. The advanced digital reporting system already in place (DHIS-2 programme) is making the CHWs work more effectively and also reduces their workload. It helps the supervisors to provide better supportive supervision to the CHWs.'
The CHWs are mainly women in Bangladesh because they have proven that they commit to staying in the system with less attrition, unlike the men. They (CHWs) are about 180,000 for the country population of 160 million. They are permanently resident in their location and work from the community clinics, each clinic serving about 6000 population since 1990. The clinics are a form of Public Private Partnership under the Community Health Support Trust since 2018 for sustainability reasons in the long term. With the services of CHWs, Bangladesh has recorded significant increases in her health indices: Maternal Mortality down by 75%, Infant Mortality down by 50%, Immunisation increased and stands at 82%. In Bangladesh CHWs bring to the table: Trust in the community users of service; timely and appropriate referral; equity; they bridge the gap between the system and those needing it; appreciation and retention by the community. Other neighbouring countries represented at the symposium seem to have also established CHW programmes including Nepal, Pakistan, Kenya, Uganda, India, etc, even though the most advanced is the Bangladesh example.
The side / parallel sessions comprised presentations from a very wide selection of country experiences (Kenya, DRC, Uganda, Nepal, India, Pakistan, Liberia, UK, France, etc) dealing with many aspects of the CHW initiatives. The HIFA Forum presentation was done by two HIFA members, Baba Aye and Polly Walker, and was very well received by the audience in the parallel session on Day 2.
The meeting recognised certain challenges with efforts to scale CHWs programme including: financing exponential increase in numbers of CHWs (even though it has been shown, not least in Bangladesh, that the programme is cost-effective); resistance to change from the present health system structure that excludes CHWs; etc.
At the side sessions that I attended I raised the fact of the information gap that exists when it comes to letting the world outside Bangladesh for instance hear the success of the policy of having the CHWs cadre and using them to spread inform and educate the users and that this is a role that HIFA online forum has as its vision. On every occasion/ session the message was well received. Hopefully with more awareness of HIFA created in Dhaka, the outcome from this symposium should include more new members joining the forum.
The Organisers of the 2nd Global CHW Symposium in Dhaka, Bangladesh from 22-24th November 2019 deserve a huge congratulation for the success due to the excellent planning and execution in all parameters of conference assessment. Particularly the flow of the over 600 participants from the plenaries to side sessions and back, and to many health breaks and refreshments was exemplary. Also worthy of high appreciation is the contribution and assistance by many Development partners and NGOs such as USAID, BMGF, WHO, UNICEF,
The take home message for all the countries, especially the LMICs must be that to achieve UHC and SDGs, they must establish a CHW programme without delay as the clock ticks towards 2030, and integrate it to their existing health system (usually primary, secondary and tertiary levels), and not as volunteers but as trained, supported, respected and appreciated health workers. There needs to be another level that is closer to communities (home clinics), the Community Health Worker Level (CHW) for all the many reasons that the symposium participants received, if they want to achieve UHC and SDGs. For those countries that already have a cadre called CHW for their PHC, they need to give these new level of workers another name, but they must be fully integrated into the health system as the first contact point for each community. Descriptions from this symposium, shows and it is obvious that this new cadre can be created without conflict of roles with any existing cadre, because they are primarily for promotion and prevention services at the home and family points.
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HIFA profile: Joseph Ana is the Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety in Calabar, Nigeria. In 2015 he won the NMA Award of Excellence for establishing 12-Pillar Clinical Governance, Quality and Safety initiative in Nigeria. He has been the pioneer Chairman of the Nigerian Medical Association (NMA) National Committee on Clinical Governance and Research since 2012. He is also Chairman of the Quality & Performance subcommittee of the Technical Working Group for the implementation of the Nigeria Health Act. He is a pioneer Trustee-Director of the NMF (Nigerian Medical Forum) which took the BMJ to West Africa in 1995. He is particularly interested in strengthening health systems for quality and safety in LMICs. He has written Five books on the 12-Pillar Clinical Governance for LMICs, including a TOOLS for Implementation. He established the Department of Clinical Governance, Servicom & e-health in the Cross River State Ministry of Health, Nigeria in 2007. Website: www.hriwestafrica.com Joseph is a member of the HIFA Steering Group and the HIFA working group on Community Health Workers.
Email: jneana AT yahoo.co.uk