“We think,” said Nathaniel Ebo Nsarko, who heads Ghana’s chapter of the One Million Community Health Workers Campaign, which is helping coordinate the installation, that “this is the answer to universal health — to send in people to their homes to engage them, to share what they must do and what they mustn’t do to keep healthy.”
The World Health Organization estimates that more than 400 million people throughout the globe lack access to basic health services. Many live in remote areas such as Abosamso, where it’s impractical staff and to build health centers.
Ghana is one of countries turning to CHWs. The idea isn’t new; the model has been around for around 80 years. The advent of village health workers, or so “barefoot doctors,” dates to China’s Rural Reconstruction Movement in the 1930s. But in recent decades, it has become established to advance health. Countries like Ethiopia have used the approach to slash maternal and child mortality rates, including a 64 percent fall between 2000 and 2015 in deaths among Ethiopian children under five years old.
In Ghana, the government has long relied on local volunteers to deliver medical care services. But government officials say the needs are too great to rely too much on these volunteers, who will grow fatigued from the requirements.
So now the Ghanaian government has started to pay CHWs. Other countries have tried initiatives, but the scale and the rate of the effort of Ghana make it distinctive. If it succeeds, it could signal a path.
No one is following Ghana’s progress than the American pediatrician and public health specialist Sonia Sachs. The effort is her brainchild, drawing lessons from the Millennium Villages Project that her husband, the economist Jeffrey Sachs, started in 2004. That project, carried out across 14 sites in 10 countries, attempted to wed a variety of interventions to help lift rural communities out of poverty.
Among them were paid CHWs drawn from regions. Though Sonia Sachs is still analyzing the research from the general project, she states that “there were certain things that were obvious right then and there.” One of these was simply that paid CHWs ” really save lives.” That spurred her to begin the campaign.
Paying CHWs has long been a topic for debate, however. Some critics of the practice argue that it destroys a spirit of volunteerism that draws people to the positions in the first place. Communities and humanitarian organizations across the world have experimented with offering incentives, including providing bicycles and T-shirts to volunteers. Others highlight the social status quo in trained and being selected as a CHW.
Debra Singh, whose doctoral research in Uganda focused on how best to motivate volunteer CHWs, found that alongside regular training, abstract returns like making the gratitude of their community could play an essential role in keeping volunteers. But she acknowledged that the trend now is toward remuneration as more responsibilities are layered on the CHWs.
She cautioned, though, that as governments move to introduce paid CHWs, they have to consider how those programs will be maintained by them. When Ethiopia started to pilot its now widely celebrated Health Extension Worker program in 2002, it pulled together a mixture of funds from regional governments, the national government and donors. The program now supports more than 38,000 health extension workers, but manages to pay them just about $35 per month — a small salary even by the standards of one of Africa’s poorest countries.
Beginning in 2013, the Sachs team started working together with 10 countries on strategies to introduce or increase CHWs and pay them a minimum wage, even as it searched for external funding to support those aims. The idea quickly gained traction in Ghana, a country that in 2000 had already started a transition from a health system driven by where facilities existed, toward a new focus on delivery of services to communities in need.
That year the government started introducing fundamental health outposts around the nation staffed with community health officers trained in community-based medicine who could circulate in their areas and boost prevention strategies. They called on volunteers to supplement those efforts, but over time, Nsarko said, those volunteers became less and less engaged in these outreach efforts.
“They played a crucial role in helping us,” he said. “But they always do this on an empty stomach.” In 2010, an evaluation of the health system showed levels of fatigue. Officials became concerned about losing gains they had made, including an estimated fall of nearly 25 percent, between 2005 and 2015, in the number of children who died before reaching their fifth birthday.
From the time they were approached by Sachs’s initiative, officials were receptive to the notion of shifting some responsibilities to CHWs. The crucial moment came in June 2015, when Sonia and Jeffrey Sachs pitched the idea to John Mahama, who was then Ghana’s president. Because of global support for the idea, Ghana would have to find ways to finance a CHW program that is paid . The Sachses saw an opportunity to join their efforts to the goals of Ghana’s Youth Employment Agency (YEA).
The agency was formed to create jobs for secondary school graduates younger than 35, to help curb the country’s severe youth unemployment issue. It’s financed by a tax on cell phone users. The Sachs team suggested that if CHWs met the agency’s criteria, they could be hired by YEA and fold them into the health system.
Mahama agreed initially to use YEA to hire 5,000 of the more than 30,000 CHWs the effort requested. The country’s parliament raised that number to 20,000 for two years at a cost of $25 million for the first two decades, enough to pay each CHW a salary of approximately $100 per month at the time the program started.
More than 100,000 young people applied for the positions when they were declared at the start of 2016, according to Nsarko, and the final 20,000 were selected after interviews with community leaders. Their training was completed by August and they were deployed by the end of 2016.
The participants’ first task was to conduct a thorough survey of their communities. Each CHW was assigned roughly 100 households, and weeks going door to door asking about peoples’ health and noting those with needs like women or diabetics experiencing complicated pregnancies. They continue to make those rounds and follow up with people who require extra attention. And they will slowly take on more responsibilities.
Nsarko is currently anticipating results that exceed Ethiopia’s. While that country’s program focuses primarily on helping mothers and young children, Ghana’s CHWs train to provide a range of emergency and preventive health services to everyone.
There have been some problems. While the government has agreed to pay the CHWs’ salaries, funding gaps remain. Some training sessions were shortened because money had run out, and there were delays in payments to the CHWs as a new president, Nana Akufo-Addo, came into office in January. YEA officials said while they cleaned up the payroll, the interruptions were temporary. Nonetheless, it remains unclear whether the new administration is going to be as dedicated to the program as Mr. Mahama was.
Back in Abosamso, Richard Appiah Kusi, a neighborhood health officer who helps oversee the CHWs, expresses confidence in them, stating that while the delays have caused stress, “they will not leave.”
“The CHWs,” he said, “are willing to work.”