Four Days at the World Health Assembly (continued) - Leveraging CHWs for UHC

As mentioned in my first series of updates, I attended an interesting side session to the WHA on CHWs and UHC organized by World Vision International (WVI). CORE's old friend, Tom Davis, facilitated the session. I'm too lazy to write all my notes about it, but I thought that one introductory presentation, in addition to being short [I'm a believer, but I'm not practicing] hit a lot of key points through the experience of WVI in different countries.

I'll try to have one more update on my time at WHA after that. But for now, I'm ceding the floor to Dan Irvine, Sr Director, Sustainable Health, WVI - here is his text with slides.

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The Universal Health Coverage goal today is presenting us a seemingly insurmountable challenge: 50% of the world’s population does not have access to health services; there is a current gap of 18 million healthcare workers.

Additionally, the UHC agenda is opening up a realm of health and well-being issues that historically have not been prioritized - issues like mental health, early child development, violence, sexual and reproductive health, non-communicable disease, and nutrition.  Our colleagues in the health system, and particularly at the front lines, are increasingly straining to effectively address these needs.

So who better to ensure that all people, everywhere, are reached with diverse health services than community health workers?  CHWs have always been at the heart of the Primary Health Care movement.  Since Alma Ata they have represented one of our strongest links between formal health systems and communities. 

We know today that CHWs are successful health agents when they are appropriately supported.  The WHO CHW guidance published last year, and the CHW resolution that will be passed in this 72^nd world health assembly, are testaments to a new global confidence in the potential of CHWs, supported by an ample evidence base.  WHO notes that CHW platform support has been “uneven”, and in my experience that is certainly true.  World Vision frequently employs the CHW Assessment and Improvement Matrix to assess CHW program functionality, and we often identify sub-optimal support, for example in supportive supervision and incentive structures.

This has to change.  I believe one of the key messages of this session today is to advocate utilization of excellent available global CHW guidance, including the most recent WHO guidance, as well as many other important tools, some of which are listed on your handouts.  We should not be seeing today gaps in CHW platforms that have been identified consistently over the past years as marginalizing CHW results.  We have identified these challenges, we have developed guidance for implementers to address them – we all need to use the guidance, and shame on us if we don’t.

Now let’s talk a bit more about the next generation of CHWs…  In 2015 I directed a census of CHWs being supported by World Vision in 48 countries around the world.  One of the outcomes of our census that I found particularly intriguing was this analysis of the diverse activities they were engaging in – 25 activities in all.  As you consider the proportion of engagement in each activity, bear in mind that this is based on 220,000 CHWs we supported at the time.

You will note that amongst the activities many are closely aligned with core reproductive maternal, newborn child health and nutrition interventions.  But note also that nearly half of the programs state addressing early child development, 37% addressed adolescent health, and over half supported parenting groups. 

Over the last few years we have been exploring somewhat non-traditional roles for CHWs.  This month we are just concluding a study in four countries: Kenya, Tanzania, Myanmar and Bangladesh, on CHW address of violence against children.  This follows a study we published last year examining national policy alignment with the WHO Action Plan to Combat Violence, wherein we found some positive trends, but little policy implication for CHWs.

In the current study we interviewed 412 CHWs across these countries and have frankly been somewhat surprised to find that the majority already consider addressing violence against children as part of their role, they observe situations of violence in the household, and are actively intervening.  They also state a desire for capacity building to better address this violence.  With 1.7 billion children facing situations of interpersonal violence each year globally, World Vision will be testing how to best support CHWs to help them.

Last year we were thrilled to see publication of the Nurturing Care Framework for Early Childhood Development, which calls for an integrated approach towards the young child cohort inclusive of health, nutrition, water and sanitation, early stimulation, child protection and caregiving.  The framework suggests a critical role for the frontline health workforce in these objectives as this cadre most typically engages families in regards the well-being of young children.  In our experience, once again it is CHWs that present one of the best opportunities to support this multi-sector approach.

World Vision began integrating early child development interventions into core health CHW platforms many years back, and have worked with partners at Harvard, Aga Khan, Johns Ho

pkins and Al Quds universities to evaluate impact of the approach in a number of countries.  In this example in Palestine we found that inclusion of psychosocial first aid and early stimulation components resulted in significant gains across three standardized ECD scales, with positive effects for mothers as well as the children.

Time after time, whether it be diagnosis and treatment of infectious disease, treatment of severe acute malnutrition, or addressing violence and caregiving, we have seen that properly supported lay health workers can effectively extend service coverage.  In this case World Vision worked with WHO and the University of South Wales to test CHW delivery of a mental health intervention addressing distressed victims of gender-based violence in Kenya. 

The Problem Management Plus intervention involves facilitation of five behavioral treatment sessions with distressed women on an individual basis.  Our trial in Kenya demonstrated that the CHW facilitated approach outperformed the standard enhanced usual care approach.

Once again, Universal Health Coverage means that all people, everywhere, have affordable access to support for all issues affecting their physical and mental health and well-being.  If we are to realize this goal we must have a strong primary health care system, and I believe that CHWs are at the heart of that system.

Dan Irvine. 5/21/2019 [Dan_Irvine at WVI dot Org]