By Sonia Ehrlich Sachs and Jeffrey Sachs

Key Policy Messages

• The greatest revolution in public health today is the rise of the professionalized Community Health Worker (CHW).

• CHWs are most effective when professionalized (remunerated, trained, supervised, and provisioned).

• CHWs are a remarkable bargain, costing $7 annually per person covered

• The expansion of CHWs, particularly in low-resource settings, is critical to achieving SDG 3.

The greatest revolution in public health today is the rise of the professionalized Community Health Worker (CHW). The evidence is overwhelming that professionalized CHWs can greatly improve health delivery at low cost in countries at all income levels,[1] and are therefore vital to realizing Universal Health Coverage (UHC), a target of Sustainable Development Goal 3, which aims to ensure healthy lives and to promote wellbeing for all at all ages. The recent commitment by African leaders to deploy “2 million African community health workers”[2] to fight AIDS and other diseases is a breakthrough in the quest for UHC. So too is the launch on October 26th, 2018 of the “WHO guideline on health policy and system support to optimize community health worker programmes,” which marks a critical codification of the basic principles of this newly recognized professional cadre.
 
CHWs have long played a role in national health programs. China’s public health campaigns of the 1950s and 1960s were enabled by the famous “barefoot doctors.” The 1978 Alma Ata Declaration, which called for Health for All by 2000, envisioned the massive deployment of CHWs. Two widely admired, large-scale CHW initiatives were launched during the early part of the Millennium Development Goals (MDGs). One was Ethiopia’s deployment of Health Extension Workers (HEWs), undertaken by Dr. Tedros Adhanom Ghebreyesus, then Minister of Health; the other India’s deployment of Accredited Social Health Activists (ASHAs). Work led by Dr. Miriam Were, Vice Chancellor of Moi University in Kenya, and Dr. Henry Perry from Johns Hopkins University, also demonstrated the efficacy of large-scale CHW deployment in Africa and Latin America.
 
CHWs are local workers, typically with a secondary education, trusted by the community in which they live and serve. In the past, CHWs were volunteers, often with minimal training, supervision and meagre provisions. Compensation, if any, would be gifts from the community. 
 
The concept of CHWs as professionalized health workers – remunerated, trained, supervised, and provisioned – emerged in the early 2000s. One key development was the rapid expansion of mobile phone coverage into remote, low-income, rural communities starting around 2005, which enabled supportive supervision, as well as monitoring via real-time data for policy dashboards and for expert-system guidance. As CHW responsibilities expanded, so too did the need for better training, supervision, and remuneration.
 
Online tools for CHWs burgeoned after 2010 with the arrival of smartphones programmed with new public-health applications such as Dimagi’s CommCare and other systems. Other new technologies, such as community-based rapid diagnostic tests for many diseases (most notably malaria), and new medicines greatly expanded the effectiveness of CHWs. CHWs gained versatility, with new roles and responsibilities in the continuum of care.
 
In 2006, the Millennium Villages Project (MVP) introduced professionalized CHWs at Millennium Village sites in ten countries in sub-Saharan Africa. In the MVP context, professionalization meant remuneration, training, supervision, provisioning with mobile phones (ultimately smartphones), information systems, and backpacks with kits of medicines, diagnostics, and other tools. The end line evaluation of the MVP recently published in The Lancet Global Health demonstrates the efficacy of the MVP health system, built heavily on the cadre of professionalized CHWs.[3]
 
At the World Economic Forum in 2013, the MVP and Columbia University’s Earth Institute launched the One Million Community Health Worker Campaign (1mCHWc).[4] Novartis’ CEO at the time, Joe Jimenez, joined the program on behalf of Novartis and other companies, and President Paul Kagame of Rwanda represented the MDG Advocates and the UN Broadband Commission. The goal of the 1mCHWc was to support African nations to mobilize at least 1 million professionalized CHWS across the continent.
 
The 2014 Ebola epidemic of West Africa further demonstrated the essential role of CHWs. Their relative absence in Liberia, Sierra Leone, and Guinea at the start of the epidemic was one key reason the epidemic spread nearly uncontrolled in the early phase: community health delivery was scant or non-existent in the impacted communities, and communities’ trust of public health institutions was low. Several groups, most notably Last Mile Health in Liberia, Partners in Health in Sierra Leone, and the Earth Institute in Guinea, introduced CHWs for Ebola case management, contact tracing, reporting, surveillance, public awareness, and trust-building between the communities and public health institutions.
 
The experience led to a further boost of support by African leaders for CHW deployment. Yet, despite the proven success of CHWs and calls for increased international support for CHW financing, the international community did little at that point to step-up its financing of CHWs. In this context, the 1mCHWc launched a detailed costing of the deployment of CHWs. The results, published in The Bulletin of the WHO, showed that CHWs are a remarkable bargain, costing $7 annually per person covered and approximately $3,750 annually per CHW.[5]
 
The next breakthrough came with the 2015 decision by Ghana’s former President John Mahama to deploy a national cadre of 20,000 CHWs in Ghana, with a stipend paid by the Youth Employment Agency within the Ministry of Employment and Labour Relations. President Mahama recognized the double benefit of a national CHW program in bolstering public health while providing a valuable career path for young secondary school graduates engaged locally in national service. His successor, President Nana Akufo-Addo, Co-chair of the SDG Advocates, has not only continued the program but is complementing it with a national program of telemedicine for both CHWs and clinics. 

UNAIDS is a leading champion of CHW scale up, in recognition of the vital role CHWs play in the implementation of UNAIDS’s 90-90-90 program to bring the AIDS epidemic to an end by 2030. The UNAIDS program calls for 90 percent of HIV-infected individuals to know their status through testing; 90 percent of those who know their status to be put on antiretroviral medicines (ARVs); and 90 percent of those on ARVs to successfully suppress their viral load. By 2030, the goal would be to reach 95-95-95. The consequence would be to break the transmission of HIV/AIDS.

CHWs are needed at each step of the 90-90-90 cascade: to identify HIV-infected individuals, to enable them to start ARVs, and to help them adhere to drug regimens. These are tasks for which CHWs are uniquely capable. One can identify comparable unique CHW capacities in other similar disease-control contexts such as malaria control. 
 
For this reason, the leadership of UNAIDS, in conjunction with the 1mCHW Campaign and the UN Sustainable Development Solutions Network, brought the CHW campaign as a key part of 90-90-90 to African Union (AU) leaders in 2017.[6] AU leaders endorsed a scale up to 2 Million African community health workers. In 2019, the AU is considering the establishment of new funding modalities to support CHW scale-up. 
 
Recently, a consortium of philanthropic foundations and funding agencies have pledged $50 million to scale up 50,000 CHWs in 6 countries with the leadership of Last Mile Health and Living Good, contingent on a matching $50 million. One question about this initiative is the reported intention of Living Good to develop a cost-recovery model through social marketing of drugs and other health treatments, an approach that has a disappointing record in the past (e.g. in the failed era of social-marketing of anti-malaria bed nets during 2000-2005, before the mass, free distribution of bed-nets that we advocated in the UN Millennium Project, 2005).
 
An important new paper by Victoria Chou, Henry Perry, and others demonstrates that the expansion of CHWs could avert an astounding 3 million maternal and child deaths (mid-point estimate) during 2016-2020 if the CHW cadre is expanded during that interval in 73 high-disease-burdened countries.[7] The Africa region would be the greatest beneficiary of this global effort, with an estimated 58% of the lives saved. The areas of greatest impact would include “nutritional interventions during pregnancy, treatment of malaria with artemisinin compounds, oral rehydration solution for childhood diarrhoea, hand washing with soap, and oral antibiotics for pneumonia.” One should add the long-term benefits of 90-90-90 as well.

The evidence is also growing that CHWs have a role to play in high-income countries, especially among poor and marginalized communities. These communities often suffer severe disease burdens due to the “social determinants” of health, including drug dependency, disability and chronic unemployment, mental illness, obesity, social marginalization (such as immigrant status), and poverty. CHWs can reach such marginalized individuals; enable them to interact effectively with neighbourhood clinics, hospitals, and social service agencies; help them to adhere to prescription regimens; and help them to address other urgent social needs. Manmeet Kaur of City Health Works in Harlem, New York City, USA, is demonstrating the CHW model in the context of New York’s vulnerable population.[8]
 
The revolution of professionalized CHWs has therefore begun. We now have the experience base, the burgeoning tools of the ICT revolution, the low cost of CHW systems, the readiness of political leaders to co-invest in CHWs, and the scaling-up of philanthropic contributions. What is still missing is a large-scale, globally coordinated CHW scale-up effort.
 
We call on the governing boards of the Global Fund to Fight AIDS, TB, and Malaria (GFATM), the Global Alliance for Vaccines and Immunizations (GAVI), the Global Financing Facility in Support of Every Woman Every Child (GFF), the US President’s Plan for Emergency AIDS Relief (PEPFAR), the US President’s Malaria Initiative (PMI) and others, to endorse plans for their respective organizations to channel increased funds towards the rapid scale up of CHW systems. We urge the African Union to establish a special funding mechanism, such as a new AU-supervised trust fund for African health systems, to partner with international donors and UN agencies in this effort.
 
We also call on individuals with high net worth to join the effort, following the inspiring example of Bill and Melinda Gates. The world’s 2,208 billionaires (identified on 2018 Forbes List) have an estimated combined net worth of $9.1 trillion dollars.[9] The annual cost of a fully-funded CHW system for Africa deploying 2 million CHWs is on the order of $7.5 billion per year, or roughly 0.08% of the combined net worth of these billionaires. It is hard to imagine a better investment on the planet than the CHW scale up endorsed by the African leaders.   

  [1] Perry H, Zulliger R, Rogers M. “Community Health Workers in Low-, Middle,- and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness.” Annual Review of Public Health 35 (2014):399-421.[2] UNAIDS. 2 million African community health workers. Geneva: UNAIDS, 2017.[3] Mitchell S et al. “The Millennium Villages Project: a retrospective, observational, endline evaluation.” The Lancet Global Health 6:5 (2018):e500-e513.[4] One Million Community Health Worker Campaign. New Campaign to Train One Million Community Health Workers for sub-Saharan Africa. New York: 1mCHWc, 2013.[5] McCord G, Liu A, Singh P. Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions. Bulletin of the World Health Organization 2012:91 (2013):244-253b.[6] UNAIDS. African Union endorses major new initiatives to end AIDS. Press Statement. Geneva: UNAIDS, 2017. [7] Chou V et al. “Expanding the population coverage of evidence-based interventions with community health workers to save the lives of mothers and children: an analysis of potential global impact using the Lives Saved Tool (LiST).” Journal of Global Health 7:2 (2017):020401.[8] City Health Works website, http://cityhealthworks.com.[9] Forbes. Forbes Billionaires 2018. New York: Forbes, 2018.

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