CHW Advocates are seizing power.
For too long, discussions about community health workers (CHWs) have been happening without CHWs in the room. It’s time for a change. Community health workers are seizing power.
3rd International CHW Symposium.
The 3rd International Community Health Workers Symposium was held in Liberia in March 2023. Bringing together more than 700 delegates from 46 countries.
Under the theme “Advancing Community Health Worker (CHW) Programs to build resilient and equitable health systems that accelerate Primary Health Care for Universal Health Coverage” the CHW Symposium brought together country delegations, community health workers, multi-laterals, development partners and researchers. Participants exchanged knowledge and solutions to scale and sustain community health programs for health for all. The Symposium ended with the announcement of the milestone Monrovia Call to Action.
H.E Ellen Johnson Sirleaf, former President of Liberia
“I encourage each and every one of you to rewrite our history so that this Symposium becomes an inflection point in our collective journey towards health for all. The moment before us is too important not to act. I encourage everyone to stand alongside our community health workers and make trained, supervised, supplied, protected and paid community health workers the rule, and not the exception.”
Setting the Standard.
For the first time CHWs formed part of country delegations and participated in every plenary, panel and meeting! This sets the standard for all international conferences moving forward.
Over half of the African countries in attendance – 16 in total including Liberia, Kenya, Mali, Malawi and South Sudan – facilitated CHWs in attending. CHWs from across the world were also supported in attending by NGO partners. For years, CHIC has insisted that any time community health is talked about, a CHW must be in the room. This Symposium, which featured expert testimony, leadership, and advocacy by CHWs for CHWs in every session, ushers in a new era for CHW-led decision-making: “Nothing about CHWs without CHWs!”
Having so many CHWs in one room together also allowed for international organizing on a scale not seen before. CHWs met to share ideas, offer peer support and build new relationships towards a shared mission of professional CHWs (proCHWs). CHWs in attendance noted that any efforts for meaningful CHW engagement must be inclusive, with an intersectional approach that considers gender, age, disability, geography and religion.
This Symposium sets a new standard for country delegations and inclusive panel composition—one all future high-level meetings will need to exceed.
Making proCHWs the norm.
This Symposium will be known as the one where the idea of proCHWs became the norm. Having said that, are we committed to health in theory but relativists in practice? Our next big challenge is closing the gap between what we say we believe and what we actually do!
Indisputable evidence confirms CHWs improve health outcomes with considerable equity and economic dividends. And CHWs are health workers. It’s in the name. Yet, proCHWs who are salaried, skilled, supervised and supplied remain the exception, not the norm. Half of CHWs in low and middle-income countries are not salaried and worldwide CHWs face stockouts a third of the time. It’s a dual sided human rights issue, CHWs are exploited and less effective for patients?
So, how do we make proCHWs the norm? This was the focus of the CHIC organised plenary ‘Salaries, Skills, Supervision, and Supplies: Policy and Design Considerations for Professional CHW Programs.” Panellists included Dr. Madeleine Ballard (CEO, CHIC), George Mwinnyaa (former CHW, PhD candidate and consultant), Margaret Odera (CHW Advocate and Organizer), Dr. Mohammed Abdulaziz (Africa CDC), and country delegates from Niger, DRC, Zambia and Zanizibar. During the session we addressed why the current status quo is broken, cast a vision for making proCHWs the norm worldwide, and heard from countries about their progress in establishing the health policy and systems support that CHWs need in order to deliver health for all. We also unveiled the largest-ever public-facing proCHW policy dashboard which tracks proCHW policy progress in 137 countries.
The rallying cry was clear: salaries, skills, supervision and supplies are non-negotiable. To be effective, CHWs must be treated like the professionals they are.
Dickson Nansima Mbewe, CHW, Malawi
“My call to action to leaders is this: you need us, you can’t deliver healthcare without us, so move with the world and pay us, recognize us and value us!”
CHWs seize the stage.
This Symposium proved what we have long known – that every time community health is discussed, a CHW should be in room! CHW delegates brought expertise and passion to every session, every meeting, and every hallway interaction.
Today, those – like CHWs – facing high stakes typically have low power. Yet those with high power perceive low stakes. Therefore, more resources are needed to recognize and build power within communities with the most to lose. In response, community members can address power asymmetry by recognizing, cultivating, and building their own power. This is the work of organizing. The second CHIC-organised plenary of the Symposium focused on this work.
CHWs seized the stage to present the impact of their advocacy, organizing and mobilizing. Moderated by Nicholas Oliphant from the Global Fund, CHW participants Hélène Rasoantaniaina (Madagascar), Josophine Kalombola (Malawi), Margaret Odera (Kenya), Dickson Mbewe (Malawi) and Lami Pafaliki (Togo) stole the show, brought the fire and left attendees with no doubt about the importance of CHWs being included in decision-making. They also served as an inspiration to other CHWs to organize and advocate for the health policy and systems support they need and deserve as health professionals.
This plenary shows that there is no longer an excuse to not have CHWs on the stage. The impact on the day? Every audience member hanging on to every word and filming it to look back on. And a well deserved standing ovation.
Dr Salim Hussein, Ministry of Health, Kenya
“We need to make a place for CHWs at the table, but in a chair, not on the plate!”
CHW Symposium 2023
For investing in community health programs as an integral path to universal health coverage
The Monrovia Call to Action.
On the final day of the 3rd International Community Health Workforce Symposium in Monrovia, Liberia, Minister of Health Dr. Wilhemina Jallah announced the Monrovia Call to Action.
We, the delegates of the 3rd International Symposium on Community Health Workers (CHWs) gathered by the Government of Liberia from 22 to 24 March 2023, inspired by progress of the exemplary Liberian National Community Health Program, reinforce our mutual commitment to fund, scale, and strengthen community health programs as an integral part of primary health care for the realization of universal health coverage.
We recognize:
- That CHWs deliver primary health care, improve health outcomes and save lives.
- Community health is the equity arm of primary health care, and that CHWs are leaders in providing an integrated package of services including in emerging areas, like non-communicable diseases and mental health.
- CHWs are essential to achieve global health security and play a critical role in pandemic preparedness and emergency response while helping to allay the health and economic shocks that follow.
- Investing in a professional community health workforce can produce a 10 to 1 return on every dollar invested as a result of healthier populations, increased productivity, and job creation, in particular for women. This is a ‘public good’ that should be financed from public dollars.
- That addressing the health workforce challenge is essential for progress towards all health- related sustainable development goals, universal health coverage, pandemic preparedness and response, and reducing the impacts of climate change.
- To be fully effective, CHWs need to be skilled, supervised, paid a living wage, and supplied by a well-functioning primary health care system coordinated at scale and integrated into broader public systems via data and financing.
We are urgently concerned that:
- Domestic resource allocation to the health sector remains insufficient to meet the Abuja targets. Fragmented and insufficient donor funding has worsened this situation.
- The global shortage of human resources for health is projected to be 43 million health workers by 2030.
- Recent public health threats like Ebola and COVID-19 spread in part due to weak primary health systems that were not equipped to prevent, detect, and respond to outbreaks.
- Over half of CHWs in low and middle income countries are unpaid. CHWs are out of stock of key commodities ⅓ of the time. Many receive inconsistent supervision and continuous medical education is rarely available. The failure to treat CHWs like professionals limits their ability to perform like professionals. The majority of CHWs globally are women and that women face barriers in accessing safe and decent work and leadership opportunities.
- Despite advances in healthcare systems, more than 800 million people lack access to healthcare and 54 countries are off track to reach SDG 3.
We call on the highest level of leadership including Heads of State, Ministers of Health, Ministers of Finance, and other line Ministries, the African Union, Africa CDC, bilateral and multilateral partners, the United Nations system, civil society, and the private sector, to:
- Invest in country-led community health strategies. Coordinate funding toward clear, costed, and prioritized national and sub-national community health strategies. Include core indicators on access, equity, and quality of an essential package of health services. Appropriately and incrementally increase domestic budget allocations and private sector financing for primary health care and CHWs, while decreasing out-of-pocket spending for patients. With recognition of the contributions CHWs make to disease-specific outcomes, affirm an integrated approach to service delivery.
- Make professional CHWs the norm. In line with the WHO Guidelines, ensure a cadre of CHWs is formalized, paid a fair wage, skilled, supervised, and supplied to deliver the highest quality care, and offered opportunities for career progression. This must be a just transition, undertaken with consideration for gender equity and social inclusion, to protect quality jobs for women and other marginalized groups. As valued workers, CHWs must be protected from health risks, violence, and sexual harassment.
- Integrate CHWs into human resource and health sector plans. Recognize CHWs as a core part of strong primary health care systems. This starts with counting and accrediting CHWs at national and subnational levels and mapping coverage. CHWs must be included in health sector planning including national disease strategies, implementation, technology, governance, and program monitoring. CHWs themselves, including female CHWs, must be included in decision making.
- Galvanize political support. Continue positioning community health on the political agenda, cultivate champions and key influencers, and develop investment cases to elevate the community health agenda at global, regional, and national levels.
- Track progress of CHW programs. Adopt an accountability framework ratified by countries in consultation with stakeholders including milestones, shared indicators, transparent investments by funding partners, and gender disaggregated data.
The evidence is clear. Protected, paid, trained, supervised, and supplied CHWs must be the rule and not the exception. As the CHWs of Liberia have repeatedly noted, “We are here for change.” The time to act is now. We must urgently fund, scale, and strengthen community health programs for the realization of universal health coverage and global health security.
