Community Health Workers are key to remote global care

Half the world’s population lacks access to essential health services. Community health workers play a vital role in addressing the gap in healthcare, but they are largely overlooked and underpaid. The Community Health Impact Coalition (CHIC) advocates on behalf of community health workers, also providing research and activation to support them. Dr. Madeleine Ballard of CHIC and community health worker Prossy Muyingo discuss CHIC’s work, which has been honored with the 2024 Roux Prize. 

The Roux Prize recognizes individuals all over the globe who have used evidence-based health data to improve population health. The prize is sponsored by IHME’s founding board member David Roux and his wife, Barbara.

The transcript has been lightly edited for clarity

Rhonda Stewart: Welcome to Global Health Insights, a podcast from IHME, the Institute for Health Metrics and Evaluation. I’m Rhonda Stewart. Community health workers are a critical part of health systems all over the world. This is especially true given that half the world’s population lacks access to essential health services. Community health workers address this gap, playing a vital, lifesaving role, but many of them are overlooked and chronically underpaid.

The Community Health Impact Coalition, also known as CHIC, advocates on behalf of these workers and does so much more. CHIC also provides research and activation, creating collective action and impact more powerful than a single organization could have on its own.

Dr. Madeleine Ballard is CEO and cofounder of CHIC, which is the 2024 Roux Prize winner. Now in its 11th year, the Roux Prize recognizes individuals all over the globe who have used evidence-based health data to improve population health. The prize is sponsored by IHME’s founding board member David Roux and his wife, Barbara. Dr. Ballard accepts the Roux Prize alongside thousands of community health workers, or CHWs. Prossy Muyingo is one of those health workers whose contribution makes a difference in her community every day. She joined the conversation from Uganda.

Welcome so much to you both. And Madeleine, congratulations on being named the 2024 Roux Prize winner on behalf of the Community Health Impact Coalition. And before we dive into what CHIC does, tell us a little bit about the founding of the organization. What are the problems that CHIC was created to solve?

Dr. Madeleine Ballard: Thanks so much. Community health workers, or CHWs – and we’re joined today by Prossy Muyingo, one of the community health worker members of the coalition – are a vital workforce that provides health care to their neighbors, everything from birth control injections to HIV care management. In many countries in Africa, CHWs treat over half of all malaria cases. Undeniable evidence shows that CHWs deliver primary health care in a way that improves access, increases equity, and saves lives. So CHWs are essential for realizing universal health coverage and reaching global goals. But despite their tireless efforts, millions spend years earning little to no pay, straining their ability to support their families and also serve their patients. And this exploitation doesn’t just harm CHWs, it also undermines health quality worldwide. So it’s a dual-sided human rights issue. CHWs are both underpaid and overworked, and so patients suffer.

Rhonda Stewart: Madeleine, let’s come back to that question a bit later, in terms of the equity piece and the double-sided nature of the work, I’m interested to hear from both of you, Madeleine and Prossy, when we say that half the world’s population lacks access to essential health services. What types of services do we mean specifically?

Dr. Madeleine Ballard: You want to come in, Prossy?

Prossy Muyingo: CHIC delivers a wide range of services tailored to the needs of their communities in both low- and high-income countries, as well as in rural and urban settings. In the rural, low-income areas, CHWs focus on essential primary health care, such as immunization, treating common childhood illnesses, and controlling communicable diseases. In high-income urban environments, they tend to facilities, access to health services, and support patients with chronic illnesses. No matter where they are, CHWs build trust within communities, share important health information, screen for common health issues, and gather data that helps improve health decision-making. They are key in connecting communities in health care systems, making it easier for people to get the care they need, and addressing important factors that cause ill health. But again, when we don’t treat them like professionals, it’s hard for CHWs to perform like them. Right now, CHWs in low- and middle-income countries are out of stock a third of the time. 86% of CHWs in Africa are unsalaried. This is untenable for them and the patients they serve. CHWs must be salaried, skilled, supervised, and supplied.

Rhonda Stewart: So these are really important points. I think many people would be quite surprised to learn that so many CHWs, so many community health workers, are unsalaried. And it is very much untenable, as Prossy mentioned. And so how does CHIC’s model differ from other organizations that work with community health workers? There is certainly an equity component to the work that CHWs do in terms of delivering care. But then there is also an important component in terms of the support for the CHWs themselves. So how does CHIC’s model address both of these things?

Dr. Madeleine Ballard: Absolutely. I think it’s clear that to close the health care access gap that Prossy just described, and the gender equity and labor equity gaps that Prossy described, we need to do things differently, not just with medical innovation, but also with collaboration for better design of these systems. And our big idea as a coalition is collective action through radical collaboration. So, Community Health Impact Coalition is a network of 10,000 CHWs, including Prossy, and health organizations across 60 countries. And together, we can wield influence on a scale sufficient to change global norms. So we are making professional community health workers the norm – salaried, skilled, supervised, supplied – by changing global guidelines, funding, and national policy. And these are kind of our three levers for change. Ultimately, system change is about transforming the structures that kind of hold a problem in place, and for community health workers, the reason they’re in the situation that Prossy just described is really that lack of global guidance from industries to take action, a funding gap to make the changes required, and just national policies that don’t set up CHWs for success. So we kind of use three interconnected tactics, research, advocate, and activate, to change those conditions. So we research together CHWs M&E [monitoring & evaluation] experts, and advocates alike, to equip international norm setters with evidence they need to create proCHW guidelines and the guidelines that really drive investment and national policy in 190 countries. We advocate to influence global financing institutions to increase proCHW funding, and then we activate in-country networks of CHWs, and Prossy can speak more to this, to win and deliver national policy. And so in short, what we’re doing is driving adoption of high-impact community health systems design with those responsible for policymaking, for financing, and for implementing community health programs. And taken together, it’s a pretty powerful machine, right? A shared vision of health for all without really caring who gets the credit.

Rhonda Stewart: In terms of the policy impact, it would be great to hear, Prossy, a little bit more about your work as a community health worker. Tell us about something that you’re particularly proud of, or tell us about some of the policy impact you’ve seen that Madeleine was just mentioning.

Prossy Muyingo: As a community health worker in my daily work, I assess, treat, and care for children under the age of 5 for common diseases like malaria, pneumonia, and diarrhea. I support pregnant mothers through antenatal care and counsel women on family planning. Additionally, I conduct social talks both in the community and at the nearby health facilities to raise awareness and improve health practices. I also represent the expertise and the collaboration of thousands of CHW advocates globally working together to elevate the profession and strengthening health systems.

Dr. Madeleine Ballard: And what are you proudest of, Prossy, in all that work?

Prossy Muyingo: I’m proud of many moments in my career as a CHW, but one that stands out is that I realize that we as CHWs could be recognized as professionals. We often work in difficult conditions, but seeing our efforts acknowledged globally has been incredibly empowering. Another thing I'm proud of is the moment when I shared the platform with other health professionals and was honored with a Heroines of Health Award by Women in Global Health in 2023, an acknowledgement of the critical work we do on the ground.

Rhonda Stewart: Wonderful. And Prossy, tell us, how did you become a community health worker? What interested you about getting involved?

Prossy Muyingo: I wanted to bridge the gap between my community and the facility. I wanted to be the first beneficial being. I’m also a mother in the community. Still, I wanted to go abroad on my community healthy talks. I think I wanted to sound knowledgeable in my community. I wanted even to be a leader in my community. When the local leaders, I can bring something on the table because I’m a CHW, meaning they still trust me to give the right information about health.

Rhonda Stewart: Prossy has spoken about the important role of creating trust in the community, the leadership role that CHWs play in a community. Madeleine, tell us a little bit about some of CHIC’s achievements in terms of impact.

Dr. Madeleine Ballard: So CHIC ultimately has made significant contributions in terms of the recognition of community health workers and the vital role that they play in health systems around the world. There’s been a real Overton window shift, whereas previously I think there was a big conversation about well-meaning maternal volunteers, and now there’s a growing consensus, whether that’s from the World Bank, or 40 ministries of health, or the Global Vaccine Alliance, that community health workers are professionals, deserve to be treated as such, and that health outcomes are better when we do this. And so as a coalition, we’ve worked with international bodies to develop and implement guidelines that help standardize and professionalize the community health workforce. So seven of our eight best practices were enshrined into the WHO guideline. We contributed to the first-ever guidance on counting and recognizing and accrediting CHWs. And we really continue to grow the evidence with a number of peer-reviewed publications that have been viewed, I think, at this point, about 160,000 times. If you’ve ever heard CHWs are out of stock a third of the time, as Prossy just said, 86% of CHWs are unsalaried in Africa, or that CHWs maintain care during pandemics, these are all CHIC research findings, and those have done a lot to shape the understanding in the field. And we’ve seen that then influence global financing institutions, right? We talked about guidelines, funding, and policy. So we’ve had big wins with funders such as the Global Fund, President’s Malaria Initiative, who’ve shifted more resources toward professionalizing CHWs. And as Prossy said, we’ve engaged over 10,000 CHWs who’ve been trained in advocacy, who are forming national associations, and who are sitting at these tables from which they’ve long been excluded. And we’re currently at 40 countries with professional CHW policy where CHWs are accredited and salaried, but we’re not stopping until we get the other 60. So more work to do.

Rhonda Stewart: And Madeleine and Prossy, what’s next for CHIC in terms of some of those ambitions and goals? You mentioned wanting to continue to bring the research and the advocacy and the work to even more community health workers and more collaborations. What’s next?

Prossy Muyingo: CHIC is a global movement committed to making community health workers a professional and recognized part of the health system worldwide. Moving forward, CHIC aims to focus on three key areas. The first one will be research. CHIC is dedicated to providing evidence to policymakers and goal setters to ensure that CHWs are recognized and supported through guidelines for professional CHWs. The second one is advocacy. CHIC will continue to influence global financing institutions to ensure that more resources are allocated to CHW use. We have the tools, training, and support needed to succeed. The third is activation. CHIC is working on expanding its reach, collaborating with governments, and further engaging communities to activate the next generation of CHWs and advocates driving lasting change in global health. I’m really looking forward to that day. We will have a national association of CHWs and eventually an international association, so if you want to be part of the story with us, join us and get involved.

Rhonda Stewart: Wonderful. Madeleine, anything else to add?

Dr. Madeleine Ballard: Not a lot to add to that answer. I think just, you know, we’ve put professional CHWs in the spotlight, and now it’s time to make them the standard. So I’d echo what Prossy said: Join us.

Rhonda Stewart: Madeleine and Prossy, thank you so much. Congratulations again on the Roux Prize win, and best of luck with your important and transformative work.

Dr. Madeleine Ballard: Thanks so much, Rhonda.

Rhonda Stewart: Details about the Community Health Impact Coalition can be found at joinchic.org.