Tuesday, 2 April 2013

One Million Community Health Workers for sub-Saharan Africa until 2015 (this is NOT a satire)

This is NOT a April fool hoax nor a satire, but shall explain to you how one Million Community Health Workers can be produced and deployed across sub-Saharan Africa until 2015:
“We are launching a new campaign that aims to expand and accelerate community health worker programs in sub-Saharan African countries, scaling them up to district, regional, and national levels to meet the health-related Millennium Development Goals. With the use of the latest communications technology and diagnostic testing materials, these frontline workers link the rural poor to the broader healthcare system of doctors, nurses, hospitals and clinics.
The new campaign will work with governments and aid agencies to finance and train the cadre of health workers, each of whom would serve an average of 650 rural inhabitants, at an estimated cost of $6.58 per patient per year. this adds up to an estimated $2.5 billion, which includes funding already being spent by NGOs and governments on these programs. These estimates fall within projected governmental health budgetary constraints and are within the boundaries of donor assistance already pledged and anticipated.
How it works:
Point-of-care diagnosis: Biomedical technology has now produced rapid home test kits for malaria and HIV diagnosis, sputum collection for the detection of tuberculosis by genetic amplification, and pregnancy tests. These innovative instruments have enormous potential for impacting healthcare provision in the developing world, especially at the periphery of the health system and in rural areas.
Scalable supervision: Broadband access and smartphones can link community health workers to the national health system and allow for real-time disease surveillance, child and maternal health monitoring, mobile training, supply chain management and capturing of vital events.
Standardized care: Arming lay health workers with consistent supplies of life-saving medicines and easy-to-follow treatment protocols guarantees a minimum quality of services delivered to these clients. Active care and disease detection according to rigorous guidelines has greater benefit to the formal health system than the usual passive case detection and referrals to upper levels of care.
Rapid training: There is persuasive evidence that short-term intensive trainings on the most critical competencies for community healthcare delivery can be effective for deploying on-the-ground, functional frontline health workers at scale, without a large initial time lag between recruitment and deployment.”

Thomas Schwarz, Medicus Mundi International Network
Published as editorial in: MMI Network News, April 2013

  • The text of this post is taken from the “about us” page of the One Million Community Health Workers campaign http://1millionhealthworkers.org/about-us. The campaign was launched at the Davos World Economic Forum in January 2013.
Notes by TS:
  1. The fact sheet of the campaign lists the following partners: GAVI Alliance, Glaxo Smith Kline, Office of the U.S. Global AIDS Coordinator, RESULTS, Roll Back Malaria, The Global Fund to Fight AIDS, Tuberculosis and Malaria, U.S. Centers for Disease Control and Prevention (CDC) UNAIDS, UN Broadband Commission for Digital Development, United Nations, Executive Office of the Secretary-General, USAID, the World Bank. The full list of partners also shows those directly interested in the deal, mainly IT and diagnostics industry.
  2. The following alternative titles for this editorial were finally dropped for the sake of political correctness: (1) High-tech, low skills, good money (2) It's the economy, stupid (3) Warning: This medicine may affect your health (system)
  3. Recent articles promoting the One Million Community Health Workers campaign include: 1 million community health workers in sub-Saharan Africa by 2015. Prabhjot Singh and Jeffrey D Sachs in: The Lancet, 29 March 2013; Deployment of community health workers across rural sub-Saharan Africa: financial considerations and operational assumptions. Gordon C McCord, Anne Liu & Prabhjot Singh in: Bulletin of the WHO, April 2013
  4. Next week is World Health Workers Week: “Moving toward Universal Health Care depends upon everyone having access to a skilled, motivated, supplied and supported health worker within a robust health system.”
  5. Looking forward to the long expected publication of WHO guidelines on scaling up and transforming health workers education later on this year. See www.who.int/hrh/education/initiatives 
  6. To state it again clearly: this is NOT a satire. Your feedback is most welcome and will be published here.


  1. I have two remarks.

    1. Alma Ata project has failed because it was not possible to recruit world-wide PHC workers among the local population. As planned in Alma Ata PHC workers should be chosen from the local population, knowing local conditions and local social structure, speaking local dialect etc. In 1950-ties the Chinese Communistic government first has not accepted the Chinese traditional healers in formal health services structure as not being enough “materialistically” oriented. Later on the government has calculated that there were 250.000 traditional healers, who have some medical experience and considerable confidence of the population in China. Finally the government has included all these workers into health services structure, has offered them a training and supervision. This was an important element of Chinese successes in promotion health care in population at large.

    The conditions have changed since that time with simple diagnostic tests being available now, easier communication means and better educational possibilities. Therefore Million PHC worker program is a good idea on conditions that “local” PHC workers are well selected, their simple activities and responsibilities properly defined, basically training performed and right evaluation system developed.

    In 1948, as a medical student during vacation I was personally involved in training rural PHC workers in war devastated areas in northern-east Poland. The workers were trained in hygiene and sanitation, first aid, maternal and child care, immunization and were aware where find an additional help if needed. They do their work with satisfaction and with success in difficult post-war time.

    2. Years ago I suggested that Medical Faculties in Africa should prepare medical doctors mainly able to solve local African needs not trying to reach an international level of medical expertise (partly useless in Africa conditions), which make the graduates able to work in developed countries, where the responsibilities of health services are different. The negative answer to this proposal was based on an assumption, that there is “one global medicine”, which is not true; the medical problems are far different in various parts of the word and the ways to solve these also differ. The second fact was pointed that a great part of students in African universities, supported by their families, are expected to re-pay the sponsors the cost of education, by working in developed countries. The emigration, so harmful for the African region, was anticipated even before the individual studies were undertaken and accepted by university authorities, responsible for planning best curriculum for the region.
    The idea that local medical associations (which are not interested in emigration and feel better local health services needs), would probable better influence the university curriculum in Africa than WHO itself, being far from peripheral areas in the world, which matters and traditionally trying to made “globally uniform” standards. Every teaching or training, including medical studies, has to respect the final aims and conditions of work for which it is undertaken, otherwise it become partly useless and unrealistic, not mention money lost. This rule is also true for medical education, what ever it is: academic or professional.

    With regards,
    Professor emeritus Zbigniew Pawłowski, MD, DTMH

  2. The one million campaign sounds quite in order, it's what has been happening in the past three years in Zimbabwe. Community Health Workers now do point of care tests for malaria, not yet for TB and they keep few medicines stocks and report on diseases occurring in the community. The only problem is they can not substitute the nurses and doctors that are still very short, and medicines are still not available in the clinics which train monitor and supply them, so it makes it impossible for them to have stocks.

    Training for surveillance has not received funding, so there are just national and provincial trainers, districts should train their facility staff, who will in turn train the community workers. My point is that community workers work best if the upper levels have been exposed to training and are provided with resources because once they detect a disease or condition, they render the first intervention which becomes only appropriate when they have received relevant training from their supervisors; the clinic staff and their district health teams, to which they should refer patients for more comprehensive management after the initial contact.

    Each country has their unique circumstances, but my take is that we shouldn’t overload these cadres on the pretext they will take over the work of the trained personnel. In Zimbabwe, we have always needed the CHWs even when our system was performing at its best.

    Warm regards from Zimbabwe

    Itai Rusike, Executive Director
    Community Working Group on Health (CWGH)
    PHM Zimbabwe Focal Person


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