Season 2, Episode 4: The Community Health Impact Coalition's Campaign to Professionalize Community Health Work Globally

Many health systems around the world rely on community health workers (CHWs) who play vital roles in health promotion, disease prevention, and primary care. While CHWs in some countries are not paid or receive only small stipends and operate without a great deal of support, guidance, or professional standards, one global movement is trying to change that. In this episode, Joseph Harris sits down with Dr. Lennie Bazira - a medical doctor and Policy Director for the Community Health Impact Coalition (CHIC) - and Jannet Otieno - a community health worker in Kenya. CHIC's membership includes thousands of CHWs and dozens of health organizations in 60+ countries who are working to make professional CHWs the norm worldwide by changing guidelines, funding, and policy. They discuss the important work community health workers do and the challenges involved in making change. 

Transcript

Global Health Politics Podcast

Season 2, Episode 4: The Community Health Impact Coalition's Campaign to Professionalize Community Health Work Globally

SPEAKERS

Joseph Harris, Dr. Lennie Bazira, Jannet Otieno, 

Joseph Harris  00:01

Welcome to the Global Health Politics Podcast, where we go beyond the articles and books and have real intimate conversations with people working in the field of global health today. I'm your host. JOSEPH HARRIS,

Joseph Harris  00:27

Today, I'm really pleased to have the opportunity to learn more about the Community Health Impact Coalition, a global movement that includes thousands of community health workers and dozens of health organizations in over 60 countries around the world. These workers and organizations, alongside allies and partners, are making professional community health workers the norm worldwide by changing guidelines, funding and policy together. They're working to ensure community health workers, those on the front lines providing health care outside of hospitals, are treated as professionals with salaries, skills, supervision and supplies. Today, I have the pleasure to speak with two Community Health Impact Coalition affiliates, Dr. Lenny Bazira, a medical doctor and Policy Director for CHIC and Jannet Otieno, a community health worker herself in Kenya. What is the Community Health Impact coalition? And why was it founded?

Dr. Lennie Bazira  01:23

So Community Health Impact Coalition (CHIC) exists to make professional community health workers the norm by changing guidelines, funding and policy. It was formed by a group of six like minded organizations in 2019 with the focus of advocating together to make sure that we have the policy and funding that supports community health workers who are salaried, skilled, supervised and supplied. It currently has more than 30 members, thousands of community health worker advocates, allies and partners who together share the value of ensuring that professional community health workers become the norm worldwide.

Joseph Harris  02:14

You note that on the CHIC website it says that as far back as 1998, the World Health Organization noted that there is no longer any question of whether community health workers can be agents in improving health. The question is how their potential can be realized. Can you give listeners a bit more context on what that means, where'd that quote come from, and what have previous studies found in terms of the value and impact of community health workers?

Dr. Lennie Bazira  02:42

So as far as back as 1978 with the Alma Ata declaration, everyone was recognizing that community health workers are important if we are to achieve universal health coverage. However, there have been so many declarations, but with no clear impacts or evidence, and we need to put our money or our efforts in the words that we say. But with CHIC, we have realized since 2019 that radical collaboration, coordinated advocacy  targeting global level, we can make sure that there's better and more funding, both from donors and funders, and domestic resource mobilization, informed by research and evidence and coordinated national level advocacy that includes community health workers. We can actually realize this, and we are seeing evidence that right now, we have countries where the policy exists and actually a legal framework that is provided by those policies. Community health workers are starting to actually be professionalized in a number of countries.

Joseph Harris  03:56

And Dr. Bazira, I understand that CHIC was founded as a loose collaboration between six established organizations working in the community health worker field but has actually evolved to thousands of community health workers and organizations in over 60 countries. What originally drew you all together to do this work, and why are you still collaborating this way today?

Dr. Lennie Bazira  04:19

Because I think there's a saying that together, you can go further. And the reason the six organization came together - led by Partners in Health, Living Goods, Last Mile Health, Muso, Possible, Integrate Health and others - was that they were implementing community-led programs. However, they needed a collective voice, so that they are speaking the same language, advocating for the same rights, but organizations speaking for community health workers was not enough. We needed community health workers to be at the table. Within CHIC, there's a saying, "Nothing about us, without us." And that's why we brought in thousands of community health workers by training them. We have an online advocacy course so that somebody like Jannet, who will be also speaking very shortly, are able to share their lead stories, are able to share the impact of the work that they do in the communities. And then that way, when policy makers or funders are making decisions, there's evidence to support on what we're advocating for.

Joseph Harris  05:27

And you mentioned that Partners in Health was a lead organization. Can you just share with our listeners who are the other established organizations that were part of this original partnership?

Dr. Lennie Bazira  05:39

So there was, of course, Partners in Health, Living Goods, Integrate Health, Possible, Last Mile Health, who are what we call the first six.

Joseph Harris  05:49

That's great. And are there more today?

Dr. Lennie Bazira  05:53

Oh, yes, right now, have more than 30 organizations and close to 100 allies. 

Joseph Harris  05:59

Wow. 

Dr. Lennie Bazira  05:59

And organizations, and we have brought more than 15,000 community health workers into the movement.

Joseph Harris  06:06

That's amazing. And as a coalition, you have this principle that guides your work of "collective action through radical collaboration." Can you talk a bit about that? What areas? What does that mean? And what areas do you collaborate on?

Dr. Lennie Bazira  06:21

So for us, what it means that we have to have the shared value, like for the organizations that are in the coalition. They don't just be part of your coalition. They have to bring what you call sweat equity, be willing to put in the work. By that, what do I mean when they're in countries implementing service delivery projects. They actually working with Ministries of Health and other stakeholders in that country to demonstrate best practices to ensure that the community health workers who are working with deliver different services -  whether TB, HIV, maternal health - they are treated as professionals. They are being remunerated for the work that they do. And then "radical collaboration" is we believe in something. We are speaking the same language. If you are speaking to donors or to presidents or ministers, our members are speaking the same language. We are, they are, transparent. So like, they don't come into the coalition and say one thing, but in the field, do something differently. That's what we mean. It's radical collaboration. It is sweat equity. As long as your values align with what the condition is all about, then they are welcome to become members.

Joseph Harris  07:34

That's fascinating. Dr. Bazira, you've offered a really thoughtful overview of the organization and sort of its historical arc. I want to direct a couple questions at Jannet, who is a community health worker, who's joining us today, who I understand has been working as a community health worker for quite some time, and has some really interesting personal stories that have brought her into this work. Jannet, could you say a little bit about your own introduction to this work and also how community health workers are really leading the charge in this work?

Jannet Otieno  08:19

Community health workers, CHWs like myself, are at the heart of the health system in the underserved communities. We need this work because we live the realties. We aim to change. Whether it is HIV, TB or cervical cancer, we are often the first and sometimes the only point of the contact of health information and services. Our leadership is grounded in trust and need, lived experience and unshakable commitment to our communities. We don't just implement programs, we drive them, and we share policies and we hold the system accountable.

Joseph Harris  09:16

Can you share with us a little bit about community health programs and the role that community health workers have played in organizing in the country where you come from? How'd that get started, and what are the really important contributions that this program makes there?

Jannet Otieno  09:37

Here in Kenya, community health workers are part of structured system in primary health care at the grassroots level. We are organized under bodies like ARCHVO-K. ARCHVO-K means Advocates for Community Health Volunteers of Kenya, where I served as a member-representative there. This platform allows us to unite our voices and push for policy reforms and promote professional development. Through organizing, we have moved from being invisible volunteers to recognize the urgency of health change.

Joseph Harris  10:27

What are some policy reforms that you've advocated for, that you're particularly proud of?

Jannet Otieno  10:35

The community movement in Kenya started in informal groups of volunteers in circling out fashion. But as the burden of diseases increased, and with more evidence showing our impact, we started organizing formally. ACHVO-K emerged from this need for a collective voice and advocacy. For me personally, it was my own journey living with HIV and experiencing stigma that pushed me into this work. I knew I couldn't I couldn't let others suffer alone in the silence.

Joseph Harris  11:15

What challenges do community health workers face in conducting their work in Kenya?

Jannet Otieno  11:20

In Kenya, we host a lot of challenges, like right now we thank CHIC because CHIC has been helping us with a good push. For us, we normally say "nothing about us, without us," so that has made us nowadays small challenges, because we normally say nothing should be discussed without us at that table.

Joseph Harris  11:50

And Dr. Bazira, can you say a bit about the kinds of challenges that community health workers face in other countries? Are they similar or different than in Kenya? It sounds from from Jannet that they've managed to overcome challenges that they face through collective action.

Dr. Lennie Bazira  12:11

Yeah. So basically, in most of the countries, community health workers, sadly are still being treated as volunteers, not just being treated as volunteers. They are sent out into the communities to provide services without adequate training in some cases, without adequate supplies, which includes commodities or even protection for themselves. They are not properly supervised. Sometimes they face issues of security and personal safety. And then, of course, there's also gender-based violence and because a country like Kenya, where we have advocated together with our community health workers with a strong political commitment that's always important, because in Kenya, from the highest political leader who is the president, he has been able to emphasize that community health workers are important, changing their name from volunteers to promoters. So in Kenya, you find that they are now properly...they are paid, not a full salary...minimum wage, but at least they are paid. They are trained. There's a system whereby they know where they are supervised. They are part of the healthcare system. But in other countries, we have a Policy Dashboard right now on our website, which we call the CHW Policy Dashboard, we are trying to track all Low and Middle Income Countries, 137, and right now, out of 137 countries, we have data for 99, and out of 99 only 49 have policies in place that actually accredit and pay a salary, sometimes not a minimum wage, to their community health workers. But even among the 49 that have a policy in place, less than half of those actually fully implement the policies. So we still have so many countries out there, even that do not provide the basic support for the community health workers, even though they still work, they still provide the services in their communities where they live.

Joseph Harris  14:20

So what I'm hearing from you is that Sheik is really trying to expand the professionalization of community health workers to improve living standards for the community health workers, also standards in terms of training and monitoring and supervision. Is that right? 

Dr. Lennie Bazira  14:38

Yes. 

Joseph Harris  14:40

So in the past 15 years, there's been growing support at the global level for universal health coverage, which I know you're aware. How has that growing openness to universal health coverage translated into support to community health workers? Has it? One could imagine how community health worker programs might support universal health coverage, but is that always the case? How have those two different ideas connected with one another?

Dr. Lennie Bazira  15:10

I think the different...the acknowledgement that to achieve universal health coverage, you need community health workers, that is, I would say 100% everyone who is talking about universal health coverage, we all agree on that, that if we're to achieve universal health coverage by 2030, it basically happens at the primary health care level. Community health workers work at the primary health care levels. They are the frontline health care workers between the former health care system and the communities. There's no way you can talk about universal health coverage without talking about community health workers, so everyone who is talking about that will mention community health worker.s The difference is for us, within CHIC, we say, "Yes, community health workers are important to achieve universal health coverage. However, they need to be treated as professionals because they work. They are the ones providing the prevention, the health information, the referrals, the follow-ups. When they are pandemics, they are the ones who are the first point of reference. They are the ones who are there in the communities providing surveillance data to prevent future pandemics, like, for example, during COVID, community health workers in countries where they were supported, they make sure that communities receive Personal Protection Equipment. Communities accepted vaccines where there were community health workers. It did happen as well, if you recall at the beginning of Ebola, some high-level opinion leaders did mention that, "Oh, Africa, where most of our work is, that people will be dying in the streets because of Ebola, it did happen...sorry, because of COVID-19, it did happen, and the main reason was because community health workers stepped up. They provided information when the vaccines became available. They made sure that there was acceptance, and COVID-19 was not a disaster, as people had thought it would be in Africa. When you compare, for example, to what happened in the US and other developed countries in Africa and some of other Low and Middle Income Countries, the situation was different, and the reason was community health workers, and that's why they are the critical component for us to achieve universal health coverage, but we want to make sure they are not exploited for that is that is injustice. They should be supported to make sure that their contribution to universal health coverage is properly recognized, compensated and appreciated.

Joseph Harris  17:45

And so what I'm hearing from you is that these community health workers are really not just frontline health workers. I mean, in the COVID crisis, we always talked about  essential workers. And it sounds like certainly, community health workers are that, but they're also much more. I'm hearing that they play a really key role in, for example, breaking down stigma towards vaccines, delivering services that are critical at times, for example, during pandemics and and that you're really advocating for their further deepening and integration into into health systems.

Dr. Lennie Bazira  18:24

Yes, that's what I'm pushing for. Because if you look at every aspect of the healthcare system, there's always a community health worker bridging the gap. When you look at HIV and AIDS, it's community health workers who make sure that there's the messaging, the information for prevention is reaching the population. The other ones, we ensure that those on and provide a treatment adhere to their drugs. It's community health workers. When it comes to TB, is community health workers who are there providing what we call Directly Observed Treatment Services to make sure we don't get MDR-TB. When it comes to maternal health, the other one in the communities talking to mothers emphasizing the need for skilled birth attendant and antenatal care, they're the ones talking to mothers about vaccinating their children. When it comes to COVID-19, it was community health workers telling people that, yes, vaccines are safe. And we have many testimonials from our community health workers saying, "Yes, look at me. I'm taking the vaccine so you can do it." And because they live in the communities, they are trusted. It's, it's really, that's why. But what we are saying, "They are trusted, they are knowledgeable. They know what is happening. They can make a difference." But we want to make sure that there's care for those who provide care to others, and that's why community health workers, that's why CHIC exists to advocate with them, to make sure that the professionalization happens.

Joseph Harris  19:58

And so this, this idea that they are from the community, working in the community, sounds really important.

Dr. Lennie Bazira  20:04

Yes, very important, because it's more acceptable because it's not...community health workers don't work from away in the US. They will be within that local place. They are not going to move from one state to another because we need them to be in the communities because they are serving their neighbors. They are known the opinion leaders, because trust is built, because somebody knows you intimately. And that's why community health workers are important, because they live in the communities, and they serve within the communities where they live. 

Joseph Harris  20:36

And I understand that CHIC does research as well to expand ideas of what is possible in community health and to overcome institutional obstacles. Can you share a bit more about that? What work and research in particular has the coalition led that's really pushed boundaries of what's possible in relation to community health workers and health systems?

Dr. Lennie Bazira  20:59

Well, CHIC does research, so we conduct our own research, but we also collect research from different other publications that we put on our website. For one of the research that we have published is the one - if I can mention one in the interest of time - is what we call the return on investment..they have provided evidence that for every dollar invested in a community health worker, you will realize a ripple effect of ten dollars. Why do we say that? Because when you invest in a community health workers, you're preventing sicknesses, you're preventing children from missing school. We are showing that actually people remain economically productive within their communities. They can work, they can contribute. And that research of the 10-to-1 return on investment is supported by almost everyone. It's one of the ones. But then there are others that also have research that we have shown the evidence for COVID-19 and the impact of community health worker distributing Personal Protection Equipment in various countries, and how that was able to prevent COVID-19 being a disaster in those countries, rather than becoming where there were no community health workers, we have more than 100 other publications on our website for examination,

Dr. Lennie Bazira  22:09

That sounds like quite an impact: ten dollars for every dollar spent.

Dr. Lennie Bazira  22:29

Yes!

Joseph Harris  22:31

Can you talk about the shifting landscape globally towards recognizing community health workers as professionals? I know, for example, in some countries, there been strikes that have fought for increasing wages and professional standards for community health workers. What role if any, has CHIC played in these changes?

Dr. Lennie Bazira  22:53

So for us, our role is that, like I said, we we provide the evidence, so we have the research that we can use as evidence for that advocacy. But you also we don't advocate as organizations. We have community health workers like Jannet being able to come in and tell their stories. We've have community health workers speaking at every...like World Health Assembly recently, at the United Nations General Assembly, and when a community health worker steps on the stage and shares what they have been able to do and what they are doing, that makes more of an impact than somebody who is not like working in the communities telling that story. And that because they speak in front of CEOs, like we had the community health workers on the same stage as the CEO of GAVI. We had a community health worker on the panel with two ministers, one from Uganda and one from Sierra Leone, basically saying, "Yes, you have a policy in my country, but I know thousands of my colleagues are not being paid and properly trained, and yet the policy exists. So what are you going to do for us to bring that policy?" And that minister was being put to task in front of different stakeholders, which means when they go back, they are going to be forced to act. But also not just for the minister, they were talking to funders, "You've been you keep saying, we support community health workers, but show us the evidence actually, the money that you're providing to the different...NGOs or governments, actually, it includes key performance indicators that track how community health workers are supported." So that's how CHIC works. It's like we have the evidence that it works. If you invest in community health workers, we have community health workers as part of our advocacy team, telling their stories, challenging all of us to do the right thing, and then we have this radical collaboration for all of us doing the same thing, but also focusing on changing policy at the national level because we believe that's where the change and sustainable change will come from.

Joseph Harris  25:12

I love that story that you shared about the community health worker's story at the World Health Assembly, and sort of having an impact on ministers that have to go back and then do something about it. Are there similar kinds of presentations or opportunities to testify before Parliament at the national level? How does advocacy happen practically at the national level?

Dr. Lennie Bazira  25:39

it does happen, and I'll give an example of Kenya where a journey it comes from. So she mentioned ACHVO-K, which is an Association of Community Health Workers in Kenya. They did write, actually, a memorandum to the to their Parliament in Kenya when the government was discussing the Community Health Bill, actually putting together their case, saying what they do, the challenges they face, and are making their requests, their demands known. And that memorandum and their contribution to the bill actually contributed to the current change in Kenya, where the community health workers are being organized as professionals and with proper training, digital tools, salary stipend, not a full salary yet, so they are still advocating for that. In Kenya, it has happened. They did that.

Joseph Harris  26:34

That's great. Can you say more about the concrete impacts that you've had like, for example, how how much have community health workers seen their their salaries increase after this kind of advocacy? And are we seeing community health worker programs in places where we haven't seen them before because of this?

Dr. Lennie Bazira  26:59

So I can give...Kenya first: when before advocacy with community health workers and CHIC advocacy supporting community health workers, the majority they were considered volunteers, even their name was community volunteers. But because of the advocacy, the president himself, the current president, Ruto, made the pronouncement the change that they should their name should change from being called volunteers to being called promoters. And he specified the amount of money they should be paid every month. And he made it a mandate between the national government and the county government to do that. That's one country. In another country, in Malawi, where we have NGOs and community workers advocating, and Malawi is one of the least income countries in the world. However, community health workers are on the government payroll. There's a policy in place that was passed and in within that policies being implemented, and community health workers actually are paid salary. They are on the government payroll. So that is a few examples I can give. We still have...we have no countries if you want, but we are seeing that change happening again. Another country: in Liberia, in 2023 we had the Community Health Worker Symposium, during which the vice president came into the meeting, community health workers had spoken and given their testimonies. And after that, the government made the pronouncement, invested $1 million to support the salary payment of community health workers in Liberia. So we are seeing the impact of advoacy actually starting to improve.

Joseph Harris  28:42

That's great. And a moment ago, you had mentioned, you know, sometimes the impact is on government, sometimes the impact is on donors. Both are clearly important, and some may be more important in one setting and some more important than in another. Can you say a bit about who, who usually pays for these programs? Is, is that are the efforts typically more directed towards donors, or more directed or government? You know, who funds these?

Dr. Lennie Bazira  29:12

So basically, our advocacy...so we have three tactics within Community Health Impact Coalition. We have the research that I mentioned provide the evidence, and that evidence is both for the norm setters that WHO makes sure that they have the right guidelines in place because countries rely on that, but also evidence for countries discussing policy change or investment options. But then we also have the global level advocacy, and that effort is directed at global the funders or donors, so like Global Fund or GAVI, and at that level, really, we target to make sure that in their strategies, when because they are deciding how they are going to fund countries, implement programs. It includes a component for community health worker support. So we saw, for example, advocacy at the Global Fund. Global Fund now has key performance indicators that clearly indicates how the money they give to their countries will include, will be tracked on how much they are putting into community health programs, including community health worker support. GAVI CEO Sania Nishstar has promised that right now GAVI strategy will include support for community health workers. But we are very much aware that the change happens at the countries because we need the policies in place that will ensure that that is sustained. So in countries, in terms of where the money comes from, it's a mix. Sometimes it's donors or funders supporting community health programs, but also governments may put in some money. But the key is that we want the government to just to make the decision to lead, to coordinate on how much community health workers are being paid, how the training is being conducted, who becomes the community health workers who get supervised, what digital tools they're being provided, and that sort of thing because, if you like, our target is both global and national. But for sustainability, we believe, for countries, if they have the policies and the strategies to implement those policies, then the change will be more sustainable.

Joseph Harris  31:29

I mean, one of the things that's so striking about what you share is, you know, we normally think of community health workers as working at the local level. I mean, it's about as local as can possibly be, you know, right in communities, and you're talking about a sophisticated strategy of advocacy that is taking place across a lot of different levels. Right? Community health workers training other workers to be advocates, focusing on the national level, the global level, at multiple stages, the World Health Assembly, parliaments, and it's just quite striking.

Dr. Lennie Bazira  32:09

Yes. So basically we have community health workers who are participating in research, as researchers with their subjects. We have community health workers who are global advocates, who speak on international stages, like you just mentioned. We have community health workers in their own country speaking at national level with different stakeholders, whether it's politicians or ministers of health and others, and then we have the majority within their communities, because also there, you need advocacy, mobilizing within the communities, not just for this to be supported, but to make sure that they are changing lives and they're improving health outcomes.

Joseph Harris  32:52

Yeah, that's great, and holding policy makers accountable for making sure these policies actually are concrete, it sounds like as well. 

Dr. Lennie Bazira  33:04

Definitely. 

Joseph Harris  33:05

Could you share a bit more about your work training, community health worker advocates and what specifically those advocates advocate for?

Jannet Otieno  33:12

Yes, I can share. Training has been a game changer. Through CHIC and ACHVO-K, we have trained CHWs in digital advocacy, storytelling and leadership. I have seen CHWs transforming from shy to silent and silent to powerful advocates, advocates speaking in parliaments or online meetings. This training equips them with influence, policy, organize their peers and engage with decision makers directly,

Joseph Harris  33:39

And Dr. Bazira to take things back to the sort of global level, looking at your work across a number of countries, there's this Policy Dashboard that's on your website, and you alluded to this, and it tracks the number of countries, for example, that currently have one or more accredited and salaried community health worker groups. And since the time that we began these conversations about doing this interview, we've seen that number grow, and now that number stands at 49 out of out of 95 countries, and it was just 47 out of 94 a short time ago. Can you say more about how that number has grown over time, and what has been the response by health professionals like nurses and doctors to the growing professionalization of health workers?

Dr. Lennie Bazira  34:48

Okay, so basically, the Policy Dashboard was launched in 2023 actually when we started the number of countries with at least one group of community health workers that was salaried and accredited was 24, so since then, the number has grown. And how has it grown? So through advocacy, so CHIC-led advocacy, our members and community health workers in different countries. During the policy windows...we target active policy windows to make sure that during the stakeholder discussions, we provide the evidence we are in the room. Community health workers are in the room really making a case of why we need them to be professionalized, and so that's how the numbers grow. But also we've had countries whereby the policy was there, but maybe we didn't have the information because countries were doing things differently. There wasn't much collaboration. So from the numbers growing, we have new information that we've received a lot of policy information from Latin America in the last few months, but also we have seen policy change in that part of the world, like in Guatemala recently where actually with advocacy, through community health workers actively advocating for change, the policy change actually, I think, is the most recent one that has changed, whereby now community health workers in that country are contingent salary. So it's basically coordinated advocacy, being able to provide the evidence when needed, and ensuring that advocacy is not just for NGOs speaking with governments, but community health workers are in the room where those discussions are being made and the decisions are being made.

Joseph Harris  36:36

I love how you're really trying to empower the community health workers themselves. That's, I think, really interesting and important. One could imagine tensions sometimes arising in relation to professional jurisdiction between, for example, nurses and community health workers, both sort of subordinate to doctors, directly engaging with patients and and there being some professional tensions there. How has CHIC navigated these challenges, and what are some examples of success?

Dr. Lennie Bazira  37:12

I think the key is really dialogue and being able to show the evidence. Personally, I am a doctor, and I've had some of my colleagues ask me, "Why am I advocating for professional community health workers when doctors in a number of countries are not paid adequately?" Yeah, which is a reality. However, it is to show them, "Look, there's no way we can achieve the kind of health outcomes that we need if we don't have community health workers." And every nurse or doctor or midwife that works at a facility, they all rely on community health workers. I used to work in the field. When I used to...before I moved to the US, when I worked in the facility, I needed the community health worker so to make sure that they spoke to mothers who needed skilled birth attenders, and they had some maybe different perceptions, not trusting the healthcare system. When I was working in HIV and AIDS, we relied on community health workers on what we call treatment adherence. So it's basically for the profit for the other professions. And we still have some tensions because the challenge is, "There is no adequate investment in health. The money is not enough." So even the other professionals, they are not paid...They're not paid adequately, but at least they are paid. They will say, our salaries are delayed, so we work with our community health worker and say, "Look, you get paid. You on the government payroll, even if your salary is delayed, you are kind of assured it will come. But community health workers, they work with you, they support the work to make sure you succeed." If they work on prevention, they reduce the burden of the health facility because people don't get too sick. But the challenge between you and them is that they are not being recognized. Everyone expects them to work as volunteers, and yet you are no one wants to, because they also have families. They have children. They need to feed their their families, they have to pay rent. But basically, it's when you have the dialogue, the tension ceases. So right now, we still have tensions in some of the countries, but the this whole thing of task sharing is acknowledged by almost every healthcare professional. We all acknowledge we need community health workers, but it's basically being able to make people aware on why they're important and why they should be supported. Because if you continue treating them as volunteers, it's like...it's a human rights issue. You ask...the first question I ask: how many of us would want to work as a volunteer? And none of us want to, and once you start that conversation, they are ready to listen. We are still in dialogue. I wouldn't say we are 100% there yet. We still have those who kind of believe maybe we should go through. The money is not enough. So as much as you advocate for professional community health workers, we also advocate with other groups, like the frontline healthcare coalition, we advocate for all other healthcare workers who increase investment in health overall.

Joseph Harris  40:35

Dr. Bazira, you're both a Policy Director, but you also mentioned a medical doctor yourself as someone who is a doctor but also has worked very closely with community health workers. Can you share a personal story about their value? Where have you seen their contribution just prove really critical?

Dr. Lennie Bazira  41:00

I think I can share very briefly. So before I move to the US, I was working in Nigeria, and at that time, though, it was the peak of the HIV and AIDS epidemic, and while having challenges with what you call mother-to-child transmission because there were two things in some parts of Nigeria: women were not delivering at a facility. For the children were not getting...the mothers were not getting the prophylaxis, and the children were not getting time prophylaxis to make sure they are born HIV-free. So what we had to do is really mobilize community health workers and make sure that we train them on the messaging and also to talk to the mothers, because the mothers trusted them. They lived in their communities. And then we got a few of those who are living with HIV and AIDS, like Jannet mentioned, to share their stories, like get a mother who took the treatment and was able to get pregnant and gave birth to a negative, an HIV-negative child. And we saw a change in Nigeria by the time I left. I left Nigeria in 2010. We're having...like zero children being born with HIV. And I would credit to...okay, we did provide the drugs from the facility, but most of the work was because community health workers stepped in and talked to the mothers and followed up because the child has taken the medicine for four weeks after being delivered, and it was community health workers doing the work. And with that, I would say that positive health outcome, I would say 90% of it attributed to community health workers. So together, for me, that was a game changer. As a doctor, when I started realizing...it was like I was being paid at the end of the day, at the end of the month, I got a salary. But the community health workers did not get a salary because they were being treated as volunteers, and that's why, like, now I advocate for that to change.

Joseph Harris  43:04

Yeah, so often we, we hear about these miracle drugs, you know, like, like AIDS treatment. But I love how you bring into the story the role that community health workers play as people and in making this actually happen. I want to ask a question directed at both of you, and that is, are CHIC's lessons transferable to other contexts? One can imagine some governments might not be friendly to radical approaches to coalition building, paying health workers who have been volunteers. Could you say more about the value of being open to what CHIC and CHIC-type movements have to offer is?

Dr. Lennie Bazira  43:48

I would say what CHIC does is transferable, and the key is that transparency and radical collaboration. We collaborate with ministers of health. Whenever we have, like, a side event in any of this international forums, whether it's the United Nations General Assembly or World Health Assembly, we invite ministers of health. Sometimes we even have ministers of finance who speak, and they hear, so..,and we are open because we also want to understand where they're coming from, and that's why I mentioned though the challenge they always have is like, "We don't have adequate resources for health, but now you're asking us to add another group of healthcare workers the payroll." Okay, open the dialogue. Then we start giving them the evidence on the return on investment, on what it would mean sharing that limited budget, You have with a group of healthcare, professional healthcare workers who are going to make sure that diseases are prevented in the community before they become too expensive to be treated at your tertiary institution. And once you open the dialogue and then you start discussing...yeah, have a policy, have a legal framework, have your investment case, and then at the global level, we are advocating on behalf...make sure that if they are funders who are funding your country, they actually also investing in primary health care and community health programming to support your own national resources. So it's a dialogue. But we don't like say...we don't talk at government. We discuss with them, so we consider government as our partners within the coalition. But maybe Jannet may have something to add on as well.

Jannet Otieno  45:45

After doing my advocacy training, which I was shown at CHIC, we got a roundtable with the government, those people in government, the head of states. That is where we started to know that having round tables with them, talking about whatever we are doing in the community, talking about how things are going in the community about health. That is where they found us very much attractive, and that is where we started moving, from Ministry of Health, from the Members of Parliament, from the Senate, that is where we go.

Joseph Harris  46:41

That's great. And Dr. Bazira, you had offered sort of an overview of the impacts across the globe and the advocacy strategy, and obviously we acquainted the listeners with the Policy Dashboard. Can you point to particular models of community health worker programs in the work that you've done around the globe, both in terms of the impact that they've had in on the health of people in the country where they're working and contributions to the health system, but also programs that have you might consider models in terms of what they've achieved, in terms of advocacy for things like salary, status, accreditation standards, those kinds of things?

Dr. Lennie Bazira  47:39

So in terms of the impact, like community health worker contribution to the health outcomes. So if I could give an example, recently, Burkina Faso, one of the smaller countries, also in West Africa, they passed a policy that recognizes community health workers and being professional, and this provides clear guidance on how they should be framed, supervised and paid. But in that country, what informed the outcome of our policy was they linked to the health outcomes. So the leadership was interested on improving maternal and under five health outcomes. And so the evidence was one of our founder members actually living goods and supported community health workers in a district and had evidence to show that actually, when you invest in community health workers, you reduce maternal mortality, you reduce infant and under five children mortality. And once that evidence was presented to the stakeholders, who included the government, donors, funders, researchers, academia and other health professionals, there was consistent...actually, if that is what you can achieve, if you properly invest in community health workers, then let's have a policy that ensures their professional rights. Then there was another component of that, whereby the country had was undergoing some security issues. There was, I think there had been a coup, and there was also evidence that there was research that had been done, was one of our members called Muso Health, to show that the impact of community health workers in conflict results, because, like I said, public health workers live in the communities when people pull out, when no one can move, because they're the communities, they will stay. They'll provide the services that are needed, even when there's a security [issue] and even between the different fighting groups, because they appreciate the services they provide, somehow they are protected. So that evidence...the there's a paper that was done by Muso Health from Mali. Burkina Faso was able to draw on that and say, since we also have areas of conflict, if we invest in community health workers and pay them to stay in the community and serve the people, we are going to make sure that we prevent preventable death, and so that's why the stemming of the impact occurred. So we have seen community health workers improving health outcomes, but being the one staying to provide services, especially when there's conflict. But also we've seen in other countries, among refugee communities, like, for example, in a country like South Sudan, which has been at war for years now, since they broke up from Sudan recently...in 2024 they also passed a policy that recognizes community health workers as policies called the Bern Initiative. And one of the reason was that country, most of the communities, they're under conflict. There's fighting day in and day out. So most doctors and nurses will need people. People will be able to move to facilities, but they can actually access services through community health workers. So another impact in conflict. Community health workers...here you lastly...I know we are coming to the top of the hour...during the Ebola outbreak, I originally come from Uganda, community health workers were the ones actually who were the forefront fighting Ebola, making sure it does not spread, and localizing it in the community where it had broken up, and preventing death again. Now the country has a policy in place, not yet fully prevented, that organizes community health workers' professions.

Joseph Harris  51:34

Now the US is, unfortunately, one of those countries without an accredited and salaried community health worker group. Is CHIC doing any work to build community health workers in the US? What challenges need to be overcome to do that?

Dr. Lennie Bazira  51:50

So CHIC...so the US is not like a focus country per se because it's considered a High Income Country. However, we do collaborate. So the US has an association of community health workers called the National Association of Community Health Workers. Naturally, they were all partners and allies within the CHIC. But for them, the advocacy, because the US is very decentralized, there has been some wins in some states where they are like Medicare and Medicaid can actually reimburse community health work. They're still advocating. They've been to Congress. They've been in different states, whereby now there, there are bills that support them to get paid. Of course, in the US, it is not the same as in other countries, because it's insurance-based, but I've seen some successes where actually, by now, I think the what needs to be they're still advocating for is for private insurance also to start reimbursing community so we collaborate with them. We don't actively advocate in the US for community health workers, but we are allies and partners in the same fight.

Joseph Harris  53:06

Before this conversation, I was aware of community health worker programs in places like Brazil and in Thailand, and also the Health Extension Worker Program in Ethiopia, but you really expanded, I think, the listeners' views of the different kinds of contexts where we see community health workers operate. From in pockets in the US, as you mentioned, but also in conflict-affected countries that you mentioned, like South Sudan and also programs in Burkina Faso in Mali. The work of CHIC has recently been recognized in the form of a number of important international awards. Can you share a little bit about those awards and how it's been recognized?

Dr. Lennie Bazira  53:55

So...and we are very grateful for those awards. So we got the Roux Prize Award, and that was mostly because of the research that we do, being able to provide the evidence and the data that decision makers need to inform that the work on the decision that they're making. So that was one we got. The Schwab Award, which is mostly basically entrepreneurs. Again, our model of radical collaboration and advocacy was being recognized, and our recent award was from the Skoll Foundation. They have been funding us for our work, but basically it was, it was more of like seeing the way we work, the ability to work with community health workers, to bring non-government organizations, to bring governments, to bring norm-setters, to bring funders, to actually start having the same vision. That is, I think, that's the recognition we are. That's why we have those awards. And when we get those awards, it's not basically to build our own institution, because we consider ourselves as a party. It is to make sure that to strengthen the foundation and empower community health workers as advocates, and being able to see like the 137 countries I mentioned at the beginning, all are professional community workers in place. So we, we take those awards to further amplify the advocacy, the importance of ensuring that community health workers are being professionalized, because once community health workers are properly supported, billions of people who actually receive the health care otherwise when they would never have received it at all. But again, it's not just the people who get care. It's ensuring those providing the care, community health workers, are also cared for. So those are awards and recognition of our mode of work that enable us to take our work and scale it out further and empower community health workers to remain in the fight.

Joseph Harris  55:57

That's really thoughtful. This last question is directed at both of you, and that is, if you had to give someone listening who wants to get involved in expanding the role of community health workers in their own country and improving their standards and salaried positions of workers, one piece of advice. What would it be?

Jannet Otieno  56:20

I would start by listening to us, community health workers. We know what works and what is missing. Organize them, train them in the advocacy, pay them fairl,y and include them in decisions that affect their work. CHWs should never be an afterthought. CHWs are valued and supported by lifting entire communities.

Dr. Lennie Bazira  57:01

Yeah, well said, Jannet. I think in addition to what Jannet has said, Joseph, listening with them, my advice would be, make them at the center of the decision, organize with them and not for them, and then back their leadership with the right policy, the right funding and the political will because that's how we can create real and lasting change to make the professional community of workers the normal way. That's what my advice would be. Thank you.

Joseph Harris  57:35

Great advice. We've been here today with Dr. Lennie Bazira, Policy Director of the Community Health Impact Coalition, also called CHIC, and also Janet Otieno, a community health worker living with HIV who's been working on these issues in Kenya. Thank you both for joining us on the Global Health Politics Podcast, and I wish you continued success in your work.

Dr. Lennie Bazira  58:23

Thank you, Joseph, thank you for having us. We appreciate it.

Joseph Harris  58:26

This episode of the Global Health Politics podcast was produced by Joshua Emokpae. Thanks for listening.