I have been prompted to share my thoughts and stimulate a discussion on this topic by a number of recent events. There is an ongoing online conversation moderated by GHWA on “frontline health workers” that is a spin off from the multiple meetings on community health workers that we discussed in June and July 2012. In Uganda, parliament declined to pass the national budget unless government increased the health budget for recruiting rural health workers. The government accepted this demand and increased the salaries of only doctors in rural health centers by four times, surpassing senior consultants and professors! The African Women Parliamentarians met in Johannesburg in mid- October where ACHEST presented a paper on the tools needed by the parliamentarians to advocate for increasing financing for health especially MDG 4 and 5. It is apparent from all these events that gaining more clarity and a shared vision on how to strengthen health systems by contextualizing interventions based on the way they work for ordinary households as complex adaptive systems, could help us to focus our discussion and efforts for better and sustainable results. This is how I see it in the African context.
The statement that “Health is made at home and only repaired in health facilities when it breaks down” is well known in Uganda. The report and recommendations of the WHO Commission on Social Determinants of health and the advocacy for embedding implications for population “health in all policies” all reaffirm the centrality of linking the way in which people live out their daily lives with consequences for their health outcomes.
It is therefore an imperative of all effective health systems to be permanently focused on where and how people live namely: households, communities and workplace. Mechanisms for mediating these linkages will vary and are influenced by context. Here is one example. Growing up in one part of rural colonial Africa, this is what I saw: it was an administrator; the local chief who knew the village thoroughly and ensured that all households in the communities complied with the public health act: domestic hygiene with clean homesteads, pit latrines, nutrition and granaries for food security, checked that girls were old enough to marry, settled disputes for law and order etc. He was backed up by a professionally trained public health assistant who covered a wider area. There was a health facility in the village where illnesses were treated by non-physician cadres.
At its best, the routine governance of society should be the foundation of the health system by ensuring that laws, regulations and good practice are complied with by all: that homesteads are hygienic, mothers attend ante natal clinics, children are immunized, the nearest health facility has required personnel and supplies, the referral system is in place, the correct food crops are grown and stored properly, all children are going to school, the rural road network is maintained, law and order is enforced etc. This should be the job description of the village or community administrator as the very first frontline health worker. The roles of the general administrative cadres must include and prioritize health and such officials need management skills and authority and not health training. Embedding health goals and aspirations in routine governance of society will facilitate the achievement of health in all policies objective and address social determinants of health at all levels. Where and how are health workers brought into play at this level?
Health workers at the first level of contact of households with the health system , should be “needs based” and with health training sufficient to provide them with the competencies needed to perform roles at that level that are defined by the upstream leadership of the national health system. Their roles may be that of community drug distributers, vaccinators, pregnancy monitors, growth monitors, vector controllers, vital statistics collectors etc; depending on local health priorities and they maintain household health registers. The entire frontline health workforce is ideally community based working alongside and coordinated by the integrative administrator. These cadres operate through structured linkages with first level health care facilities from which they receive technical back up, referrals and supportive supervision; and through which they access the payroll to be equitably compensated for their contribution as regular established personnel of the health system.
The health facility should therefore be within the community and as close to households as possible to ensure a networked linkage to all community based health workers. These health workers perform in inseparable teams: clinical, laboratory, surgical, midwifery, nursing and outreach. Packages of health services cannot be delivered to the required standard if the teams are incomplete or if some members are less motivated than others. These teams of health workers have different levels of competencies for managing a range of common local health conditions including skilled deliveries, maternal and child health. Some of these will be sophisticated undertaking major surgical procedures such as Caesarian sections with highly trained cadres including nurses, laboratory workers and physicians. These in turn will be linked to a referral system with other facilities providing more specialized care.
Coordination, supervision and accountability are assured by health technical administrative cadres, general administrators and political leaders at district, provincial and national level. The loop is then completed on the demand side for quality services by civil society advocating for rights, freedom of speech, free press and democracy. At national level, stake holder forums (CCFs) oversee integrated health workforce planning and management.
Given the above scenario, could we not achieve more sustainable progress by putting more emphasis on securing effective integrated societal governance with health at the center, focus on tools such as the budget process for resource allocation and monitor for accountability and results? As for health workers, could we not achieve quicker and sustained results if we focus our efforts in establishing effective in-country partnerships (CCFs) and less on stratifying them?
I look forward to receiving your comments.