Bridging Gaps: Global Examples of Community Health Worker Programs

1. Global Health Lecture Series • September 20, 2017 • Julie St. John, • Associate Chair, • MPH Program, Abilene Bridging Gaps: Global Examples of Community Health Worker Programs

2. Activity

3. Key Topics • Who are CHWs? • What is their role? • Where are CHWs utilized? • Why are CHW programs successful? • How can we engage the CHW model? Maria Davila, Promotora from Mexico

4. Who are CHWs? https://youtu.be/rwCAMNxoMX4

5. Frontline public health workers who are leaders or trusted members of, and/or have an unusually close relationship or understanding of the community they serve. This trusted relationship enables them to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWdefinition American Public Health Association Community Health Worker Section

6. Indigenous members from a community who love their community and want to see people’s health and lives improve—so they give unselfishly of their time and energy (often with no or little pay) not because it’s a “job” but because it’s a work of love for them. CHWs do everything from holding hands when someone is sick to calling thirty agencies to assist a resident with a particular need. St. John Definition Promotora in the Dominican Republic

7. Other names for CHWs • Camp health aides • Case management aides • Colonia Health Workers • Community health agents • Community health representatives (CHRs) • Community support workers • Human service workers • Lady health workers • Lay Health Advisors • Lay health workers • Life skills counselors • Non-traditional Health Workers • Outreach educators • Outreach Workers • Peer health educators • Peer health promoters • Peer navigators • Promotores • Social and human service assistants • Social work assistants • Indigenous or Village Health Workers

8. Leaders/Trusted Members Community Serve Characteristics South Texas Promotoras

9. Relationship with the community Honest & respectful Personal strength & courage Patient & kind Not judgmental Motivated & committed Caring & empathetic Promotora Qualities Dinorah Martinez, Promotora from Mexico

10. Dependable Creative Persistent Flexible Open to change Deep desire to help Promotora Qualities Promotora Team, South Texas

11. Communication Interpersonal skills Teaching skills Organization skills Advocacy Skills Capacity Building Networking Knowledge-based health information Core Competencies

12. Emerging Competencies • Facilitation • Strategic thinking • Community organizing • Program planning • Team collaboration • Problem solving/solution funding •  Service Coordination (case/care management) • Research

13. Interpretation & translation services Culturally appropriate health education & information Assess clients’ needs Assist clients in accessing needed healthcare Eligibility screenings Informal counseling & guidance on health behaviors Arrangement of transportation Roles & Responsibilities

14. Advocate for individual & community health needs Provide some direct services (first aid, blood pressure checks) Refer clients to health & social services Conduct public health research Provide of emotional support Maintain client records Roles & Responsibilities

15. Models of Care • Member of care delivery team • Navigator • Screening and health education provider • Outreach-enrolling-informing agent (“Outreach worker”) • Organizer • Research team member

16. The Literature • Increase health-related knowledge • Increase self-care practices & health outcomes • Higher rates of health promotion course completion • Increase screening rates • Facilitate behavioral change by providing encouragement, support, & serving as role models • Decrease high-risk behaviors in target population

17. The Literature • Case management/service coordination results in better follow-up with medical care • Cost savings • Reduced Emergency Department utilization • Decreased hospitalization • CHW use is highly valued by administrators, program staff, & clients

18. Reasons Employers Utilize Promotores • Successful utilization • Cost effective • Improved health outcomes • Organize communities • Develop comprehensive health action plans • Programs addressing health disparities are more effective when using one-to-one outreach by promotores

19. History of CHWs • “Farmer Scholars’’ trained in China in the 1930s • 1960s-1970s, small CHW programs began emerging in various countries (Latin America) • Experience from CHW programs predating the 1970s provided inspiration for much larger CHW programs in numerous low-income countries in the 1980s

20. Workforce Development • 1966-1972: experimental responses to persistent problems of poor/unreached areas • 1973-1989: short-term public/private grants aimed at health promotion & access to care • 1990-1998: State & Federal Initiatives promoted standardized training; greater recognition for CHWs; communication among CHW initiatives • 1999-2017: Public policies/legislation addressing CHWs, their use & certification

21. Certification/Credentialing • Alaska: Community Health Aide Program (CHAP) established in 1964 • Texas & Ohio: formalized programs (late 1990s) • Minnesota: Credentialing requirement for CHWs who can be paid through Medicaid reimbursement • Indiana: standard requirements under specific programs • The Cornell “Family Development Certificate” -default certification in about 16 states

22. Certification/Credentialing • Increased Personal Skills • Professional Recognition • Opportunities • Better Help Others

23. Barriers/Challenges • Funding • Lack of accepted CHW standards, competencies, & training • Lack of direct reimbursement for CHW services by Medicaid & other programs • Not recognized as legitimate providers or member of health/human service team

24. Best Practices • Collaboration & inclusiveness in development & decision-making • Targeted training for the roles & interventions promotoras will perform/provide • Educational standardization/certification • Targeted interventions: specifically defined activities that the CHW is competent to provide

25. Best Practices • On-going, high quality research on outcomes & cost-effectiveness • Diversified funding sources • Understanding of & partnerships with other health workers, health and social service providers and government agencies • Champions & visionaries to move forward

26. And that’s just in the U.S.!

27. Global CHW Programs Countries where World Vision supports CHW programs

28. Bangladesh: Shasthya Shebika • Shasthya Shebika (SS) Program • 1970s first tried male paramedics; shifted to lesser-trained females • ~100,000 SSs • 4 weeks basic training by local BRAC • Provide health promotion & sell health products • Community selects/supports SS • Successes/challenges

29. Afghanistan • Developed in 2003 (World Bank, USAID, European Union) • ~19,000 CHWs: volunteer male & female teams trained by NGOS • Three 3 week modules; 1 month field training • Provide health promotion & health services (*case mangmt & FP) at village health post • Shura-e-sehie (health committee) • Dec. 5 = National CHW Day • Key challenges: illiteracy; poverty, poor security

30. Brazil: Community Health Agent • Family Health Strategy (1980s, 1994)-CHAs (2002); +236,000 CHAs (33,000 teams) • Selected by local health committees, literate, work in community they reside • 8 weeks formal didactic training; 4 weeks supervised field training (FT salaried workers) • Provide comprehensive, promotive, preventive, recuperative, rehabilitative services • Successes—MDGs • Challenges: high turnover, lack of linkages, differences in care provider, fee-for services

31. Zambia: Community Health Assistant • 2011-2012 (workforce shortage, <1/1000); 5000 CHAs • Split time between health post (20%) & community (80%) for household visits, community education, & health promotion activities • 1 yr formal training; 12 modules (prevention, promotion, curative care); education requirements (18-38 yrs old) • 2,600 ZMK per month (US$465) + benefits • Supervised by in-charge at nearest rural health center • Funded by government & private funds Gathering evidence of impact • Challenges: regular supervision; transportation/distance; delay in payment; large catchment areas; communication challenges; lack of role clarity

32. Discussion Questions • What similarities do you see? • What are major differences? • How do these models compare to U.S. model? • How could some of the challenges be addressed?

33. Key Concepts • Extraordinary diversity in CHW engagement • Changing from ‘band-aid’ (stop-gap) to expanded roles & importance • Expanded roles • Funding streams • Universal implementation challenges & successes

34. Take home lessons • CHWs needed in addition to other healthcare professionals • Use a team approach • Don’t decentralize health systems until CHW program is solid • Promote national insurance to cover CHW services

35. Bridging the Gap

36. References • A Brief History Of Community Health Worker Programs. 1st ed. Henry Perry, 2017. Web. 29 Mar. 2017. • Beals, Joel. "Who Are Promotores(As)/Community Health Workers? - MHP Salud". MHP Salud. N.p., 2017. Web. 19 Mar. 2017. • "CDC - Community Health Worker Resources - STLT Gateway". Cdc.gov. N.p., 2017. Web. 15 Mar. 2017. • Community Health Worker Advocacy Toolkit: Changing Health Policy To Promote Sustainability. 1st ed. Available at: http://peersforprogress.org/wp-content/uploads/2013/12/20131206_wg6_chw_advocacy_toolkit.pdf. Accessed March 10, 2017. • Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Hirsch, G. R., Willaert, A. M., Scott, J. R., Holderby, L. R. And Fox, D. J. "Community Health Workers: Part Of The Solution". Health Affairs 29.7 (2010): 1338-1342. Web. 18 Apr. 2017. • Perry, H, et al. (2014). Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers. Web. September 2017.

37. Questions?

38. Thank you! Julie St. John, DrPH, MA, CHWI julie.st-john@ttuhsc.edu