In many countries, community health workers (CHWs) are the backbone of the health system, providing frontline care where it is most needed. These health workers are members of the community who are selected and trained to provide basic health care services. Their work is lifesaving, as the communities they serve are often more than 5 kilometres from the nearest health facility, making it harder for people to access health care. CHWs often provide preventive, promotional, curative, and rehabilitation services, as well as referral of more severe cases to specialised health facilities.

In recognition of CHWs’ vital work, the third International Community Health Workforce Symposium was held in Monrovia, Liberia this March, bringing together more than 700 delegates from 46 countries. Palladium representatives from Mali, Nigeria, Uganda, and the United States gave presentations and had the chance to connect with community health workers, government officials, donors, and implementing partners.

The event highlighted the critical role community health workers play in building and sustaining resilient, equitable health systems advancing towards universal health coverage. The symposium culminated with the reading of the 2023 Monrovia Call to Action, which includes statements regarding CHWs, urgent concerns, and calls to action for all stakeholders.

“To be fully effective, CHWs need to be skilled, supervised, paid a living wage, and supplied by a well-functioning primary health care system coordinated at scale and integrated into broader public systems via data and financing,” states the Call to Action.

“Community health workers are trained front line workers,” explains Oladipo Akinmade, Palladium's Ebonyi State Director, Integrated Health Program and an attendee of the Symposium. “The health system should provide for their needs and create an enabling environment for them to perform their role effectively. They are an extension of the health facility and an integral part of the primary healthcare structure.”
During her opening remarks, Her Excellency Ellen Johnson Sirleaf, Liberia’s former president and Africa’s first female head of state, stated that “90% of health needs can be met through primary health care; therefore, community health workers cannot be an afterthought during budget and policy decisions.”

In addition to providing essential primary health care, their vital role in global health security is becoming increasingly recognised, especially in the era of COVID-19.

The Symposium being hosted in Liberia after the country’s devastating Ebola outbreak in 2014-2016 and years of postponing the Symposium due to COVID-19 served as a powerful recognition of community health workers’ place on the front line of defence against epidemics. Liberia tragically lost 8% of its doctors, nurses, and midwives to Ebola—some of whom were working on a volunteer basis.

In the face of incredible risk, Liberia’s community health workers were resilient and innovative, rapidly deploying strategies including active case-finding, where workers would proactively ask community members specific questions about their health to identify individuals exhibiting symptoms and track the spread of disease.

At the Symposium, Dr Mohammed Abdulaziz, Head of the Division of Disease Outbreak and Prevention at the Africa Centres for Disease Control and Prevention, praised the heroic efforts of Liberia’s health workers during the outbreak and said that he wants to use Liberia as a model to ensure that Africa moves forward together toward universal health coverage.

Palladium’s delegates agreed that the highlight of the week was the opportunity to hear community health workers from a wide range of countries share their experiences on the front lines. “The Symposium brought to light the need to recognise CHWs as an integral part of the health system. They deserve a trained, salaried, and supported place in the health sector,” adds Akinmade. Before an audience of government, donor, and partner representatives, CHWs communicated the challenges they face in their work, as well as what motivates them to continue amidst such difficult circumstances.

For example, CHWs from Central African Republic and Niger described the obstacles created by traditional gender norms, which may require female CHWs to obtain male permission to enter a household to provide care, or to request their husbands’ permission to travel for work. A delegate from Chad shared that to ensure care for regions that become inaccessible during the country’s rainy season, CHWs are given medical supplies for the next several months at the start of the season, which may last up to half the year.

Unsurprisingly and importantly, one of the key themes CHWs highlighted was the critical need to be paid regularly for their work, as many countries still rely on a community health workforce made up of unpaid volunteers. In many countries, CHWs are not even recognised as formal members of the health workforce, meaning that in addition to being unpaid, CHWs are not protected by national labour laws or afforded the legal rights of public servants.

This is slowly changing through the efforts of advocates, including CHWs. In Mali, the government passed a decree in April 2022 formalising CHWs’ status as an official cadre of health workers—a monumental success to which Palladium contributed through the USAID-funded Health Policy Plus project in partnership with national stakeholders and CHWs. Despite the milestone, CHWs are still not being consistently paid with domestic resources, making further advocacy vital.

Through USAID-funded programs including the Integrated Health Program in Nigeria, Uganda Health Systems Strengthening, PROPEL Health, and others, Palladium continues to work in partnership with national and local stakeholders to secure the rights, payment, and proper supplying of community health workers.

The Symposium was an opportunity to both learn and share Palladium's innovations through presentations and posters, including on improving access, quality, and uptake of integrated health services in Nigeria; community-level data reporting and use and community health worker-to-client ratios in Uganda; and data visualisation for advocacy and decision-making in Mali. Presenters included Dr Zainab Mohammed and Dr Oladipo Akinmade, Dr Betty Atai and Steven Kikomeko, Dr Seydou Traore, and Mackenzie Schiff. Special thanks to co-authors from Uganda’s Ministry of Health, USAID/Mali, USAID/Uganda, Nigeria Integrated Health Program, and Uganda Health Systems Strengthening project. For more information, contact info@thepalladiumgroup.com.