Realising the untapped potential of Community Health Workers

The problem we are addressing is how we bridge the gap between the health system, specifically primary care, and underserved and vulnerable communities (henceforth UVC).  For these communities, the access, representation, understanding and navigation of what the health system is the Community Health Worker (henceforth CHW). We know that strengthening the support, training and stature of the CHW opens and improves primary care for underserved and vulnerable catchments.  The global shortage of human resources for health is projected to rise to 18 million health workers by 2030, with more acute shortages in Africa and South Asia. (Community health workers at the dawn of a new era: 4. Programme financing. https://health-policy-systems.biomedcentral.com/track/pdf/10.1186/s12961-021-00751-9.pdf)  

In Kenya, vulnerable populations have lacked beneficial connection with health care providers because CHWs are not recognized by the ministry as critical part of human resource in the implementation of health care services. Whilst in other African health systems they are a public health employee.

The community health workers are the persons who will be able to reach out to families and assist them navigate healthcare and social service systems. The poor management of care process and care transitions for vulnerable populations has been under looked hence most communities, families and individual patients globally experience a significant social isolation. Poor knowledge due to lack of proper sensitization has compromised determination of eligibility of individuals in enrolling them to insurance plans. Generally, most rural Kenyan families have no health insurance covers as a result of poor economic status or are simply not informed of the various options that can make health care accessible to them. Having an insurance cover culturally and socially remains prestigious for many African Families who often opt for herbal or traditional methods of care and treatment and is associated with the rich. CHWs will be of great help to act as eye openers to communities and families in linking them to insurance covers.

Health care providers serving UVC populations are not able to exhibit cultural competence without proper linkages being established. The health professionals and stakeholders are mostly not informed or educated on the community health needs that need to be addressed at any given time because data is never adequately collected to relay the relevant information to the stakeholders to inform programs and policies. Culturally appropriate health education on topics related to chronic disease prevention, physical activity and nutrition lacks greatly and needs to be addressed if optimum care is to be achieved universally. Lack of proper engagement of CHW’s has resulting in weak advocacy and data to support underserved individuals or communities to receive services and resource allocation to address their health needs. Informal counseling, health screenings and referrals has not been embraced as a key process in disease prevention, early detection of illnesses and linkage to right levels of health care. Lack of health personnel available to carry out community sensitization for all matters related to health since an empowered community is able to achieve optimum levels of health. Social determinants of health in communities are not well addressed because of acute shortages of health personnel, poor data management systems under utilization of the already demotivated CHWs.

Community health workers (CHWs) are lay members of a given community who work with incentives or as volunteers with existing health management systems in both rural and urban populations.  CHWs usually share ethnicity, language, socio-economic status, and life experiences with the community members they serve. They are identified as community health advisors, lay health advocates, outreach educators, community health representatives, peer health promoters, and peer health educators. CHWs typically reside in the community they serve, they have the unique ability to bring information where it is needed most and that’s why our solution is making use of CHWs in reaching out to communities, collecting significant data that will help stake holders and policy makers in ensuring that communities receive quality services.

Our proposed solution is a joint effort with the University of Pretoria COPC (Community Oriented Primary Care) team leveraging learnings and best practices of primary service innovation in South Africa and Kenya.  The goal of this partnership is to ensure improving services qualitatively and quantitatively through community empowerment and provision of referral procedures. Our solution seeks to create feasibility for the CHWs performance and subsequent recognition by the ministry. CHWs will be used to reach out community residents where they live, eat, play, work, and worship with them. CHWs being the frontline agents of change will help reduce health disparities in all underserved communities. CHWs will offer interpretation and translation services, provide culturally appropriate health education and information to  help people get the care they need, give informal counseling and guidance on health behaviors, advocate for individual and community health needs, and provide some direct services such as first aid and blood pressure screening.

The solution will ensure health providers are empowered and offered trainer CPDs which will ensure CHWs are trained and guided to deliver their mandate to the communities and individuals. We shall ensure linkages between the CHWs team and the professional health workers at the facilities to ensure that health needs of communities are well addressed. Working with CHWs will enhance referrals and coordination of care between frontline health workers within marginalized communities and higher levels of care irrespective of geographical location.

Expanding availability of affordable effective community health services and treatments using data through simple apps installed on mobile phones which will target people’s health needs. The data will be conveyed to stakeholders and policy makers to advice on proper decision making towards health implementation strategies. Community health workers will be collecting data relevant to address health care gaps in the community, creating service demand through community sensitization for better health seeking behaviors. Adolescent health will be strengthened through   health education and establishment of youth friendly services in all health facilities. Defaulter tracing will be made easy and follow up strategy through the CHW collaboration with health care professionals. Administrative offices will be used to keep track of the clients and patients served within these communities especially those on long term treatments, mental illnesses, home deliveries, teenage pregnancies and all public health matters.

Primary health care is the cornerstone of health systems across the globe. This type of care focuses on disease prevention, early detection, diagnoses, treatment, rehabilitation, and palliative care. Strong primary care systems lower health care costs, reduce hospital visits and better health outcomes.

Working with the COPC team we are currently identifying and reviewing communities for consideration in South Africa and Kenya for appropriateness, impact, replication and scaling potential.  Our solution serves both rural and urban populations, the marginalized, poor and the rich, women of reproductive health, adolescents and the youth, under-fives, and the elderly. These persons lack access to essential services and the knowledge that technology brings about innovative ways of serving them better. Social cultural factors affect health seeking behaviors too making the populations more vulnerable to preventable conditions. Other traditional practices contribute to gaps in health care delivery system, Myths and misconceptions, discrimination against women and youths with lack of data deployment for improvement. Gender based violence has affected health seeking behaviors coupled with death threats and disease transmission as well as contributing to unwanted pregnancies.

Having complete data to pinpoint specific gaps in care and understand their causes in order to plan. There has been lack of Data to help track Primary health care services, such as total number of health care workers serving a particular population, the medicines and supplies available and the out-of-stock commodities, essential, service delivery assessment that can dictate what quality of services populations get when need be and health care service seeking behaviors in communities. 

Access to essential health services especially diagnostics has been a challenge especially in the hard-to-reach areas, and urban populations are affected by cost. While the rural populations are affected by distance to health facilities, geographical locations may hinder innovation through technology with Stigma cutting across as another huddle to access of care. This makes access to preventive, curative and rehabilitative health services more difficult. Lack of recognition of the CHWs who contribute greatly in linking communities, families and individuals to health care has left many un attended and others may lose their lives to preventable conditions and situations.  The solution targets marginalized communities, women of reproductive age, childbearing group, those using family planning, youths and adolescents, the elderly, mentally challenged, children above 5 years and all under-fives.

In Kenya, ReaMedica Healthcare Kenya Ltd (henceforth ReaMedica) is a health service provider with public-private-partnerships in the areas of maternal health, price sensitivity and elasticity for imaging services and data collection.  Pilot programmes and partners include the PharmAccess Foundation of East Africa, Philips Kenya Ltd, and the Murang’a County Department of Health. In August, ReaMedica received institutional training accreditation from the Nursing Council of Kenya.  We would begin with the existing relationships to identify and establish the Terms of Reference and necessary authorisation/Memorandum of Understandings to implement the programme in Kenya.  In South Africa, the COPC would lead the parallel process.  

The COPC’s range of current collaborative research projects spans the areas of respiratory health, diabetes, demographic health surveillance, substance use, social determinants of health, dental health research, nutrition and COPC implementation. The plan is to expand beyond these and incorporate other entities through a trans-disciplinary research platform, and also change the core business towards more research and capacity development than project implementation.

Both ReaMedica and COPC models of care and engagement have always been driven by a user-centric system of engagement, input, design and iteration.  User lead design, unearthing and recognising the structure of community leadership is critical to sustainable solutions. To ensure meaningful guidance, we do and will engage the communities with conversations and surveys from CHW’s, staff, community leaders and members and focus groups.  We maintain this process of interaction throughout the programmes sharing data and insights with the community leaders and the appropriate public health officials.  

The Challenge would provide the financing and a recognised macro-level partner/funder to accelerate this multi-geography transdisciplinary project.  ReaMedica and the COPC teams are already in discussions for planning and scoping a mutual engagement in early 2023.  The Challenge would allow us to significantly scale our scope for engagement.

We believe that our solution improves the approach to the problem because we (ReaMedica and COPC) has implemented and run programmes that seek to collect, organise and analyse data for the purpose of improving informed evidenced decision-making. ReaMedica’s pilot with Murang’a County Department of Health for a nurse-led mobile model of prenatal point-of-care ultrasound and the PharmAccess Foundation of East Africa’s price-sensitivity of imaging services for private clinics coalesced seemingly bifurcated data sets.  We extrapolated data combined with questionnaires focused on the social determinates of health that allowed us to connect ability to pay, access to services, business and financial sustainability, cost of time and behavioural economics.  The COPC already has an extensive history and multiple data sets that provide guidance and pitfalls of systems structures and interventions which we (ReaMedica) are seeking to replicate as applicable.  

Perhaps an oversimplification, but the catalytic nature of our engagement is that we are already sharing, discussing and refining collaborative knowledge opportunities.  However, a platform such as Solve would exponentially expand the awareness of these efforts to other networks of partners and transdisciplinary researchers, institutions (public, private and academic) and policy makers that can leverage the work being done. 

Broadly, our solution will ensure communities have improved access to health care services, they will be able to make informed choices, it will as well increase health and screening modalities through the expansive data collection, sharing and informed strategic planning based on the specific health needs of the community.

The solution will ensure there exists a better understanding between community members, the health and social service system. The community will have enhanced communication with health care providers and increased utilization of all available health care services. There will be improved adherence to health recommendations and reduced need for emergency and specialty services.

In Kenya, in the next 12 months, as a Nursing Council of Kenya institutional training organisation ReaMedica is seeking to develop a primary care CHW training programme with the purpose to better harmonise the patient hand-offs and synergies linking CHW’s and the public health system. Nurse-midwives, in Kenya a overwhelming the conduit of the public health system for CHW’s and the communities they manage. The curriculum is intended to broaden and level-up a CHW’s primary care knowledge and data collection. In Kenya, the education of CHW’s is not uniformed and often narrowly prescribed by a donor or the project scope.  An approved curriculum and funding would target trainings for 1,000 unique (first-time) CHW’s and with a Train-the-Trainer modality by Year Five trainings could reach 10,000 + unique trainings and refreshers annually.  Assuming, dependent of community catchment, a Kenya CHW is responsible for 30-70 households (dependent on geography spread and density) the data collection potential is immense.  The COPC CHW is responsible for 200 households.

The measurements would include the  number of CHWs who receive education through our platform and training institution, the program activities for all CHWs engaged in activities for the consumers of health care services, the total number of CHWs involved in community activities including catchment population, households covered, Data Collected from households, Health care system planning meetings based on the collected data, Patient demographic information, morbidity and mortality data, Number of Referrals done by CHWs, Education programs Facilitated by CHWs, Community screening and assessment data, Nutritional assessment report for children and the elderly, and facility reports on Integrated management of child hood illnesses. Family planning uptake reports, women attending Antenatal care in the community, number of deliveries by skilled birth attendants, under-fives attending immunization, youth and adolescents accessing reproductive health services at the facilities and number of referrals for emergency or specialty care.

As an example, a curriculum for nurse-led prenatal point-of-care ultrasound has already been approved by the Nursing Council of Kenya, the nurse regulatory and accrediting body. Guided by the NCK we are aligning the rollout and implementation of the training programme to comply with the requirements for awarding Continuing Professional Development credits, that are required to maintain an active nurse license. Based on our data and experience estimate that a rural Antenatal Care nurse in a rural community could scan over 300 mothers monthly with training and equipment support.  One hundred trained nurses could perform approximately 36,000 scans yearly.  We would follow the same process for a CHW curriculum. 

Our solution focuses on broadening a CHW’s basic knowledge understanding that for vulnerable and marginalised communities, CHW’s represent the health system and that that greater empowered integration will lead to improved quality and access to basic health services.  The teams in Kenya and South Africa.

ReaMedica seeks to strengthen the linkages between informal healthcare providers, CHW’s, and the formal health system in a Kenya pilot community.  In a previous pilot with the Murang’a County Department of health, we worked with rural public clinics and staff to introduce prenatal ultrasound services to communities with minimal access to ultrasound services and poor or meager antenatal health indicators.  The clinics were selected by the Department Of Health.  We discovered and focused on filling information gaps for the nurse-midwives on international and national policies and recommendations and how to communicate the benefits and disabuse beliefs that ultrasound was a measure of last resort for acute situations.  We also mapped improving the coordination of service providers from antenatal clinics to birthing hospitals, to foster evidence-led decision-making and to improve overall child health outcomes.

Using a participatory action research approach, we showed that a mobile model of nurse-led point-of-care ultrasound model improved accessibility (95 per cent of the mothers scanned had their first ultrasound using this modality), improved outcomes (we detected 12 per cent of the pregnancies needed further investigation) and was financially viable for the uninsured.  This framework informs the foundation of our theory of change.  We recognise the danger of interpreting a previous programme as normative guidance. However, we believe that identifying promising activities, we can reasonably expected to influence performance with a greater probability of success and drives a system of continuous learning.  

Our solution will leverage the COPC health information application which is currently being revised.  The mobile phone application would be installed on every CHW’s phone (realistically smart phones and airtime, separately or a combination of both, would need to be provided).  The app will collect data from households, and this data will be relayed to a main server at the health facility serving the community. The health records officers will reorganize the data and share it in the health platform for the health management teams to see. Our solution also uses simple screening gadgets that will help in early diagnostics for the communities. The screening gadgets will be used to communicate complications or risky situations for clients to seek care early enough. In areas with poor or now coverage/connectivity the app does allow for porting and uploading the information later.  We also would include paper-based logging of information when necessary with transcription and data input at a centralised adminstrative location.

We use an electronic health records system for the clinic in Nairobi.  During our pilot in Murang'a County we captured data paper surveys, calculated and organised it in an excel spreadsheet which, with a writing analysis, provided to the Murang'a County Department of Health. 

Previously mentioned, ReaMedica is incorporated Kenyan company.  Although the founder is a foreign resident of Kenya the staffing is fully host-county nationals with a female Executive Director. In promoting inclusiveness and equity we have employed and offered training to persons neither university degrees nor healthcare qualifications/experience.  In our recruitment process, interviewers are balanced by gender and level and we also conduct initial online interviews without video as to avoid potentially inadvertent biases based on appearance. 

RMH is a for-profit social enterprise whose customers are professional healthcare workers, county health departments and private consumers.  We address the gaps in the market for services such as professional requirements (Continuing Professional Development credits) as individual health workers and county health systems trainings.  The imaging services are accessed by the middle class and our mobile model of scanning engagements reach impoverished, working poor and middle-class expectant mothers typically seeking services at public health facilities. Beneficiaries are the mother, families and partner health providers on an a business-to-business and business-to-government level.  ReaMedica is also a training vendor for Philips Kenya.

The business-to-consumer model provides value to individuals and vulnerable populations through affordable access to quality imaging services. We achieve affordability and quality outcomes through a Value-based Care framework focused on a nurse-midwife led model of primary care, imaging diagnostics and women's reproductive health services.

Our financial model is a fee-for-services model to the consumer. To health professionals it a tuition based payment which is paid by the professional or may be contracted through a private organisation, NGO or Kenya government entity. We also work as a training vendor service contracts international companies. Our relocation to Nairobi and the subsequent relaunch with engagements secured, depending on the terms of payment we will cover our cash flow positive in 60 days.     

We are rolling out training professional development programmes with expected revenue of $100,000 in Year 2 and annual service contracts of approximately $50,000 annually.  Patient revenue at the end of year 2023 in Nairobi is projected to exceed $150,000 with a 10 per cent growth rate and opening a second location by end of 2023 with MRI capabilities.