Rural communities in low- and middle-income countries face specific challenges in accessing health care. Residents either have to travel long distances to reach health facilities with better and more comprehensive services, or stay in their remote locations where there are severe health worker shortages and limited resources, and thus a significantly poorer quality of health care. And yet, these communities are often the most vulnerable and most in need.
So how can we overcome these barriers to provide everyone with the health care they have a right to? How do we maximize the available healthcare resources to effectively address inequalities and ensure sustainable service delivery?
“Rural citizens have, by and large, been discriminated against. They have not received an equitable share of public health financing, as historically the emphasis has been on urban areas and hospitals as opposed to rural communities and primary healthcare,” points out Russell Rensburg, Director at the Rural Health Advocacy Project (RHAP), an apolitical body dedicated to promoting health for South Africa’s rural communities. Speaking at the launch of RHAP’s Protecting Healthcare in Times of Economic Crisis report, Rensburg tells us that there are, however, equitable solutions for rural health, such as re-orienting healthcare systems towards primary healthcare and harnessing the tremendous potential of frontline healthcare workers – particularly community health workers (CHWs).
The Frontline Health Workers Coalition (FHWC) defines frontline healthcare workers (HCWs) – particularly CHWs – but also nurses, midwives, pharmacists, and doctors, as those directly providing services where they are most needed, especially in remote and rural areas. They are the first and often only link to essential health services for millions of people living in developing countries. And yet, there are dire frontline health worker shortages throughout the world, and especially in Africa. In South Africa, for example, around 60% of HCWs are working in the private sector, which means just 40% are servicing 80% of the country’s population who attend public healthcare facilities. Of these, the large majority of HCWs are working hospitals in urban and peri-urban areas, leaving rural communities, which comprise about 40% of the country’s population, extremely underserviced. In other words, the problem is two-fold: not only are there not enough frontline health workers, but the valuable cadre of HCWs that could be used to enhance service delivery are not being deployed to the areas that need them the most, nor are their capacities being used to the best advantage. The solution, therefore, is also two-fold: capitalize on the primary healthcare system and task-shift to CHWs and other lay health workers.
According to the RHAP report, one of the most significant cost drivers in both public and private healthcare systems in South Africa is the concentration of resources and services in hospitals. Hospicentric health systems tend to rely on expensive curative services at the expense of early interventions aimed at disease prevention and health promotion. This approach is far more expensive than primary healthcare. Prioritizing primary healthcare is therefore an important strategy for improving access to and reducing the cost of care. CHWs have an essential role to play in this regard given the vast array of services they can provide, from tuberculosis (TB) screening and HIV testing to health education, family planning, and even basic care and treatment.
“Balancing the need to contain costs while still improving the availability of healthcare professionals means that health systems often need to be innovative in their supply and distribution,” Rensburg contends. “Task-shifting, which involves the rational redistribution of tasks among health workforce teams, is potentially an excellent strategy for increasing access to health services. When working alongside other healthcare providers such as nurses and doctors, CHWs are a cost-effective option in supporting programs aimed at broadening access to priority primary healthcare interventions.”
Drawing from the World Health Organization (WHO) 2014 report Making Fair Choices on the Path to Universal Health Coverage, RHAP asserts that a sufficiently resourced and well-trained workforce is the most important component of an effective healthcare system. However, it seems that many low- and middle-income countries cut or freeze posts rather than spending more on their workforce. RHAP Technical Advisor Marije Versteeg-Mojanaga explains that because there are simply not enough resources, priority-setting is unavoidable. Based on the WHO’s ethical priority-setting framework, priority should be given to those who are most disadvantaged in terms of health status and social determinants, such as income, deprivation, and other associated factors, like rural location. Surely the obvious solution then is to invest more in the frontline health workforce servicing these priority areas?
However, as Rensburg points out, reprioritizing spending and utilizing available resources more efficiently require health information systems that accurately reflect where and how money is being spent and what outcomes are achieved with this expenditure. Yet one of the most significant challenges confronting governments trying to manage health budgets and financing is the absence of timely, accurate, and detailed data.
Nonetheless, government spending isn’t solely responsible for the dearth of CHWs. “Most CHWs are volunteers and have no career path,” emphasizes Rensburg. “This leads to a high level of dissatisfaction.” So is understanding the needs of this highly mobile workforce and creating incentives and an enabling environment the answer to building this much-needed health workforce sector? Without a doubt, confirms Rensburg. But even more importantly, it is time we start professionalizing the CHW service with standardized training and a code of practice to really address the issues they face.
Read more in the Rural Health Advocacy Project’s Protecting Healthcare in Times of Economic Crisis report.