By Staff Writer: Jennifer Grundman
Among the many causes often touted as contributing to the high costs of American health care are lack of access to primary care and overuse of emergency department services. These two tend to be connected: Consistent primary care encourages steady use of preventive measures against chronic conditions and decreases the frequency with which people visit emergency rooms — visits that are often much more expensive than visits to a primary care provider. Though the Affordable Care Act attempts to alleviate this problem by providing greater funding for primary care and incentives for medical students to specialize in it, the dearth of primary care doctors remains ominous.8 Yet all hope is not necessarily lost, and the United States might do well to look at examples set by several countries that rely on community health workers (CHWs) to improve primary care access for underserved and lower-income people.
Precisely defining CHWs can prove elusive, since they tend to vary widely in their level of formal medical education and in their specific duties.17 Broadly speaking, they are workers who receive circumscribed medical instruction and serve communities where access to health care facilities is limited.17 The roots of CHWs as a group can be traced back to two major beginnings: First to 19th-century Russia, as physician assistants called “Feldhsers,” who worked in rustic areas with sparse connections to major medical facilities, and then to early 20th-century China, where so-called “Barefoot Doctors,” after receiving a brief health-related education, administered essential medical aid to agricultural communities.16,17 Though the CHW movement suffered setbacks in the 1980s because of restrictions on public-sector financing and poor organization of CHW programs, since the 1990s, CHWs have become increasingly common in developing nations like Pakistan, India, and several African countries. 16
Their reemergence can be attributed to their demonstrated effectiveness in the countries they serve, especially in areas like maternal health, children’s health, and in connecting rural people to physicians. A 2013 study, for instance, reported that CHWs in low-and middle-income countries were useful in delivering preventive care for mothers and children, such as in helping lower rates of diarrhea in children. 9 As USAID’s Maternal and Child Survival Program reports, CHWs can be thanked for a 37 percent reduction in child mortality over the past two decades, along with a reduction of maternal mortality by 34 percent between 1990 and 2008.5 In addition, a study published in early 2017 found that CHWs, partnered with a team of physicians and psychiatrists in a community-based mental health program in India, were able to improve rural households’ knowledge of mental health disorders, ensuring that people would be more likely to consult a doctor. 19
Despite these examples of the success of CHW programs, on a global scale, it is difficult to determine just how many CHWs are currently active; the World Health Organization, for instance, as of 2014, lacked a data set specifically concerning them. 1 This scarcity is both emblematic of the struggle to grow CHWs as a global health force and representative of the problems governments face when trying to integrate them into more formal health care systems. Without worker data, CHW advocacy groups are bereft of valuable arguments in their favor, and governments have little information to go on when justifying their inclusion in health sectors. 1 Some projects, such as the One Million Community Health Workers Campaign, seek to rectify this by pushing for increased statistics and numbers of active CHWs, basing their advocacy off of successful case studies of CHWs in several developing countries. 14
One of the most lauded CHW programs is in Brazil, where CHWs have become institutionalized as a core part of the government’s Family Health Strategy, which is an integral component of the country’s Unified Health System. This program links Community Health Agents (who are essentially the same as CHWs), nurses, physicians, and medical specialists into one team that serves an area of a few thousand people, with each Agent on the team providing care for up to 150 families.22 Started in 1994 as the Family Health Program,15 the project, as of 2015, is a major part of primary care for 62 percent of the population, an increase of 58 percent from its reach in 1998. 13 Agents working for the program visit their assigned families monthly, checking if their clients have attended their health care appointments, if they are maintaining their medication schedules, and staying up-to-date regarding any other relevant health-related information. In addition, the Agents tend to make note of any troubling indicators, such as abuse or drug usage.13
Agents are fully integrated into the Brazilian health care system and are considered government workers.23 As a 2015 report by the World Health Organization explained, Brazil’s CHW program is financed through various sources, including taxes and employer health insurance purchases, and states and municipalities are required to pay up to 15 percent of their budgets on health care.7 The health care system in general is financed by both private and public sectors, with nearly the same percentage of inpatient care covered by each, though municipal governments are, as of 2013, responsible for around 84 percent of primary care. Significantly, the number of hospitals in Brazil has not increased; there has been a conscious push in the country to emphasize primary care and downplay the “hospital-centric, curative care model” by increasing the use of ambulatory services.6 Overall, there is evidence to suggest that Brazil has mostly been successful in its aims to provide universal health care and lessen inequities in the system. From 1988 to 2010, over a quarter of Brazil’s population obtained health coverage, with 75 percent of Brazilians receiving it through the Unified Health System.3 Furthermore, studies have shown that the Brazilian health system, with its focus on primary care, has reduced hospitalizations.6
But how might CHW programs work in developed countries? In fact, it is possible to look to the U.S. for an example of how such programs are being implemented; several states have growing forces of CHWs, who are widely seen as important to improving primary care access and rendering guidance in what is often a confounding medical system. 2,20 For instance, Texas, the first state to introduce a certificate program for CHWs, 18 had 1900 CHWs in 2012, a growth of nearly 200 percent over three years. 21 As a report on CHWs in Texas reveals, a sizable portion of Texan employers were interested in increasing their numbers of CHWs, and the use of them was effective in cutting down on hospitalizations, lowering the cost of care, and promoting better use of medical homes. Some of the best-valued functions of CHWs in Texas were also found to be providing education about health and services, along with increasing clients’ access to care.21
Texas uses a type of CHW called a promotor(a), a CHW who shares a culture or lives in a region with the particular community he or she serves. These types of CHWs have been found to be especially helpful in targeting Hispanic and rural communities and people who are otherwise hard to reach.4 To become a CHW in Texas, prospective workers must either complete a training program of 160 hours or show that they have completed 1000 hours of relevant work in the past six years. As of 2012, there were around 25 facilities — such as health centers and community colleges — that offered this type of training to prospective CHWs.21
The potential benefits of a comprehensive CHW program are hard to understate, yet these programs have difficulty finding stable financing in the U.S. In the same Texas report, it was noted that the Texas Tech University Health Sciences Center Navigator Program found that CHWs were useful in serving as links between health agencies and communities, helping to manage chronic diseases and to educate communities regarding health-related matters. Funding for CHW programs, though, tends to be unsteady, comes from both public and private sectors, and mostly arrives in the form of grants.21 Auspiciously, however, the Affordable Care Act created a provision that preventive services provided by non-licensed health workers (i.e., CHWs) under Medicaid can be reimbursed, increasing the potential for states to be able to effectively use and finance CHW programs.11
One of the most universally noted assets of CHW programs has been their general tendency to lower health care costs for consumers. In the Texas report, it was found that three organizations in the private sector — Christus Health, Baylor Health Care, and Gateway Community Health Center — all saw their CHW programs result in cost-reductions through lower hospital admissions and emergency department visits, higher rates of which are typically culprits in lamentations about steep health care bills.21 Increasing access to primary care, and reducing the number of emergency room visits, especially among lower-income populations who often use emergency rooms for preventive care (instead of trips to primary care doctors who refer them to specialists, in turn forcing them to pay copayments they cannot afford) could potentially cut down on the $30.8 billion spent per year, as of 2013, by the U.S in unnecessary emergency department visits.12 Some progress has been made in this area though the Affordable Care Act,10 but more will have to be done, especially in light of the law’s uncertain future. In addition, though there are numerous case-studies exemplifying the cost-effectiveness of CHW programs, among which are studies conducted in Denver, Baltimore, and among Hispanic adults, further research is needed to create a more comprehensive view on CHW programs’ potential cost savings.2
Organizations in the U.S. that have experience with active CHW forces already have some salient recommendations for other nascent CHW programs: Support the integration of CHWs into health teams composed of other health professionals (such as physicians), increase the variety of work CHWs can practice, ensure that CHWs can effectively serve as links between patients and other health care providers, create a clear system to financially back CHW services and keep them sustainable, and provide standardized training for CHWs.20 Whether more states choose to implement CHW programs — and whether those states will follow the recommendations of those who have already done so — remains to be seen, though the effectiveness of these workers in bringing affordable primary care to larger numbers of people is becoming more evident. And in a new era of greater uncertainty about American health care’s future, expansion of CHW programs might at least provide one way of improving the industry’s accessibility.
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- A Commitment to Community Health Workers: Improving Data for Decision-Making. Rep. N.p., n.d. Web.
- Bovbjerg, Randall, Lauren Eyster, Barbara Ormond, Theresa Anderson, and Elizabeth Richardson. The Evolution, Expansion, and Effectiveness of Community Health Workers(2013): n. pag. The Urban Institute. Web.
- “Brazil’s March towards Universal Coverage.” WHO. World Health Organization, n.d. Web.
- Community Health Workers Evidence-Based Models Toolbox. Rep. U.S. Department of Health and Human Services Health Resources and Services Administration, Aug. 2011. Web.
- “Community Health Workers.” Maternal Child Survival Program. N.p., n.d. Web.
- Couttolenc, Bernard, and Tania Dmytraczenko. UNICO Studies Series 2: Brazil’s Primary Care Strategy. Rep. Washington, D.C.: World Bank, 2013. Web.
- Dahn, Bernice, Addis Woldemariam, Henry Perry, Akiko Maeda, Drew Von Glahn, Raj Panjabi, Na’im Merchant, Katy Vosburg, Daniel Palazuelos, Chunling Lu, John Simon, Jerome Pfaffmann, Daniel Brown, Austin Hearst, Phyllis Heydt, and Claire Qureshi. Strengthening Primary Health Care through Community Health Workers: Investment Case and Financing Recommendations. Rep. World Health Organization, 2015. Web.
- Freundlich, Naomi. Health Reform & You — Primary Care: Our First Line of Defense. Rep. The Commonwealth Fund, n.d. Web.
- Gilmore, Brynne, and Eilish Mcauliffe. “Effectiveness of Community Health Workers Delivering Preventive Interventions for Maternal and Child Health in Low- and Middle-income Countries: A Systematic Review.” BMC Public Health 13.1 (2013): n. pag. Web.
- Hernandez-Boussard, Tina, Carson S. Burns, N. Ewen Wang, Laurence C. Baker, and Benjamin A. Goldstein. “The Affordable Care Act Reduces Emergency Department Use By Young Adults: Evidence From Three States.” (n.d.): n. pag. Health Affairs. U.S. National Library of Medicine, Sept. 2014. Web.
- Katzen, Amy, and Maggie Morgan. Affordable Care Act Opportunities for Community Health Workers: How Medicaid Preventive Services, Medicaid Health Homes, and State Innovation Models Are Including Community Health Workers. Rep. Center for Health Law & Policy Innovation, Harvard Law School, 30 May 2014. Web.
- “Low-Income Patients Say ER Is Better Than Primary Care.” Robert Wood Johnson Foundation, 12 July 2013. Web.
- Macinko, James, and Matthew Harris. “Brazil’s Family Health Strategy – Delivering Community-Based Primary Care in a Universal Health System — NEJM.” New England Journal of Medicine. N.p., n.d. Web.
- “One Million Community Health Workers.” One Million Community Health Workers. N.p., n.d. Web.
- Paim, Jairnilson, Claudia Travassos, Celia Almeida, Legia Bahia, and James Macinko. “The Brazilian Health System: History, Advances, and Challenges.” The Lancet 377 (2011): n. pag. Web.
- Perry, Henry. “A Brief History of Community Health Worker Programs.” (n.d.): n. pag. Web.
- Perry, Henry B., Rose Zulliger, and Michael M. Rogers. “Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness.” Annual Review of Public Health 35.1 (2014): 399-421. Mpoweringhealth.org. Web.
- “Rural Health Information Hub.” Community Health Workers Toolkit: Training Approaches, State Certification Programs. N.p., n.d. Web.
- Shidhaye, Rahul, Vaibhav Murhar, Siddharth Gangale, Luke Aldridge, Rahul Shastri, Rachana Parikh, Ritu Shrivastava, Suvarna Damle, Tasneem Raja, Abhijit Nadkarni, and Vikram Patel. “The Effect of VISHRAM, a Grass-roots Community-based Mental Health Programme, on the Treatment Gap for Depression in Rural Communities in India: A Population-based Study.” The Lancet Psychiatry (2017): n. pag. Web.
- States Implementing Community Health Worker Strategies. Rep. Centers for Disease Control and Prevention, Dec. 2014. Web.
- Texas Community Health Worker Study. Rep. N.p.: n.p., 2012. Department of State Health Services and Health and Human Services Commission. Web.
- Wadge, Hester, Yasser Bhatti, Alexander Carter, Matthew Harris, Greg Parston, and Ara Darzi. “Brazil’s Family Health Strategy: Using Community Health Care Workers to Provide Primary Care.” The Commonwealth Fund. N.p., n.d. Web.
- Zulu, Joseph Mumba, John Kinsman, Charles Michelo, and Anna-Karin Hurtig. “Integrating National Community-based Health Worker Programmes into Health Systems: A Systematic Review Identifying Lessons Learned from Low-and Middle-income Countries.” BMC Public Health 14.1 (2014): n. pag. Web.