Health care systems cannot be supported by the efforts of a few. But in many low- and middle-income countries worldwide, one medical specialist may be responsible for the health of millions. In Vietnam, where I work, there is one psychiatrist for 300,000 people. For many people in need, health care is simply unavailable. The inability to provide care, particularly in rural areas, results in increased morbidity and mortality. More community health workers (CHWs) are necessary to provide care where treatment is unavailable.
CHWs are lay people or non-professional health personnel who provide focused health care in local communities. CHWs work with health ministries, non-governmental organizations (NGOs), international organizations, and many other groups. From malaria to mental health, studies find that CHW interventions improve health and are cost-effective.
Despite their merits, many CHWs are employed as temporary workers. After projects end or funding runs out, many CHWs no longer work in a health care capacity. Whether CHWs retain the skills (e.g., data collection) and knowledge (nutrition counseling) they have gained is unknown. Even with long-term projects, education and career advancement may be unavailable, which are important reasons for attrition among CHWs. Poor retention leads to poorer health outcomes for populations served, higher program costs, and threatens program sustainability.
New Training Methods for CHWs
Because current training methods are inadequate, new methods are necessary to retain and train CHWs. The traditional method of training is for an outside or local expert or peer to provide in-person training to a group of CHWs. While effective, the reach of such methods is limited. Today, we live in a world of massive open online courses. Online learning and job training is a promising way to increase the number of CHWs. Although online learning and job training have been available for quite some time, these modalities are not extensively used for health care capacity building. Furthermore, many online courses and training opportunities in health care are focused on doctors, medical students, and nurses. In order to adequately train CHWs, a shift of focus is necessary.
Medical and academic knowledge can complement CHWs’ local expertise, enabling them to deliver effective and safe care. Further, online certification will help ensure attainment of an adequate level of knowledge necessary for the CHW’s role. Refresher courses can be delivered online to maintain the quality of health provided by CHWs. Online training can decrease the cost of training new workers for the start-up phase of a project or when attrition occurs.
Online learning and training will come with growing pains. Advancements in technology are increasing a user’s ability to access the internet, but user-friendly design will be necessary to encourage use, particularly for internet naïve populations. Whether courses can provide the specific skills necessary for individual interventions has yet to be seen. Even with sufficient training, supervision by other health providers is necessary to ensure effectiveness. Further, without partnerships across the board, particularly with government agencies, using the internet to build health care capacity will be challenging.
Online Learning in Global Health
Caveats aside, now is an exciting time for online learning in global health. The Medical Education Partnership Initiative is an innovative program that aims to improve medical education at a number of African medical schools, and online learning is one component. NextGenU.org is a new health care-oriented online learning platform that offers free courses, which may soon include a course for CHWs on substance use screening. Recently, the Fogarty International Center launched a new program to build global health research capacity in low- and middle-income countries. Hopefully, more of these programs will focus on CHWs.
In global health, more resources need to be dedicated to in-country training. Many CHWs are motivated for reasons besides monetary gain to solve health problems. If their passion can be met with education and career opportunities, a more stable and qualified workforce can be developed. Now is the time to enable community health workers to reach their full potential, not as temporary workers, but as community health providers.
Importantly, CHW interventions should not only be seen as a solution in low- and middle-income countries, but as a cost-effective solution in high-income countries like the United States. Still, similar training challenges exist in the U.S. CHW programs are unstandardized and not well integrated into the U.S. health care system. More proponents are supporting CHWs as key players for increasing primary care. It will be interesting to see if their roles are expanded in the post health care reform era.