Throughout the developing world, deflated national budgets and caps on government spending imposed by international financial institutions have led to an exodus of healthcare professionals and the collapse of health care delivery systems. In Haiti’s Central Plateau, there is just one doctor for every 50,000 people (compared to one for every 358 in the United States and the World Health Organization’s recommended ratio of 1 to 1,000). Patients must walk for hours to reach a clinic, often to discover that no staff or medications are available. In a cruel irony, these dismal conditions are used to justify further neglect by those who argue that this “infrastructure gap” makes it impossible to deliver life-saving treatment to the poor.

Improving salaries and working conditions for doctors and nurses is one key to closing that gap. Partners In Health’s model of community-based care emphasizes another underutilized and undervalued resource for overcoming barriers to healthcare delivery – patients and other community members trained and paid to serve as community health workers. At PIH sites in Haiti, Peru, Chiapas, Boston, Rwanda, and Lesotho, community health workers connect clinics with local communities by serving as counselors, educators, treatment providers, and advocates experienced in local needs. By delivering services to patients in their homes, community health workers improve adherence to treatment and reduce the burden of time and money on both patients and health care systems.

Overcoming barriers to health care

Many barriers stand in the way of poor people seeking medical care – transportation costs, social stigma, lack of information, discrimination by medical personnel, shortage of time. Even when treatment is available free of charge, these and other barriers too often prevent people from accessing the health care that they need and to which they are entitled.

For nearly two decades, PIH community health workers have helped patients overcome these and other barriers to care by accompanying them through treatment, monitoring their needs for food, housing, and safe water, leading education campaigns, and empowering community members to take charge of their own health. As members of the communities they serve, community health workers can establish relationships of trust with their patients, bridging the gap between the clinic and the community.

Community health workers can also help health care systems overcome personnel and financial shortages by providing high-quality, cost-effective services to community members in their homes, and by catching serious conditions at an early stage, before they become more dangerous and expensive to treat. In addition to strengthening health infrastructure, community health worker programs also boost the local economy by creating paying jobs.

Delivering life-saving treatment every day

One of the key services provided by PIH community health workers is daily supervised treatment for patients living with HIV/AIDS and tuberculosis (TB). Medications for HIV and TB must be taken with precise regularity to be effective. Their side effects can be debilitating, or even deadly. Furthermore, if these complex treatments are not taken correctly, a patient can develop resistance, rendering the medication ineffective. For years, these obstacles were used to justify denying access to treatment for people living in poor countries. But the success of PIH and other organizations using community health workers helped demolish the excuses and change the policies.

At PIH sites in Haiti, Rwanda, Boston, and Lesotho, all patients beginning treatment for HIV or TB are paired with a community health worker. Every day, these community health workers visit patients in their homes to supervise treatment, ensuring they take their medications regularly and correctly. Over time, they teach their patients how to manage complex treatments, cope with side effects, and identify the signs and symptoms of impending illness. This support enables people with HIV or TB to live longer and healthier lives, with less chance of developing resistance to their medications.

In Haiti, Zanmi Lasante community health workers first began providing daily medications for people living with HIV in 1999. At that time, prevailing wisdom in public health claimed it was impossible to provide high-quality treatment and follow-up for people living with HIV in developing countries. But the success of ZL’s patients proved otherwise. Today, more than 800 community health workers from ZL visit more than 1,600 patients every day to administer antiretroviral medications, and monitor the health of a total of 8,000 people living with HIV. Thanks to their careful follow-up, most patients who come to ZL in need of antiretroviral therapy begin treatment in less than two weeks, and over 98 percent of patients have continued taking treatment for life.

Engaging the community
in the struggle for health and human rights

While making daily rounds to the homes of HIV and TB patients, community health workers strengthen connections between the clinic and the community, helping improve understanding of the barriers to health faced by local people. By accompanying patients day by day, community health workers develop a deep awareness of the effects of illness and poverty in their community. Because of their local knowledge and personal commitment, community health workers may be able to support their communities in addressing broader barriers to health, including oppression, violence, and social and economic injustice.

In Chiapas, Mexico, community health workers, or promotores, play a prominent role in health education efforts in communities served by PIH’s partner EAPSEC. Promotores work to improve health conditions by conducting workshops and trainings sessions on themes such as building local health care systems, mental health, sexually transmitted infections, conflict resolution, and environmental health.

In Boston, community health workers from PIH’s Prevention and Access to Treatment and Care (PACT) program have created a network of support, education, and intervention for people in some of the poorest areas of the city. PACT’s Fuerza Latina program trains patients who are in the early stages of recovery from drug use to do outreach among their peers, providing street-level HIV counseling and testing, HIV prevention education, condom distribution and needle exchange in the Boston area. Since the program’s inception, the promotores of Fuerza Latina have provided more than 1,000 people with street-level counseling and accompaniment to detox or HIV counseling and testing services, and have distributed more than 9,000 safer sex kits.

Fair pay for heroic work

Health care programs that rely on community health workers have achieved success throughout the world. Yet continuing pressure on developing countries to cut expenditures has discouraged many governments from investing in public health. As a result, many of those who do make use of community health workers classify these positions as “health volunteers," denying fair payment and adequate training for the essential and compassionate work of visiting patients daily in their homes. International donors and many nongovernmental organizations with much greater resources have followed suit.

There is no excuse for withholding payment for the highly skilled services of community health workers, who accompany patients through their greatest struggles and put themselves at daily risk of contracting deadly diseases. Furthermore, payment to community health workers directly benefits the health and welfare of the community by providing a source of income for people who are often patients themselves or are at risk of disease from hunger and other symptoms of poverty. PIH provides and advocates for professional treatment of community health workers—including fair payment, ongoing training, and provision of necessary supplies—so they may perform their vital work to the highest standards. In some communities, training and employment of community health workers makes PIH not only the main health care provider but the biggest employer and source of adult education.

The highest standard of care: community-based care

Community health workers provide a highly effective and affordable way for health care systems to ensure high standards of patient care. But the benefits to patients, communities, and health workers themselves extend beyond simple cost-effectiveness. Community health workers build trust between healthcare professionals and the community they serve. They educate and empower their neighbors to identify and overcome barriers to health.

By providing treatment to patients in their homes, community health workers also protect them against one of the greatest risks for catching and spreading disease – spending time in a hospital or clinic. Infections acquired during a hospital stay (known as nosocomial infections) are extremely common, and not only in developing countries. In the United States, an estimated 10 percent of hospital patients (or about two million people a year) are infected during their stay, at a cost of around 90,000 deaths and $4.5 billion a year. Hospitals are also breeding grounds for drug-resistant pathogens. Again in the US, more than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs most commonly used to treat them.

By improving adherence to treatment, monitoring medical and socioeconomic needs, empowering patients, and reducing the risk of hospital-acquired infections, community health workers make possible a model of comprehensive, community-based care that is the highest standard of care available anywhere, especially for patients suffering from chronic disease.