Community health and equity of outcomes: the Partners In Health experience
Enthusiasm for incorporating community health workers (CHWs) into health systems has resurfaced because of a growing commitment to achieve universal health coverage. Despite calls for universality, however, donor financing and programme architecture remain largely focused on narrow programmes, frighteningly reminiscent of the post-Alma Ata experience. To avoid repeating history, it will be important to understand how CHWs can support health systems beyond vertical interventions. We present here how one non-governmental organisation, Partners In Health (PIH), has worked with over 13 000 CHW colleagues in ten countries to advance health equity and achieve greatly improved clinical outcomes.
What is considered success in community health is typically framed by what is held to be affordable. At worst, community health systems are underfunded, failing by design, and show no effect on mortality.1x1Hazel, E, Bryce, J, and IIP-JHU iCCM Evaluation Working Group. On bathwater, babies, and designing programs for impact: evaluations of the integrated community case management strategy in Burkina Faso, Ethiopia, and Malawi. Am J Trop Med Hyg. 2016;
Crossref | PubMed | Scopus (3) | Google ScholarSee all References Frustrated by imposed limitations, the global public health community aims for humble reductions in mortality without recognising that celebrating meagre improvements might only truncate ambition. The values of equity and human decency demand that we aim to address the entire burden of disease, including for all ages. The technology to do so is available, but distribution, imagination, and resolve lag behind.
Public health pedagogy, too often underpinned by 20th century neoliberal economic ideology, demands that interventions be cheap above all else. Cost constraints, however, are always changing as new technologies and markets become available. PIH began designing clinical systems in the late 1980s to achieve nothing less than an absolute equity of outcomes for anyone anywhere. Hypothesising that structural barriers to care born out of extreme poverty were a major factor leading to poor outcomes in patients with tuberculosis, the PIH team in Haiti launched an analysis that compared free medical care alone with free care plus a range of socioeconomic supports (tabletable).2x2Farmer, P, Robin, S, Ramilus, SL, and Kim, JY. Tuberculosis, poverty, and “compliance”: lessons from rural Haiti. Semin Respir Infect. 1991;
PubMed | Google ScholarSee all References The results were remarkable: a 100% clinical cure in all patients receiving full support, versus only 56% cure and 10% mortality in patients receiving free care alone. This provision of clinically excellent care with robust, concurrent social supports became known in Haiti as accompaniment, and has defined PIH’s approach ever since.
Accompaniment is both a philosophical stance and a rubric for programmatic design. In practice, it amounts to walking with the patient through a journey.10x10Farmer, P. Partners in help: assisting the poor over the long term. Foreign Aff. 2011; Jul 29;
Google ScholarSee all References Regarding tuberculosis, it differs sharply from previous strategies, such as directly observed treatment, short-course (DOTS), and centres the axis of effect on supporting vulnerable people instead of policing compliance. This focus on vulnerability moves interventions away from education campaigns alone because of the observation that true change comes from augmenting agency through material investments. This is relevant for all diseases, not only community-based interventions, and especially for serious illness or injury that require referral to clinics and hospitals. The core lesson of the accompaniment approach is that health systems have a responsibility to “meet patients where they are” with new materials, methods, and means as necessary, until outcomes are equitable. A true measure of success is renewed trust in the health system.
These values are achieved when CHW programmes follow three principles: (1) CHWs must be professionalised members of the care delivery team, which means they are recruited, paid, and supported for long-term retention; (2) CHWs must be positioned as bridges to care, not islands; (3) CHW programme budgets must make room for community work, and not health work alone, by assigning appropriate patient ratios and a manageable scope of work.
These three principles expand opportunities for the health system to understand and engage with community spaces previously out of range. This new functionality provides new care opportunities otherwise not possible. Co-mastery of community complexity is work that CHWs do better than others, if positioned and supported appropriately.
The accompaniment approach in action has achieved remarkable clinical results in multiple disparate contexts, many unprecedented. The table presents how CHWs have contributed to larger health-care system strengthening efforts, their tasks mapped out across the care delivery value chain, to produce excellent outcomes for different diseases and in disparate contexts.
Those who promoted selective primary health care in 1979 said that the ambitious goals set at Alma Ata were “above reproach” but “unattainable”.11x11Walsh, JA and Warren, KS. Selective primary health care: an interim strategy for disease control in developing countries. New Engl J Med. 1979;
Crossref | PubMed | Scopus (543) | Google ScholarSee all References PIH’s clinical achievements receive admiration while also being called unrealistic and unsustainable.12x12Gilks, C, AbouZhar, C, and Türmen, T. HAART in Haiti—evidence needed. Bull World Health Organ. 2001; 79: 1154–1155
PubMed | Google ScholarSee all References There is peril in plotting successes on graphs defined by limited aspiration and ideologically truncated budgets. As the global health community becomes reinvigorated by a spirit of justice above expediency, the PIH experience in building community-led health systems offers clear evidence of what is possible.
DP reports grants and non-financial support from PIH fundraising, during the conduct of the study, and occasionally engages in short-term consultancy work to various non-governmental organisations or foundations when asked for advice on a project. Most recently, this has included work with the Samuel Family Foundation, Eleanor Crook Foundation, and Last Mile Health. He was invited to the Institutionalizing Community Health Conference, hosted by USAID and other partners, but paid his own transport, room, and board. This Comment reflects work at PIH, which is funded by PIH’s fundraising. The manuscript had no specific funding source. The Sall Family Foundation gave a grant to PIH to support cross-site community health learning and advocacy, which indirectly supported the writing of this manuscript. PEF and JM declare no competing interests. We acknowledge the assistance of Milenka Jean-Baptiste, Priya Schaffner, Didi B Farmer, Ralph Ternier, Wesler Lambert, Fernet Leandre, Sonya Shin, Henry Makungwa, Basimenye Nhlema, Emily Wroe, Peter Niyigena, Mara Kardas-Nelson, Likhapha Ntlamelle, Lassana Jabateh, Julia Rogers, Harriet Napier, Hector Carrasco, David Giber, and Gabriela Sarriera.