A new era for community health in countries of low and middle income?
Authors: Niall Winters, James O'Donovan, Anne Geniets
Journal: The Lancet Global Health (2018)

It is predicted that by 2030 there will be a worldwide shortage of over 14 million health workers.1WHOGlobal strategy on human resources for health: workforce 2030.http://apps.who.int/iris/bitstream/10665/250368/1/9789241511131-eng.pdf?ua=1Date: 2016Google Scholar To help to address this pressing problem, the World Economic Forum taking place in Davos, Switzerland, saw the launch of a new 4-year US$100 million fund to support two non-governmental organisations, Last Mile Health and Living Goods, to train 50 000 community health workers (CHWs) in six countries.2Cheney C New initiative leverages technology and philanthropy to reinvent community health care.https://www.devex.com/news/new-initiative-leverages-technology-and-philanthropy-to-reinvent-community-health-care-91878Date: 2018Google Scholar The funding is contingent on both organisations raising $50 million, which will then be matched by organisations and individuals including UBS, Richard Branson, Jeff Skoll, the ELMA foundation, and Chris Hahn of the Children's Investment Fund Foundation. This is a potentially game-changing development for the sector. The project has two core components. The first is the use of mobile technologies for training, decision support, and data collection (known as mHealth).3Royston G Hagar C Long LA McMahon D Pakenham-Walsh N Wadhwani N Mobile health-care information for all: a global challenge.Lancet Glob Health. 2015; 3: e356-e357Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar The partnership will continue to use Living Goods' SmartHealth App and a "new digital education solution" from Digital Campus, working in collaboration with Last Mile Health. This essentially presents videos and quizzes to CHWs on key topics such as pneumonia and malaria recognition, treatment, and prevention. The second is the social entrepreneurship model developed by Living Goods, whereby CHWs sell drugs and other health treatments such as oral rehydration solutions and soaps at a discounted price. They describe this work as creating "super scalable networks of 'Avon-like' health entrepreneurs".4Living Goods.https://livinggoods.org/what-we-do/Date: 2018Google Scholar Various organisations training CHWs, including Last Mile Health and Partners In Health, have a tradition of designing programmes that take a "preferential option for the poor",5Farmer P Pathologies of power: health, human rights, and the new war on the poor. University of California Press, Berkeley2003Google Scholar meaning they aim to provide the best care possible to marginalised poor people and often go to great lengths and expense to do so. This approach seems to contrast with organisations, such as Living Goods, which pursue more utilitarian strategies to train CHWs in lower-middle-income countries. This, alongside the ambitious programme of work that the partnership is seeking to achieve, raises several fundamental challenges. The first challenge is to balance the funders' requirement for cost-effectiveness with the health-care needs of poor people. The role of private equity in public health is ethically complex and Kim and co-workers6Kim JY Farmer P Porter ME Redefining global health-care delivery.Lancet. 2013; 382: 1060-1069Summary Full Text Full Text PDF PubMed Scopus (201) Google Scholar have cautioned against using cost-effectiveness as the main metric by which to judge global health programmes, arguing instead for a "broader normative framework for global health delivery". The second challenge is to make digital education in mHealth a success. To do so, the complexities of the relationship between pedagogy and technology design and implementation must be addressed.7Winters N Oliver M Langer L Can mobile health training meet the challenge of 'measuring better'?.Comp Educ. 2017; 53: 115-131Crossref Scopus (11) Google Scholar More robust evidence on how mobile technology can support reflection, regular supervision, mentoring, and feedback is also required. Simplistic approaches that rely on exposure to information as a proxy for education should be avoided, particularly for CHWs dealing with the complex realities of caring for the most marginalised groups. The third challenge is that of rapid scale-up. Frameworks have been developed that could help to identify approaches that are unlikely to be sustainable, achievable at scale, or contribute to health-system strengthening.8Greenhalgh T Wherton J Papoutsi C et al.Beyond adoption: a new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies.J Med Internet Res. 2017; 19: e367Crossref PubMed Scopus (710) Google Scholar This will ensure that appropriate attention is given to the dynamic interactions and complex social systems in which mHealth is being implemented. The fourth challenge is more complex. As CHWs in the Living Goods model are recompensed on the basis of the amount they sell, there could be a possibility of overtreatment.9Lenzer J Unnecessary care: are doctors in denial and is profit driven healthcare to blame?.BMJ. 2012; 345: e6230Crossref PubMed Scopus (25) Google Scholar This could pose ethical concerns for CHWs: as they become better trained and their decision-making process improves, they could face having to choose between what is profitable for them and what is best for patient health. Training on how to negotiate these tensions for 50 000 CHWs will be required. The fifth challenge relates to on-the-ground implementation. The CHWs in the proposed programme will probably have more training and can distribute drugs, unlike government-trained CHWs. This can leave the other active CHWs feeling demotivated and neglected.10Mercader HF Kyomuhangi T Buchner DL Kabakyenga J Brenner JL Drugs for some but not all: inequity within community health worker teams during introduction of integrated community case management.BMC Health Serv Res. 2014; 14: S1Crossref PubMed Scopus (9) Google Scholar The potential for segregation to occur must be minimised. In conclusion, although we welcome the positive potential of this initiative, we urge caution in its implementation. Work to fundamentally tackle the five challenges will be difficult, but it is needed to ensure health systems are strengthened through this new private–philanthropic partnership. We declare no competing interests. Mobile health-care information for all: a global challengeAccess to health-care information for citizens is a key determinant to reach both the Millennium Development Goals (MDGs) and the emerging post-2015 Sustainable Development Goals, but this challenge has repeatedly been relegated to the sidelines.1 What might kickstart progress? An obvious candidate is the mobile phone, which is becoming ubiquitous in low-income and middle-income countries. Full-Text PDF Open Access