Community health and equity of outcomes: the Partners In Health experience
Authors: Daniel Palazuelos, Paul E Farmer, Joia Mukherjee
Journal: The Lancet Global Health (2018)

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.1Hazel E Bryce J IIP-JHU iCCM Evaluation Working GroupOn 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; 94: 568-570Crossref PubMed Scopus (17) Google Scholar 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 (table).2Farmer P Robin S Ramilus SL Kim JY Tuberculosis, poverty, and "compliance": lessons from rural Haiti.Semin Respir Infect. 1991; 6: 254-260PubMed Google Scholar 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.TableCommunity health strengthens the value chain to achieve equity of outcomesPreventionSurveillance, diagnostic tests, and start of treatmentOngoing management of the diseaseManagement of clinical deterioration and end-of-life careResultsLarger health-care system strengthening effortsHaiti: village health workers for tuberculosisInformation, education, communicationActive case finding and referral for tuberculosisDaily home visits for 1 month (tuberculosis medications brought to patient's home) with monthly reminders to follow up at the clinic. Additional social supports include $30 monthly cash stipends for 3 months, nutritional supplements, transport reimbursement ("donkey rental fees")Home visit from clinic staff if patient fails to follow up, side-effect surveillance100% clinical cure in all patients receiving free care and socioeconomic supports vs 56% cure, 10% death in free care alone patients2Farmer P Robin S Ramilus SL Kim JY Tuberculosis, poverty, and "compliance": lessons from rural Haiti.Semin Respir Infect. 1991; 6: 254-260PubMed Google ScholarFunctioning referral facility with hospitalisation, basic lab capacity, no user fees, staff support (for MD, nurse, other ancillary staff), improved supply chain, integrated team care, contact screening, BCG vaccine for infantsHaiti: accompagnateurs (accompaniers) for HIVInformation, sexual, education, communication, condom promotion, family planning, vaccinesActive case finding and referral (for tuberculosis, HIV, STDs)Daily home visits for DOT-HAART (HIV medications brought to patient's home), personal emotional support, confidentiality assurance. Additional social supports coordinated with social work team, and sanitation engineer employed to improve access to clean waterSide-effect surveillance, early referral for known complications, active case retention via home visits from clinic staffReaching a population of 550 000, 8000 patients with HIV actively followed; 0% mortality in first 100 fully supported patients, vs 14–29% mortality in other groups; 86% suppressed viral load in a subset of patients3Koenig SP Leandre F Farmer PE Scaling-up HIV treatment programmes in resource-limited settings: the rural Haiti experience.Aids. 2004; 18: S21-S25Crossref PubMed Scopus (164) Google ScholarVoluntary counselling and testing, comprehensive treatment for HIV and OIs, tuberculosis, STDs, and women's health (including prenatal care and PMTCT), functioning referral facility with hospitalisation (including extensive renovations, space for clinical exam, pharmacy, addition of electricity, safe blood transfusion), basic lab capacity including flow cytometer, staff supports (for MD, nurse, pharmacist, administrators), improved supply chain, integrated team careChiapas, Mexico: acompañantes (acompaniers) for diabetes, hypertension, other chronic diseasesInformation, education, communicationParticipate in active case- finding campaigns for multiple chronic diseasesWeekly home visits to offer emotional support and instrumental support (i.e. organising pills in pillboxes, supporting self-management, mobilising social supports), escorting to MD primary care visits. Additional social supports include, mental health support through psychoeducation classes, transport support to referral networksSide-effect surveillance, active case retention via home visits, regular meetings with clinicians to discuss patient managementTwice the odds of clinical control in diabetes and hypertension sustained beyond 2 years4Newman PM Franke MF Arrieta J et al.Community health workers improve disease control and medication adherence among patients with diabetes and/or hypertension in Chiapas, Mexico: an observational stepped-wedge study.BMJ Glob Health. 2018; 3: e000566Crossref PubMed Scopus (36) Google ScholarFunctioning primary care facilities providing comprehensive ambulatory patient care, basic laboratory capacity, no user fees, staff supports (for MD, nurse, other ancillary staff), improved supply chain, referral network supports, integrated team carePeru: CHWs for MDR or XDR tuberculosisInformation, education, communicationActive case finding and referral, contact tracingDaily home visits for DOT-Plus daily during treatment (tuberculosis medications brought to patient's home), emotional support during home visits and via group therapy sessions. Additional social supports include housing assistance, opportunities for income generation, nutritional support, transport support, housing supportSide-effect surveillance, early referral for known complications, active case retention via home visits, adverse event management, home visits, analgesia66·3% of 603 patients with MDR tuberculosis cured, 60·4% of 48 patients with XDR tuberculosis cured5Mitnick CD Shin SS Seung KJ et al.Comprehensive treatment of extensively drug-resistant tuberculosis.New Engl J Med. 2008; 359: 563-574Crossref PubMed Scopus (338) Google ScholarCommunity-based care strategy (active outreach, comprehensive ambulatory patient care, close coordination with national tuberculosis programme, close communication with patients and families), functioning referral facility with hospitalisation and resective surgery when needed, basic and specialised laboratory capacity (individualised regimens via drug susceptibility testing), diagnostic algorithms to treat with at least 5 drugs and to aggresively address side-effects, no user fees, staff supports (for MD, nurse, other ancillary staff), integrated team careMalawi: village health workers for Kaposi's sarcoma and palliative careInformation, education, communicationActive case finding and referralRoutine home visits for psychosocial support and to promote ART/chemotherapy adherence. Additional social supports include transport voucher (for those with oedema or dyspnoea)Side-effect surveillance, escorting to care when interim illnesses requiring attention identified, active case retention via home visits, end-of-life care (symptom control and emotional support)83% survival 12 months after chemotherapy (95% CI 74–89), 77% retained in care6Herce ME Kalanga N Wroe EB et al.Excellent clinical outcomes and retention in care for adults with HIV-associated Kaposi sarcoma treated with systemic chemotherapy and integrated antiretroviral therapy in rural Malawi.J Int AIDS Soc. 2015; 18: 19929Crossref PubMed Scopus (37) Google ScholarLongitudinal care for monitoring, analgesia and symptom control, functioning referral facility with hospitalisation, referral network supports including access to referral oncologist if needed, basic lab capacity (including biopsy confirmation if needed), no user fees, staff supports (including task shifting to trained clinical officers), improved supply chain, availability of chemotherapy (bleomycin/vincristine or paclitaxel), premedication, antibiotic prophylaxis and ART via standardised protocols, integrated team careLesotho: maternal mortality reduction agents for maternal healthInformation, education emphasising the benefits of facility-based care, communicationActive case finding and referral of pregnant womenRoutine home visits for progress assessments by CHWs (many of whom are former traditional birth attendants), escorting to care (to ANC, delivery, and postpartum services). Additional social supports include food in the maternal lying-in house, new baby-starter packs for all mothers, breastfeeding replacement option for HIV+ mothersEarly referral for known complicationsNo deaths in first 2 years despite a >350% increase in deliveries by the second year; 49 transferred for complications7Satti H Motsamai S Chetane P et al.Comprehensive approach to improving maternal health and achieving MDG 5: report from the mountains of Lesotho.PLoS One. 2012; 7: e42700Crossref PubMed Scopus (25) Google ScholarComprehensive care (including risk screening, tetanus immunisation, family planning, pap smears, tuberculosis, HIV, pMTCT and STI care)linked to maternal health care, compassionate care in a functioning birthing centre, maternal lying-in houses, functioning referral facility with hospitalisation (and access to caesarean section and transfusion), basic laboratory capacity, no user fees, staff supports (especially to nurse midwives), integrated team careRwanda: accompagnateurs (accompaniers) for HIV and tuberculosisInformation, education, communicationActive case finding and referral, proactive HIV testing in clinicsDaily home visits for DOT-HAART, emotional support (CHW companionship, support groups), progress assessments, motivational interviewing, escorting to care. Additional social supports include nutrition support (monthly food packages), transport allowances for routine visits, and for the most vulnerable, housing assitance or home repairs, employment training/microfinance activities, intermittent economic support and school or health insurance fees were availableSide-effect and OI surveillance, early referral for known complications, active case retention via home visits92·3% retention (versus 70% Africa average), 97·5% with viral load less than 500 copies per mL, 5% mortality8Rich ML Miller AC Niyigena P et al.Excellent clinical outcomes and high retention in care among adults in a community-based HIV treatment program in rural Rwanda.J Acquir Immune Defic Syndr. 2012; 59: e35-e42Crossref PubMed Scopus (134) Google Scholar;44·3% reduction in prevalence of depression, more than twice the gains in perceived quality of life, increased perceived social support in the first year of treatment9Thomson DR Rich ML Kaigamba F et al.Community-based accompaniment and psychosocial health outcomes in HIV-infected adults in Rwanda: a prospective study.AIDS Behav. 2014; 18: 368-380Crossref PubMed Scopus (29) Google ScholarFunctioning referral facility with hospitalisation, ambulance network to facilitate district hospital access for acutely ill, basic laboratory capacity including flow cytometer, tuberculosis screen with chest x-ray, no user fees, staff supports including mentorship and enhanced supervision (MD, nurse, other ancillary staff), electronic medical record to support continuity of care and to prompt clinical responsiveness, integrated team careANC=Antenatal care. ART=antiretroviral therapy. CHW=community health worker. DOT=directly observed tharapy. DOT-plus=DOT for MDR/XDR tuberculosis. HIV=human immunodeficiency virus. STI=sexually transmitted disease. HAART=highly active antiretroviral therapy. MD=medical doctor. MDR=multidrug resistant. PMTCT=prevention of mother-to-child transmission of HIV. OI=opportunistic infection. STD=sexually transmitted disease. XDR=extensively drug resistant. Open table in a new tab ANC=Antenatal care. ART=antiretroviral therapy. CHW=community health worker. DOT=directly observed tharapy. DOT-plus=DOT for MDR/XDR tuberculosis. HIV=human immunodeficiency virus. STI=sexually transmitted disease. HAART=highly active antiretroviral therapy. MD=medical doctor. MDR=multidrug resistant. PMTCT=prevention of mother-to-child transmission of HIV. OI=opportunistic infection. STD=sexually transmitted disease. XDR=extensively drug resistant. Accompaniment is both a philosophical stance and a rubric for programmatic design. In practice, it amounts to walking with the patient through a journey.10Farmer P Partners in help: assisting the poor over the long term.Foreign Aff. 2011; Jul 29; Google Scholar 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".11Walsh JA Warren KS Selective primary health care: an interim strategy for disease control in developing countries.New Engl J Med. 1979; 301: 967-974Crossref PubMed Scopus (633) Google Scholar PIH's clinical achievements receive admiration while also being called unrealistic and unsustainable.12Gilks C AbouZhar C Türmen T HAART in Haiti—evidence needed.Bull World Health Organ. 2001; 79: 1154-1155PubMed Google Scholar 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.