Never before has global health security been a topic of discussion around both the resolute desk and the kitchen table. Also, never before has the importance and heroism of frontline health workers been more evident, whether they be nurses and doctors in the United States or community health workers in places like sub-Saharan Africa. By some estimates, more than 115,000 health workers have died in the line of duty battling the coronavirus. But the reality is that community health workers have been on the frontlines of global health for far longer than the last eighteen months. Investing in and expanding the number and capacity of community health workers across the world is the necessary condition to ending the coronavirus and preventing the next pandemic.
Across sub-Saharan Africa, community health workers play a critical role in responding to the coronavirus and extending live-saving health education and care to the most remote, marginalized, and vulnerable communities. The community health workforce is over 70 percent women from rural and poor communities, many of whom are unpaid for their work, treating diseases such as malaria with tools that fit in a backpack—including rapid diagnostic tests, antimalarial medicines, and insecticide-treated bed nets. Community health workers also provide family planning services, protecting the health of women and mothers.
But more than that, this frontline workforce also creates significant capacity in the health system. They are our eyes and ears on the ground carrying out routine care, and the first to detect and report unusual fevers—a front line of surveillance for future pandemics. As Dr. Raj Panjabi, the U.S. President’s Malaria Coordinator, and former CEO of the organization that trained over one thousand health workers in Liberia during the Ebola outbreak said, “Alarms do not ring themselves, healthcare workers do.”
Yet community health workers are underfunded, underemphasized, underpaid, and under equipped to sustainably protect people. The October 2019 Global Health Security Index Report prophetically found that only 27 percent of countries had an updated health workforce strategy which mandates that healthcare workers receive training and access to infection prevention and control measures. Even more telling is that only 3 percent of countries had shown a public commitment to prioritizing healthcare services for workers who become sick as a result of participating in a public health response.
The funding gap for community healthcare workers needed in sub-Saharan Africa is $5.4 billion. But investing in a workforce that is majority women can promote gender equality and results in a positive return—as high as 10:1 when accounting for increased productivity from a healthier population, avoiding high costs of health crises, and impact of increased employment. A resilient community health system supports those women with adequate pay, training, management, protection, access to diagnostics and medicines, and robust connections to the lab systems that provide the data for global health security.
It doesn’t matter what policies are in place, what medicines are available, or how equipped the hospital is, if patients don’t have access to those things. Community health workers bridge that gap, bringing treatment and quality care where there would otherwise be little to none. And they do so in the most challenging contexts such as monsoons, civil unrest, or new outbreaks such as Ebola.
Community health workers are therefore the key to pandemic preparedness and response. Global health leaders and donors such as the United States, and its partners in the G20, have a key role in robust financing to ensure community health systems are aligned around a country’s own vision for sustainable impact. Indeed, the Biden administration has taken decisive action since its first week to create an integrated global health security strategy including a global financing mechanism for pandemic preparedness and response. Community health workers should feature prominently in this strategy and the United States should invest its resources and diplomatic leverage for their critical missions.
Many in the global health community worry about the supposed conflict between investments which are “horizontal” or “vertical.” Namely, they want to know whether these investments are being made either in systems or in specific diseases, but not both. This false dichotomy has paralyzed many policymakers. Community health workers can focus on disease-specific interventions such as finding and treating fevers due to malaria or delivering antenatal information to prevent mother-to-child HIV transmission, and they can deliver those services in an integrated and preventative way, shaped by household needs and supported by communities.
Community health workers are vital to finishing the job of ending the HIV, tuberculosis, and malaria epidemics—three diseases on which bipartisan U.S. global leadership is historic and unparalleled. Preventable diseases primarily kill the world’s poorest and most marginalized. They need access to health education, freedom from stigma and discrimination, and affordable medicines and care. Community health workers, by nature of living among the communities they serve, can meet these needs.
The President’s Emergency Program for AIDS Relief (PEPFAR) and especially the U.S. President’s Malaria Initiative (PMI) and the Global Fund to Fight AIDS, Tuberculosis (TB) and Malaria have worked to build health systems in their goal to end diseases. The most notable health system investment has been in hiring, training, and equipping community health workers to screen for HIV, TB, and malaria, link patients to facility care for testing and treatment, or deliver diagnosis and care right at the household. Pandemic preparedness should build on this. These local leaders have demonstrated resilience and agility grappling with the coronavirus. It works best to not reinvent the wheel, but to scale up resources through such tested platforms with established partners, often in civil society.
As Americans reassess their role in the world, and as the Biden administration works to rebuild America’s standing, it’s important to recall what makes the United States exceptional. The combination of America’s ability to solve complex problems, the deep technical expertise among Americans, and the innovation of its public and private researchers is unmatched. These strengths fuel U.S. soft power worldwide because they contribute to security, improve millions of lives, build local capacity and expertise, and demonstrate our generosity. Even increased global health investments would be a small cost compared to our military budget. Investing in community health workers in a way that recognizes their heroism, compensates them for their work’s dignity, and protects their well-being is what will protect the shared futures of Americans through the pandemic and beyond.
Joshua Blumenfeld is Managing Director of Global Policy and Advocacy and Chief Legal Officer at Malaria No More.
Mark P. Lagon is Chief Policy Officer at Friends of the Global Fight Against AIDS, Tuberculosis and Malaria.