Strengthening community health worker program in Belize

INTRODUCTION

The current drive towards universal health coverage presents an opportunity to support the CHWs and integrate them into the health system for the realization of their potential contribution in the context of primary health care and resilient health system.¹

Community health workers play a critical role in decreasing inequalities by reaching those with the most health disparities and most challenges accessing care as the equity arm of primary health care.² Their roles are critical for the achievement of universal health coverage and the sustainable development goals (SDGs) especially in low-income and middle-income countries (LMICs).³ They serve as the bridge between the formal health system and the community to address unmet needs for health services, promote health-system resilience, foster continuation of essential services and support effective emergency responses.⁴ They work with other cadres of the health system to ensure health services at gross root level to deliver primary health care which is a backbone of universal health coverage. The contributions of CHWs have not been limited to low-income countries. More recently, the use of CHWs has attracted attention in some high-income countries where despite more developed health systems, there are large inequities in healthcare access and outcomes amongst different population groups.^5,6 The growing interest in CHWs in high-income countries is being driven by concerns about shortage in health workforce and the escalating burden of chronic and complex diseases that is driving a significant increase in health services demand and costs in many developed countries.^5-7 Studies of CHWs interventions in high income countries; especially in the United States, Australia and Central America show largely positive effects on health outcomes, especially among low-income racial and ethnic minorities.^5-8

Belize is an upper middle-income country located in central America and its health system is based on a primary health care model. This is predicated on reality that country has a widely dispersed rural population, migrant and indigenous population and inadequate number of skilled health workers especially in the rural and hard to reach areas. Belize health system is decentralized into four regional health administrative authorities that oversee the six districts in the country for effective management. Community health workers are widely dispersed and found in most villages in Belize. They are involved in the provision of basic health services, such as monitoring blood pressure and blood glucose, facilitate access to contraceptives, providing basic first aid, home visits to chronically ill patients, pregnant women and nursing mothers, individuals at high risk of health problems, persons with disabilities and older persons. They monitor growth of children, screen for malnutrition, diagnose and treat a limited range of common diseases (e.g., diarrhea). They support during mobile clinics and outreaches and perform simple diagnostic measures including rapid diagnostic test for malaria, nasal swab for collecting samples for COVID-19 test and contact tracing during COVID-19 pandemic and support patients in adherence to treatment.

The study describes how Belize, an upper middle-income country is strengthening its community health worker program performance to address the gap in access to health service in the country following the critical role they played during the COVID-19 pandemic, both in the response and maintenance of essential primary health care services.⁹

LITERATURE SEARCH

A descriptive study through review of grey literature detailing the process for strengthening the community health worker program in the country using the Community Health Worker Assessment and Improvement Matrix (CHW AIM) tool.¹⁰ The documents included Belize health sector strategic plan (2014-2024), Belize ministry of health and wellness operational plan (2022-2023), Belize ministry of health and wellness health education and community participation bureau (HECOPAB) operational plan (2022) and evaluation of the community health extension programme in Belize (2013).^11-14 The results were thematically analysed based on a conceptual framework on factors influencing the performance of community health worker program.¹⁰

This is organized into three themes identified as key elements for improving the performance of community health workers.¹⁰ These are (1) Linkages of the CHW with the health system (2) career advancement and (3) financial incentives.

THEME 1: LINKAGE OF COMMUNITY HEALTH WORKERS WITH THE HEALTH SYSTEM

The community health workers in Belize are recognized as part of the formal health system with policies and strategies in place that define their roles, tasks, relationship to health system.^11,12

The CHW programme was established in 1982, with technical and financial support from the United Nations children’s fund (UNICEF). It falls within the purview of health education and community participation bureau (HECOPAB), the health promotion arm of the Ministry of Health tasked with responsibility for planning, coordinating and implementing health promotion activities at the community level throughout the country. The CHWs in all the six health districts are supported and supervised by district health educators and connected community health activities to the structured health system through village health committees (VHC). However, the VHCs are not functional in some communities and require to be strengthened.

HECOPAB coordinates the recruitment, training, certification, supervision, accreditation and supplies and equipment for the CHWs. There is a national health budget which has provision for the activities of CHWs (salary, training, supplies and supervision) though very low when compared to overall budget allocated for health. It is expected that with the approval of the increase in the monthly stipends for the community health workers, the budgetary allocation for the CHW program at the national and regional level will increase.

There is a database of the mapping of all the active CHWs which provides the basic information about each of the CHWs including their location, qualification, year of service as CHWs, year of accreditation etc. This mapping will be further enhanced through a functional national georeferenced CHW master list/registry which will help to uniquely identify, effectively describe, enumerate, locate and contact all CHWs in the country. The CHW master list is critical for strategic planning, training, deployment, payment, supply, supervision, monitoring and evaluation of CHWs in the context of broader human resources for health (HRH) and primary health care (PHC) systems.

The CHWs usually refer patients/clients who require health care services to the nearest health facilities using a standardized referral form and information flows back to CHWs with a returned referral form. However, most health care workers do not complete the returned referral form to provide update to the CHWs on the patients/client referred, which is a major challenge for an effective two-way referral system needed to strengthen and ensure continuum of care.

There is a paper-based community health information system (CHIS) for capturing the monthly activities of the CHWs and monitoring their performance. There is ongoing process of digitalizing the CHIS and linking with the national HIMS which will ensure the community-level data flow to the health system.

CAREER ADVANCEMENT FOR COMMUNITY HEALTH WORKERS

The government of Belize supports CHWs who perform well and who express interest in advancement when opportunity exists. One of the key activities in the national annual community health operation plan is recruitment of CHWs as permanent staff of the health facilities. ¹³ In order to achieve this, some CHWs have been provided scholarship to go to school while still working as CHWs and others supported to attend relevant training to learn new skills to advance their roles. Specifically, some CHWs were supported to attend other relevant training organized by the government or non-governmental organization for specific skills like basic life support etc. needed to be employed as caretakers /practical care attendants (one of the health workforce cadres in the country). Some of the community health workers with the relevant training have been prioritized and employed as caretakers (practical care attendants) in the health centers within their communities.

However, there is need to put in place transparent guideline and mechanism to ensure fair assessment of CHWs to reward good performance and for the release of poorly performing CHWs from their duties.

FINANCIAL INCENTIVES FOR COMMUNITY HEALTH WORKERS

The first evaluation of the community health workers program was conducted in 2013 to assess its effectiveness and gaps.¹⁴ The evaluation assessed the program as successful and effective in supporting Belize’s primary health care system. However, the evaluation identified financial constraints to supporting the CHWs, specifically their monthly stipends have remained unchanged at $100BZD (50USD) since 1994 despite their expanded duties and scope of work overtime and recommendation was made for increased monthly incentives based on their expected roles.

The Ministry of Health and Wellness leveraged on the significant role the CHWs played during the COVID-19 pandemic to advocate for increased monthly stipends as part of the measure to strengthen the community health program to build a more resilient health system based on the lessons learnt from the pandemic. This advocacy resulted in the government’s approval of increase of the monthly incentive of the CHWs from 100BZD (50USD) to 500 BZD (250USD) which is commensurate with duties and expected roles. The government approval was followed by budgetary allocation by the ministry of finance for commencement of the payment with effect from 1^st April 2023 in all the health regions.

DISCUSSION

Community health workers are essential in building resilient primary health care system for achieving universal health coverage. However, there is need for enabling environment to motivate and improve their performance. Integration of CHWs into the health systems has been recognized as a critical factor in ensuring a sustainable community health workforce and achievement of the full potential of the CHWs essential for strong and effective primary health care system. ^15,16

One of the recommendations adopted at the seventy-second world health assembly as part of broader health workforce strategies and financing for community health worker program was ‘to allocate adequate resources from domestic budgets and from a variety of sources, required for the successful implementation of community health worker programmes and integration of community health workers into the health workforce in the context of investments in primary health care, health systems and job creation strategies, as appropriate’.¹⁷

A scoping review on CHW programmes ‘integration into national health systems noted that although some similarities were observed, evidence of integration on most CHW programme components varied across countries depending on respective health system.¹⁸ This is determined by the extent to which the ministry of health has policies in place that integrate and include CHWs in health system planning and budgeting to support and sustain CHW programs at district, regional and national levels.^19,20 The gains from integration depend, however, on the strength of the health system supporting the CHW. Strong health systems that incorporate CHWs are invaluable for coordination and cooperation during critical times, as demonstrated during the 2014-2015 West African Ebola epidemic and COVID-19 pandemic.^9,21,22 Similar to the study, a systematic review in developing countries reported that sustainable integration of CHWs into health care systems requires the formulation and implementation of policies that support their work, high-performing health systems with sound governance, adequate financing, well-organized service delivery motivation, collaborative and supportive supervision, and a manageable workload are essential.¹⁵

The CHWs in United State have increasingly come to be seen as important members of primary health care delivery teams leading to the US bureau of labor recognizing community health worker as labour category and their potential to contribute to the health system has been highlighted in the patient protection and affordable care act.²³ This has created a policy environment for effective integration of CHWs into primary care settings which will ensure sustainability of the community health workforce.²⁴

Career advancement as reported in this study is recognized as a major type of non-financial incentives for CHWs. Various studies found that opportunities for career advancement is one of the several important non-financial incentives that can improve CHW motivation, though the feasibility and implementation modalities may vary across different context.^25-28 These findings show lack of opportunities for professional growth drive dissatisfaction and that more effective and equitable career pathways for CHWs would provide motivation for CHWs to remain in the workforce, promote retention and contribute to organizational quality improvement.^25-28 A randomized control trial on recruitment of a new health worker position, the community health assistant (CHA) in Zambia found emphasizing career incentives, such as opportunities for promotion and further professional development, rather than social incentives, attracted workers who were more qualified and performed better on the job in terms of clinic utilization, home visits, household behaviours and child health outcomes even though there was no difference in job retention between the two groups.²⁹

One of the recommendations of the WHO guideline on health policy and system support to optimize community health worker programmes is to provide career ladder for practicing CHWs and suggested that the availability and definition of career ladder opportunities should be embedded in CHW programme design from the outset.³⁰ In line with this WHO recommendation, the recruitment of CHWs as permanent staff of the health facilities is one of the key activities in the country community health operation plan.¹³ However, there is no clear guideline or selection criteria on the eligibility or conditions to be met for CHWs to be considered for recruitment as suggested in the WHO policy that further education and career development are linked to selection criteria, duration and contents of pre-service education, competency-based certification, duration of service and performance review.³⁰ There is need to establish transparent guideline and mechanism to guide the recruitment of CHWs as permanent staffs in the health facilities in Belize.

The incentivization of CHWs has been much debated and focused on the trade-offs between reliance on volunteerism underpinned by intrinsic motivation of volunteers and the need to recognize and remunerate work fairly.^31,32 Financial incentives have been linked to CHWs’ motivation and retention and has become more necessary especially as expectations in the form of tasks and workload expand.^33,34

In the context of task-shifting health services to community providers to fill human resource gaps, there has been an expansion of CHWs’ role and workload. WHO guideline for optimizing health system and policy support for optimizing the contribution of CHWs recommends remunerating practising CHWs for their work with a financial package commensurate with the job demands, complexity, number of hours, training and roles that they undertake.³⁰ The increase in the stipends for the CHWs in Belize was based on the recommendation from this WHO guideline with expanded role and responsibilities of the CHWs and more hours committed to perform their duties. In recognition of the critical role of community health workers in delivery of services across global health programs, the United States supports efforts to professionalize these cadres across the globe. In June 2021, the U.S. president’s malaria initiative (PMI) changed its policy to allow for the payment of CHW salaries and stipends with PMI funds, while advancing efforts to catalyze other donors and work with partner governments on a sustainable approach for governments to assume primary responsibility for health worker salaries over time.³⁵

The financial incentives will also help in addressing gender disparities with almost all the CHWs in Belize being female and may also contribute to an even greater return on investment, matching health-related benefits with larger societal benefits that come from female empowerment and social cohesion especially that most of the community health workers in a lot of countries are females.³⁶

The increase in incentive payment for community health worker in Belize will also contribute to achieving poverty reduction which is one of the objectives of the ‘Plan Belize’ which is the country’s medium-term development strategy.³⁶

The sources of funding for the payment of financial incentives for the CHWs in most of the community health programs ranges from the national government to a combination co-sharing between national and subnational government, contribution from the communities and external donors.^38,39

Similar to Belize, the monthly payment for the CHWs in India, Pakistan, Iran and Nepal is from the national government.^40,41 While in Liberia and Ethiopia is from Domestic and donor fund.^41,42 The incentives for the CHWs in Zimbabwe, Sierra Leone, Guatemala, Panama, Mexico is funded mostly by NGO partners and donors.^39,42-46 The monthly incentives in these countries ranged from 42USD to 280 USD.^40-46 Funding from government has important advantages, most notably job security for the individual CHWs. However, one of the inherent problems with government funding is the lack of strong political support to continue funding levels for CHW programs in the face of competing demands which causes cutbacks in funding when government shortfalls.

Therefore, CHW programs are commonly one of the first budget items to be cut when budget pressures arise.^39,40 There is need to legislate the cabinet approval for increase in the CHWs incentive in Belize so that irrespective of the government in power the incentives will be sustained.

Strengthening the community health worker program offers a significant long-term return on investment by facilitating equitable access to quality primary health care service and essential public health functions essential for building a resilient health system.

CONCLUSION

The study contributes to the existing literature on strengthening of community health worker program to enhance the primary health care system and build a more resilient health system for better preparedness and response for future pandemics with focus on an upper middle-income country.

The current investment in CHW program in Belize should be sustained and areas that require more attention strengthened to enhance the performance of the CHWs and leverage on the strengths of the CHW programme to achieve better health outcomes.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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