D-tree and Medic: Advancing Universal Health Coverage through our shared commitment to digitally empowering Community Health Workers

The 77th session of the UN General Assembly kicks off this week, providing the opportunity for global leaders to come together and discuss some of the world’s most pressing challenges and solutions. At D-tree and Medic, we are excited to lead and participate in discussions about how we collectively can accelerate impact towards the vision of a world where everyone has access to the healthcare they need to live longer and healthier lives. As leaders in the digital community health space, we are advocating for three approaches we believe should be central in getting us closer to achieving Sustainable Development Goal 3: Good Health and Wellbeing.

COVID-19 resoundingly demonstrated that underinvestment in health systems globally costs millions of lives each year. Nearly everything we know about the spread of COVID-19 and how communities were impacted – both directly by the virus and indirectly due to the resulting discontinuity of essential care – has come through data from facility-based care. Yet, half of the world’s population cannot access even the most basic facility-based care because doctors, nurses and clinics are physically inaccessible, unaffordable or under-resourced. There is an urgent need to expand visibility into the care that these millions of families receive outside of facilities and under the watch of Community Health Workers (CHWs) – trusted members of the communities where they live and work, and often the first point of care for most families, especially in remote communities. Unfortunately, most CHWs are disconnected from the formal health system and are largely unpaid and unsupported after a few days of training. 

System strengthening and change are needed at an unprecedented scale to ensure people can access the care they need and deserve.

Medic and D-Tree collectively support community health initiatives and have collaborated with the Zanzibar Ministry of Health (MoH) to achieve the full national scale of Jamii ni Afya, a community health program with a robust digital component built on the Medic-stewarded, open-source Community Health Toolkit (CHT). Jamii ni Afya leverages apps that guide Community Health Volunteers (CHVs) to provide standardized, quality services to communities, enabling the Zanzibar MoH to integrate digitally-enabled CHVs into their formal Community Health Strategy and help bring high-quality health services to the doorsteps of all 1.6 million people living in Zanzibar. Through our experience, we’ve identified three essential approaches for successful community health initiatives that are dedicated to deepening funding and commitment during UNGA and beyond.

1. Community Health Workers need to be compensated for their work.

CHWs are critical in areas with fewer health facilities or workforce shortages, thus influencing the need to have more CHWs as accessible points of care. They provide feedback loops that anticipate needs and generate learning to ensure that quality healthcare is delivered to those in last-mile areas. Despite their critical role in providing care, most CHWs remain unpaid. New research from CHIC and The Lancet Global Health highlights that nearly 60% of health workers from low- and middle-income countries receive no salary despite being able to maintain speed and coverage of community-delivered care during the COVID-19 pandemic. Conversations around compensation for CHWs should not focus on why, but on how funding should be allocated. If CHWs are fairly compensated, they will be increasingly motivated to continue providing high-quality health services that eventually can lead to achieving Universal Health Coverage.

2. By bringing the right digital tools to health workers, we can improve quality and equity of care and increase long-term local sustainability.

By 2030, we are expecting to see a shortage of 15 million health workers, with low- and middle-income countries being mostly affected. This puts increased pressure on health workers and communities already at risk of not receiving the care they need and deserve. We believe that digital solutions have the potential to respond to this challenge. With informed and empowered leadership, the implementation of global standards, and a focus on interoperability, the “right” technologies have great potential to address inequity for the people and places where it is needed most. Leadership from public, private and funding organizations can contribute to this ongoing transformation, ensuring the technology will be used efficiently to improve the health and wellbeing of the most marginalized communities.

Unfortunately, many digital health solutions today fall short because they are not guided by the local context and needs, but are based on the newest innovations. Digital health implementers need cross-cutting expertise in health and technology to not risk missing critical aspects of design or implementation which can lead to that promising digital innovations may never reach wide implementation or institutionalization. Investing in Global Goods – like the Community Health Toolkit – is an important opportunity to scale digital health around the world. It is an essential path to local ownership and financial sustainability in Low- and Middle- Income Countries (LMICs).

3. Working closely with governments will be key for sustainability and scalability. 

We believe that one of the keys to the success of Jamii ni Afya is that the government has been in the driver’s seat from the onset and that the digital components have truly been based on the government’s needs. To make improvements to a health system that lasts, the process can’t be a series of one-off, uncoordinated interventions — they need to be an evolving journey.

Jamii ni Afya is one of the first digital community health programs to scale nationally by the government and its impact has been impressive. 75% of community health volunteers meet performance targets due to strong, digitally enhanced supervision systems, and 86% of pregnant women deliver in health facilities – a 28% increase over the national average.

Our experience from Jamii ni Afya also tells us that part of the program’s success is that the vision has always been for the MoH to eventually be fully in charge of all programmatic, operational and technical aspects, with our support as needed. To get there, we are currently at the early stages of putting together a transition plan and ensuring the Ministry has the capacity and knowledge required not only to keep the digital system updated but also to make modifications as needed. This is a model we’d like to replicate in other countries we work in, and that we’d like other actors to take after. 

D-tree and Medic look forward to contributing to and following the discussions during UNGA. Follow us on Twitter (Medic, D-tree) and LinkedIn (Medic, D-tree) to stay updated about how we will continue to strengthen health workforces in low- and middle-income countries and empower CHWs by bringing to them the right digital tools.