Community Health Workers: Heroes of Rural Healthcare

Dear Editor,

Poor health outcomes globally are partly attributable to the fact that only 25% of physicians and 38% of nurses provide care to rural populations. This situation is worsened in Nigeria by a critical shortage of a competent healthcare workforce (1). Recruiting and retaining healthcare workers in rural areas is challenging due to limited incentives, lack of motivation, and inadequate retention strategies for healthcare staff. In Nigeria, primary health care (PHC) is the sector where the deficiencies in medical personnel, both in terms of quantity and quality, are most pronounced (2).

The healthcare workforce in Nigeria comprises various cadres of health professionals. In rural communities, PHC facilities, managed by Local Government Authorities, act as the entry point into the Nigerian health system, providing essential healthcare services to residents. Community health workers (CHWs) constitute the majority of healthcare staff in these facilities. These multivalent workers deliver healthcare services, which encompass the core components of PHC, regardless of individuals' location or occupation.

Providing critical care to mothers and children in underserved areas demands significant dedication and resilience. Community health workers are pivotal in bridging the healthcare gap in rural African communities, where the scarcity of health professionals often limits access to quality healthcare and even life-saving services (3).

Community Health Practitioners in Nigeria are trained and licensed by the Community Health Practitioners Registration Board of Nigeria (CHPRBN). These cadres include Community Health Officers (CHOs), Community Health Extension Workers (CHEWs), and Junior Community Health Extension Workers (JCHEWs). These health professionals are recognized for improving rural residents' access to healthcare services, promoting healthy living, and preventing diseases through behavioral change communication. Community health workers treat minor illnesses and guide patients to appropriate levels of care when specialized treatment is required. Typically, they are employed by the communities they serve and have received less formal training than conventional medical professionals. In many African communities, especially for pregnant women, they serve as the first point of contact for medical attention.

Different African nations employ varying approaches to utilizing CHWs for community care, but the outcomes are often similar—saving lives and preventing health complications for the continent's most vulnerable and hard-to-reach populations (3). Numerous studies highlight the significant impact of CHWs on healthcare delivery in Nigeria, particularly in maternal and child healthcare and disease prevention. Community health workers are critical to the delivery of Primary Healthcare, especially in rural areas. To address community needs, some CHWs in Nigeria have even taken up informal task-shifting. They have been instrumental in managing chronic conditions such as diabetes and hypertension (4).

Health service interactions with CHWs have been shown to significantly increase the likelihood of women intending to use modern contraceptives, compared to women without such interactions (5). A fundamental tool in CHW training is the National Standing Orders (NSOs), which serve as guidelines for managing patients in the absence of a medical doctor (6). Community health workers often provide services beyond the scope defined by the National Standing Orders. These unofficial task-shifting activities are primarily motivated by a desire to serve their communities (4). Another study found that CHWs are widely utilized to diagnose and treat malaria, provided they receive adequate training and do not spend excessive time on the job (7).

There is a significant disparity in the accessibility and availability of healthcare, particularly for vulnerable communities, due to the massive migration of healthcare professionals out of the country. The healthcare professionals who remain are often unwilling to work in rural areas, primarily due to inadequate social infrastructure and, in certain regions, insecurity. Nevertheless, CHWs consistently demonstrate a willingness to provide healthcare services, even if it requires going the extra mile. The services provided by CHWs need to be upgraded to compensate for the absence of doctors and nurses. Employing more CHWs is essential to meet the demands of the population they serve, and ensuring their adequate training and retraining is crucial, especially considering the unique and emerging diseases in Africa.

Primary health care facilities must also be adequately equipped with the resources necessary for CHWs to perform their duties effectively. The availability of appropriate transport systems is crucial to support outreach services and the referral of patients, particularly in hard-to-reach areas. Additionally, the integration of digital health technologies, such as mobile health and telemedicine, has the potential to enhance the efficiency and reach of CHWs' services.

It is recommended that the Nigerian government explore ways to augment the CHW workforce by offering incentives for recruitment and retention. For instance, financial incentives for working in rural or hard-to-reach areas, as well as opportunities for advanced training and professional growth, could help retain CHWs (8). The efforts of CHWs in delivering healthcare to the doorsteps of community members, preventing diseases, managing minor ailments, referring cases as outlined in the NSOs, and providing maternal and child health care have significantly alleviated the disease burden, especially at the grassroots level.

Building the capacity of CHWs is imperative to further enhance the quality of their services. Updating training manuals and expanding the scope of healthcare services provided by CHWs have become necessary to address the health challenges affecting the nation’s population effectively.