The Power of Professionalising Community Health Workers

[Music] Billions of people live in poverty around the world. The reasons are complex and multifaceted, and no one solution exists. But there is hope. There are people working hard to create a better and fairer world. In this series, we talk to inspiring individuals who we believe are true change makers, and in our eyes, dead-set legends. Welcome to Philanthropod. I'm your host Anubarawath, and this is your place to connect and learn about their journeys of change and what inspires them. [Music] Welcome to Philanthropod, everyone. Today's conversation will be an interesting one. It sits at the intersection of history, health systems, and a very practical questions. Who actually delivers care? Back in 1978, the World Health Organization helped shape a vision through a declaration called the Alma-Ata Declaration. Health for all grounded in primary care and delivered as close to communities as possible. At the centre of that vision were community health workers. And yet, nearly five decades on, the reality is more complex. Community health workers are everywhere, but are often not recognised formally in the system. They are underpaid, under supported, and too often treated as an informal layer rather than a professional workforce. That's where today's guest comes in. Madeline Ballard is the founder and CEO of the Community Health Impact Coalition, or Sheep. A global coalition working to professionalise community health workers at scale. Sheep brings together governments, NGOs, and implementers across multiple countries with a very simple and in some ways radical proposition that community health workers should be salaried, skilled, supervised, and fully integrated international health systems. It's a model that's grounded in evidence, but also in coordination. Aligning actors, shaping policy, and pushing for a different way of thinking and supporting frontline care. Sheep is also a school awardee recognised by the School Foundation for its leadership in advancing this agenda globally. Madeline, welcome to Philanthropod. Thank you so much, Geneva. Madeline, you've built Sheep into a global coalition with community health workers right at the centre. We get into the details of Sheep, but can you take us back to the beginning when you were working in Liberia and the idea of Sheep was just a seed? What were you learning about community health workers that made you feel that something like this organisation needed to exist? So, at that time, and still, to some extent today, a huge portion of the world, about a billion people, mostly in sub-Saharan Africa and South Asia, will never see a health worker. You know, we'll have no access to even the most basic health services, not hospital, not clinic, not a nurse. And so the question really is with why? And in Liberia, I was working with a group of people who were HIV positive, who had returned to Liberia after the Civil War, answering then President Sir Leif's call to the diaspora to help come rebuild the country. And it had remarkable success in making HIV care available even in the most rural areas. And how did they do this post-war? Well, basically at that time again, there were about four doctors for four million people, and we were in the rural southeast of the country, and they said, listen, if we wait for doctors, like we're all going to die. So simple is that. We need to find ways to get these medications that keep us alive and turn HIV from a death sentence into basic, the iconic care condition into the hands of folks who are nowhere near a doctor or won't be for some time. And they convinced the minister of health to allow a pilot. And the result of that pilot were we're startling, you know, there was something like these are not exact figures, but 90 plus percent of the people who were being enrolled by non-physician clinicians onto HIV care and were being followed up by community health workers, people who are delivering their care, you know, straight to their neighbors doorsteps. We're alive and in care, and then in the capital city with some of the doctors, the alive and care rate was maybe one third of that. And that wasn't because the doctors were doing a good job. It was just because if someone didn't show up, they didn't go find them. If someone was having a really difficult reaction to this life changing diagnosis, they weren't able to kind of come and sit with them day after day to help them acclimatize. If someone was throwing up or finding it very difficult to keep the quite toxic medications down because they weren't eating enough, you know, the doctors weren't any able to support them with food. And those are all things that came in health workers were doing. And so it was at that time that we kind of asked the question, listen, you know, the founders of this of this work, where HIV positive. But epidemiologically, the things that were really making people sick and leading kids to lose their lives in that area were things like malaria, diarrhea, pneumonia. And so the question was asked, how do we, as a care network, do more and what would that require? And at the time, community health workers in Liberia were called general community health volunteers. And we said, well, listen, you know, if you try to put out a really high performing products and you had a factory where you didn't pay your workers, you didn't really supervise them. They were out of stock maybe one third of the time. And the last time they were trained was nobody can quite remember, you know, what type of product do you think you'd get? Probably an nonexistent one. That was really what we saw with a lot of general health services in rural Liberia. This is a population where the vast majority of people are living in rural areas, multiple hours from a nearest health system. So he said, well, listen, what if we actually treated community health workers like professionals, what a radical idea, you know, just like nurses, just like doctors, just like anyone else who's providing life saving care to people in their moment of need. And that put Liberia onto a real life changing and life saving trajectory where they ultimately adopted that approach nationwide and saw, for instance, one of the fastest drops in the incidence of malaria, you know, ever recorded in the in the years following the introduction of that program. And so, I think, of course, as with all national policy rollouts, there's been bumps along the way, but at this at this juncture, Liberia has really emerged as, you know, being up there with Brazil, Ethiopia and some of the four runners of this idea, which 10, 15 years ago when we were starting community back coalition was quite rare, maybe a handful of countries treated community health workers like professionals and is now an emerging standard. 50 countries now a credit and salary community health workers as part of their national health programs. That's incredible. I mean, that's a great story to start telling the story of Sheik Madeline just for a little bit of history, though, when, you know, back in 1978 with the whole Alma Mater Declaration, community health workers were at the central idea of that vision. But it didn't materialize. I don't know if you could list out some of the main reasons why that vision didn't materialize as in why sort of languished till sort of sheik immersion kind of, you know, took the agenda forward again. Yeah, it's interesting. There have been an number of so came the health workers for context. Again, these are people who are delivering care to their neighbor's doorstep have been around for more than 100 years. They've been they were known in Russia as falchers and the 1950s, the what became known as the barefoot doctors of China became quite famous and you're right in 1978 at the conference of Alma Mater, which is a huge international health meeting with people from the United States. You know, host, I think it was hosted by W for the World Health Organization, but UNICEF, it was attended by thousands of representatives 130 countries. And it was here were the vision of primary health care was related to the first time. So prior to 1978, a lot of international health was focused on what we call vertical programs, disease elimination programs, like trying to eradicate malaria, the eradication of smallpox. And obviously, while we still have malaria today, the eradication of smallpox was was successful. But I think folks came to realize shortly after that success, that the existence of kind of a single dose field deployable vaccine. It was what made smallpox eradication uniquely feasible and there probably wasn't going to be a magic bullet intervention for every single other disease. And so we had to figure out how we were going to treat them rather than just eliminate them in one big global push. How do we actually treat them, you know, this Tuesday, next Tuesday and on a Tuesday, 50 years from now. And that's what was really what people were thinking about coming into Alma Mater. And so community health workers were talked about as a central part of the strategy towards this goal of kind of comprehensive universal primary health care. They famously set the goal for health for all by the year 2000 at Alma Mater, but you know, altogether now what year is it it's 2026. So great question. What happened. I would say there's kind of three reasons for that really bold vision. And you know, found it pretty quickly. First is that the Alma Mater declaration actually didn't specify who would be. pay for primary healthcare scale up worldwide. So there's this 80 page report on the conference, and I think there's a single paragraph that discusses financing. And what you saw was that number 10s and 10s of countries after Al-Mada started these community health national programs. And then there were all these academic papers published in the mid and late 80s being like, "Ah, can many outworkers don't work?" And it's like, "What do they have work?" Or are they without pay, without supplies, without supervision, and without training? And I think that was kind of the key gap that we seized on to. I think contextually, there was also the sovereign debt crisis that happened around that time, which dried up international aid left a lot of countries, you know, facing cuts to social services. And the real nail on the coffin was the emergence, also at that time, of kind of an alternative international health agenda that found a lot of support among decisions and makers in what was a kind of a shifting ideological climate, the emergence of what was called selective primary health care. So rather than universal, which is a bit of an oxymoron, but basically there was this paper written at that time by these researchers called Julia Walsh and Kenneth Warren. And they basically said, "Listen, let's do high impact low-cost platform. We'll do growth monitoring or rehydration therapy, breastfeeding immunizations." So it came to be known as goby because of those four interventions and they're starting letters. And I people found that really simple and really appealing. I was like, "Oh, man, this is great for this economic climate. We're really excited about this." But I think what is unfortunately true is some people are sick with things that extend well beyond those four interventions. And even though they were later expanded to, you know, I think seven, you know, there was family planning in there, maybe female literacy, food supply. First of all, ultimately that wasn't enough for to keep children and families thriving. And number one, but number two, it particularly wasn't enough because it was layered on top of this delivery system, which was really not fit to deliver any sort of information, whether it was seven or 14 or two, two, two, two, eight. And we kind of, that was kind of the situation that just lingered for many years until there was another wave of enthusiasm around community health that came in the 2000s, which was because of HIV and that sort of pandemic spiraling out of control. Again, community health workers were remembered. And so there's all this investment into what was the bend called, "tash shifting." How can we do more? But still there wasn't that support. And still, the activities were not the table kind of saying, "Here's what I need to do. Excellent work." And again, that fizzled out. And then we've most recently just lived through kind of a third wave of remembering community health workers in the COVID pandemic. But I think this one has been different for a number of reasons that I'm happy to have you talk about. So that really lays it out, you know, the big gaps that were in the system. And of course, with your sort of early work in Liberia, you also, since then, there were a few other organizations that were also using community health workers in their work. Going back to the origins of she, about eight organizations came together to create the platform for what she is today. And it's a very loud voice in our sector with community health workers at its center. How were you able to organize lobby and advocate to get your message across in those early days with little or no funding? And when I mean early days, I just mean relatively recently, like, you know, 2018-19, how were you able to get everybody together to advocate, to make this voice really loud? It's a great question. Yeah, you're right. Community health health and back coalition started as a loose collaboration between six established organizations in the community health field. And we were quickly joined by others. For those who might be familiar, partners in health, living goods, loss malhealth, mooso, possible in Nepal, and injured great health. And all of the care workers and researchers and advocates in those organizations shared a similar experience, which was that they were in there, you know, much like I was in my corner of Liberia. They were in their corner of Mali or Kenya or Nepal or Chogo. And they were having a similar experience where they were having really outlier results. They were the ones who were publishing some of these papers that showed dramatic declines in the deaths of children under five, dramatic declines in the amount of sickness and population. And then when they went to take these results to the national government and say, hey, we should do this all over the country. They were all running into the same set of barriers. And I think that was the start of the coalition. And there's two things that are going on here. One is, you know, first of all, why are they taking into the national government? A layperson might ask. And the reason is because governments in most countries are the single-slider provider of health care. And then the second question is, well, why were they facing resistance? Right? Because governments, we're not going up against the tobacco industry, right? Like governments share our interests. We all want healthy kids, healthy mothers, productive populations. You know, this isn't the case where governments don't care. They absolutely do. So why are we still seeing so many people unserved? And when we map that collectively, that's when we realize, oh, goodness, we're all facing the same challenges. And the answer we came to was basically kind of three conditions are constraints that we're holding the government back. And I think this is key to understanding the whole story. So stay with me here. The first was that there were actually at that time. And you know, when we were starting out 2017, no international guidelines on how to design community health delivery, which sounds like really boring and technical. But those are actually the blueprints for health systems in hundreds of countries. And without that authoritative international consensus, telling a health minister, hey, here's what good looks like. It's risky for that minister to commit. You know, he or she is saying what you're saying? This is really establishing evidence base. And if that's the case, welcome, the World Health Organization, the Africa CDC, all these people we look to from normative guidance haven't written a single thing about it. The second constraint that ministers were facing and any business person I think could was probably thinking this in the back of their head start up capital, right? The running costs of community health worker programs, as you might expect, are pretty low. 3% of your national health budget, 7%, and it's not very expensive, you know, or rehydration salts. But the startup capital, the cost of initially recruiting all these women initially training them, making sure that the data being collected in Timbuktu gets back to Bamako. That infrastructure required to get a program off the ground. There was a financing gap. And the most global financing institutions at that time were very happy to pay for things like refresher training, but weren't directing capital in a way that was catalytic, that helped governments make the transition to these professional systems. And the third, I think this is one of the major reasons that this pen, you know, COVID pandemic has been different for health systems and health delivery than the two sort of moments of community health worker attention we discussed in Alma Aada and in the early 2000s, the sort of HIV pandemic was that again, for the long time, there was just no perfect unified professional voice for community health workers. No organized domestic command, no coalition of voices telling governments, hey, like here's what we need to provide excellent care. Here's what's going on in the system now. Here's how we can fix it. And these three conditions are kind of the load bearing beams and they're what hold the problem in place. And they're exactly what our emerging coalition chose to work on and change. That's fantastic. So sheek is very clear. You want governments to pay, train, supervise and integrate community health workers into the health system. And as you've just mentioned, one of your early wins was actually having WHO release the community health worker guidelines that recommend seven out of the eight pro CHW best practices outlined by the coalition. And that was a big win obviously because now you can take that in your organizations that you work with and that are part of the coalition can take that to their ministries of health and say, okay, here's what the WHO recommends. Let's try and implement this and find the financing for it. Madeline, you talk a lot about professionalizing community health workers. And I know, you know, we've mentioned it a little bit, but what does it actually look like in practice? Back 15 years ago when I was working in Liberia, here's what a typical process might have looked like, a non-professional process, if you will. There might have been a big international health NGO that I got a grant maybe from, let's say, USAID back when that existed to do a specific thing testing for tuberculosis. And so they would go into the village and say who wants to do this work. And typically authorities in the village, maybe a chief would recommend someone that person would maybe go through a couple days of non-assessed training. they would come back to the village with maybe some tuberculosis tests. They would likely be never coached or supervised again. Did the data that they were collecting about the health visits they made might go back to the program. It likely wouldn't go back to the central health system. It probably wouldn't come back to them in the form of coaching or improvement. Before long, they would be out of stock of those tests of treatment, have no ability to really refer someone who was sick to get additional care. Then that worker would either continue to try to serve their community with literally no support in a heroic but ultimately exploited. They would very understandably go to a town or into the fields to try to generate income and a livelihood a different way. And so you kind of were facing this double-sided crisis where either again you're really setting up the health systems on the back of the volunteer work of the poor, which I think is something that we should all question. Or those people very understandably leave post and then we're back to where we started this podcast, right? A billion people are not getting care. And obviously all of that changes once a community health worker is treated like someone and anytime you're in their job, we've all done this. You know, we've gone through a crew and processes. So we've done training that we've had to demonstrate our competence. Probably before we pour a slushy in the convenience store, never mind before we're treating children with life. You know, life in altering or in injured illnesses, we would. But what we were reporting on might get audited. We would get coaching. There would be some sort of regular resupply of the things that we need to work the day in, day out. And of course, you know, it's great to care for our neighbors out of the goodness of our heart. But if we're doing it, you know, 20, 30, 40, 50, 60, 70 hours a week, there are school fees to pay and other things that need to be tended to in our own households too. And we would be compensated for that time. No, everything you say is absolutely spot on. And it's important to kind of just talk about why it's so important to do just the basic things for community health workers. Madeleine Sheik has also been very busy in building an evidence base and trying to publish as much research as possible about the importance and relevance of community health workers and the impact that they make. You know, you alluded to the COVID pandemic and how things changed because of community health workers in the community. I wonder if you can just quickly talk us through how that research and how this body of evidence that you're building has actually influenced policy or funding decisions and perhaps the COVID pandemic is an example or one of them. But what are some of those big examples of positive change that you've been able to rally together and move things along? Sure, I think that first thing was was really capturing the size of the problem, you know, I've been kind of spitting out some facts here. What we call first sentence of the paragraph facts, 86% of CWs in Africa, unsalored out of stock, you know, one third of the time. Those those are based on community health impact coalition research. The foundation of our understanding of the size of the issue comes from research that we've done alongside community health workers to understand where we're starting from and where we need to go. So I'd say that's one. Of course, the problem is necessary, but not sufficient. You have to you have to also demonstrate what's possible. And one of the pieces that we published during COVID actually demonstrated that in countries or districts where community health workers were treated as professionals. So they were salary skills to provide supplied and they had received personal protective equipment care was not disrupted, which is to say that they basically in pandemics. It's not the disease itself that kills people. It's disruptions to a essential health services, which can ultimately kill more people than the outbreak itself. And you know, we saw that happen in Ebola, you know, I think use of primary health care services dropped by 18%. So we all remember SARS again, and it's right care decreased by 23%. That's what kills. And in co in COVID, because we had this data sharing mechanism set up between a number of sites where coalition members operated. So it's a very quickly notice test and publish the fact in a very robust, you know, multi country time series analysis. The extent to which professional students were able to reduce those essential health service disruptions. And we found that they can help maintain community provision during COVID. And in many and the conclusion is basically that wow, you know, you want to talk about probably how to prepare this. And the strong health system having the strong community health system is one of the best things we can do to protect against pandemics that might, you know, start in one corner of the world, but ultimately reach our door if they're not contained. And so, yeah, it was really incredible to see those results, you know, which spanned from January, I think 2018 to all the way to June 2021. And I think that actually led to us working with the World Health Organization and UNICEF on guidance in the pandemic for how can you help us to be involved in the vaccine rollout. And it led some of the service gaps that we had quantified during the pandemic, particularly around PPE for personal protective equipment for C H. And we used led to us starting half Africa, the COVID action fund for Africa, which was actually after UNICEF and the World Health Organization, I think the third largest procure of protective equipment period in the world in 2020. And we're able to get that protective equipment to the last mile. So more and more places could have results like the ones that we were capturing in our research. We didn't just dump PPE. We were working directly with health systems and asking them for the first time to start to count how many key members are there. Where are they and lay that foundation for recognition and professionalization post pandemic. And I think we've seen those results in 2023, you saw seven countries adopt 70 countries adopt pro CW policy in 2024. You saw the same. And even in 2025. And this was interesting because we actually just published a giant five paper series on the cost effectiveness of this care because we knew well after the COVID we're going to see a real inflationary environment. We're going to see financial contraction. We knew that that was coming. We published a bunch of data on costs and what it costs to run and the return investment. And we're able to have conversations with ministries of health in 2025 who were facing real fiscal constraints, not just because of the quote unquote inflationary environment post COVID, but because of these very severe and very sad and cuts to aid. And we saw even still in that environment. Five new countries adopt this policy in a context where everybody would have understood if you know they would take a U turn and say, hey, we committed to this, but now we can't afford it. Actually, what government said instead was, hey, I used to have $10 to spend on health. Now I have seven. I'm definitely still spending one on this. This is an easy and quick and effective way where I can build state capacity in a context where, you know, I'm feeling a little bit maybe on my own or or, you know, we've seen disruptions in recent years. So I think that those are a couple different examples of how evidence interplays with with with guidelines and ultimately with with with policy. I think, you know, the way I look at cheek is, you know, you started, you know, not that long ago, 2017, 2018, I think you were properly formalized. And it's just been like this snowball effect that you've just picked up organizations that participate in the coalition. There's active participation by them. Ministries of health have started to listen because there's more and more partners talking about it in the various countries. And you're at this point where so many countries are signing on to pro C H W policies, despite funding shortfalls and shifting priorities. That's absolutely incredible. If you look five years into the future, Madeline, what would she need to be for you to feel that even more progress has been made? I think one of the most important things that we've done over the last five years is launch what we call the pro siege W. So professional community health worker policy dashboard. And this is a dashboard that looks at national policies in over 100 countries. And whether or not those countries are again paying and accrediting community health workers as part of their national health systems. And obviously, you know, good policies. It doesn't mean that. that everything that's being implemented exactly perfectly, but it's absolutely necessary as a precursor to great care because it's the national commitment and plan basically for how these services are gonna be rolled out. And you need to at least, you know, start with a good plan and go from there and an illegal commitment. And that map, that dashboard has been catalytic, I think, for our movement. And then that, first of all, it's been a scoreboard. It's really plainly shown the progress that we're making year on year in terms of the number of countries who are making this transition towards professional CWs. And it sparks so many really compelling conversations because when you look at that map, what you very plainly see is that income is not a predictor of whether countries have a proceeds to be policy, geography, region, language. There are countries of every type that have made this commitment, which means that if you haven't, there's probably someone like you who has and you can learn from them and you can join this progress that's unfolding across the globe. And I think not only is it a scoreboard for us, in a sense, it's also a strategic plan because it also shows when existing policies are expiring and when decision windows are coming up for countries and they're the moments that we rally around as a coalition. And so these two things paired together give me a lot of, maybe, excitments the wrong world. We're in a very challenging period, but hope and fortitude that we'll see continued progress in the next five years. At this point, we started, we said, we wanna see 95 countries with this policy. We're at 50. I just gave you some of the numbers over the last couple of years. Just purely mathematically within five, seven, 10 years, we will get to 95 countries. We will have dragged this idea from something that was the laughing stock of the health system. Many people called professional C.Ws or the idea of them, the Cadillac of health. And I think we've pretty randomly convinced everybody at this point that it's not the Cadillac. It's just the car. These are just the ingredients of what's required to do the basics. And so I'm very excited to see how much we've been able to accelerate progress at that time, how close we are to 100, 'cause even at the rate that we've been going in a five six countries a year, we'll be that much closer. And I'm really excited about the 2.0 version of that dashboard that we're launching this year and we'll be using in the years to come, which doesn't just show whether a country has a policy, but also indicates the degree to which it's being implemented. So it gives a sense of, okay, is this a paper tiger or have countries actually committed domestic financing put in place these data feedback loops and generally set up the system to make this transition. And so over the next five, 10 years, we wanna take that number from country, the proceeds should be from 50 to 100. And we wanna take the number of countries implementing with excellence from wherever it is now to the same as the number of countries with that policy. And I think this is just a critical, you can play the clip in the pocket or half way there. It's a great, it's a good for our podcast. And we've done it in such a remarkable short amount of time. And I'm really excited to see what we can do in the next five years. - Madeline, thank you so much for this very insightful conversation. The work you've done with community health workers as a coalition, the idea of community health workers is not new, but what you've been able to pull together through your coalition and through partners sort of rallying around this idea and making strides and actually getting countries to adopt CHW policies is absolutely wonderful. Community health workers are definitely the backbone of primary healthcare. And we will definitely be cheering you on into the future and looking forward to those hundred countries signing on and implementing those policies. Thank you so much. Once again, for joining us on philanthropy. - Thank you so much, Nibbos. It's really been a pleasure. I really appreciate your support of this work right from the very beginning. And you're your help now. And telling this story where we are and where we're about to go together. So, excited for these next couple years. - Thanks, Madeline. As I reflect on this conversation, what stands out is how often global health revisits the same ideas, but struggles to fully implement them. Community health workers are a perfect example. The vision has been there since Alma Ata. The evidence is now available. The need is undeniable and yet the gap persists. Not because we don't know what works, but systems haven't been designed to support it at scale. What she represents is a different approach. It's not a new intervention or new technology. It's a commitment to doing something properly. Aligning financing, policy and delivery around a workforce that already exists but hasn't been fully recognized. And perhaps that's the broader lesson. Progress and global health isn't always about discovering something new. Sometimes it's about taking what we know and implementing the systems to make it work. Thanks for tuning in to this episode of Philanthropod. This series is powered by the Australian International Development Network who are seeking to foster more and better giving for developing countries. Be sure to check out the show notes for any relevant links. To stay updated with future episodes, don't forget to follow our podcast. Just hit the follow button on your preferred platform, whether it's Apple Podcasts, Spotify or wherever you tune in. And if you like what you hear, then share it with your friends, rate or review it. Until next time.