Community health workers play an important role in reducing maternal and child mortality, but as international researchers in the field, our experience shows that much more can be done to support them.
From our experience working with the non-governmental organization BRAC in Africa, we have seen that women and children are the main victims of conflicts and lack of adequate health infrastructure, especially in lower-income regions like South Sudan and northern Uganda. In South Sudan, which has the highest maternal mortality rate in the world, a woman has a one in seven chance of dying during childbirth in her lifetime.
Community health workers -- recruited from the communities they serve and going door to door with basic health messages and medicines -- are the backbone of under-resourced health systems. After some training, they often work as volunteers because they care for their communities. Most of them are poor women with heavy workloads and existing responsibilities; they are often looking for ways to assist their neighbours while providing for their own families.
How can we support these health workers when governments and NGOs often lack the financial resources to pay them a full-time salary? This is the question we addressed on November 18, at the Global Symposium on Health Systems Research in Vancouver. From our field research, a promising option has emerged: innovative social enterprise business models.
Social enterprise is a business activity -- an exchange of goods and services -- that is undertaken primarily to achieve social objectives. BRAC- a global non-governmental organization that has expanded to work in 11 countries from its original base in Bangladesh -- raises about 75 per cent of its development program funding through social enterprise activities such as microfinance and selling feeds and seeds. BRAC has trained over 75,000 community health workers worldwide.
BRAC and Cape Breton University in Canada -- which has a unique MBA program in community economic development -- are combining their expertise in social enterprise to pilot test and evaluate the most promising social business models. The research is funded by the Innovating for Maternal and Child Health in Africa initiative.
Our research to date shows four social enterprise business models that could allow community health workers to generate income while caring for mothers and children:
Model 1: Selling basket of health products
Community health workers can generate additional income through sales of medicines, personal care products and other household goods that promote family health and well-being. In this model, community members fund community health workers directly. We found that it is most suitable for lower-middle income communities with sufficient disposable income and density to support purchases and door-to-door sales.
Model 2: Outreach from mission-driven private clinics
This model uses a portion of the revenues from public-private partnership clinics and hospitals to pay for the free door-to-door outreach of community health workers to low-income neighborhoods. Wealthier fee-paying patients pay for this model. It is most suitable for communities with large disparities between rich and poor as well as regions where a significant share of the population has formal education, mobility and sufficient disposable income to enable access to private health care.
Model 3: Cross subsidization from other enterprise activities
In this model, non-healthcare related enterprises and utilities provide stable, year-round funding to support community health workers, by offering a share of user-fees, levies or supplemental income. The customers of these enterprises and utilities pay for health costs and community health workers' salaries. For example, a social enterprise in India that sells clean water to communities is also funding local primary health care. This model is most suitable for smaller rural communities that are economically homogenous and regions that prioritize investment in non-health related sectors.
Model 4: Payment in agricultural commodities
In some low-income countries such as South Sudan, areas relying on subsistence agriculture do not have a cash economy. In these contexts, community health workers cannot sell health-related products to subsidize their incomes, as community members do not have cash to pay for medicines. Our project is exploring the viability and feasibility of having the health workers receive payment in agricultural commodities with the support of an organization like BRAC that can aggregate and market the commodities on their behalf. This model is still in the early experimental stage.
Innovating for women's livelihoods and health
By generating evidence and recommending effective social enterprise models for community health workers, we aim to make a significant contribution to improving women's economic empowerment and maternal and child health. Our efforts are in line with national governments policy directions and the results will directly inform, strengthen and scale up BRAC program efforts in Sierra Leone, Liberia, South Sudan and Uganda.
The ultimate goal is to reduce maternal and child mortality. Together we aim to turn research into action for some of the most vulnerable people in the world.
Dr. Jenipher Twebaze Musoke is the Director of Research for BRAC Africa.
Dr. Kevin McKague is an Assistant Professor of Social Entrepreneurship and Strategy at Cape Breton University in Canada.
This blog is part of the series: "Resilient and Responsive Health Systems for a Changing World" by the Canadian Society for International Health and Health Systems Global, to share the central issues explored at the 4th Global Symposium on Health Systems Research in Vancouver, 14-18 November 2016.