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Community Health Workers: A Model for the Global Health Community

Paul Farmer, MD, PhD, an anthropologist and physician, discusses how community health workers helped Rwanda achieve the steepest declines in mortality ever documented. 

Not just medicine, but its delivery

“If you build it, they will come.” This iconic line from the movie Field of Dreams worked for Kevin Costner – he built a baseball field and athletes appeared – but it doesn’t apply to healthcare systems. For example, what value can a hospital provide if a patient lives hundreds of miles away and doesn’t own a car?

Paul Farmer, MD, PhD, Chief of the Division of Global Health Equity at Brigham and Women’s Hospital (BWH), says that a robust healthcare system requires three components: hospitals for critical illnesses, accessible outpatient clinics, and community-based care. Community health workers (CHWs) bridge the gap by connecting patients to resources. They are the boots on the ground in care delivery.

CHWs are essential in rural settings where they visit patients’ homes and may accompany them to doctor’s appointments. They help connect patients to transportation, financial support and support groups.   

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Butaro Hospital in Rwanda. In 2011, doctor’s quarters were built here for US doctors to train and teach Rwandan doctors as well as provide care.

An initiative to transform Rwanda’s healthcare system

In 2013, Rwanda, the most population-dense country in sub-Saharan, had one doctor for every 20,000 people (in Boston, MA there’s a doctor for every 100 people). As such, Rwanda’s healthcare system struggled to provide adequate care to its population of over ten million people.

That was until a global initiative, developed by the Rwandan government and Ministry of Health in partnership with 22 United States medical schools and academic medical centers including BWH, built the country’s healthcare infrastructure and recruited and trained medical professionals, including 60,000 community health workers. From 2003 to 2013, child mortality fell dramatically in Rwanda, and life expectancy nearly doubled.  

“This success wouldn’t have been possible without the CHW structure as a part of the care cascade. The impact of more community health workers has been significant. The steepest declines in mortality ever documented, anywhere at anytime have been in Rwanda over the last decade,” says Dr. Farmer.   

Thinking about the systems of healthcare delivery

Dr. Farmer, who was the subject of the 2003 bestseller Mountains Beyond Mountains, and the current film Bending The Arc, has spent his career bringing healthcare to the poorest people in the poorest nations. In 2001, he established The Division of Global Health Equity with Jim Kim and Howard Hiatt, and has worked in Rwanda since 2005.      

Working within the Rwanda’s Ministry of Health, Dr. Farmer helped build provider capacity including establishing the population of community health workers who are now spread out in small towns and rural villages, helping people assess the medical care they need.  

Rwanda currently outperforms many countries in health outcomes for people with chronic illness, such as AIDS and tuberculosis, in large part because of the community health workers who accompany patients to their treatments. 

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In 2001, Dr. Farmer established The Division of Global Health Equity at BWH with Jim Kim and Howard Hiatt, and has worked in Rwanda since 2005.

Components of a strong healthcare system

Dr. Farmer has traveled to dozens of countries working to strengthen health systems often by developing local training and pipelines of providers, as well as building hospitals and conducting public health research. He sees these components as deeply interwoven.

“If you look in all the places we work, from the United States, to Russia, to Rwanda, to Haiti, you'll see that the weakness or absence of one part of the three-part formula – hospital, clinic, community health worker – the health outcomes are weak,” says Dr. Farmer.

Dr. Farmer says that Rwanda’s remarkable success was the product of using our imagination to rethink how the systems deliver care to the patients who need it. These models are being are being replicated in the US, including at BWH where understanding patients, access, and ideal settings of care can help lead to better outcomes and healthier lives.  

Want to Learn more?

The Global Health Equity Grand Rounds provide an interactive forum for both speakers and attendees to stay abreast of their colleagues’ work, share best practices, and engage in constructive conversation with peers in the global health community. Watch the most recent Grand Rounds here. At the Global Health Hub, read first-hand accounts of doctors addressing health disparities around the world. 

- By Dustin G. 

Paul Farmer, MD, PhD, Chief of the Division of Global Health Equity at Brigham and Women’s Hospital (BWH), discusses how BWH physicians are working with partners around the world to strengthen health systems and reduce health disparities.