We are already applying lessons from Africa in New York’s Harlem

In time, it will be natural to see exchanges and mutual learning between Community Health workers with health systems as different as Brazil, Nigeria, United States and India’s – but in the meantime we need 1 million more to deliver the Millennium Development Goals.

With one thousand days to achieve the Millennium Development Goals, low-income countries are redoubling their efforts to reach their most vulnerable citizens. In the process, communities have been recognized as being central to achieving the goals of universal primary care. This deep relationship has come through the hard work of building linkages between households and health facilities through Community Health Workers (CHW). The basic principle of supporting full-time, paid CHWs in communities is taking root in the United States in the context of health care reform, and forms basis for a global exchange.

Across 10 countries in Sub-Saharan Africa in the Millennium Villages Project, a CHW plays a decisive role in reducing child mortality and supporting maternal health. In the example of malaria, CHWs work in the following manner: when a child has a fever, a CHW is alerted in one of three ways: (1) the mobile phone-enabled emergency response system; (2) symptom recognition during a regular household visit; or (3) a community member request for the CHW’s presence based on acute symptoms. Upon arrival in the household, the CHW quickly administers a rapid diagnostic test (RDT) for malaria, part of the standard CHW supply kit, to the child with the fever. If the test is positive, the CHW uses a mobile phone to record the encounter, register the results, receive confirmation on dosage, and alert the primary health care system to support follow up. The CHW then provides the requisite treatment dose of Coartem (or other first-line medicine) on the spot, ideally around thirty minutes after arrival onsite.

At large scale in Sub-Saharan Africa, the CHW has the power to contribute to the achievement of the MDGs for a handful of targeted conditions as described for malaria above. We have launched the One Million CHW Campaign  to ensure that the evidence-based impact of a CHW is available across rural areas where poverty and disease burden is greatest. A recent report commissioned by the Gates Foundation concluded that 3.6 million child deaths could be averted if coverage was expanded to the countries with the highest burden of child mortality. Talking seriously about this degree of scale-up is possible through the intense focus on scalable supervision, rapid training through mobile learning platforms, real-time monitoring of progress and innovations in communications between the community settings and clinic. Although the condition focus is significantly different in the US, the basic systems and unique ambassadorial function of a CHW remains the same.

Taking the learning to Harlem

The Earth Institute is the founding technical advisor for City Health Works  a social enterprise based in Harlem, New York City, which is building a financially sustainable CHW system for the US. A Robert Wood Johnson funded study estimates that 30 percent of health is shaped by health behaviors and 40 percent by social and economic factors, while only 20 percent by clinical care. Yet, clinics and hospitals are not optimized to monitor and improve behavioral and social determinants of health in the neighborhoods they serve. The US health system lacks a dedicated, interdependent platform to support primary prevention and long-term behavior change in community settings. The need for a scalable system to cost-effectively reach low resource communities outside of clinic and hospital settings is becoming particularly urgent as Accountable Care Organizations and Medical Homes take form. These institutions will now be held financially accountable for patient populations’ health outcomes. Cost and quality pressures are mounting as the medical burden of obesity accounts for $168 million dollars a year (16.5% of health spending). Rates of obesity-related chronic conditions across the United States have increased rapidly over the last 30 years, with 79 million Americans pre-diabetic, 26 diabetic and one out of three American adults having high blood pressure. Further, individuals with chronic conditions have double the rate of depression relative to healthy individuals.

In a setting like Harlem, the CHW has three major functions, which include 1) early risk detection, 2) chronic condition self-management coaching for individuals and groups and 3) coordination of care with primary health care systems. Unlike facility based medical personnel, the CHW works in the community where they live and can develop a culturally matched, long-term relationship with the people they serve. Furthermore, they are well positioned to be advocates for social determinants of health such as improved housing conditions and increasing the availability of nutritious food choices. The goal of our work with City Health Works is to develop the right balance of financial support from insurers, hospital systems, and healthy local businesses to sustain a paid network of CHWs. As this work evolves, the most essential lessons we have learned through the Millennium Villages Project and One Million CHW Campaign augment the decades of experience by US-based groups.

We anticipate that in time, it will be natural to see exchanges between CHWs with health systems as different as Brazil, Nigeria, United States and India’s. The fundamental relationship between community and health systems is foundational to achieving universal primary health care, and CHWs are in the best position to help the world reach this goal.


Jeffrey D. Sachs is a world-renowned professor of economics, leader in sustainable development, senior UN advisor, bestselling author, and syndicated columnist. Professor Sachs serves as the Director of The Earth Institute, Quetelet Professor of Sustainable Development, and Professor of Health Policy and Management at Columbia University. He is Special Advisor to United Nations Secretary-General Ban Ki-moon on the Millennium Development Goals, having held the same position under former UN Secretary-General Kofi Annan. He is Director of the UN Sustainable Development Solutions Network.

Prabhjot Singh is the Director of Systems Design at the Earth Institute and Assistant Professor of International and Public Affairs at Columbia University. He is the co-chair of the One Million Community Health Worker Campaign, which is an initiative of the African Union and UN Sustainable Development Solutions Network. Domestically, he focuses on developing community-based health care delivery systems, where he is a practicing doctor in East Harlem.