In recognition of World Health Worker Awareness Week, GAPP is pleased to share an interview we conducted with Cate Oswald and Mia Scott from Partners In Health.

Daniel Maweu, nurse-midwife and reproductive health care educator with PIH Liberia, instructing a nurse on how to check for clinical jaundice in a premature baby at J.J. Dossen Hospital. (Photo by Jason Amoo / Partners In Health)

How do you define health worker?

According to the World Health Organization (WHO) “Health workers are people whose job it is to protect and improve the health of their communities.” This includes clinicians, nurses, community health workers, volunteers, among many others. Healthcare workers fill many rolls, with different levels of training and background, yet are all essential. 

What role have health workers played in the HIV/AIDS response historically? 

Health workers have been absolutely essential leaders in so many ways. From the earliest days, when everyone else was running away, they stood in solidarity with — and fought for — their patients who were dying because they couldn’t get access to treatment. They were leaders in the fight for treatment access, a fight that led to the creation of PEPFAR and Global Fund. If not for their heroic actions, we would not be where we are today.

In addition, health workers — specifically community health workers — have been key to reaching and treating patients in rural settings. We saw this particularly profoundly during the COVID-19 pandemic.  

Why are health workers so critical to reaching the goal of ending AIDS as a public health threat by 2030?

The 2022 UNAIDS report highlighted the inequities posing the biggest challenges to ending the AIDS epidemic. The new law criminalizing anyone known to be LGBTQ in Uganda is a recent, particularly egregious example. We can have all the tools at our disposal to prevent and treat HIV/AIDS, but if we’re not simultaneously also calling out and advocating for structural societal changes, we won’t be successful. Health workers continue to be on the front line, saying that these inequities cannot stand; that we have to address them before science can do its job.

People have to be able to access treatment and care, free of stigma or criminalization, in order to be virally suppressed. Health workers continue to fight for access to these tools everywhere and are utilizing their voices as leaders and advocates.

What do you think are the most important investments we should be making in health workers? Why are those investments so critical?

Partners In Health’s (PIH) philosophy is that people are the backbone of the health system. They must be well supported, compensated, trained, mentored, and provided the equipment and supplies to do their work.

The biggest push needs to be fair pay. So many more high quality training programs now exist for all different cadres of health workers. There’s recognition that we have a huge global health worker shortage, especially in sub-Saharan Africa. But there aren’t viable, long-term, sustainable career paths for people who are going into these essential professions.

At PIH, we have seen how long it has taken for health workers to be added to the national government’s payroll; it can take years. Before that, they might have volunteered for years despite the fact that many are trained professionals. We need to pave the way for people when they do choose health work as a profession, so that they are able to serve in their own communities rather than being forced to search for better opportunities elsewhere to be able to support their families.

Studies show that health outcomes improve considerably when community health workers are salaried, skilled, supervised, and supplied. Yet, half of all community health care workers in low and middle income countries are still not salaried.

“People are the backbone of the health system. They must be well supported, compensated, trained, mentored, and provided the equipment and supplies to do their work.”

We need to ensure that health workers can provide the highest quality of care, that they have ample career advancement opportunities, and that they are adequately paid for their level of expertise. But we also need to support their overall wellness; making sure that they have a safe environment and the proper protective equipment. In addition, they must have the ability to take care of their mental health. As we saw during the COVID pandemic, a lot of health workers were overworked and burnt out. They need and deserve ongoing support.

How can increased investment in health workers through HIV programs benefit overall global health and pandemic preparedness? And vice versa — how can investment in pandemic preparedness for health workers benefit HIV?

The single biggest funding envelope that’s been available to stop an infectious disease is HIV/AIDS funding through PEPFAR and the Global Fund. So our biggest driver of health systems strengthening funding globally has been through the lens of HIV.

“We were utilizing HIV funding as what we call a ‘battle horse’ for investing in the whole system.”

In Haiti, where PIH has had patients on antiretroviral treatment since the mid 90s, we have used HIV funding as what we call a ‘battle horse’ for investing in the whole system. Governments and partner organizations have been able to rely on that consistent source of funding, and that has enabled us to build systems around health workers in a way we wouldn’t have been able to otherwise.

In the last 20 years, the HIV movement has been able to help ensure that a multidisciplinary care team of health care professionals is available at facilities and that they have access to the commodities needed to treat patients.

How has PIH helped to support health workers?

Our theory of change is centered on ensuring that we’re not just offering  treatment for one disease, but looking at the whole community and family. An individual might need support for managing their HIV, but they might also need mental health support; they might have an NCD; they might also be pregnant. Ensuring that all of those services are available in the same location — and that staff are constantly trained, provided mentorship, coaching, and opportunities for on the job learning — has been essential.

We invest deeply in health worker training and have partnerships with a number of nursing and midwifery schools in the countries where we work. We also run the University of Global Health Equity, with students and faculty from over 25 countries around the world. Our late co-founder, Dr. Farmer, was so proud of what had been accomplished — a medical school and masters programs in global health delivery, all on a beautiful, rural Rwandan hillside where you wouldn’t expect to see world class training. Through these programs, we are  equipping the next generation of leaders with health equity as their lens.

We work in rural communities in Liberia and have partnered with the local university which offers a bachelors in nursing program supported by leaders of nursing excellence from around the world. That training program has led to more nursing students passing their national boards  every year. Because we’ve been able to offer a state-of-the-art precepting space at the public primary health center and the district hospital, we’ve also been able to create really strong career pathways and training. And we’ve worked with the Central Ministry of Health to gradually add more health workers to the government payroll.

Of the countries where we work, the Government of Rwanda has been the biggest success story in terms of adding health workers to the national payroll. This  has allowed our funding to gradually be invested in establishing more specialty services — such as oncology, mental health, surgery, and other chronic conditions — over the past 18 years. In addition, we’re renovating and adding on to the Butaro District Hospital, which serves as the teaching hospital for the University of Global Health Equity. In recognition of how important the facility will be for training, the government of Rwanda is adding dozens of new staff at all levels of the hospital to greatly expand services for the population and training for the students.

Finally, it’s been just a little more than a year since the unexpected death of PIH’s founder, Paul Farmer. During World Health Worker Week, what lessons or messages do you think he would want us to bear in mind?

Dr. Farmer was a model health worker up until his last moments – he had been rounding at the Butaro District hospital the night he passed away. In the days before, he sent messages to the team about how he was the happiest he had ever been. He was so thrilled to be teaching the next generation of Rwandan health care leaders.

He’s known in so many different circles for his scholarly work, his teaching, and his activism. But we believe he is most deeply missed by the health worker community for the example that he left us — that every person is a person and worthy of dignity and care