Community mobilization is pretty fashionable these days, but apparently not fashionable enough to register among the 17 goals and 169 targets of the United Nations Sustainable Development Goals. One reason might be the cost. A 2012 study by Gordon McCord and colleagues estimated the costs of deploying 1.1 million community health workers (CHWs) in Sub-Saharan Africa (about 1 per 650 inhabitants, depending on density) at around $2.6 billion per year, or $2.72 per inhabitant. Those are some intimidating figures until you start to consider the potential benefits of community mobilization. Some of these advantages parallel those outlined in a high-level report on Community Health Workers issued in conjunction with the Financing for Development Conference. Others relate to the broader functions of mobilization outside the health sector.
Let’s remember that when we talk about mobilization and mobilizers, we are not just talking about a single workers, but about a nexus of community leadership boards, paid workers, and franchisees working together and holding one another to account. In the photo, a leader of a women’s participation group led by India’s Urban Health Resource Centre collects contributions for a truly voluntary group in a locked box (thanks Pyper Scharer for the photo, and Siddharth Agarwal for inviting Pyper). But back to the benefits!
1) Well-trained mobilizers deliver immediate and enduring impact: In the McCord study, about half of the $2.6 billion estimated cost includes a selective limited but high-impact array of services potentially stored in the mobilizer’s backpack, including treatments that could dramatically reduce 3 of the leading causes of death and disease in Sub-Saharan Africa (diarrhea, pneumonia, malaria), make a serious dent in HIV/AIDS, tuberculosis and maternal mortality through better detection, and conduct essential growth monitoring to prevent childhood malnutrition and stunting. The high-level report reports on a range of 300,000 to 3 million lives saved per year due to CHWs. More importantly, CHWs offer enduring set of impacts that would persist through every stage of the epidemiologic transition. In developed countries, mobilization is now seen as critical to reducing the burden of obesity and other lifestyle-related diseases. By contrast, many disease-specific interventions like insecticide-treated bednets are targeting single disease burdens that will decline over time.
2) Mobilization is a health security best-buy: Aside from the work mentioned above, we are just beginning to appreciate the exceptional returns to community mobilization in preventing and containing infectious disease. During the recent Ebola epidemic, it has become increasingly clear that community mobilizers were the only real bulwark against the epidemic, especially in the absence of effective treatments being delivered to local populations. Mobilization would have been even more effective at early detection if they had been building on long-established provider-client relationships rather than starting from scratch in the midst of a crisis. Looking beyond Ebola, a recent scoping report by the International Initiative for Impact Evaluation (3ie) reviews increasingly strong evidence that mobilizers increase the acceptance of high-priority immunizations. Mobilizers are especially useful in ensuring uptake of the polio vaccine, potentially averting billions of dollars in extra costs associated with delays in eradication programs.
3) Mobilizers can deliver a much wider array of goods and services: Successful and established mobilizers can sit at the heart of an ecosystem of goods and services that extends well beyond the health sector. Historically, the mobilizer role has been limited to CHWs and agricultural extension agents. More recently we have seen key innovations in which established community mobilizers can play a key role. Local partnerships for disaster recovery and resilience and conflict resolution are essential to programmatic impact and local security. Social franchising in key sectors like health, energy, insurance and livelihoods offer multiple pathways to enhanced impact and financial sustainability.
4) Mobilizers and information technology work great together: Human mobilizers are not a substitute for emerging technologies like mobile applications, but rather an incredible complement. Mobilizers can bridge the gap between citizens and technology over the short-run, help to manage the transition to IT-based solutions, and employ technologies in ways that enhance reach and reduce costs. Mobilizers can use mobile phones to enhance the reach of behavioral messages, optimize appointments, conduct community conversations, and announce public meetings. Mobilizers can better coordinate service delivery through volunteers or franchisees using mobile technologies and manage supply chains and other logistics. In data collection, mobilizers can transition from collecting community-level data and impressions to individual-level service data as technology permits. Most importantly, as basic functions of logistics, outreach, and service delivery become more routinized, mobilizers and their constituents can transition into the high-value space of visualizing, analyzing and solving local development problems with local solutions. This cannot happen overnight, but it will also not happen in 15 years unless the civic infrastructure is developed now, in parallel with improving broadband networks.
5) Mobilization carries unexpected societal benefits: Under just the right conditions, mobilization is the ultimate “killer app” for development because it generates demand AND facilitates supply while ALSO genuinely inspiring people. Put them all together, and social mobilization may be the closest thing we know of to a true driver of exceptional human development achievement (warning, paywall, contact me if you’d like a copy). Cuba’s ability to eliminate mother-to-child transmission of HIV and potentially export advanced biomedical therapies began a half-century ago with a highly-integrated community health care system that could actually be used to measure local demand and set priorities accordingly. In Bangladesh, Gonoshasthaya Kendra’s women- and mobilization-centered approach to health systems generated the market knowledge, the esprit de corps, and the workforce necessary to begin manufacturing and exporting drugs off the WHO Essential Medicines List.
6) But, the science of mobilization is in its infancy: All that being said, there is much we don’t know about preconditions, best practices and complementary investments necessary for achieving broadly transformative results through mobilization. The 3ie scoping paper highlights a number of key uncertainties, including the need for localized approaches, better models for co-management, and integrated solutions to addressing supply bottlenecks.
We also need to be sure that mobilizers are combined with the other targets of Goal 18: mobilization of the full community, registration and identification of individual people (something CHWs are very useful for), community-relevant data that is made accessible to communities, and transparent access to government, donors and the UN.
While specific solutions need to be localized, overall success will depend on our ability to set capacity and finance targets, create standards, and share best practices through a coordinated, global framework. By setting mobilization targets today, we would have 15 years to achieve basic targets and set aspirations for the future. But every mobilizer we put in place along the way will start paying dividends immediately.