PERSPECTIVE o further develop the prom- approach to CHw certification as the strong network of commu- ise of CHWs, policymakers and across states. Certification helps nity health centers, could facili- health system leaders could take to professionalize the community tate CHW integration into the five initial steps. First, the evi- health workforce, driving quality health system. The timing for in- dence base for CHW programs standards for training and per- vestment in CHWs is also pro should be shored up, through formance. The experience that pitious, given the post-ACA land both additional, pragmatic clini- Massachusetts had with policy de- scape and the potential for cal studies and consensus assess- velopment toward its 2010 CHW- meaningful job creation. Although ment of completed research. The certification law may hold lessons the operational challenges of Community Preventive Services for a national effort.5 CHW integration are manifold Task Force could perform the evi- Fourth, the Sl billion second the global experience offers hope dence assessment, building on the round of Health Care Innovation for U.S. communities. 2007 Community Health Worker Awards from the Innovation Cen- National Workforce Study, Addi- ter of the Centers for Medicare anE/M.org vailable with the full text of this article examining disease-specific, single- could include a focus on CHW- From the School of International and Public ses of CHW integration into prl- vations had beneficial effects on sity, and eth Institute, Columbia Univer- site pilots to larger-scale analy- based interventions. If such inno- Affairs and E Mount Sinai Hospital both in New York tary care, drawing from global population health and cost, CMS (P.S. ) and the Department of Veterans Af research paradigms. 4 could consider payment schemes fairs, Washington, DC(. A.C.) Second, policymakers could ad- to more broadly support CHW 1. Singh P. Sachs JD. 1 Million dress continued stagnation in job programs- for example, as part health workers in sub-Saharan Africa by 2015 growth by promoting CHWs as a of Medicaid case management. Lancet 2013: 382: 363-5 linchpin for health system re- Fifth, dedicated community Global experience of community healt structuring. Indeed, Section 5313 health workforce organizations workers for delivery of health related Millen of the aca was dedicated to could collaborate with insurance nium Development Goals: a systematic re- grants for underserved commu- companies and hospitals to mea- view, country case studies, and recommen- nities to employ CHWs -but sure return on investment and ystems. Geneva: World Health O was left unfunded. Revisiting this refine clinical protocols that sup- tion, 2010 possibility could be productive, port CHWs, as well as informa 3.KangoviS,LongJa,EmanuelE.commU- since the federal government is tion technology linking patients, Arch Intern 4. Victora CG, Black RE, Boerma JT, Bryce ng and training of ACA"naviga- The most crucial lesson from Measuring m pact in th e Mitenn ium D rs”to lobal CH that th to large-scale effectiveness evalua- new health insurance exchanges. community rootedness of CHWs tions. Lancet 201137785 isting CHWs might be a natu- should be retained through care- Martin CM, Fox D), Hirsch( ral fit for this role- and newly ful, representative selection and change to promote communit trained ACA navigators might by ensuring that CHWs spend ers: lessons from Massachu consider becoming CHWs. most of their time in the com- health reform era. Am J Public Health 2011 Third, the Department of La- munity. In the United States, cer- Do: 10.1056/NEJMp1305636 bor could support a harmonized tain structural advantages, such Copyright o 2013 Massachusetts Medical Society Big Pharma and Social Responsibility-The access to medicine index Hans V. Hogerzeil, M.D., Ph.D. espite much progress in the medicines. 1 Many of the most widening gaps between rapidly of t sast decade, about one third neglected people live in sub-Saha- growing middle classes and poor e world's population still has ran Africa, but another billion live people who live on less than a 10 regular access to essential in emerging economies that have dollar a day. 2 Such people face N ENGL J MED 369; 10 NEJM.ORG SEPTEMBER 5, 2013PERSPECTIVE 896 n engl j med 369;10 nejm.org september 5, 2013 To further develop the prom￾ise of CHWs, policymakers and health system leaders could take five initial steps. First, the evi￾dence base for CHW programs should be shored up, through both additional, pragmatic clini￾cal studies and consensus assess￾ment of completed research. The Community Preventive Services Task Force could perform the evi￾dence assessment, building on the 2007 Community Health Worker National Workforce Study. Addi￾tional studies should move beyond examining disease-specific, single￾site pilots to larger-scale analy￾ses of CHW integration into pri￾mary care, drawing from global research paradigms.4 Second, policymakers could ad￾dress continued stagnation in job growth by promoting CHWs as a linchpin for health system re￾structuring. Indeed, Section 5313 of the ACA was dedicated to grants for underserved commu￾nities to employ CHWs — but was left unfunded. Revisiting this possibility could be productive, since the federal government is investing $67 million in the hir￾ing and training of ACA “naviga￾tors” to help consumers with the new health insurance exchanges. Existing CHWs might be a natu￾ral fit for this role — and newly trained ACA navigators might consider becoming CHWs. Third, the Department of La￾bor could support a harmonized approach to CHW certification across states. Certification helps to professionalize the community health workforce, driving quality standards for training and per￾formance. The experience that Massachusetts had with policy de￾velopment toward its 2010 CHW￾certification law may hold lessons for a national effort.5 Fourth, the $1 billion second round of Health Care Innovation Awards from the Innovation Cen￾ter of the Centers for Medicare and Medicaid Services (CMS) could include a focus on CHW￾based interventions. If such inno￾vations had beneficial effects on population health and cost, CMS could consider payment schemes to more broadly support CHW programs — for example, as part of Medicaid case management. Fifth, dedicated community health workforce organizations could collaborate with insurance companies and hospitals to mea￾sure return on investment and to refine clinical protocols that sup￾port CHWs, as well as informa￾tion technology linking patients, CHWs, and providers. The most crucial lesson from global CHW programs is that the community rootedness of CHWs should be retained through care￾ful, representative selection and by ensuring that CHWs spend most of their time in the com￾munity. In the United States, cer￾tain structural advantages, such as the strong network of commu￾nity health centers, could facili￾tate CHW integration into the health system. The timing for in￾vestment in CHWs is also pro￾pitious, given the post-ACA land￾scape and the potential for meaningful job creation. Although the operational challenges of CHW integration are manifold, the global experience offers hope for U.S. communities. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From the School of International and Public Affairs and Earth Institute, Columbia Univer￾sity; and the Department of Medicine, Mount Sinai Hospital — both in New York (P.S.); and the Department of Veterans Af￾fairs, Washington, DC (D.A.C.). 1. Singh P, Sachs JD. 1 Million community health workers in sub-Saharan Africa by 2015. Lancet 2013;382:363-5. 2. Bhutta Z, Lassi Z, Pariyo G, Huicho L. Global experience of community health workers for delivery of health related Millen￾nium Development Goals: a systematic re￾view, country case studies, and recommen￾dations for integration into national health systems. Geneva: World Health Organiza￾tion, 2010. 3. Kangovi S, Long JA, Emanuel E. Commu￾nity health workers combat readmission. Arch Intern Med 2012;172:1756-7. 4. Victora CG, Black RE, Boerma JT, Bryce J. Measuring impact in the Millennium Devel￾opment Goal era and beyond: a new ap￾proach to large-scale effectiveness evalua￾tions. Lancet 2011;377:85-95. 5. Mason T, Wilkinson GW, Nannini A, Martin CM, Fox DJ, Hirsch G. Winning policy change to promote community health work￾ers: lessons from Massachusetts in the health reform era. Am J Public Health 2011; 101:2211-6. DOI: 10.1056/NEJMp1305636 Copyright © 2013 Massachusetts Medical Society. community health workers Big Pharma and Social Responsibility — The Access to Medicine Index Hans V. Hogerzeil, M.D., Ph.D. Despite much progress in the past decade, about one third of the world’s population still has no regular access to essential medicines.1 Many of the most neglected people live in sub-Saha￾ran Africa, but another billion live in emerging economies that have widening gaps between rapidly growing middle classes and poor people who live on less than a dollar a day.2 Such people face