Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
SlideShare a Scribd company logo

2013 community health workers nej mp1305636

•
•
Roger Zapata
Roger Zapata

This document discusses the potential for community health workers (CHWs) to improve health outcomes and reduce costs in the United States. It makes three key points: 1) CHWs have been shown to be effective in improving health in multiple areas like maternal/child health and chronic disease management in other countries. Expanding CHWs in the US could improve health and create new jobs. 2) There are three models for organizing CHWs in the US - as extensions of hospitals, through community non-profits, or through dedicated management organizations. More research is needed but CHW programs have shown potential to reduce costs for Medicaid/Medicare patients. 3) Policy changes like developing the evidence base on CH

1 of 3
PERSPECTIVE n engl j med 369;10  nejm.org  september 5, 2013894 Risks (and Benefits) in CER Trials Community Health Workers — A Local Solution to a Global Problem Prabhjot Singh, M.D., Ph.D., and Dave A. Chokshi, M.D. In the face of persistently lack- luster job creation, the U.S. health sector is paradoxically seen as both a contributor to tor- pid macroeconomic growth and a source of local employment op- portunities. Labor costs account for more than half of U.S. health care spending, but as payment structures shift from volume- based reimbursement to the re- warding of value in improving health, the locus of health care delivery will expand from facili- ties to communities. Ideally, pa- tient care will take place not just in episodic encounters but also through continuous, community- based partnerships that include new entities and workers. Else- where in the world, such care has involved the use of commu- nity health workers (CHWs) — lay community members with focused health care training. We believe that scaling up the com- munity health workforce in the United States could improve health outcomes, reduce health care costs, and create jobs. In many countries, CHWs are becoming paid, full-time members of community health systems. In sub-Saharan Africa, the One Mil- lion Community Health Workers Campaign is training, deploying, and integrating CHWs into the health system.1 In India, 600,000 CHWs are paid through a fee-for- service system to perform a spe- cific set of primary care func- tions, such as immunization. In Brazil, community health agents are part of family health teams that now care for 110 million people. And growing evidence re- veals the effectiveness of inter- ventions by CHWs in multiple health arenas, such as maternal and child health and chronic- disease management.2 CHWs have been part of the U.S. health care landscape for decades, serving as community advocates, social activists, health promoters, and patient navigators, among other roles. In California and other border states, promotoras and promotores de salud address re- productive health, diabetes, and cardiovascular health. In Arkan- sas, CHWs have been shown to reduce Medicaid spending by reaching out to people with long- term care needs; in Alaska, they’re part of an effective primary care extension system. Multiple states have created formal accreditation programs for CHWs, and in 2009, the Department of Labor recog- nized CHWs’ jobs as a distinct category of employment. Yet de- spite these gains — and in part because of the organic way in which CHWs have emerged — there is little standardization across health systems in terms of gaining access to CHWs, integrat- ing them into health care pro- cesses, and compensating them. There are three models for or- ment of the risks and benefits of the study as a whole. This ap- proach often requires analysts to make judgments when compar- ing one sort of risk to another. The communication of informa- tion on these various forms of risks and benefits to potential study participants requires a bal- ancing act. Detailed explanation of each separate risk may be over- whelming and confusing. Sum- maries of the risks may oversim- plify or underemphasize particular risks.5 Evaluation of the accept- ability of studies and of the ad- equacy of consent forms must reflect consideration and com- munication about these potential risks and benefits both separate- ly and as a whole. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From the Department of Medical Ethics (C.F.) and the Committees for the Protec- tion of Human Subjects (M.S.), the Chil- dren’s Hospital of Philadelphia, Philadel- phia; and the Children’s Mercy Bioethics Center, Children’s Mercy Hospital, Kansas City, MO (J.D.L.). This article was published on August 21, 2013, at NEJM.org. 1. Kass N, Faden R, Tunis S. Addressing low- risk comparative effectiveness research in proposed changes to US federal regulations governing research. JAMA 2012;307:1589-90. 2. Department of Health and Human Ser- vices. Notice of a Department of Health and Human Services public meeting. Fed Regist 2013;78(123):38343-5 (http://www.gpo.gov/ fdsys/pkg/FR-2013-06-26/pdf/2013-15160 .pdf). 3. Feudtner C. Ethics in the midst of thera- peutic evolution. Arch Pediatr Adolesc Med 2008;162:854-7. 4. Vist GE, Bryant D, Somerville L, Birming- hem T, Oxman AD. Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not partici- pate. Cochrane Database Syst Rev 2008;3: MR000009. 5. Schreiner MS. Can we keep it simple? JAMA Pediatr 2013;167:603-5. DOI: 10.1056/NEJMp1309322 Copyright © 2013 Massachusetts Medical Society. The New England Journal of Medicine Downloaded from nejm.org on July 3, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
n engl j med 369;10  nejm.org  september 5, 2013 PERSPECTIVE 895 community health workers ganizing U.S. CHWs: employment of CHWs as extensions of hospi- tal systems, management of CHWs through community-based non- profit organizations, and man- agement of CHWs by entities that operate at the interface between health systems and the commu- nity (see table). The first two ap- proaches reflect CHWs’ historical roles — as a means for broaden- ing the health care system’s reach and as community activists and health educators. The third ap- proach aims to synthesize these roles while borrowing principles from global experiences with scalability and opportunities for financial sustainability. For exam- ple, the Prevention and Access to Care and Treatment (PACT) proj- ect drew from the nonprofit or- ganization Partners in Health in integrating CHWs into a care- management program for patients in Boston who have HIV–AIDS. The PACT model was subsequent- ly expanded to cover patients with diabetes or other chronic condi- tions. More generally, organiza- tions dedicated to CHWs could support health systems by re- cruiting, training, and supervising CHWs. Longitudinally developed expertise in CHW management allows such organizations to pro- vide interventions that are costly when delivered by more exten- sively trained health care workers and that are difficult to coordi- nate in community settings. The Affordable Care Act (ACA) includes levers to shift our health care system’s focus toward com- prehensive, high-quality care for populations. Through structures such as accountable care organi- zations and incentives such as readmissions penalties, hospitals are increasingly responsible for the care of patients both in and outside the hospital. For example, hospital systems have invested in care coordinators, aiming to re- duce readmission rates by strati- fying patients according to risk level and tailoring their discharge interventions. As these systems look further beyond their own walls, they may see opportunities for lower-cost, CHW-based pro- grams to demonstrate superior value.3 Beyond reducing readmissions, CHW programs may help to ad- dress the root causes of prevent- able chronic disease. Social ex- clusion, poverty, marginalization, and the built environment con- tribute to the high burden of chronic disease, particularly in low-income communities. But so- cial services addressing these so- cial determinants of health are too often fragmented. CHWs who can integrate knowledge of the local social service milieu with knowl- edge of patients’ individual cir- cumstances can create a vital link for vulnerable populations. In con- cert with social workers, CHWs can mobilize social support, cre- ate avenues for family members to engage in the care process, and strengthen long-term commu- nity relationships that help pa- tients sustain healthful behaviors. There’s also an economic ra- tionale for considering CHW pro- grams. Employment of CHWs creates meaningful job growth for people with lower educational attainment (passage of the Gen- eral Educational Development [GED] or higher tests) — often in low-income communities that have been hardest hit by the eco- nomic downturn — and particu- larly for women. From the per- spective of a health system, CHWs may be a bargain, with mean an- nual pay of about $37,000 in 2012. Further research is needed to assess the cost-effectiveness of interventions by CHWs, but pilot programs have shown both re- ductions in spending for Medi- care and Medicaid populations and clinical improvements in areas such as medication adher- ence and glycemic control. Models for Organizing Community Health Workers (CHWs) in the United States. Model Example Extensions of hospital or clinic systems, with health care system as base of operations; CHWs are integrated with disease- management or care teams and are focused on clinical ­services. New York–Presbyterian Hospital Washington Heights/Inwood Network (WIN) for Asthma Program, New York: CHWs serve as the single point of contact for families; in clinics, the hospital, and the community, they provide asthma education, support, and referrals for social services. Community-based nonprofit organizations, rooted in community mobilization, activism, or faith; organizations often provide a host of other services for the community, both health-related and non–health-related. Latino Health Access, Orange County, CA: CHWs educate their neighbors about a broad range of social and health issues, including nutrition, ­diabetes, mental health, domestic violence, parenting, and access to health care. Management entities, organizations dedicated to CHWs that are integrated with clinical and community organizations; oriented around financial sustainability, population and environmental health goals, and local workforce development. City Health Works, New York: A close-to-client network of CHWs who perform protocol-driven early risk detection, self-management support in community settings, and primary care coordination for chronic conditions. The New England Journal of Medicine Downloaded from nejm.org on July 3, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
PERSPECTIVE n engl j med 369;10  nejm.org  september 5, 2013896 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 The New England Journal of Medicine Downloaded from nejm.org on July 3, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.

More Related Content

2013 community health workers nej mp1305636

  • 1. PERSPECTIVE n engl j med 369;10  nejm.org  september 5, 2013894 Risks (and Benefits) in CER Trials Community Health Workers — A Local Solution to a Global Problem Prabhjot Singh, M.D., Ph.D., and Dave A. Chokshi, M.D. In the face of persistently lack- luster job creation, the U.S. health sector is paradoxically seen as both a contributor to tor- pid macroeconomic growth and a source of local employment op- portunities. Labor costs account for more than half of U.S. health care spending, but as payment structures shift from volume- based reimbursement to the re- warding of value in improving health, the locus of health care delivery will expand from facili- ties to communities. Ideally, pa- tient care will take place not just in episodic encounters but also through continuous, community- based partnerships that include new entities and workers. Else- where in the world, such care has involved the use of commu- nity health workers (CHWs) — lay community members with focused health care training. We believe that scaling up the com- munity health workforce in the United States could improve health outcomes, reduce health care costs, and create jobs. In many countries, CHWs are becoming paid, full-time members of community health systems. In sub-Saharan Africa, the One Mil- lion Community Health Workers Campaign is training, deploying, and integrating CHWs into the health system.1 In India, 600,000 CHWs are paid through a fee-for- service system to perform a spe- cific set of primary care func- tions, such as immunization. In Brazil, community health agents are part of family health teams that now care for 110 million people. And growing evidence re- veals the effectiveness of inter- ventions by CHWs in multiple health arenas, such as maternal and child health and chronic- disease management.2 CHWs have been part of the U.S. health care landscape for decades, serving as community advocates, social activists, health promoters, and patient navigators, among other roles. In California and other border states, promotoras and promotores de salud address re- productive health, diabetes, and cardiovascular health. In Arkan- sas, CHWs have been shown to reduce Medicaid spending by reaching out to people with long- term care needs; in Alaska, they’re part of an effective primary care extension system. Multiple states have created formal accreditation programs for CHWs, and in 2009, the Department of Labor recog- nized CHWs’ jobs as a distinct category of employment. Yet de- spite these gains — and in part because of the organic way in which CHWs have emerged — there is little standardization across health systems in terms of gaining access to CHWs, integrat- ing them into health care pro- cesses, and compensating them. There are three models for or- ment of the risks and benefits of the study as a whole. This ap- proach often requires analysts to make judgments when compar- ing one sort of risk to another. The communication of informa- tion on these various forms of risks and benefits to potential study participants requires a bal- ancing act. Detailed explanation of each separate risk may be over- whelming and confusing. Sum- maries of the risks may oversim- plify or underemphasize particular risks.5 Evaluation of the accept- ability of studies and of the ad- equacy of consent forms must reflect consideration and com- munication about these potential risks and benefits both separate- ly and as a whole. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From the Department of Medical Ethics (C.F.) and the Committees for the Protec- tion of Human Subjects (M.S.), the Chil- dren’s Hospital of Philadelphia, Philadel- phia; and the Children’s Mercy Bioethics Center, Children’s Mercy Hospital, Kansas City, MO (J.D.L.). This article was published on August 21, 2013, at NEJM.org. 1. Kass N, Faden R, Tunis S. Addressing low- risk comparative effectiveness research in proposed changes to US federal regulations governing research. JAMA 2012;307:1589-90. 2. Department of Health and Human Ser- vices. Notice of a Department of Health and Human Services public meeting. Fed Regist 2013;78(123):38343-5 (http://www.gpo.gov/ fdsys/pkg/FR-2013-06-26/pdf/2013-15160 .pdf). 3. Feudtner C. Ethics in the midst of thera- peutic evolution. Arch Pediatr Adolesc Med 2008;162:854-7. 4. Vist GE, Bryant D, Somerville L, Birming- hem T, Oxman AD. Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not partici- pate. Cochrane Database Syst Rev 2008;3: MR000009. 5. Schreiner MS. Can we keep it simple? JAMA Pediatr 2013;167:603-5. DOI: 10.1056/NEJMp1309322 Copyright © 2013 Massachusetts Medical Society. The New England Journal of Medicine Downloaded from nejm.org on July 3, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
  • 2. n engl j med 369;10  nejm.org  september 5, 2013 PERSPECTIVE 895 community health workers ganizing U.S. CHWs: employment of CHWs as extensions of hospi- tal systems, management of CHWs through community-based non- profit organizations, and man- agement of CHWs by entities that operate at the interface between health systems and the commu- nity (see table). The first two ap- proaches reflect CHWs’ historical roles — as a means for broaden- ing the health care system’s reach and as community activists and health educators. The third ap- proach aims to synthesize these roles while borrowing principles from global experiences with scalability and opportunities for financial sustainability. For exam- ple, the Prevention and Access to Care and Treatment (PACT) proj- ect drew from the nonprofit or- ganization Partners in Health in integrating CHWs into a care- management program for patients in Boston who have HIV–AIDS. The PACT model was subsequent- ly expanded to cover patients with diabetes or other chronic condi- tions. More generally, organiza- tions dedicated to CHWs could support health systems by re- cruiting, training, and supervising CHWs. Longitudinally developed expertise in CHW management allows such organizations to pro- vide interventions that are costly when delivered by more exten- sively trained health care workers and that are difficult to coordi- nate in community settings. The Affordable Care Act (ACA) includes levers to shift our health care system’s focus toward com- prehensive, high-quality care for populations. Through structures such as accountable care organi- zations and incentives such as readmissions penalties, hospitals are increasingly responsible for the care of patients both in and outside the hospital. For example, hospital systems have invested in care coordinators, aiming to re- duce readmission rates by strati- fying patients according to risk level and tailoring their discharge interventions. As these systems look further beyond their own walls, they may see opportunities for lower-cost, CHW-based pro- grams to demonstrate superior value.3 Beyond reducing readmissions, CHW programs may help to ad- dress the root causes of prevent- able chronic disease. Social ex- clusion, poverty, marginalization, and the built environment con- tribute to the high burden of chronic disease, particularly in low-income communities. But so- cial services addressing these so- cial determinants of health are too often fragmented. CHWs who can integrate knowledge of the local social service milieu with knowl- edge of patients’ individual cir- cumstances can create a vital link for vulnerable populations. In con- cert with social workers, CHWs can mobilize social support, cre- ate avenues for family members to engage in the care process, and strengthen long-term commu- nity relationships that help pa- tients sustain healthful behaviors. There’s also an economic ra- tionale for considering CHW pro- grams. Employment of CHWs creates meaningful job growth for people with lower educational attainment (passage of the Gen- eral Educational Development [GED] or higher tests) — often in low-income communities that have been hardest hit by the eco- nomic downturn — and particu- larly for women. From the per- spective of a health system, CHWs may be a bargain, with mean an- nual pay of about $37,000 in 2012. Further research is needed to assess the cost-effectiveness of interventions by CHWs, but pilot programs have shown both re- ductions in spending for Medi- care and Medicaid populations and clinical improvements in areas such as medication adher- ence and glycemic control. Models for Organizing Community Health Workers (CHWs) in the United States. Model Example Extensions of hospital or clinic systems, with health care system as base of operations; CHWs are integrated with disease- management or care teams and are focused on clinical ­services. New York–Presbyterian Hospital Washington Heights/Inwood Network (WIN) for Asthma Program, New York: CHWs serve as the single point of contact for families; in clinics, the hospital, and the community, they provide asthma education, support, and referrals for social services. Community-based nonprofit organizations, rooted in community mobilization, activism, or faith; organizations often provide a host of other services for the community, both health-related and non–health-related. Latino Health Access, Orange County, CA: CHWs educate their neighbors about a broad range of social and health issues, including nutrition, ­diabetes, mental health, domestic violence, parenting, and access to health care. Management entities, organizations dedicated to CHWs that are integrated with clinical and community organizations; oriented around financial sustainability, population and environmental health goals, and local workforce development. City Health Works, New York: A close-to-client network of CHWs who perform protocol-driven early risk detection, self-management support in community settings, and primary care coordination for chronic conditions. The New England Journal of Medicine Downloaded from nejm.org on July 3, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
  • 3. PERSPECTIVE n engl j med 369;10  nejm.org  september 5, 2013896 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 The New England Journal of Medicine Downloaded from nejm.org on July 3, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.