Community Health Workers (CHWs) are called by a variety of names
including Health Auxiliaries, Barefoot Doctors, Health Agents,
Health Promoters, Family Welfare Educators, Health Volunteers,
Village Health Workers and Community Health Aides. These individuals
can be enormously effective. They can perform preventative medical
services, monitor the community's health, identify patients at
particular risk, act as liaisons between the community and the
health system, interpret the social climate, as well as provide
basic curative services. They are also often the only practical
means of providing longevity and breadth to a health program.
Community Health Workers are currently providing at least the
following types of services in different parts of the world:
- First aid
- Surgery assistance
- Operating room technician and equipment sterilization
- Treatment of minor illnesses
- Dispensing drugs
- Giving pre- and postnatal advice
- Delivering babies
- Giving child care advice
- Nutrition education, monitoring and feeding
- Immunization education, monitoring, and dispensing
- Family planning services
- Sanitation and hygiene promotion and education
- Communicable disease screening, monitoring, follow-up and medication
- Assisting in health center activities
- Making health care referrals
- Performing school health activities
- Collecting vital statistics
- Maintaining records, making reports
- Performing home visits
- Participating in community meetings
But, CHWs can only do these wonderful things if they are well-trained
and working in a well-designed program, with proper supervision
and support, and with a clear understanding of the social dynamics
of the individual community that they serve. Analysis of many
such programs around the world has yielded clues to the success
or failure of these programs. In general CHWs are more likely
to be effective if they are truly representative of the community,
are chosen by the community, and are well supported. Surveys indicate
that mature women tend to show greater longevity as career CHWs
than any other group. But, many experts acknowledge that local
conditions and customs may demand that certain tasks be performed
by men and others by women. The ability of a CHW to read has not
been shown to be necessary in a properly designed system.
Important elements of support include a good initial training,
good supervision, regular continuing education, and access to
further information whenever needed. In addition the CHWs must
be provided with sufficient supplies, practical patient referral
options, adequate funding, recognition of their importance and
a voice in the running of the program.
Some potential problems include:
Politicization of the CHW can occur in a variety of ways. Sometimes
their work causes them to highlight inequality and social injustices
which may be root causes of ill-health in the area. This can be
life -threatening to the CHW where governmental authorities perceive
them to be supporting a "communist," "guerrilla" or "insurgency
movement." Conversely, the CHW may be at risk from insurgency
groups who do not wish "governmental agents" to be seen providing
helpful services in the area.
Conflicts with other health providers
Competition and "turf battles" can arise between CHWs and doctors,
nurses and traditional healers in the region. Avoiding this situation
depends upon a clear understanding of the social dynamics, health
resources and needs of the individual area being served. It may
or may not be a good idea to train traditional healers as CHWs.
Again, a thorough understanding of the social dynamics is critical.
Trying to enlist the help of the individuals who feel threatened
for CHW training or supervision can sometimes diffuse the situation
as can including them in referral patterns where possible.
Association with unpopular themes
Sometimes the CHW becomes associated with a given health theme
which is promoted by the government or relief organization but
which is socially unpopular. An example might be family planning
in China where resentment of government-imposed family planning
is not uncommon. Under such circumstances the CHW may be seen
as not being on the side of the community.
Lack of community interest
Sometimes in spite of obvious health care needs and a clear role
for CHWs, a community would prefer to dedicate its limited resources
to a different kind of project such as irrigation. This preference
may result in lack of cooperation and funding critical to the
success of the project.
It is also worthwhile to note that communities are rarely composed
of completely like-minded individuals with a common purpose and
a full spirit of cooperation. More likely different elements will
have different agendas, and understanding these subtleties is
vital for effective planning.
Two useful textbooks on this subject are WHO's The Community Health Worker and Stephen Frankel's The Community Health Worker, Effective Programmes for Developing Countries.