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 provision 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 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.