Community health workers: Understated front-line providers
By: Kristy Yiu
We reflexively turn to doctors when we get sick, but what if there are no doctors in your community or their services are not easily accessible? Such is the case for citizens of many developing countries like Haiti, where there are only 0.25 physicians per 1000 population (statistics from 1998). For the sake of comparison, Canada, a developed country, had 1.858 physicians per 1000 population in the same time period (statistics from 1998). In situations in which physicians do not meet the population needs, community health workers (CHWs) step in as front-line health care providers.
The World Health Organization defines CHWs as “community members [who] render certain basic health services to the communities they come from;” in addition, they “must respond to local societal and cultural norms and customs to ensure community acceptance and ownership.” In other words, CHWs are members of the community they serve, and therefore should have a good understanding of the cultural norms within their community. As do many non-profit health care organizations working in developing countries, Partners in Health (PIH) recognizes the pressing demand to fill this gap in patient care and actively trains and promotes the use of CHWs in communities. Almost 30 years ago, PIH started their premier CHW program in Haiti and has now hired and trained 12 000 CHWs around the world through its development of the program over the years.
Many may see CHWs as a lesser replacement for doctors due to the perception of their role as simply providers of basic primary care with a lack of formal training. However, they are much more than a substitute for doctors; instead they act as “crucial adjuncts” who work alongside other professionals in the formal health care system. Not only do CHWs manage care and treatment, they also provide prevention and perform with a level of cultural sensitivity that foreign physicians may not necessarily possess. While physicians may primarily focus on acute treatment, CHWs put their efforts towards long-term care. Thus, it only seems befitting that CHWs are called accompagnateurs in Haiti, which essentially means someone who “is trusted and welcomed into patients’ homes” and will “[accompany them] in their journey through sickness and back to health.” This sentiment regarding the necessity of CHWs are shared by many non-profit health care organizations that depend on these unsung heroes to run their daily operations. One example is the Comprehensive Rural Health Project in Jamkhed, Maharashtra, India. Its founders, Raj and Mabelle Arole, once commented to New York Timescolumnist, Tina Rosenberg, about the importance of CHWs in bridging the gap that doctors do not fill in providing prevention care. In her article, Rosenberg wrote that “[The Aroles] decided that doctors were not the way to help rural villages…Villages need to end deadly superstitions about health. They need to end discrimination against women and Untouchables, and to learn about hand-washing, nutrition, breast-feeding and simple home remedies. Doctors do none of these things.” Contrarily, CHWs’ inherent knowledge on the cultural norms of the communities in which they work allows them to act as “cultural brokers,” and thus enables them to tackle health problems in ways that a foreign doctor cannot.
Not only is the role of a CHW important in providing care in the local health care system, the establishment of this post also creates jobs for those in need of dignified work, which in turn, would allows them to lead a healthy and productive life. In the example of PIH, the non-profit organization recognizes that women, especially those in developing countries, “often face the dual challenge of caring for children and being the breadwinner for the household in places where formal jobs are hard to come by.” Being a CHW can provide these women with a sense of accomplishment in being able to give back to the community, as well as the financial independence to support their families. Sori Santana, a Boston-based PIH CHW who works with patients living with HIV, shared her story on her journey and role as a CHW. In addition to being able to support her three young children, being a CHW with PIH’s Prevention and Access to Care and Treatment (PACT) program allowed her “to do something that [she] felt good about. [She] always loved helping people…and [she] found PACT.”
On the other hand, patients also value the service provided by CHWs. A tuberculosis patient who participated in a study on the perception of CHWs in Western Kenya said “I can talk about [CHWs] because they usually visit me. Given my health condition…they usually come and check my blood pressure and find out how I am doing.” This positive sentiment is shared by other community members, such as the local religious leader who commented that “the community appreciates their work. They have a good approach.” In addition, a traditional healer noted that “Mostly the CHWs are good. They visit us at home and when they find a patient who has not gone for medical attention, they advise that person to be taken to the hospital…Since they have undergone training, they can easily identify signs of HIV…”
Beyond personal anecdotes, research has demonstrated the success of CHWs’ work in communities around the world. Various research papers have affirmed CHWs’ work and their integral role as a member on health care teams managing patients with diseases such as diabetes and tuberculosis. Swider conducted a literature review on the outcome effectiveness [RB15] of CHWs and concluded that there was preliminary support for CHWs’ role in increasing access to care. For example, one of the included studies compared the immunization rates of a population with CHW contact to a statistical model without any contact. It estimated that 44% of the follow-ups were completed due to CHWs reaching out to patients. However, despite the general positive views on CHWs, Swider also warned that while “CHWs show some promise as an intervention, the role can be doomed by overly high expectations, lack of clear focus, and lack of documentation.” To complement the emerging role in the health care field and the increasing use of CHWs, further research is required to develop the role of a CHW to its full potential.
In the wise words of the PIH founder, Paul Farmer, “Hire CHWs to serve [the patients]…If we train village health workers, and make sure they’re compensated, then the resources intended for the world’s poorest…would reach the intended beneficiaries. Training and paying village health workers also creates jobs among the very poorest.” From Haiti to Rwanda, Navajo Nation, Malawi, or Mexico, all CHWs truly embody the mission of PIH: “We go. We make house calls. We build health systems. We stay.” CHWs assume an understated role that has become indispensable in many communities around the world.
