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Community Health Workers

Community health workers (CHW) are members of and chosen by the community to serve, then trained to provide medical care. Programs involving CHW in China, Brazil and Iran have demonstrated that utilizing such workers can improve health outcomes for large populations in under-served regions. In many developing countries, especially in Sub-Saharan Africa, there are critical shortages of professional health workers. Current medical and nursing schools cannot train enough workers to even keep up with internal and external emigration, deaths from AIDS and other diseases, low worker productivity or population growth. “Task shifting” of primary care functions to community health workers, trained to provide essential, safe, and highly effective health care is considered to be a means to improving the health of millions at reasonable cost.

History

Individuals provided care to members of their community for thousands of years. In addition to heir healing function such persons were often respected members of the community involved in religious, social and political life. The knowledge of medicinal herbs and healing techniques was passed down from generation to generation and gender was often less constraining than it was in other walks of life. Religious practice and beliefs were often crucial factors.

Scientific medicine has evolved slowly over the last few millennia and very rapidly over the last 150 years or so. As the evidence mounted of its effectiveness, belief and trust in the traditional ways waned. The rise of university based medical schools, the increased numbers of trained doctors, the professional organizations they created and the income and attendant political power they generated resulted in license regulations. Such regulations were effective in improving the quality of medical care but also resulted in a reduced supply of providers. This further increased the fees doctors could charge and encouraged them to concentrate in larger towns and cities where the population was denser, hospitals were more available and professional and social relationships more convenient.

In the 1940’s Chairman Mao Tse Tung in China faced these problems. His anger at the “urban elite” medical profession over the maldistribution of medical services resulted in the creation of “[Barefoot Doctors]”. Hundreds of thousands of rural peasants, chosen by their colleagues, were given rudimentary training and assigned medical and sanitation duties in addition to the collective labor they owed the commune. By 1977 there were over 1.7 million barefoot doctors. As professionally trained doctors and nurses became more available, the program was abolished in 1981. Many Barefoot Doctors passed an examination and went to medical school, many became health aides. The majority were relieved of duty.

Brazil undertook a medical plan named the Family Health Program in the 1990s that made use of large numbers of CHW. Between 1990 and 2002 the infant mortality rate dropped from about 50 per 1000 live births to 29.2. During that period the Family Health Program increased its coverage of the population from 0 to 36%. The largest impact appeared to be a reduction of deaths from diarrhea. Though the program utilized teams of physicians, nurses and CHW, it could not have covered the population it did without the CHW. Additionally there is evidence in Brazil that the shorter period of training does not reduce the quality of care. In one study workers with a shorter length of training complied with child treatment guidelines 84% of the time whereas those with longer training had 58% compliance.

Iran utilizes large numbers of para-professionals called behvarz. These workers are from the community and are based in 14,000 “health houses” nationwide. They visit the homes of the underserved providing vaccinations and monitoring child growth. Between 1984 and 2000 Iran was able to cut its infant mortality in half and raise immunization rates from 20 to 95%. The family planning program in Iran is the most successful in the world. Fertility has dropped from 5.6 in 1985 to 2 in 2000. Though there are many elements to the program (including classes for those who marry and the ending of tax incentives for large families) behvarz are extensively involved in providing birth control advice and methods. The proportion of rural women on contraceptives in 2000 was 67%. The program resulted in profound improvement in maternal mortality going from 140 per 100,000 in 1985 to 37 in 1996.

Current Status

Cost and access to medical care remain problems of worldwide scope. They are particularly severe in the developing world and it is estimated one million more health care workers are needed in Africa to meet the Millennium Development Goals. Doctors are few and concentrated in cites. In Uganda some 70% of medical doctors and 40% of nurses and midwives are based in urban areas, serving only 12% of the population. Medical training is long and expensive. It is estimated that to meet health workforce needs using the American or European model, Africa would need to build 300 medical schools with a total training cost of over $33 billion and it would take over 20 years just to catch up. In many countries salaries of doctors and nurses are less than that of engineers and teachers. Bright young medical professionals often leave practice for more lucrative opportunities. Emigration of trained personnel to countries with higher salaries is high. In Zambia of the 600 doctors trained since independence it is estimated only 50 practice in their home country. In some countries AIDS is killing experienced nurses and doctors amounting to 30-50% of the number trained yearly. Though many countries have increased their spending on health care and foreign money has been injected, much of it has been on specific disease oriented programs. Health systems remain extremely weak, especially in rural areas. The World Health Assembly in 2006 called for, “A health workforce which is matched in number, knowledge and skill sets to the needs of the population and which contributes to the achievement of health outcomes by utilizing a range of innovative methods”

Community health workers are thought to be part of the answer. They can be trained to do specialized tasks such as provide sexually transmitted disease counseling, directly observed therapy, or act as trained birth attendants. Others work on specific programs performing limited medical evaluations and treatment. Others have a far broader primary care function. With training, monitoring, supervision and support such workers have been shown to be able to achieve outcomes far better than baseline and in some studies, better than physicians.

Important attributes of community health workers are to be a member of and chosen by the community they serve. This means they are easily accepted by their fellows and have natural cultural awareness. This is crucial because many communities are disengaged from the formal health system. In Sub-Saharan Africa 53% of the poorest households do not seek care outside the home.Barriers include clinic fees, distance, community beliefs and the perception of the skills and attitudes of medical clinic workers. Community health workers are unable to emigrate because they do not have internationally recognized qualifications. Finally, the variation in incentives between areas of the country tends to be low. All these factors combined with strong community ties, tend to result in retention at the community level.

Much remains to be learned about the recruitment, training, functions, incentives, retention and professional development of community health workers. Learning developed in one country may not be applicable to another due to cultural differences. Health worker adaptability to local requirements and needs is key to improving medical outcomes. That being said, it has been estimated that six million children’s lives a year could be saved if 23 evidence based interventions were provided systematically the children living in the 42 countries responsible for 90% of childhood mortality. Over 50% of this benefit could be obtained with an integrated, high-coverage, family-community care based system, Large numbers of community health workers may be the single most important group of the team needed to achieve such goals.