CHWs (25) Role of CHWs in disability and rehabilitation (6) Addressing the diversity of CHW roles

6 June, 2019

Dear Mohammad Ali Barzegar and all,

On behalf of the CHW working group,thank you all for your contributions so far. Please continue to share your thoughts, experience and expertise by email to:

Dr Barzegar, you raise an important wider area of debate about pre-service training: "I also whole heartedly support the integration of CBR into Primary Health Care (PHC), and add to the Job description of CHWs."

As a personal comment, I am impressed - and daunted - by the huge diversity of roles that CHWs can potentially play in primary health care, and the evidence that supports this.

The selected highlights of the Guideline note: 'There is growing recognition that community health workers (CHWs) are effective in the delivery of a range of preventive, promotional and curative health services. They can contribute to reducing inequities in access to care.' The guideline emphasises maternal and newborn health, child health, communicable diseases, non-communicable diseases, trauma, surgical care, mental health, sexual and reproductive health... and they are also important in helping people to access health services and to advocate for their health rights.

This begs a number of questions: Should each and all of these (not to mention rehabilitation) be added to the job description of CHWs? Should every element be included in the pre-service training of every CHW?

As our discussion moves towards selection, training and certification of CHWs, I invite comments on the breadth and depth of pre-service training that CHWs need, and to what extent such training should be standardised.

The Guideline addresses these questions:

'For CHWs receiving pre-service training, should the curriculum address specific versus nonspecific competencies? For CHWs receiving pre-service training, should the curriculum use specific delivery modalities versus not?'

The Guideline is unequivocal: 'The scope and roles of CHWs vary substantially across countries and CHWs, hence it is not possible to standardize the scope of pre-service education and contents of curricula.... The most appropriate contents of CHW training should be established at the country level (either in a national or subnational context) on the basis of local needs and circumstances.'

This is reflected in Recommendation 3 of the Guideline: 'WHO suggests including the following competency domains for the curriculum for pre-service training of CHWs, if their expected role includes such functions.'

On the other hand, the Guideline says: 'A broad set of core competencies may ensure that all CHWs have the basic skills necessary to adequately carry out their role.'

If I am interpreting this correctly, there is a shift from the idea of a primarily universal curriculum for CHWs towards one where pre-service training is tailored according to a country's needs.

This also has the advantage of addressing unrealistic expectations of individual CHWs to become competent in an unfeasibly wide range of tasks. Furthermore, it opens up the option for CHWs who have completed basic training (in line with national priorities) to receive further modular training in specific areas of health (in line with the CHW's interests) and thereby become specialised CHWs.

There are caveats, however. As the Guideline notes, 'CHWs are often trained unimodally to specialize in the care of a single patient condition, such as diabetes or HIV' (this is also the case in training of lay health workers in mental health). So in some situations there may be a case for permitting such specialist training without the need for prior general CHW training.

Also, there would need to be a balance between general and specialist training. 'A model based exclusively on specialised CHWs might carry risks of fragmentation of care, resulting in gaps in service provision and inefficiency.'

Many thanks, Neil

Coordinator, HIFA Project on Community Health Workers

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: