CHWs (28) What are your thoughts on the Guideline? (15)

7 June, 2019

Dear Colleagues:                                6 June, 2019

A few thoughts on community health workers:

1.  Were primary health care for all accepted as the essential, most cost beneficial and humane way of keeping us healthy, especially in societies in demographic transition, community health workers will be needed to carry out, under supervision, the day to day basic curative and preventive activities. The reason for this is that there will never be enough trained nurses much less doctors willing to live & work in the rural areas, peri urban slums, and inner city barrios, where most of the most poor and needy reside. (And even if there were, those most-in-need communities couldn't afford to pay for such highly trained personnel).

2. Because training cannot overcome character deficits, CHW selection must include community input, so as to ensure that they are inherently caring, linguistically and socially acceptable and have the kind of ties to the community that will keep them there for long enough to settle in, learn their trade and faithfully serve their people. Other selection criteria like trainability, capacity to overcome superstition and habit, and ability to accept supervision and literacy should be the purview of health professionals.

3. Since community workers, however intelligent, are rarely educated enough to understand the scientific bases for sterile technique, nutrition science, bacteriology versus virology, immunology, acid base balance, genetics, hyper- and hypo-tension, etc., etc., (and since the quality of practice of even highly trained doctors deteriorates without supervision or peer pressure!), they need regular supervision, continuing education and, for those with potential, some kind of career ladder, so as to maintain standards and avoid "burn-out".

4. This supervision should be shared by the district  health team and by the health committee of the target community since only the latter can reliably assess whether the CHW is really     reaching out and getting out to those most in need, and whether they really care about what they are doing!

5. Every primary care team needs to meet regularly, (at least every two weeks), and the CHW's need to be part of that meeting so that a) their contributions are recognized, b) their                  observations recorded and respected, and c) so that they learn and develop team loyalty.

6. If/when their supervisors are absent, there needs to be a well planned & rehearsed referral system in place so that emergencies and urgencies get to a higher level of health care     before anyone's life or health is imperiled.

Allowing deaths or serious deterioration of patients under CHW care to occur (and then blaming them for this) cannot be permitted!


Nicholas Cunningham MD Dr P.H.

P.S. to Byan Pearson (my old friend from Ilesha!): I believe that CHW's should be considered "para'professionals" not professionals; they have their expertise, and in time come to know their communities far better than the professionals! But, I believe that credentials matter... and that the educated health professionals need to be respected for what they know, teach and practice!

HIFA profile: Nicholas Cunningham is Emeritus Professor of Clinical Pediatrics & Clinical Public Health at Columbia University, New York, USA. He is interested in International Primary Maternal and Child Health Care, community owned, professionally overseen, and supported by $/power interests, encorporating integrated cure/prevention, midwifery/child care, child saving/child spacing, nutrition/infection, health/education (especially female), monitored but not evaluated for at least 5-10 years, based on methods pioneered by David Morley at Imesi (Nigeria) and by the Aroles at the Jamkhed villages in Maharashtra State in India. Totatot AT