Within the comments of the overall WHO guideline this past week, there has been a tension between the de facto acceptance of CHWs within the health system and practical considerations of exactly what their role should be.
Rachel inquired on June 5th, "How can we promote career development of young CHWs who are committed to their communities' health but want to continue their education and advance within the health sector? What are viable CHW career paths? While CHW professionalization and recognition is essential for SDGs and promoting decent work, there may inevitably be community health volunteers who continue to provide support in their communities on an ad-hoc, part-time basis. What do we, as a global health community, do to harness and appropriately recognize their roles as well?"
On June 6th, Bryan added, "If CHWs are recognised as 'real' health professionals, integrated into the district health team (and remunerated) - then progress can and will be made."
Finally, on June 8th, Massimo pointed out, "So far governments pay for their health workers that are officially trained, wear a uniform, work in the thousand rural dispensaries/health centres/hospitals. This personnel is the one that communities recognized as their health providers, from ever. CHWs just came 'recently' brought forward by foreign INGOs that like the idea of their service and support($) them."
As you can see, our HIFA network is split on what "community integration" should look like -- prioritization of government health workers, total acceptance of CHWs, or something in between.
A few reflections:
1. CHWs, in one form or another, have been around for over half a century (and probably longer). China's first CHWs from the 1950s were called "barefoot doctors" ( https://www.who.int/bulletin/volumes/86/12/08-021208/en/). CHWs were integral to the success of the Matlab, Bangladesh studies in the 1970s that helped to spread contraceptive use globally ( https://www.icddrb.org/research/platforms/field-sites/more-on-matlab ). There are numerous other examples as well. We cannot therefore contend that CHWs "just came 'recently' bought forward by foreign INGOs."
2. However, Massimo's point is important -- what is the effect of the existence of CHWs within the flow of the health workforce? As Rachel asked, how do we "harness and appropriately recognize" those CHWs who "continue to support in their communities on an ad-hoc, part-time basis"? Is there simultaneously space for those CHWs who want opportunities for career advancement and those that enjoy the status of serving the community in limited ways? If career advancements are provided for CHWs, does that disrupt the country's traditional medical education system?
These questions reminded me of Luis Tam and Muluken Melese's April 2019 piece in John's Hopkins' Global Health NOW Newsletter ( https://www.globalhealthnow.org/2019-04/community-health-workers-and-vol... ). They envision a primary health care model based on their work in rural Peru and Ethiopia, in which "government-paid, full-time CHWs providing comprehensive services to a given population, with a primary health center hub as the base of operations. Each CHW, in turn, would lead a team of part-time community health volunteers providing limited health education and referral services?such as maternal and newborn health, nutrition, hygiene, tuberculosis, malaria, and HIV/AIDS?to a small number of neighboring families.
These are the kinds of discussions that HIFA is perfect for -- sifting through the general guidelines and sharing contextual learnings that are may or may not be applicable to all.
HIFA profile: Amelia Plant is the Portfolio & Impact Manager at Preston-Werner Ventures, a San Francisco-based foundation looking to create scalable impact at the intersection of climate change and social justice. Amelia specializes in sexual reproductive health and rights, focusing on family planning information & access. She is currently based in Cairo, Egypt. She is a member of the HIFA working group on Family Planning and the HIFA wg on Community Health Workers.
asiplant AT gmail.com