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Module 1: Who Are Community Health Workers and What Do They Do?

When asked about a single intervention that would do the most to improve the health of those living on less than $1 a day, Paul Farmer, the founding director of Partners In Health (PIH) said,

“Hire community health workers to serve them. In my experience in the rural reaches of Africa and Haiti, and among the urban poor too, the problem with so many funded health programs is that they never go the extra mile: resources (money, people, plans, services) get hung up in cities and towns. If we train village health workers, and make sure they’re compensated, then the resources intended for the world’s poorest – from vaccines, to bednets, to prenatal care, and to care for chronic diseases like AIDS and tuberculosis – would reach the intended beneficiaries. Training and paying village health workers also creates jobs among the very poorest.” (1)

Raj and Mabelle Arole, founders of the Comprehensive Rural Health Project in Jamkhed, Maharashtra, India expressed similarly strong opinions concerning the necessity of community health workers (CHWs). They believe that not only could CHWs remove the problem of the last mile, but that they could also provide prevention, which is a significant yet overlooked aspect of healthcare.  The New York Times columnist Tina Rosenberg writes about the Aroles that “They decided that doctors were not the way to help rural villages.  The vast majority of sickness in rural areas could be prevented with clean water, waste-disposal systems and more diverse farming.  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.”(2)  In this view, CHWs are not merely a lesser substitute for doctors, but rather crucial adjuncts.  

CHWs can assume a wide variety of roles in healthcare. Just as surgical task shifting provides low cost yet effective surgical care in the absence of surgeons, community health workers help the poor overcome barriers to accessing effective healthcare in the absence of physicians and nurses. Anybody can be trained as community health workers due to the versatility of this profession. For example, even patients themselves are often trained as community health educators in order to educate their peers regarding healthcare issues.  In developing countries, CHWs can contribute to increased access to the formal healthcare system or improved patient adherence to treatment regimens, among numerous other roles.

In sub-Saharan Africa, the model for primary care at the level closest to the community includes one or two community health workers per population of 1000-5000 people.  These CHWs are trained to provide basic medical and preventive care.(3)  According to Berman et al. (1987), community health workers (CHWs) are “local inhabitants given a limited amount of training to provide specific basic health and nutrition services to the members of their surrounding communities. They are expected to remain in their home village or neighbourhood and usually work part-time as health workers.  They may be volunteers or receive a salary. They are generally not, however, civil servants or professional employees of the Ministry of Health.”  Berman et al. (1987) also note that, ”[in South Africa] in 2004, the term community health worker was introduced as an umbrella concept for all the community/lay workers in the health sector, and a national CHW Policy framework was adopted.”  CHWs were initially promoted in the 1978 Alma Ata Declaration on Primary Health Care and were integrated into many countries’ health systems.  However, due to inappropriate top-down implementation, the CHW programs failed and ultimately diminished during the 1980s and 1990s.  In the late 1990s and early 2000s, CHWs reemerged as a valuable health resource to face the epidemics of malaria, tuberculosis (TB), and HIV/AIDS, and are now being used for a wide variety of health conditions in both the developing and developed worlds.(4)

HIV/AIDS

Hermann et al. (2009) state that in low-income countries in sub-Saharan Africa, “the most crucial bottleneck for scaling up ART and managing an effective system of chronic ART care is the lack of qualified human resources for health.”(5)  Due to the health professional shortages and national scale-ups of antiretroviral therapy (ART) distribution, the World Health Organization (WHO) introduced the idea of “task-shifting” in which community health workers are trained in certain aspects of care.  For example, CHWs can help promote voluntary HIV testing and serve as “home-based carers [caretakers], DOTS [Directly Observed Therapy, Short Course for TB] supporters, prevention of mother-to-child transmission (PMTCT) counselors, adherence counselors, support group facilitators.”  In South Africa, CHWs have been seen “as an indispensable extension of the reach and strength of professional involvement in ART services.”(6) In these positions, CHWs can take some of the burden off of professional health workers and the overloaded healthcare systems of many sub-Saharan African nations while also strengthening both the quality of and access to care for people living with HIV/AIDS (PLWHA).(7)

An example of CHW roles and responsibilities in national HIV/AIDS responses is shown in the CHW program run by the Department of Health in the Outer West District of the eThekwini metropolitan municipality in and around Durban, South Africa.  In this program, CHWs are responsible for “monitoring DOTS (directly observed treatment, short course) for TB (TB-DOTS); educating constituents about HIV; reporting acute sickness, injuries, and probable cases of HIV infection or TB to clinics; promoting healthy practices; and collecting data on household structure (age, general health, and family role), sanitary conditions (availability of clean water, sustainable gardens, and waste disposal methods), and specific health conditions (HIV/AIDS and TB, mental health concerns, maternal and antenatal health status, and child immunization and health status).” Different CHWs can be trained in any area of health or quality of life that is important to PLWHA, including nutrition, mental health, and prenatal care.(8)

Mental Health Care

Low-income African countries have a severe dearth of mental health professionals; CHWs can contribute to expanding access to mental health care. In all of Ethiopia, for a population of 77 million, there are only 18 psychiatrists, no clinical psychologists, and only one psychiatric hospital in the capital of Addis Ababa.  Like other African countries, a vast majority of mental health professionals work in the capital cities, leaving rural areas with no mental health care.  Unfortunately, primary care does not include mental health care in these countries.  Families have historically served as the primary caretakers for mentally ill individuals, and traditional healers often serve as the only source of therapy.  Because of the financial, social, or psychological burden, families will sometimes tie up, chain, or neglect these individuals.  Finding support among its sample population, Alem et al. (2008) suggest that some community health workers should be trained with mental health skills and be able to refer patients with extreme conditions to mental health professionals.(9)

North America and Europe

In the United States, CHWs focus on different health conditions and issues. Many CHWs aim to empower consumers to advocate for quality care, utilize self-help practices, exercise their rights as patients, take advantage of community resources, and learn about their risks for certain health conditions, to name a few responsibilities.  CHWs are also used to reach vulnerable minority groups.  For example, the California Black Health Network uses CHWs to lead education and prevention programs for African Americans regarding major health conditions and patients’ rights and responsibilities.   The Community Health Worker/Promotora Network has CHWs “create connections between Latino communities, health agencies, and community-based organizations by addressing informational, cultural, socioeconomic, and linguistic gaps… The network’s members, who primarily serve the state’s Spanish-speaking community, are removing cultural and linguistic barriers, increasing the trustworthiness of the institutions they represent, and expanding institutions’ service delivery to include health education and prevention strategies.”   In this context, CHWs are expanding access to marginalized groups who experience significantly more barriers to care, much like what CHWs experience in developing countries for rural populations.(10)

In the United Kingdom, the National Health Service (NHS) has created an “expert patients” program for its national chronic disease management program.  Expert patients are individuals who have been living with a chronic illness for years and who serve as volunteer counselors for others recently diagnosed with the same condition. The long-term experiences of the expert patients are regarded as valuable knowledge. The aim of this program is to expand and improve care for patients living with chronic illness.(11)

The Responsibilities & Impact of Community Health Workers

Community health workers perform a wide range of vital healthcare roles in their communities:

• They supervise the treatment of patients living with terminal illness so that they can live healthier and longer lives. For instance, at Partners In Health, community health workers in Haiti, Rwanda, Boston, and Lesotho work to ensure that HIV/AIDS and tuberculosis (TB) patients take their medications correctly and regularly in order to prevent them from developing drug resistance, or worse yet, to prevent fatal side effects arising from the misuse of these medications.
• They serve as counselors, helping poor patients overcome the barriers that prevent them from seeking vital healthcare.  Patient barriers to care include transportation, lack of awareness, fear, and healthcare costs. Community health workers are knowledgeable about local needs and sensitivities, and thus are in a position to gain their patients’ trust and to bring them to the clinics to receive medical treatment.
• They act as healthcare educators, providing vital education about the healthcare options that are available. By leading education campaigns in their communities and raising awareness among community members regarding health issues, community health workers encourage community members to take charge of their own health.
• They keep a lookout for people who show signs of developing a serious condition. Identifying and treating a disease at an early stage makes it less dangerous and less expensive to treat, thereby reducing the overall financial burden on the healthcare system.
• They possess indispensable knowledge about the challenges faced by patients who seek healthcare. Since they make daily rounds to the homes of the patients and accompany patients to the clinics, community health workers understand first-hand the unique needs of the local patients. They also see the effects of illness and poverty in their community. Their insights are important for shaping healthcare policies and healthcare delivery methodologies. 
• Patients are sometimes trained as community health workers so that they can initiate outreach programs to help their peers. In Boston, Partners in Health trains patients who are former drug users to do outreach among their peers in the areas where HIV is prevalent. According to PIH’s website, “since the program’s inception, the promotores of Fuerza Latina [the name of the program] have provided more than 1,000 people with street-level counseling and accompaniment to detox or HIV counseling and testing services, and have distributed more than 9,000 safer sex kits.”(12)
• They provide treatment to patients in their homes so that they do not have to risk catching or spreading disease in a hospital or clinic. 

The Benefits of Using CHWs to Deliver Care

According to Allies for Quality, lay health workers comprised of local community members have certain advantages over other healthcare workers. For example, they can more easily communicate with and gain trust from their patients; they can develop culturally relevant and highly accessible health materials and information; they can help adapt the health care system to better suit their population’s needs; and they can be cost-effective extensions of the healthcare system.  With these capacities, CHWs “can successfully engage significant numbers of consumers in increasing knowledge and reducing barriers to health care quality.”(13)  Moreover, the founders of the Comprehensive Rural Health Project in Jamkhed “found that lack of education was an advantage for village health workers.  They knew how their neighbors lived and thought.”(14) Serving as trusted liaisons between communities and the formal healthcare system, CHWs can provide invaluable progress in the removal of barriers to healthcare.

In addition, Hermann et al. (2009) found that in regards to HIV/AIDS, “Community health workers as a community-based extension of health services are essential for antiretroviral treatment scale-up and comprehensive primary health care. The renewed attention to community health workers is thus very welcome, but the scale-up of community health worker programmes runs a high risk of neglecting the necessary quality criteria if it is not aligned with broader health systems strengthening. To achieve universal access to antiretroviral treatment, this is of paramount importance and should receive urgent attention.”(15)

The issue of sustainability and quality of CHW programs will be addressed in the next section.

Footnotes

Healthcare Workers Online Course

• Table of Contents
• Module 1
• Module 2
• Module 3
• Module 4
• Module 5
• Module 6
• Module 7