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)
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)
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)
As in developing nations, CHWs in developed areas strive to expand access to groups that experience significant barriers to health care.(10) These barriers are similar to those in developing nations: poverty, lack of transportation, low levels of education and literacy, and misconceptions about health care services and disease. For instance, in focus group interviews and surveys conducted by CHWs with Bangladeshi diabetes patients in New York City, patients reported facing cultural barriers to health management (including the prevalence of high-fat traditional Bangladeshi foods) in addition to logistical barriers to care (such as difficulties communicating with health care providers and “navigating the health care system” due to limited English proficiency within the immigrant community).(11)
In the United States, CHWs aim to empower consumers to advocate for quality care, use self-help practices, exercise their rights as patients, take advantage of community resources, and learn about their risks for certain health conditions . CHWs also work to improve health outreach efforts to vulnerable patient populations. For example, the California Black Health Network uses CHWs to lead education and prevention programs for African Americans to address major health conditions and patients’ rights and responsibilities. The Community Health Worker/Promotora Network uses CHWs, or “promotoras”, to “create connections between Latino communities, health agencies, and community-based organizations by addressing informational, cultural, socioeconomic, and linguistic gaps”. Texas was a pioneer in authorizing promotora certification, and the large Latino immigrant presence in Texas, combined with a history of limited public funding for health care, has made promotoras a valuable health resource in many areas. Public health organizations and health care providers often employ promotoras to improve patient outreach. For instance, a Planned Parenthood branch in South Texas uses promotoras to teach reproductive health in lower-income Latino communities.(12) In the United Kingdom, the National Health Service (NHS) has created an “expert patients” program designed to expand and improve care for patients living with chronic illness. Expert patients, individuals who have been living with a chronic illness for years, serve as volunteer counselors for others recently diagnosed with the same condition.(13)
Although efforts to engage community members in the health care process vary across the nation, a number of models for CHW programs exist. The Camden Coalition of Health Care Providers, founded by Dr. Jeffrey Brenner in 2002, uses home visits and phone calls to help patients manage chronic health conditions and improve their overall health. The Coalition strives to improve the health of “the most expensive one %” of patients in Camden, New Jersey, most of whom live in poverty, have poorly managed chronic health conditions, and are receiving low-quality and inconsistent care, resulting in numerous preventable emergency room visits. Total average monthly hospital costs and hospital and emergency room visits made by the Coalition’s first thirty-six patients fell by 40 and 56 %, respectively, after the patients began working with Brenner’s team.(14)
The Special Care Center in Atlantic City, New Jersey, a clinic led by Harvard-trained internist Rushika Fernandopulle, employs “health coaches”, community members hired to help the clinic communicate effectively with patients who have “exceptionally high medical expenses” and monitor their progress. The program’s health coaches are in frequent contact with patients, in person and via phone and email, to verify they are taking their medications and following their doctors’ instructions.(15) Following the community health worker model, PACT (Prevention, Access to Care and Treatment), associated with Partners in Health, pays community members to visit patients to ensure medical compliance and offer social support. PACT, based in Boston, Massachusetts, helped develop a similar program in New York City, called the Care Coordination program.(16)
The effects of CHWs on public health in the United States are not consistent across all communities and health measures. A CHW intervention targeting childhood asthma in low-income families in King County, Washington, provided one group of families with in-home support and education from CHWs, in addition to the clinic-based nurse support and educational resources that the control group received. During home visitations, CHWs assessed environmental triggers and allergens specific to each home environment in order to develop asthma management plans for the participating families. CHWs also provided anti-allergen bedding, low-emission vacuums, and cleaning kits. The home-based CHW outreach efforts resulted in significantly more symptom-free days compared to the in-clinic care group, although the CHW intervention did not yield a significant reduction in the use of emergency care services.(17)
Meghea et al. (2012) studied the impact of CHWs on mother-reported infant health in a study of 530 infants in Kent County, Michigan. Medicaid-insured women received home visits by nurses and CHWs during pregnancy and throughout the infant’s first year. In addition to services provided by the traditional state program (e.g. nutritional guidance and parenting education), women in the CHW-nurse program received “intensive relationship-based social support” from CHWs. There were no differences in infant health between the nurse and CHW-nurse care groups, as measured by incidence of asthma, wheezing, croup, ear infections, emergency room visits, and hospitalizations. Although the addition of CHWs in this study did not improve infant health outcomes, the authors suggest that CHW interventions directed at specific childhood health conditions, such as diagnosed asthma, may be more effective than interventions designed to improve overall infant health.(18)
Community health workers perform a wide range of vital healthcare roles in their communities:
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.”(20) 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.”(21) 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.”(22)
The issue of sustainability and quality of CHW programs will be addressed in the next section.
(1) Yamey G, on Behalf of the Interviewees 2007 Which Single Intervention Would Do the Most to Improve the Health of Those Living on Less Than $1 Per Day?. PLoS Med 4(2007): e303.
(2) Rosenberg, Tina. “Villages Without Doctors.” New York Times 14 February 2011. Accessed 17 February 2011.
(3) Alem, Atalay, Lars Jacobson, and Charlotte Hanlon. “Community-based mental health care in Africa: mental health workers’ views.” World Psychiatry 7(2008): 54-57. Accessed on 1 February 2011.
(4) Schneider, Helen, Hlengiwe Hlophe, and Dingie van Rensburg. “Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects.” Health Policy and Planning 23(2008):179-187.
(5) Hermann, Katharina, Wim Van Damme, George W Pariyo, Erik Schouten, Yibeltal Assefa, Anna Cirera, and William Massavon. “Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities.” Human Resources for Health. 7(2009): 31.
(6) Schneider, Helen, Hlengiwe Hlophe, and Dingie van Rensburg. “Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects.” Health Policy and Planning 23(2008):179-187.
(7) Simon, Sandrine, Kathryn Chu, Marthe Frieden, Baltazar Candrinho, Nathan Ford, Helen Schneider, and Marc Biot. “An integrated approach of community health worker support for HIV/AIDS and TB care in Angonia district, Mozambique.” BMC International Health and Human Rights 9(2009).
(8) Suri, Arjun, Kevin Gan, and Stephen Carpenter.”Voices from the Field: Perspectives from Community Health Workers on Health Care Delivery in Rural KwaZulu-Natal, South Africa.” Journal of Infectious Diseases. 196(2007): 505-511.
(9) Alem, Atalay, Lars Jacobson, and Charlotte Hanlon. “Community-based mental health care in Africa: mental health workers’ views.” World Psychiatry 7(2008): 54-57. Accessed on 1 February 2011.
(10) “Allies for Quality Care: Lay Health Workers’ Role in Improving Health Care Quality.” California Health Care Foundation. November 2003. Accessed 23 Janurary 2011.
(11) Islam, N.S., Tandon, D., Mukherji, R., Tanner, M., Ghosh, K., Alam, G., Hag, M., Rey, M.J., Trinh-Shevrin, C. (2012). Understanding barriers to and facilitators of diabetes control and prevention in the New York City Bangladeshi community: a mixed-methods approach. American Journal of Public Health, 102(3): 486-90.
(12) Kolker, C. 5 January 2004. “Familiar faces bring health care to Latinos; ‘Promotoras’ act as bridge to hard-to-reach”. The Washington Post.
(13) Hermann, Katharina, Wim Van Damme, George W Pariyo, Erik Schouten, Yibeltal Assefa, Anna Cirera, and William Massavon. “Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities.” Human Resources for Health. 7(2009): 31.
(14) Atul Gawande. January 2011. “The Hot Spotters: Can we lower medical costs by giving the neediest patients better care?”The New Yorker Magazine.
(16) Rosenberg, Tina. February 2011. “A Housecall to Help with Doctor’s Orders.”TheNew York Times.
(17) Krieger, J., Takaro, T.K., Song, L., Beaudet, N., Edwards, K. (2009). A randomized controlled trial of asthma self-management support comparing clinic-based nurses and in-home community health workers: the Seattle-King County Health Homes II Project. Arch Pediatr Adolesc Med, 163(2): 141-9.
(18) Meghea, C.I., Li, B., Raffo, J.E., Lindsay, J.K., Moore, J.S., Roman, L.A. (2012). Infant health effects of a nurse-community health worker home visitation programme: a randomized controlled trial. Child: care, health, and development, doi: 10.1111/j.1365-2214.2012.01370.x.
(19) "Partners in Health: Healthcare Delivery." 2006. Accessed 6/9/2009.
(20) “Allies for Quality Care: Lay Health Workers’ Role in Improving Health Care Quality.” California Health Care Foundation. November 2003. Accessed 23 Janurary 2011.
(21) Rosenberg, Tina. “Villages Without Doctors.” New York Times 14 February 2011. Accessed 17 February 2011.
(22) Hermann, Katharina, Wim Van Damme, George W Pariyo, Erik Schouten, Yibeltal Assefa, Anna Cirera, and William Massavon. “Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities.” Human Resources for Health. 7(2009): 31.