Community Health: Fashion or Function?

The shortage of healthcare workers now stands at external pagemore than four million globallycall_made. The WHO estimates thatexternal page57 countriescall_made, most in Africa and Asia, face critical shortages which hinder their ability to meet the Millennium Development Goals and provide basic primary health services. With long lead times for training and development, as well as structural inefficiencies in health worker placement (migration, for example), this gap will not be filled by physicians and nurses quickly or cheaply.

Health worker shortages have caused many countries, donors and implementers to scramble for human resources to fill the void. In particular, the rollout of treatment for HIV/AIDS in sub-Saharan Africa has underscored the need for quick yet sustainable human capacity in health systems. Looming funding shortages have shifted any expectation that resources will be available for costly and long-term solutions.

In this context, Community Health Workers (CHWs) have re-emerged as a solution to the workforce crisis. Recent evidence has shown that CHW programs can external pagesignificantly improvecall_made health outcomes in countries with the most critical shortages. Global and country policymakers have lauded the approach as cost effective and called upon health systems to delegate tasks to lesser skilled workers including CHWs (known as 'task-shifting'). However, CHW programs vary considerably by country and program. Is the CHW renaissance merely fad, or truly functional?

Definitions and controversies

Community Health Workers (CHWs) are not a new phenomenon. Barefoot doctors emerged in China in the 1950s and became a national program in the 1960s, to wide acclaim. The external pageAlma Ata Declaration of 1978call_made then put CHWs on the global policy stage by highlighting their contribution to the health workforce. The 1980s witnessed a proliferation of programs as population health programs became popularized and the sheer scope of public health overwhelmed the existing, traditional workforce.

Community health programs have struggled to define the CHW role, which has caused some of the controversy around their deployment. Much of the literature defines a CHW as a multi-disciplinary health advocate, chosen by the community, working exclusively in the community in which they live. This strict definition has often been loosened by program designers and policymakers to include any lay worker who is working in facilities or communities in a health capacity. This wide ranging application of the term has led to confusion, most tellingly amongst community members and health professionals. The WHO has recently released aexternal pagetypologycall_made of CHWs, which may help to clarify the situation.

Training duration and supervision also vary significantly. In Brazil, where CHWs, or 'Community Health Agents,' provide comprehensive services to half the Brazilian population, CHW training includes a two-month residential course and one month of field work. They are supervised by a nurse and operate as a family health team. By contrast, CHWs in Kenya receive three weeks of training, are responsible for just a small subset of health issues and are supervised by field staff.

Payment and incentives are also a source of much divergence. Programs and policies range from voluntary roles to - although rare - salaried workers. Studies have found that a mix of financial and non-financial incentives is best suited to motivating workers. However, programs may try to cut costs by limiting compensation to CHWs, compromising the effectiveness of incentives andexternal pagepossibly even undermining the role.call_made In a external pagehigh-profile casecall_made involving 'Lady Health Workers' in Pakistan, a six-month delay of salaries hindered the roll-out of the country's anti-polio campaign.

The disparity in program quality has led to under-representation of successful CHW programs or, at the opposite end, hype about programs that are less-than-effective. The risk is that CHW programs will be dismissed as a "human resource flash-in-the-pan", as external pageone studycall_made quipped.

What matters? Policy and programming

A external pagerecent reportcall_made by the WHO provides a comprehensive assessment of the evidence supporting CHW programs and outlines recommended policies derived from the literature. Key among these recommendations is that "programs should be coherently inserted in the wider health systems." But this is easier said than done. Since CHW programs are often donor-funded, implementation by multiple stakeholders and the resulting lack of integration into government employment cadres and training platforms often results in fragmentation.

The WHO goes on to recommend that "CHW programs should also ensure a regular and sustainable remuneration package that is complemented with other rewards and incentives" and that "programs should have regular and continuous supervision and monitoring systems in place". Systems for compensation and supervision do not come cheaply, lessening the possibility that CHW programs are a 'cheap fix' for human resource challenges in healthcare.

These recent WHO recommendations represent two key points for policymakers and implementers. First, CHW programming, which has classically been separate from facility care, is now being promoted as an integrated component of health systems. Rather than acting as a second-class supplement to facility care, CHWs are seen to play a role in creating linkages for healthcare from facility to community. Second, and related, the CHW role is being 'professionalized', through higher standards for training, supervision and remuneration.

No silver bullet, but a component of care

Increased exposure and recognition of CHW policies and programming is a welcome addition to the human resources for health dialogue. However, it is important that CHWs do not get classified as a "cheap and easy" solution to the health worker shortage. Integration of CHWs into national health systems, and the corresponding necessity of sustainable remuneration, supervision and training platforms, requires careful and sustained planning and funding.

The emerging consensus is that CHWs can make a significant contribution to health outcomes in cases where considerable investment is made in policy and program design. Community health workers are not a panacea for the health worker shortage, but, with careful planning and implementation, they can be a successful solution to bridge the human capacity gap in resource-constrained countries.