When asked by the journal PLoS Medicine “which single intervention would do the most to improve the health of those living on less than $1 per day?”, the global health icon Dr. Paul Farmer answered: “Hire community health workers to serve them.”
The argument was not new—community health workers (CHWs) have been promoted since at least the 1950s—but the argument for CHWs has been controversial. The term “community health worker” has been applied to a myriad of different actors, but generally describes local people who are trained to work in their (usually rural) town on a range of health problems from education to medication delivery. CHWs often make housecalls, and have been conceptualized as “an army of one” for health, like Halo officers roving through the landscape with vaccines and bandages instead of guns and grenades:
But CHW programs have also been criticized for providing substandard, unreliable medical care; some have argued that CHWs should be volunteers, to promote community “bonding” and “empowerment”, but shouldn’t be paid because such a system would be “unsustainable”. CHW programs in Tanzania, Colombia, Jamaica, and Botswana have been recently defunded under this premise. In this week’s blog, we ask: what do we know about CHWs? Do CHW programs “work”, and should we pay for them?
Why bother with CHWs?
When country ministers signed an agreement to deliver “Health for All” by the year 2000 in the 1978 Alma Ata Declaration, many saw CHWs (modeled after China’s “barefoot doctors”) as a means to achieve the task. Reports on the capacity of health systems reveal a shortage of more than 4 million healthcare workers; among 15 countries in sub-Saharan Africa, there are five or fewer physicians per 100,000 people (that’s about one-fourth as many as could conceivably care for a population of 100,000). Many institutions like the WHO and UN have argued for “task shifting” away from doctors to nurses and CHWs, so that patients who otherwise would not see any providers can obtain some form of healthcare. CHWs have also been viewed as an opportunity for social mobilization around health, giving voice to community members otherwise excluded from healthcare delivery decisions (e.g., providing the opportunity for a non-elite community member to reveal what health problems are of high community concern but haven’t entered into the planning of bureaucrats).
Does task-shifting work, or make outcomes worse? In our review of the data, the answer depends on a few key factors: training, supervision, and support.
When CHWs are effective (and not): the data
After the Alma Ata Declaration passed in 1978, CHW programs abounded in developing countries experiencing ongoing liberation struggles, such as Tanzania and Zimbabwe, where health equity and CHW training was considered part of the broader movement for post-colonial social justice and local healthcare access. But with the 1980s economic recession, CHW programs were harshly defunded as part of World Bank structural adjustment programs, which emphasized private-sector health system development and reduced government spending on community health projects.
A few key CHW programs survived. In Indonesia, CHWs were trained in early 1980s to provide family planning and post-partum services, particularly diarrhea treatment and early vaccination for infants. They reported a 30% decline in infant mortality within seven years and a several-fold rise in immunization coverage. The program was continuously funded by the central government, but local boards selected and distributed payment to CHWs. Local selection seemed to ensure that the most popular, widely-accepted community members were chosen for the task. The CHWs were also supported by doctors at local health posts, so that they were not left to fend for themselves when questions or concerns arose about patients. Individual CHWs would undergo specific training modules and narrow their focus on a few key community problems (such as identification and treatment of infant diarrhea), not to all health conditions. Tasks too complex for a CHW would be referred to the central health center.
In this context, there has been a long debate about how many functions a CHW can perform. In Burkina Faso, where CHWs primarily served an education function, two-thirds of ailments had to be referred to the next level of care, resulting in frustration among patients. Part of the problem may have been that the CHWs could not offer significant medical treatment. In many studies, CHWs who provide only “education” are among those least effective; having some actual medical services to offer results in fewer dropouts among both patients and providers in CHW programs.
As Rony Brauman, former president of Doctors Without Borders, argued sarcastically: “We think that the world’s poor and destitute will have the right to benefit from our generosity through the promotion of health education. The West will have the doctors; the developing world will have ‘health educators.’”
Most studies suggest, however, that having CHWs be too “general” in their medical skill-set is a mistake; this leaves CHWs with limited education to attempt to provide services they are not equipped to offer, resulting in substandard care. As CHWs typically have limited primary education, providing dedicated training in one or a few key protocols (how to identify and treat just one or two common conditions) has been more effective that trying to create a substandard generalist doctor (see examples in child health, TB, malaria, HIV and respiratory infection treatment).
In other words, it seems unwise to expect CHWs to provide “primary care”. They can, however, provide continuous chronic care services quite well. As Farmer described the Partners in Health CHW program, “It’s probably the best model for chronic disease, period. If you break your arm, it’s one thing. You get your arm set. Hopefully, it heals. But, if you have diabetes, say, or major mental illness or AIDS, then you’re going to need people to help you along the way for a long time. We call that accompaniment. Our health workers accompany their neighbors.” And it takes much less effort, no matter where you live, to have your neighbor visit you at home than for you to visit the city hospital.
Contrasting the programs in Brazil and India provides an illustration of these principles. Brazil’s Programa Agente Comunitário de Sáude started in the 1980s, paying CHWs to receive training and provide diarrhea management, vaccinations, and breastfeeding education to their communities. The program was a economic stimulator, providing new jobs to 7,300 people. For less than $1.50 per person served, Brazil was able to pay twice the average rural salary to hire CHWs that were supervised closely by registered nurses. The CHWs reduced infant mortality by 32% within five years and increased the rate of exclusive breastfeeding significantly. By 2004, the program covered 66 million people nationally (about 40% of the population). By 2005, hospitalization rates had dropped from 52 to 38 per 10,000 as a result of the program’s involvement in chronic antenatal care services.
Brazil’s program has been centrally-funded by the national government to provide even the poorest states with redistributed tax funds from wealthier locales, and to ensure a steady stream of funding when local areas experience droughts or natural disasters that spark recessions. This seems crucial to financing CHW programs. The data on community financing shows that such programs are rarely successful unless institutionalized (e.g., China); nearly all local community financing schemes have failed due to irregularities in the stream of funding, manifesting in high CHW drop-out rates and program collapse. CHW programs that depend on community financing have twice the attrition rate as those who receive a government salary. In Nigeria, for example, half of CHWs dropped out within two years of their training. In Brazil, local boards still manage the programs at the municipal levels for CHW selection, hiring and firing of workers, and selection of standardized training materials to emphasize locally-prevalent health problems. But dedicated national funds provide the ultimate monetary supply, allowing for sustenance of the program through general taxes. Cost-effectiveness studies have been widely favorable toward funding CHW programs as a means of delivering such local health services (e.g., see the most widely-cited cost-effectiveness assessments, in Kenya and Bangladesh).
In contrast to Brazil, India created a program that did not pay its CHWs, that relied on local finances exclusively, did not have backup support by nurses or doctors for the CHWs, and tried to replace primary care training and distribution of new doctors with generalist CHWs. Very limited initial training (without continuing education) was provided. The program descended into chaos. Local physicians viewed CHWs as competition, and actively tried to sabotage the CHW program. CHWs themselves failed to come to work after their training, demanding remuneration. Promoters of the program deflected attention to these ongoing conflicts and praised the program’s philosophical focus on “volunteerism” as a reflection of community “empowerment”.
The state ministers of Chhattisgarh identified the ongoing problems with the national Indian program and generated their own local program, which paid CHWs, engaged them in a continuous training and supervision process with doctors at state health posts, and focused the CHWs in areas that were not competing with existing providers. The CHWs were expected to work for two to three hours per day for two to three days per week, allowing time for farming and other breadwinning activities. The state’s CHWs were also dedicated to a narrow set of tasks: scheduled antenatal care, diarrhea and malnutrition treatment, and malaria diagnosis for referral. While the national program essentially became defunct, the Chhattisgarh state’s program continues today.
“Empowerment” does not come in a package
By their very nature, most evaluations of CHW programs have been anecdotal, as in our examples above. As a result, we can glean lessons about broad issues like payment, political procedure, and supervision by comparing CHW programs in different countries, but the real specifics of “how best to implement” a CHW program remain a data-free zone.
Even when CHWs are paid, support is provided in both monetary and medical terms to create program infrastructure and supervision, and national governments provide funding that is distributed by local boards to select the best workers and dedicate them to the most pressing local problems… not everything goes well. The reality is that CHW programs appear to thrive in already-mobilized communities. They struggle, however, when they are given the responsibility to mobilize the community themselves.
Nearly every article on CHWs tries to emphasize their role as a mechanism for community “empowerment” or at least community participation. But the most successful programs appear to have derived out of broader social reforms taking place. For example, the Brazilian program was part of a broader package of national job creation and economic recovery (a New Deal-type program for all of Brazil’s sectors, not just healthcare). This is also true of CHW programs in the Philippines, Kenya, and in many liberation struggles against politically-oppressive governing bodies.
On the other hand, CHW programs like the ones in Ecuador and Nicaragua were stifled when CHWs were expected to engage with communities that did not open their doors to them. Data from both programs shows that even well-trained, centrally-supported local CHWs had essentially no impact when community members were politically stifled and living such chaotic and oppressed lives that they had no desire to engage with CHWs who might be viewed as agents of the state.
An extensive review of CHW program successes in poor communities concluded that “the concept of community ownership and participation is often ill-conceived and poorly understood.” It cannot be simply pre-packaged, but comes from dedicated long-term work with local community politics. And even the best CHW program may not provide any meaningful health services in a hostile environment.
So if we are to answer the question of which single intervention would do the most to improve the health of those living on less than $1 per day, the answer may be a ballot box, not a CHW.
Model programs have showed us that CHWs can improve access and outcomes, contingent on their program support. What does it take to provide adequate CHW support? A few key expectations need to be set:
 There exists no evidence to suggest that voluntary CHW programs can be sustained. Being a CHW is a job, just like being a doctor. It doesn’t mean CHWs are not going to be passionate about their jobs, but we can’t expect them to provide reliable medical care with 100% effort if we don’t pay them. We can’t fire someone for substandard work when they’re volunteering, and we can’t attract people to undergo rigorous training and consistently dedicate time to a voluntary service project when that time could be spent making money. Most CHWs are poor, and their time spent being a CHW is time lost from other forms of breadwinning. Saying that volunteerism is more “empowering” than payment is simultaneously accepting a program while undermining it—it’s admitting the program must be useful, but not bothering to pay for its value.
 CHW programs are not a panacea to real health systems. But CHWs can help improve patient outcomes with adequate training and supervision, if appropriate tasks are given for a CHW’s educational level. No amount of information technology or fancy-looking cellphone software given to CHWs will fix the fact that they didn’t go to medical school. It’s just the reality of working with providers at different levels of training, just as in your local doctor’s office: if a nurse practitioner is dedicated only to helping diabetics use their insulin correctly (e.g., how to draw the insulin out of the bottle, measure the right amount, inject it in the right way, and watch for problematic complications), then they can see more diabetics, and do a better job managing this aspect of diabetes than a doctor can. A diabetic nurse becomes an expert on insulin management. Most doctors who prescribe medicines for diabetes every day don’t know the difference between two different brands of insulin needles, but diabetic nurses do, and they often have more time and better long-term rapport with patients than do doctors. On the other hand, if you have an odd growth on your back, you’ll want to see a doctor to tell you if it’s melanoma or a benign cyst; you don’t want a minimally-trained CHW at that time. If you do see a CHW for the growth, you’ll want them to have a physician available for backup.
 As a result, we can’t pretend that CHW programs are creating a “health system” or “primary care”. CHW programs can be effective for narrow tasks or a few key programs, and can serve a starting base from which to build further health systems. But the bottom line is that if we never pay for infrastructure, it will never come. If we say that only the cheapest interventions are “sustainable” for the poor, and everything else is “unsustainable”, then the poor will never have anything built in their communities, and will perpetually get “health educators” who provide no meaningful health care. We have to create national (and international) redistribution systems to fund meaningful infrastructure (including human infrastructure), as the failure of local financing systems has revealed.
As Rony Brauman described the origins of the CHW endorsement by international aid agencies: “The basic assumption was that 90% of the world’s diseases could be easily prevented or treated. This sentence crops up again and again in the official reports of UNICEF, WHO, UNDP…this assumption is absolutely false—it’s a demagogic lie that enables a number of NGOs and health and humanitarian institutions to establish their own special laws for the poor…We will have real practitioners; they will have community health workers…In just a few months after the 1978 conference, WHO trained teams of so-called community health workers—giving them pills, disinfectants, a few drugs, whatever… That was much easier and cheaper than getting involved in real healthcare policy for the Third World, which implies that you train people seriously, you pay them, and you organize a huge administrative and logistical system in order to supply health centers, health posts, and hospitals that allow them to function, that allow them to bring real medical care to deprived areas. But the WHO could justify this because those community health workers were getting rid of 90% of the diseases through health education and basic healthcare. Of course, the people who established and promoted this program would never have permitted themselves or their children to be treated by those community health workers. This is what I meant by a “two-level law”—I don’t know how to translate it into English, but I think you can understand.”
“Empowerment” and “development” are not things we can deliver in a CHW program. We have to work for the re-shifting of social injustices through daily politics. It means having to deal with local and national bureaucracies, probably for a very long time, to ensure that health issues are addressed as part of the broader package of social reforms to help the lives of the rural poor. In that broader scheme, CHWs are no panacea, but they can be one part of a wider effort to achieve a few key healthcare goals, if we let them.