Respond to this article

Community health workers

The worldwide shortage of healthcare staff means that necessary treatments are often not delivered. Lay people, without full medical training, are stepping up to meet local needs, as Vijaya Bhatt and Aaradhana Jha explain

Doctor training a health worker in Brazil

Human resources are one of the vital determinants of the quality of health services. The number of health workers has been linked to the output of a health system and the health outcomes in a society. The number of health workers is also a key indicator of a country's capacity to increase delivery of interventions.^w1-w4

Countries with acute shortages in personnel urgently need a rapid increase in the number of health workers (box),^w4 and the use of community health workers is a possible solution.^w7

Community health workers are people chosen by the community who are trained to deal with the health problems of people in the community and may or may not be paid. They are known by different names in different countries. For example, in Nepal they are female community health volunteers; in India village health guides; and in Bangladesh shastho shebikas.

Community health workers apply their understanding of the complex community psychology, culture, and other social factors to connect healthcare consumers with providers. Their role is not only to involve rural people in the provision, monitoring, and control of basic health services but also to place "people's health in people's hand."^w8

A valuable role

Throughout Nepal by 2003 more than 48,550 trained volunteers were working. In India as of 2000 about 323,000 village health guides were working. And in Bangladesh by 1999 25,140 shastho shebikas were helping 35 million people.^w8 In northeastern Brazil a few years after their recruitment, community health agents were visiting 850,000 families a month, and some of the big drops in infant mortality are attributed to the services that they provide.^w6

Studies from South East Asia and Africa show that community health workers are cost effective, providing curative health services and specific health programmes.^w3 Their actions can improve health outcomes, especially in child health and antenatal care.^w7 Community health workers can also act as a complementary force to promote use of existing health services.^{w1 w7}

In Bhutan, with doctors scarce, the people turn to village health workers. People do the same in other poor countries^w8—and in some parts of rich countries.^w10 Cochrane studies, mostly from the United States, Canada, and the United Kingdom, have also shown that lay health workers are effective, at least for some kinds of health care, such as programmes related to lung infections and malaria.^w9

Although lay health workers are primarily intended to provide preventive and promotive health care, the community expects them to treat common diseases.^w8 The evidence from Nepal and Bangladesh shows that prevention is extremely hard to sell, but curative care is generally more welcome and appreciated by the community. In Nepal community members prefer lay health workers to distribute drugs and provide treatment rather than to provide health education.

Also, lay workers themselves want to be trained to distribute drugs.^w8 In many poor countries, such as Nepal, most doctors are concentrated in the cities,¹¹ and community health workers run health centres in rural areas.¹²

The need for education

The effectiveness of the health workforce depends mostly on its knowledge and skills and has become a serious concern in poor countries.^{w3 w13-w15} The academic background and training of community health workers vary widely in different regions. According to the World Health Organization community health workers should have a level of basic education that enables them to read, write, and do simple mathematical calculations.^w8

KAMPALA/UGANDA

In Bangladesh shastho shebikas receive basic training that lasts for three weeks followed by refresher training for one day every month for two years. This training focuses on health education and delivery of basic care, such as family planning, nutrition, immunisation, and so on.^w8 In India village health guides receive training for three months.

In east Africa most healthcare providers work in isolated rural areas, with few opportunities to update their competencies. This means their performance deteriorates and has generated a need for a programme to improve their efficiency.^w16

In Nepal female community health volunteers receive an initial 15 days of training followed by two days of refresher training every six months. They reported with frustration that contrary to their fellow villagers' expectations they were not able to treat illnesses, and they unanimously asked to be given more medical training and more drugs. Training has now been formally identified as the most important component of the programme.^w8

Properly designed training programmes help to raise the productivity of community health workers. Algorithms help workers diagnose and treat less serious illnesses and even enable them to deliver services that are traditionally provided by doctors.^w6

In Nepal improvements in training, supervision, and supply of community health workers has improved their skills.^w7 A programme for acute respiratory infection was successful because the volunteers were given good training and guidelines.^w8

More than 25 countries in Africa use simplified guidelines to train health workers, which are based on WHO's guidelines for the integrated management of adolescent and adult illness. These enable them to deliver curative interventions.^w1

Risks and benefits

Clinical officers in Malawi who perform emergency caesarean sections reported an overall maternal death rate of 1.3%, which is high but much lower than expected if services did not exist.

In many poor countries midwives and other skilled health workers provide high quality surgical abortions. Although general fear for safety and quality is justifiable when non-medically qualified health staff are employed, this should be weighed against the fact that they might be much safer than nothing.^w3

In 1999 WHO launched a mental health project in Ghana that trained village volunteers to identify, refer, and follow up people who have mental disorders in their villages. This was successful, and the government has adopted the project and extended it to other districts, again showing that health workers can be used in specific health programmes after training.^w1

Continuous training also motivates community health workers to work in rural areas.^w8 This was shown by a study in north Vietnam.^w17

Strategic challenges

Training strategies have to be developed and validated by researchers, depending on the facilities available and the desired results from health workers. Interactive training, with as much hands-on real life experience as possible, and curriculums that are based on need are more likely to transfer knowledge and skills into practice.^w1

BABY CLINIQUE IN MOZAMBIGUE

Use of lay people as formal health workers raises questions about the roles they can undertake at a given level of training and their recruitment, retention, and level and method of remuneration.^w1

Because programmes that involve community health workers may not be the answer to all problems on all occasions, complementary strategies must be developed to tackle the shortage of health workers. The addition of services to pre-existing means of delivery, often referred to as "piggybacking,"^w1 and integrating health workers with other development workers have to be considered—for example, as at the Rural Unit of Health and Social Affairs in Tamil Nadu, India.^w18

Evidence shows that community health workers thrive in an already empowered community but struggle where they are given responsibility for galvanising and empowering a community. A key challenge also lies in getting the community to participate effectively with community health workers.^w7 Using community members in programmes run by health outlets—for example, awareness programmes—to promote other community members to use health services and to participate in decision making about health services and their management.

This "mobilisation" of community members and local clubs—for example, at Jamkhed, in Maharashtra, India^w19—can be vital. These efforts not only improve health but also empower a community with self reliance and control over the factors that affect their health.^{w18 w19} Essentially important are community education and awareness programmes that have positive influence in changing health related behaviours and increase reception of preventive and promotive health care.

In summary

Substantial emphasis is put on training medical and nursing staff as a solution to shortages in human resources, but these strategies have many constraints. For example, there may be a lack of medical schools—two thirds of sub-Saharan African countries have only one medical school, and some have none. Training takes time—at least five years to train a doctor and three to train a nurse. And training takes money^w3—the annual training costs range from $1.6m a country a year to almost $2bn in a large country like India.^w1

Community health workers' programmes require substantial financial and other resources, but they have less of the constraints surrounding training new doctors and nurses. Also, because auxiliary workers' qualifications are not recognised internationally their use to some extent also tackles the problem of migration of health workers.^{w1 w3}

Globally, community health workers provide basic health services to a large number of populations, including poor people from rural areas. But their efficiency is limited by lack of knowledge and skill. Continuing medical education and training programmes should provide problem oriented education, which would enable community health workers to conduct programmes and provide primary health care.

Competing interests: None declared.

References w1-w19 are on student.bmj.com.

Vijaya Raj Bhatt, intern, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
Email: vj@iom.edu.np
Aaradhana Jivendra Jha, intern


Student BMJ 2007;15:337-382 October ISSN 0966-6494

1. The World Health Report 2006. WHO[homepage on internet]. ©WHO2007.Accessed on August 30, 2007. Available from: http://www. who. int/ whr/2006/en/
2. Chen L., Evans T., Mogedal S., and Omaswa F. “Working Together to Tackle the Crisis in Human Resources for Health.” High Level Forum on the Health Millennium Development Goals: Selected Papers 2003-2005: Health Systems. ©WHO, 2006.
3. Hongoro C, McPake B. How to bridge the gap in human resources for health. Lancet 2004; 364:1451-1456. Accessed on August 30, 2007. Available from http://www.thelancet.com/journals/lancet /article /PIIS01406 73604172292/fulltext
4. WHO. The World Health Report 2003: Health Systems: Principled Integrated Care. WHO, Geneva.
5. WHO, Regional Office for Africa. The Health of the People-The African Regional Health Report: National Health Systems- Africa’s Big Public Health Challenge: Human Resource: A Continent in Crisis. WHO, Regional Office for Africa, 2006.
6. Sandiford P. “Improving Health Workforce Performance.” High Level Forum on the Health Millennium Development Goals: Selected Papers 2003-2005: Health Systems. ©WHO, 2006.
7. Lehmann Uta and Sanders David. “Community health workers: What do we know about them?” World Health Organization [homepage on internet]. WHO; cWHO2007. Accessed on May 10, 2007. Available from: http://www.who.int/hrh/documents/ community_health_workers.pdf
8. “What Works for Children in South Asia: COMMUNITY HEALTH WORKERS” UNICEF[homepage on internet].UNICEF; © The United Nations Children’s Fund (UNICEF) Regional Office for South Asia, 2004. Accessed on May 10, 2007. Available from: http://www.unicef.org/rosa/community.pdf
9. Lewin SA, Dick J, Pond P, Zwarenstein M, Aja G, van Wyk B, Bosch-Capblanch X, Patrick M. "Lay health workers in primary and community health care."The Cochrane Collaboration[homepage on internet]. © The Cochrane Collaboration. Accessed on August 30, 2007. Available at: http:// www. cochrane.org/reviews/en/ab004015.html.
10. “Community Health Workers: Essential to Improving Health in Massachusetts” [Findings from the Massachusetts Community Health Worker Survey]. Mass.Gov[homepage on internet]. Mass.Gov [The Official Website of the Commonwealth of Massachusetts]; Commonwealth of Massachusetts: Massachusetts Department of Public Health. Accessed on May 10, 2007. Available from: http://www.mass.gov/dph/fch/pco/community_health_workers_narrative.pdf
11. Prasad Pratap Narayan, Thakur Rama Shanker, Aacharya Ramesh Prasad. “Surgery in Rural Nepal” [monograph on the Internet]. Australian Broadcasting Corporation [homepage on the Internet]. Australia: Australian Broadcasting Corporation; c2005. Rural. Accessed on Oct. 2, 2005. Available from: http://abc.net.au/ rural/worldhealth/ papers/45.htm
12. Shankar PR, Partha P, and Shenoy N. “Self-medication and non-doctor prescription practices in Pokhara valley, Western Nepal: a questionnaire-based study.” BMC Fam Pract. 2002; 3: 17. Accessed on Oct. 2, 2005. Available from: http://www. pubmedcentral.nih.gov/articlerender.fcgi? artid=130019
13. Okolo S N and Ogbonna C. “Knowledge, attitude and practice of health workers in Keffi local government hospitals regarding Baby-Friendly Hospital Initiative (BFHI) practices.” European Journal of Clinical Nutrition. May 2002, Volume 56, Number 5, Pages 438-441. Accessed on May 10, 2007. Available from: http://www.nature.com/ejcn/journal/v56/n5/full/1601331a.html
14. Qayad Mohamed Gedi. “Competence of maternal and child health clinic workers in detecting malnutrition in Somalia.” Afr Health Sci. 2005 December; 5(4): 319–321. Accessed on May 10, 2007. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi? artid=1831951
15. MCKINNON M. D, INSALL C, GOOCH C. D and COCKCROFT A. “ Knowledge and Attitudes of Health Care Workers about AIDS and HIV Infection before and after Distribution of an Educational Booklet.” Occupational Medicine 1990;40:15-18. Accessed on May 10, 2007. Available from: http://occmed.oxfordjournals.org/cgi/content /abstract /40 /1/15
16. “Regional Consultation on Continuing Medical Education (CME) in East Africa” [Report from first CME workshop, Uganda 2002]. Exchange [homepage on internet]. Exchange, London[hosted by Healthlink Worldwide and supported by the UK Department for International Development (DFID)]; © 2000-2005 Exchange, London. Accessed on May 10, 2007. Available from: http://www.healthcomms.org/learn/learn02.html
17. Dieleman Marjolein, Cuong Pham Viet, Anh Le Vu, and Martineau Tim. “Identifying factors for job motivation of rural health workers in North Viet Nam.” Hum Resour Health. 2003; 1: 10. Accessed on May 10, 2007. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=280735
18. Srilatha V. L., Krishamurty V. G., Sundar Rao P. S., Mukarji D. S., Abel R., Steinhoff M. C., and Vance J. C. “Changes in Health Care Parameters Following the Introduction of a Comprehensive Rural Development Scheme in South India.” J Trop Pediatr 1988 34: 225-230. Accessed on August 30, 2007. Available from: http://tropej.oxfordjournals.org/cgi/content/abstract/34/5/225
19. Moazzem Hossain SM, Bhuiya A, Khan AR, Uhaa I. Community development and its impact on health: South Asian experience. BMJ 2004;328: 830-833; Accessed on August 30, 2007. Available from http://www.bmj.com/cgi /content /full /328/7443/830

       

 Printable version    Download PDF    E-mail this to a friend    Respond to this article