The History of Community Health Worker
The concept of using community members to render certain basic health services in communities from which they come has a 50-year history at least. The Chinese barefoot doctor program is the best known of the early program, although Thailand, for example, has also made use of village health volunteers and communicators since the early 1950s (Kauffman & Myers, 1997; Sringernyuang, Hongvivatana & Pradabmuk, 1995).
Barefoot doctors were health auxiliaries who began to emerge from the mid-1950s and became a nationwide program from the mid-1960s, ensuring basic health care at the brigade (production unit) level (Zhu et al., 1989; see also Hsiao, 1984; Sidel, 1972; Shi, 1993). Partly in response to the successes of this movement and partly in response to the inability of conventional allopathic health services to deliver basic health care, a number of countries subsequently began to experiment with the village health worker concept (Sanders, 1985).
The early literature emphasizes the role of the village health workers (VHWs), which was the term most commonly used at the time, as not only (and possibly not even primarily) a health care provider, but also as an advocate for the community and an agent of social change, functioning as a community mouthpiece to fight against inequities and advocate community rights and needs to government structures: in David Werner’s famous words, the health worker as “liberator” rather than “lackey” (Werner, 1981). This view is reflected in the Alma Ata Declaration, which identified CHWs as one of the cornerstones of comprehensive primary health care. Examples of VHW initiatives in Africa driven by this rationale include Tanzania’s and Zimbabwe’s VHW programs in their early phase. Both were set in the political context of wholesale systemic transformation (decolonization and the Ujamaa movement in Tanzania, and the liberation struggle in Zimbabwe), and both focused on self-reliance, rural development and the eradication of poverty and societal inequities.
Then came the economic recession of the 1980s, which seriously jeopardized particularly the economies of developing countries, and brought shifts in the policy environment as the focus on liberation, decolonization, democratization, self-reliance and the “basic needs” approach to development was replaced by World Bank-driven policies of structural adjustment and its successors. The collapse was further facilitated by the fact that many large-scale programs had suffered from a number of conceptual and implementation problems such as “unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality” (Gilson et al., 1989). While many policy-makers turned their attention away from CHWs altogether, others, wanting to rescue the concept and practice, suggested subtle shifts, as the following quote from a WHO publication on CHWs illustrates: CHW programs have a role to play that can be fulfilled neither by formal health services nor by communities alone. CHW programs were the first to fall victim to new economic stringencies and most large-scale, national programs collapsed (although numerous nongovernmental organizations (NGOs) and faith-based organizations (FBOs) continued to invest in mostly small, community-based health care). Ideally, the CHW combines service functions and developmental/promotional functions that are, also ideally, not just in the field of health. Perhaps the most important developmental or promotional role of the CHW is to act as a bridge between the community and the formal health services in all aspects of health development….the bridging activities of CHWs may provide opportunities to increase both the effectiveness of curative and preventive services and, perhaps more importantly, community management and ownership of health-related programs… CHWs may be the only feasible and acceptable link between the health sector and the community that can be developed to meet the goal of improved health in the near term (Kahssay, Taylor & Berman, 1998).
Although this concept of CHWs continues to focus on their role in community development and bridging the gap between communities and formal health services, their role as advocates for social change has been replaced by a predominantly technical and community management function. Over the years, and within the prevailing political climate, this pragmatic approach to CHWs has gained currency, and undoubtedly today constitutes the dominant approach, although the fundamental tension between their roles as extension worker and change agent remains and will be discussed below. Examples of CHW programs implemented as part of wider health sector reform processes, aiming to enhance accessibility and affordability of health services to rural and poor communities within a PHC approach, can be found in numerous low-income countries in the 1970s and 1980s, three of which are sketched below. Indonesia restructured its health system in 1982, with a focus on district health development. Village health volunteers, selected and paid by local communities, became part of health posts set up within each district. Their activities included family planning, health education, growth monitoring, nutrition support, immunization and treatment, particularly of diarrhoeal diseases. Initial reports showed remarkable results. Yahya reports that the dramatic increase in village health posts led to significant health status achievements: infant mortality dropped by 30% within seven years and immunization coverage improved many-fold (Yahya, 1990). In Ghana, the Ministry of Health introduced substantial numbers of community or village health workers in the late 1970s as part of a substantial review and reorganization of MoH activities aimed at implementing PHC strategies (Morrow, 1983). The initiative was driven by the MoH and integrated into the National Health Service structure, with the MoH providing training, technical supervision and necessary supplies. In Niger, CHW programs evolved from the work of volunteer health workers whose work started in the late 1960s in the primarily agricultural Maradi Department, along the Nigerian frontier, with a population of 730 000 people (Fournier & Djermakoye, 1975). Since 1963 Niger had a rural extension service (animation rurale), which promoted community development schemes characterized by voluntary participation. In the Ministry of Health, a 10-year plan from 1965 to 1974 set out the principles governing the training of village health workers and traditional birth attendants.While emphasizing community ownership and participation, all these projects were initiated and driven by central government.
Unfortunately, we could not find any literature on lifespan or impact of these programs. Another source of CHW initiatives is faith-based organizations, which, over the decades, have combined missionary with practical work to improve the health, education and social conditions of communities. By their very nature, these initiatives are driven by a different rationale, and the challenges they confront are often somewhat different. Today’s renewed focus on the use of CHWs has its rationale primarily in a recognition that service needs, particularly in remote and underprivileged communities, are not met by existing health services, particularly given increased needs created by HIV/AIDS in many countries and worsening health worker shortages. CHWs are used primarily to render basic, mostly curative health services within homes and communities and to assist health professionals with their tasks.
