Community Health Workers: Liberators or Lackeys? [1]
David Werner had raised this question in 1981, and today 16 years later, it is still valid. Community Health Workers can be paid workers or volunteers [2], and both situations have implications for strategies of supporting them, and articulating expectations from them. Under the leadership of Jack Bryant [3], Community Health Sciences Dept of Aga Khan University, two models of CHW were tested. One was called ‘CHS led’ model in which an honorarium was paid to the CHWs, and the other was Community led model where health volunteers worked with the PHC team. The striking feature of the latter was manifest in a question a health volunteer asked the community health nurse, ‘why are you late today?’. The paid CHW, would never have the courage to ask such a question, and their subordination was embodied in their remark when at a meeting in the PHC center, they refused to sit on the chair of the field director of the PHC program. ‘we can’t sit on that chair’, said one when she was being goaded to take the chair, looking at the large black, high back chair, leaning back, behind a desk. What is the source of power of a CHW, one could ask. What ‘power’ does a CHW have when she is subordinate to the PHC team, and undertake tasks determined by the PHC Team, compared to a CHW who derives her strength from the community to which she is accountable.
The trend in approach to CHW is more to seek improvement in her performance, and for fulfilling the task assigned to her. A systematic review of published articles on CHWs was said to provide following key messages:
1. A systematic review of 140 quantitative and qualitative studies identified factors related to the nature of tasks and time spent on delivery, human resource management, quality assurance, links with the community, links with the health system and resources and logistics having an influence on CHW performance.
2. Good performance was associated with intervention designs involving a mix of incentives, frequent supervision, continuous training, community involvement and strong co-ordination and communication between CHWs and health professionals, leading to increased credibility of CHWs.
3. When designing CHW programmes, policymakers should take into account factors that increased CHW performance in comparable settings, to maximize programme outcomes. [4]
As is quite apparent from the above points, CHWs is seen as a means for achieving some objectives, which are supposed to ensure health of the population being served. This is what makes them ‘lackeys’ (doing what has been assigned by somebody else), and not liberators, as Paolo Freire outlines liberation and liberators.
The notion of ‘liberator’ that is invoked in David Werner’s article is well explained in Paolo Freire’s thoughts and practices.
This person is not afraid to meet the people or to enter into a dialogue with them. This person does not consider himself or herself the proprietor of history or of all people, or the liberator of the oppressed; but he or she does commit himself or herself, within history, to fight at their side.” Paulo Freire, Pedagogy of the Oppressed
“Liberating education consists in acts of cognition, not transferals of information.” [5]
For a CHW to be a liberator means she is a critical thinker who recognized the structures of oppression which lead to poor health outcomes. In other words she would understand the importance of social determinants of health (SDH). She would be trained to reflect, analyze and facilitate the community to do the same, so that they could explore options for actions. In other words, the pedagogy used for CHWs would be critical. It would not only be based on scientific knowledge, but also on Freirean principles of education. (Education as liberation and not domestication.)
CONCLUSION
… the point is that if poor health is a political problem it will need a political not a technical solution. The answer is not more health care workers. The answer is health care workers who I. – can mobilize their own communities to improve their own health. Susan Rifkin [6]
There are many developing countries where the State commitment to the health of the poor is grossly inadequate. (Example Pakistan). Where there is no state, then other actors are needed – both professionals, and the community (the oppressed groups specially). How CHWs become liberators means they can mobilize/engage/involve communities to address social determinants of health, and also hold the state accountable
Role of CHWs as leaders and not mere agents of health managers is the goal to promote and support.
1. David Werner had raised this issue in his article The Village Health Worker, Lackay or Liberator. 1981(http://www.fastonline.org/CD3WD_40/JF/JF_VE/SMALL/27-714.pdf)
2. CHWs are volunteers in Kenya and Iran, to name some countries . In Kenya, when I had an opportunity to meet some CHWs I was struck by the role of a church in creating economic opportunities for them.
3. Jack Bryant had led the US delegation to the Alma Ata meeting in 1978. He was a friend of Hafden Mahler and was instrumental in getting Mahler spend a week in the department of Community Health Sciences (CHS) of Aga Khan University (AKU), Karachi. He was committed to PHC which was integrated in the undergraduate medical education of AKU.
4. Shared in list serve of HIFA (health information for all) (HIFA@dgroups.org; on behalf of; Neil Pakenham-Walsh neil.pakenham-walsh@ghi-net.org. Jan 17, 2017)
5. Paulo Freire (https://www.goodreads.com/author/quotes/41108.Paulo_Freire)
6. Quoted in HEALTH PROMOTERS, POLITICAL STRUGGLE AND SOCIAL TRANSFORMATION , A Framework for Systematizing the Experience of a Popular Health Education Project in Chile A Master’s Project Completed by Karen L. Anderson
HIFA profile: Kausar Skhan is with the Community Health Sciences Dept of Aga Khan University, Karachi, Pakistan. kausar.skhan AT aku.edu