Community Health Worker - Current Status

Current Status

Cost and access to medical care remain problems of worldwide scope. They are particularly severe in the developing world and it is estimated one million more health care workers are needed in Africa to meet the health-related Millennium Development Goals. Doctors are few and concentrated in cites. In Uganda some 70% of medical doctors and 40% of nurses and midwives are based in urban areas, serving only 12% of the population. Medical training is long and expensive. It is estimated that to meet health workforce needs using the American or European model, Africa would need to build 300 medical schools with a total training cost of over $33 billion and it would take over 20 years just to catch up. In many countries salaries of doctors and nurses are less than that of engineers and teachers. Bright young medical professionals often leave practice for more lucrative opportunities. Emigration of trained personnel to countries with higher salaries is high. In Zambia of the 600 doctors trained since independence it is estimated only 50 practice in their home country. In some countries AIDS is killing experienced nurses and doctors amounting to 30-50% of the number trained yearly. Though many countries have increased their spending on health care and foreign money has been injected, much of it has been on specific disease-oriented programs. Health systems remain extremely weak, especially in rural areas. The World Health Assembly in 2006 called for, “A health workforce which is matched in number, knowledge and skill sets to the needs of the population and which contributes to the achievement of health outcomes by utilizing a range of innovative methods”.

Community health workers are thought to be part of the answer. They can be trained to do specialized tasks such as provide sexually transmitted disease counseling, directly observed therapy for tuberculosis control, or act as trained birth attendants. Others work on specific programs performing limited medical evaluations and treatment. Others have a far broader primary care function. With training, monitoring, supervision and support such workers have been shown to be able to achieve outcomes far better than baseline and in some studies, better than physicians.

Important attributes of community health workers are to be a member of and chosen by the community they serve. This means they are easily accepted by their fellows and have natural cultural awareness. This is crucial because many communities are disengaged from the formal health system. In Sub-Saharan Africa 53% of the poorest households do not seek care outside the home. Barriers include clinic fees, distance, community beliefs and the perception of the skills and attitudes of medical clinic workers. Community health workers are unable to emigrate because they do not have internationally recognized qualifications. Finally, the variation in incentives between areas of the country tends to be low. All these factors combined with strong community ties, tend to result in retention at the community level.

Much remains to be learned about the recruitment, training, functions, incentives, retention and professional development of community health workers. Learning developed in one country may not be applicable to another due to cultural differences. Health worker adaptability to local requirements and needs is key to improving medical outcomes. That being said, it has been estimated that six million children’s lives a year could be saved if 23 evidence based interventions were provided systematically the children living in the 42 countries responsible for 90% of childhood mortality. Over 50% of this benefit could be obtained with an integrated, high-coverage, family-community care based system. Community health workers may be an integral and crucial component of the health human resources team needed to achieve such goals.