History
Scientific medicine has evolved slowly over the last few millennia and very rapidly over the last 150 years or so. As the evidence mounted of its effectiveness, belief and trust in the traditional ways waned. The rise of university based medical schools, the increased numbers of trained physicians, the professional organizations they created, and the income and attendant political power they generated resulted in license regulations. Such regulations were effective in improving the quality of medical care but also resulted in a reduced supply of clinical care providers. This further increased the fees doctors could charge and encouraged them to concentrate in larger towns and cities where the population was denser, hospitals were more available, and professional and social relationships more convenient.
In the 1940s Chairman Mao Tse Tung in China faced these problems. His anger at the “urban elite” medical profession over the maldistribution of medical services resulted in the creation of "Barefoot doctors". Hundreds of thousands of rural peasants, chosen by their colleagues, were given rudimentary training and assigned medical and sanitation duties in addition to the collective labor they owed the commune. By 1977 there were over 1.7 million barefoot doctors. As professionally trained doctors and nurses became more available, the program was abolished in 1981 with the end of agricultural communes. Many Barefoot Doctors passed an examination and went to medical school. Many became health aides and some were relieved of duty.
Brazil undertook a medical plan named the Family Health Program in the 1990s that made use of large numbers of community health agents. Between 1990 and 2002 the infant mortality rate dropped from about 50 per 1000 live births to 29.2. During that period the Family Health Program increased its coverage of the population from 0 to 36%. The largest impact appeared to be a reduction of deaths from diarrhea. Though the program utilized teams of physicians, nurses and CHWs, it could not have covered the population it did without the CHW. Additionally there is evidence in Brazil that the shorter period of training does not reduce the quality of care. In one study workers with a shorter length of training complied with child treatment guidelines 84% of the time whereas those with longer training had 58% compliance.
Iran utilizes large numbers of para-professionals called behvarz. These workers are from the community and are based in 14,000 “health houses” nationwide. They visit the homes of the underserved providing vaccinations and monitoring child growth. Between 1984 and 2000 Iran was able to cut its infant mortality in half and raise immunization rates from 20 to 95%. The family planning program in Iran is considered highly successful. Fertility has dropped from 5.6 lifetime children per woman in 1985 to 2 in 2000. Though there are many elements to the program (including classes for those who marry and the ending of tax incentives for large families), behvarz are extensively involved in providing birth control advice and methods. The proportion of rural women on contraceptives in 2000 was 67%. The program resulted in profound improvement in maternal mortality going from 140 per 100,000 in 1985 to 37 in 1996.
Read more about this topic: Community Health Worker
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—Frances A. Griffin, U.S. suffragist. As quoted in History of Woman Suffrage, vol. 4, ch. 19, by Susan B. Anthony and Ida Husted Harper (1902)
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