Sunday, March 20, 2011

Community Health Workers, Again

I wasn’t terribly eloquent in my last posting about community health workers.  Here’s another try.

There’s nothing more valuable than a good community health worker.  For a limited investment of time (9 months give or take a few in South Sudan) and money (usually on the part of a NGO like mine), you can provide a community that previously had no health workers with someone capable of diagnosing and treating the most common diseases in that community (in South Sudan malaria and diarrhea for the most part, or pregnancy complications) and when to refer on to a higher level of care.  When this happens, it’s a beautiful model. 

When it doesn’t—and it doesn’t far more often than anyone would like to admit—community health workers are at best a drain on expenses with little to show for it and at worst a THREAT to community health instead of an asset.  They can lure organizations and communities into complacency and miss opportunities for training higher level health care workers, breed antibiotic resistance strains of diseases by misuse of antibiotics, or give a false sense of security to people who actually need higher levels of care, among other things.  If you think about CHWs usually are—rural, uneducated and as often as not illiterate or semi-literate people pulled from their communities and given tremendous responsibility with short training courses—this isn’t terribly surprising.

There’s been some pretty positive attention paid to community health workers recently, namely in a recent New York Times article about a couple of apparently very successful CHW programs in India.  Luckily, some deeply wise person at the New York Times wrote a companion article about the things you need for a CHW program to be successful.   The article talks about really important things—make the program sustainable enough so that it can last after the donor leaves!  Teach the CHWs to teach so even if the CHW doesn’t last some of their lessons will! Provide support for newly trained CHWs so they don’t feel stranded and alone!  Expand in ways that make sense for the specific setting and situation!  Get the country’s government on board!  But…

There’s always a but.  These things are HARD.  Really hard.  Of COURSE we want to do supportive supervision for the CHW, to watch how they practice and build their skills one-on-one based on each CHWs specific strengths and weaknesses. Of COURSE we want to design a program that can last long after we don’t have money from a donor anymore (emergency grants are usually 1-2 years at most).  Of COURSE we want the CHWs to teach their communities how live healthier lives.  But supportive supervision involves enough organization employees to conduct regular visits to remote and widely dispersed sites, and a security situation that allows these workers to safely go out into communities, and enough vehicles to get out to remote sites (and donors are often reluctant to fund vehicles and the fuel and insurance they take). 

This isn’t to say it can’t be done, and it isn’t to say it shouldn’t be tried.  Like I said, a good CHW is priceless.  But it is to say that I (and this is MY take on the issue) think that it is something that is being entered into too casually at the moment, without full consideration or regard for the immense complexities CHWs can entail.  

So what’s the solution?  Some it is sort of beyond the scope of my blog (does this blog have a scope?), but entail proper budgeting in the proposal where we ask the donor for money for these programs.  Another aspect involves a realistic appraisal of our limitations as an organization, and identifying and addressing these from the beginning instead of waiting until they become problems.

There’s also the “big” solution:  train enough mid-level (registered nurses and midwives) and higher-level (physicians) health workers that you no longer have to rely on CHWs.  This is the way South Sudan has recently decided to go.  But it has a long road ahead of it—curricula must be developed, schools started, qualified candidates found, and graduates placed and willing to stay in remote, rural communities across South Sudan.  Right now, there 0.5 physicians and 9 registered nurses per 100,000 people, and these are heavily concentrated in the central Equatoria region, around Juba.  And here’s a sobering thought:  even if you do all that, it’s likely that some more developed country (UK, US, Australia, in particular), itself experiencing a shortage of qualified health care workers, will snatch your newly trained health workers.  It has been estimated that as many as half the doctors in many African nations end up leaving these countries, and each time a physician leaves, it represents a net transfer of assets of approximately $600,000 from poor to wealthy country.  Those who stay are drawn to cities, not the distant areas of the country that need them the most.

Like most things in public health, this isn’t a clear cut issue.  And it’s one of the areas where my field—monitoring and evaluation—is most important.  Are CHWs actually working?  Do they decrease mortality and morbidity?  When they do, what are they doing right?  When they don’t, what’s going wrong?  Rigorous evaluation (did it work?) of CHW programs will help provide these answers, and sharing these answers among different organizations and governments will help make sure that organizations don’t keep repeating each others mistakes—and can repeat each others successes.

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