Sometimes I start writing a post and it ends up somewhere completely different than I had originally imagined it. My last post, on why there might be less good global health blogging out there than you'd expect, was actually originally going to be a simple link and quote from what I think is a very good post. A global health blogger named Emma notes some recent coverage of community health worker programs in the NYTimes (Villages Without Doctors). Then Emma writes:
There’s nothing more valuable than a good community health worker. [...Some reasons they're good....] 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.
Emma also highlights a companion NYT piece called What Makes Community Health Care Work?
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).