12.11 Community health workers

12.11 Community health workers
Oxford Textbook of Public Health

12.11
Community health workers

Suwit Wibulpolprasert

Introduction

Broad perspective of ‘health’ and the limitations of health professionals
The origin of community health workers

Definition and role of the community health worker

Responsibilities of community health workers

Should community health workers provide medical services?

Community health workers: successes and failures

Community health workers: conditions for success

Community health workers during rapid socio-economic change

Community health workers: not the end of Health for All–primary health care
Chapter References

Go to the people
Live among them, Learn from them
Plan with them, work with them
Start with what they know, build on what they have
Teach by showing, learn by doing
Not a showcase but a pattern
Not odds and ends but a system
Not piecemeal but integrated approach
Not to conform but to transform
Not relief but release
Y.C. James Yen
Introduction
Broad perspective of ‘health’ and the limitations of health professionals
The Executive Board of the World Health Organization (WHO) proposed redefining ‘health’ as ‘A dynamic state of complete physical, mental, social and spiritual well-being, and not merely the absence of diseases and infirmity’ (WHO 1998). The words in italics were added to the original definition as it appeared in the 1948 constitution of the WHO (WHO 1999a).
This new definition of ‘health’ further broadened the initial perspective to include the ‘spiritual’ dimension of health, and to stress its ‘dynamicity’. Nevertheless, the new definition still affirms that health is ‘a state of well-being’.
This broad perspective of health underscores its multifactorial nature. Health improvement depends much on the educational status (particularly of women), and other socio-economic development as on the development of the health-care systems (Roemer 1991; WHO 1999b) (Fig. 1).

Fig. 1 Multifactorial relationship of health and its determinants.

As health is a state of well being, anyone who acts to improve well being can be broadly designated as a ‘health worker’. Examples include

mothers who try hard to nurse and protect their babies

farmers who produce food for nutrition

teachers who provide education to increase an individual’s wisdom and to empower the community

engineers who build roads and provide electricity to rural villages

priests and monks who provide counselling to reduce mental stress, and encourage people to decrease their greed and selfishness, contribute significantly to improving the mental and spiritual dimension of health.
This holistic concept of health also emphasizes the intersectoral and participatory concept of ‘All for Health’ in addition to the human right concept of ‘Health for All’. The holistic and broader perspective of health is usually neglected and seldom considered or taught among health professionals. They usually confine themselves within the narrow perspective of disease and medical technology oriented health-care systems.
With the advent of modern health-care systems, health professionals who possessed the modern medical knowledge rose to power at the expense of previously prevailing self-care practices and community healers. These modern health professionals, with their power of new wisdom and their financial and political power, sometimes played an important role in shaping the health-care systems of their country more towards professionalism than for public interest. Starr (1984) described clearly the role of the medical profession in structuring the American health-care system.
Training health professionals in sophisticated modern health technology is costly. Modern health professionals usually work in expensive technologically oriented urban health-care infrastructures. In addition, they usually come from better-off families and thus are reluctant to work in the remote rural areas or among the poor urban slum dwellers. Because of their narrow perspective, high cost, and inequitable distribution, most modern health professionals provide inadequate responses to community health demands, particularly in the remote areas and urban slums. Thus self-care practices and traditional community healers still exist both in remote rural areas and in urban communities. However, with misguided modern health legislation, these community healers often become illegal.
The origin of community health workers
Accessibility to modern health-care services depends not only on its availability but also on its affordability, cultural acceptability, and its effectiveness (Fig. 2) (WHO 1984). Most developing countries cannot afford to build adequate modern health-care infrastructures to be accessed by every citizen. The existing public and private health facilities usually provide modern health services that are unaffordable for many, if not most. Those that provide free health services may provide substandard services which are unacceptable for the people. Finally many of these modern health services are not cost-effective because they are based on professional interests. Some even cause iatrogenic illnesses.

Fig. 2 Coverage of health services. (Adapted from WHO 1984.)

Countries usually respond to the problem of inadequate physical access to professional services first by providing a lower level of health personnel. For example, the posts of auxiliary midwives and junior sanitarians have been developed in Thailand since 1953. Apart from providing maternal and child care, and sanitation services, these auxiliary personnel also deliver basic medical care services. This inadequacy of professional services and the use of lower-level health personnel also occurs in more developed countries. In the United States and Canada, physician assistants and nurse practitioners have been developed since the mid-1960s (Jonas 1998). Nevertheless, even with the expanded services provided by these auxiliaries, basic health services are still not accessible by large number of rural villagers and poor people in urban slums. In many cases, rural health facilities have inadequate human resources or unqualified health personnel. Urban-trained health personnel, brought up in a different social and cultural background, also lack an understanding of the local community. Thus this problem is caused by multiplicity of complex socio-economic and cultural factors.
Inadequate access by a large part of the population to basic health services prompted many countries to start piloting the creation of systematically trained local community health workers. For example, in Thailand, the first pilot project to involve the community and appoint community health workers for sanitation activities, was started in 1960 (Vacharothai 1978). In the Democratic People’s Republic of Korea, female sanitation monitors have been recruited and trained since 1955. However, a reliance on pilot or small-scale top-down projects not adapted to the local conditions, and a lack of community participation and consequently of local support and resources, have resulted in disappointments and failures. In the early 1970s, the health of the Chinese people improved spectacularly partly as a result of what we now call the nationwide primary health care approach. One of its guiding principles was the utilization of community health workers to:

extend health services to the places where the people live and work

support communities to identify their own health need

help people to solve their own health problems.
This new idea, that communities should assume substantial responsibility for their own health, brought a new dimension to the management of health-care services. It opened up an opportunity to redraft and expand basic health services.
The Alma-Ata International Conference on Primary Health Care in 1978, organized jointly by the WHO and the United Nations International Children’s Emergency Fund (UNICEF), proposed the development of national community health worker programmes as an important strategy for improving access to primary health care (WHO 1978). Since then community health worker programmes have expanded to all developing countries. Table 1 provides the overall picture of community health workers in nine countries of the WHO’s South-East Asia region.

Table 1 Main categories of community health workers (CHW)/volunteers in nine countries of the WHO’s South-East Asia region, by country

After two decades of development, ample evidence has been published on the community health worker’s role as a key agent in improving health. The World Bank (1994) described the importance of community health worker programmes to the success of health development in Africa. Walt (1990) concluded that community health workers not only provide basic health services but also promote the key principles of primary health care—equity, intersectoral collaboration, community involvement, and the use of appropriate technology. Community health workers have shown that they can reduce mortality and improve other indices of health status. In certain communities they can satisfy basic health-care needs which cannot realistically be met by other means (WHO 1989).
Definition and role of the community health worker
Community health workers are defined differently in different countries according to the needs of the country and the resources available for satisfying them. Their roles and responsibilities are also varied.
The WHO (1978) defined community health workers as people with limited education, trained in a short time to carry out either a wide range or restricted aspects of health-care services. They should come from the community in which they live and should be chosen by it. The WHO further defined community health workers as:
Men and women chosen by the community, and trained to deal with the health problems of individuals and the community, and to work in close relationship with the health services. They should have had a level of primary education that enable them to read, write and do simple mathematical calculations. (WHO 1987)
Most community health workers are volunteers and receive short but systematic training. However, some receive longer-term training and even civil servant status, for example auxiliary midwives in Myanmar and community health aides in Jamaica.
To clarify further the definition of community health workers, a WHO study group (WHO 1989) proposed that community health workers should be:

members of the communities where they work

selected by the communities

answerable to the communities for their activities

supported by the health system but not necessarily a part of its organization

have shorter training than professional workers.
Thus community health workers are generally part-time volunteers rather than full-time public employees.
Community health workers may have different job titles and have different responsibilities in different countries. They may be called community health workers, village health volunteers, village health communicators, health guides, sanitation monitors, barefoot doctors, Feldschers, and so on.
In India, the national community health worker programme, started in 1977, was changed to the Community Health Volunteer Scheme in 1979 to stress their ‘volunteer’ nature. In 1981, with the change in government, the programme was renamed the Health Guides Scheme (Bose 1983).
Table 2 shows the different categories of community health workers in response to the nine elements of primary health care in Thailand (Wibulpolprasert 1991).

Table 2 Categories of community health workers (CHWs) and community financing schemes for nine elements of primary health care, Thailand, 1988

Responsibilities of community health workers
Community health workers usually serve the role of educators, communicators, problem detectors, problem solvers, community organizers, and leaders for health. They serve as the link between the community and the health-care systems. They play an important role in galvanizing communities for action, and provide information that promotes individual and family self-care and responsibility as integral components of everyday life.
Some community health workers support delivery of general basic health services, for example village health volunteers in Bangladesh, Bhutan, and Thailand. Others play more specific roles, for example trained traditional birth attendants and village sanitary craftsmen in Thailand, and sanitation monitors in the Democratic People’s Republic of Korea.
The specific role of community health workers has to be adapted to local situations and health demands. Nevertheless, their roles need to be specifically defined. Table 3 provides an example of the clearly defined specific responsibilities of village health communicators and volunteers in Thailand.

Table 3 Responsibilities of village health communicators and volunteers in Thailand

As community organizers and leaders for health, community health workers also play key roles in the establishment and management of community financing schemes for health development (Table 2). As a member (and leader) of the community, the community health worker can incorporate health into all community development activities, which is difficult for health professionals. In many countries community health workers combine service functions and developmental functions that are not just in the field of health. The relative importance of these two functions varies according to the socio-economic situation and the availability and accessibility of local health services. The service function is less important where there is ready access to health-care facilities. The developmental function is useful in all circumstances and is crucial in less developed communities.
Table 4 shows the duties of community health workers in 11 different countries (WHO 1987). Most community health workers have educational and motivational roles as well as delivering first-aid treatments and dispensing basic drugs. However, in some countries they provide more specific or sophisticated services. For example, community health workers in Columbia and Papua New Guinea also give injections, particularly for immunization. Community health workers in Botswana, Sudan, and Yemen provide regular school health activities. In Botswana, Jamaica, China, and Papua New Guinea they assist in health centre clinic activities.

Table 4 Duties of community health workers in different countries

Should community health workers provide medical services?
The preventive and health promotion roles of the community health workers are usually readily accepted by health professionals. However, their role in providing basic medical care is a controversial. Health professionals, particularly medical professionals, often allege that community health worker programmes, which train community health workers in basic medical care, promote quackery. Both scientific rationale and vested interests are involved in the professional movement against community health worker programmes.
Those who support community health worker training in basic medical care argue that the training not only provides more accessibility to villagers according to their need, but also creates social credit and acceptability for the community health workers so that providing other preventive and health promotion activities are much easier. In addition, knowledge and skills in basic medical care may help to prevent epidemics from breaking out through early case detection.
Training community health workers in basic medical care should thus be carried out cautiously with strong supervision to prevent them from overtreating patients, and particularly from providing care for private benefits. It is clear that all community health worker programmes should include basic medical care as one of their core responsibilities (Table 4).
Community health workers: successes and failures
Over the past two decades many countries have experimented with the use of community health workers to provide primary health care. Although there is ample evidence of success, community health worker programmes have had some mixed results. Examples are discussed below of the successes and failures of the community health worker programmmes in both developing and developed countries.
Traditional birth attendants and maternal mortality
In the Gambia and Indonesia, studies have shown that traditional birth attendants who were not backed up by strong basic health services were unable to decrease the risk of maternal mortality (World Bank 1993). Conversely, in Bangladesh, a programme to train and support midwives to work with traditional birth attendants helped to lower maternal mortality by 60 per cent over a 10-year period (World Bank 1993). This is clear proof of the need for regular, systematic, and intensive supervision and support from existing basic health services. Strong support by the basic health services will ensure continuous motivation and continuity as well as a high quality of service. Community health worker programmes should thus be developed and strengthened along with the basic health services.
Organized community health workers in Jamaica
The Jamaican community health worker programme, launched in 1977, recruited many community health workers from different communities. A large group sought and obtained civil service benefits. In 1985 salaries for briefly trained community health workers were to be equivalent to two-thirds that of registered nurses with 3 years training. Shortages of higher-level staff prompted many health centres to substitute community health workers for nurses. Although they appear to be cost-effective, community health workers became increasingly linked to the health system, while their availability to the community diminished. For economic reasons, the programme has been greatly reduced. In 1989, in Hanover parish only one-third of the community health workers originally trained were still active. Fifty per cent had been laid off and the remainder had retired or emigrated in 1985 and 1986 (World Bank 1993; Kahssay et al. 1998).
Community health workers of non-governmental organizations
The Pastoral da Crianca, a community health worker programme instated in 1983 by the Catholic Church in Brazil, had 47 000 community health workers throughout the country in 1992, with 1.5 million children enrolled in the programme. It received strong support from Ministry of Health, UNICEF, and the Barnard Van Leer Foundation and other non-governmental organizations. Community health workers provided health education to low-income mothers, and monitored the growth of infants and young children. An evaluation carried out in 1990 found that health and nutritional indicators for young children enrolled in the programme were significantly better than indicators from similar communities in which the Pastoral da Crianca had no activities (World Bank 1993).
Sri Lanka Health Volunteer Corps
The building of a Health Volunteer Corps in Sri Lanka, begun in the early 1980s, had selected and trained 10 000 volunteers by the end of 1989. The continued training of volunteers boosted the volunteer force to 40 000 by 1996. They receive an initial 2-week training; review meetings and supervisory field visits by primary health care teams provide ongoing support. The success of this model is demonstrated by its adoption by non-governmental organizations and the plantation sector to improve the health of their workers and communities (WHO 1999b).
Community health workers in Thailand
Community participation was started in Thailand in 1960 in the nationwide sanitation programme (Vacharothai 1978). The Village Health Sanitation Project allowed, for the first time, many villagers to work alongside government officials. This success led to the project for training of traditional birth attendants and village health volunteers. In 1974, a comprehensive primary health care development project, the Lampang Health Development Project, was initiated, with support from the American Public Health Association, the University of Hawaii, and the USAID. It focused on the development of basic rural health infrastructures as well as community health workers. Its success and the Alma-Ata Declaration were the foundation for the development of the nationwide primary health care programme in 1979. Within 5 years, every village was provided with trained village health volunteers and communicators.
Extensive recruitment and training of the village health volunteers and communicators, together with the development of many community financing schemes and other specialized community health workers, successfully improved the coverage of many health service targets, such as family planning, maternal and child health, immunizations, sanitation, nutrition, and access to essential drugs. Nevertheless, problems in the selection, training, supervision, and incentives provided resulted in a high attrition rate. A 1988 evaluation found attrition rates of 62.4 per cent and 24.9 per cent for village health communicators and village health volunteers respectively (Hongwiwatana et al. 1988).
In the early 1990s, with rapid economic growth, massive urban migration of rural villagers, and even labour migration abroad, many community health workers had to be replaced and retrained. Most community health financing schemes faded away or were integrated into bigger multipurpose village development funds. In 1994, all village health communicators were upgraded to village health volunteers, and community run primary health care centres were set up in every village, supported by the health centre personnel. These primary health care centres were equipped with some basic equipment and drugs, for example, stethoscopes, sphygmomanometers, thermometers, urine test sticks, and basic essential drugs.
Village health volunteers are well recognized at a national level. They have special uniforms, receive free medical care (for their whole family), and receive daily allowances for their meetings. However, they are still volunteers. A National Health Volunteer Day on 20 March of each year was also established in 1995.
Kenyan experience in community-based health care in Saradidi
This project, which was started in 1981, recruited two community health workers from each village. They received intensive 2-week introductory training with further continuous training on analysis of priority health problems and some specific basic health skills. The community health workers contribute as much as 80 per cent of the project’s voluntary time. Some of the very good community health workers become trainers of the newcomers. The project found that creating a new system of village health committees was inappropriate. It was best to strengthen and work within the existing leadership and community organization structures, such as clans, women, and other activity groups (Kaseje 1990).
Three-Generation Volunteer Corps (Komaki City, Japan)
The Three-Generation Volunteer Corps, a community volunteer organization, was formed in 1986 in Komaki City. It consisted of the Silver Volunteer Corps for the elderly, the Women’s Volunteer Corps, and the Junior Volunteer Corps for junior high school children. Their activities focus mainly on the social dimensions of health, for example visits to bedridden elderly and elderly people living alone, litter gathering, road safety training, and fund raising. They try to nurture mutual understanding and exchange among volunteers in an effort to achieve communities where everyone can ‘live without worry’ in a friendly community atmosphere (Ministry of Health and Welfare 1994).
Attempts at community health worker development in the United States
Community health worker initiative in New York City
A conference called ‘Learning from our Neighbours: Lessons for New York City from the Developing World’ was convened in June 1997. The conference offered seven recommendations focused at supporting and strengthening community health worker activity in New York City. An advisory group has been established by the Department of Health to prioritize the conference recommendations and to develop a plan to move the community health worker agenda forward (Kahssay et al. 1998).
The National Community Health Advisor Study
The University of Arizona has completed a national study of the situation of community health worker programmes in the United States (the National Community Health Advisor Study). The study recommends the core role and competence of community health workers, career and field development for community health workers, community health worker evaluation strategies, community health worker’s role in the changing health-care system, and the special needs of youth community health workers. The study proposed an evaluation framework including process and outcome measures on four levels: individual, programme–organization, community–agency, and external linkages (Kahssay 1998).
Community health workers: conditions for success
Early evaluations of community health worker programmes indicate four necessary (but difficult) conditions for success: community health workers must be well trained, well supervised, well provided with logistic support, and linked to well-functioning district health systems for referral when needed (World Bank 1993). These four conditions are relevant technical and managerial conditions which require clear policy and leadership support. Experience from many developing countries indicate the following conditions for the success of community health worker programmes.
Strong political support
Initiating a community health worker programme means accepting the Health for All policy based on primary health care. It means also that the limitations of health professionals and the potential of the community are well accepted. This inevitably means a decision to put more resources into primary health care, which include resources to support activities to establish and strengthen community health workers. It may also mean shifting resources from secondary and tertiary care in urban areas to support basic health services and primary health care in the rural settings. Shifting of resources is a painful process which requires strong political leadership. Strong political support is also needed for the community health worker programmes to overcome resistance and win acceptance from health professionals.
The Alma-Ata Declaration on the Health for All policy based on primary health care provided very strong political support for community health worker programmes in many developing countries. The Kenyan community-based health-care project initiated in 1979 is a good example of this (Kaseje 1990).
Political commitment for further and real decentralization of health services also allows more active participation by the community. At the local level, political leadership support from village leaders, religious leaders, teachers, and other informal leaders are crucial to the success of community health worker programmes.
In Thailand, political commitment towards rural development, including rural health development, during the early 1980s was so strong that significant resources were shifted from urban provincial hospitals to strengthen rural district hospitals, health centres, and community health worker programmes. In 1983, the budget of the district and subdistrict health programme, which used to be lower than those of the provinces, became higher (Fig. 3). At the same time the Ministry of Public Health announced a ministerial regulation allowing basic medical practices by rural health centre personnel including community health workers. Because of strong political support and social movement, there was very little resistance from the Medical Association.

Fig. 3 Shift of budget allocation due to the strong political leadership in the rural development programme. (Adapted from Wibulpolprasert 1999.)

In India, the turbulent political scene between 1977 and 1980 placed severe constraints on the community health worker programme. The Health Minister, who initiated the programme in October 1977, was strongly attacked by the medical profession. Attacks on the minister were, in fact, attacks on the community health worker scheme itself. This was the worst possible political context for the new scheme, and its credibility suffered as a result. A drastic change in the funding arrangement from 100 per cent central funding in 1977 to 50 per cent in 1979 brought it to a grinding halt in several states. In December 1981, the government decided to make the scheme 100 per cent centrally financed in order to restore the programme (Bose 1983).
In Cuba, the national political leaders decided to focus on the equitable distribution of health professionals down to the grass root level. The community health worker programme was thus very weak and ineffective. However, with the success in building an equitable and widely accessible health-care system, in addition to other other socio-economic equities, the health of Cubans improved greatly (Werner 1983).
Intersectoral approach
The priorities of most rural communities are roads, water for agriculture, electricity, schools, and employment rather than health. In order to attract higher priority and more community involvement, community health worker programmes should be integrated into the overall community development programmes. This fulfils the holistic approach of the Health for All concept.
This intersectoral concept although not difficult to accept, is not easy to implement. In most developing countries, ministries usually have their own vested interests in maintaining a vertical bureaucracy. Vertical non-integrated activities are normal phenomena in different ministries or in different departments or divisions within one ministry. Thus it is not uncommon to see health, education, rural development, and agriculture ministries compete for the recruitment of volunteers in the villages.
During the height of primary health care development in Thailand in the mid-1980s, many vertical health activities existed in a single village. In many villages, the Village Drug Fund, Sanitation Fund, Nutrition Fund, Mosquito Net Fund, and Tooth-brush and Tooth Paste Fund, were implemented separately. They also created different categories of community health worker (Table 2). These fragmented community health activities created management confusion among villagers and community health workers. These vertical health activities were usually short lived and finally the many piecemeal community financing schemes were integrated into single multipurpose village health development funds (Wibulpolprasert 1991). All categories of community health workers were also integrated into the single category of village health volunteers.
In 1983, 5 years after the implementation of the primary health care programme in Thailand, a more integrated multisectoral development based on the basic minimum need approach and quality of life campaign was established (Fig. 4). This multisectoral approach started from the central level, under the National Rural Development Committee chaired by the Prime Minister, down to the village level under the Village Development Committee. Basic minimum need indicators became the basic tools to measure quality of life of the villagers, forming an information system shared by all ministries (Nittayarumphong 1990). Although the system changed over time and with changes in governments, the basic minimum need–quality-of-life concept and indicators remained. There has been an annual report on the basic minimum need indicators for each village since 1986. Those villages with the lowest basic minimum need indices are considered as having a lower quality of life and thus receive higher priority in public resources allocation (Ministry of Interior 1999).

Fig. 4 The implementation of primary health care and integrated rural development in Thailand. BMN, basic minimum need; MOPH, Ministry of Public Health; PHS, provincial health service; QOL, quality of life; TCDV, technical co-operation among developing villages; VHVs/VHCs, village health volunteers and communicators. (Adapted and updated from Nittayaramphong (1990).)

Active community participation
Sustainability of community health worker programmes very much depends on acceptance by communities, its relevance to their demands, and their participation. Active community participation should be included in all activities of the community health worker programmes, from community preparation, selection of community health workers, decision on the types and strategies of health development activities, and management of the programmes.
Active community participation is not easy to achieve in the prevailing provider–client relationship between government officials and villagers of most rural communities. Reorientation of the health personnel perspective and the release of community potential are essential for its achievement. This requires not only community preparation but also active preparation of health personnel. Socio-economic and political reform of the country towards increasing decentralization and participatory democracy is also conducive to its success.
One approach to increasing active community participation is to make community health worker programmes more flexible. Most developing countries implement community health worker programmes on a single rigid top-down primary health care model. This approach usually leaves little room for the lower-level health personnel and the community to make adjustments to fit the local context. A rigid top-down primary health care model implemented on a nationwide scale may yield rapid impressive results, but is usually short lived.
One good example is the village drug funds in Thailand. This programme was started as a rigid top-down community financing scheme in 1981. Within 6 years, there were 27 135 village drug funds, covering 45 per cent of all rural villages. However, a census survey in 1998 found that only 15 per cent of the original village drug funds still existed. Those that survived were modified mainly by integrating into the multipurpose village grocery stores. These modifications were decided upon and implemented by active community leaders in consultation with the local health personnel.
Village leaders, either formal or informal, are important human resources who can actively participate in community health worker programmmes. Religious leaders, school teachers, youth leaders, and leaders of women’s groups can also be active in community health worker programmes. Local health personnel should contact these leaders and seek their opinion and support for the success and sustainability of community health worker programmes.
Efficient management of community health worker programmes
Management makes the impossible possible. (Drucker 1977)
Although community health worker programmes may be rational and receive high political support, managing a community health worker programme is not an easy task. Several issues in the management of community health worker programmes need to be addressed.
Preparation of health personnel
This is one of the most crucial components of community health worker programmes. Health personnel, particularly at the district level, are the prime (and closest) trainers and supporters of community health workers. Their attitude and skills towards working in partnership with community health workers need to be developed and monitored. Two types of health personnel should be considered as follows.
Health personnel directly related to community health workers
These are mainly personnel at the district-level health infrastructures (e.g. district hospitals and health centres). They are in direct communication with community health workers and are responsible for community preparation and selection, and the training of community health workers, providing them with supervision and support. They need to be trained to become trainers themselves, primary health care supporters, and social advocators. Most important is the development of a positive attitude towards community health workers, and respect for the community’s capabilities and community skills. They should be able to build up friendly working relations with community leaders, community health workers, and active members of the community. These skills will enable them to be efficient supporters of community health workers.
Their preparation can be achieved through short courses, on-the-job training in primary health care, community health worker programmes, and training methodology.
In the Thai primary health care programme, a three-tier training for trainers programme was started in 1977. The three tiers include central, provincial/district, and subdistrict trainers. It took 3 years to complete the training of all the subdistrict trainers in all 72 provinces. Table 5 summarizes the systematic three-tier training system.

Table 5 The three levels of training for trainers of primary health care programmes in Thailand

Training materials and guidelines for health personnel should be locally prepared. They may be adapted from the one prepared by WHO (McMahon et al. 1980). Table 6 provides an example of the items for the training modules for Thailand.

Table 6 Items in the training for trainers of primary health care programmes in Thailand

Reorientation of basic education curricula to build up understanding, positive attitudes, and community skills for health professionals is also a very important undertaking.
In 1980, the Fourth National Medical Education Conference in Thailand concluded that all medical schools should produce doctors with four basic skills: clinicians, trainers, managers, and primary health care supporters. Since then the curricula of all medical schools have been reformed to incorporate community medicine in all courses as well as to establish a specific community medicine course for medical students. The curricula of other health professionals were also reformed towards more community orientation and a more primary health care approach. These reforms allowed students to have more exposure to real community health problems and contact with rural health personnel and community health workers. Almost all health professionals now have to spend at least 4 weeks in community hospitals and/or health centres. Many medical schools, nursing colleges, and public health colleges recruit their students from local provincial high school students. These students, after graduation, have more understanding of the community and work longer in their own locality.
In Mexico, the Autonomous Metropolitan University in Mexico City has adopted community-oriented medical education since the early 1980s. It consists of a series of 12-week problem-oriented multidisciplinary models. The medical students have opportunities to work with students from other disciplines, for example, nursing, social work, community planning, and agronomy. The students spend their fifth year of study in a rural setting. Students are assessed on both the adequacy of their clinical management skills and their community skills (Braveman and Mora 1987).
In India, the Christian Medical College and Hospital at Vellore has developed a programme to train ‘basic doctors’ who can function in any setting. The training has four phases. During the first phase in the preclinical years students are divided into groups of two or three and live for 2 weeks in a rural community. Each group is assigned 12 to 15 households to study in detail. They also work with community leaders and health workers in providing health services. The second phase lasts for 2 weeks in the first clinical year. The students, in groups of 10 to 12, undertake field investigations on morbidity and mortality in two to three villages. They also plan a programme for a defined health problem. The third phase lasts 2 to 3 weeks in the second clinical year. Students, in groups of five to six, evaluate the health status of a community and then plan, implement, and assess a programme. The last phase includes a 3-month community posting during the 1-year compulsory internship. They act as members of a health team and participate in all primary health care programme activities (Joseph 1985).
Other health personnel
Other specialized health professionals (e.g. medical specialists, laboratory and radiological technicians, hospital managers, and other supportive hospital personnel), although they do not relate directly with community health workers, also need an understanding and positive attitude towards them. They usually receive referred patients from health personnel and community health workers. They should also undergo short course training on primary health care and community health worker programmes. Activities, which allow them to participate in community health worker programmes (e.g. as trainers in basic medical care) will provide them with better understanding of the programme.
Selection of community health workers
The selection of the right community health worker is the beginning of a successful community health worker programme. Selecting wrong community health workers results in low productivity, a high drop-out rate, and many other problems as mentioned above in the case of Thailand.
Selection guidelines
Each country and community should establish its own selection guidelines for community health workers that best suit their needs and resources.
Some important qualities may be availability of time, community acceptability, social standing, long-term commitment to the community, and ability to influence community members particularly mothers. In situations where community health workers are to perform a wider range of services that require longer-term training, educational attainment may be an additional quality. All selection criteria should be clearly stated and agreed upon by the community. Table 7 gives an example of the selection criteria for community health workers in Thailand.

Table 7 Selection criteria for village health communicators and volunteers, Thailand

Selection method
Selection of community health workers may depend on a systematic sociometric approach or more preferably on a socioculturally accepted method determined by the community. In Thailand the early community health worker programme tried using a systematic sociometric method to identify village health communicators. Village health volunteers were further selected from among the communicators. Table 8 shows the questionnaire for the development of a ‘sociogram’ for identifying village health communicators in Thailand. Figure 5 shows an example of one such sociogram. Although it is a systematic approach, it is quite tedious and not easy to carry out. An assessment in 1986 found that sociograms were not always used. Village health communicators and volunteers were selected by simple village meetings or sometimes selected directly by the village leaders or health officers. The current selection method uses a more direct approach through community meetings or a meeting of the community committee.

Table 8 Questionnaire for the development of a sociogram for selecting village health communicators (VHC), Thailand.

Fig. 5 Diagrammatic representation of the sociometric method of selecting village health communicators in Thailand: the broken lines indicate the boundaries of communication in the village; the circles indicate the village health communicators. (Source: Office of the Primary Health Care 1985.)

Women as community health workers
Some countries (e.g. Indonesia, the Democratic People’s Republic of Korea, and Nepal) select mostly female volunteers. The role of women in the family as health caregivers is known to be of great importance. A study of health-seeking behaviour in 16 developing countries found that women most often make decisions about health-care use, including self-care. At least 75 per cent of health-related decisions take place within the family. Involving women as volunteers enhances their confidence, skills, and status in the community, and thus contributes to the improvement of their own health as well as that of their families and the community (WHO 1999b).
Traditional healers as community health workers
In some instances, traditional healers accepted by most villagers, are good community health workers. Rural midwives or traditional birth attendants are useful community health workers. They are frequently one of the few workers to whom the community is willing to provide financial support. Community health workers who were traditional healers may function better than other community health workers.
A WHO evaluation of community health workers participating in a programme for the detection of malaria in northern Thailand found that traditional healer volunteers were more active in pursuing and identifying malaria cases than other volunteers and that they tended to remain in the programme longer because their service enhanced their standing in the community. Villagers indicated that they felt more confident about having someone they already knew as the village traditional healer draw their blood and administer treatment.
The WHO (1991) conducted a worldwide survey of 17 projects where traditional healers were trained and functioned as community health workers. These projects were located in all the regions of the WHO, except the European region. Eight of them had trained traditional birth attendants; others had trained traditional herbalists, spiritual healers, and even bone-setters. Most were government sponsored.
This survey summarizes several advantages of using traditional healers as community health workers.

1.
Traditional healers are willing to work in community health care and take on primary health care activities when they are given appropriate training. They can also establish good working relations with local health personnel. They are socioculturally accepted human resources with a good service attitude. Being community health workers usually boosts their acceptance by the community.

2.
Traditional healers can be trained to perform a wide range of primary health care tasks. Appropriate knowledge and skills on the main elements of primary health care can be taught to traditional healers, from health education to providing basic medical care and essential drugs.

3.
Traditional healers have produced several positive results. Projects that have attempted to evaluate the results of training have reported a number of positive outcomes. Most of the positive outcomes are changes in the attitude and practice of traditional healers, a high degree of acceptance by villagers, and an increase in coverage of basic health services. However, their success depends on strong support from basic health services.
Nevertheless, there are some obstacles and constraints of using traditional healers as community health workers.

1.
Lack of policy directive: in many countries, traditional healers have been prohibited from practising. Dialogue with health personnel is usually missing and they sometimes become competitors. Without clear government policy, it may be difficult to overcome this problem.

2.
Conflict with modern medical practices: harmful traditional practices are often a cause of conflict between traditional healers and modern medical practitioners. The contrast between the traditional holistic, spiritual healing orientation and the modern biomedical treatment-oriented approach is the second cause of conflict. Conflict of interest is also a component of the problem. However, these conflicts are not insurmountable if mutual respect and effective communication can be achieved. Clear role and communication systems, achievable through workshop meetings and group activities between health personnel and traditional healers, need to be formulated. This will reduce the opportunity for conflict and improve relationships. In Botswana, after a joint workshop with modern health workers, traditional healers agreed to promote the use of oral rehydration salt for the treatment of diarrhoea. They also agreed to refer patients with symptoms suggestive of tuberculosis or with bleeding during pregnancy.

3.
Educational level of traditional healers: many traditional healers have a low level of literacy, which is a major obstacle to training. Special training methods, using pictorial learning materials and hands-on practical training are required, as demonstrated in community health worker programmes in Ghana and Swaziland. Conventional methods such as lectures and use of written materials were not appropriate.
Community preparation and involvement
It is very important that the community be adequately prepared before selection of community health workers. Health personnel at the peripheral health centres are usually assigned to perform this task. Preparation of the community should focus on creating an understanding regarding the functions and roles of community health workers, learning the expectations of the community, and formulating agreeable selection guidelines for community health workers. Formal selection guidelines should not override community choice and local circumstances. Community leaders and committees must participate actively in selecting community health workers.
Community preparation can be achieved through informal discussions with village leaders, discussions in village committees, and other more formal communication channels. Although this is a very important step, the local health personnel are usually not well trained enough to prepare the community adequately. Many of them use the traditional top-down approach, which usually results in selecting the wrong community health workers and leads to a high drop-out rate. Thus training local health personnel in community skills is one of the most important training modules.
Training and supervision of community health workers
Training
Community health workers usually received short-term training varying from a few days to a few weeks. Those that provide a wider range of services may receive a longer period of training. Training usually focuses on basic health issues covering elements of primary health care, such as basic medical care and essential drugs, nutrition, family planning, sanitation, immunization, maternal and child health, and control of local communicable diseases. Training material, particularly self-learning materials, are very helpful. The WHO (1977, 1987) has developed model learning and working materials that countries can adopt for the training and supervision of community health workers. Table 9 lists the self-learning modules for community health workers in Thailand. It is clear that apart from health issues, some health-related agricultural issues are also covered (modules 24–30). These self-learning modules are published and distributed to all community health workers.

Table 9 Self-learning modules for village health communicators and volunteers, Thailand

Some community health workers with specific responsibilities may receive practical training on specific issues. For example, traditional birth attendants may be trained in maternal and child health and aseptic delivery, and village sanitary craftsmen in the building of latrines and water jars.
After initial training, continuous follow-up training is essential. In Thailand, after an initial training programme of 15 days, village health volunteers receive monthly/bimonthly visits, meeting, and training. Two- to three-day refresher courses are organized for all community health workers every year. Special monthly newsletters and journals for their continuing education plus other educational materials are regularly provided. Since 1979, the Folk Doctor Foundation, a non-governmental organization, has published the Folk Doctor Magazine monthly in support of community health workers as well as for the public. In some countries (e.g. Botswana, Jamaica, China, and Papua New Guinea), community health workers assist regularly in the health centres and receive continuous training.
Training, retraining, and activities to support continuous education are usually the main sources of expense in community health worker programmes.
Supervision and logistical support
Continuous supervision through regular visits, meeting, and training are important to maintain community health worker morale and skills. This requires strong basic health infrastructures at the district level. Thus basic health services need to be developed alongside primary health care and community health worker programme. Well-motivated and well-trained health personnel are the best supervisors and managers of community health worker programmes.
A regular schedule of supervision and meetings should be created which focuses on general as well as specific issues. Some forms of regular supervision are established in most community health worker programmes. The ‘barefoot doctors’ in China work in the local health centre every week and receive supervisory visits by health-centre staff.
Those community health workers who provide services which require logistical support, need to have their supplies replenished regularly (e.g. supplies of the contraceptive pill, condoms, and essential drugs). Good management systems to supply these materials regularly from the local health centres and hospitals have to be carefully established. District community hospitals or polyclinics may be the best depot for logistical support to health centres and community health workers.
Tools for assessing local needs
Simple tools are required for community health workers to assess local needs. These will allow them to play a more significant role and to achieve easy acceptance by villagers. It also allows them to understand the situation in their villages better. Additionally, these tools provide better opportunities for active community participation by each member of the community. These should be easy to understand and use, and should take into account the local level of education and skills. A number of such tools have been developed and applied, including the self-survey form in Indonesia, the basic minimum needs survey in Thailand, and the community-based information system for monitoring services and identifying at-risk groups for follow-up action in Bangladesh. Such tools provide methodologies for communities to assess their own problems, determine priorities, plan actions, and monitor and evaluate progress. However, substantial efforts are required to improve and simplify them so that they can be used by communities with minimal education.
To address the community situation holistically, these tools should be integrated rather than piecemeal. Table 10 shows the basic minimum needs indicators used for monitoring progress of quality of life development in villages in Thailand. It was developed in 1986 and has had several modifications. In the 1998 version, at least 20 out of the 39 indicators are directly health related; the rest are related to the overall well being of the villagers (Ministry of Interior 1999).

Table 10 The basic minimum needs and indicators, Thailand, 1998

Incentives for community health workers
Community health workers are not government employees—they are volunteers. Adequate incentives in various forms increase their commitment and productivity. An evaluation of the community health worker programme in Thailand in 1988 found that the most important problem inhibiting community health workers’ work is the inadequate financial reward. Community leaders and committees should play an active role in making decisions on the incentives for community health workers.
Social incentives
Social recognition and appreciation by health personnel are valuable incentives at little cost. The provision of certificates, badges, and uniforms enhances self-esteem and social status. Preferential reception for patients referred to the health service facilities by community health workers provides strong social recognition. In some countries (e.g. Thailand), the ‘best performing’ community health workers are given awards during the National Village Health Volunteer Day, and opportunities to travel within the country.
Financial incentives
Schemes based on financial incentives (e.g. the Jamaican community health worker programme) often collapse when the incentives are discontinued. Where financial incentives are necessary, the community should be consulted and decide on the suitable recompense. For sustainability and acceptance, financial incentives should come more from the community than from the government.
The WHO Study Group (WHO 1989) warned against a ‘fee-for-service’ arrangement, because of its tendency to concentrate on curative services, for which community health workers can charge fees. However, fee-for-services for preventive and health promotion tasks may be allowed, for example, for the distribution of contraceptive pills and condoms.
Other additional incentives, such as free medical care for community health workers and their family members, and nominal profit from sales of essential drugs, may be given. Nevertheless, direct financial remuneration is usually counterproductive and is not recommended unless the time required to carry out the functions assigned requires a significant portion of the day.
Continuing education
Some community health workers with an adequate level of education may be good candidates to be recruited into health personnel training colleges. These students usually have a better attitude towards the community as well as better community skills. Nevertheless, this incentive may also have some detrimental effects and have to be carried out with great care and highly selectively. China’s barefoot doctors provide a good example.
The barefoot doctors contributed greatly to the success of preventive health which had a proven effect on mortality and morbidity in China. In the late 1970s and 1980s, as a result of changes in economic policy and in the demand for medical care, they were offered the opportunity to become village doctors through training and qualifying examinations. They then provided more sophisticated services and, in many provinces, moved to a fee-for-service financing system. Thus a national community health worker programme evolved to become a private practice model free from any governmental guidance. The effect was a decline in preventive and promotion services (Rohde 1983; Zhu 1989; De Geyndt et al. 1992).
Resources support
Community health worker programes require quite high initial investment plus additional reinvestment in training, management, logistics, and supervision. Although the need for resources is quite high, it is nevertheless usually a small fraction of the total national health budget.
In Thailand, the budget for community health worker programmes increased from US$14 million to US$51 million and US$201 million for the fifth (1982–1986), sixth (1987–1991), and seventh (1992–1996) 5-year health development plans respectively, eqivalent to 0.79 per cent, 1.73 per cent, and 2.25 per cent of the total government health budget during the respective periods. During the economic crisis (1997 to 1999), there was a 17.3 per cent reduction in health budget. The budget for community health worker programmes, although protected, was reduced by 15 per cent in real terms (Ministry of Public Health 1999). This inevitably had a negative impact on community health worker programmes.
Clearly calculated and planned resource support is basic to the success of all community health worker programmes. Shifting of health resources requires strong political leadership. Apart from public resources, additional resources can be recruited from the community. Community financing schemes can be established to support various elements of primary health care, or to support integrated community health development activities. These additional resources may be used to provide incentives to community health workers. For example, in Thailand the multipurpose village development fund pays the village sanitary craftsmen to build latrines and water jars. The dividend from these community financing schemes, if substantial enough, may also encourage active community participation. However, these community financing schemes require good management under transparent and participatory community management structures. In many cases where the community structures are weak, there may be corruption and disruption of the activities.
Evaluation of community health worker programmes
Evaluating any health programme is a complex and difficult exercise, starting with the problem of methodology. Although there is general agreement on the measurements in terms of reductions in morbidity and mortality, the methodology for evaluating social impact is more complex. Qualitative phenomena such as community participation, behaviour, and perception are difficult to measure. Some subjectivity, and therefore criticism, are inevitable. No matter how complex and difficult, a built-in system of monitoring and evaluation of community health worker programmes is needed from formulation through to implementation. The evaluation is intended not only to measure the progress and the success but also to yield necessary proposals for further development. Necessary relevant, valid, and reliable indicators need to be developed to measure the inputs, processes, and outcomes of the programme. The WHO has developed handbooks on health programme evaluation, and the development of indicators for monitoring progress towards Health for All by the Year 2000 (WHO 1981a,b). Apart from the built-in system, some periodic external evaluations are needed to guide further development of the community health worker programme.
Information from the built-in monitoring and evaluation system of the Thai primary health care programme in 1986 revealed several constraints in the community health worker programme, such as high drop-out rates, low-levels of activity, and low morale. This led to a systematic external evaluation in 1988. This evaluation resulted in the abolishment of the village health communicators, an increase in social and financial incentives, and more involvement of village leaders and village committees, as well as the further strengthening of health service system support (Hongwiwatana 1988).
Community management structures
Community health workers should not be left alone in the community. Links to ommunity infrastructure will not only result in higher levels of acceptability but also allow community health workers to access community resources conducive to health development. Community health workers should be included as members in the community development committee.
Some separate village health development committees have been set up. Top-down establishment of village health committees may be unsuccessful or even counterproductive. In the Saradidi project in Kenya, it was found that reorganizing the community or setting up a new leadership system of the village health committee was not appropriate. Village health committees proved to be a failure. It was best to strengthen and work within the existing leadership and community organization structures, such as clans, women’s groups, and other community groups. It may be better to have task forces to undertake a specific activity for a very specific period of time. The task forces can report directly to the general meetings convened and chaired by a traditionally recognized and respected leader in the village.
Certain community financing schemes may provide a good basis for the activities of the community health workers in the community development committee. It can also increase their community management skills. The resources generated can be used for further development of community health workers and the community.
For example, including the Village Drug Revolving Fund as part of the Integrated Village Development Fund provides visible activity of community health workers and involvement of the community on the provision of essential drugs. Figure 6 shows the three important components for community health development—community health workers, committees, and community financing schemes (Wibulpolprasert 1991).

Fig. 6 Conceptual framework for community development in support of primary health care (PHC) and Health For All (HFA). CHWs, community health workers; PMC, primary medical care; SMC, secondary medical care; TMC, tertiary medical care.

Community health workers during rapid socio-economic change
Rapid socio-economic change results in demographic and epidemiological transition, decentralization, health-care reform, and public sector reform. Economic development also causes changes in the demand for health care. More highly educated people require more professional services. These changes create incompatibility between the existing role and capacity of community health workers, the expectation of the community, and the real health problems.
Thus the role of community health workers in addressing new and emerging health challenges in a changing socio-economic and political environment is critical.
Demographic and epidemiological transition
There is a significant trend towards more elderly people and more chronic diseases, both communicable and non-communicable, in most countries. These chronic diseases (e.g. diabetes mellitus, hypertension, coronary heart diseases, cerebrovascular accidents, HIV/AIDS, malignancy, and mental health problems) require behavioural changes for prevention and long-term community care and support for treatment.
Most community health workers were trained on the issues related to the eight main elements of primary health care. In many communities, these are now irrelevant to their actual health problems. In other communities, community health workers are facing the double burden of both types of disease at the same time.
The technologies and strategies used for the prevention and treatment of these chronic health problems require totally different knowledge and skills of community health workers. Thus retraining and retooling for community health workers is unavoidable. The retraining should be targeted not only at community health workers but most importantly also at the rural health personnel and health professionals who supervise them.
New forms of community setting and services may be a focus of campaigns, including advocacy for healthier lifestyles, consumer protection, and delivery of basic care for the chronically ill. Community health workers may be trained to monitor blood pressure, fasting blood sugar or urine sugar levels. Tuberculosis patients on a schedule of directly observed treatments may be monitored and supervised by community health workers. The primary health care centres in Thai villages are equipped with the necessary medical instruments and the community health workers (village health volunteers) are trained to do the job.
Changing demand of the community
Better-educated and better-off rural villagers demand better quality professional health services. Community health workers and health personnel need to be retrained and rearmed with more knowledge and skills relevant to the demand. This may require community health workers with a higher level of basic education. Nevertheless, it should be noted that higher educated and better-trained community health workers may focus more on curative services as in the case of China’s barefoot doctors.
In the more developed communities, the health volunteer concept needs to be further extended to workplaces, schools, institutions, youth organizations, and among the elderly in order to develop the capacity of these various groups to assume responsibility for their own health and the health of their communities. Examples are the community health worker projects in Japan and the United States (Ministry of Health and Welfare 1994; Kahssay et al. 1998).
Decentralization of health services
Various degrees of decentralization, from deconcentration, delegation, devolution to privatization (Kolehmainen-Aiken and Newbrander 1997) greatly affect the role of community health workers. Those community health workers who are active members of local community committees or local government can influence the reform of the decentralized health services to be more responsive to local demand and more supportive of primary health care.
In the midst of the privatization movement, the focus of community health worker programmes on preventive and health promotion primary health care services, should be considered as ‘public goods/services’. This means that they should not be forced to operate in an open and competitive market. Despite the possible changing role of the government from service provider to regulator, community health worker programmes should continue to be subsidized by the government and the community. The community health workers’ spirit of volunteer work should be maintained.
New financing schemes
Governments, particularly those of the least developed countries pushed by the development banks, are placing too much hope on new resource schemes such as privatization, community financing, increasing or introducing user fees, and health insurance. If these changes are not carefully carried out, they may shift resources from preventive and health promotion activities towards high-technology curative services.
Community health workers may need to be trained to participate in the management of these new resource schemes, or even become the manager themselves. Retraining of community health workers and local health personnel in managing these new financing schemes are needed to maintain their efficiency and transparency.
Community health workers: not the end of Health for All–primary health care
Although community health workers may improve health under the Health for All–primary health care policy, they are the tools or means to arrive at Health for All. They are the ‘change agents’ for better health by promoting the capacity for self-care and community care.
The final goals or targets are the empowerment of the people to be able to take good care of their health and to be able to use and support health service systems efficiently and equitably. Thus we need to go beyond community health worker programmes to reach directly the families and the people. In Thailand, family health leaders have been recruited and trained since 1996. In 1998, there were 1 177 464 family health leaders.
Innovative strategies using mass media, public advocacy and campaigns, economic incentives, and legislation to empower individual self-care capacity are the new and challenging paradigm of primary health care.
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