The Next Generation of Community Health Worker Programs

Just recently, leading global health expert Dr. Paul Farmer was asked, "Which single intervention would do the most to improve the health of those living on less than $1 per day?" He responded, "Hire Community Health Workers to serve them."
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By John Zervos and Dana Parke

Just recently, leading global health expert Dr. Paul Farmer was asked, "Which single intervention would do the most to improve the health of those living on less than $1 per day?" He responded, "Hire Community Health Workers to serve them."

What is a Community Health Worker?

The first large-scale Community Health Worker (CHW) program dates back to 1960's China. Needing to provide low-cost health services to a significant rural population, China looked to farmers as the solution. The "Barefoot Doctor" program emerged, providing 3 to 6 months of intensive training to thousands of rural farmers -- men and women who had no previous medical education. China's barefoot doctors continued to farm, but were also able to provide basic health services within their communities. They mixed both western and traditional methods, and community members trusted and listened to their advice.

Success of the Barefoot Doctor campaign is debatable as little data was obtained on health outcomes. However, the model indisputably showed that laypersons have vast potential to act as health care providers and promoters.

This Barefoot Doctor model has been embraced in a variety of contexts and by a variety of countries. Indeed, even the New York City Health Department embraced the model by training CHWs to care for its underserved tuberculosis positive population, demonstrating that the Barefoot Doctor campaign is also efficacious in "developed" countries.

Today, "Community Health Worker" serves as an umbrella term for dozens of different iterations, such as community health advocate and community navigator. Across the globe, over 1.3 million CHWs provide a diverse set of services (and outcomes), including outreach and community mobilization, case management, health promotion and system navigation. Some also manage Directly Observed Treatment Short course (DOTS) programs for Tuberculosis or HIV positive patients, and refer ill community members to hospitals.

Although CHW programs cannot be generalized, all find commonality by embracing the same fundamentals of the Barefoot Doctor campaign: CHWs are trusted members of the communities they serve, CHWs provide health services with adequate training and CHW programs create jobs that improve health.

So why, 50 years later, do experts continue to see CHW programs as a cutting-edge solution to global health challenges?

The simple answer is that what services CHWs provide, and how these services can benefit communities, are still being explored. Some of the more innovative CHW programs continue to rely on the same foundation of the Barefoot Doctor campaign (trust, opportunity, improved health), but have expanded the role of the CHW. Some programs have expanded by focusing on a specific topic (e.g. maternal health), while others have integrated novel technologies (e.g. mHealth applications) and/or have focused on innovative financing and sustainability measures (e.g. incentive schemes).

Here are some examples:

1) In India, Dr. Vikram Patel is transitioning laypersons into mental health providers.

2) In the USA, seven states have enacted laws that enable some services provided by CHWs to receive reimbursement from Medicaid.

3) CommCare, a smartphone application, now allows any CHW with a smartphone to receive information and collect population data.

4) The MOTECH Ghana program provides community nurses a mobile phone application to upload records to a centralized database and to facilitate follow up with patients.

Is it time to define "Community Health Worker" or is there a next generation of Community Health Worker Program?

Internationally, as well as in the United States, there have been efforts to define and regulate the scope of services that CHWs provide. On the one hand, a specific definition is an important step to ensure sustainable programs. Proponents of this view warn that an unclear definition may compromise the quality of patient care, resulting in poor outcomes and wasted programmatic expenditures. On the other hand, a strict definition may limit innovation in a field that continues to evolve and improve.

In the United States, debate centers largely on whether or not to develop a standardized competency-based training and certification system for CHWs. Yet it is difficult to imagine a system that encompasses the many roles different CHWs play; is it appropriate to require career CHWs to become certified in a curriculum that may not match, or may even limit, the good work they perform on a daily basis?

And still, even as these debates continue regarding a rigid definition of "Community Health Worker," the role of the CHW continues to evolve and improve. One study in Chicago looked to answer the question of whether CHWs could be involved in the research process, a role typically reserved for a trained researcher. The study found that indeed they could -- CHWs actively participated in the research process by collecting qualitative evaluation data in the field. The growing use of CHWs in research has multiple benefits: the CHW develops useful skills, the community is more involved and the investigators are able to increase access to targeted populations. CHWs are increasingly seen as "change agents" who play a major role in community mobilization; thus, their inclusion is vital in creating sustainable relationships and translating data to address local health needs.

CHW programs are a proven low-cost intervention in resource-limited settings, and studies have shown CHWs can successfully implement programs and even conduct fieldwork. Is it possible that they can also be a part of the solution creation? Today, a majority of CHW programs are tied exclusively to narrowly defined health outcomes and solutions identified from "outside" of the communities in which they serve. But most agree that when health challenges (and solutions) are identified locally, and communities obtain the support to create solutions, community residents are more likely to embrace the intervention. It is time for CHW programs and policy makers to believe that CHWs can not only be a successful part of an intervention but that they can also help design them. The next generation of CHW programs should be designed by Community Health Workers themselves. Policy makers should provide opportunities and resources to pilot, evaluate and scale-up solutions created by CHWs and for the communities they serve. Before we define, let us see what CHWs are capable of accomplishing.