What are the basic skills/competencies a Community Health Worker (CHW) should have? More precisely, which are the desirable characteristics of a CHW?

(M. Chowdhury) Any discussions on the CHWs and their desirable characteristics or
skills/competencies would depend on the context in which they are located. Obviously my views are specific particularly to the context of Bangladesh. CHWs are required and imperative in my opinion if only there is an apparent shortage of health workforce to provide basic services, particularly to the poor, women and other marginalized groups.  In our situation where the CHW models have proliferated, there are several skills/characteristics can be identified. These would include:

1. Willingness and have spare time to serve the poor and other disadvantaged groups in their own village/community
2. Ability to learn and practice how to treat common illnesses
3. Not too old, not too young. Preferably married women with no young children
4. Some literacy (although many CHWs in Bangladesh don’t have it)
5. Should have links with a functional health system (for supervision, accountability and continuing education)
6. Trusted in the community
7. Not solely dependent on the income from the health work.

Although practiced historically, the present-day CHWs are a post-Alma Ata phenomenon. However, the barefoot doctors scheme in China and other countries in Latin America and Africa (Tanzania, Mozambique) were also seen before 1978. In a 1989 publication the WHO idealized CHWs in the following way:

• Members of the community where they work
• Selected by the communities
• Answerable to the communities for their activities
• Have much shorter training than professional workers
• Supported by the HS but not necessarily part of the organization

(F. Nyonator) The Term Community Health Workers have been used for many entities in different countries such as Village Health Workers/Aides; Community Health Aides/Auxiliaries, Health Promoters/Educators etc. In most developing countries they have one thing in common – they work in villages and communities to provide a variety of services on individual and house to house basis. There is also the misconception that ‘CHW’s’ should provide only minimal care and as such should have only minimal training.  Our experience with the Community-based Health Services and Planning (www.ghana-chps.org ) is to orientate our frontline health providers, the Community Health Nurses (CHN) and place them in communities that have been demarcated and sensitized. They are then re-designated as Community Health Officer (CHO). Their main mandate is to provide Primary Health Care to individuals and household. In the Ghanaian context, the basic skills/competences of this type of Community Health Worker required are those needed for service provision in these broad areas:

• Promotion and prevention
• Management of minor/common ailments and their referrals; and
• Case detection, mobilization and referral

The specific duties and responsibilities include:

• Community and compound level education on primary health care;
• Immunizing and providing pre and post natal care delivery;
• Supervising and monitoring sanitation efforts;
• Provision of nutrition education and care;
• Primary care for simple cases of diarrhoea, malaria, acute respiratory diseases, wounds and skin diseases;
• Providing referrals for more serious afflictions;
• Provision of education on prevention and management of STDs and HIV/AIDS;
• Provision of family planning services and referrals;
• Supervision and monitoring of community volunteers’ and TBAs;
• Conducting disease surveillance; and
• Submission of written reports to the Sub-District Health Team.

Services are provided in accordance with the existing regulation of the Ghana Health Service. Clearly, this type Community Health Worker has a lot more service responsibility than the traditional ‘village volunteers’ and requires a great level of skills mix.

CHWs have worked in many countries worldwide for many years. In some countries CHWs are affiliated to the MOH, others to community organizations or NGOs. Some get paid and others volunteer. According to your experience, what works best to reach the most vulnerable populations?

(M. Chowdhury) Here too, it depends on the context. But since we wish the CHWs to serve the disadvantaged sections in particular and not many public sector workers are traditionally known to do this well (‘the inverse care’ theory), it would be advisable to be linked to a non-government sector organization. But it is also important for them that a substantial incentive scheme is built in as most of these workers are themselves poor.

(F. Nyonator) The Ghana initiative makes the community service provision an integral part of the District Health Systems and as such the Community Health Officer in this definition is an auxiliary nurse (and sometimes  professionals  such as nurse midwives, disease control offices etc) and is an employee of the Public Health Sector. This has been grounded in many years of experimentation with volunteers at the community levels. These experiences are well documented and show that the deployment of  village volunteers was not sustainable and since they were not part of the formal system, the village volunteers  were difficult to be supervised. Reorienting and equipping the original frontline health workers to reside in the communities provides the best option for service delivery and for supervision.

The Ghanaian experience has shown that this can be done in the public sector as well as in the private sector where in some districts alliance has been developed with private midwives to serve as CHO’s.  Incentive schemes for the Community Health Officers is a very important aspect of the sustainability of the initiative and it applies both in the public sector as well as private sector.

Can CHWs be engaged in compiling information for primary health care (PHC) information systems?

(M. Chowdhury) As I mentioned it is desirable that the CHWs have some literacy. If they are they can perform their tasks better. Also they can help collect good and credible info for their own use as well for the health system. At BRAC we are making use of them for collecting info on new pregnancies for a maternal new born and child health program. By being in and part of the communities, they know vital events much more than the dedicated workers whose task is to visit house-to-house to collect such info. This is obviously true in countries where the vital registration system is virtually absent or deficient.

(F. Nyonator) In the context of the Ghanaian situation, the CHO’s are part of the official health systems and as such serve as the lowest end (or the first point) of the information system especially for primary health care. In other systems, like the Guinea Worm Programme or the Community-based Distribution of Ivermectin, our experience is that volunteer Community Health Workers are useful in the compilation of information for primary Health Care provided they are well supervised.

Some countries are proposing training less skilled health workers to assume some of the functions previously intended to be filled by highly trained nurses and doctors. This is proposed as a strategy to address the problem of "brain drain"- both to substitute for those who have migrated and as a long term solution as health workers with only basic skills will not as easily migrate.  What lessons can you draw from training and deploying community health workers that will inform this strategic decision?

(M. Chowdhury) Migration is a major contributor to the current health workforce crisis (ref. WHO World Health report 2006). This includes not only low-income to high income countries but also intra-country migration such as from rural to urban areas.  Fortunately the CHWs rarely migrate (at best they migrate from one village to another, may be). In some countries the CHWs also do many work of the so-called skilled worker. For example, In Nepal and Bangladesh, CHWs have been shown to treat pneumonia cases well. In Bangladesh, CHWs provide TB treatment through DOTS with excellent results (Lancet, 350:169-172, 1997).

(F. Nyonator) The truth is that most countries are reprioritizing the production of health workers towards the need of their populations. What majority of the population in developing countries need is quality basic primary care delivered by adequate numbers of frontline health workers. The training midlevel cadres to deliver these basic quality services might be seen by some as an effort to address the issue of the ‘brain drain’, but,  it is in reality a reprioritization process to address the human resources for health needs of most developing countries. This should not be seen as  skills substitution! Professional Nurses and Doctors are essential to countries’ health systems; however, it had been fashionable to produce them in large numbers to the detriment of the production of midlevel cadres for PHC. The experience with the Ghanaian programme is that there is the need to concentrate on the production of midlevel cadres who will be deployed as CHO’s and   in Districts where the CHO’s are deployed and engaged with the communities, for example, institutional maternal mortality  in the District Hospitals decrease dramatically.