The shortage of health staff in developing countries has led to renewed interest in community-based health care workers. However, poor populations are increasingly accessing health services from a wide variety of providers operating as private or semi-private agents in unregulated markets. In this environment, is there a role for the community health worker? Researchers at the Institute of Development Studies, in the UK, and BRAC University, in Bangladesh, consider what can be learned from community health worker (CHW) programmes over the past 30 years. Following the shift towards primary health care in the 1970s, many countries invested in CHWs who received basic training and were often volunteers. However, from the 1980s onwards, most CHW programmes went into decline. Key factors in the decline included the global economic recession, political instability, neo-liberal economic policies and difficulties in financing the programmes. CHWs also received little support in terms of training, management and supervision, and were sometimes seen as lacking legitimacy. Those who were volunteers often dropped out due to lack of motivation. The study highlights the case of BRAC, a non-governmental organisation which has used community health volunteers (CHVs) in rural Bangladesh since the 1970s. It faced many of the problems which ended CHW programmes elsewhere, but dealt with them by providing regular training and supervision, opportunities to sell high-quality health supplies, and ongoing support and monitoring. CHVs are an essential part of its wider community development programme. BRAC also trains specialist workers in particular health conditions such as acute respiratory infections and TB. Other findings included the following. In recent years health services have become pluralistic, so there are a large number of different kinds of health provider and types of care. People are increasingly able to access health information from pharmacies, social networks and the media, and obtain drugs and other commodities from private suppliers. Boundaries between public and private providers are often blurred and systems of quality assurance, regulation and supervision have suffered, while skills have also declined. CHWs have often been pushed into failing prevention programmes or have adapted to these changes by marketing their own skills. The researchers conclude that community health workers with little formal training do have a future. However, they will need to adapt to an environment where they must compete with other providers and prove their competence. They need to establish legitimacy and trust, and this is more likely in larger community development programmes with regular monitoring. They also need a livelihood that can be sustained. The researchers propose four possible different models for community-based health agents of the future: workers with a basic set of general skills but linked to a reputable supervisory agency; they are still needed where there are shortages of skilled staff workers specialised in a particular health condition; they face less direct competition once their legitimacy is established but need well-designed training and consistent supervision the \"expert patient\" or advocate, who is a patient with a chronic disease, such as diabetes, who can manage their own condition and support others in doing so; preliminary evidence from Cambodia suggests it is a highly effective approach community-based facilitators who act as brokers between communities and health service bureaucracies and markets.
Social Science and Medicine (2008) 66 (10) 2096-2107 [doi:10.1016/j.socscimed.2008.01.046] Special issue: Future Health Systems (Eds Bloom, G.; Standing, H.)