Global health's durable dreams: ethnography, ‘community health workers’ and health without health infrastructure

Abstract

Tracing the persistence of community health workers (CHWs) as a key category in both global health policy and anthropological representation, this article asks how enduring scholarly investments in CHWs can reveal changing political stakes for both health work and ethnographic research. Amid renewed calls for a focus on health systems and universal health coverage, the article suggests that the durability of attention to CHWs is instructive. It simultaneously points to the imbrication of health with political and social relations and clinical and technological infrastructures as well as to how ethnographic investments in health systems can sometimes obscure the ambivalent politics of health. Drawing on fieldwork with CHWs, NGO staff and public health officials, and on public health literature on CHWs, it argues for greater attention to the political ambivalence of health labour. It suggests that the experiences of health workers themselves can serve as analytical examples in this regard, pointing to analyses that begin not with normative notions of health systems or the conceptual boundaries of global health ‘projects’ but with a focus on the contested relations through which health labour is realized over time. Such attention can also indicate possibilities for health beyond dreams of projects, clinics or health systems.

Capture‐recapture

“…Also highly coveted were monthly incentives given to peer educators charged with reaching MSM to count and refer them to HIV testing. Across global health discourse and monitoring and evaluation documents, peer educators, as one iteration of a vast global network of “community health workers” (McKay 2020), are idealized as selfless volunteers dedicated to their community. NGO staff members, too, internalize logics that valorize unpaid altruistic volunteerism: on one occasion, a “troublesome” peer educator named Fatsani, who rarely met his monthly quotas of “MSM reached,” was accused of “poisoning” the other peer educators working in his district by “making their passion into a commercial endeavor.” In this rendering, Fatsani's refusal to “work”—and his repeated complaints about inadequate payment—taint dominant discursive renderings of peer education as selfless, voluntary, and driven by passion for community.…”

The effect of health promotion on primary health care services: an analysis of primary health care policy

“…Conclusively, the Nigeria's Federal Ministry of health found that Nigerian"s health system is filled with high level of corruption and fraud; ineffective coordination among the three levels of government; the attitude of health workers towards patients; poor health service delivery; inadequate public and private health funding; poor working environment, limited opportunities for continuing education, massive migration of health workers to greener pastures; poor implementation of guidelines, few training opportunities; poor skills for supplychain management among providers; poor location of healthcare centers; poor utilization of research findings; lack of effective leadership for the successful implementation of health promotion and community participation in PHC [6]. According to the World Health Organization, PHC could only achieve its goals, be more responsive and accountable to societal needs through the appointment of good leaders to coordinate primary health care services.…”

“…According to a study conducted in Nigeria showed that most Federal and State hospitals are built in the city; so nearly all the health workers want to work in the city because of their remuneration, infrastructure, other opportunities, and benefits [6]. These opportunities make most of the competent health care professionals to be working and even some are still struggling to work with the Federal and State hospitals in the cities, leaving the grass root health centres (local government hospitals) with no choice health workers [7].…”