Retreat from Alma Ata? The WHO's report on Task Shifting to community health workers for AIDS care in poor countries

Abstract

This paper examines the potential of community health worker (CHW) programmes, as proposed by the WHO's 2008 Task shifting to tackle health worker shortages -Global recommendation and guidelines, to contribute to HIV/AIDS prevention, care and treatment and the achievement of various Millennium Development Goals in low income countries. It examines the WHO proposal through the lens of a literature review of factors that have facilitated the success of previous experiences of shifting tasks from health workers to trained lay people. The WHO has taken account of five key lessons learned from past CHW programmes (the need for strong management, appropriate CHW selection, suitable training, adequate retention and incentive structures, and good relationships with other healthcare workers). It has, however, neglected to emphasise the importance of the 'community embeddedness' of health volunteers, found to be of critical importance to the success of many past CHW programs. We have no doubt that the WHO Plans will increase the number of workers able to perform medically oriented tasks. However, we argue that without community embeddedness CHWs will be unable to perform the socially oriented tasks assigned to them by the WHO, such as health education and counseling. We locate the WHO's neglect of community-embeddedness within the context of a broader global public health trend away from community-focused primary health care towards biomedically-focused selective health care.

Strengthening Community Participation in Primary Health Care: Experiences from South Africa

“…Successful CHW programmes require external organisations to play a signifi cant role in supporting, managing and providing materials (Campbell and Scott, 2011). As such, the Project worked extensively to strengthen links between the CHWs and public sector agencies (Department of Health, Municipality and Department of Welfare) and two NGOs (a missionary NGO and a counselling NGO).…”

“…Ensuring sustainable and meaningful payment for CHWs is necessary for programme success (Campbell and Scott, 2011). Payments increase retention, and build recognition among community members of the valuable work of CHWs in delivering health services.…”

“…It is sometimes conceptualised as empowerment oriented, viewing CHW programmes as springboards for (a) general community strengthening for prevention and health-enhancing social development; and (b) the empowerment of health vulnerable groups such as youth and women (Rifkin, 1996). Successful programmes typically rely on community embeddedness (Campbell and Scott, 2011;Bhattacharyya et al, 2001).…”

“…Successful CHW projects need to be embedded in communities (Campbell and Scott, 2011). The Entabeni Project was conceptualised and run as a community-led project, with a central role played by local residents in shaping and determining the direction of the Project.…”

“…The volunteers' work constituted a 'bottom-up' project, initiated and staff ed by local people (mostly unemployed and poorly educated women) in response to the desperate suff ering of people dying of AIDS, often with little or no access to any formal health care. These health volunteers were referred to as 'community health workers' in line with international trends (Campbell and Scott, 2011).…”