Posted on 11 July 2017
Improving global health depends on the coming together of groups and individuals from different backgrounds and perspectives. The ‘Inspiring Communities in Global Health’ workshop enabled a truly interdisciplinary conversation between historians, social scientists, psychologists and other health professionals. The workshop set out with two key objectives: first, to explore the role of community health workers (CHWs) in global health and in particular their contribution to delivering universal health coverage; and second, to highlight the evolution of ideas and practices which have historically influenced the work of CHWs. These objectives were pursued by considering the impetus towards the mobilization of communities in the definition of health policies and in the delivery of care, as well as the role played by CHWs in this process. The discussion placed special emphasis on examining the evolving role of CHWs throughout the twentieth century, and the influence of the past on the contemporary work and challenges faced by CHWs in different parts of the world.
The first panel (featuring presentations from Sarah Hartley, Ben Walker, Alexander Medcalf and Socrates Litsios) focused on the history of CHW programmes and their antecedents, drawing attention to the linkages between past developments and the character of contemporary public health. The discussion touched upon the shift in programmes delivered by missionaries and faith based organisations, which previously focused on a top‑down approach where communities were seen as passive, towards a model where community participation was encouraged. The discussion highlighted however that there is still substantial scepticism from the communities, and that the work of social movements remains very different from that of missionaries. Various tensions can be pinpointed even between different religious groups, for instance. The panel emphasized the need to explore other faiths and their role in public health and in CHW programmes.
The second panel (featuring presentations from Monica Saavedra, Atsuko Naono, Karina Kielmann and Rosie Steege) explored the interlinked roles played by colonialism, religion and gender in public health. It also considered issues of funding, sustainability, education level and gender bias in the health sector. The diversity of situations in this regard is evident: Mozambique only provides conditions for male CHWs to work, while Brazil has an overwhelming majority of female CHWs. Both cases show profound gender disparities: while the former reflects how adverse conditions make it difficult for women to participate as CHWs, the latter reproduces patriarchal norms where primary health care is seen as a woman’s work and the precariousness of CHW work reflects the broad precarious nature of work for women. The discussion highlighted that addressing the gender gap is not simple: a gender‑transformative policy would entail the integration of men and women, sensitisation and flexibility for CHWs. Such complexity is often overlooked. Furthermore, the panel emphasised the need for intersectionality in order to bridge the gap between what policies say and what happens on the ground.
Panel Three (with presentations from Emma-Louise Anderson, Polly Walker, Miriam Taegtmeyer and Xun Zhou) discussed the need for a systematic assessment of poverty and social vulnerabilities, and how they impact upon CHW work. A lingering question remains regarding modernisation and its implications. While there are cases such as Brazil, where the population aspires to private health insurance, there are also cases like China where demand for CHWs in some rural regions continues to be strong. These differing cases can be better understood if we understand what is it that CHWs are offering which cannot be otherwise obtained: is it local knowledge, a more personal relationship or trust?
In Panel Four, João Nunes (University of York) spoke about CHWs in Brazil and the practical challenges of implementing universal health coverage; tensions between the empowerment of CHWs and their simultaneous vulnerability, pertaining to precarious job conditions, low salaries, lack of mental health and occupation health support and persistence of prejudices. Gabriela Lotta (Federal University of ABC, Brazil) spoke about her ethnographic research with Brazilian CHWs: her work shows how CHWs act as ‘street-level bureaucrats’, interpreting and translating health directives and acting as mediators between health authorities and the population. Sandra Jovchelovitch (London School of Economics and Political Science) explained how CHWs can be seen as local knowledge holders, and argued for the need to focus on local epistemologies and the possible interactions and partnerships that can be held with local knowledge communities. Rather than discarding knowledge that has less power than others to establish their legitimacy and authority in public arenas, it is important to retrieve the potential of all knowledge systems.
The day concluded with a presentation from Prosper Tumusiime (WHO Regional Office for Africa) who highlighted the important roles played by health extension workers in Ethiopia, the health surveillance assistants in Malawi, the village health teams in Uganda, community health workers in Rwanda, and the community health services improvement (CHIPS) compounds in Ghana. He emphasised that to in order move forward we first need to review our history and seek to learn from it.
While the ideas shared by the speakers showcased varied experiences, it was broadly concluded that CHWs play a key role in the public health arena. Across regions in Africa, Asia and South America, the contributions of CHWs have been noteworthy. Their work, which has often been limited to child and maternal welfare, is now expanding. Throughout the day, the discussion emphasised the need to integrate intersectionality in the debate about CHWs. Gender, class, ethnicity, caste and race influence the working and effectiveness of CHWs, and given that CHWs reach out to the remotest of populations in various countries, these ideas are often deeply entrenched. CHW work is not merely limited to rural populations; they have proven to be very effective in reaching out to the urban population as well. This reflects their evolving and imperative role in contemporary public health sphere. Several speakers demonstrated that there is little to no critical assessment of the role that community health workers play‑ almost giving a pious, unquestionable character to the job. This can be problematic in over‑ estimating the capabilities of CHWs. Such factors need to be considered when defining the roles and tasks for CHWs. But it is equally essential to address the vulnerabilities that CHWs face and the issues that limit their capabilities: low income, unstable work‑routine, non‑flexible work regimes, weak career prospects, safety issues, amongst many other issues.
The workshop emphasised the need to acknowledge the complex intermesh of ideas and interests impacting on CHWs, but also to determine better ways to address these complexities. As was pointed out often during the day, learning from our history is essential in shaping our future.
This workshop was convened by Dr João Nunes and Dr Alexander Medcalf, funded by their Wellcome Trust Seed Award ‘Community health workers in Brazil and the global movement for universal health coverage’. This support, along with that of the Department of History and the Department of Politics at the University of York, is gratefully acknowledged. Dr Nunes and Dr Medcalf were assisted by Pallavi Karnatak, from the Department of Politics, in the organization of the workshop and the drafting of this report.