Despite the now near-universal agreement within the global public health community that community healthcare workers (CHWs) can play an effective and often necessary role in delivering testing, treatment and care to under-resourced communities, there has been little consensus as to how such workers should be trained and paid, and/or where they fit within greater healthcare structures.
Many CHWs work part time, often as stipended or unstipended volunteers, and receive minimal training when compared with their clinically-based counterparts. Such workers also have a high rate of turnover, with low retainment cited as a concern for organisations hoping to offer patients continuous care.
The CHW discussion continued at the 40th Union World Conference on Lung Health in Cancun, Mexico in early December, with Partners in Health (PIH) advocating for better pay and training for CHWs. The organisation also claims that CHWs should be considered to be equally important as nurses and doctors.
Given the amount of time and commitment needed for community-based workers to adequately address patient needs, Dr. Michael Rich of Partners in Health says that asking people to volunteer for little or no pay is “unrealistic. They need to be adequately compensated.”
As such, the organisation pays CHWs for part time work. Going rates depend on the country: in Rwanda, for example, Partners in Health gives CHWs $56 US a month.
While Rich notes that this is “embarrassing low compared to what some of us make,” he contends that such jobs are “very sought over” and that there is a “low turn over rate.” Generally, CHWs are “very content with their jobs,” and “satisfied with their payment.”
Given that this work is not full time, Rich claims that CHWs are able to dedicate approximately half of their economic time to pursuing other work.
Beyond simply paying CHWs, Partners in Health also advocates changing what Dr. Joia Mukherjee, the organisation’s medical director, considers a “very top down and…clinic [focused] approach” in which CHWs are seen as peripheral to medical teams instead of an integral part of the greater health care system.
“Paying them is key, but also making sure that they’re really part of the team,” says Mukherjee. “We have excellent retention of CHWs in Haiti and Lesotho, and [those are places] where they really are part of the team.”
She continues: “Part of what we [aim to] do with CHWs is truly change the philosophy of what is valued. The way to really empower people is to give them a job and work with them to hear what they say. In [Partners in Health’s] Lesotho [programme], the CHWs get to drive what happens...for home visits. It’s up to that person’s clinical judgments and social judgment. It really is humbling” for a doctor to hear from the community, she says. “We need to sensitise the medical establishment to the needs of the community.”
“[We’re] really trying to reverse the power,” says Mukherjee. “[TB] is a disease of poverty; it’s also a disease of disempowerment.”
In response to the successes of Partners in Health programmes and other CHW models, the Rwandan government recently announced a “massive scale-up of CHWs,” says Rich, with 45,000 such workers currently operating in a country with a population of 10 million; three CHWs are available for each village area of 100-150 houses.
“Rwanda really is taking the lead [with regards to community-based health care] with [this] massive scale-up,” he says.
Other countries that are also heavily reliant on CHWs have not been as supportive. Dr. Mavis Nonkunzi of South Africa’s TB/HIV Care says that the organisation, in conjunction with the Treatment Action Campaign, have campaigned for the country’s government to officially recognise CHWs as health care workers.
While a standardised stipend does exist for CHWs, Nonkunzi claims, “it’s far less for those who work with TB than [those who work] with HIV.” TB CHWs receive a fixed stipend for their work, while those focusing on HIV receive a stipend per patient.
According to Rich, Partners in Health aims to “measure the impact and outcome of CHWs. If we can show that paying them a fair salary may result in better outcomes” then more countries could follow Rwanda’s lead. Given the large amount of work that many CHWs do, community-based healthcare in which CHWs are paid is a “really inexpensive programme,” says Rich. Regardless of the cost of such programmes, Mukherjee contends, “it’s not more expensive than…people dying of treatable diseases.”
Mukherjee, J. Management of TB and HIV care in hurricane settings: perspectives from the Western Hemisphere. Presented at the 40th Union World Conference on Lung Health, 2009.
Nonkunzi, M. Engaging community members in integrated TB-HIV and PMTCT services and infection control. Presented at the 40th Union World Conference on Lung Health, 2009.
Rich, M. A network of community health workers keeping the community healthy: experiences from Rwanda. Presented at the 40th Union World Conference on Lung Health, 2009.