Community health workers and treatment
One approach to strengthening the active engagement of communities in health development is to train and deploy people as community health workers. Antiretroviral treatment programmes in resource-limited settings have so far not often built on existing community worker programmes, but it is important that countries assess their experiences in this area and look for chances to work with community health worker cadres and recruits drawn from associations of people living with HIV/AIDS (see Box 3.5).
Community health workers have functioned successfully in small-scale nongovernmental programmes, as well as in large-scale national programmes integrated into the public health system. In many countries in sub-Saharan Africa, for example, faith-based organizations have provided quality care for 20 years. Many faith-based health care facilities have large staffs of outreach workers, home and community health workers, who function in unique networks (29). Other organizations with similar networks have also played important roles in HIV/AIDS prevention and care. The 3 by 5 initiative will partly be run through these infrastructures, using the capacities and networks already in place.
Involving community health workers is a prime area for the practical approach to increasing treatment coverage. Although current knowledge is far from exhaustive, the existing evidence provides enough information to enable planners and implementers to move immediately to build programmes in a step-by-step, problem-solving manner, tackling obstacles as they arise. Operational research will be vital in providing quick feedback on lessons learnt from community health worker participation, as programmes scale up. This research must be planned and budgeted for.
Community health workers should not be viewed simply as local helpers who can temporarily take on tasks the formal health care delivery system lacks the resources to perform. They are not primarily a cheap way to deal with human resource constraints. Rather, community health worker programmes can and should be seen as part of a broader strategy to empower communities, enable them to achieve greater control over their health and improve the health of their members.
The following areas are vital for achieving success:
Inclusion of curative activities: communities are usually in direct need of curative care. If community health workers are not involved in this area, people are less interested in and supportive of their activities (30). Experiences from Nepal, for example, show that when policies were established that allowed community health workers to dispense medication, community workers’ motivation and their acceptance by the wider community increased (31). Poor performance of community health worker programmes is also frequently associated with an insufficient supply of drugs (32, 33) .
Supportive supervision, strong linkage with health professionals and referral systems: recent experiences show that, with supervision, HIV/AIDS treatment programmes relying extensively on community health workers are able to maintain quality (34). Experience in antiretroviral treatment from Haiti, Rwanda and South Africa shows that supervision is effectively provided by regular meetings, simple forms that facilitate reporting and feedback, and willingness of health professionals to engage with communities (19, 20). A community health workers’ programme should be integrated into a referral system that includes more advanced care centres able to respond to problems that cannot be solved at lower levels.
Remuneration: where financial compensation is provided to community health workers, both benefits (retention of workers) and negative effects (being viewed by communities as government employees) have been found (28). Community health workers who volunteer can usually contribute only a limited time each week.
Innovative ways to compensate volunteers for their time have been introduced. For example, community volunteers involved in the onchocerciasis control programme in Kabarole district, Uganda, combined the distribution of drugs to control onchocerciasis with the retail of condoms which became an effective income-generating activity (35). In several countries, volunteers receive no payment, but do receive incentives with monetary value, for example a bicycle that can be used for other purposes. Payment is needed to sustain the required level of commitment in the long run whenever community health workers are contributing an amount of time comparable to that given by professionally trained health workers. No community health workers’ programme, whether relying on volunteers or paid workers, is without costs, and every such programme will need a budget to be effective and sustainable.
Relationship with the community: support and recognition from community organizations and leaders, and appreciation from members of the community, are identified as critical incentives for community health workers (36). Fostering such relationships will mean involving associations of people living with HIV/AIDS and other community-based organizations and leaders whose support will be vital. Through their networks, community organizations may complement community health workers by tackling needs such as nutrition and income generation. Efforts to keep community health workers strongly attached to community organizations are therefore important. This can be accomplished by working through existing community-based organizations in setting up and monitoring the community health workers’ programme. It will be critical to put in place arrangements that guarantee accountability. One way to achieve this is to give the community organizations, rather than the formal health care system, control over monetary or other compensation for community workers.