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Community health workers: promoters or inhibitors of primary health care?

This article analyses the shortcomings of primary health care systems (PHC) particularly those relating to the selection training and the quality of community health workers CHW. Although most countries have endorsed the PHC approach this has not resulted in significant national political decisions or a fundamental reorientation of policies that would be conducive to its successful application. Too often PHC is viewed as a health service strategy to be initiated by the health sector and the concern of that sector alone. Intersectoral cooperation to promote the concept has received little attention. The major responsibility for carrying out PHC services often rests with CHW; how well the tasks are performed depends on their calibre and suitability for the job. Yet it is in the area of manpower recruitment that some of the basic principles of the community health care approach are ignored and community participation overlooked. Many facets of rural life like the absence of proper channels through which people can articulate their needs and the lack of influence of women in village affairs have led to the abuse of the selection process of community health workers. Influential persons tend to get chosen regardless of commitment suitability competence or the intelligence needed to undergo the required training and the ability to adapt their training to individual situations. The training process is itself irrelevant to real situations and curriculum unrelated to the job at hand. The system of incentives and rewards has negated the most important characteristic of the community health worker--that of being 1 of the people. For the successful implementation of PHC other echelons of health care must be involved in it providing technical support supervision referral logistic support as well as continuing education and a reliable back-up for CHW. An efficient and inexpensive communication system between the health professionals and CHW is essential and should encourage mutually beneficial dialogue between the 2 groups. CHW