Listening to Community Health Workers: How Ethnographic Research Can Inform Positive Relationships Among Community Health Workers, Health Institutions, and Communities

摘要

Many actors in global health are concerned with improving community health worker (CHW) policy and practice to achieve universal health care. Ethnographic research can play an important role in providing information critical to the formation of effective CHW programs, by elucidating the life histories that shape CHWs’ desires for alleviation of their own and others’ economic and health challenges, and by addressing the working relationships that exist among CHWs, intended beneficiaries, and health officials. We briefly discuss ethnographic research with 3 groups of CHWs: volunteers involved in HIV/AIDS care and treatment support in Ethiopia and Mozambique and Lady Health Workers in Pakistan. We call for a broader application of ethnographic research to inform working relationships among CHWs, communities, and health institutions. Particularly after the Alma Ata Declaration of 1978, 1 many countries institutionalized community health worker (CHW) programs as a strategy to extend primary health care to impoverished populations, and to address the relationship among poverty, inequality, and community health. 2–4 Currently, many actors in the field of global health are reaffirming the importance of CHWs in achieving universal health care. For instance, 2011 saw the Frontline Health Workers Coalition and the One Million Community Health Worker Campaign emerge in the United States through partnerships among universities, philanthropic foundations, international nongovernmental organizations (NGOs), and multinational pharmaceutical companies. Major global health institutions have identified massive shortages of CHWs, and have called for innovative and evidence-based policies that improve recruitment, retention, and performance of community health workforces. 5–9 Across contexts, CHW programs vary considerably in terms of job descriptions, remuneration, and structural relationships to intended beneficiaries and to governmental, nongovernmental, and donor organizations. Complex political and economic challenges also surround CHW policy and practice in many contexts. Our work as ethnographers in 3 CHW contexts—Ethiopia, Pakistan, and Mozambique—suggests that positive working relationships among CHWs, the institutions that deploy them, and communities are crucial, yet are rarely treated as an explicit goal. On the basis of our findings in these diverse contexts, we identified 3 underresearched areas of ethnographic inquiry that, if given sufficient attention, can greatly inform such relationships. The first is CHWs’ life courses, and how they have shaped CHWs’ desires for alleviation of their own and others’ economic and health challenges. The second is the quality of existing relationships between CHWs and intended beneficiaries, particularly those who are poorer and more marginalized. And the third is the ways in which policymakers, donors, and CHWs themselves negotiate and compromise on CHW policy decisions. These areas of inquiry may be more crucial in contexts where CHWs are regarded more as labor resources deployed by health institutions and less as partners with a seat at the table of policy development, but will still be important in places where CHWs are more active in the process of policy change. We elaborate on our ethnographic research involving participant observation and interviews with CHWs and policymakers and implementers in Ethiopia, Pakistan, and Mozambique. In Ethiopia, research focused on volunteer CHWs specializing in HIV/AIDS care and treatment support in the capital city, Addis Ababa, between 2006 and 2009. In Mozambique, research focused on volunteer CHWs working within HIV/AIDS treatment programs in the town of Chimoio between 2003 and 2010. Although both of these urban contexts are characterized by high rates of unemployment, chronic malnutrition, HIV infection, and inequality, people—including CHWs—in these contexts have different historical experiences of, for instance, colonialism, war, structural adjustment, and the role of religious institutions in health care. 10 In Pakistan, research focused on Lady Health Workers (LHWs) employed by the health department, between 2008 and 2011. These CHWs provide a variety of health services to their neighbors, from family planning education to tuberculosis treatment support, in a severely underresourced and sometimes corrupt health system that lags behind those of other countries in the region. 11–13.