Going Global!

I spent the last 2 days discussing community health workers and community empowerment with a group of people from all over the world. I joined delegates from India, Iran, Bangladesh, Pakistan, Brazil, Ecuador, Kenya, South Africa, the Congo, Canada*, Australia* and New Zealand* - and was also lucky enough to meet with some of the people I will meet in South Africa in October for part 2 of my fellowship.

Just some of our International grouping!

The focus of the two day event was on Comprehensive Primary Health Care (CPHC) and it marked the end of a 4 year international study co-ordinated by Ron Labonte at the University of Ottawa and David Sanders at the University of the Western Cape in South Africa. The project - ‘Revitalising Health Care for All’ - involved 20 projects in 20 different countries and more than 60 researchers.

The projects had identified a number of key themes - many of which were of interest and relevance to my fellowship including: 

1.  Community Health Workers  (CHWs)
2. Community Empowerment
3.  Inter-sectoral working

We know that models and roles of Community Health Workers (CHWs) across the world vary. As just two of many examples, in northern India the ASHA (Accredited Social Health Activists) are volunteers whose role is focused around child and maternal health whilst in Iran the 'Behvarz' are paid, permanent employees of the health system who receive 2 years training to prepare them for their role which is focused on helping to build community capacity and mobilising community members. 

Despite these differences - learning from the experience of other countries where health needs, resources and policies may be very  different to the UK, was extremely helpful in terms of offering an alternative perspective - though it seems many issues are the same the world over.

We were reminded that the original rationale for CHWs in the developing world was to address the fact that poor families were less likely attend or access state health care facilities, and that CHWs could have a role in increasing access to services.   The findings from the project also demonstrated a number of other potential roles undertaken by CHWs:

1.      Health care provider

2.      Advocate for community

3.      Agent of social change

4.      Facilitating inter sectoral / partnership work

Some research gaps in relation to CHWs were identified which reflect some of the outstanding questions have about Community Health Champions in the UK:

1.      What are the communities views on CHWs?

2.      What factors constrain or facilitate CHWs in operating as agents of change?

3.      What factors and polices could improve recruitment and retention of CHWs?

4.      Which roles should CHWs undertake?

5.      What are the possible negative effects of CHW programmes?

6.      What payment and support systems are needed?

There was also much discussion about the wider social determinants of health (e.g. housing, education, poverty) and the role of community health workers in helping to address these. This quote clearly illustrates the need to not just tackle ‘health’ as an issue – but also those factors that impact on health:

“what good will it do to treat people’s illnesses…and then send them back to the conditions that make them sick?”

Community participation and empowerment processes were also recognised as effective in improving population health and increasing levels of social capital.  We talked about mobilising communities as part of the wider CPHC agenda - and how CHWs may have a role in identifying and mobilising community assets.

There were questions raised around the somewhat sticky issue of how we define and measure community empowerment - and how we demonstrate empowerment in a way that speaks to funders and policy makers, so that they take it seriously. Seems this isn't an issue unique to the UK...but just how do you convince funders to pay for empowerment activities when they are so often hooked on tangible, measurable health outcomes such as smoking cessation or reduced hospital admissions? Whilst we have developed some ideas around this linked to our work on demonstrating social capital and our Altogether Better Evidence Reviews on empowerment and well-being (both of which I was able to 'plug'!) it remains a challenge.

Ron Labonte (Project Grantholder) and Sara (Iran),
Sara (Canada) and Sarah (UK)!

There was lots of interest in our work in the UK and  - all in all - it was a great forum with a great bunch of people -  all passionate about improving health equity and health outcomes for all and I was very glad to be part of it.

The ’Revitalising Health for All’ project has database of articles on CPHC from each of the participating countries.



* most delegates were working in low to middle income countries. Those people from Australia, New Zealand and Canada were representing Indigenous communities within those countries who still face many barriers to health care and are considered low/middle income countries within wealthier nations.