The Value and Role of Community Health Workers

Whilst in Montreal (back in June…seems an age ago!), I attended the Public Health Association of Canada’s Annual Conference which was a 4 day event attended by around 700 academics, service providers and policy people from across the country.

Talking about Health Champions in Montreal!

On the first day of the conference, I contributed to a half day session on “Exploring intersectoral partnerships in working with Community Health Workers (CHW)/Lay Health Workers in Canada and internationally”. I was invited to do short input about Community Health Champions (as a form of Lay Health Worker) and the Altogether Better programme. The session was hosted by Population Health Improvement Research Network (PHIRN) at the University of Ottawa.

 

During the session, we also heard from Terry Mason (an Independent Public Health Policy Consultant from Boston, Massachusetts) who spoke on ‘The Importance of Community Health Worker Leadership in Developing the Field’ and the need for recognition of the CHW role. Ronald Labonté  from the University of Ottawa gave us an international perspective and Sara Johnson, from the Ontario Federation of Indian Friendship Centers talked about Improving Urban Aboriginal Health Outcomes. Ivy Bourgeault (University of Ottawa), talked about the increasing global interest in CHWs and Sara Torres (University of Ottawa) talked about her PhD on Models of collaboration between immigrant community-based organizations and public health units.

Me, Ivy Bourgeault, Terry Mason, Sara Torres, Sarah Johnson

The group discussion that followed was lively and generated a number of interesting issues and questions around Community Health Workers (CHWs). I’ve attempted to summarise some of the key points below:

CHWs: Volunteers or Paid Roles?

• Different models of CHWs exist - from volunteer to paid para-professional role. Does using volunteers give the state the opportunity to step back / take less responsibility and reduce service provision?
• Both paid CHWs and volunteers co-exist in some places. Would paying CHWs act as a disincentive? The keenest people maybe those who do the work for the love of it – this may be lost if CHWs were to be paid. Need to consider what motivates CHWs and the different motives for different people (e.g. retired skilled people wanting to volunteer ‘v’ people seeing volunteer role as a step on a pathway to personal development and employment).
• What is the role of empowerment? Not just for the communities /’end user’ but also the impact of skills development for the CHWs.
•  What rewards / benefits should CHWs get? e.g. education, training, professional advancement, financial reward?

The key roles of the CHW

• CHWs are critical linkers /bridges to services. In Dakar there are 2000 new immigrants arriving every day and the role of CHWs is to link these people to services
• How can CHWs be used to help improve social cohesion – especially amongst Aboriginal communities?
• Could CHWs be involved in other roles aimed at increasing health equity? E.g. use CHWs to help identify child labour victims. How much can CHWs realistically take on? Need to consider what CHWs role should be (e.g. to refer well and develop relationships).
•  Community Health Representatives (CHR) are paid CHWs in 9 communities in Quebec working with 1^st nation people. Focus is on prevention and management of diabetes. Use a train the trainers approach. CHRs are recruited from communities and are respected by the community. In some rural communities, CHR are particularly valuable as they may be the only public health presence.
• Legitimation of CHWs role is linked to the internal policies of the organisations to which CHWs are linked. An internal policy statement should state what the role of CHWs is and what support they will receive – this will allow CHWs to make claims for support. For CHWs to do a good job – they need to be supported well and have access to resources and to professionals. These should be stated as the ‘rights’ of CHWs.

Professionalisation and Recognition ‘v’ Community Credibility?

• How can we make CHWs more recognised – to ensure they are at the centre (or at least ‘at the ‘table’ not ‘on the menu’). Should CHWs be more formally part of the health system? Need to consider what health systems are about. Should CHWs be part of how health services are revised and changed?
•  The ‘Professionalism’ debate creates tension between the need to generate more credibility and recognition for CHWs and the need to maintain their valuable ‘grass roots’ connections and community links. If CHWs become more highly ‘professionlised’ they may lose some credibility with the community with whom they work.
• In some places, people (CHWs) without statutory authority (i.e. not part of the state) were seen as more ‘fair’ and the most trusted source of information regarding health issues. This means they could be a good mechanism for accessing target communities. This may be lost if they became paid state employees.
•  Need to build up intersectoral health councils / partnership working methods to look at community problems together and explore how these can be addressed. Is there a role for asset based community development approaches to address the wider determinants of health?
• Should CHWs be organised /unionised (as in some parts of the US?)? In Massachusetts, the ‘certification’ of CHWs resulted from having powerful CHW leaders who organised for recognition. The Association of CHWs has set standards and requirements for CHWs (Terry Mason, Boston). The mobilisation / organisation of CHWs can allow them to look at what they need to do to work more effectively.

What does anyone think….? Feel free to post any comments or further questions.