News & Events

What Makes Community Health Care Work?

February 18, 2011, 9:00 pm

What Makes Community Health Care Work? (follow link for full article)


In response to Tuesday’s column about two programs in India that train relatively uneducated women as their villages’ health workers, readers provided an avalanche of information about other community health worker programs around the world. Gregory Ortiz from London (95) wrote about Operation ASHA, which has semi-literate counselors treating tuberculosis in slums in India and Cambodia. In thefield from Alaska (109) wrote about para-dentists in rural Alaska.

Marianne Loewe (121) from Santa Ana, Calif., commented on her organization, Concern America, which works with health promoters in Colombia and Central America.

Several readers also noted that the idea of doctoring by lay people is not new; it was done on a colossal scale in China under Mao. In the Barefoot Doctor program, which began in the late 1960s, each commune trained workers to do basic preventive and curative health care, paying them in work points. When the communes were dissolved in 1981, so was the program. Many of the Barefoot Doctors became standard doctors, charging patients and concentrating on curative medicine.

The Barefoot Doctors inspired international interest in the idea of community health workers, and a wave of smaller programs began in the late 1970s and 1980s. “The use of ‘village health workers’ has been going on for years and [in] many developing countries,” wrote RM from Washington (42) “Some have worked all right, some not, and the question of sustainability is always a major one. And few have been taken to scale. The real question is why some work better and are more sustainable than others, and secondly, how can the successful models be taken to scale?”

Ashim Hajra
An eye examination by a Jamkhed community health worker.

RM is correct. Community health worker programs are widespread, and they are not new. But the majority of the programs begun three decades ago failed rapidly. And most of the ones that readers mentioned are small, when the need for them is enormous. It is worth looking at some of those that have thrived — including Jamkhed and SEARCH, the groups featured on Tuesday — to see what they have done right.

Finance creatively. Some of the programs that failed collapsed because they were financed by outside donors, and those donors eventually pulled out. Readers of Fixes by now know the column’s obsession with sustainability. This is a real problem for community health workers. They save society money in the long run by making people healthier — but that doesn’t help the specific organization that is paying in the short run. The women who do this work surely deserve decent pay. But to do that on a large scale is expensive. How do you find money that doesn’t go away?

Different organizations have answered this question differently. SEARCH gives its workers a small stipend — and the program has stayed very small. The Jamkhed program doesn’t pay workers. Raj Arole, its founder, argued to me that this was a philosophical decision: the health workers should be partners. Maybe — but what’s surely true is that Jamkhed didn’t have the money. (The entire organization’s budget is about a half million dollars a year, and that includes the cost of running a hospital.) Jamkhed’s health care workers are compensated with business training and access to microcredit, and I met many who had started successful businesses — growing fruit, selling glass bangle bracelets, or renting out a jeep. One of the beautiful mysteries of the Jamkhed program is why these women still spend hours a day doing volunteer work. Many women said they value the respect it gives them in their communities and the satisfactions of being useful.

A different, ingenious approach is taken by BRAC in Bangladesh. Nearly 30 years old, BRAC is a poverty-fighting organization, and a giant one — health care is only one of the things its 28,000 employees do. It also has more than 80,000 community health workers, which it calls volunteers, who cover more than 100 million people.

The volunteers work on basic maternal and child health, but their biggest job is curing tuberculosis, a very labor-intensive enterprise. The hard part of curing TB is ensuring that patients keep taking all their medicines for six months. So BRAC’s village health workers watch their patients swallow their pills every day. This is a proven health intervention called DOTS, for Directly Observed Treatment, Short-course, that has greatly improved TB cure rates around the world.

Mushtaque Chowdhury , who was deputy executive director of BRAC and oversaw its health programs, said that compensation for health workers was critical for success. But BRAC can’t pay 80,000 salaries. So, like Jamkhed, BRAC offers its health volunteers income opportunities. Unlike Jamkhed — where health workers make money in non-health businesses — BRAC’s plan encourages the volunteers to spend their time on health care.

When a health volunteer goes on her rounds, she carries a basket of goods such as sanitary napkins, soap, condoms, packets of oral rehydration salts, iron pills and bandages that BRAC sells her at cost. She sells them to her patients at a 10 or 15 percent markup. (Some other programs have chosen not to take this route, as they believe it encourages women to push products their clients don’t need.) Her second money-making opportunity is really clever: With money from the Global Fund to Fight AIDS, Tuberculosis and Malaria, BRAC pays her every time she finds someone with TB, and every time a patient completes a 6-month course of TB medicines. (Patients also have a financial incentive to finish treatment, as they are required to post a bond of about $3 when they start treatment. They get it back when they complete their course of medicines.) BRAC’s rates of detecting and curing tuberculosis are excellent — much better than the government’s.

Teach. Jamkhed, among other groups, emphasizes teaching. Its health workers teach families about preventing disease, and train others in the community to deliver babies. Teaching helps the impact persist even if the health worker does not.

Don’t strand workers. Every manager knows it’s important to keep workers from feeling isolated and burning out. “Normally what happens is a nongovernmental group goes to a village, trains a community health worker, then leaves them on their own,” said BRAC’s Chowdhury. “Soon they lose interest or she becomes a traditional village doctor,” abandoning the preventive work that is the basis of rural health. Community health workers need to be a part of a larger health system.

BRAC and Jamkhed, among other programs, keep up their health workers’ skills and morale with regular group training. And as numerous readers pointed out, community health workers do not remove gall bladders or diagnose cancer — there needs to be a next level of health care for patients who need it. At Jamkhed, villages are visited periodically by a mobile team of doctor, nurse and social worker. They see cases the community health worker cannot treat. Even before Raj and Mabelle Arole started Jamkhed’s health worker program they had established a small hospital in Jamkhed. It has grown; in 2009 Jamkhed opened a new 50-bed hospital.

Grow your own way. BRAC’s community health worker network is big enough to rival many countries’ government health programs. Faruque Ahmed, who is director of health, said that BRAC scaled up slowly. The impetus came after a Bangladesh organization invented oral rehydration therapy — a packet of sugar and salts that families can mix with water at home to stop diarrhea. BRAC sent workers to train one woman in every single household in Bangladesh — that’s 30 million homes — to use the therapy. “It took 10 years,” said Ahmed. “But that was the first time we got the confidence to grow.” The lessons BRAC learned from that campaign showed it how to expand. In 2003 and 2004, with money from the Global Fund, BRAC expanded its community health volunteer network from about 13,000 to 80,000.

Ashim Hajra
A Jamkhed worker teaches childcare.

But there are many ways to have a big impact. SEARCH is still a small program. But it has a loud echo because Save the Children’s Saving Newborn Lives program is using it as a laboratory and training center, with financing from the Bill and Melinda Gates Foundation. SEARCH pioneers and tests new tasks for health workers, and Saving Newborn Lives helps replicate the studies and teach what is learned to others. In 2003, for example, Ethiopia decided to start a community health worker program to help families keep their babies and small children healthy. Saving Newborn Lives brought key officials from Ethiopia’s health ministry to SEARCH to show them that relatively uneducated health workers can successfully diagnose and treat child pneumonia — a leading killer of children — with oral antibiotics. Ethiopia then adopted the same policy.

Convince governments. Except for unusual organizations like BRAC, big means government. Governments can do successful, large-scale community health worker programs — Nepal has for the last couple of decades. The Saving Newborn Lives program works with governments in Africa, Asia and Latin America, helping them set up intelligent structures for community health workers and incorporate effective interventions, such as curing pneumonia.

Jamkhed is another program that has grown by teaching — including teaching governments. People come from 30 different countries to study at Jamkhed each year, but perhaps the program’s biggest impact is in the Indian state of Andhra Pradesh, which has repeatedly sent teams of health officials to learn from Jamkhed and then train others. A third of its districts — home to some 24 million people — are now implementing Jamkhed’s methods.

Community health workers are greatly improving life for millions of people around the world where doctors and nurses don’t go. But as lots of readers pointed out in their comments, the United States is not rural India. We can still benefit from community health workers, though — in a different way. When I write again in two weeks, I’ll look at programs here in the United States that use lay people alongside doctors and nurses to solve some of the thorniest problems in American health care.

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Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and now a contributing writer for the paper’s Sunday magazine. Her new book, “Join the Club: How Peer Pressure Can Transform the World,” is forthcoming from W.W. Norton.