By Kate Hawkins
On the 12 June 2017 the University of York’s Department of Politics and Centre for Global Health Histories held a fascinating meeting which explored the impetus towards the mobilization of communities in the definition of health policies and the delivery of care; and the role played by community health workers (CHWs) in this process. It was a chance to look backwards and get a historical view of the formation and adaptation of CHW programmes in different settings as well as looking at some of the more contemporary challenges and how these two things might relate. Three elements of the discussion stood out for me: religion, gender, and community and participation.
Recently I have been working with colleagues on a literature review on gender and CHW programming which is part of a larger paper. One of the things that struck me is the only papers that we found that made an explicit link between gender and religion were those from Muslim-majority countries. One can only speculate at the reasons for this. These papers tended to focus on how becoming a CHW increased women’s mobility in settings where they have traditionally stayed in the home and how this can be an empowering experience. They also point to the potential dangers of women breaking social norms and their vulnerability to attack and sexual assault by men when out and about in the course of their work. It may be due to our search terms, or the journals we are limited to, but I was surprised at the lack of papers where Christianity was at the forefront of analysis. As an atheist, I have had time to contemplate faith while at meetings on CHW programming that begin (and often end) with a prayer. The workshop was refreshing in that we heard new perspectives on how Christianity has influenced the conception and function of CHW programmes in different settings.
What became clear from our discussions is that Catholic and Protestant organisations have different models of mobilising communities, and attitudes towards them, which plays out in the design and functioning of CHW programmes. Ben Walker presented on Medical missionaries, Community Health Workers and NGOs competing and creating universal health care in Ghana between 1967-1983. Ben challenged the perception that the implementation of Community Health Workers was an entirely secular venture by describing the way in which missionaries and Churches in Ghana were involved in their formation. He tracked the changing attitudes amongst the Presbyterian and Catholic churches in Ghana across the 1950s to the 1970s in order to show how, whilst initially mission doctors and Ghanaian Christian health work prioritised a hierarchical relationship with local communities, reformations in mission theology in the 1960s shifted their practices. Particularly he emphasised how Vatican II, medical missionaries connection to local anthropologists and Christians studying at U.S. public health schools all encouraged community-oriented perspectives on how to incorporate Ghanaians into medical work.
We heard how Liberation Theology (of the type found mostly in Latin American countries) purposefully centred on the agency of communities and their active participation in overcoming socio-economic inequity. This essay by Paul Farmer describes how this approach underpins community health interventions in Partners in Health. We heard how in the Brazilian health system Catholic and African religions are integrated and this was central to the development of their model of health care. Community conceptions of what constitutes good health and wellness were what shaped the interventions provided, which is why homeopaths/herbalists are licencedproviders of care. Polly Walker described how World Vision’s faith-based approach to development has evolved over the past 60 years, moving away from a provider-beneficiary relationship towards a model of transformational development and partnership (which reflects local ownership and definition).
REACHOUT was represented by Rosie Steege who reflected on some of the gender issues that have been raised as part of the work of the consortium and in her PhD research. She concluded that gender impacts upon CHWs in a multitude of ways and current CHW policies do not acknowledge the complexity gender plays ‘supply side’. This is a missed opportunity to promote gender transformative approaches at all levels of the health system. Her overall argument was that approaches on the ground are often governed by gender but not gender transformatory policies as a result they are sub-optimal.
Gender was also a focus in the presentation by João Nunes (Department of Politics, University of York) on CHWs in Brazil. He described CHWs as simultaneously vulnerable and empowered and in part this is because a big percentage of them are women (98% in some states). CHWs are often precariously employed with short term contracts, underpaid, and seen as disposable members of the health teams. They experience occupational health problems, such as trauma, stress, and physical injuries. João described how the community health programme is deeply heteronormative. Women are chosen as CHWs as men are not allowed to go into people’s homes unaccompanied, reflecting dominant conceptions of what is ‘appropriate’ for men and women. He relayed an anecdote where a member of staff recounted, ‘we have one male CHW but he is a homosexual so that is alright’. Heteronormative structures are very much present in many of the CHW programmes that I have seen – in anything from the way that households are defined, to assumptions about women’s caring responsibilities and natures, to CHW attitudes towards clients who break norms related to sexuality such as having children as teenagers – but they are rarely remarked upon. It would be great to see further analysis of this area.
Group discussion focused on whose ends are served by pushing women into positions where they are vulnerable to community violence and other forms of harm. I have long wondered why there is not more discussion about workplace health and safety in relation to CHW programmes. Employers have a responsibility to those who labour for them whether their workplace is an operating theatre or a doorstep.
Community and participation
In the CHW world there can be a tendency to posit communities as benign and all community participation as positive. Yet conversations at the workshop pointed to some of the limits of CHW programmes and how good intentions within drives for community health could have negative unanticipated consequences.
An excellent presentation by Karina Kielmann (Institute of Global Health & Development, Queen Margaret University) described how relationships and provider/client interactions are key to the delivery of HIV interventions through CHW programmes. She talked of how pre-existing social bonds can be instrumentalised by community health programmes and these can have negative consequences. For example, the creation of ‘expert patients’ to support adherence to ARV treatment in Malawi weakened horizontal links between peers and therapeutic solidarity as their positions were professionalised. In Zambia, the professionalisation of home based care practices meant that CHWs were less involved in physical care and did not support households through the provision of food. As their traditional role transformed people felt surveilled and policed by CHWs who were thought to adopt a berating attitude and meddle in household affairs through their treatment adherence practices.
Emma-Louise Anderson (University of Leeds) presented a paper on dependent agency and the limits of community mobilisation for democratisation and equity. Based on work in Malawi and Zambia (both countries which are extremely aid dependent in terms of their HIV programmes) she described how networks of people living with HIV and the support groups that followed from them are considered potential mechanisms to foster equity. However, in these settings aid recipients are ‘dependent agents’ who are constrained by exclusionary informal networks, donor recipient relationships and patronage politics. This is not to say that they were powerless and there were many ways in which structures were subverted, for example, through 1) the outward performance of compliance, such as using human rights language without a commitment to their realisation for all; 2) extraversion, or making dependency obvious so that it is advantageous in terms of additional resources; and 3) resistance below the line such as using euphemisms, stretching rules, and dragging feet. Nevertheless, community health in this environment has undermined the solidarity, accountability, transparency and the trust needed for democracy. It has led to the exclusion of certain groups and the pitching of different communities against each other. CHW interventions need to better understand the behind the scenes ways local people are enmeshed in unequal power hierarchies and social obligations if their programmes are to be successful.
In other conversations, we discussed how regimes of expertise and practice take up and then discard community members as the popularity of CHW programmes ebb and wane. One participant described CHWs as the ‘handmaidens’ for opening up markets for Western drugs as part of a global trend that is moving away from community care towards biomedical interventions.
The workshop was an excellent opportunity for academics from different backgrounds and disciplines to come together and share. I am hopeful that it will lead to fruitful collaborations in the future.