"International Health-care system...What to do to improve the U.S.'s health system"
Global health organizations have been studying ways to create efficacious care within and across the many national, ethnic, and cultural contexts. Several models have been shown to be particularly effective regardless of context. Using extant secondary research, this report will provide the fundamental framework for a model that is agile, comprehensive, and eminently adoptable.
Five contexts in which the model was implemented are briefly discussed: Alaska, Iran, Jamaica, and Rwanda. These implementation settings have the following attributes in common: Sparse populations, cultural and ethnic influences that differ from the physicians and administrators of the healthcare programs, and the need for regular follow up care and consultation. The information provided does not focus on any particular disease or disorder, but rather describes a system for addressing the needs of communities in rural or poorly resourced areas.
The healthcare model centers on the training and deployment of community health aides who are recruited from the indigenous populations in any given area. Using community health aides provides a link between the rural communities and the public health facilities that are located in areas with denser populations. Uniformly, the outcomes of programs that utilize community health aids exhibit improved service utilization and better take-up of preventative health practices. This report includes recommendations for the improvement of international healthcare that are based on the successful programs using community health aides around the world.
Following the introductory section, a brief overview of each of program in the four locations leads the discussion. The results section lists a primary lesson learned -- one from each of the four programs. The healthcare problems in the Mississippi Delta provide a backdrop against which the recommendations gleaned from the example programs may be set. These lessons are converted to recommendations that are presented in the final section.
3. Current Research on the Community Health Aides Model
The average population density in Alaska is 0.3 per square kilometer, and when non-indigenous populations are excluded from the count, the density is reduced to 0.04 per square kilometer (Haraldson). The vast distances between native villages coupled with a very harsh climate has made it extremely difficult to develop and maintain modern services of any sort that indigenous people can readily access (Haraldson). Radical improvements have been made in the morbidity and mortality rates of indigenous Alaskan populations, as a combined result of socioeconomic development and efficient rural health programs (Haraldson).
In the 1960s, when the United States Public Health Service assumed responsibility for healthcare to native settlements, community health aides were established to provide, among other things, environmental sanitation and maternal and child health care (Haraldson 1988). The community health aides began receiving standardized training in 1968 (Haraldson). Training of the rural community health workers emphasizes primary care and methods to deal with the problems that take the lions' share of rural health care services and resources (Haraldson). Notably, immunization, health education, and prevention are key components of the training curricula (Haraldson). Each village council choses a native woman (typically), who has achieved nine years of formal schooling, to receive the community health aide training (Haraldson). Radiotelephone communication occurs daily with doctors; difficult cases are referred to regional hospitals via any one of 350 airports and all-weather airstrips (Haraldson).
Community health aides take refresher coursework and are supervised by public health nurses -- and occasionally by physicians -- from the village clinics (Haraldson). Remuneration averages amounts that are roughly equivalent to the earnings of primary school teachers (Haraldson). Nearly half of the program costs are accounted for by airfare and air services for the patients and for the community health aides and other medical staff (Haraldson). As it is configured, the community health aide program provides complete geographic coverage and accessibility as a front-line service for all Alaskan villagers (Haraldson). The community health aides are considered to be a "vital peripheral branch" of the public healthcare team (237). The idea of providing rural healthcare through the services of paraprofessionals who receive about a half-year of training would have been "dismissed as unrealistic" roughly fifty years ago (237). The community health care concepts and methods have undergone thorough testing and evaluation, evolving over time to become well adapted to the program purpose and to the unorthodox manner and conditions by which the services are provided (Haraldson).
The Alaskan community health care program is able to "discourage a brain drain from rural areas" by continuing to rely on trainees who are selected by fellow-villagers, who live and work among their own tribespeople, who are not mistrusted by villagers on the basis of linguistic or cultural differences (Haraldson 237).
The Iranian community health aide system began in the 1980s when the Ayatollah Khomeini returned to Iran (Hansen 4). The revolution that began around that time promised social justice to the rural villagers (Hansen 4). Under the shah, there were no doctors in rural Iran, and more than a half of the country's population lived in roughly 60,000 villages that were located outside the major population centers (Hansen 4). For approximately every 1,50 (Hansen 4)0 villagers who were within about one hour's distance on foot, the Iranians constructed health houses (Hansen 4). These 1,000 square foot hut-like structures had sleeping quarters for staff and equipped examination rooms (Hansen 4). One male and one female community health worker constituted the staff for each health house (Hansen 4). The community health care workers had received basic preventative health care training, and focused on providing advice about family planning, nutrition, giving immunizations, taking blood pressures, keeping track of prenatal care needs of villagers, and even monitoring environmental conditions in the villages, such as water quality (Hansen 4). Patients who needed more intense care or surgery were referred through a single system that extended across all of the care level tiers: from health house to rural health center to the district hospitals (Hansen 4). Roughly 17,000 health houses today are successfully meeting the needs of 23 million Iranians living in rural areas (Hansen 4). The outcomes of the community health care system are telling: an impressive narrowing of the disparity between urban and rural Iranians; the Iranian rural infant mortality rate fell by 75%; the overall national birthrate has been lowered. Indeed, the World Health Organization has given high praise to the Iranian system for, inter alia, its preventative primary care (Hansen 4). The Iranian community health workers are responsible for the well being of their fellow villagers from birth.
The articulation and integration of services that takes place across the tiers is what makes the system unique and strongly contributes to the robust delivery of services.
The community health aide situation in Jamaica is instructive as it illustrates how small chances can impact the integrity of the community health aid design and program functioning (Cumper and Vaughan 365). When the community health aide program was first implemented in Jamaica, the focus was clearly on promoting preventative measures, motivation of patients to continue treatment and follow regimens, the provision of patient health education, identifying relevant issues to midwives and public health nurses, provide assistance to clinics and schools in routine care, and determine the need for and provide referrals (Cumper and Vaughan 365). The scope of direct services and education provided included child health, immunization, family planning, nutrition, and sanitation (Cumper and Vaughan 365). Over a period of seven years, the scope of services and functions provided by the community health workers narrowed, at the same time that connections with the health centers have become more robust (Cumper and Vaughan 365). As community health workers increasingly become full-time employees -- with a tighter schedule of task assignments and government regulations to consider -- the community health workers were less able to make themselves available to community members (Cumper and Vaughan 365). Softer consultation services suffered from this change, reducing the capacity of community health workers to provide patients with advice, information, and help (Cumper and Vaughan 365).
A fundamental aspect of this change was the migration of community health aides from their homes in rural communities and villages to the more populated areas where the health centers are located (Cumper and Vaughan 365). With this change, the community health workers began to consider themselves based in the centers, and so adopted the centers' hours and formal labor organization affiliations (Cumper and Vaughan 365). Community health workers perceive that their roles are nursing auxiliaries, which conveys heightened their status, but also simultaneously served to reduce the flexibility with which the community health workers met their responsibilities (Cumper and Vaughan 365). Two particularly important ramifications have emerged: 1) Patients accessing services at the health centers had some level of formal education, which means that patients with less education -- the original target population for the community health aides program -- do not have sufficient contact with community health aides; and, 2) The salary of community health aides has risen to two-thirds that…