Community Health Aides: Improving International Healthcare

Introduction

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 existing secondary research, this report provides a 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 share the following attributes: sparse populations, cultural and ethnic influences that differ from those of the physicians and administrators overseeing 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 critical link between rural communities and the public health facilities located in more densely populated areas. Uniformly, programs that utilize community health aides exhibit improved service utilization and better uptake of preventative health practices. This report includes recommendations for the improvement of international healthcare based on the successful programs employing community health aides around the world.

Following this introduction, a brief overview of each program in the four locations leads the discussion. The results section lists one primary lesson learned 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 applied. These lessons are then converted into recommendations presented in the final section.

Community Health Aide Programs Around the World

Alaska

The average population density in Alaska is 0.3 persons per square kilometer, and when non-indigenous populations are excluded from the count, that density falls to 0.04 per square kilometer (Haraldson). The vast distances between native villages, coupled with a very harsh climate, have made it extremely difficult to develop and maintain modern services of any kind that indigenous people can readily access (Haraldson). Radical improvements have nonetheless 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 healthcare (Haraldson 1988). The community health aides began receiving standardized training in 1968 (Haraldson). Training of rural community health workers emphasizes primary care and methods for dealing with the problems that take the largest share of rural healthcare services and resources (Haraldson). Notably, immunization, health education, and prevention are key components of the training curricula (Haraldson). Each village council selects a native woman — typically one who has achieved nine years of formal schooling — to receive community health aide training (Haraldson). Daily radiotelephone communication occurs with doctors, and 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 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 patients and for community health aides and other medical staff (Haraldson). As 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 a "vital peripheral branch" of the public healthcare team (Haraldson 237). The idea of providing rural healthcare through the services of paraprofessionals who receive about half a year of training would have been "dismissed as unrealistic" roughly fifty years ago (Haraldson 237). The community healthcare concepts and methods have undergone thorough testing and evaluation, evolving over time to become well adapted to the program's purpose and to the unorthodox conditions under which services are provided (Haraldson).

The Alaskan community healthcare 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 communities, and who are not mistrusted on the basis of linguistic or cultural differences (Haraldson 237).

Iran

The Iranian community health aide system began in the 1980s when Ayatollah Khomeini returned to power (Hansen 4). The revolution that began around that time promised social justice to rural villagers (Hansen 4). Under the shah, there were no doctors in rural Iran, and more than half of the country's population lived in roughly 60,000 villages located outside the major population centers (Hansen 4). For approximately every 1,500 villagers within about one hour's walking distance, the Iranians constructed health houses (Hansen 4). These roughly 1,000-square-foot hut-like structures contained 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 workers received basic preventative healthcare training, and focused on providing advice about family planning, nutrition, immunizations, blood pressure monitoring, prenatal care tracking, and even monitoring environmental conditions such as water quality (Hansen 4). Patients who needed more intensive care or surgery were referred through a unified system extending across all tiers of care — from health house to rural health center to district hospitals (Hansen 4). Roughly 17,000 health houses today successfully meet the needs of 23 million Iranians living in rural areas (Hansen 4).

The outcomes of the Iranian community healthcare system are telling: an impressive narrowing of the disparity between urban and rural Iranians; the rural infant mortality rate fell by 75%; and the overall national birthrate has declined. The World Health Organization has given high praise to the Iranian system for, among other things, its emphasis on 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 across the tiers is what makes the system unique and strongly contributes to the robust delivery of services.

Jamaica

The community health aide situation in Jamaica is instructive because it illustrates how small changes can undermine the integrity of the community health aide design and program functioning (Cumper and Vaughan 365). When the program was first implemented in Jamaica, the focus was clearly on promoting preventative measures, motivating patients to continue treatment and follow their regimens, providing patient health education, identifying relevant issues to midwives and public health nurses, assisting clinics and schools in routine care, and determining the need for — and providing — referrals (Cumper and Vaughan 365). The scope of direct services and education included child health, immunization, family planning, nutrition, and sanitation (Cumper and Vaughan 365).

Over a period of seven years, the scope of services provided by community health workers narrowed, even as connections with the health centers grew more robust (Cumper and Vaughan 365). As community health workers increasingly became full-time employees — with tighter schedules of task assignments and government regulations to observe — they 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 informal help (Cumper and Vaughan 365).

A fundamental aspect of this shift was the migration of community health aides from their homes in rural communities to the more populated areas where the health centers are located (Cumper and Vaughan 365). With this change, community health workers began to consider themselves based in the centers and adopted the centers' hours and formal labor organization affiliations (Cumper and Vaughan 365). Community health workers came to perceive their roles as nursing auxiliaries, which conveyed heightened status but simultaneously reduced the flexibility with which they met their responsibilities (Cumper and Vaughan 365).

Two particularly important ramifications emerged: first, patients accessing services at the health centers tended to have some level of formal education, meaning that patients with less education — the original target population — had insufficient contact with community health aides; and second, the salary of community health aides rose to two-thirds that of registered nurses, increasing the desirability of the position and drawing far more candidates than the program design originally intended (Cumper and Vaughan 365). Funds that could have been used to hire more registered nurses and physicians were being diverted to community health aide positions that no longer fulfilled the program's original purpose (Cumper and Vaughan 365).

The professionalization of community health aides in Jamaica illustrates the potential for co-optation of the program in the interest of the aides themselves and, presumably, for the convenience of health center staff (Cumper and Vaughan 365). The Jamaican program provides the strongest insight from the four case studies — albeit a cautionary one — illustrating a potential problem for other nations whose community health aide programs are at earlier stages of development.

Rwanda

The rural population of Rwanda has about one physician for every 20,000 people in a healthcare system that continues to struggle in a post-genocide environment (Kraemer). Partners in Health (PIH), a non-governmental organization, the Clinton Foundation, and the Rwandan Ministry of Health (MOH) have partnered in an initiative to bring to Rwanda the community-based care model originally developed in rural Haiti (Kraemer). The model is based on community health workers (CHWs) who are trained, employed, and compensated by Partners in Health and the Rwandan MOH (Kraemer).

Prior to the arrival of PIH in Rwanda in 2005, community-based care was provided by three kinds of health workers: the Animateurs de Santé (Health Facilitators), traditional birth attendants (TBAs), and workers of the Home-Based Malaria (HBM) program (Kraemer). Most of these community health workers were not compensated, nor did they receive any formal, organized training (Kraemer). Under the new model, community health workers receive training in primary care, childhood illnesses, family planning, hygiene, malnutrition, and reproductive health. Training also includes a component focused on the treatment of HIV, tuberculosis, and malaria; CHWs emphasize the regular and dose-appropriate administration of medications and educate patients about completing their regimens in order to avoid drug resistance and ensure maximally effective treatments (Kraemer).

The first two years of Partners in Health's work served as a catalyst for the Ten Principles of Rwanda Scale-Up and the Rwandan District Health System Strengthening Framework (Kraemer; "Partners in Health"). By 2014, the comprehensive implementation plan sought full scale-up across 27 districts in response to ten goals, and was designed to include universal healthcare services, socioeconomic aid to remove barriers to treatment, and access to nutrition services and medications (Kraemer; "Partners in Health"). This work falls primarily to Rwandan community health workers, who are elected to their positions by community members and receive support from local leaders in the districts (Kraemer; "Partners in Health").

Because community health workers are place-bound by their chosen obligation to their umudugudu (village), rural Rwandans are not dependent on foreign healthcare workers or doctors, but are instead positioned to be self-sufficient and to benefit from medical innovations through their established collaboration with PIH and the Rwandan MOH (Kraemer; "Partners in Health"). The accompagnateurs, modeled after the community health workers who originated in Haiti through the work of Partners in Health, provide medical and socioeconomic aid to Rwandan villagers — actions that have contributed to the harmonization of the national system of health workers.

Results and Lessons Learned

The four programs examined each yield a distinct primary lesson:

Alaska: The maintenance of reliable, highly trained, locally respected, and indigenous community healthcare workers who remain in their villages is essential to program success.

Iran: The integration of services across structural tiers supports robust, well-articulated delivery of care. A unified referral chain — from health house to rural health center to district hospital — ensures that patients receive the appropriate level of care without gaps.

Jamaica: The professionalization of community health aides allowed the program to be co-opted in a manner that benefited health center staff and the aides themselves over the patients the program was designed to serve.

Rwanda: The accompagnateurs provide both medical and socioeconomic aid to Rwandan villagers, and their community-rooted, elected status has helped stabilize and harmonize the national system of health workers.