The current issue of the Annals of Anthropological Practice is a special issue, entitled “Community Health Workers and Social Change: Global and Local Perspectives.” The issue comprises an introduction by Kenneth Maes and five articles, the abstracts of which are below. Enjoy!
Major global health institutions, public and private, currently see community health workers (CHWs) as crucial resources. But the daily experiences and complex motives of CHWs, as well as their concerns and criticisms, remain poorly understood by the institutions that promote their value and draw on their labor. Donors, states, NGOs, and other public health institutions often approach the motivations and performance of CHWs as problems that can be solved with a mix of psychological, economic, and management theories; novel incentive packages and supervisory structures; and surveys, interviews, and randomized controlled trials. This special issue shifts the goal toward documenting power inequalities, labor relations, and interactions among CHWs, donors, health officials, supervisors, and care recipients. The articles in this issue offer valuable ethnographic accounts of CHWs in 21st-century Africa, Latin America, and Asia, and deliver a clear message: CHWs participate in important relationships and politics, seeking change in their own job conditions and roles, and other social, political, and economic changes. These forms of “participation” are variable, evolving, and shaped by unique local histories as well as transnational policies and norms. The articles here aim to demonstrate that ethnography and mixed methods can help bring about improvements in policy and practice by explaining and interpreting CHW practices and governance and by encouraging global health actors to treat CHWs not as magic bullets or human resources, but as people with multiple skills, desires, and perspectives.
In December 2012, militants began targeted attacks on workers going door to door in Pakistan delivering polio vaccine, including members of a community health worker cadre called Lady Health Workers (LHWs). Over the next several years, more than 50 workers, most of them women, were murdered as they worked. Media accounts frequently refer to these workers as “aid workers” or “heroes.” This paper complicates and theorizes this conception. Two conflicting moral economies around the work of LHWs existed before the targeted killings began; both have amplified since. One, shared among the LHWs themselves, centers around ideas of community health work as deserving of remuneration just like other government work. The other, promoted by the Global Polio Eradication Initiative at the international level, conceptualizes ground level workers like LHWs as “heroes,” not as labor—eclipsing the LHWs’ own discourse in the international sphere.
Extension agents or agents of change?: Community health workers and the politics of care work in postapartheid South Africa
Christopher J. Colvin and Alison Swartz
Global public health discourse and practice around community health workers (CHWs) often invoke two distinct ideal types: the CHW as an “extension agent” of biomedical health services, bringing health services into community and household settings, and the CHW as a progressive “agent of change,” working with communities to mobilize socially and politically around health inequities and identify and tackle the social determinants of health. In this article, we examine the experience of postapartheid South Africa with CHWs and take a critical look at the degree to which these conventional models of CHWs account for how CHWs in South Africa have emerged, what kinds of work they have done, how they have organized themselves, and what impacts they have had. In the end, we argue that these two models miss much of what is interesting and important about the lives and work of CHWs in South Africa. We further make the case that both mainstream and progressive public health academics and activists tend too often to frame—and reify—CHWs as a much-anticipated solution to a variety of (much bigger) health system and political problems. We maintain, instead, that to adequately understand and support the work of CHWs, one must begin by situating community-based care work within a much broader analysis of these problems.
Using community health workers:: Discipline and Hierarchy in Ethiopia’s Women’s Development Army
Kenneth Maes, Svea Closser, Ethan Vorel, and Yihenew Tesfaye
In this article, we use semistructured interviews and documents produced by Ethiopian government officials and international health donors to examine two key features of the nation’s community health worker (CHW) program: (1) the process and criteria of selecting community health workers; and (2) policies, rhetoric, and experiences of payment and empowerment. We examine these from the varied perspectives of district health officials, Health Extension Workers, and leaders and members within Ethiopia’s so-called Women’s Development Army, whom we interviewed during 2012–14. According to national policymakers and policy documents, the goals of the Women’s Development Army are twofold: first, to reduce mortality and second, to produce “model” women, who discipline themselves and their neighbors to enact healthy behaviors. The Army is supposed to simultaneously “empower” these women to be more autonomous from husbands and more active in development-oriented work. Yet one of the key criteria sought by district-level health officials—willingness to “accept what we teach them and implement what we tell them”—highlights that Army leaders are to remain subordinate to government health officials. Many female members of the Women’s Development Army expressed ambivalence about their selection, particularly as the position was unpaid. Some questioned why women were expected to volunteer when men had previously been paid to do similar work. These data emphasize the differences in goals, aims, and experiences among various actors involved in CHW programs, and the need for researchers to address whether or not respondents are comfortable to express perspectives that might question dominant goals and discourses.
Launched in 2003 by the leftist government of Hugo Chávez, Venezuela’s Barrio Adentro (Inside the Poor Neighborhood) health care program is deeply dependent on local community health workers to implement and administer clinics and various health initiatives. Based on ethnographic research conducted between 2006 and 2009, this article analyzes the experiences of Barrio Adentro community health workers (promotores) in a working-class neighborhood in Caracas, the capital city of Venezuela. My research reveals that community health workers understood their relationship to the state as fraught, but fundamentally collaborative. In contrast, they viewed local residents as the main threat to achieving their community health goals, based on perceptions that some residents were apathetic or politically opposed to the government’s programs to promote social change. In situating this analysis in the broader social and historical context, I show how community health workers represent one of the most significant forms of state-supported activism in a country that has radically expanded social and political participation for historically marginalized groups in the name of “21st century socialism.” I argue that the state’s antineoliberal discourse, substantial investment in public health care, and employment of Cuban doctors distinguish community health work in Barrio Adentro from the experiences of community health work in other areas of Latin America, where community participation has also been framed as a form of empowerment but often serves as a mechanism to devolve state responsibilities for health care onto local communities. In focusing on the broader social, political, and economic context that gives meaning to Barrio Adentro activists, this analysis offers insights that may be applied to community health initiatives in other settings.
Guatemala is one of the first countries in the Americas to establish community health worker (CHW) programs, and CHWs have served a central role in both large-scale national programs and small-scale nongovernmental organization (NGO) projects. The role of CHWs, including their training, responsibilities, and idealized identities, has never been uniform, and has fluctuated over time in response to changing international health paradigms, national socioeconomic and political processes, and local-level power structures and expectations of the position. In this paper, I examine the changing nature of CHWs in the Central Highlands of Guatemala by focusing on the case of the Behrhorst Clinic in Chimaltenango, Guatemala. The Behrhorst Clinic was one of the first to implement a CHW program in Guatemala, and is one of the few NGOs in the region to operate continuously since the 1960s, providing a unique case study to examine the history and transformation of CHWs in three distinct sociopolitical periods: the Primary Health Care era (1960s–1970s); the sociopolitical violence (1970s–1980s); and the aftermath of the violence (1980s–2000s). This longitudinal analysis of the Behrhorst health promoter program highlights central, ongoing issues facing CHW programs in Guatemala and beyond including: the political susceptibility of community participation and empowerment programs; community participation and representation; and the long-term and intergenerational impact of CHW positions that function as a mechanism for socioeconomic advancement through the provision of curative services.
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