"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
VISIONS OF THE FUTURE: Building Tomorrow's Community Health Workforce
As part of the ‘Symposium on CHWs and Their Contribution Towards the Sustainable Development Goals’ Makerere University (Uganda), CHW Central, Nottingham Trent University (UK), and World Vision are supporting a series of interviews with academic leaders and experts in international health development and delivery fields to provide their vision of the future of CHWs in a new light.
We will explore: How can CHWs create lasting impacts in the era of the Sustainable Development Goals? What steps need to be taken to scale up, empower, and create changes within in our global workforce?
The interviews will be posted on CHW Central over the next weeks as part of the preparation for the Symposium taking place from February 21st-23rd in Uganda. Past interviews will be posted in the CHW Hub.
Read our third interview with Kavita Bhatia below.
Dr. Kavita Bhatia is an experienced independent researcher in community health, based in India. She holds a MA and PhD in Social Work from the Tata Institute of Social Sciences, India. Having had a wide exposure to voluntary and government health settings in India through research and evaluation, she began a focus on CHWs of large-scale Community Health Worker programs, in the public sector. After completing her PhD on the Asha program, a public CHW program of India, she decided to focus on this predominantly female workforce. She conducts ongoing research on the ASHA program, networks, advocates, and supports grassroots Asha networks. Her publications can be seen here: http://ashavani.org/resources
Kavita is the owner and manager of Ashavani.org, an independent not-for-profit e-repository for the professional growth, and advocacy for women community health workers. It also attempts to create an independent space for isolated CHWs working in communities to come together and network amongst themselves. Learn more about the e-portal here: http://www.ashavani.org
If you would like to know more about Dr. Bhatia’s work, here is an archive of her publications: http://bit.ly/2kDRkiI
What is your vision of how ‘tomorrow’s CHWs’ will contribute to gender equity and the empowerment of women and girls?
CHWs are all about simplifying technology and medical knowledge through social techniques and then conveying this information and the gains of this knowledge to the community. This is the role CHWs play, so I think the major contribution, and early CHW programs showed the way, is towards the demystification and decentralization of health care. How does this come into gender equity and involvement? Because the people doing this are women, predominantly. Large-scale programs will further break the barriers to enable people to have access to control their own health and healthcare. Women CHWs will work to break down barriers to empower people over their own health care. Right now, there is a predominance of men and medicine in health care. We need to empower women within this. The power and control of the CHW workforce is not currently optimised. I think that there is such a potential power within this women work force. Being women… there is an inherent gender sensitivity in what they do. By empowering the CHW, we empower the woman, by putting supportive structures in place for her. To further this CHWs need to be supported and empowered to participate in supervision and management structures and given voice within the health care programs.
How do CHW programs contribute to the goal of empowerment of women and girls, and how could that be enhanced in the future?
They should be empowered to be involved in community health care governance at the local level, in health and sanitation committees. These are dominated by men, so she may not be included or she may not have a voice. From there to positions in the village councils, this active inclusion in governance is critical. They can also take over the training and monitoring part of it also. The trade unions have worked to empower them, to be knowledgeable about their rights as well. There is an inherent strength and centeredness in rural women that has been tapped well by them.
Do you see a role for CHWs in promoting gender equity in their communities and households they serve?
I would say by the sheer presence of CHWs in the village communities we are moving towards the goal of empowerment of women and girls. One woman in the village can make a difference. She is trained by the government and goes about her work in the village, breaking the societal norms and barriers of movement and accessibility for women. It can send out a powerful message. We have ASHAs contributing to sex education and talking about contraception to men, women and adolescents. Sex education, contraception, lay counselling is already happening… we need to be on that and maybe take more steps towards preventing violence against women.
What role might CHWs play in the prevention of violence against women? How could this be achieved through the SDG era?
I would like to add here that let us not forget about preventing under age marriages. ASHAs have the courage, they have the ability, to address these issues but only if they are backed by the law of the land and the police. Otherwise they are just sticking their necks out, as its one woman alone in a village – just remember that. They need to be supported. If ASHAs are to counter violence, it is the job of the local government to support them, to provide them with institutional protection.
Could CHWs have a role in preventing child and forced marriage and female genital mutilation?
When activists have tried to publicly address issues of domestic abuse or underage marriages and haven’t had the proper backing and support of the law, they themselves have faced violence. They need institutional support and backing to do this. So, yes, CHWs can have a role in the prevention of child marriage and FGM but they should be backed by the institution that they work for...they should be able to inform the police and the police should respond. With the support systems in place they can do this, it’s very appropriate – they have the courage and they have the willingness to do it. Even in their regular course of their work they need to be protected to ensure their own safety.
What policy changes do you think we need to address to enable your vision of an empowered female CHW workforce?
The basic thing is to take ownership. The government, the health structure, which involve CHWs in their work should take full ownership of their CHWs and make that clear to the community. I’ll give you a quote from one ASHA - it’s a very telling sentence - An [ASHA] said "they don't hold our hand and they don't let go of our hand". So I would say pay them, give them social security, have avenues for grievance redressal, career ladder for those who wish (not everyone wishes) continual education. For the community, they should provide education of the community towards the CHW, I call it CHW sensitivity. This goes hand in hand with gender sensitivity, for the community as well as for the full time health staff.
Changes in medical education and in the health care services which are very curative-care centric and doctor-centric. What is happening today is that there is a gap. You have the curative care, you have the medical knowledge, but you don’t have structured involvement of social scientists and social techniques in place, so very good programs don’t translate or implement so well on the ground. You need planned avenues for the social scientists to enter into health care systems. They should be at the highest levels of policymaking and program planning. Currently we have them at some levels of supervision and in research. We need them in program planning. This is the vision I have for a policy change to take place.
We do need an improvement in CHWs’ working conditions but we also need reform in medical education to incorporate the social elements of health care. Health care is not only technology, we need a whole multi-disciplinary team, public health workers, social workers, communication specialists, counselling specialists together supporting community health. The healthcare team needs to be much broader than it what it is now in order to translate medical knowledge and technology to care.
Any final thoughts and comments?
Yes. I think for Ashavani, it all started at the grass root level, this creation of open spaces for interaction and mutual networking, it was the ASHA who showed me the way. They themselves were already in the process of creating open spaces that are not influenced by trade unions or health care systems or even by their families. Just one community health care worker to another, working on their own and with each other. So I think in the future if they can systematically network and operate in this way they can overcome the isolation CHWs typically operate in. And soon they won’t need Ashavani at all. As for the larger scenario, if I can end with a quote by Rudolf Virchow that I read in a wonderful book called an Atlas of Rural Health …“Medicine is a social science and politics is nothing else but medicine on a large scale.”
All CHW Visions interviews have been conducted and compiled by Polly Walker.
Polly Walker has provided technical leadership to World Vision’s community health worker (CHW) program portfolio over the 5 years. During this time she has overseen their expansion of CHW support growing from 70,000 in 2011, to over 220,000 CHWs in 48 countries. She is the co-author of Timed and Targeted Counseling: a comprehensive course for community health workers, now operating in 38 countries. Over the last 12 years of her career she has focused on CHWs, authoring over 20 CHW training modules, designed mHealth applications used in 7 countries, written various publications on ICCM, quality assurance and supportive supervision, as well as the Core Group’s CHW Principles of Practice in 2013. Polly is known for her work as an advocate for government-led harmonization and scale-up, as well as for her work in developing innovative family inclusive psychosocial approaches to community health care.