Tomorrow’s CHWs: Reaching the Most Vulnerable Families and Addressing Social Determinants

By: Professor Robert Dingwall, Nottingham Trent University

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.

Join us as we begin this conversation with our first interview of the series below.

Personal Bio: Robert Dingwall is a consulting sociologist and part-time professor at Nottingham Trent University. He began his career with a PhD in medical sociology at the University of Aberdeen for a study of the education of health visitors. He then worked at the University of Oxford, where he contributed to developing the sociology of law as a field of research in the UK. He was subsequently appointed Professor of Sociology at the University of Nottingham, where he founded the Institute for Science and Society, an interdisciplinary research group investigating issues in science, technology and society. This included work on the ethics of pandemic planning as a member of a committee advising the UK government. After leaving that post in 2010, he established Dingwall Enterprises Ltd., offering a range of consulting services. Robert is a Fellow of the Academy of Social Sciences and an Honorary Member of the Faculty of Public Health.  For more information about Robert Dingwall visit: http://www.dingwallenterprises.co.uk and follow him on twitter: @rwjdingwall

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Interview questions:

What is your vision of “Tomorrows CHWs” and the role that they can play in the SDG era?

I think that the important thing is to learn from “yesterday’s CHWs” and to be sure that we are not reinventing the wheel. Health care systems everywhere are realising that it is not possible to achieve health for all goals exclusively through the work of health professionals. Such services are too expensive and too limited in its reach. At the same time, it is essential to bring more ‘professionalism’ to the work of CHWs. They need to develop a knowledge base for their practice and an explicit understanding of the skills that will be helpful to them. This may be a ladder for their own social mobility and we should not be afraid of that. Enthusiastic amateurism is not the way forward. 

 

Taking a ‘social determinants of health’ approach, what is the unique contribution of community health workers?

The unique contribution of CHWs is their ability to reach parts of the community that professional services may find it hard to access, whether because of resource issues or cultural issues. This enables them to advance public health goals by operationalizing them in ways that are sensitive to local priorities and understandings and by mobilizing local resources that may not be available to professionals. However, they also have an important role as advocates from communities to official health care systems in reconciling top-down population health goals with bottom-up local needs and preferences.

 

Who are the ‘most vulnerable families’, what are their health and social care needs?

I think we need to be careful about drawing up lists of “most vulnerable families” according to external criteria. This is something that needs to be determined in context. Apparently vulnerable groups can have a surprisingly high degree of resilience that may be disrupted by insensitive interventions. When planning for pandemic influenza, for example, it emerged that one of the most vulnerable groups might be young single professionals living alone. They might be well-housed, well-fed and affluent, but their high degree of autonomy placed them at risk when they fell ill with a potentially lethal infectious disease. Pandemic planners might need to prompt them to create a ‘buddy system’ of mutual aid, borrowing from community interventions for HIV/AIDS. More usually, of course, vulnerability will be associated with various forms of social exclusion or marginalization. However, we need to discover how these impact on communities, and identify the potential strengths that these communities already have, and how they perceive their needs, before pressing ahead.

 

How can CHWs be better equipped to respond to the complex needs of vulnerable families? What are the challenges and gaps?

CHWs potentially have two assets: an understanding of the community with which they are working and acceptability to that community. These need to be complemented by training that equips them to engage the community in discussions about change and to act as advocates for that community to external agencies. Some of this is about the acquisition of biomedical knowledge and evidence-based practice, but the CHWs must have space to translate these in ways that are locally acceptable. Their own expertise must be acknowledged and respected. If they are to be effective, they must be able to act as mediators rather than as emissaries or evangelists for an external vision of community development or public health. Their own personal goals and achievements should also be acknowledged. For some, working as a CHW could properly be the beginning of a ladder that takes them into training as health care professionals. There is nothing wrong about this aspiration and we need to be careful not to treat them as servants who should be kept in their place.

 

Equity in health care (UHC) access is emphasized in the SDGs, what is the contribution of CHWs in making health systems more equitable?

CHWs are a huge resource of information on the way health systems impact on the lives of their intended beneficiaries and of ideas about innovation in delivery. We need to treat them as key informants, in the way that an anthropologist or sociologist would, with knowledge that can supplement the quantitative data that tends to dominate in health system management and planning. Metrics may help to ask questions about service organization and delivery but they rarely provide the answers. CHWs can help to fill that gap, if we let them.

 

Can you give an example of a strong ‘equity’ driven approach with CHWs and how this has worked?

Most of my work in this field has been historical, looking at the early experiences with CHWs in 19th and early 20th century Britain and the ways in which their work became increasingly professionalized. This did not necessarily obstruct an ‘equity’ driven approach but did make it dependent on the willingness of local policy elites to invest in and accept the legitimacy of such an approach. From the 1950s until the 1970s, for example, the city of Aberdeen in Scotland was able to achieve some of the best maternal and child health outcomes in Europe despite high degrees of poverty and insecure employment because of the strong commitment of local politicians, and public health and clinical leaders to expenditure on community oriented services delivered by locally-trained health visitors. Although this was a professional service, it had much in common philosophically with contemporary CHW work.

 

Any final thoughts and comments?

I have recently been writing about the failures of public health policy in relation to Ebola, Zika and the threat from emerging infectious diseases. In my view WHO has lost its way in relation to public health since the high point of the Alma Ata declaration. It has become obsessed with biomedically-led interventions such as the development of vaccines and forgotten that the first line of defense against any newly emerging disease is social and behavioral. CHWs are absolutely central to this. They will save thousands of lives while scientists in the Global North are pottering away in their laboratories.

 

All CHW Visions interviews have been conducted and compiled by Polly Walker. 

Bio:  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 Counselling: 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.