Who is Your Healthcare Provider? The Importance of Definition
Paul Farmer and colleagues make a very compelling case for broadening the traditional concept of provider of health services in the US. Given the shortage of health staff in developing countries the community can be tapped into to find members who can provide a necessary bridge between the patients and the healthcare facilities. The most common example of this expanded definition of health provider are community health workers. Members from the community can be trained to detect early signs of disease so that treatment can be promptly solicited or to monitor that people on treatment comply to their schedule. Similarly, they can offer social and psychological support to patients whose ills are not merely medical. Their role has two key advantages: firstly, it relieves the burden of daily duties to be carried out by medical staff such as doctors and nurses; secondly, it saves money as diseases can be detected at early stages and treatment is followed by patients thus avoiding complications or new diseases.
Examples of programs which rely on community health workers and were successful in improving the health of the patients abounds in both developing and developed countries. The expansion of health workforce through community health workers is indeed very much in vogue in countries that have limited capacity of medical staff. There is however an aspect which often goes overlooked: definition and roles of community health workers change greatly from one context to another and are often very vague. The point is that the definition and roles performed matter a great deal when it comes to examining if community health workers can make a difference.
Getting the definition right: the WHO conducted a systematic review of the community health workers programs around the world. They collected information around nine dimensions: from the recruitment criteria to the training content, duration to the roles performed as far as to the supervision and performance incentive. The report found out two things:
1. studies which evaluate the impact of CHWs program fail to break down the information along the 9 dimensions (e.g. recruitment and education criteria etc.). As a result, it is difficult to associate which factor was decisive to achieve the desired outcome. In other words, was the refresher training or the initial level of education which made the difference? Or was none of them and it was the provision of a salary which contribute to the outcome? Or was the quality of the supervision?
2. few of the studies evaluate programs which are run at scale and for a long period and therefore is difficult to assess whether (and how) CHWs can be organically integrated into the health system.
Some of the interventions worked insofar as they achieved the intended goal so why we should care about getting the details right?
The devil is in the details: why definition matters? First of all the task a CHW is expected to perform will tell what are education and recruitment criteria to set, what is the ideal training duration and content, what are the performance incentives and career pathways to offer and what is supervision needed. So when you start planing about CHW stop, breathe and think: is the CHW only expected to advice about antenatal and prenatal care or also to provide home care for low birth wights children? Finding the answers to these questions will help to get the rest of the program together.
The second answer is that if we do not know the details, it is difficult to learn from mistakes or to replicate successes. Consider the examples of two imaginary CHWs: Reema and Brenda. They are both maternal community health workers whose role is therefore to improve maternal health in their communities. Reema’s role is however more clearly defined: she has to advise women on antenatal and prenatal care, offer malaria intermittent preventive treatment, screen for HIV/STI. Brenda on the other hand is only told to visit pregnant women in her community but not guidelines is provided on what kind of information she is expected to collect. Another difference is training: Reema received an initial 4 weeks training followed by on the job training of 2 months; Brenda on the other hand received only a 2 weeks theoretical training. One had the chance to learn by doing and to learn from her mistakes, the other did not get any of those chances. Another difference has to do with supervision: Reema’s supervisor has only 20 CHWs to advise and therefore has the chance to regularly meet with them, listen to their problems and give advice. On the other hand, Breand has a supervisor who oversee 60 CHWs and therefore has not the time to regularly meet with them.
Then an evaluation comes and finds out that maternal deaths decreased in Reema’s community while no significant change was observed in Brenda’s community. On this basis, the study concludes that the evidence about the impact of maternal CHWs is mixed. Well, the point is that by comparing Reema and Brenda one is comparing an apple and orange: they have very little in common apart from the flimsy definition of maternal CHWs.
David Bornestein on the Opinionator reviews the success of the Nurse-Family Partnership, an organization in the US which relies on trained nurses to offer a panoply of support services to poor mothers outside the conventional health facilities. His point is that if policymakers will replicate the model faithfully they will obtain the same success. Yet, the emphasis and attention of policymakers is more about replication than faithful copy. As he points out, if one does not get the details right then one ends up with a mixed bag of results. Detractors of the initiatives will have an easy chance to discredit the program and lobby for a withdrawal of funds. CHWs programs around the world stands to face the same risk; to ensure that we learn from mistakes and that we do not end up with a bag of mixed results more time and attention should be paid to get the definition and the details right.