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“Lackeys or liberators” revisited: Community health workers and health system accountability

Earlier this week, a group of 30 researchers, program implementers, and activists met in Washington, DC, to develop a research agenda on “community health worker voice, power, and citizens’ right to health.” The meeting was convened by Columbia University’s Averting Maternal Death and Disability Program and American University’s Accountability Research Centre. Participants drew from social accountability theory and CHW experiences in India, South Africa, Brazil, Guatemala, Pakistan, Ethiopia, Malawi, Peru, and the USA to explore the factors that can promote or undermine community health workers’ ability and interest in fostering health system accountability to the community.

Some early notes and reflections:

Accountability goes in multiple directions: In order to understand CHWs as agents to improve the accountability of the health system to communities, we needed to discuss the accountability of CHW to their communities and to the health system. While CHWs are often intended to be accountable to their communities, many ultimately serve as the nurse’s helper, promoting reproductive control and immunization but unable to work on issues beyond a narrow biomedical lens. Some even serve private healthcare providers, taking commissions from private hospitals to bring patients. And what about the health system’s accountability to CHWs? Many CHWs lack employment rights, have minimal career progression opportunities, and experience stress and physical danger while going about their work.

He who pays the piper: Remuneration of CHWs remains contested. The participants were not afraid to re-examine this debate from the perspective of social accountability. If CHWs are paid by the government, how can they hold it to account? Isn’t it the case that he who pays the piper calls the tune? But insisting that CHWs work as volunteers brings out questions of exploitation, particularly since most CHWs are women. Moreover, voluntarism can also undermine the capacity to work towards social accountability: unpaid CHWs may lack time to devote to monitoring and planning and may lack the status required to raise their voices. Several participants emphasized that CHWs must be empowered themselves in order to empower communities. How does not being paid for one’s work affect empowerment? Do CHWs gain moral currency as volunteers or lose community respect?

Social accountability is a collective process. There are hundreds of thousands of CHWs in a number of countries represented at the meeting. If these CHWs are health system employees delivering quality health care, then they are indisputably advancing the right to health in the communities served. However, improved provision of services may not have a visible social impact. Social accountability is defined by Joshi and Houtzager (2012) as the “ongoing engagement of collective actors in civil society to hold the state to account for failures to provide public goods.” In the context of CHWs, this would require CHWs working together with their communities or with other CHWs. What programmatic components and contextual conditions enable collective identities and agendas to be developed among CHWs themselves and between CHWs and their communities? We discussed CHW labor rights organizing, their engagement with civil society, and their involvement in Village Health Committees as possible routes. Of course, CHW ability to participate in these processes depends on their interest and relative power in the health system and larger political context. Which brings us to our next point.

CHWs as people: Community health workers are not saints, liberators, or lackeys. They are people, often women, doing their best within weak health systems, difficult social hierarchies, and systems of deep economic inequity. Accountability is ultimately about power, and regardless of what CHW policy dictates, CHWs do feel accountable to someone. Demanding accountability from the state involves challenging systems that benefit the powerful. How much can and should be expected of CHWs, in terms of taking on the risks associated with accountability functions? In what conditions can CHWs make these demands?

It is remarkable that against all odds, we heard many examples of CHWs finding mechanisms to try to improve the responsiveness of government systems and engage in collective activism: CHWs fighting against government-sanctioned deforestation; CHWs striking and marching to demand better employment conditions and the resources necessary to provide health care in their communities; CHWs helping individuals to overcome systematic social exclusion; CHWs who could not directly protest health system failures using their insider knowledge to tip off community monitoring groups. CHWs are diverse and capable. Researchers, policymakers, and activists should listen to CHWs to identify when and how to support CHWs to engage in the larger, collective project of claiming their own rights and those of their fellow community members.

About Stephanie Topp

College of Public Health Medical and Veterinary Sciences, James Cook University, Australia. Twitter: @globalstopp

About Kerry Scott

Johns Hopkins School of Public Health, USA & Independent research consultant, India

About Marta Schaaf

Program on Global Health Justice and Governance, Columbia University Mailman School of Public Health, USA
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