THE VILLAGE HEALTH WORKER LACKEY OR LIBERATOR
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THE VILLAGE HEALTH WORKER LACKEY
OR LIBERATOR - extracted text
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VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14, COMMUNITY CENTRE, S.D.A.,
NEW DELHI 110 016
PHONES : 668071, 668072
GRAM :-"VOLHEALTH" New Delhi-110 016
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C-53
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T.nncialoro --563
THE VILLAGE HEALTH WORKER
LACKEY OR LIBERATOR ?
DAVID WERNER
Throughout Latin America, the programmed use of health auxiliaries has,
in recent years, become an important part of the new international push of
‘‘community oriented” health care. But in Latin America village health
workers are far from new. Various religious groups and non-government
agencies have been training promotores de salud or health promoters for
decades. And to a large (but diminishing) extent, villagers still rely, as they
always have, on their local curanderos, herb doctors, bone setters, traditional
midwives and spiritual healers. More recently, the medico practicante or
empirical doctor has assumed in the villages the same role of self-made
practitioner and prescriber of drugs that the neighbourhood pharmacist has
assumed in larger towns and cities.
Until recently, however, the respective Health Departments of Latin
America have either ignored or tried to stamp out this motley work force of
non-professional healers. Yet the Health Departments have had trouble
coming up with viable alternatives. Their Western-style, city-bred and citytrained M Ds. not only proved uneconomical in terms of cost effectiveness;
they flatly refused to serve in the rural area.
The first official attempt at a solution was, of course, to produce more
doctors. In Mexico the National University began to recruit 5000 new medical
students per year (and still does so). The result was a surplus of poorly
trained doctors who stayed in the cities.
The next attempt was through compulsory social service. Graduating
medical students were required (unless they bought their way off) to spend
a year in a rural health center before receiving their licenses. The young
doctors were unprepared either by training or disposition to cope with the
health needs in the rural area. With discouraging frequency they became
resentful, irresponsible or blatantly corrupt.
Next came the era of the mobile clinics. They, too, failed miserably.
They created dependency and expectation without providing continuity of
service. The net result was to undermine the people's capacity for self care.
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it was becoming increasingly clear that provision of health care in the
rural area could never be accomplished by professionals alone. But the
medical establishment was—and still is—reluctant to crack its legal monopoly.
At long last, and with considerable financial cajoling from foreign and
international health and development agencies, the various health depart
ments have begun to train and utilize auxiliaries. Today, in countries where
they have been given half a chance, auxiliaries play an important role in the
health care of rural and periurban communities. And if given a whole chance,
their impact could be far greater. But, to a large extent, politics and the
medical establishment still stand in the way.
My own experience in rural health care has mostly been in a remote
mountainous sector of Western Mexico, where, for the past 12 years I have
been involved in training local village health workers, and in helping foster a
primary health care network, run by the villagers themselves. As the villagers
have taken over full responsibility for the management and planning of their
programme, I have been phasing out my own participation to the point where
I am now only an intermittent advisor. This has given me time to look more
closely at what is happening in rural health care in other parts of Latin
America.
Last year a group of my co-workers and I visited nearly 40 rural health
projects, both government and non-government, in nine Latin American
countries (Mexico, Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica,
Venezuela, Columbia and Ecuador). Our objective has been to encourage a
dialogue among the various groups, as well as to try to draw together many
respective approaches, methods, insights and problems into a sort of field
guide for health planners and educators, so we can all learn from each other’s
experience. We specifically chose to visit projects or programmes which
were making significant use of local, modestly trained health workers or
which were reportedly trying to involve people more effectively in their own
health care.
We were inspired by some of the things we saw, and profoundly disturbed
by others. While in some of the projects we visited, people were in fact
regarded as a resource to control disease, in others we had the sickening
impression that disease was being used as a resource to control people. We
began to look at different programmes, and functions, in terms of where
they lay along a continum between two poles : community supportive and
community oppressive.
Community supportive programmes or functions are those which
favourably influence the long-range welfare of the community, that help it
stand on its own feet, that genuinely encourage responsibility, initiative,
decision making and felf-reliance at the community level, that build upon
human dignity.
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Community oppressive programmes or functions are those which, while
invariably giving lip service to the above aspects of community input, are
fundamentally authoritarian, paternalistic or are structured and carried out in
such a way that they effectively encourage greater dependency, servility and
unquestioning acceptance of outside regulations and decisions; those which
in the long run are crippling to the dynamics of the community.
It is disturbing to note that, with certain exceptions, the programmes
which we found to be more community supportive were small non-government efforts, usually operating on a shoestring and with a more or less
subrosa status.
As for the large regional or national programmes—for all their inter
national funding, top-ranking foreign consultants and glossy bilingual bro
chures portraying community participation—we found that when it came down
to the nitty-gritty of what was going on in the field, there was usually a
minimum of effective community involvement and a maximum of dependency
creating handouts, paternalism and superimposed, initiative destroying norms.
I don't have time to elaborate here, but anyone who is interested in a
more detailed account of community supportive and oppressive health pro
gramming may send for a copy of a paper I presented in England last year
entitled Health Care and Human Dignity.
*
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In our visits to the many rural health programmes in Latin America, we
found that primary health workers come in a confusing array of types and
titles. Generally speaking, however, they fall into two major groups :
auxiliary nurses
or health technicians
health promoters
or village health workers
—at least primary education plus
1-2 years training
—average of 3rd grade education
plus 1-6 months training
—usually from outside the community
—usually from the community and
selected by it
—usually employed full time
—often a part time health worker
supported in part by farm labor
or with help from the community
—salary usually paid by the programme
(not by the community)
—may be someone who has already
been a traditional healer.
*
Health Care and Human Dignity by David Werner, 1976. Available through the Hesperian
Foundation, P.O. Box 1692, Palo Alto, California 94302, USA. Please send 82.00 U.S. to
cover copy and postage. Also available from VHaI (C-52).
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In addition to the health workers just described, many Latin American
countries have programmes to provide minimal training and supervision of
traditional midwives. Unfortunately, Health Departments tend to refer to
these programmes as "Control de Parteras Empiricas”—Control of Empirical
Midwives—a terminology which too often reflects an attitude. Thus to Mos
quito Control and Leprosy Control has been added Midwife Control. (Small
wonder so many midwives are reticent to participate I) Once again, we found
the most promising work with village midwives took place in small non
government programmes. In one such programme
*
the midwives had formed
their own club and organized trips to hospital maternity wards to increase
their knowledge.
What skills can the village health worker perform ? How well does
he perform them ? What are the limiting factors that determine what he
can do ? These were some of our key questions when we visited different
rural health programmes.
We found that the skills which village health workers actually performed
varied enormously from programme to programme. In some, local health
workers with minimal formal education were able to perform with remarkable
competence a wide variety of skills embracing both curative and preventive
medicine as well as agricultural extension, village cooperatives and other
aspects of community education and mobilization. In other programmes—
often those sponsored by Health Departments—village workers were permitted
to do discouragingly little. Safeguarding the medical profession's monopoly
on curative medicine by usinp the standard argument that prevention is more
important than cure (which it may be to us but clearly is not to a mother
when her child is sick) instructors often taught these health workers fewer
medical skills than many villagers had already mastered for themselves. This
sometimes so reduced people’s respect for their health worker that he (or
usually she) became less effective, even in preventive measures.
In the majority of cases, we found that external factors, far more than
intrinsic factors, proved to be the determinants of what the primary health
worker could do. We concluded that the great variation in range and type
of skills performed by village health workers in different programmes has
less to do with the personal potentials, local conditions or available funding
than it has to do with the preconceived attitudes and biases of health
programme planners, consultants and instructors.
In spite of the often
repeated eulogies about “primary, decision making by the communities
themselves", seldom do the villagers have much, if any, say in what their
health worker is taught and told to do.
* In Plnalejo, Honduras.
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The limitations and potentials of the village health worker—what he is
permitted to do and, conversely, what he could do if permitted—can best be
understood if we look at his role in its social and political context. In Latin
America, as in many other parts of the world, poor nutrition, poor hygiene,
low literacy and high fertility help account forthe high morbidity and mortality
of the impoverished masses. But as we all know, the underlying cause—or
more exactly, the primary disease—is Inequity : inequity of wealth, of land, of
educational opportunity, of political representation and of basic human rights.
Such inequities undermine the capacity of the peasantry for self care. As a
result, the political/economic powers-that-be assume an increasingly pater
nalistic stand, under which the rural poor become the politically voiceless
recipients of both aid and exploitation. (See Figure 1) In spite of national,
foreign and international gestures at aid and development, in Latin America
the rich continue to grow richer and the poor poorer. As anyone who has
broken bread with villagers or slum dwellers knows only too well : health of
Fig. 1
Too oftenald end exploitation go hand In hand.
of poor on rich, of rural
(national, foreign,
connunity on central govt.
mu!tinational)
Weaker people
and of central govt, on
foreign and multilateral
agencies.
Increased
debt
(poor owe rich)
THE
AID
CYCLE
\
Increased
exploitation
Increased outside
manipulation and control
\
Humiliation, decreased
dignity, increased
irresponsibility, sense
of futility, misdirected
anger.f
(.
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the people is far more influenced by politics and power groups, by distribution
of land and wealth, than it is by treatment or prevention of disease.
Political factors unquestionably comprise one of the major obstacles to
a community supportive programme. This can be as true for village politics
as for national politics. However, the politico-economic structure of the
country must necessarily influence the extent to which its rural health pro
gramme is community supportive or not.
Let us consider the implications in the training and function of a primary
health worker:
If the village health worker is taught a respectable range of skills, if he
is encouraged to think, to take initiative and to keep learning on his own, if
his judgment is respected, if his limits are determined by what he knows and
can do, if his supervision is supportive and educational, chances are he will
work with energy and dedication, will make a major contribution to his
community and will win his people’s confidence and love. His example will
serve as a role model to his neighbours, that they too can learn newskills
and assume new responsibilities, that self-improvement is possible. Thus
the village health worker becomes an internal agent-of-change, not only for
health care, but for the awakening of his people to their human potential ...
and ultimately to their human rights.
However, in countries where social and land reforms are sorely needed,
where oppression of the poor and gross disparity of wealth is taken for
granted, and where the medical and political establishments jealously covet
their power, it is possible that the health worker I have just described knows
and does and thinks too much. Such men are dangerous I They are the
germ of social change.
So we find, in certain programmes, a different breed of village health
worker is being molded ... one who is taught a pathetically limited range of
skills, who is trained not to think, but to follow a list of very specific instru
ctions or "norms”, who has a neat uniform, a handsome diploma and who
works in’a standardized cement block health post, whose supervision is
restrictive and whose limitations are rigidly predefined. Such a health worker
has a limited impact on the health and even less on the growth of the
community. He—or more usually she—spends much of her time filling
out forms.
In a conference I attended in Washington last December, on Appropriate
Technology in Health in Developing Countries, it was suggested that
"Technology can only be considered appropriate if it helps lead to a change in
the distribution of wealth and power". If our goal is truly to get at the root
of human ills, must we not also recognize that, likewise, health projects and
health workers are appropriate only if they help bring about a healthier
distribution of wealth and power ?
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We say prevention is more important than cure.
willing to go ? Consider diarrhoea :
But how far are we
Each year millions of peasant children die of diarrhoea. We tend to
agree that most of these deaths could be prevented. Yet diarrhoea remains
the number one killer of infants in Latin America and much of the developing
Fig. 2
WE SAY PREVENTION IS MORE IMPORTANT THAN CURE—
BUT WERE SHOULD PREVENTION BEGIN ?
Needless Suffering and Dehumanization
Disproportionately high morbidity and mortality
(especially infants, mothers and young men)
t
t
Infections, such as diarrhoeas and pneumonia, violence, etc.
Poor nutrition, poor hygiene; low literacy, high fertility.
|
Low initiative, misdirected anger
Inequity of :
Wealth
Land
Health Care
Education
Representation
Human Rights
t
Existing Power Structure
—financial power groups
Private
—political power groups
Governmental
Foreign
‘
—medical establishment
—legal profession
GREED
Multinational
—religious power groups
A
i
J
*
(short sighted self-interest)
CAUSE
PREVENTIVE
MEASURES :
Social reform
Humanization
(or revolution)
(Evolution)
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world. Does this mean our so-called “preventive" measures are merely
palliative ? At what point in the chain of causes which makes death from
diarrhoea a global problem (see Figure 2) are we coming to grips with the
real underlying cause. Do we do it ...
... by preventing some deaths through treatment of diarrhoea ?
... by trying to interrupt the infectious cycle through construction of
latrines and water systems ?
... by reducing high risk from diarrhoea through better nutrition ?
... or by curbing land tenure inequities through land reform ?
Land reform comes closest to the real problem. But the peasantry is
oppressed by far more inequities than those of land tenure. Both causing
and perpetuating these crushing inequities looms the existing power stru
cture : local, national, foreign and multinational.
It includes political,
commercial and religious power groups as well as the level profession and
the medical establishment. In short it includes ... oursieves.
As the ultimate link in the causal chain which leads from the hungry child
with diarrhoea to the legalized inequities of those in power, we come face to
face with the tragic flaw in our otherwise human nature, namely greed.
Where, then, should prevention begin ? Beyond doubt, anything we can
do to minimize the inequities perpetuated by the existing power structure will
do far more to reduce high infant mortality than all our conventional preven
tive measures put together. We should, perhaps, carry on with our latrine
building rituals, nutrition centers and agricultural extension projects. But
let’s stop calling it prevention. We are still only treating symptoms. And
unless we are very careful, we may even by making the underlying problem
worse ... through increasing dependency on outside aid, technology and
control.
But this need not be the case. If the building of latrines brings people
together and helps them look ahead, if a nutrition center is built and run by
the community and fosters self-reliance, and if agricultural extension, rather
than imposing outside technology encourages internal growth of the people
toward more effective understanding and use of tneir land, their potentials
and their rights ... then, and only then, do latrines, nutrition centres and
so-called extension work begin to deal with the real causes of preventable
sickness and death.
This is where the village health worker comes in. It doesn't matter much
if he spends more time treating diarrhoea than building latrines. Both are
merely palliative in view of the larger problem. What matters is that he get
his people working together.
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Yes, the most important role of the village health worker is preventive.
But preventive in the fullest sense, in the sense that he helps put an end to
oppressive inequities, in the sense that he helps his people, as individuals
and as a community, liberate themselves not only from outside exploitation
and oppression, but from their own short-sightedness, futility and greed.
The chief role of the village health worker, at his best, is that of liberator.
This does not mean he is a revolutionary (although he may be pushed into
that position). His interest is the welfare of his people. And, as Latin
America's blood-streaked history bears witness, revolution without evolution
too often means trading one oppressive power group for another. Clearly,
any viable answer to the abuses of man by man can only come through
evolution, in all of us, toward human relations which are no longer founded
on short-sighted self-interest, but rather on tolerance, sharing and
compassion;
I know it sounds like I am dreaming. But the exciting thing in Latin
America is that there already exist a few programmes that are actually
working toward making these happen—where health care for and by the
people is important, but where the main role of the primary health worker is
to assist in the humanization or, to use Paulo Freire's term, conscientization
of his people.
Before closing let me try to clear up some common misconceptions.
Many persons still tend to think of the primary health worker as a
temporary second-best substitute for the doctor ... that if it were financially
feasible the peasantry would be better off with more doctors and fewer
primary health workers.
I disagree. After twelve years working and learning from village health
workers—and dealing with doctors—I have come to realize that the role of
the village health worker is not only very distinct from that of the doctor,
but, in terms of health and well-being of a given community, is far more
important. (See Appendix)
You may notice I have shied away from calling the primary health worker
an 'auxiliary'. Rather I think of him as the primary member of the health team.
Not only is he willing to work on the front line of health care, where the needs
are greatest, but his job is more difficult than that of the average doctor. And
his skills are more varied. Whereas the doctor can limit himself to diagnosis
and treatment of individual “cases", the health worker's concern is not only
for individuals—as people—but with the whole community. He must not only
answer to his people's immediate needs, but he must also help them look
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ahead, and work together to overcome oppression and to stop sickness before
it starts. His responsibility is to share rather than hoard his knowledge, not
only because informed self-care is more health conducing than ignorance
and dependence, but because the principle of sharing is basic to the well
being of man.
Perhaps the most important difference between the village health worker
and the doctor is that the health worker's background and training, as well
as his membership in and selection by the community, help reinforce his will
to serve rather than bleed his people. This is not to say that the village
health worker cannot become money-hungry and corrupt. After all, he is as
human as the rest of us. It is simply to say that for the village health worker
the privilege to grow fat off the illness and misfortune of his fellow man has
still not become socially acceptable.
Forgive me if I seem a little bitter, but when you live with and share the
lot of Mexican villagers for 12 years, you can’t help but feel a little uncom
fortable about the exploits of the medical profession. For example, Martin,
the chief village medic and coordinator of the villager-run health programme,
I helped to start, recently had to transport his brother to the big city for
emergency surgery. His brother had been shot in the stomach. Now Martin,
as a village health worker supported through the community, earns 1,600 pesos
($80.00) a month, which is in line with what the other villagers earn. But the
surgeon charged 20,000 pesos ($1000.00) for two hours of surgery. Martin
is stuck with the bill. That means he has to forsake his position in the
health programme and work for two months as a wet-back in the States—in
order to pay for two hours of the surgeon’s time. Now, is that fair ?
No, the village health worker, at his best, is neither choreboy nor auxiliary
nor doctor's substitute. His commitment is not to assist the doctor, but to
help his people.
The day must come when we look at the primary health worker as the key
member of the health team, and at the doctor as the auxiliary. The doctor,
as a specialist in advanced curative technology, would be on call as needed
by the primary health worker for referrals and advice. He would attend those
2-3% of illnesses which lie beyond the capacity of an informed people and
their health worker, and he even might under supportive supervision, help
out in the training of the primary health worker in that narrow area of health
care called Medicine.
Health care will only become equitable when the skills pyramid has been
tipped on its side, so that the primary health worker takes the lead, and so
that the doctor is tap and not on top.
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Fig. 3
TIPPING THE HEALTH MANPOWER PYRAMID ON ITS SIDE
THE PYRAMID AS IT SHOULD BE
The community is on the bottom of the stack.
The community health worker assumes
Each level is rigidly delineated.
the lead role in the health team.
Fig. 4
The primary health worker
lives and works at the level
of the people.
His first job is to share
his knowledge.
(illustration from the book
Where There is No Doctor
by David Werner).
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APPENDIX
Comparison of the Medical Doctor and the Primary Health Worker
(Note : The medical doctor as described here is the typical Western-style
M.D. as produced by medical schools in Latin America. Clearly,
there are exceptions. Most Latin American medical schools are
beginning to modify their curricula to place greater emphasis on
community health. However, not modifications but radical changes,
both in selection and training, are needed if doctors are ever to
become an integrated and fully positive part of a health team that
serves all the people.)
CONVENTIONAL DOCTOR
VILLAGE HEALTH WORKER
(at the best)
Class
Usually upper middle class
From the peasanty
How chosen
By medical school for :
grade point average;
economic and social
status.
By community for : interest,
compassion,
knowledge of
community, etc.
Preparation
Mainly institutional, 12-16
years general
schooling,
4-6 years medical training.
Training concentrates on
* physical and technologi
cal aspects of medicine.
* and gives low priority to
human, social and politi
cal aspects.
(This is
now changing in some
medical schools )
Mainly experiential. Limited,
key training appropriate to
serve all the people in a given
community :
* Dx & Rx of important disease
* Preventive medicine
* Community health
* Teaching skills
* Health care in terms of econo
mic and social realities, and
of needs (felt and long term)
of both individuals and the
community.
* Humanization (conscientization) and group dynamics.
Qualification
Highly qualified to diagnose
and treat individual cases.
Especially
qualified
to
manage
uncommon
and
difficult diseases.
Less qualified to deal effe
ctively with most important
diseases of most people in
a given community.
Poorly qualified to supervise
and teach VHW. Well quali
fied in clinical medicine, but
not in other more important
aspects of health care; he
tends to favour imbalance;
wrong priorities.)
Moreq ualified than doctor to
deal effectively with the impor
tant sicknesses of most of the
people.
Non-academic quali
fications are : Intimate know
ledge of the community, lan
guage, customs, attitudes to
wards sickness and healing.
Willingness to work and enrn
at the level of the community,
where the needs are greatest.
Not qualified to diagnose and
treat
certain
difficult
and
unusual problems; must refer.
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Orientation
Disease/T reatm ent/In divi
dual patient oriented.
Primary Job
Interest
The challenging and interes
ting cases. (Often bored by
day to day problems.)
Attitude
toward the
sick
Superior. Treats people as
patients. Turns people into
''cases”
Underestimates
people's
capacity for self-care.
Health/Community oriented.
Seeks a balance between cura
tive and preventive. (Curative
to meet felt needs, preventive
to meet real needs.)
Helping people resolve their
biggest problems because he
is their friend and neighbour.
On their level.
as people.
Treats patients
Mutual concern and interest
because the VHW is village
selected.
Attitude of
the sick
toward M.D.
or VHW
Hold him in awe. Blind trust
(or sometimes distrust).
See him as a friend. Trust him
as a person, but feel free to
question him.
How does
Medical
Knowledge
Hoards it.
Delivers "services",
discourages self-care, keeps
patients helpless and de
pendent.
Shares it.
Encourages informed self-care,
helps the sick and family under
stand and manage problems.
Accessibility
Often inaccessible, espe
cially to poor.
Preferential
treatment
of
haves over have-nots.
Does some charity work.
Very accessible.
Lives right in village.
Low charges for services.
Treats everyone equally and
as his equal.
Consideration for
economic
factors
Overcharges.
Expects disproportionately
high earnings.
Feels it is his God-given
right to live in luxury while
others hunger.
Often prescribes unnecessa
rily costly drugs.
Overprescribes.
Reasonable charges.
Takes the person's economic
position into account.
Content (or resigned) to live
at economic level of his people.
Prescribes only useful drugs.
Considers cost.
Encourages
effective home remedies.
Relative
Permanence
At most spends 1-2 years in
a rural area and then moves
to the city.
A permanent member of the
community.
Continuity
of Care
Can't follow up cases becacuse he doesn’t live in
the isolated areas.
Visits his neighbours in their
homes to make sure they get
better and learn how not to
get sick again.
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Cost
Effectiveness
Too expensive to ever meet
medical needs of the poorunless used as an auxiliary
resource for problems not
readily managed by VHW.
Low cost of both training and
practice.
Higher effectiveness than doctor
in coping with primary problems.
Resource
Require
ments
Hospital or health centre.
Depends
on
expensive,
hard-to-get equipment and
a large subservient staff to
work at full potential.
Works out of home or simple
structure.
People are the main resource.
Present
Role
On top.
Directs the health team.
Manages all kinds of medical
problems,
easy
or
complex.
Often overburdened with
easily treated or preventa
*
ble
illness.
On the bottom.
Often given minimal responsibility, especially in medicine.
Regarded as an auxiliary (lackey)
to the physician.
Impact
on the
Community
Relatively
low
(in part
negative).
Sustains class differences,
mystification of medicine,
dependency on expensive
outside resources
Drains resources of poor
(money).
Potentially high.
Awakening of people to cope
more effectively with
health
needs, human needs, and ultimately human rights.
Helps community to use resources more effectively.
Appropriate
(future ?)
Role
On tap (not on top).
Functions as an auxiliary to
the VHW, helping to teach
him more medical skills and
attending referrals at the
VHW's request. (The 23%
of cases that are beyond
the VHW's limits.)
He .is an equal member of
the health team.
Recognized as the key member
of the health team.
Assumes leadership of health
care activities in his village, but
relies on advice, support, and
referral assistance from the
doctor when he needs it.
He is the doctor's equal (although his earnings remain in
line with those of his fellow
villagers.)
TWO
APPROACHES
Taking care of others
Take £ pi lls
z/ times o- day
Pon't aslc
Questions./ r
TO
CARE
HEALTH
I,1
leoj-nro ca-ffoi
selves,
V
_
___________ wr
I
THE LAND OP
KNOWLEDGE
'-------- ---------■tlra-nE/J
l pO.\
THE PIT OF
IGNORANCE
encourages dependency
and loss of freedom .
encourages independence,
self-reliance and equality
VH LAGE HEALTH WORKERS CAN HELP DOCTORS LEARN THE SECOND APPROACH
Position: 1802 (5 views)