Strengthening the performance of community health workers in primary health care : report of a WHO Study Group, meeting held in Geneva from 2 to 9 December 1987

1. Introduction -- 2. The place and role of community health workers in national health systems -- 3. Weaknesses of existing programmes -- 4. Strategies for action -- 5. Conclusions -- 6. Recommendations -- Acknowledgements -- Reference -- Selected further reading

Investigates reasons for the frequent failure of national health systems based on primary health care to make effective use of community health workers. Noting that programmes using these workers have reached a crisis in many countries, the report critically assesses different national experiences in order to pinpoint weaknesses, trace key mistakes, and define corrective actions. Throughout the report, advice and recommendations are guided by the need to strengthen the performance of community health workers through a better understanding of their role, functions, and requirements for formal support. The report opens with a brief historical overview of problems that have arisen in the use of community health workers and reasons for these problems. Against this background, the report turns to the task of identifying and defining weaknesses in existing national programmes. Eight weaknesses are identified, ranging in nature from policy and organizational errors that have built failure into the system to problems of poor selection, insufficient training, inadequate motivation, and lack of reward. These weaknesses are more thoroughly explored in the next section, which sets out the strategies and lines of action needed to overcome each problem. Governments are advised that formal selection criteria should not override community choice and local circumstances, that national or regional training institutions should be avoided and district or local training encouraged, that a problem-solving approach to training is most productive, that communities should contribute towards the costs of programmes, and that a fee for service arrangement for remuneration is unwise. The need to appreciate the high costs of training, supervision, personnel, and transport is clearly stated. Above all, readers are challenged to understand that many failures in the implementation of national programmes are due to inadequacies in planning and management and cannot be attributed to either the concept of community health workers or the performance of individual workers. The final sections condense the contents of the report into a series of precise conclusions and recommendations intended to guide the reshaping of national programmes.