This article is part of the following series: Health for all? Critical perspectives on Universal Health Coverage
“Health for All?” critically explores global moves towards Universal Health Coverage and its language of rights to health, equity, social justice and the public good. Highlighting emerging ethnographic and historical research by both young and established scholars, the series explores the translations and frictions surrounding aspirations for “health for all” as they move across the globe. The series is edited by Ruth Prince.
As the COVID-19 pandemic continues, Community Health Workers (CHWs) – a diverse group of workers who receive different forms of training and remuneration – remain the frontline providers of care and advice in many parts of the world and are being called upon to implement new government interventions. This piece contextualises the work of these CHWs by examining the return of large-scale CHW programmes within the broader Universal Health Coverage agenda of the last decade. By focusing on the introduction of a large-scale CHW programme in rural Zambia, I consider what kind of coverage these programmes offer in practice and how they might change state accountability and citizenship.
Zambia’s new Community Health Workers
It is a hot morning in early November 2019 and Mutinta and John are travelling by motorbike along the dry footpaths and uneven roads of rural southern Zambia.[i] They are visiting different households as part of their routine “health promotion” activities and, on this morning, I am accompanying them with my friend and research assistant, Passwell. Mutinta and John know the route intimately because they both grew up in this area and, as we follow behind on our own motorbike, Passwell and I often find ourselves struggling to keep up. When we arrive at our first stop, around 15 kilometres away from the rural health centre where we began, we greet the residents of the household and are invited to sit down on small wooden stools under the shade of a tree. This large household is home to a middle-aged man and his six wives, along with several other relatives. As with other household visits, John and Mutinta stick to their routine: John asks various questions to the assembled group, while Mutinta records their answers in a large register she carries in her rucksack. The records of their household visits and the details they collect are supposed to be sent to the district medical office once a month.
This interaction is friendly and relaxed. John asks where they are drawing their water from and if they are boiling it or treating it with chlorine. He wants to know if there is a rubbish pit, a dish rack, and a pit latrine in the household. John then asks the group range of questions about how to prevent common illnesses and diseases. He begins by asking if they know what causes malaria, what the symptoms are, and how can it be prevented. John tries to encourage family members to answer these questions for themselves in these meetings and he or Mutinta offer corrections and additional comments along the way. These interactions are conversational and Mutinta and John are engaged and attentive throughout.
On this particular morning, as the conversation about malaria unfolds, one of the women, Sarah, says she thinks she might be experiencing some of the symptoms they are discussing. After asking a few further questions, John produces a rapid diagnostic test from his bag. He gently rubs one of Sarah’s fingers with an antibacterial wipe and she winces slightly as he pierces her fingertip with a lancet. John then squeezes a small droplet of blood onto the testing strip. Several minutes later, the test shows a negative result. John writes a referral form for Sarah and instructs her to travel to the clinic as soon as possible so that one of the health workers can try to identify the cause of her symptoms. As John later explains, Sarah is fortunate to live only 15 kilometres away from the nearest health centre; there are other households they visit which are 75 kilometres away.
Mutinta and John are at the forefront of a new large-scale Community Health Worker (CHW) programme that began in 2012 as part of Zambia’s broader efforts to achieve Universal Health Coverage. In partnership with various global health organisations – including the Clinton Foundation – the Zambian Ministry of Health introduced this programme to train and deploy a new cadre of government CHWs to work in some of the most remote areas of the country. Mutinta and John were part of the first cohort of these new CHWs to graduate and begin working. I have recently been conducting ethnographic research exploring the introduction of this programme from the multiple perspectives of government officials, global health partners, CHWs, and rural citizens.
The architects of Zambia’s new CHW programme have been influenced by the emergence of the Universal Health Coverage agenda. Many proponents of Universal Health Coverage argue that large-scale, government-sponsored CHW programmes are a “cost-effective” way of dramatically improving health coverage in countries that suffer from a shortage of health workers and in which many citizens struggle to access basic healthcare. There are a number of advocates of these programmes today, including the World Health Organisation (WHO), the Clinton Foundation, and the campaign group “One Million Community Health Workers”, who wish to “accelerate the attainment of universal health coverage in rural sub-Saharan Africa” by helping governments to “scale-up nationally recognised CHW programmes”.[ii] These advocates argue that CHWs should be recruited through “community” selection or participation; they should be trained and paid a salary by the government; and they should be posted to remote and rural areas where they can provide basic forms of healthcare and engage in “health promotion” activities.
The return of these kind of large-scale CHW programmes to the policy agenda is a striking development because the last time they were being advocated seriously was during the Alma Ata era in the 1970s, when the ambition to achieve “health for all” was first articulated.
From Alma Ata to Universal Health Coverage
The vision of primary health care that was articulated in the 1978 Alma Ata Declaration gave a prominent place to large-scale CHW programmes and to CHWs themselves, who were regularly depicted as heroic actors who both represented, and cared for, their “communities” (see Metcalf and Nunes 2018). This idea of primary health care was also based on a critique of “top-down” interventions in favour of a vision of “increased community participation” (Basilico et al. 2013: 79). At this time, a joint report by the WHO and UNICEF suggested the following:
For many developing countries, the most realistic solution for attaining total population coverage with essential health care is to employ community health workers who can be trained in a short time to perform specific tasks … In many societies, it is advantageous if these health workers come from the community in which they live and are chosen by it, so that they have its support. (1978: 32)
CHW programmes at this time were ambitious and idealistic state-led initiatives that were intended to offer all citizens the possibility of accessing comprehensive healthcare. Many countries implemented large-scale CHW programmes during this period, including India, Uganda and Mozambique. However, by the 1980s and 1990s, cuts to healthcare spending and structural adjustment programmes many of these programmes had fallen into disrepair or been abandoned due to cuts to healthcare spending and structural adjustment programmes. These CHW programmes became difficult to coordinate and fund while at the same time, donors and NGOs increasingly preferred to implement selective disease programmes, especially in response to the HIV/AIDS crisis. With the rise of neoliberal economics and selective primary healthcare, national CHW programmes became unpopular, although CHWs continued to be recruited as valuable volunteers who could help NGOs to implement their programmes (Maes 2014; Nading 2013). A certain vision of CHWs as selfless and dedicated (and therefore capable of working without payment) persisted during this period, even if the idea of large-scale government-coordinated CHW programmes fell out of favour.
When set against the history of these health reforms, it seems that the return of these CHW programmes to the policy agenda might represent a genuine change of direction in several respects. Firstly, these CHW programmes are intended to offer comprehensive healthcare to people in rural areas; this is a move away from the kind of selective treatment associated with so many NGO health interventions, such as TB or HIV/AIDS programmes. Secondly, advocates of these programmes seem to recognise that the state, rather than NGOs or the market, has a vital role to play in extending health coverage.
In the context of the broader Universal Health Coverage agenda, the return of these large-scale CHW programmes raises a number of interesting questions for anthropologists. At the present moment, when state resources and capacities are limited, how are governments attempting to implement such ambitious, large-scale programmes? What role are global health “partner” organisations continuing to play in these supposedly state-led programmes? And might we see a move away from the kind of “therapeutic” or “biological” citizenship that accompanies selective health interventions (in which claims-making is tied to a particular disease category) towards something that comes to resemble a more comprehensive (or “universal”) form of citizenship and claim-making?
The past few decades of global health partner and NGO involvement in Zambia has profoundly shaped the landscape of rural healthcare, including the attitudes and expectations of government health officials, health professionals, and rural citizens. And this has made it incredibly difficult for the government to introduce a new cadre of health workers in partnership with outside global health organisations. In rural Zambia, many new government CHWs are often seen as simply another group of short-term, donor-funded volunteers.
Partnerships, Resources, and Citizenship
After their graduation, Mutinta and John were posted back to their home area. They were sent home with certain resources and supplies (such as bicycles and umbrellas) given to them by the Clinton Foundation. At first, when these items broke or needed to be repaired, Clinton Foundation officials often delivered new items (in particular, bicycles) directly to CHWs like Mutinta and John in their home areas – therefore “bypassing” district-level government health officials. During the first few years of the programme, newly qualified CHWs also had their salaries partially funded by the Clinton Foundation and had to sign employment contracts with both the Ministry of Health and the Clinton Foundation. At the same time, the Clinton Foundation was heavily involved in the supervision and monitoring of these newly qualified CHWs, in order to demonstrate to their directors and donors that the programme was improving “health outcomes”. Therefore, in the early years of the programme, CHWs like Mutinta and John often felt that they were accountable to both the government and the Clinton Foundation.
Perhaps unsurprisingly, this kind of “partnership” produced certain difficulties. These new CHWs seemed to be affiliated with the Clinton Foundation and yet they were simultaneously government employees. In a context where parallel implementation and supervision was taking place, many government health workers (from nurses to clinical officers to district medical officials) had great difficulty in understanding the position and role of people like Mutinta and John. Many formal government health workers believed that these new government CHWs were simply volunteer CHWs who were sponsored by an NGO or partner organisation. Many new CHWs were therefore excluded from the meetings, training workshops, health campaigns, and other activities. A number of the CHWs told me that, even today, they do not feel they have been accepted by many of their government colleagues.
Consequently, these CHWs have faced great difficulty in accessing resources, particularly as the Clinton Foundation is now phasing out its initial financial support for the programme; indeed, it is formally a government programme so they are “handing over” to the Ministry of Health. If we reconsider the encounter I described above, when Mutinta and John arrived at Sarah’s homestead, this was in many ways a textbook household visit. John and Mutinta engaged in their health promotion meeting and then referred Sarah to the clinic for further treatment. But although John and Mutinta (and many CHWs like them) are doing this kind of day-to-day work, they are doing so with extremely limited resources. The motorbike that John and Mutinta were using that morning was borrowed from one of John’s friends and they paid for the fuel from their own salaries. On the morning when we met Sarah, John was able to find a rapid diagnostic test in the clinic’s supplies but, as Mutinta and John later explained, it has been many years since they last received the supply of equipment and basic medicines that they were trained to use. They have to improvise by borrowing equipment and medications from the clinic’s already under-stocked pharmacy.
These circumstances have further political implications when it comes to thinking about claims-making and citizenship. Initially, I wondered if the presence of a new kind of government health worker – who was able to move beyond the selective models of health coverage that have been central to NGO interventions – might alter rural citizens’ relations to the state and even potentially enable more expansive forms of claim-making.
In practice, I have found that many people in the area who were visited by Mutinta and John did not know that they were government employees. A few days after the encounter with Sarah at her homestead, I returned with Passwell to visit and interview the family members. Although the middle-aged man, Mr Nyamba, told us that he knew that Mutinta and John must be government workers, his response was not typical. On other occasions, people told us that Mutinta and John must be NGO workers or volunteers. But despite the common confusion about whether Mutinta and John were government or NGO workers, the most widespread attitude among people in the area was that it did not matter, as long as Mutinta and John were able to help them. Ramah McKay (2018) has shown in her work in Mozambique that the boundaries between NGO and state agencies in healthcare provision are often unclear (or relatively unimportant to people) because individual health workers themselves regularly mediate access to both government and NGO health programmes. Similarly, in rural Zambia, CHWs like Mutinta and John are often not seen, first and foremost, as NGO workers or government workers, but rather as individuals who – for the time being – are able to provide certain forms of assistance in a landscape of healthcare that is shifting and unreliable.
When it comes to understanding the effects of the Universal Health Coverage agenda, it is important to situate the implementation of recent programmes in relation to the past thirty years of health reforms. The proliferation of NGOs and global health partners who dominate the landscape of rural healthcare makes it difficult for rural residents to recognise the presence of the state in the provision of healthcare. The kind of large-scale CHW programmes that we might see in the future will not resemble the vision of primary health care that was first developed during the time of Alma Ata – even if the current proponents of Universal Health Coverage draw so heavily on the ambitious rhetoric of the era of “health for all”. At the present moment, in the context of the COVID-19 response, it is possible that CHWs will acquire new forms of governmental authority and the difference between NGOs and governmental health workers may become more significant and visible, particularly in places where new large-scale CHW programmes are being implemented. Mutinta and John – and other CHWs in Zambia – may have to take on new roles that differentiate them from other local actors and this may have a more profound effect on the relations between rural citizens and the state than the introduction of the new CHW programme has had so far.
[i] All of the names used here are pseudonyms.
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Kenneth Maes. 2014. “Volunteers are not paid because they are priceless”: Community Health Worker capacities and values in an AIDS treatment intervention in urban Ethiopia. Medical Anthropology Quarterly 29 (1): 97-115.
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James Wintrup received his PhD in anthropology from the University of Cambridge in 2017 and is currently a Postdoctoral Research Fellow at the University of Oslo. His research explores the social and political effects of health interventions in rural Zambia. He has conducted research on Christian medical humanitarianism and its afterlives in rural Zambia. As part of the ERC-funded project “Universal Health Coverage and the Public Good in Africa”, he is currently carrying out research on a new government programme that aims to extend health coverage to rural populations in Zambia by training and deploying a new cohort of Community Health Workers (CHWs).
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