How Agency Policies & Procedures Protect Community Health Workers

The World Health Organization defines community health workers, or CHWs, as community-selected community members who "have shorter training than professional workers" and are "supported by the health system." CHWs are a vital, expanding part of the global health care workforce, particularly in developing countries and the impoverished sectors of wealthier nations like the United States and Canada, where doctors and nurses are in short supply. Like all health workers, CHWs require protective policies and procedures from their agencies.

Paid Versus Volunteer Service

Many agencies, for example in Bangladesh and the Solomon Islands, have suffered from high CHW turnover rates because of inadequate or no pay, coupled with high and ill-defined workloads. An agency can properly nurture its CHWs' motivation and morale if it is unequivocal from the start about whether their work is volunteer or for pay; if volunteer, what incentives they should receive; and if for pay, who exactly pays their salaries.

Job Task Definition

An agency can best recruit and retain competent, ethical CHWs if it clearly defines their job tasks in accord not simply with reasonable expectations for local conditions, but national and local laws and international best practice standards. Guidelines should spell out when CHWs need to refer cases to doctors or nurses. CHWs worldwide increasingly face a process called "task shifting," which Family Health International defines as training and "allowing lower-level healthcare providers to perform some of the tasks normally reserved for higher-level providers." For example, in Africa it is not nurses or doctors but trained CHWs who often distribute condoms and CycleBeads counseling and supplies. These are appropriate tasks to shift to CHWs. But it would be dangerous, illegal and overwhelming if an agency expected its CHWs to, for example, insert intrauterine devices.

Training, Supervision and Continuing Education

The Health Workforce Advocacy Initiative stresses that CHWs in the field need proper supervision and support services to perform their jobs. "Pre-service and even in-service training have to be supplemented with mentoring and supervision that help make the training stick and that help adapt it to local circumstances. [CHWs] need supervisors who can answer their questions and help them problem-solve the inevitable barriers that arise to service delivery," it states.

Confidentiality and Its Limits

Respect for patient confidentiality is an ethical and legal responsibility of all health care workers, including CHWs, even as they must recognize exceptions to it, for example when a patient is suicidal. An agency must offer lucid guidance concerning its own confidentiality requirements and those of the law. Because CHWs come from the communities they serve, issues of confidentiality can be quite pressing and immediate for them.

Liability and Accountability

An agency with a clear, well-communicated chain of command is best equipped to prevent unethical and illegal actions on the part of staff and to respond constructively when these do occur. Because CHWs serve, are chosen by and are accountable to their very own communities, community leaders and members often need to be included in that chain of command.