Community Health Workers

Abstract
Introduction: Community health workers (CHWs) have been proposed as a means for bridging gaps in healthcare
delivery in rural communities. Recent CHW programmes have been shown to improve child and neonatal health
outcomes, and it is increasingly being suggested that paid CHWs become an integral part of health systems.
Remuneration of CHWs can potentially effect their motivation and focus. Broadly, programmes follow a social,
monetary or mixed market approach to remuneration. Conscious understanding of the differences, and of what
each has to offer, is important in selecting the most appropriate approach according to the context.
Case descriptions: The objective of this review is to identify and examine different remuneration models of CHWs
that have been utilized in large-scale sustained programmes to gain insight into the effect that remuneration has
on the motivation and focus of CHWs. A MEDLINE search using Ovid SP was undertaken and data collected from
secondary sources about CHW programmes in Iran, Ethiopia, India, Bangladesh and Nepal. Five main approaches
were identified: part-time volunteer CHWs without regular financial incentives, volunteers that sell health-related
merchandise, volunteers with financial incentives, paid full-time CHWs and a mixed model of paid and volunteer
CHWs.
Discussion and evaluation: Both volunteer and remunerated CHWs are potentially effective and can bring
something to the health arena that the other may not. For example, well-trained, supervised volunteers and
full-time CHWs who receive regular payment, or a combination of both, are more likely to engage the community
in grass-roots health-related empowerment. Programmes that utilize minimal economic incentives to part-time
CHWs tend to limit their focus, with financially incentivized activities becoming central. They can, however, improve
outcomes in well-circumscribed areas. In order to maintain benefits from different approaches, there is a need to
distinguish between CHWs that are trained and remunerated to be a part of an existing health system and those
who, with little training, take on roles and are motivated by a range of contextual factors. Governments and
planners can benefit from understanding the programme that can best be supported in their communities,
thereby maximizing motivation and effectiveness.

Analisou-se a implementação do modelo de atenção da Política Nacional de Saúde Indígena (Pnaspi) no Distrito Sanitário Especial Indígena do Alto Rio Negro, à luz da diretriz da atenção diferenciada. A temática foi investigada sob três perspectivas: formulação da diretriz; itinerários terapêuticos em aldeias indígenas; atuação dos Agentes Indígenas de Saúde (AIS). Pesquisa qualitativa, apoiada na perspectiva antropológica de Menéndez sobre modelos de atenção. A coleta de dados compreendeu observação participante, entrevistas e análise documental. A formulação da diretriz da atenção diferenciada enfatiza a adequação de tecnologias e profissionais, minimizando a dimensão da coexistência e disputas entre formas de atenção. A perspectiva de análise dos modelos de atenção desde os sujeitos, proposta por Menéndez, mostrou-se fundamental para demonstrar que a partir dos itinerários terapêuticos é possível verificar a coexistência e a articulação de diversas formas de atenção. A começar da análise das rotinas dos AIS não foi possível encontrar a inclusão ou o reconhecimento das representações e práticas indígenas de saúde. Destaca-se a autoatenção, protagonizada por sujeitos e famílias.
Palavras-chave Saúde de populações indígenas, Serviços de saúde do indígena, Noroeste amazônico, Agentes comunitários de saúde

The implementation of the National Policy for Healthcare of Indigenous Peoples (Pnaspi) in the Alto Rio Negro Amazon region was analyzed based on the principles of the differentiated care model. This theme was investigated from three perspectives, namely the formulation of the guidelines, the therapeutic itineraries in indigenous villages, and the work routines of the Indigenous Community Health Agents (AIS). It involved qualitative research based on the anthropological perspective of Eduardo Menéndez. The techniques used were participant observation, interviews, and, document analysis. The formulation of the guidelines of differentiated care emphasizes the adaptation of technologies and professionals, minimizing the coexistence and disputes among healthcare models. Menéndez’s perspective focused on the viewpoint of the subjects was crucial for identifying the coexistence and articulation among different forms of care in the villages through the healthcare itineraries. Nevertheless, it was not possible to identify the inclusion of indigenous health practices and representations through the work routines of the Indigenous Community Health Agents (AIS). The focus was on self-care developed and practiced by the subjects and their families.
Key words Health of indigenous people, Indigenous health services, Cultural competency, Community health workers

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