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Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia

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  • Wintrup, James

Abstract

National community health worker (CHW) programmes were central to the vision of primary health care that emerged from the Alma-Ata declaration of 1978. CHWs were identified as agents who could offer basic medical treatment and promote community participation and empowerment. Despite the ambitions of this era, many national CHW programmes were neglected, starved of funding, or discontinued in the decades that followed. These programmes were difficult to sustain in a context of rising debt and structural adjustment, but they also suffered due to poor implementation and a lack of clarity about the role and identity of CHWs. Nevertheless, national CHW programmes have returned to the policy agenda in the past fifteen years and key figures and organisations within global health have begun to argue that they offer a way of strengthening health systems and achieving universal health coverage (UHC). Based on ethnographic research conducted between 2019 and 2020, this article examines a new national CHW programme that has been introduced in Zambia. However, as I show in this article, Zambia's new CHW programme has suffered from many of the same key problems that affected the programmes of the Alma-Ata era: insufficient funding, poor implementation, and a lack of clarity about the role of CHWs. This article shows how these mistakes have been repeated and asks why the lessons of the Alma-Ata era have been lost. Three central problems are identified: national CHW programmes continue to be underfunded and regarded as a “cheap” solution; global health organisations and actors today prioritise technical and quantitative approaches when they design and implement these programmes and therefore overlook the historical experiences and qualitative research of the past thirty years; and, finally, policymakers continue to gloss over the tensions and contradictions within the idea of the “community health worker” itself, creating unclear and unrealistic expectations for CHWs.

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  • Wintrup, James, 2023. "Health by the people, again? The lost lessons of Alma-Ata in a community health worker programme in Zambia," Social Science & Medicine, Elsevier, vol. 319(C).
    • Handle: RePEc:eee:socmed:v:319:y:2023:i:c:s0277953622005639
    DOI: 10.1016/j.socscimed.2022.115257
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    References listed on IDEAS

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    1. Angus Deaton, 2020. "Randomization in the Tropics Revisited: a Theme and Eleven Variations," NBER Working Papers 27600, National Bureau of Economic Research, Inc.
    2. Walt, Gill & Perera, Myrtle & Heggenhougen, Kris, 1989. "Are large-scale volunteer community health worker programmes feasible? The case of Sri Lanka," Social Science & Medicine, Elsevier, vol. 29(5), pages 599-608, January.
    3. Glenton, Claire & Scheel, Inger B. & Pradhan, Sabina & Lewin, Simon & Hodgins, Stephen & Shrestha, Vijaya, 2010. "The female community health volunteer programme in Nepal: Decision makers' perceptions of volunteerism, payment and other incentives," Social Science & Medicine, Elsevier, vol. 70(12), pages 1920-1927, June.
    4. Cueto, M., 2004. "The origins of primary health care and selective primary health care," American Journal of Public Health, American Public Health Association, vol. 94(11), pages 1864-1874.
    5. Berman, Peter A. & Gwatkin, Davidson R. & Burger, Susan E., 1987. "Community-based health workers: Head start or false start towards health for all?," Social Science & Medicine, Elsevier, vol. 25(5), pages 443-459, January.
    6. Warren, Kenneth S., 1988. "The evolution of selective primary health care," Social Science & Medicine, Elsevier, vol. 26(9), pages 891-898, January.
    7. Deaton, Angus & Cartwright, Nancy, 2018. "Understanding and misunderstanding randomized controlled trials," Social Science & Medicine, Elsevier, vol. 210(C), pages 2-21.
    8. Naila Kabeer, 2019. "Randomized Control Trials and Qualitative Evaluations of a Multifaceted Programme for Women in Extreme Poverty: Empirical Findings and Methodological Reflections," Journal of Human Development and Capabilities, Taylor & Francis Journals, vol. 20(2), pages 197-217, April.
    9. Twumasi, Patrick A. & Freund, Paul J., 1985. "Local politicization of primary health care as an instrument for development: A case study of community health workers in Zambia," Social Science & Medicine, Elsevier, vol. 20(10), pages 1073-1080, January.
    10. Maes, Kenneth C. & Kohrt, Brandon A. & Closser, Svea, 2010. "Culture, status and context in community health worker pay: Pitfalls and opportunities for policy research. A commentary on Glenton et al. (2010)," Social Science & Medicine, Elsevier, vol. 71(8), pages 1375-1378, October.
    11. Pfeiffer, James, 2003. "International NGOs and primary health care in Mozambique: the need for a new model of collaboration," Social Science & Medicine, Elsevier, vol. 56(4), pages 725-738, February.
    12. Maes, Kenneth & Kalofonos, Ippolytos, 2013. "Becoming and remaining community health workers: Perspectives from Ethiopia and Mozambique," Social Science & Medicine, Elsevier, vol. 87(C), pages 52-59.
    13. Wintrup, James, 2022. "Promising careers? A critical analysis of a randomised control trial in community health worker recruitment in Zambia," Social Science & Medicine, Elsevier, vol. 299(C).
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