Labour exploitation among community health workers

Abstract

In The Lancet Global Health, Madeleine Ballard and colleagues1Ballard M Olaniran A Iberico MM et al.Labour conditions in dual-cadre community health worker programmes: a systematic review.Lancet Glob Health. 2023; 11: e1598-e1608Google Scholar report on dual-cadre systems, in which unsalaried community health workers work alongside paid health-care workers. The finding that nearly 60% of unsalaried workers and one in ten salaried workers experience labour exploitation is concerning. Considering that community health workers are primarily women of colour, exploitation of this workforce is a predictable consequence of patriarchy, racism, and ongoing legacies of colonisation that must be addressed. As a first step to achieving greater equity for community health workers, health systems and international non-governmental organisations (NGOs) must engage in a radical rethink about their conceptualisation of the role of community health workers. Community health workers are frontline professionals who share deep trust, cultural alignment, and lived experience with the communities where they live and serve. They have unique roles and skills in public health that enable them to assess community strengths and challenges and advocate for sustainable local solutions to social and health problems.2Rosenthal EL Menking P St. John J et al.C3 project findings: roles & competencies.https://www.c3project.org/roles-competenciesDate accessed: August 15, 2023Google Scholar However, health systems and NGOs often undervalue community health workers by labelling such workers as laypersons while simultaneously expecting them to address structural inequities and scarcity of health resources through so-called task-shifting.3Coales K Jennings H Afaq S et al.Perspectives of health workers engaging in task shifting to deliver health care in low-and-middle-income countries: a qualitative evidence synthesis.Glob Health Action. 2023; 162228112Crossref Scopus (0) Google Scholar Assigning community health workers complex medical tasks without providing commensurate remuneration and training could be more accurately described as burden-shifting. In our view, placing the onus of fixing under-resourced systems on women of colour who have seldom been served by such systems is unethical. Volunteer community health workers often forgo economic opportunities, educational pursuits, and time with family due to their role, all of which might further entrench the very health disparities community health worker programmes aim to eliminate. In areas with a high prevalence of violence, or endemic communicable illnesses, the lives of community health workers are at risk. Ending labour exploitation of community health workers will require health systems and NGOs to demonstrate a true commitment to equity through consistent, equitable budget allocations for community health workers. Community health workers are often motivated by a desire to serve the communities that hold them in high esteem. However, as Ballard and colleagues report,1Ballard M Olaniran A Iberico MM et al.Labour conditions in dual-cadre community health worker programmes: a systematic review.Lancet Glob Health. 2023; 11: e1598-e1608Google Scholar failing to provide some community health workers with a salary establishes an inequitable, hierarchical working environment, and erodes this foundation of trust because community members call into question whether they should trust the health recommendations of individuals whose employers deem them unworthy of a salary. Health systems and researchers might conclude that community health worker interventions that such workers have had no involvement in designing are unsuccessful when, in fact, health systems do not provide community health workers with adequate training, supervision, role definition, or compensation.4Scott K Beckham SW Gross M et al.What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers.Hum Resour Health. 2018; 16: 39Crossref PubMed Scopus (280) Google Scholar In an assessment of multiple international community health worker programmes, Kok and colleagues note a “need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of community health workers, communities, health professionals and other actors in the health system, if community health workers performance is to improve”.5Kok MC Broerse JEW Theobald S Ormel H Dieleman M Taegtmeyer M Performance of community health workers: situating their intermediary position within complex adaptive health systems.Hum Resour Health. 2017; 15: 59Crossref PubMed Scopus (85) Google Scholar Health systems and NGOs must embrace community health workers as a unique, professional workforce both capable and worthy of self-determination. As a first step, organisations employing community health workers must adopt one of the key principles of the disability rights movement: “nothing about us without us”.6Charlton J Nothing about us without us: disability oppression and empowerment. University of California Press, Oakland, CA1998Crossref Google Scholar Such organisations should insist that community health workers are present and powerful in all circumstances in which decisions about community health workers are made. For example, community health workers must be involved in developing programmes, hiring criteria, training curricula, programme budgets, evaluation plans, workforce policy, and pay equity. We challenge systems to go beyond merely ensuring that community health workers have input in decision making processes. Instead, they should support community health workers to build their own power and decision making capacity. Community health workers deserve opportunities to develop community health worker-led networks or professional associations to advocate for for better working conditions and promote policies to support their workforce. Although our context varies, as a founding board member and the inaugural executive director of the National Association of Community Health Workers in the USA, we believe our community health worker policy platform,7National Association of Community Health WorkersThe National Association of Community Health Workers calls on public and private institutions to respect, protect, and partner with community health workers to ensure equity during the pandemic and beyond.https://nachw.org/wp-content/uploads/2021/03/NACHW-National-Policy-Platform-2021.pdfDate accessed: August 16, 2023Google Scholar which advances respect, protection, and authentic partnership with community health workers is relevant worldwide. Community health workers and trusted allies have worked towards advancing the workforce in the USA, including garnering recognition by numerous federal agencies; inclusion as health professionals in federal legislation; the development of hundreds of local and state level community health worker-led alliances, networks, coalitions and associations; and the launch of our national organising body in 2019. We are confident that community health workers in all geographies and social contexts have the capacity to define and realise their profession to address the historic oppression and crucial needs of communities from which they emanate. Community health workers are the workforce we need for the world we want. Health systems and NGOs must treat community health workers with respect and dignity by ensuring equitable compensation and promoting self-determination. It is time to end the exploitation of community health workers. We declare no competing interests. Labour conditions in dual-cadre community health worker programmes: a systematic reviewUnsalaried community health workers in dual-cadre programmes often face labour exploitation, potentially leading to inadequate health-care provision. Labour laws must be upheld and the creation of professional community health worker cadres with fair contracts prioritised, international funding allocated to programmes that rely on unsalaried workers should be transparently reported, the workloads of community health workers should be modelled a priori and actual time use routinely assessed, community health workers should have input in policies that affect them, and volunteers should not be responsible for the delivery of essential health services. Full-Text PDF Open Access

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