IDEAS home Printed from https://ideas.repec.org/a/eee/socmed/v319y2023ics0277953622005639.html
   My bibliography  Save this article

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

Author

Listed:
  • 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.

Suggested Citation

  • 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
    as

    Download full text from publisher

    File URL: http://www.sciencedirect.com/science/article/pii/S0277953622005639
    Download Restriction: Full text for ScienceDirect subscribers only

    File URL: https://libkey.io/10.1016/j.socscimed.2022.115257?utm_source=ideas
    LibKey link: if access is restricted and if your library uses this service, LibKey will redirect you to where you can use your library subscription to access this item
    ---><---

    As the access to this document is restricted, you may want to search for a different version of it.

    References listed on IDEAS

    as
    1. 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.
    2. Angus Deaton, 2020. "Randomization in the Tropics Revisited: a Theme and Eleven Variations," NBER Working Papers 27600, National Bureau of Economic Research, Inc.
    3. Deaton, Angus & Cartwright, Nancy, 2018. "Understanding and misunderstanding randomized controlled trials," Social Science & Medicine, Elsevier, vol. 210(C), pages 2-21.
    4. 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.
    5. 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.
    6. 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.
    7. 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.
    8. 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.
    9. 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.
    10. 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.
    11. Warren, Kenneth S., 1988. "The evolution of selective primary health care," Social Science & Medicine, Elsevier, vol. 26(9), pages 891-898, January.
    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).
    Full references (including those not matched with items on IDEAS)

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. 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).
    2. 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.
    3. Druetz, Thomas & Kadio, Kadidiatou & Haddad, Slim & Kouanda, Seni & Ridde, Valéry, 2015. "Do community health workers perceive mechanisms associated with the success of community case management of malaria? A qualitative study from Burkina Faso," Social Science & Medicine, Elsevier, vol. 124(C), pages 232-240.
    4. Kabeer, Naila, 2020. "‘Misbehaving’ RCTs: The confounding problem of human agency," World Development, Elsevier, vol. 127(C).
    5. Giovanni Dosi, 2022. "The Agenda for Evolutionary Economics: Results, Dead Ends, and Challenges Ahead," LEM Papers Series 2022/24, Laboratory of Economics and Management (LEM), Sant'Anna School of Advanced Studies, Pisa, Italy.
    6. Annie George & Kim M Blankenship, 2015. "Peer Outreach Work as Economic Activity: Implications for HIV Prevention Interventions among Female Sex Workers," PLOS ONE, Public Library of Science, vol. 10(3), pages 1-14, March.
    7. George W. Norton, 2020. "Lessons from a Career in Agricultural Development and Research Evaluation," Applied Economic Perspectives and Policy, John Wiley & Sons, vol. 42(2), pages 151-167, June.
    8. Fatoumata Nankoto Cissé, 2022. "How impact evaluation methods influence the outcomes of development projects? Evidence from a meta-analysis on decentralized solar nano projects," Documents de travail du Centre d'Economie de la Sorbonne 22008, Université Panthéon-Sorbonne (Paris 1), Centre d'Economie de la Sorbonne.
    9. Edward, Anbrasi & Branchini, Casey & Aitken, Iain & Roach, Melissa & Osei-Bonsu, Kojo & Arwal, Said Habib, 2015. "Toward universal coverage in Afghanistan: A multi-stakeholder assessment of capacity investments in the community health worker system," Social Science & Medicine, Elsevier, vol. 145(C), pages 173-183.
    10. Closser, Svea & Mendenhall, Emily & Brown, Peter & Neill, Rachel & Justice, Judith, 2022. "The anthropology of health systems: A history and review," Social Science & Medicine, Elsevier, vol. 300(C).
    11. Yonatan Eyal, 2020. "Self-Assessment Variables as a Source of Information in the Evaluation of Intervention Programs: A Theoretical and Methodological Framework," SAGE Open, , vol. 10(1), pages 21582440198, January.
    12. Fatoumata Nankoto Cissé, 2022. "How impact evaluation methods influence the outcomes of development projects? Evidence from a meta-analysis on decentralized solar nano projects," Post-Print halshs-03623394, HAL.
    13. Randall S. Brown, 2023. "2020 Rossi Award Lecture: The Evolving Art of Program Evaluation," Evaluation Review, , vol. 47(2), pages 209-230, April.
    14. Naritomi, Joana & Sequeira, Sandra & Weigel, Jonathan & Weinhold, Diana, 2020. "RCTs as an opportunity to promote interdisciplinary, inclusive, and diverse quantitative development research," World Development, Elsevier, vol. 127(C).
    15. Rifat Atun & Thyra de Jongh & Federica V. Secci & Kelechi Ohiri & Olusoji Adeyi, 2009. "Clearing the Global Health Fog : A Systematic Review of the Evidence on Integration of Health Systems and Targeted Interventions," World Bank Publications - Books, The World Bank Group, number 5946, December.
    16. Fatoumata Nankoto Cissé, 2022. "How impact evaluation methods influence the outcomes of development projects? Evidence from a meta-analysis on decentralized solar nano projects," Université Paris1 Panthéon-Sorbonne (Post-Print and Working Papers) halshs-03623394, HAL.
    17. Jennings, Michael, 2015. "The precariousness of the franchise state: Voluntary sector health services and international NGOs in Tanzania, 1960s – mid-1980s," Social Science & Medicine, Elsevier, vol. 141(C), pages 1-8.
    18. Vikram Tyagi & Sophie Webber, 2021. "A rusting gold standard: Failures in an Indonesian RCT, and the implications for poverty reduction," Environment and Planning A, , vol. 53(5), pages 992-1011, August.
    19. Kvangraven, Ingrid Harvold, 2020. "Impoverished economics? A critical assessment of the new gold standard," World Development, Elsevier, vol. 127(C).
    20. Standing, H. & Chowdhury, A. Mushtaque R., 2008. "Producing effective knowledge agents in a pluralistic environment: What future for community health workers?," Social Science & Medicine, Elsevier, vol. 66(10), pages 2096-2107, May.

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:eee:socmed:v:319:y:2023:i:c:s0277953622005639. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Catherine Liu (email available below). General contact details of provider: http://www.elsevier.com/wps/find/journaldescription.cws_home/315/description#description .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.