From the Field: a Community-Centered Approach
In the field of global health, community-centered models are increasingly popular. Such models have sought to counter the traditional Western aid “do as we say” approaches to development and health, suggesting that people within affected developing world communities are valuable resources towards improving their own well-being. This may seem like such a commonsensical notion, but 24 years ago when organizations like Paul Farmer’s Partners in Health emerged on the scene, the idea of using community health workers (CHWs) was unpopular in mainstream health and development work. Even today, as my experience in Malawi has revealed, there are tensions between traditional and Western responses, between accepting international aid (which often comes with conditions) or struggling without assistance, between relying on the more than 200 NGOs to attend to the well-being and success of the nation or building internal capacity to reduce foreign dependency…
Yesterday, after a field visit to a government-run district hospital in a rural community just 60 kilometers out of the capital of Lilongwe, many of these issues were brought to the forefront of my mind as I observed the process for hiring CHWs. There were six candidates for two slots, and with training just three weeks around the corner, the odds were in favor of a very productive day. We arrived early, thirty minutes before we were scheduled to start, but after more than an hour, we were still missing some of the interview panelists. When they all arrived, I was struck by the size of the panel. In addition to the Regional Manager and myself as an observer, there were two HR people from the facility, two facility nurses, and a government official from the labor bureau, all of whom insisted on being a part of the interview process. (I later noticed that in addition to the snacks and drinks provided, we all received a “lunch stipend” for our involvement – a cultural expectation, I was later informed, that may have contributed to the unusually large involvement).
What should have been an easy though tedious process – as I expected – was actually a challenging one. The CHW requirement of being an HIV-positive mother with a young child who has disclosed her status was met by only one candidate; a male applicant even showed up. It was hard to watch the others turned away – some with primary school education, one with a high school diploma – hopeful that they could take a job that pays so little as a means of supporting their families and their life. But it was great to see that the one eligible candidate – a 31 year old woman – was a model example: she was a young mother, still married (which is not always common when a husband knows the wife’s status), who had overcome the fear of stigma so as to share her status with her entire village. She was educated through primary school, articulated herself well throughout the interview, and passed the written portion of the interview with flying colors; the only mistake she made was in writing 2011 as 20011, which reminded me of the numeracy challenges among the CHWs we will train. She was confident that she could share her experiences with other women living positively and looked forward to using her new income to buy more nutritious food for her family.
Before we left for the day, she was formally offered a position and a plan was hatched by the panelists for an additional candidate search. As I thought of the process – the late start, the emphasis on snacks and drinks during the interview, the expected lunch stipends for the numerous panelists and travel vouchers for applicants, and attracting more unqualified than qualified candidates – I realized that what I regarded as unnecessary inefficiencies and expenses may have been considered culturally acceptable, and in some ways culturally-expected. In fact, my organization provided fewer perks than most, which could also have contributed to the low applicant turnout.
And so I am left struck and perplexed by the challenges of merging different cultures for the best outcome in global health. I cannot purport that my experience was typical – in fact, the Regional Manager suggested new challenges have emerged this year – but my on-the-ground observations will be valuable as we continue to improve the program here. My field visit revealed that the global community is making positive strides through the use of culturally-acceptable approaches and an emphasis on community inclusion; however, there is still much more work to be done. We have to learn to blend the NGO and government sectors for long-term sustainable, nation-driven improvements. We have to learn to continually adapt Western models in different local contexts, and perhaps strive for more ideas to emerge from within these local contexts. And we – who come from the “outside” but with a passion and desire to work in under-served areas – have to learn to understand, respect, and in some ways challenge the myriad of cultures we will continually find ourselves in on the journey to improving health and well-being worldwide.