Experts’ tools, altruists, and job-seekers: visions of community health workers in Ethiopia’s antiretroviral centre of excellence

Abstract

This article reports on research conducted during 2007–2008 within an antiretroviral therapy (ART) programme in Addis Ababa, run as a partnership between NGOs, government health officials, and international donors. Through examination of the discourses of professionals in NGO and government sectors, and of the community health workers (CHWs) who delivered ART support and home-based care, I show how a policy of volunteerism worked on the ground, through complex interactions that generated targeted success: thousands of new patients getting on and adhering to free ART, and living longer. CHWs were variously treated by these other actors as human resources to be managed, as heroic and altruistic volunteers, and as potentially self-interested. CHWs behaved as altruistic and self-sacrificing volunteers, yet also attempted to assert – individually and collectively – their desires to gain employment in order to better themselves and their communities. Much of the growing body of research on CHWs studies down, adopting a human resources mentality and collecting data from CHWs, to help identify policies by which health systems might more cost-effectively use CHWs in the production of better population health. Rather than a critique of this mentality, the research presented here represents a shift to studying both up and down structures of CHW programme implementation and governance, to help understand the varied ways in which CHW programmes in Africa today work, and how CHWs’ interests and power over their job conditions and social policies will evolve.

Cet article rend compte des recherches menées au cours de 2007–2008 dans un programme de thérapie antirétrovirale (ARV) à Addis-Abeba, géré en partenariat par des ONG, des fonctionnaires gouvernementaux de la santé, ainsi que des donateurs et organisations internationaux. En examinant les discours des professionnels dans les secteurs des ONG et du gouvernement, ainsi que des travailleurs de la santé communautaires (TSCs) qui ont apporté un soutien pour ceux sous thérapie antirétrovirale et des soins à domicile, je montre comment une politique de bénévolat a fonctionné sur le terrain grâce à de complexes interactions qui ont généré des succès ciblés: des milliers de nouveaux patients qui ont obtenu et adhéré à la thérapie ARV gratuite vivant plus longtemps. Les TSCs ont été traité par ces autres acteurs de manières diverses : comme ressources humaines à gérer, comme bénévoles héroïques et altruistes, et comme agissant potentiellement pour leurs propres intérêts. Les TSCs se sont comportés comme des bénévoles altruistes et dévoués, mais ils ont aussi tenté de faire valoir, de manières individuelle et collective, leurs désirs d’obtenir un emploi pour améliorer leur sort et celui de leurs communautés. Une grande partie du nombre croissant de recherches sur les TSCs étudient vers le bas, en adoptant une mentalité de ressources humaines et la collecte de données à partir des TSCs, pour aider à identifier les politiques par lesquels les systèmes de santé pourraient utiliser les TSCs de manière plus rentable dans la production d'une meilleure santé publique. Plutôt qu’une critique de cette mentalité, la recherche présentée ici représente un glissement vers une étude à la fois vers le haut et vers le bas des structures de mise en œuvre et de gouvernance des programmes de TSCs, pour aider à comprendre les diverses façons dont les programmes de TSCs fonctionnent en Afrique aujourd'hui, et comment les intérêts et le pouvoir des TSCs sur leurs conditions d'emploi et les politiques sociales vont évoluer.

Keywords:

• Antiretroviral therapy
• global health partnerships
• community health workers
• volunteerism
• sustainability
• resistance

Mots-clefs:

• La thérapie antirétrovirale (ARV)
• les partenariats pour la santé mondiale
• les travailleurs de santé communautaires (TSCs)
• le bénévolat
• la durabilité
• la résistance

Acknowledgements

This paper is based on the generosity of the CHWs and nurses whom I encountered in Addis Ababa. The directors and staff at the Hiwot HIV/AIDS Prevention, Control and Support Organization the Medhen Social Center, and the HIV/AIDS Department at ALERT Hospital in Addis Ababa also generously granted me access to conduct research with their staff, and facilitated many of my efforts. I am deeply grateful for the advice and mentoring I received during fieldwork and writing from so many health professionals and scholars in Ethiopia and abroad. Special thanks are due to Rebecca Warne Peters and Claire Wendland for their comments on the manuscript at multiple stages, and to two anonymous reviewers. Finally, Yihenew Tesfaye, Selamawit Shifferaw, and Meli contributed invaluable research assistance, moral support, and intellectual discussion in support of this research.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1. Generally speaking, community health workers are one of a variety of health workers who work within the realm of primary or community health care, spending different proportions of their time in clinical facilities, community outreach locations, and the homes of people who, despite struggling with various illnesses, have long lacked dependable access to primary health care. In general, CHWs receive less formal training than nurses, and spend more of their time performing house visits and community outreach in comparison to other health professionals (see Earth Institute 2011, 11–12).

2. Most recent studies of CHW performance involve pre- and post-intervention assessments, cohort studies, and sometimes quasi-experimentation (e.g. Alam, Tasneem, and Oliveras 2012).

3. The profile is available at http://hbswk.hbs.edu/item/7540.html (accessed June 1, 2015).

4. These included the Christian Children’s Fund of Canada, the Ethiopian North American Health Professionals Association (an association of Ethiopian health professionals within the diasporas in the US and Canada), and Jhpiego (a non-profit affiliate of Johns Hopkins University).

5. I obtained ethical approval from Emory University, Addis Ababa University’s Faculty of Medicine, and ALERT Hospital.

6. See http://www.coregroup.org/about-us/who-we-are-and-what-we-do (accessed January 10, 2016).

7. HAPCO was established to coordinate and facilitate Ethiopia’s multisectoral response to HIV/AIDS. In 2002, the national HAPCO put forward a Policy on Supply and Use of Anti-Retroviral Drugs, and in 2005, it issued a Strategy and Guidelines for Implementation of Anti-Retroviral Therapy.

Additional information

Funding

The research here and the write-up process were made possible through a dissertation award from the US National Science Foundation (BCS-67062516), fellowships and awards from the National Institutes of Health (D43 TW01042 and T32 HD007338-23), Emory University’s Global Health Institute, Emory’s AIDS International Training and Research Program, and Oregon State University’s Center for the Humanities.