The Lives of Community Health Workers

Local Labor and Global Health in Urban Ethiopia

Kenneth Maes

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781315400761
• Edition: 1
• Topic: Social Sciences
• Subtopic: Anthropology
• Index: Social Sciences

The importance of community health workers is increasingly recognized within many of today's most high-profile global health programs, including campaigns focused on specific diseases and broader efforts to strengthen health systems and achieve universal health care. Based on ethnographic work with Ethiopian women and men who provided home-based care in Addis Ababa during the early roll-out of antiretroviral therapies, this book explores what it actually means to become a community health worker in today's global health industry.

Drawing on the author's interviews with community health workers, as well as observations of their daily interactions with patients and supervisors, this volume considers what motivates them to improve the quality of life and death of the most marginalized people. The Lives of Community Health Workers also illuminates how their contributions at a micro level are intricately linked to policymaking and practice at higher levels in the field of global health. It shows us that many of the challenges that community health workers face in their daily lives are embedded in larger social, economic, and political contexts, and it raises a resounding call for further research into their labour and health systems they inhabit.

1
Community Health Worker Payment and Participation in Addis Ababa’s Alicha Millennium

There is a roughly seven-and-a-half year gap between the Ethiopian and Gregorian calendars. So when I returned to Addis Ababa to begin fieldwork in April 2007, Ethiopia was just a few months away from the year 2000. The turn of the Ethiopian millennium was accompanied by government discourses about an Ethiopian economic and cultural “renaissance.” Residents in Addis Ababa were less optimistic. In early September, a few days before New Year’s Eve, some Ethiopian friends told me over dinner that it had become popular to refer to the new era as “ye’alicha millennium.” The term alicha refers to a “bland” stew lacking spice, particularly the mix of red pepper, salt, garlic, ginger, and other herbs known as berbere. Since the prices of these key ingredients in Ethiopian cuisine had skyrocketed along with other staples, people in the capital were settling for blander dishes, if they could afford food at all. In rural folk experience, being deprived of spice is a sign of impending famine or declining household economic status and food security (Amare 1999; 2010).

Unfortunately, the Ethiopian Y2K coincided with the global food crisis of 2007 and 2008, the largest shock to the global economy since the early 1970s when a similar food price crisis rocked the world. In mid-2008, global food prices escalated rapidly to 150% of their 2006 prices, driven by a “perfect storm” of increased global demand for food and biofuel crops, harvest shortfalls, rising petroleum costs, climate change, depreciation of the US dollar, and food price speculation (Dawe 2008, 2009; Headey and Fan 2008; Robles et al. 2009). While price increases were seen globally, the impact was predicted to be greater in low-income countries where poverty was combined with high spending on food as a proportion of total household expenditures (Ivanic and Martin 2008; Zezza et al. 2008). This was particularly true for Ethiopia, where food prices had been increasing since 2004—the same year that free ART became widely available. Available data showed that beginning in August 2004, Ethiopia’s food price index had been even higher than the world index (International Monetary Fund 2008; Loening et al. 2009; Ulimwengu et al. 2009).

Food price inflation in Ethiopia, furthermore, was closely tracking global oil prices. Ethiopia imports the majority of its petroleum from Saudi Arabia and other countries in the Middle East. Faced with a surge in oil prices on top of food prices, the Ethiopian government decided in early 2008 to end government fuel subsidies. Virtually overnight, the price at the gas pump climbed from 7.77 Ethiopian birr (about 0.75 USD) to 9.60 birr (about 1 USD) per liter. Along with the resulting surge in public transportation prices, long waits at fill stations generated plenty of frustration.¹

Skyrocketing rents were another important and despised fact of life in 2007 in Addis Ababa. Several factors were driving this surge, including food price inflation, an influx of diaspora members who returned to Addis Ababa from North America and Europe in anticipation of the millennium celebrations, and a general failure of the supply of housing in Addis Ababa to keep up with rapid population growth driven by rural-to-urban migrations. The year 2007 saw newspaper reports and public discussions about the increasing number of “moon houses” (chereka bet), shanties constructed under the cover of night in vacant lots and fields dotting the capital city.² Renters generally had little protection from landlords who decided to raise their rent, and many faced either paying ever-higher rents month to month or moving out to make way for someone else who would. The synergy of hikes in the cost of food, transportation, and housing was astounding to people in Addis Ababa.

Ethiopia’s prime minister at the time, Meles Zenawi, blamed merchants and landlords for artificially inflating prices and rents. Many people in Addis blamed the government, however, for not doing enough to control inflation.³ In mid-2008, after several months of contemplating policies, the Ethiopian government decided to begin purchasing wheat on the world market and provide it to urban households and millers at subsidized prices. Addis Ababa’s city government also began to sell thousands of public “condominium” style housing units at low cost to citizens. The government dispersed the condos across several massive complexes and rationed them through a lottery system. After an initial registration, the government randomly chose several waves of winners and offered low down payments (about 2,000 USD) and cheap home loans to complete the purchase. The lottery favored women: the policy was that seven out of every ten “winners” would be women.⁴

While these moves perhaps helped to quell dissent and reduce some of the food and housing insecurity rampant in the capital, they did nothing to address the concurrent rationing of water and electricity that was also testing the patience of Addis Ababa residents. In 2007 and 2008, when water flowed perhaps once in a week or for a couple of hours in the middle of the night, access was easier in households that had private water sources. Women and children from poorer households who got water from collective faucets could expect to wait several hours in line to fill up a couple of 20-liter jerry cans. Recurrent electricity out-ages were yet another feature of daily life in Addis in 2007 and 2008.⁵ At night, eerie darkness shrouded the scores of people walking the streets, only visible when lit by the headlights of passing cars. Sometimes the outages followed a somewhat regular schedule—for instance, every Monday and Wednesday from 8:00 a.m. to 8:00 p.m. But they often struck without warning. For businesses without access to generators or fuel, the blackouts were crippling.

The irony of the conditions of the new millennium was not lost on residents of Addis Ababa: a “renaissance” into a world characterized by skyrocketing food prices as well as rationing of housing, water, electricity, and gas. This is the economic context in which the CHWs in this book lived and worked.

Nearly all of the 110 volunteer CHWs that we randomly surveyed during 2008 could be labeled poor, with per capita household incomes of 0.40 USD per day on average. This level of income actually falls below standard international cutoffs of “extreme” and even “ultra” poverty. When I sorted the CHWs’ incomes into ordinal categories, the cutoffs had to be set incredibly low and close together: under 16 cents, 16 to 33 cents, 33 to 66 cents, and above 66 cents. Only 11% of the sample was in the “least poor” category, in which they might still be earning less than one USD per day.⁶

The data on food insecurity were just as astonishing, though understandable in light of the obvious difficulties people in Addis Ababa faced in finding work and making money. Twenty-five percent of the sample reported “mild” food insecurity, meaning they had at least worried about their household food access in the previous month or ate foods that were less preferred and even unwanted. About 35% reported “moderate” food insecurity, meaning they had reduced the quantity of the food that they ate in the previous month. Another 20% reported severe food insecurity, meaning that at least once in the previous month, they or someone in their household had gone a whole day without eating or had gone to bed hungry because of a lack of food. In total, 80% experienced some form of food insecurity. Eskinder, a middle-aged man and one of the volunteer CHWs I followed closely (and about whom we’ll learn much more in the next chapter), summed up the feeling of many of his peers: “Nowadays, it is only that life is expensive and there is no employment.” These conditions, in turn, led many people as well as me to ask the following question: Why didn’t the ARV program create paid jobs that could have helped address the widespread unemployment and food insecurity that Eskinder lamented?

The Global Sustainability Doctrine Meets Ethiopia

Answering this question requires examining factors that shape funding levels and patterns in contemporary CHW programs. Perhaps one of the most important factors is what’s called the sustainability doctrine: the idea that health development projects are sustainable only when local organizations can take over a project and sustain it with local initiative and labor when the donors who originally financed it pack up and leave (Swidler and Watkins 2009; Watkins and Swidler 2013). In this approach to sustainability, which is commonly adopted by global health donors and thus by the institutions they give money to, creating jobs and paying local labor with international donor funds is considered a bad idea, because these expenditures cannot be sustained by cash-strapped local organizations and governments when international funding is pulled out. With the sustainability doctrine in effect, “volunteerism”—calling on local people to donate their time and energy to a health or development program—becomes the best policy option (Swidler and Watkins 2009).

To get a sense of how the sustainability doctrine works, one can look to a study published in 2014 by Marie-Renée B-Lajoie and colleagues, which sought to investigate how global NGO officials conceptualize the question of CHW motivation and incentivization. The study targeted NGO officials in the CORE Group, a US-based network of influential NGO and government partners that “generate collaborative action and learning to improve and expand community-focused public health practices for underserved populations around the world.”⁷ The CORE Group is thus an important locus of knowledge and power in the global health field today, one that strongly promotes a reliance on CHWs. In interviews, some CORE Group NGO officials expressed the belief that paying CHWs can economically empower them and lead to superior performance. Some also recognized that problematic inequalities exist between underpaid CHWs (who tend to be women) and well-paid, high-level officials (who more often tend to be men). The fact that viewpoints like this exist within the CORE Group is encouraging. The comments of these \ NGO officials, however, point\to the ultimate influence of international donors and their notions of sustainability: “Donor practices and what other organizations and governments were offering CHWs had the biggest influence on NGO practices, particularly in defining what is ‘sustainable’ beyond the duration of the programme” (B-Lajoie et al. 2014: 7). CORE Group program managers described an “inherent tension” between their objectives and the priorities of donors. Some described resistance from donor agencies to incorporate financial incentives if they could not be sustained. Not surprisingly, this pushed programs to move away from paid job creation. The NGO officials also identified competition between programs over short-term grants as a major barrier to effective capacity building within their CHW programs. These comments from officials and managers in some of the most prominent and active global health NGOs highlight the influence that donors have over norms and policies that deeply impact the lives of poor people.

An unwillingness to pay for local labor and create jobs on the part of donors is partly a result of the macroeconomic concerns of the World Bank and IMF and the legacies of structural adjustment, which involved slashing government payrolls in order to reduce wage bills (Cometto et al. 2013; Goldsbrough 2007; Ooms et al. 2007; Pfeiffer and Chapman 2010; Rowden 2009).⁸ Structural adjustment was thus identified in the WHO’s 2006 World Health Report as a “driving force” of a global human resources for health crisis (WHO 2006). The IMF and World Bank may no longer continue to openly discourage governments from raising public sector payroll expenditures, encourage NGOs to take over public health services, and simultaneously discourage donors from funding NGO payroll expenditures. Nevertheless, the damage has been done. In the wake of structural adjustment, paying for essential labor became widely imagined as financially unsustainable, and promoting unpaid community-based health care thus became economically imperative (Campbell et al. 2008; Dräger et al. 2006; Farmer 2008; Pfeiffer 2013). In following this entrenched set of values, expectations, and policies, community health programs in low-resource areas have had to rely on local people’s willingness to donate their labor. Since global donors have simultaneously been motivated to pay for high-level “expert” labor (i.e., NGO officers, consultants, and auditors), the sustainability doctrine exacerbated a salient inequality between local, underpaid laborers and salaried, transnational professionals in many African health programs.

The sustainability doctrine has, of course, been questioned and criticized. Interestingly, the Ethiopian government joined this cast of critics in the first decade of the 21st century. In 2003, Ethiopia’s Federal Ministry of Health initiated a national Health Extension Program (HEP) that has since played a big role in putting Ethiopia on the global health map. The HEP is commonly called the Ministry’s “flagship” initiative and the “bedrock” of Ethiopia’s attempt to accelerate the expansion of primary health-care coverage, particularly for people who live in rural areas where access to services is often highly limited (FMOH 2007). The HEP involved the construction of thousands of new health posts throughout the countryside as well as the creation of full-time, salaried CHW jobs for roughly 34,000 young Ethiopian women. Health Extension Workers or HEWs have at least six and in many cases ten years of schooling, and then receive one year of health education before being deployed to a health post in one of Ethiopia’s approximately 15,000 kebeles, the lowest level of government administration in the country. As CHWs, HEWs are responsible for a large number of primary health-care services, including prevention and treatment of some infectious diseases (e.g., malaria); improvement of water sources and nutrition; family planning; routine vaccinations and supplementary vaccination campaigns; facility-based pre-, peri-, and postnatal care for mothers and newborns; surveil-lance of illnesses; and collecting and reporting data on health-services utilization and population health indicators.

In return for their work, HEWs receive a monthly salary, about $112 as of mid-2014, which puts them near the bottom of the public worker pay scale but nevertheless fundamentally distinguishes them from the “volunteer” CHWs deemed “sustainable” within the sustainability doctrine. Ethiopia’s previous minister of health, Dr. Tedros Adhanom, highlighted this policy decision by calling the sustainability doctrine into question in the pages of the WHO Bulletin. In an interview published in 2009, he identified the key to the success and sustainability of the HEP as “engaging health extension workers as full-time salaried civil servants” and thereby “moving away from volunteerism” (WHO 2009).⁹ Ethiopia’s Fourth National Health Accounts also asserts that job creation and the engagement of HEWs as “full-time government-salaried civil servants” marked “an important shift away from volunteerism—a feature viewed as key to HEP’s early success and long-term sustainability” (FMOH 2010: v).

In voicing this sustainability heterodoxy, the Ethiopian minister of health had an important partner: the World Health Organization. In 2008, WHO asserted that “essential health services cannot be provided by people working on a voluntary basis if they are to be sustainable” (WHO 2008):

While volunteers can make a valuable contribution on a short term or part time basis, trained health workers who are providing essential health services, including community health workers, should receive adequate wages and/or other appropriate and commensurate incentives…. [T]he burden of evidence indicates that stipends, travel allowances and other non-financial incentives are not enough to ensure the livelihood of health workers and that the absence of adequate wages will threaten the effectiveness and long-term sustainability of community health worker programmes.

(WHO 2008: 35–36)

In short, poor people do not want to simply donate their labor, and unpaid workers will eventually seek other opportunities or perform poorly, thus imperiling public health programs. Others have voiced this commonsense view. Based on his extensive experience working with Mozambique’s public health system, anthropologist James Pfeiffer argues that paying CHWs helps guarantee that a health-care program will be sustainable (as well as more universal and equitable in its coverage of populations in need) (Pfeiffer 2013: 178). And in the Public Broadcasting Service (PBS) documentary House Calls and Health Care, which showcases the work of the well-known international NGO Partners in Health (PIH) in Rwanda and deals explicitly with the question of whether or not to pay CHWs, physician-anthropologist and PIH co-founder Paul Farmer claims that he had never seen a project be effective for long without compensating its community health workers.¹⁰

These statements, uttered by actors as varied as Ethiopia’s minister of health, WHO, and anthropologists deeply engaged in the field of global health, mobilize alternative conceptualizations of sustainability and development, emphasizing a need for governments and their donors to commit to sustained funding for community health worker salaries in order to improve and sustain health-care delivery systems. They challenge the sustainability doctrine by suggesting that the widespread reliance on unpaid labor creates programs that are unsustainable.

When I conducted research on CHWs focusing on HIV/AIDS in Addis Ababa in 2006–2008, however, there was no movement away from volunteerism. The government did not attempt to deploy its own salaried workforce of caregivers and treatment supporters. Instead, as in other African countries, large numbers of people continued to be recruited solely for unpaid “volunteer” positions (Maes and Kalofonos 2013). A brief examination of the HEP makes it clear that the Ethiopian government had given serious thought to whether or not CHWs should be expected to donate their labor. Given that the government rhetorically and practically “moved away from volunteerism” with the HEP in the countryside, the government’s willingness to accept the involvement of thousands of unpaid “volunteer” CHWs organized by multiple NGOs in the urban AIDS sector demands explanation.

One factor behind why job creation was never an explicit goal in this particular arena is that the amounts of labor deemed necessary to ensure the success of ART for millions of Ethiopians and Africans was massive. International organizations knew from experience th...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• CONTENTS
• List of Figures
• Acknowledgments
• List of Abbreviations Used in the Text
• Introduction
• 1 Community Health Worker Payment and Participation in Addis Ababa’s Alicha Millennium
• 2 Becoming a Community Health Worker: A Biosocial and Historical Perspective
• 3 Some Assembly Required: Community Health Worker Recruitment and Basic Training
• 4 To Care and to Suffer: Community Health Work Amid Unemployment and Food Insecurity
• 5 Where There Is No Labor Movement
• Conclusion: Listening to Community Health Workers: Recommendations for Action and Research
• References
• Index