Scott Kerry, Shanker Shobhit
Institute of Social Psychology, London School of Economics, London, UK.
AIDS Care. 2010;22 Suppl 2:1606-12. doi: 10.1080/09540121.2010.507751.
This paper is a contribution to the growing literature on how best to design and support community health worker (CHW) programmes to maximise their positive impact. CHWs are laypeople trained to promote health among their peers. To do so they are commonly tasked with providing basic curative services, promoting the use of existing health services, facilitating cultural mediation between communities and healthcare providers and encouraging critical reflection and dialogue on social health issues. This paper presents a case study of a CHW project in rural Uttarakhand, north India, called the Accredited Social Health Activist (ASHA) programme. While the ASHA programme is not specifically targeting HIV/AIDS, CHW programmes have been flagged as a key means of addressing health resource shortages in poor countries, especially in relation to HIV/AIDS. This study of the ASHA programme provides insights into how best to support CHW programmes in general, including those focused on HIV/AIDS. The research involved 25 interviews and five focus groups with ASHAs, health professionals and community members as well as over 100 hours of non-participant observation at public health centres. The research investigated contextual features of the programme that are hindering the ASHAs' capacity to increase quantitative health outcomes and act as cultural mediators and agents of social change. Research found that ASHAs were institutionally limited by: (1) the outcome-based remuneration structure; (2) poor institutional support; (3) the rigid hierarchical structure of the health system; and (4) a dearth of participation at the community level. The conclusion suggests that progressive policy on CHW programmes must be backed up by concrete institutional support structures to enable CHWs to fulfil their role.
本文旨在为日益增多的关于如何最佳设计和支持社区卫生工作者（CHW）项目以最大化其积极影响的文献做出贡献。社区卫生工作者是经过培训以在同龄人中促进健康的非专业人员。为此，他们通常负责提供基本治疗服务、推广现有卫生服务的使用、促进社区与医疗服务提供者之间的文化调解以及鼓励就社会健康问题进行批判性反思和对话。本文介绍了印度北部北阿坎德邦农村地区一个名为“认证社会健康活动家”（ASHA）项目的社区卫生工作者项目的案例研究。虽然ASHA项目并非专门针对艾滋病毒/艾滋病，但社区卫生工作者项目已被视为解决贫困国家卫生资源短缺问题的关键手段，特别是在与艾滋病毒/艾滋病相关的方面。对ASHA项目的这项研究为如何总体上最佳支持社区卫生工作者项目提供了见解，包括那些专注于艾滋病毒/艾滋病的项目。该研究涉及对ASHA工作人员、卫生专业人员和社区成员进行25次访谈和5次焦点小组讨论，以及在公共卫生中心进行超过100小时的非参与式观察。该研究调查了阻碍ASHA工作人员提高定量健康成果以及充当文化调解人和社会变革推动者能力的项目背景特征。研究发现，ASHA工作人员在制度上面临以下限制：（1）基于结果的薪酬结构；（2）机构支持不足；（3）卫生系统僵化的等级结构；（4）社区层面参与不足。结论表明，关于社区卫生工作者项目的进步政策必须有具体的机构支持结构作为后盾，以使社区卫生工作者能够履行其职责。
