Kane Sumit, Kok Maryse, Ormel Hermen, Otiso Lilian, Sidat Mohsin, Namakhoma Ireen, Nasir Sudirman, Gemechu Daniel, Rashid Sabina, Taegtmeyer Miriam, Theobald Sally, de Koning Korrie
Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
Royal Tropical Institute, KIT Health, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
Soc Sci Med. 2016 Sep;164:27-34. doi: 10.1016/j.socscimed.2016.07.019. Epub 2016 Jul 20.
In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'Empowerment of communities'. To be able to empower the communities they serve, we argue, it is essential that CHWs themselves be, and feel, empowered. We present here a critique of how diverse national CHW programs affect CHW's empowerment experience.
We present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used.
CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact.
While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters.
在低收入和中等收入国家，社区卫生工作者（CHW）越来越多地发挥与健康促进相关的作用，包括“增强社区权能”。我们认为，为了能够增强他们所服务社区的权能，社区卫生工作者自身必须获得并感受到赋权。在此，我们对不同国家的社区卫生工作者项目如何影响社区卫生工作者的赋权体验进行了批判。
我们对低收入和中等收入国家社区卫生工作者项目的文献系统综述结果以及6个国家案例研究（孟加拉国、埃塞俄比亚、印度尼西亚、肯尼亚、马拉维、莫桑比克）进行了分析。采用了Lee和Koh的分析框架（赋权的4个维度：意义、能力、自主决定权和影响力）。
社区卫生工作者项目通过为社区卫生工作者提供获取特权医学知识的机会、将社区卫生工作者与正规卫生系统联系起来以及为他们提供从事有意义和有影响力工作的机会，来增强社区卫生工作者的权能。然而，这些赋权影响不断受到以下因素的阻碍：对工作环境缺乏控制感，以及感到得不到支持、不被赏识和被低估。社区卫生工作者表达了无力感，以及对组织流程和关系安排如何阻碍他们实现预期影响的沮丧情绪。
虽然解决健康获取问题的责任越来越多地落在社区卫生工作者和社区卫生工作者项目身上，但应该关注社区卫生工作者自身的经历。社区卫生工作者项目需要超越对社区卫生工作者的工具主义方法，在与社区卫生工作者互动时采取发展和赋权的视角。社区卫生工作者项目应该系统地识别剥夺权能的组织安排，并采取措施加以补救。这样做不仅将提高社区卫生工作者的绩效，还将为社区卫生工作者发挥其作为社会变革推动者的潜力铺平道路，而不仅仅是发挥他们作为健康促进者的作用。
