THE VILLAGE HEALTH WORKER --
LACKEY OR LIBERATOR?
964 Hamilton Avenue
Palo Alto, California 94301, USA
International Hospital Federation Congress
Sessions on Health Auxiliaries and the Health
22 - 27 May, 1977
THE VILLAGE HEALTH WORKER --LACKEY OR LIBERATOR?
-- David Werner --
Throughout Latin America, the programmed use
of health auxiliaries has, in recent years, become an important
part of the new international push of 'community oriented'
health care. But in Latin America village health workers are
far from new. Various religious groups and non-government
agencies have been training promotores de salud or health
promoters for decades. And to a large (but diminishing) extent,
villagers still rely, as they always have, on their local
curanderos, herb doctors, bone setters, traditional midwives
and spiritual healers. More recently, the médico practicante
or empirical doctor has assumed in the villages the same role
of self-made practitioner and prescriber of drugs that the
neighborhood pharmacist has assumed in larger towns and cities.
Until recently, however, the respective Health Departments
of Latin America have either ignored or tried to stamp out
this motley work force of nonprofessional healers. Yet the
Health Departments have had trouble coming up with viable
alternatives. Their Western-style, city-bred and city-trained
M.D.s not only proved uneconomical in terms of cost effectiveness;
they flatly refused to serve in the rural area.
The first official attempt at a solution was, of course,
to produce more doctors. In Mexico the National University
began to recruit 5000 new medical students per year (and still
does so). The result was a surplus of poorly trained doctors
who stayed in the cities.
The next attempt was through compulsory social service. Graduating
medical students were required (unless they bought their way
off) to spend a year in a rural health center before receiving
their licenses. The young doctors were unprepared either by
training or disposition to cope with the health needs in the
rural area. With discouraging frequency they became resentful,
irresponsible or blatantly corrupt.
Next came the era of the mobile clinics. They, too, failed
miserably. They created dependency and expectation without
providing continuity of service. The net result was to undermine
the people's capacity for self care.
It was becoming increasingly clear that provision of health
care in the rural area could never be accomplished by professionals
alone. But the medical establishment was--and still is--reluctant
to crack its legal monopoly.
At long last, and with considerable financial cajoling from
foreign and international health and development agencies,
the various health departments have begun to train and utilize
auxiliaries. Today, in countries where they have been given
half a chance, auxiliaries play an important role in the health
care of rural and periurban communities. And if given a whole
chance, their impact could be far greater. But, to a large
extent, politics and the medical establishment still stand
in the way.
* * * * *
My own experience in rural health care has mostly been in
a remote mountainous sector of Western Mexico, where, for
the past 12 years I have been involved in training local village
health workers, and in helping foster a primary health care
network, run by the villagers themselves. As the villagers
have taken over full responsibility for the management and
planning of their program, I have been phasing out my own
participation to the point where I am now only an intermittent
advisor. This has given me time to look more closely at what
is happening in rural health care in other parts of Latin
Last year a group of my co-workers and I visited nearly 40
rural health projects, both government and non-government,
in nine Latin American countries (Mexico, Guatemala, Honduras,
E1 Salvador, Nicaragua, Costa Rica, Venezuela, Colombia and
Ecuador). Our objective has been to encourage a dialogue among
the various groups, as well as to try to draw together many
respective approaches, methods, insights and problems into
a sort of field guide for health planners and educators, so
we can all learn from each other's experience. We specifically
chose to visit projects or programs which were making significant
use of local, modestly trained health workers or which were
reportedly trying to involve people more effectively in their
own health care.
We were inspired by some of the things we saw, and profoundly
disturbed by others. While in some of the projects we visited,
people were in fact regarded as a resource to control disease,
in others we had the sickening impression that disease was
being used as a resource to control people. We began to look
at different programs, and functions, in terms of where they
lay along a continuum between two poles: community supportive
and community oppressive.
Community supportive programs or functions are those which
favorably influence the long-range welfare of the community,
that help it stand on its own feet, that genuinely encourage
responsibility, initiative, decision making and self-reliance
at the community level, that build upon human dignity.
Community oppressive programs or functions are those which,
while invariably giving lip service to the above aspects of
community input, are fundamentally authoritarian, paternalistic
or are structured and carried out in such a way that they
effectively encourage greater dependency, servility and unquestioning
acceptance of outside regulations and decisions; those which
in the long run are crippling to the dynamics of the community.
It is disturbing to note that, with certain exceptions, the
programs which we found to be more community supportive were
small non-government efforts, usually operating on a shoestring
and with a more or less sub-rosa status.
As for the large regional or national programs-- for all
their international funding, top-ranking foreign consultants
and glossy bilingual brochures portraying community participation--we
found that when it came down to the nitty-gritty of what was
going on in the field, there was usually a minimum of effective
community involvement and a maximum of dependency-creating
handouts, paternalism and superimposed, initiative destroying
I don't have time to elaborate here, but anyone who is interested
in a more detailed account of community supportive and oppressive
health programming may send for a copy of a paper I presented
in England last year entitled "Health Care and Human
In our visits to the many rural health programs in Latin
America, we found that primary health workers come in a confusing
array of types and titles. Generally speaking, however, they
fall into two major groups:
or health technician
or village health workers
at least primary education plus
1 - 2 years training
usually from outside the community
usually employed full time
salary usually paid by the program
(not by the community)
average of 3rd grade education
plus 1 - 6 months training
usually from the community and
selected by it
often a part time health worker
supported in part by farm labor or with help from
may be someone who has already
been a traditional healer
In addition to the health workers just described, many Latin
American countries have programs to provide minimal training
and supervision of traditional midwives. Unfortunately, Health
Departments tend to refer to these programs as 'Control
de Parteras Empíricas'--Control of Empirical Midwives--a
terminology which too often reflects an attitude. Thus to
Mosquito Control and Leprosy Control has been added Midwife
Control. (Small wonder so many midwives are reticent to participate!)
Once again, we found the most promising work with village
midwives took place in small non-government programs. In one
such program (in Pinalejo, Honduras) the midwives had formed
their own club and organized trips to hospital maternity wards
to increase their knowledge.
* * * * *
What skills can the village health worker perform?
How well does he perform them? What are the limiting factors
that determine what he can do. These were some of our key
questions when we visited different rural health programs.
We found that the skills which village health workers actually
performed varied enormously from program to program. In some,
local health workers with minimal formal education were able
to perform with remarkable competence a wide variety of skills
embracing both curative and preventive medicine as well as
agricultural extension, village cooperatives and other aspects
of community education and mobilization. In other programs--often
those sponsored by Health Departments--village workers were
permitted to do discouragingly little. Safeguarding the medical
profession's monopoly on curative medicine by using the standard
argument that prevention is more important than cure (which
it may be to us but clearly is not to a mother when her child
is sick) instructors often taught these health workers fewer
medical skills than many villagers had already mastered for
themselves. This sometimes so reduced the people's respect
for their health worker that he (or usually she) became less
effective, even in preventive measures.
In the majority of cases, we found that external factors,
far more than intrinsic factors, proved to be the determinants
of what the primary health worker could do. (See Outline 1.)
We concluded that the great variation in range and
type of skills performed by village health workers in different
programs has less to do with the personal potentials, local
conditions or available funding than it as to do with the
preconceived attitudes and biases of heath program planners,
consultants and instructors. In spite of
the often repeated eulogies about "primary decision making
by the communities themselves," seldom do the villagers
have much, if any, say in what their health worker is taught
and told to do.
The limitations and potentials of the village health worker--what
he is permitted to do and, conversely, what he could do if
permitted--can best be understood if we look at his role in
its social and political context. In Latin America, as in
many other parts of the world, poor nutrition, poor hygiene,
low literacy and high fertility help account for the high
morbidity and mortality of the impoverished masses. But as
we all know, the underlying cause--or more exactly, the primary
disease--is inequity: inequity of wealth, of land, of educational
opportunity, of political representation and of basic human
rights. Such inequities undermine the capacity of the peasantry
for self care. As a result, the political/economic powers-that-be
assume an increasingly paternalistic stand, under which the
rural poor become the politically voiceless recipients of
both aid and exploitation. (See Figure 3.) In spite of national,
foreign and international gestures at aid and development,
in Latin America the rich continue to grow richer and the
poor poorer. As anyone who has broken bread with villagers
or slum dwellers knows only too well: health of the people
is far more influenced by politics and power groups, by distribution
of land and wealth, than it is by treatment or prevention
Political factors unquestionably comprise one of the major
obstacles to a community supportive program. This can be as
true for village politics as for national politics. However,
the politico-economic structure of the country must necessarily
influence the extent to which its rural health program is
community supportive or not.
Let us consider the implications in the training and function
of a primary health worker:
If the village health worker is taught a respectable range
of skills, if he is encouraged to think, to take initiative
and to keep learning on his own, if his judgment is respected,
if his limits are determined by what he knows and can do,
if his supervision is supportive and educational, chances
are he will work with energy and dedication, will make a major
contribution to his community and will win his people's confidence
and love. His example will serve as a role model to his neighbors,
that they too can learn new skills and assume new responsibilities,
that self?improvement is possible. Thus the village health
worker becomes an internal agent-of-change, not only for health
care, but for the awakening of his people to their human potential.
. . and ultimately to their human rights.
However, in countries where social and land reforms are
sorely needed, where oppression of the poor and gross disparity
of wealth is taken for granted, and where the medical and
political establishments jealously covet their power, it is
possible that the health worker I have just described knows
and does and thinks too much. Such men are dangerous: They
are the germ of social change.
So we find, in certain programs, a different breed of village
health worker is being molded . . . one who is taught a pathetically
limited range of skills, who is trained not to think, but
to follow a list of very specific instructions or 'norms',
who has a neat uniform, a handsome diploma and who works in
a standardized cement block health post, whose supervision
is restrictive and whose limitations are rigidly predefined.
Such a health worker has a limited impact on the health and
even less on the growth of the community. He--or more usually
she--spends much of her time filling out forms.
* * * * *
In a conference I attended in Washington last
December, on Appropriate Technology in Health in Developing
Countries, it was suggested that "Technology can only
be considered appropriate if it helps lead to a change in
the distribution of wealth and power." If our goal is
truly to get at the root of human ills must we not also recognize
that, likewise, health projects and health workers are appropriate
only if they help bring about a healthier distribution of
wealth and power?
Factors that Influence What a
Primary Health Worker Can Do
Factors influencing personal potential
- cultural background
- level of literacy influencing
- personal factors
- special talents
- learning capacity
- acceptance of VHW and program by community
- health priorities within the community
- available funding (from
within the community)
- attitudes, open or preconceived, as to what the
VHW should be taught and permitted to do
- length, content, quality and appropriateness of
- limitations of 'norms' imposed on health worker
by outside authorities (e.g. Health Dept.)
- ability or inability of instructors and supervisors
to build upon the existing knowledge, skills and cultural
perspectives of the VHW.
- available funding (from outside the community)
What the health worker can do is too often limited
by external factors (doctors and politics) rather than determined
by his personal capabilities and potential.
Fig. 3 Too often aid and exploitation go hand in hand.
We say prevention is more important than cure. But how far
are we willing to go? Consider diarrhea:
Each year millions of peasant children die of diarrhea. We
tend to agree that most of these deaths could be prevented.
Yet diarrhea remains the number one killer of infants in Latin
America and much of the developing world. Does this mean our
so?called 'preventive' measures are merely palliative? At
what point in the chain of causes which makes death from diarrhea
a global problem (see Outline #2) are we coming to grips with
the real underlying cause. Do we do it . . .
- by preventing some deaths through treatment of diarrhea?
- by trying to interrupt the infectious cycle through construction
of latrines and water systems?
- by reducing high risk from diarrhea through better nutrition?
- or by curbing land tenure inequities through land reform?
Land reform comes closest to the real problem. But the peasantry
is oppressed by far more inequities than those of land tenure.
Both causing and perpetuating these crushing inequities looms
the existing power structure: local, national, foreign and
multinational. It includes political, commercial and religious
power groups as well as the legal profession and the medical
establishment. In short it includes . . . ourselves.
As the ultimate link in the causal chain which leads from
the hungry child with diarrhea to the legalized inequities
of those in power, we come face to face with the tragic flaw
in our otherwise human nature, namely greed.
Where, then, should prevention begin? Beyond doubt, anything
we can do to minimize the inequities perpetuated by the existing
power structure will do far more to reduce high infant mortality
than all our conventional preventive measures put together.
We should, perhaps, carry on with our latrine building rituals,
nutrition centers and agricultural extension projects. But
let's stop calling it prevention. We are still only treating
symptoms. And unless we are very careful, we may even be making
the underlying problem worse . . . through increasing dependency
on outside aid, technology and control.
But this need not be the case. If the building of latrines
brings people together and helps them look ahead, if a nutrition
center is built and run by the community and fosters self-reliance,
and if agricultural extension, rather than imposing outside
technology encourages internal growth of the people toward
more effective understanding and use of their land, their
potentials and their rights . . . then, and only then, do
latrines, nutrition centers and so-called extension work begin
to deal with the real causes of preventable sickness and death.
This is where the village health worker comes in. It doesn't
matter much if he spends more time treating diarrhea than
building latrines. Both are merely palliative in view of the
larger problem. What matters is that he get his people working
Yes, the most important role of the village health worker
is preventive. But preventive in the fullest sense, in the
sense that he help put an end to oppressive inequities, in
the sense that he help his people, as individuals and as a
community, liberate themselves not only from outside exploitation
and oppression, but from their own short-sightedness, futility
The chief role of the village health worker, at his best,
is that of liberator. This does not mean he is a revolutionary
(although he may be pushed into that position). His interest
is the welfare of his people. And, as Latin America's blood-streaked
history bears witness, revolution without evolution too often
means trading one oppressive power group for another. Clearly,
any viable answer to the abuses of man by man can only come
through evolution, in all of us, toward human relations which
are no longer founded on short-sighted self-interest, but
rather on tolerance, sharing and compassion.
I know it sounds like I am dreaming. But the exciting thing
in Latin America is that there already exist a few programs
that are actually working toward making these things happen--where
health care for and by the people is important, but where
the main role of the primary health worker is to assist in
the humanization or, to use Paulo Freire's term, conscientización
of his people.
Before closing let me try to clear up some common
Many persons still tend to think of the primary health worker
as a temporary second-best substitute for the doctor . . .
that if it were financially feasible the peasantry would be
better off with more doctors and fewer primary health workers.
I disagree. After twelve years working and learning from
village health workers--and dealing with doctors--I have come
to realize that the role of the village health worker is not
only very distinct from that of the doctor, but, in terms
of health and well-being of a given community, is far more
important. (See appendix.)
You may notice I have shied away from calling the primary
health worker an 'auxiliary'. Rather I think of him as the
primary member of the health team. Not only is he willing
to work on the front line of health care, where the needs
are greatest, but his job is more difficult than that of the
average doctor. And his skills are more varied. Whereas the
doctor can limit himself to diagnosis and treatment of individual
'cases', the health worker's concern is not only for individuals--as
people--but with the whole community. He must not only answer
to his people's immediate needs, but he must also help them
look ahead, and work together to overcome oppression and to
stop sickness before it starts. His responsibility is to share
rather than hoard his knowledge, not only because informed
self-care is more health conducing than ignorance and dependence,
but because the principle of sharing is basic to the well-being
Perhaps the most important difference between the village
health worker and the doctor is that the health worker's background
and training, as well as his membership in and selection by
the community, help reinforce his will to serve rather than
bleed his people. This is not to say that the village health
worker cannot become money-hungry and corrupt. After all,
he is as human as the rest of us. It is simply to say that
for the village health worker the privilege to grow fat off
the illness and misfortune of his fellow man has still not
become socially acceptable.
||The primary health worker lives and works
at the level of the people. His first job is to share
(Illustration from the forthcoming English edition of
Where There is No Doctor by David Werner)
Forgive me if I seem a little bitter, but when you live with
and share the lot of Mexican villagers for 12 years, you can't
help but feel a little uncomfortable about the exploits of
the medical profession. For example, Martin, the chief village
medic and coordinator of the villager run health program I
helped to start, recently had to transport his brother to
the big city for emergency surgery. His brother had been shot
in the stomach. Now Martin, as a village health worker supported
through the community, earns 1,600 pesos ($80.00) a month,
which is in line with what the other villagers earn. But the
surgeon charged 20,000 pesos ($1000.00) for two hours of surgery.
Martin is stuck with the bill. That means he has to forsake
his position in the health program and work for two months
as a wet-back in the States--in order to pay for two hours
of the surgeon's time. Now, is that fair?
* * * * *
No, the village health worker, at his best, is neither choreboy
nor auxiliary nor doctor's substitute. His commitment is not
to assist the doctor, but to help his people.
The day must come when we look at the primary health worker
as the key member of the health team, and at the doctor as
the auxiliary. The doctor, as a specialist in advanced curative
technology, would be on call as needed by the primary health
worker for referrals and advice. He would attend those 2-3%
of illnesses which lie beyond the capacity of an informed
people and their health worker, and he even might, under supportive
supervision, help out in the training of the primary health
worker in that narrow area of health care called Medicine.
Health care will only become equitable when
the skills pyramid has been tipped on its side, so that the
primary health worker takes the lead, and so that the doctor
is on tap and not on top.
TIPPING THE HEALTH MANPOWER PYRAMID ON
COMPARISON OF THE MEDICAL DOCTOR AND THE PRIMARY HEALTH WORKER
(Note: The medical doctor as described here is the typical
Western-style M.D. as produced by medical schools in Latin
America. Clearly, there are exceptions. Most Latin American
medical schools are beginning to modify their curricula to
place greater emphasis on community health. However, not modifications
but radical changes, both in selection and training, are needed
if doctors are ever to become an integrated and fully positive
part of a health team that serves all the people.)
WORKER (at his best)
|Usually upper middle class
||From the peasantry.
||By medical school for:
grade point average;
economic and social status.
|By community for:
interest, compassion, knowledge of community, etc.
Mainly institutional, 12-16 years general schooling,
4-6 years medical training.
Training concentrates on:
- physical and technological aspects of medicine,
- and gives low priority to human, social, and political
aspects. (This is now changing in some medical schools.)
Limited, key training appropriate to serve all the people
in a given community:
- Dx & Rx of important disease Preventive medicine
- Community health
- Teaching skills
- Health care in terms of economic and social realities,
and of needs (felt and long term) of both individuals
and the community.
- Humanization (conscientización) and group
- Highly qualified to diagnose and treat individual
- Especially qualified to manage uncommon and difficult
- Less qualified to deal effectively with most important
diseases of most people in a given community.
- Poorly qualified to supervise and teach VHW. (Well
qualified in clinical medicine, but not in other more
important aspects of health care; he tends to favor
imbalance; wrong priorities.)
- More qualified than doctor to deal effectively with
the important sicknesses of most of the people.
- Non-academic qualifications are:
- Intimate knowledge of the community, language,
customs, attitudes toward sickness and healing.
- Willingness to work and earn at the level of
the community, where the needs are greatest.
- Not qualified to diagnose and treat certain difficult
and unusual problems; must refer.
Individual patient oriented
Seeks a balance between curative and preventive. (Curative
to meet felt needs,
preventive to meet real
|Primary Job Interest
||The challenging and interesting cases. (Often bored
by day to day problems.)
||Helping people resolve their biggest problems because
he is their friend and neighbor.
|Attitude toward the sick
||Superior. Treats people as patients. Turns
people into 'cases'
Underestimates people's capacity for self-care.
|On their level. Treats patients as people.
Mutual concern and interest because the VHW is village
|Attitude of the sick toward M.D. or VHW
||Hold him in awe. Blind trust (or sometimes
||See him as a friend. Trust him as a person,
but feel free to question him.
Mutual concern and interest because the VHW is village
|How does he use Medical knowledge?
Delivers 'services', discourages self-care, keeps patients
helpless and dependent.
Encourages informed self-care, helps the sick and family
understand and manage problems.
Often inaccessible, especially to poor.
Preferential treatment of haves over have-nots.
Does some charity work.
Lives right in village.
Low charges for services.
Treats everyone equally and as his equal.
|Consideration for economic factors
factors high earnings.
Feels it is his God-given
right to live in luxury
while others hunger.
Often prescribes unnecessarily costly drugs.
Takes the person's economic position into account.
Content (or resigned) to live at economic level of his
people. Prescribes only useful.drugs. Considers cost.
Encourages effective home remedies.
||At most spends 1-2 years in a
rural area and then moves
to the city.
|A permanent member of the community.
|Continuity of Care
||Can't follow up cases because he doesn't live in the
||Visits his neighbors in their homes to make sure they
get better and learn how not to
get sick again.
Too expensive to ever meet
medical needs of the poor-- unless used as an auxiliary
resource for problems not readily managed by VHW.
Low cost of both training and practice.
Higher effectiveness than doctor in coping with primary
||Hospital or health center.
Depends on expensive, hard-to-get equipment and a large
subservient staff to work at full potential.
|Works out of home or simple structure.
People are the main resource.
Directs the health team.
Manages all kinds of medical problems, easy or complex.
Often overburdened with easily treated or preventable
|On the bottom.
Often given minimal responsibility, especially in medicine.
Regarded as an auxiliary
( lackey) to the physician.
|Impact on the Community
|| Relatively low (in part
Sustains class differences,
mystification of medicine,
dependency on expensive
Drains resources of poor
Awakening of people to cope more effectively with health
needs, human needs, and ultimately human rights.
Helps community to use resources more effectively.
|Appropriate (future?) Role
||On tap (not on top).
Functions as an auxiliary to the VHW, helping to teach
him more medical skills and attending referrals at the
VHW's request. (The 2-3% of cases that are beyond the
He is an equal member of the health team.
|Recognized as the key member of the health
Assumes leadership of health care activities in his village,
but relies on advice, support, and referral assistance
from the doctor when he needs it.
He is the doctor's equal (although his earnings remain
in line with those of his fellow villagers).
TWO APPROACHES TO HEALTH CARE
VILLAGE HEALTH WORKERS
CAN HELP DOCTORS LEARN
THE SECOND APPROACH