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A History of Community Health Workers

One of the first systematic uses of community health workers was in the form of the "Barefoot Doctors" program in China, which was first implemented in the late 1950s and made official in 1965. Chairman Mao Zedong encouraged the development of this program in response to what he saw as a disparity in health care access between the 20% of the population who lived in urban areas, and the remainder who lived in the outlying rural areas. Because almost all of the doctors at the time were only seeing patients in the larger cities, the peasants living and working in the countryside received almost no health care at all. Mao Zedong ordered thousands of peasant workers to undergo a crash-course in basic medicine and first aid; these workers would focus their efforts on improving basic health and hygiene in the peasant populations, especially in treating a disease known as big belly which was caused by an infectious parasite. After a visit to China in 1984, Dr. Paul Bausch of Stanford University reported that the "barefoot doctors" had managed to reduce the incidence of "big belly" disease by 90% in some regions.¹

In 1978, a joint conference between UNICEF and the World Health Organization underscored the importance of Primary Health Care, which was thought of as the bridge between a community and its health care system. Specifically, they defined PHC as "essential health care . . . made universally accessible to individuals and their families in the community through their full participation and at a cost that the community and country can afford." ² During this period, Community Health Workers were seen as an important means of providing primary health care to those communities that need it most, but are paradoxically the least likely to receive it.³

In the last 20 years, Community Health Worker programs have become popular across the United States. A national survey of these programs indicates that seventeen states have CHW/CHA training and certification programs. Most of these programs are administered through community colleges and employ standardized curricula. Alaska, Indiana, and Texas have state-level certifications for their CHWs, while seven others (Arizona, California, Kentucky, Massachusetts, Nevada, New Mexico, and Ohio) are considering the development of state certifications.⁴ There are also a number of national and regional CHA/CHW associations, such as the Community Health Representative Program, the Community Health Advisor Network, and the Community Health Worker National Network Association.

¹ Valentine, Vikki. (Nov. 4th, 2005), "Health for the Masses: China's 'Barefoot Doctors'" from the National Public Radio website.
² UNICEF/WHO (1978), The International Conference on Primary Health Care, Alma-Ata, USSR.
³ Fendall, R. (1984), We Expect Too Much From Community Health Workers. World Health Forum. 5:300-303.
⁴ May, Kash, and Contreras (2004), Community Health Worker (CHW) Certification and Training: A National Survey.