By Kathy Dodworth
Margaret Odera, who lives in Mathare, Kenya, is the world’s most visible Community Health Worker (CHW). She has travelled the globe, recently addressing the 76th World Health Assembly in Geneva and was named a 2022 Heroine of Health by Women in Global Health. At home, she founded a nationwide Champions Network, while juggling her CHW duties.
Margaret has gone to extraordinary lengths to become this visible. First, her journey to serving as a CHW is rooted in her own challenging experiences in accessing appropriate health services as a mother living with HIV [1]. Second, her visibility to international agencies is grounded in years of unpaid labour. Third, she took the decision to pick up her smartphone in 2020, document her challenges and share them through social media with the world [2]. This is how myself, as other scholars, and Margaret ‘connected’.
These brave actions, circumventing hierarchies, at first put her at odds with government actors, risking her status as a volunteer and more. While Margaret is now so well-known she is untouchable, the voices of hundreds of thousands of CHWs have been systematically quashed. This may be overt, on the part of local government, or a less obvious side product of external actors putting community health success first, politics second.
Margaret Odera at the 76th World Health Assembly in Geneva, where she gave a public address. Copyright: Margaret Odera.
So how did the bottom-up ethos of community health become subverted into an exploitative industry of exacting unpaid labour, in which many non-state actors are complicit, enacted by top-down state sanction and the suppression of workers’ voices?
While advocacy groups are registering progress in making paying and professionalising CHWs the norm, community health has been a central pillar of overseas interventions by powerful agencies for over a century. Community and self-reliance were later codified within the revered Declaration of Alma Ata in 1978, becoming core to healthcare delivery in the majority world. This treaty, within which the rising influence of non-Western regions was keenly felt, laid out radical new principles in primary health and, indeed, health as a right.
Community health became symbolic of Alma Ata’s radicalism. This element was conceived as a rejection of not just Western biomedicine, but of colonial-like condescensions and modes of being. Health interventions should not be top-down impositions, as in the colonial past [3], but conducted with the people, for the people and, famously, by the people [4].
A closer reading of community health history, however, reveals problematic hangovers from colonial governance. In ‘responsibilizing’ community members to overcome ‘their own’ health challenges, space was opened to de-responsibilize colonial powers from investing in pro-poor health systems in colonized countries. Colonial regimes handed over nodal infrastructures clustered around key towns, leaving the masses unserved.
The challenges post-independence governments faced were therefore immense. In the run-up to Alma Ata, the WHO commissioned a series of studies to identify rays of light in the sea of seeming hopelessness regarding the state of healthcare in such resource-poor contexts.
Contributing scholars and practitioners clustered around bottom-up initiatives centred on self-help and voluntary labour. This type of thinking resonated with a dominant export among post-war powers, donors and philanthropists, even when its transformative potential was questioned at home. The language of these reports is a blend of mythologizing ‘traditional’ ways of life, anti-Westernism and political manifesto. Self-help spoke to all three.
Self-help had become core to revolutionary projects in health exemplars like China, Cuba and Tanzania. In the years before Alma Ata, such regimes had matched the efforts of their citizens with huge investments, leading to transformative gains. However, self-help was increasingly state-directed and coerced, which was all but erased from these studies. Often in such contexts, workers’ rights to organize were severely curtailed.
As material investments fell away in the 1980s (with some exceptions like Cuba), especially in contexts exposed to structural adjustment conditions by Western lenders, community health began to operate more in lieu of, rather than as well as, the state. Despite Alma Ata’s left-wing radicalism, community health was easily fused with conservative ideas of state retrenchment and individual self-help during the Reagan and Thatcher eras, which simultaneously abhorred workers’ rights.
Community health, underpinned by unsalaried labour, thus became a permanent state of being, palatable left and right. My recent research in Kenya unpacks how forms of violence and dispossession lead to unpaid community labour as permanent and inescapable. Community health workers have had little voice historically, drawn from the poorest and most underserved communities. This has allowed stories of health heroism to flourish in lieu of new thinking or, indeed, the fulfilment of old declarations of northern governments’ responsibilities to invest in human resourcing for health, as per Alma Ata. Planning for Where There is No Doctor simply removed the pressure to provide one.
As evidence, almost five decades on from Alma Ata, 86% of CHWs in Africa remain unsalaried. While interventions by multilateral donors and, more recently, big philanthropy remain verticalized, focusing on a particular disease or indicator, staffing remains a major blocker to comprehensive healthcare. The World Bank’s millennial foray into health added further pressure to keep the state slim and payroll low, yet the brain drain South to North has again rocketed following the COVID pandemic.
I do not challenge the effectiveness of community health for a moment. I do challenge the global injustices and inequalities that allowed it to become the core staffing option in many of the world’s poorest, politically voiceless areas. These are the same inequalities that allowed expectations to diverge North and South from late colonial times as to what a quality, well-stocked, well-staffed healthcare system should look like. We might need to return to the ambitiousness of the 1970s to ensure our expectations and humanity are shared, and so to revisit whether community health’s founding assumptions should remain sacrosanct.
References:
[1] Dimagi. 2023. “Championing a Movement to Pay and Professionalize Community Health Workers with Margaret Odera.” Accessed June 9, 2023. https://open.spotify.com/episode/0P45IwQs9Cbn8wSB99D2yH.
[2] Phone discussion with Margaret Odera, April 2023.
[3] Fanon, Frantz. “Medicine and Colonialism.” In A Dying Colonialism. New York: Grove Press, 1965.
[4] Newell, Kenneth W., ed. Health by the People. Geneva : Albany, N.Y, 1975.
Kathy Dodworth is a Research Fellow at the University of Edinburgh, currently exploring the life histories of Community Health Volunteers in Kenya. She also examines non-state legitimation in East Africa, which was the subject of her 2022 monograph ‘Legitimation as Political Practice (Cambridge University Press). She has published in the Journal of Social Policy, African Affairs, Health, Ethnography and Critical African Studies.
Cover photo credit: “Community health workers on strike” – Kathy Dodworth.
