Community health workers--resources could be better spent [letter]

I should like to comment on the article "Community healthworkers--what is their real value?" by Dandare and Shah. Many states in India have already accepted the community health worker program and are implementing it--unfortunately without much thought about what could happen in the future. The participation of the community in the selection of community health workers seems to be a good thing in theory. However we know how village assemblies and council meetings work in practive so we cannot surely expect the selection of community health workers to be unbiased. If the matter is left to the community a genuine choice of the best candidate will be the exception rather than the rule. The feudal structure of rural society has yet to change. The candidate who stands the best chance is likely to be the one who is a distant relative of the Chairman or Secretary or even just a political follower. The community really has no say in the matter only a few individuals. And even the medical proffession is powerless to do anything about ir. The cost involved in the training and retraining of community health workers is too high. With just 1.8% of the gross national product being spent on health it is item for us to think of using resources in a better way. It is not enough to say as Dandare and Shah do: "Whatever the stage at which he drops out the trained community healthworker who stays in the village is not only likely to modify his own behavior favorably in terms of health but may influence also others to do so." That in itself cannot justify the use of so many resources. If carried to a logical conclusion this argument would lead us to train 1 person in every family. At a time when quackery is rampant not only in villages but also in cities it is naive to overlook the possiblity of community healthworkers attempting to function as private medical practitioners. The multipurpose health worker who caters for a population of 5000 is not supplied with enough drugs even for conditions such as fever cough diarrhea leprosy tuberculosis and malaria. The drugs kit is usually empty through lack of funds. The community healthworker on the other hand with far less training motivation and work experience than the multipurpose healthworker is able to dispense so many drugs that he can even have a clinic in the village. A better use of resources would be to increase the number of multipurpose health workers to reduce the population for which they cater and to equip them regularly with sufficient drugs. They should of course be subject to careful supervision by the medical officer concerned. It is high time for health planners to think deeply about the community health worker scheme before implementing it. What is important is a better health service for rural people rather than a novel scheme that merely looks good on paper. (full text)