Based in the community

While there are often few physicians and nurses in resource-poor settings, a large number of underemployed or unemployed persons are frequently available. CHWs are always recruited from the communities they support. Recommendations are sought from respected members of the community such as village elders, spiritual leaders, nurses and teachers. Some programs have organized community meetings to find CHWs, while others have advertised through local newspapers and radio announcements. Religious groups, schools, and other community-based organizations providing outreach activities are also good places to find potential CHWs. Patients are another source as they are able to serve themselves and to recommend people in their village who are trustworthy and caring.

The programs in Lesotho, Haiti and Rwanda have, whenever possible, integrated community workers who are already in place - village health workers, agents de santé and animateurs de santé, respectively - into the newly formed community health worker teams.

Requirements

• The CHW must be an adult (usually over 18 years of age) and preferably literate.

• Since the CHW is in daily contact with patients in their homes, he or she should live in or close to the community served; having lived in the community for a specific number of years is often required.

• The CHW should have a background that is similar to the background of the patients so that they feel comfortable sharing their concerns. This also enables the CHW to have first-hand knowledge of the problems and obstacles patients face every day. In some cases, CHWs are themselves HIV positive or former TB patients. They frequently know someone who has HIV or TB in their community.

• Motivation and character are critical requirements. A CHW must be a trustworthy and respected member of the community with a strong desire to help the needy and a strong sense of empathy with those who are vulnerable and sick. A CHW’s work is not only focused on improving health status, but also on social justice and solidarity with the community, through working to support affected individuals and households and reduce social isolation. The profile of a successful accompagnateur at Inshuti Mu Buzima, Rwanda highlights many of these requirements.

Interviewing CHW candidates

The clinical team usually interviews people who wish to become CHWs to see if they meet the above requirements. Team members that may be involved in the interveiw process include doctors, nurses, social workers or program managers. The candidate may be asked to take a basic literacy test. He/she may also be called upon to read a medication label or write his/her name, to distinguish medications by color and size and to count the number of pills in a month's supply. In some programs, preference is given to candidates who are extremely poor and could therefore particularly use the additional income and skills-training. Given the specific vulnerabilities of women in the HIV epidemic, women may be preferred.

Pairing a patient with a CHW

CHWs are chiefly selected by patients themselves. In the case of an established program, a patient may already know a CHW in his community, and may even have been referred to the health center by him/her.

If the patient does not know any CHWs, or doesn’t feel comfortable with the one(s) he/she knows, then the clinical team suggests a possible candidate from those CHWs who live in the vicinity of the patient.