Community health worker programmes have become a prominent feature of many primary health care schemes in developing countries. This paper, which is based on a larger collaborative study undertaken in 3 countries, focuses on the experiences with such workers in Botswana, and concludes that many of the key issues that were highlighted in the Botswana study are similar to those in other countries. These can be summarized under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulty of maintaining quality of care. The future success of these workers will depend on their being integrated more systematically into local services, with concomitant strengthening of management support and supervision.
PIP: Community health worker (CHW) programs have become an important part of primary health care in developing countries. Recent research focused on the experiences in Botswana. Among the issues identified were: unrealistic expectations, poor planning, problems of sustainability, and the difficulty of maintaining quality of care. The future usefulness of these workers will depend on their integration into local services and with a strengthening of management support and supervision. This research had 3 main objectives; to review the historical development of the family welfare educators (FWE) program; to evaluate their current role and performances; and to evaluate the feasibility and desirability of FWE's becoming more community based. FWE's were spending most of their time working in health facilities and earlier reviews indicated they should be engaged mostly in home visits and other community activities. The case study confirmed that the FWE's spent most of their time doing mundane tasks such as registration, taking blood pressure, and dispensing drugs. Most of the FWE's indicated that they would prefer to do home visits. Reasons that prevent them from doing so include the opposition by nurses, opposition by FWE's because it is low status and hard work, and opposition by the communities if they perceive it as decreasing their access to curative care. The general results of this research indicates that programs differ greatly from country to country and each country needs to evaluate its own situation and decide on the feasibility of a range of options. It is also apparent that CHW programs have extended services, especially into areas where trained health workers have been lacking. For these programs to work well, and give good quality care the CHWs need good management support and supervision. The focus must be on working with local health facilities, outreach work from them and links with the community.