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44 | IEEE TECHNOLOGY AND SOCIETY MAGAZINE | SPR ING 2013
1932-4529/13/$31.00©2 013IEEE
BRIANNA BUEHLER, RENE RUGGIERO, AND KHANJAN MEHTA
Empowering
Community
Health Workers
with Technology
Solutions
AnnA FrodesiAk/WikimediA Commons
Digital Object Identifier 10.1109/MTS.2013.2241831
Date of publication: 14 March 2013
IEEE TECHNOLOGY AND SOCIETY MAGAZINE | SPR ING 2013 | 45
Great economic, social,
and structural dispari-
ties exist in the world
today, and these dis-
parities have led to
immense challenges for healthcare
facilities around the world. The
global community “lacks an equal
rights-based approach in the dis-
tribution of healthcare” [1]. The
burden of disease is growing dispro-
portionately in different regions of
the world, with developing countries
moving toward a double burden of
both chronic and infectious disease.
Many countries with low economic
and human resources have the high-
est public health burden. Of the 163
million births each year, 3–4 mil-
lion babies die in their first four
weeks, and 10.6 million children
die before reaching the age of five.
Approximately 530 000 women
die in pregnancy or childbirth each
year [1]. Over 17 million people will
die of cardiovascular disease world-
wide in 2010, with more than 60%
of the global burden of coronary
heart disease occurring in develop-
ing countries [2]. The number of
people living with HIV/AIDS world-
wide is 33.3 million, while in 2008,
1000 children became infected each
day [3]. Seventy to eighty percent
of the health problems are prevent-
able, but access and utilization of the
health systems remains low in some
regions [4].
Poverty, both in developing and
rich countries, has detrimental
effects on individuals’ and popula-
tions’ health. Poverty prevents peo-
ple from having access to the basic
amenities needed to live healthy
lifestyles, or services needed to
sustain life. Evidence has shown
that poor people “live shorter and
sicker lives” [5]. In addition, poor
people unlucky enough to become
sickened by HIV/AIDS, malaria,
or tuberculosis are at high risk
for falling into a “medical pov-
erty trap” [5]. Low income coun-
tries frequently experience “brain
drain,” as many of their most
educated healthcare professionals
leave the country for higher sala-
ries in developed nations. Health
worker migration has contributed
to the breakdown of some health
systems in Sub-Saharan Africa.
Overall, 36 countries in Africa did
not meet the target of one doctor
for every 5000 people. In 2002,
the U.K. described a nursing short-
age of 35 000, which was the same
as the entire nursing workforce of
Tanzania, Botswana, Ghana, and
Malawi combined. By some esti-
mates, Ghana lost more nurses then
it trained in 1999.
The absence of healthcare work-
ers threatens the overall health
services a country can provide
for its people. The availability of
human resources has been iden-
tified as a main determinant of
health system performance. These
global disparities, burgeoning
and shifting burden of disease,
and health worker migration have
contributed to a growing primary
healthcare crisis, especially in
the Sub-Saharan Africa region
[6]. Community Health Workers
(CHW) have stepped in to meet
these growing healthcare chal-
lenges. CHWs have worked to fill
the gap through educating and
attending to the healthcare needs
of their communities.
This article will provide evi-
dence that empowering community
health workers with appropriate
technologies can address primary
healthcare needs in developing
countries. Through a compari-
son of case studies from various
countries, a review of available
resources and challenges facing
CHWs, and primary data collected
in Kenya, we will highlight the
potential remedial impact of tech-
nology initiatives for empowering
Community Health Workers.
Community Health Workers
“The only solution for public
health is training of commu-
nity health workers. When
we talk about improvement
in primary healthcare in a
village, we are talking about
information and changing
behavior. Because commu-
nity health workers are from
the grassroots and they know
the culture, they are able to
change behavior much eas-
ier and faster.”
—Harold Kodo, national KEPI
education officer, Kenya [7]
Community Health Workers are
trained community members work-
ing in health education, prevention,
and awareness in their communities.
First introduced in the 1970s and
80s after the Alma Ata declaration
for the initiation and provision of
primary healthcare services at grass
root levels, they engage in the man-
agement and treatment of illnesses
[4]. The World Health Organization
has set minimum guidelines for the
selections of CHWs:
“CHWs should be members
of the communities where
they work, should be selected
by the communities, should
be answerable to the com-
munities for their activities,
should be supported by the
health system but not nec-
essarily a part of its orga-
nization, and have shorter
training than professional
workers” [8]
CHWs have many responsibili-
ties in a community. They conduct
home visits, provide treatment of
simple and common illnesses, and
Of 163 million births each year, 3– 4
million babies die in their first four
weeks, and 10.6 million children die
before reaching the age of five.
46 | IEEE TECHNOLO GY AND SOC IETY MAGAZINE | SPR ING 2013
offer health education including
nutrition and surveillance. CHWs
also support maternal and child
health, are involved in family plan-
ning activities, and contribute to the
treatment and care of tuberculosis,
HIV/AIDS, malaria and acute respi-
ratory disease. Trained in providing
referrals, CHWs also spend time
recordkeeping and collecting data
on illnesses within the community.
CHW programs have been devel-
oped with the goals of improving
access to healthcare and decreasing
morbidity and mortality rates. These
programs aim to lower the costs in
seeking medical advice, and create
self-reliance and local participation
in community healthcare. Increas-
ing access to resources and commu-
nity participation in turn improves
coverage and equity across the coun-
try. It has been shown that CHW
programs improve health indicators,
behaviors and utilization of services.
Such programs also improve the cul-
tural appropriateness of health and
education campaigns. The commu-
nity empowerment model of CHW
programs promotes the sustainabil-
ity of health interventions leading to
related economic benefits. CHWs
serve as a link between a commu-
nity and the national health systems
and provide insight into commu-
nity level social and environmental
determinants of health. CHWs have
been recognized as an important
tool in improving the health of a
community [4].
Case Studies
For several decades, Community
Health Workers have participated
in primary healthcare delivery in
many countries around the world.
Evidence has shown that CHWs can
aid in improving the health of a pop-
ulation, especially in areas with a
lack of healthcare professionals. The
Global Health Workforce Alliance
completed in-depth case studies of
CHW programs around the world
to evaluate the impact of CHWs on
the Millennium Development goals.
They reviewed the training, supervi-
sion, standards deployment, perfor-
mance, and impact of CHWs in the
areas of maternal and child health,
HIV/AIDS, TB, mental health,
and non-communicable diseases.
We have discussed case studies of
CHWs in Brazil, Ethiopia, Bangla-
desh, and Pakistan, to review best
practices and potential models for
other CHW programs. The case
studies offer a window into the
reality faced by CHWs. Appropri-
ate context-driven design of simple,
low-cost technologies can empower
CHWs and improve the efficiency of
isolated rural healthcare centers [9].
Computer-assisted diagnostic soft-
ware to process patients at rural clin-
ics is a feasible long-term approach,
particularly as smartphones become
accessible, affordable and capable
of supporting compute-intensive
applications [10]. Understanding the
CHW’s needs and context of use is
an important first step towards con-
ceptualizing and designing appropri-
ate technology products and services
or policy interventions. The func-
tionality and reliability of the tech-
nology itself is typically not as big
of a challenge as the usability, socio-
economics and incentive structures
for all the stakeholders [11].
Brazil
In 1988, the Brazilian Unified
Health System was developed on
the principle that health is a basic
human right of all citizens. Created
with the aim of reaching univer-
sal coverage of all people, it was
operationalized through a focus on
primary healthcare and the estab-
lishment of Family Health Program
or Programa Saude da Familia
(PSF). Through this model, a broad
range of primary care services are
provided by the Family Health
Team composed of one family doc-
tor, one nurse, one assistant nurse,
and about six CHWs. Each Family
Health Team is responsible for a
specific geographic area and moni-
toring 3000–4500 people [4].
CHWs visit each family in their
geographic area once a month, and
in the case of finding someone
sick, the CHW refers the patient
to the nearest health facility. The
CHW accompanies the patient to
the health facility, maintains con-
tact with the family, and follows up
until the health issue is resolved.
In this way, the CHW serves as
the link between the health sys-
tem and family in the community.
The Family Health Team is also
required to collect geographic,
demographic and health informa-
tion on the assigned families, and
to document the services and inter-
ventions provided. Ongoing infor-
mation management challenges
remain at PSF and in the larger
Ministry of Health, and efforts
have been made to move toward
software systems to monitor patient
information and clinical records
[4]. Brazilian CHWs are trained in
building trust within their commu-
nities, through approaching issues
of HIV/AIDS and family plan-
ning indirectly in the context of
general health [12].The estimated
yearly cost of maintaining the PSF
program is equivalent to $31 to
$50 per individual covered. The
CHWs are considered employees
of the Ministry of Health and earn
the national minimum wage about
$112 per month, paid by the central
state funds. There are also perfor-
mance based financial incentives
for CHWs in some municipalities.
Ethiopia
The current “Health Extension
Program” (HEP), started in 2004, is
Approximately 530 000 women die
in pregnancy or childbirth each year.
IEEE TECHNOLOGY AND SOCIETY MAGAZINE | SPR ING 2013 | 47
implemented by “Health Extension
Workers” (HEW), who are selected
by their communities and provided
one year of training. The require-
ments for the selection process for a
HEW state that the person must be
female, at least 18 years old, have
completed grade 10, and be a well-
respected member of the commu-
nity. The criteria are relaxed in rural
and pastoralist areas where educa-
tional requirements may not be met
by women in particular. The train-
ing is well structured with clear cur-
riculum training materials, and is
available at all the technical training
facilities around the country. In con-
trast to the CHW program in Brazil,
the HEWs in Ethiopia are entitled to
upgrade their education to a level of
registered nurses through a distance
learning program and hands-on
training [13].
The HEWs are responsible for
a population of 5000 people, and
are supported by a group of Volun-
teer Community Health Workers
(VCHW); one VCHW for every
250 people. The HEWs spend about
25% of their time on administrative
duties at the health post and 75% of
their time in the field. Part of their
field work includes training “model
families” in waste management, sep-
arating human and animal quarters,
family planning, malaria monitor-
ing, mosquito breeding sites, infor-
mation on common health problems,
and general support and encourage-
ment [4]. The HEWs have also been
tasked with HIV/AIDS education,
psychological support, prevention of
mother to child HIV transmission,
and home care visits [13].
Bangladesh
The Bangladesh Rural Advance-
ment Committee (BRAC) is the
largest national non-governmental
organization with semi-voluntary
CHWs. BRAC began in 1972 and
provides basic and curative health-
care through ShasthoSebikas (SS),
the local name for CHWs. The
SS are women between 25 and
45 years of age, with a few years
of schooling, and a willingness to
provide volunteer services in their
community. The SS work 2 hours
a day, 6 days a week for 15 days a
month. Their roles include health
education in five essential com-
ponents: water and sanitation,
health and nutrition, family plan-
ning, basic curative services and
immunization. They sell medicine,
contraceptives, sanitary latrines,
vegetable seeds, and tube-wells.
SS have a strong focus on preg-
nant women by encouraging them
to utilize services in government
facilities, visit women at 42 days
of delivery, and give special care
to low birth weight babies. They
also connect with the community
by using interactive communica-
tion through folk music and theater.
There are currently about 78 000
SS and each SS is responsible for
150-200 households [4].
Once chosen, SSs are trained in
fundamental and essential curative
health for 4 weeks, spending about
four days per week at the regional
office. They are trained specifi-
cally in the following common ill-
nesses: ringworm, scabies, worm
infestation, common cold and
cough, diarrhea, anemia, gastric
and peptic ulcers, angular stoma-
titis, and dysentery. SSs must con-
tinue monthly refresher programs
for the next two years. These meet-
ings discuss problems SSs have
encountered in the past month and
disseminate new health and nutri-
tion knowledge [4]. SS workers
are volunteers and do not receive
a salary. They make an income
from the sales of drugs and health
commodities (contraceptives pills
and condoms). Motivational fac-
tors are enforced, such as social
prestige and fame that comes with
being an SS and the enthusiasm to
work for the betterment of one’s
community. Certain paid incen-
tives have been given for specific
tasks that involve pregnancy and
health of newborns. CHWs have
been found to be more cost-effec-
tive than government services for
the implementation of the DOTS
campaign against tuberculosis in
resource-poor settings [14].
Pakistan
In 1994, the federal Lady Health
Workers Program was developed
to provide services for family plan-
ning and primary healthcare. With
about 90 000 trained Lady Health
Workers (LHW), the program was
designed to address the high mater-
nal mortality ratio of 320 deaths
per 100 000 live births. The LHW,
responsible for about 1000 individ-
uals, provides primary health ser-
vices and organizes women groups
and health committees in her area.
She is expected to visit 5–7 house-
holds each day and re-visit them
every 2 months. LHWs promote
family planning and encourage
mothers to seek pre- and post-natal
care, among other primary health
services [4].
The LHWs attend 15 months
of training consisting of two parts,
three months of integrated class-
room training and 12 months of
task-based training. After training,
the LHWs report to the training site
once a month for refresher training
and supplies, to ask questions and
turn in reports. LHWs are paid dur-
ing training followed by a salary
of Pakistani Rs. 3090 (~USD 35)
every month. They supplement their
income by selling contraceptives to
their clients. Lady Health Super-
visors are trained for a one-year
The community empowerment model
of CHW programs promotes the
sustainability of health interventions
leading to related economic benefits.
48 | IEEE TECHNOLO GY AND SOC IETY MAGAZINE | SPR ING 2013
period and provide daily support to
25 LHWs [4]. In a research study
investigating the LHW perceptions
of their own effectiveness, they
found that “nazr (evil eye), garam
& thanda (hot & cold) food, male
child preference, fear of stigma in
TB and other diseases, and fatalism”
were common barriers to their work.
This study also found that media
campaigns enhanced the credibility
of the LHWs work in their commu-
nities [15]. The LHW face challeng-
ing terrain that makes it difficult to
reach all clients in a timely fashion,
and malfunctioning equipment such
as weighing scales. The program
is currently trying to construct an
effective information system, “to
respond to the information needs of
various decision making levels of
the health system” [15].
Technologies to Aid CHWs
CHW programs have been devel-
oped in many countries with the
most successful programs target-
ing the needs of specific popula-
tions. Certain factors form the
building blocks of successful CHW
programs. First, community par-
ticipation is essential to securing
participants and involving them in
all aspects of the program. Second,
it is necessary to have adequate
and reliable resources, such as gov-
ernmental and political support to
ensure crucial involvement with the
other health sector activities. Third,
because of organizational and geo-
graphical limitations, sustained
and attentive management plays
a critical role in keeping the pro-
gram alive. Village health commit-
tees (VHCs) are often established
to take charge of selecting CHW
candidates. Fourth, CHW training
programs should ideally be located
close to the working context of the
trainee and continuing/refresher
training should be emphasized to
reinforce training and learning of
new skills. Fifth, an incentive pack-
age should be arranged, including
financial incentives, such as a sal-
ary, and non-financial incentives,
like uniforms and medicine [8].
Many challenges exist for those try-
ing to achieve these five elements of
a successful CHW program. Issues
include constrained resources and
institutional environments, prob-
lems of sustaining a volunteer
workforce due to lack of resources
for incentive packages, logistics and
supply chain obscurities, training
and supervision needs, and multi-
sectoral support. However, these
challenges also present opportuni-
ties for creating value through tech-
nology-based solutions.
Table I outlines the supplies
provided to CHWs by their central
governments to aid their work in the
community. The tools vary widely
from country to country, with some
countries providing more medi-
cines and others providing basic
medical equipment. The supplies
also highlight the various responsi-
bilities of CHWs, from flip charts
and flyers for educational outreach,
to condoms for family planning,
and chloroquine for treating com-
mon illnesses. Some of the stipula-
tions, like “bicycle, canoe or ship”
for CHWs in Brazil and various
vaccines in Haiti, raise questions
about their feasibility, practicality,
and sustainability.
Technology can empower com-
munity health workers and enhance
their effectiveness in addressing pri-
mary healthcare needs, help syner-
gize with the healthcare system, and
amplify their impact. In the case
of Brazil, the family health team
is responsible for collecting demo-
graphic data on patients and com-
munities as well as documenting
their efforts and interventions. The
Ministry of Health has made efforts
to digitize data systems and contin-
ues to struggle with the task. In the
case of Ethiopia, the HEWs spend
75% of their time in the field provid-
ing basic health services to the com-
munity [4]. Tools to improve data
collection, management, and orga-
nization would greatly enhance the
community level work of CHWs.
Access to portable basic medical
equipment and cell phone technolo-
gies could significantly advance the
CHWs ability to accurately assess
a patient’s symptoms and correctly
communicate those symptoms to a
doctor. Affordable cell phone-based
technologies can address major gaps
in knowledge and promote infor-
mation sharing among healthcare
workers at the community and dis-
trict levels.
Several technology interventions
are being designed, tested, and uti-
lized to supplement the hard work
of healthcare professionals. For
example, the Kenyan Ministry of
Public Health and Sanitation’s Divi-
sion of Immunization has initiated
a new system that uses cell phone
technology to track vaccine stocks at
various district stores. The system,
known as Healthtrack, enables users
to manage and automatically update
vaccine stock information through
their cell phones. Employees can
also communicate to each other by
sending text messages and reports
through the system [16]. In another
example, the Ministry of Health of
Zanzibar in Tanzania has initiated an
intervention termed “Wired Moth-
ers.” Wired mothers are pregnant
women with cell phones who receive
regular SMS text messages remind-
ing them of appointments and allow-
ing them to call health providers for
advice on acute or non-acute prob-
lems [17]. The government of Brazil
partnered with Nokia in 2008, to
launch Mobisus, a cellphone-based
Several technology interventions are
being designed, tested, and utilized to
supplement the hard work of healthcare
professionals.
IEEE TECHNOLOGY AND SOCIETY MAGAZINE | SPR ING 2013 | 49
program to help Brazilian health
workers effectively collect health
data including immunizations, oral
health, nutrition, and maternal and
child health [17].
CHWs and Technology:
Perspective from Kenya
In May and June of 2010, our team
of researchers from the Humanitar-
ian Engineering and Social Entre-
preneurship (HESE) Program at the
Pennsylvania State University trav-
eled to Kenya to engage with local
partners to evaluate the appropriate-
ness of a telemedicine system in the
Kenyan context and explore other
potential entry points for similar
health innovations. We conducted a
series of seven focus groups, vary-
ing in size from seven people to
a maximum of 25, with about 75
people engaged in the focus groups.
Four of the focus groups were held
in parallel to health clinics at the
Children and Youth Empowerment
Center (CYEC) in Nyeri, Kenya.
The aim of these clinics was to
provide basic health services to the
community while evaluating the
effectiveness and consistency of
our telemedicine system. The focus
group questions were developed
with the assistance and insight of
a Kenyan nurse, and approved by
Penn State’s Institutional Review
Board (IRB). The focus groups par-
ticipants included CHWs, doctors,
nurses, community members, and
local university students. During
these conversations, Community
Health Workers were repeatedly
mentioned as having a need for
technology, as well as the “respect
required to utilize medical equip-
ment” to benefit the community.
Our focus group participants also
enlightened us to some specific
challenges facing the introduc-
tion of technologies to the work of
CHWs, highlighting the importance
of partnering with local commu-
nities to gain insight, ideas, and
endorsements. We have narrated
some of the perspectives shared
by participants in the focus group
discussions in this section. Overall
our research group received posi-
tive feedback concerning the poten-
tial for telemedicine technologies to
alleviate the healthcare burden.
“I think it would best work
for people in the community
to use it (telemedicine) door
to door. This way they can
take permissions and then
get the data easily. A com-
munity nurse or doctor can
then use this and be trusted
by the community to get
information.”
Table I
Equipment and Supplies Provided to Community Health Workers in Various Countries
Brazil Ethiopia Pakistan Bangladesh
A distinctive dress and ID
badge
Clipboard
A format of Basic Care
Information System
Bicycle, canoe or ship, if the
CHW needs to reach remote
places
Scale for weighing children
at home
Chronometer to verif y
respiratory rate
Thermometer
Tape measure
Educational material
Adult and baby weighing
scales
ANC kit
Blood pressure apparatus
Fetoscope, Refrigerator
Vaccine carriers (ice bags)
Ice box, Stethoscope
Thermometer, Spatula
Torch light
Syringes and needles
Gloves, gauze, alcohol
Iodine, GV Disinfectants
cord tie
Condoms
Essential medicines
RDT for Malaria
Cotton wool
Sticking plaster
Pencil, torch with two cells
Thermometer, Scissors,
LHW kit bags (containing
weighing scale)
Salter Scale with trouser
Condoms, Oral
contraceptive pills
Simple medicines,
Oral rehydration solution,
Cotton Bandages
Benzyl Benzoate lotion,
Eye Ointment
Antiseptic lotion
Oral
contraceptive
pills
Delivery kit
Sanitary napkins
Soaps and
iodized salt
Paracetamol
Vitamins
Antihistamines
Oral
rehydration
solutions
Antacids
Anti-helminthics
Haiti Mozambique Thailand Kenya
Dressing kit
Flip chart, Educational flyers
Syringes
Weigh scales, centimeters
Thermometers
Boots, rain coats
Road to health charts
Data collec tion forms
Monthly/daily report forms
Referral forms
Phone cards, pens
Clean gloves, scalpels
Cotton, gauzes, condoms,
Vaccines (Polio, DTP, TT, BCG)
SROs, iron, folate, vitamin A
Cotton wool
Sticking plaster
Pencil, torch with two cells,
Thermometer
Scissors
CHW kit bag (weighing
scale)
Salter scale with trouser
Oral rehydration solution,
Simple medicines
Cotton bandages
Benzyl Benzoate Lotion
Antiseptic lotion
Simple non-prescription
medicines (effective in
treating common illnesses)
Herbal medications
Weighing scale
Few drugs
Some have
blood glucose
machine
One temporar y
UNFPA project
in Kenya
provides:
Training,
Delivery kits,
Manual Vacuum
aspiration kits,
Cell phones
50 | IEEE TECHNOLO GY AND SOC IETY MAGAZINE | SPR ING 2013
(Medical professional
participant, Mweiga Hospital
Focus Group, 2010)
“We can reach more people
through this telemedicine
technology. Doctors would
participate because they
want to reach the people in
the community but (pres-
ently) they cannot.”
(Medical professional
participant, Outspan Hospital
Focus Group, 2010)
“I think they (doctors) make
these kinds of decisions
(remote triage) already, it
would organize data faster
and move it at a cheaper
cost. I think it is a good idea.
I think it would help someone
far away to make a decision
or if I have a question about a
patient. Let’s assume she has
traveled, maybe consultants
can see graphs and data for
themselves to assist in making
a decision.”
(Medical professional
participant, PGH
Hospital Focus
Group, 2010)
Participants repeatedly stressed
the need for qualified, trained med-
ical personnel to operate and use a
telemedicine system. Throughout
these conversations, we learned the
diverse perceptions of the role of
CHWs working in communities.
Participants in the focus groups
described the CHWs as:
“Twenty Community Health
Worker volunteers are respon-
sible for 5000 patients - they
are responsible for those
households- if a patient has
been coughing and has not
gone to the hospital, the CHW
would go to that house and
assess and then refer them to
the hospital. A skin rash- they
might send that patient to the
hospital, but if it is something
like malaria they can recog-
nize, then they might diagnose
and treat it in the village.”
(Medical profession-
al participant, PGH
Hospital Focus Group,
Kenya 2010)
“There is one person (CHW)
per every 20 households.
The community worker is in
charge of the education of
health for these homes.”
(Medical professional
participant, Outspan
Hospital Focus Group,
Kenya 2010)
During discussions with medical
professionals as well as commu-
nity members, Community Health
Workers were frequently refer-
enced as perfect candidates to use
telemedicine systems and other
technologies:
“When a patient has been
assigned a CHW they might
become attached to those
people. They have a bit of
knowledge on health but
they know the health of every
person in the community-
we need to follow up in the
c om m u n i t y.”
(Medical professional
participant, PGH Hospital
Focus Group, Kenya 2010)
“The CHWs have a weigh-
ing scale and a few drugs.
Some have blood glucose
ma c h in es .”
(Medical professional par-
ticipant, PGH Hospital Focus
Group, Kenya, 2010)
“Yes it is difficult (to refer
a patient) when we don’t
know the fever and BP, we
are not medics. Sometimes
we cannot refer because we
don’t know exactly what the
problem is- sometimes on
the follow-up we can have a
better idea. If we find a case
that we cannot handle, then
we refer them, but if we find
something that is in our care,
then we do it.”
(Community Health Worker,
PGH Hospital Focus
Group, 2010)
The focus group part icipants quickly
grasped the concept and practicali-
ties of telemedicine and provided
valuable feedback on the challenges
and opportunities for such a system
in their community:
“We have seen in the past
that digital blood pressure
cuffs break before non-
digital cuffs, because of this
we are concerned about the
reliability of the technology.
Also, power sources in rural
and community settings
could be a challenge.”
(Medical professional
participant, PGH Hospital
Focus Group, 2010)
“When a Community Health
Worker is in the community,
he has few resources to refer
the people to, he can send
them to the dispensary for
medicine, but this (telemedi-
cine) will help connect the
CHW to a doctor…it could
best be used in places with-
out hospital where transpor-
tation is a big problem.”
(Medical professional
participant, Outspan
Hospital Focus Group,
Kenya, 2010)
Focus groups held with Kenyan
University students from Kimathi
University and Kenyan Methodist
University proved especially enlight-
ening, as the students offered some of
their own solutions to the constraints
discussed in relation to a telemedi-
cine system. The students suggested:
“If we have diseases that
have similar symptoms like
malaria and typhoid, why
IEEE TECHNOLOGY AND SOCIETY MAGAZINE | SPR ING 2013 | 51
don’t we have a database-like
setup where certain symp-
toms or vitals values will
indicate that a certain dis-
ease is occurring…. so cer-
tain symptoms or vital values
are programmed in, such that
the information doesn’t actu-
ally get sent to the doctor but
the programmed server will
alert for certain symptoms
im m ed ia te l y.”
(Kimathi University Student,
Focus Group, Kenya, 2010)
“The telemedicine system
and service should be paired
with a pharmacy, then the
medical consult could be free
and the charges transferred
to another sector like the
pharmacy. If you charge and
don’t give drugs, then people
will not come.”
(Kimathi University Student,
Focus Group, Kenya, 2010)
“Telemedicine systems should
also be connected to existing
networks, when used in the
community; they should be
connected to transportation
if needed. Also, it should be
connected with larger brands,
like Nairobi Hospital, so peo-
ple will recognize the service
and trust it.”
(Kimathi University Student,
Focus Group, Kenya, 2010)
“More rural places don’t
have electricity needed to
support the technology, is
there a way to use solar
power to power the system?”
(Kimathi University Student,
Focus Group, Kenya, 2010)
“Male and female health
workers should be partnered
together, to show respect to
patients, and give them the
option of choosing who will
treat them.”
(Kimathi University Student,
Focus Group, Kenya, 2010)
“If Community Health Work-
ers use a technology system,
it would have to be portable.
Can you make the system
small? Reduce the size so
they can travel easily with
the system.”
(Kenyan Methodist University
Student, Focus Group,
Kenya, 2010)
These responses highlight and elu-
cidate the breadth of the enlight-
ening conversations with local
participants. These conversations
were made possible only through
the relationships HESE has built
with local institutions such as Chil-
dren and Youth Empowerment Cen-
ter (CYEC). Through engaging the
community, university students, and
medical professionals, our research-
ers gained valuable feedback about
the challenges and potential of the
telemedicine system. These con-
versations sparked new research
initiatives like delving deeper into
the actual mechanics of how Com-
munity Health Workers function
in rural Kenya and the challenges
they face. This small piece of eth-
nographic research, run in parallel
to the testing of our telemedicine
system, was invaluable to develop-
ment of a long-term implementation
strategy. We acknowledge that the
opinions of local people, the future
customers and users of the system,
will determine the success of any
intervention. Combining this local
knowledge and the insight gained
by our students visiting Kenya and
seeing first-hand the context of the
healthcare system, will improve
this project and inspire the students
to engage in other technology-based
social innovations. The positive
feedback and guidance received
from these partnerships has con-
firmed that entry points exist for
technological innovation in rural
health. We encourage all social
entrepreneurs to engage local coun-
terparts, develop partnerships, and
experience how these relationships
enrich research and innovation.
Guidelines for Innovators
While technology solutions hold
great potential for addressing the
needs of developing communities,
new and advanced devices are at
high risk of becoming scrap metal
and closet clutter in developing com-
munity hospitals. The World Health
Organization (WHO) estimates
that international donors or foreign
governments fund nearly 80% of
healthcare equipment in some devel-
oping countries [18].The vast major-
ity of the biomedical equipment
is designed and manufactured in
western countries by engineers not
familiar with the physical, socio-cul-
tural and economic environment in
developing countries. In sub-Saha-
ran Africa, almost 70% of donated
medical equipment is not in use
because of lack of maintenance or
spare parts, or because local person-
nel do not know how to use it [19].
About 95% of the instruments that
are usable fail within five years since
they are all imported, extremely
expensive, not ruggedized, and not
repairable when they fail [20].
A disconnect between the func-
tionality of medical devices and
the context of developing countries
arises because of the divergent
infrastructures, social and behav-
ioral norms, and larger eco-systems
among western and developing coun-
tries. There is an emerging trend to
design devices specifically for use
in developing communities such that
they are inexpensive, rugged, robust,
and culturally appropriate. Biomedi-
cal engineers and socially conscious
designers need to be familiar-
ized with the unique challenges of
designing devices for CHWs work-
ing in resource-constrained environ-
ments. A systematic approach that
takes into consideration pertinent
anthropometric, contextual, social,
and economic considerations in the
design of appropriate technologies
is essential.
As described in the case studies,
there is often a significant discon-
nect between governmental poli-
cies related to CHWs and how the
52 | IEEE TECH NOLOGY AN D SOCIET Y MAGAZINE | SPRING 2013
system actually works. Our research
team discovered that within the
country of Kenya itself, there is a
significant variation in the CHWs’
roles, responsibilities, and resources
from region to region. Ethnographic
studies of the CHWs that capture
their resources, needs, constraints,
communication mechanisms, and
operating models can help identify
contextual constraints and keep the
technologies user-centered. Such
studies can themselves be facili-
tated by cellphones and other tech-
nologies. CHWs do not always have
access to the equipment and supplies
stipulated by the government. Study-
ing what tools CHWs have access
to and how they are actually being
used can help uncover opportunities
for innovation. CHWs travel long
distances by foot, bicycle, and public
transportation. Lightweight, por-
table, and multi-functional designs
would be well received by the CHWs.
Electric power is hard to access and
expensive, making electronic gad-
getry less attractive. Affordable
computing technologies and the
growing popularity of cellphones, an
extremely multi-functional device in
developing countries, presents many
opportunities for real-time coordina-
tion and data sharing.
The CHWs’ toolkit does not
include simple tools that would help
connect CHWs to each other, share
medical information with doctors,
or maintain digital records, transmit
information, or provide basic triag-
ing services. These technologies are
crucial to addressing the logistical
challenges posed by resource-con-
strained environments. While the
CHW programs have been success-
ful, several inefficiencies need to be
addressed to ensure that the CHWs
are working in tandem with the larger
healthcare system. Sustainable busi-
ness models and incentive structures
are crucial to empowering CHWs in
the longer term. The power of trust
and social capital in developing com-
munities must be harnessed to ensure
that the CHWs are able to work har-
moniously in their communities.
Conclusion
Community healthcare workers
play a critical role, and have great
potential for increased involvement
in addressing the health inequities
and the evolving global healthcare
crisis in developing countries. The
operating model and responsibilities
of CHWs are well-defined in some
countries, and yet to be understood
in others. CHWs have access to some
basic equipment and supplies such
as educational materials and simple
medicines, but lack communication
and data collection systems that
would greatly enhance their work.
There is a huge need for technology
and policy interventions to enhance
CHWs’ efficiency and effectiveness
in order to amplify their impact.
Our team, with students from medi-
cine, engineering, and business is
now applying ethnographic method-
ologies to understand the operating
model, challenges, and resources for
CHWs in central Kenya. This arti-
cle is meant to be a call to action,
to challenge engineers and design-
ers to further investigate the needs
of CHWs in specific contexts, part-
ner with this population, and con-
ceptualize appropriate technology
solutions. The goal is user-centered
devices that are designed for the
context, which can be seamlessly
integrated into the country’s health-
care system and function in a sus-
tainable manner.
Author Information
The authors are with the Humani-
tarian Engineering and Social
Entrepreneurship (HESE) Program,
The Pennsylvania State University,
University Park, PA.
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