Acceptable and appropriate: program priorities vs. felt needs in a CHW program

This paper explores how contested ideas of appropriate and acceptable health care, a key feature of primary health care (PHC), can influence program delivery and success. Specifically, this paper uses poor job performance as a lens to critically examine of some of the ideas and assumptions that are part of the PHC/community health worker (CHW) model. A case study of a CHW program in a low-income Brazilian community reveals that CHWs are not performing their duties. This paper argues that poor job performance is related to the problems CHWs experience as they confront conflicting ideas of what constitutes appropriate and acceptable healthcare. The general objective of this CHW program is to transmit knowledge about basic health practices to low-income populations via CHWs. As a result, the CHW program places the highest priority on health education. Community residents, however, feel that health education is not appropriate, and is therefore unacceptable. Instead, residents believe the key to improving health lies in securing concrete improvements in their living conditions (e.g. water, sewage and employment). As CHWs perform their duties they are unable to reconcile these competing demands. After becoming frustrated by failed attempts to satisfy the population with which they work (by fulfilling the demands of administrators) they develop strategies to help them cope with job stress. One of these strategies is poor job performance, which ultimately compromises the success of the program.