The divergence between community case management of malaria and renewed calls for primary healthcare

AbstractThirty years after Alma-Ata, there has been an upsurge of interest in community health workers (CHWs) in low- and middle-income countries. This echoes several strategic policies recently endorsed by the World Health Organization and its global call to re-establish the primary healthcare (PHC) policy. However, we are witnessing a reframing of this approach rather than its renewal. In particular, the way CHWs are conceptualized has changed considerably. Far from serving as promoters of social change and community empowerment, today we expect them to act as front-line clinicians. This medicalization of CHWs results from a systemic erosion of health promotion's influence over the last 20 years. Community case management of malaria perfectly illustrates this shift towards a pragmatic, medically centered, use of CHWs. Taking this example, we will discuss the pitfalls of this task-shifting strategy put forward by international health actors, and make suggestions to reattribute a mission of health promotion to CHWs, as intended by the Alma-Ata's PHC policy.Keywords: malariacommunity case managementcommunity health workersprimary healthcarehealth promotion AcknowledgementsWe thank Professors Katherine Frohlich and Vinh-Kim Nguyen for their ideas and comments on a previous version of this manuscript, as well as Dr Catherine Pirkle, Valérie Hongoh, and the Student Thinking Group on User Fees Abolition in West African Countries.Thomas Druetz is a Strategic Training Fellow in Global Health Research of the Canadian Institutes of Health Research (CIHR) and of the Quebec Population Health Research Network; he is also funded by the Québec Health Research Fund (FRQS). Valéry Ridde is a CIHR new investigator.