We have characterized the experience of being a community health worker in Palencia into three themes: getting started, the motivation required for the job and finally, the work of a CHW.
Theme 1: Getting started
There were four different ways of getting involved as a facilitador comunitario in Palencia. The most common case in this municipality was to be asked by the community to ‘step-up’ to the position. This was the case for many of the municipality’s facilitadores, who were asked to participate when the SIAS program started to work in the area. Mario was a leader in his community and was involved in other committees or initiatives before starting his work with the SIAS for his community. He had a long story of participation and leadership before deciding to focus solely on health-related issues. He told us:
"I started because the community elected me and I accepted because I am very committed to my community and have been since the very beginning… I am the president of the development committee, I am a leader in my community and like I told you, I am here working and I will work until there is no more work to be done."
Sometimes, it was the health team and not the community who approached a community member with the request to work with them. This was the case for Ana, who started to work after receiving encouragement from the doctor to join the team and act as their community counterpart. This doctor supported her when going back to school and helped Ana get the necessary skills to become a facilitador:
"[The doctor] said she could tell I was very smart and asked me if I wanted to work with her. I told her that I couldn’t read or write, so I probably couldn’t do the job. She told me that the job was a means to learn and so I started going to night school. She gave me the job and helped me to learn what to do and today I am still here."
Support from family members was an important factor when deciding to become a facilitador and parental and spousal support often played a major role in making this decision. Female facilitadores reported having the support of their spouse and the encouragement of their family members, and two of the three male facilitadores joined the program after many months of helping their wives with their workload. Their help included walking the few hours to Palencia’s health center to retrieve drugs or supplies, or assisting their wives in daylong, tiresome activities like child-growth monitoring. As Doña Carolina from Pie del Cerro explains, her husband Mario got officially involved after years of supporting and helping her do the work:
"I started when the health center invited me to participate, and I wanted to do it but I was pregnant at the time. So I worked as long as I could and then my sister and my husband helped me when I was too big. My sister stayed on even after I had the baby but then couldn’t help me anymore and my husband continued to help me with small things. Then the doctor asked me if I wanted him to officially help me, because he contributed so much already. That’s how he got the job."
Finally, the fourth way to become a facilitador is to inherit the position. This was the case for Susana, who took the job after her mother had passed away. For her, continuing her mother’s work was a way to pay tribute to her memory and it contributed to what she was already doing as the village’s teacher. By doing both jobs, she felt as if she could help the children and their mothers more. She told us:
"Working on both things (the school and the SIAS) gets me more support. It’s very important because the kids’ mothers look for me and know where to find me. Working with the school and this has shown me that people working together can improve things, and that deserves a lot of respect."
Theme 2: The motivation behind the work
For some of the facilitadores, their values and personal characteristics of leadership and commitment to learning were channeled into health by the desire to become a health professional. They expressed that from a young age, they had wanted to become nurses or physicians. However, negative experiences with the educational system when they were young, their families’ lack of funds to pay for nursing or medical school and the required travel made it impossible for them attain this particular goal. Through positive encounters with a doctor or a nurse, they were introduced to, and motivated to do primary care work. Out of these relationships, the facilitadores received one-to-one training and encouragement to learn. This made them feel special and allowed them to start working with health at the community level. Carolina, a woman who always had a desire to become a nurse herself, recalled how a nurse in the health post near her house helped get her into a study plan to become a promotor de salud and provided extra training:
"I started to work in this when I was about 15, there was a nurse in the community where I grew up that was very nice to me. I would go to the health post to help clean and that’s how I met her. Eventually there was a group of girls that wanted to learn how to inject patients, I was in that group, and that’s how I started to work. I learned how to inject and I would help to clean up the post voluntarily… I was there once a week and when sick or hurt people would come, this nurse would tell me to go with her and I would. That’s where I got practice. I learned to suture, put in an IV… That was a very nice experience… no one else there learned how to do all that but I did because I stayed with the nurse, voluntarily. She would say ‘let’s do it together’, I liked it, and I paid attention and helped her with the scissors or with other things. [After showing me] she would let me do it and that’s how I learned… Everyone knew about me so when the SIAS started to work in 1996 or 1998 the community elected me and here I am, working still. I have learned a lot more with the training the SIAS gives us too."
The facilitadores comunitarios in Palencia feel that working together and giving their time to the community is the only way to achieve a better quality of life for everyone. By sharing their time and expertise, they can help others. These values are at the core of family and community life and give the facilitadores a sense of purpose and motivation to continue, even when the work piles on top of their other family and work responsibilities. Irina, who was chosen to be a facilitadora by her community, and who has a long experience of leadership in her parish church, explained:
"[People] call me because they want me to help and I always do… it is my responsibility to do a good job because if you want what is best for your family, for your children, you also want what is best your community. That is my goal in life, to see my children grow and learn more and I tell them that participating is the way to do it. That is my purpose in life and I have served since 2004. It’s just nice to help and teach others so that everyone knows what to do and how to help."
As facilitadores work with their communities, they develop a sense of commitment and responsibility to deal with the negative aspects of the work. Some of the facilitadores reported that the workload can get too heavy at times, and that time spent outside the home trying to deal with community members that expect payment, drugs or some manner of healthcare in return for allowing their children to be weighed or vaccinated can be tiring. Sometimes, the lack of support from official community committees or from stakeholders in the municipality can make the work seem overwhelming. Aurora has worked as a facilitadora for eight years, with her husband helping her for the last four. She told us how they deal with the lack of support and the weariness that can come from the job:
"You feel the responsibility to serve because it starts like something you volunteer for and then you see it as something ‘you have to do’. It’s like a duty and you just have to do it. That motivates you, to see it like a responsibility you have so that when you come home from your normal work and are tired you keep going. It’s the sense of responsibility that keeps you going."
Theme 3: The work of a CHW
There are specific tasks that facilitadores comunitarios have to do as part of their jobs in the SIAS and in Palencia, all the facilitadores reported having clearly outlined responsibilities. Knowing exactly what was expected of them from the SIAS and from the community meant they could take on the responsibility without the fear of over committing their time or of not being able to do the job. This has allowed them to develop close relationships with their community, which has a direct impact on how they carry out and feel about their work. Isabel is a 20-year-old that inherited the position from her sister. Counting her, there have been four facilitadores in her family. For her, being a facilitadora was a way to get closer to her community. She reflected on her feelings and said:
"I am very close to the families I work with. I like how they treat me and how responsible they are when it comes to taking care of their children. All I have to do is to tell them we need to do something and they do it, even if they are busy with their housework. They know this is important and they let me work. They tell me that they will miss me when I leave the position… and I think this experience is really good and that it will help me later… I like working here."
Having an active relationship based on partnership and mutual respect and trust is at the core of the work dynamic between the health team and the facilitadores. Palencia’s facilitadores and the health team described their interactions as open, flexible and mutually satisfactory. Their relationship was based on respect and on knowing the importance of each one's role within the team. The feeling that their positive outcomes stem from their teamwork and viewing their working relationship as a collaboration has provided an opportunity for both sides to learn and grow. This has contributed to creating a good work environment that promotes personal growth. The health team doctor told us:
"Their work is very important; it helps me as a doctor so that I have information [about the people in that community] there when I need it. [The facilitadores] are definitely important because if they are not here, if they are not leaders, then all of our work come up short. That is their main role, to be leaders and to help, so we all work together."
Esmeralda started working as a facilitadora after being asked by Ana. Through her work she has been able to learn both through experience and by working together with the health team:
"I like this job because we learn new things, we learn them in a clear way so that stuff that used to be kind of blurry, things we only used to hear others talk about, we understand now. We do that because the doctors and nurses tell us about it, they talk with us and that is really good. It makes me happy to know these things and to work with them, and I will keep at it until it’s time to take my leave."
Finally, the work that the facilitadores comunitarios do was often seen as a chance to develop their leadership skills and to improve community life. This is because for them, becoming a facilitador was synonymous with becoming agents of change. Mario reflected:
"I like to work with children and see them grow and be happy. I give them vitamins and I check on them and talk to their mothers so everyone understands… now more people come to see the doctor, accept the vaccines. You have to go out and see what needs the community has and do something about it. That is why you are a facilitador."
In general, the facilitadores felt that they were doing more than just ‘going to work’. For most of them, the job was part of a larger process of community participation and leadership. Some had been involved in other projects before and some started to get involved because of this position. Many of them see it as an experience that will let them continue their community work, much like Mario:
"[Being a facilitador comunitario] helps a lot because it gives you experience and each experience helps you in the future. If you start working in this and you already have experience from another project, another job, then that helps you. If I know how to be a leader and how to be a facilitador, then I can help with so many things."
The skills facilitadores acquire also help them to plan for their future. Some of them wish to keep on serving their communities, and see their job as a part of a larger scheme that leads to a better life for all the community. The work the facilitadores do lets them learn more about the responsibilities that community leaders need to have. To accept the position of facilitador comunitario requires the development of leadership skills because once other community members and leaders recognize the work the facilitadores do, they will try to get them involved in other areas. Like Carolina said:
"People look me up because once they saw me as a leader; they always try to get me involved in everything. I give the community information and I help in any way that I can. No problem for us to do it, to help a little."