1 Community health workers as locally legitimized authorities

One of the first things that struck us was how strongly the community recognized and respected the role of community health workers. In many other parts of the world, such workers are primarily seen as intermediaries who connect communities with the formal health system. Here, however, they seemed to occupy a far more central role.

Community members turned to them for advice and guidance on health concerns. Rather than simply relaying instructions from clinics or health authorities, these workers made decisions, assessed options, and recommended treatments. In practice, they were often the first—and most trusted—point of care.

For us, this was an important lesson. It showed that the effectiveness of community health workers depends not only on their technical training, but also on the legitimacy they hold within their communities. When people trust them and recognize their authority, their impact becomes much greater.

2 Integrating traditional and biomedical medicine

Another aspect that impressed us was the pragmatic way in which community health workers combined traditional medicine and biomedical treatments in their daily practice, without seeing these approaches as contradictory. In fact, they used them together depending on the situation. For example, a health worker might recommend a plant-based remedy known within the community while also using biomedical treatments such as paracetamol. Both forms of knowledge were valued and considered useful.

We learned that their training included knowledge of medicinal plants as well as biomedical guidelines. This approach seemed particularly powerful because it recognized the knowledge that communities already possess.

In our conversations, we also heard about efforts by Asociación Sandi Yura to document traditional medicinal plants and develop educational materials to help preserve this knowledge. Some even discussed the possibility of sharing this information through digital tools, such as videos or online platforms, so that younger generations could continue learning about these practices.

For us, this integration of knowledge systems represents an important model of intercultural healthcare.

3 Understanding motivation beyond payment

Perhaps the most striking aspect of our visit was the motivation of community health workers.

All of them carry out their work without receiving any salary or financial compensation. They also have families and many responsibilities at home. We met health workers who were mothers and fathers of several children, yet still devoted a significant amount of time to supporting the health of their communities.

When we asked about their motivations, the responses did not revolve around financial incentives. Instead, they spoke about their commitment to the community and the respect associated with their role.

Being a community health worker is highly recognized and valued. The position carries prestige because it represents service to the community. People trust them, seek their advice, and acknowledge their efforts.

This led us to reflect on an important issue for community health programs. Discussions often focus on financial incentives as the primary way to sustain the work of community health workers. While economic support can be important, we observed that other forms of motivation—such as recognition, social value, and commitment to community well-being—can be equally powerful.

At the same time, we also reflected that introducing substantial financial incentives could not only change the meaning of the role, but also affect the autonomy of health workers and their connection to their communities. During our visit, we observed that many of the activities carried out by community health workers are directed by medical personnel, limiting the full use of their capacities and skills within the community. Although financial incentives provide economic benefits, in the long run they may transform the relationship between health workers and their communities, prioritizing ties with those who fund their work. However, we are also aware that relying on voluntary work carries the risk of shifting state responsibilities onto communities. In this sense, it is necessary to further explore and experiment with organizational models in which community health workers maintain their legitimacy and autonomy while also receiving fair recognition for their work.

4 Leadership as service

The experience we observed also resonated with broader cultural understandings of leadership within Indigenous communities.

In many communities in both Ecuador and Bolivia, leadership is closely linked to service. Leaders take on responsibilities for the benefit of the collective, often without financial compensation. Their authority is grounded in their willingness to contribute to the community.

Community health workers appear to embody this same principle. Their work reflects a broader cultural value in which prestige comes from serving others and strengthening the community.

Recognizing this cultural dimension is essential when designing community health initiatives. Programs that overlook these values risk undermining the motivations that sustain community-based health work.

5 Lessons from a South–South exchange

Our visit reminded us of the value of exchanges between countries of the Global South. Too often, health systems look primarily to models from high-income countries for inspiration. Yet many valuable lessons can be found in the experiences of neighboring countries facing similar challenges.

Observing how community health workers operate in the Ecuadorian Amazon encouraged us to reflect on our own practices in Bolivia. It showed us that strong community health systems can emerge when programs respect local knowledge, strengthen community leadership, and recognize the social value of those who serve.

6 Conclusion

Our experience visiting the Asociación de Promotores de Salud Naporunas Sandi Yura demonstrated that community health systems are not built solely through policies and resources, but also through relationships, cultural values, and community trust.

The community health workers we met were not simply implementing a health program. They were serving their communities in ways that combined traditional knowledge, practical care, and social responsibility.

As health systems around the world continue to invest in community health workers, these experiences remind us that sustainability depends not only on financial support, but also on recognition, cultural respect, and community legitimacy.

Declarations

ORCIDs

References

1. 
   Gurven M, Stieglitz J, Trumble B, Blackwell AD, Beheim B, Davis H, Hooper P, Kaplan H. The Tsimane health and life history project: integrating anthropology and biomedicine. Evolutionary Anthropology: Issues, News, and Reviews. 2017 Apr;26(2):54-73.
   


2. 
   Santi S, San Sebastián M. Santiago Santi, promotor de salud indígena Naporuna de la Amazonía del Ecuador. J Community Syst Health. 2024;1(1).