Program History and Development
The Community Health Representatives (CHR) program began in 1968, but not as a creation of the Indian Health Service (IHS). Initial funding came from the Office of Economic Opportunity (OEO) in 1967 to create the Community Health Aide Program. In 1969, IHS requested funds from the program to train 250 Community Health Aides in Alaska. By 1972, the last OEO-CHR program was transferred to IHS, which increased support, training 1,003 CHRs in FY '74. IHS has held that the CHR program was created to meet four needs:
- The need for greater involvement of American Indians/Alaskan Indians in their own health programs, and greater participation by Native Americans in identifying and solving their own health problems.
- The need for greater understanding between the Indian people and the IHS Staff.
- The need to improve cross-cultural communication between the Indian community health service providers.
- The need to increased basic health care and instruction in Indian homes and communities.
Implementation of the CHR program was not initiated by tribes, but by IHS to provide tribes an opportunity to become involved in health by paying staff to perform an outreach/community organization function. The CHR program was a result of Native American Tribes identifying the need for such a program, lobbying for it, and acquiring funding.
"Neighborhood workers," also known by other titles such as CHRs, etc., were, in traditional OEO style, afforded too little training and almost none in substantive areas. Had the program remained in the OEO, the question of function of CHRs might never have arisen and they might have continued to play a useful but ephemeral "helping" role. What was different in this case was that federal responsibility for the program passed from OEO to IHS; from the Community Action Program to the tribes themselves; and at a time when IHS was seeking a mechanism for Native Americans to achieve self-determination in health.
The job-related tasks of the CHR have changed somewhat throughout the years, but the original intent of IHS was that the CHR become a community health promoter/educator, a health advocate, and a health paraprofessional who would regularly visit the homes of clients and conduct health assessments and provide transportation, when needed.
Initially the CHRs may have been without direction from the Tribes or IHS. The typical IHS view towards CHRs was "hands-off," since the program was considered to be a tribal program not within IHS jurisdiction. Therefore, without concrete direction from IHS or Tribes, CHRs struggled initially with their role among their people.
Today, the history of the CHR is well documented and an integral part of the health delivery system of most tribes, nations, and villages. The CHR is seen as an agent of the people, helping their clients tend to their health needs.
Today, the CHR program has grown to over 1,400 CHRs representing more than 250 tribes in 12 service areas. Many areas have their own CHR association, designed to meet and share ideas. The National Association of Community Health Representatives (NACHR) has a representative from each area to recommend national policies and share program ideas.
(Adapted from "A Study of Indian Health Service and Indian Tribal Involvement in Health" Department of Health, Education and Welfare, 1974)
The CHR Program evolved to become the largest program originally contracted to the tribes, not only in dollars and number of people involved, but also in the number of tribes holding contracts. The first CHR activity was designed to contain the spread of tuberculosis throughout several American Indian communities. CHR contracts were held by 256 tribes who employed over 1,200 CHRs and CHAs. In terms of accomplishments, the program was most successful. The IHS described it as the tribes' own program and distributed a variety of literature and public statements praising its accomplishments.