U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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Community health representative: The first tribally contracted program, since 1968 - American indian paraprofessional healthcare providers

CHR - History&Background Development of the Program

General CHR Information

History & Background Development of the Program

It is generally accepted that the CHR program began in 1968, but the CHR program was not a creation of the Indian Health Service. The Office of Economic Opportunity (OEO) initially funded the Community Health Aide Program in 1967. In 1969, IHS requested funds to train 250 Community Health Aides in Alaska. By 1972, the last OEO-CHR program was transferred to IHS, which increased its support and training of CHRs to 1,003 in FY '74. IHS has held that the CHR program was created to meet four needs:

  1. The need for greater involvement of American Indians/Alaskan Indians in their own health programs, and greater participation by Native Americans in the identification and solving of their health problems.
  2. The need for greater understanding between the Indian people and the Indian Health Service Staff.
  3. The need to improve cross-cultural communication between the Indian community and the providers of health service.
  4. The need to increased basic health care and instruction in Indian homes and communities.

The CHR program was not initiated by the tribes, but rather was assumed by IHS to be useful in providing the 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 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 it was transferred at 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 attitude towards CHRs was "hands off", since it considered the CHR program to be a tribal program that did not fall 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 over 250 tribes in the 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.

(Excerpts from 1974, A Study of Indian Health Service and Indian Tribal Involvement in Health; Department of Health, Education and Welfare)

The Community Health Representative (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 I H S described it as the tribes' own program and distributed a variety of literature and public statements praising its accomplishments.

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