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Proceedings of a workshop held at Shiraz, , 6-13 March 1976

Editors: H.A.Ronaghy, Y. Mousseau-Gershman, and Alexandre Dorozynski © 1976 International Development Research Centre Postal Address: Box 8500, Ottawa, Canada K1G 3H9 Head Office: 60 Queen Street, Ottawa

Ronaghy, H.A. Mousseau-Gershman, Y. Dorozynski, A. Village health workers: proceedings of a workshop held at Shiraz, Iran, 6-13 March 1976. Ottawa, IDRC, 1976. 48p.

/IDRC pub CRDI/. Compilation of seminar papers on /health service/s in /rural area/s of /Iran/, /Nepal/, the /Philippines/, /Thailand/ and /Papua/ /New Guinea/, with emphasis on the /training/ of /auxiliary health worker/s includes /list of participants/, /statistical data/.

UDC: 614.2 ISBN: 0-88936-106-1

Microfiche Edition $1

Layout and design: S. Clerget-Vaucouleurs IDRC-074e

Proceedings of a workshop held at Shiraz, Iran, 6-13 March 1976

Editors: H.A. Ronaghy, Y. Mousseau-Gershman, and Alexandre Dorozynski

p3928

The views expressed in this publication are those of the individual authors and do not necessarily represent the views of IDRC. Contents

Foreword Y. Mousseau-Gershman 5 iran Village health workers in Iran Hossain A. Ronaghy 6 Middle level health workers training project in Iran Hossain A. Ronaghy 11 Evaluation of Iranian village health workers efficacy Bahram Zeighami and Elaine Zeighami 14 Health or development? Training of frontline health workers, particularly in Lorestan, Iran M. Taghi Farvar 21 nepal

Health care in Nepal Moin Shah 25

!IL t_Jtppines

Health care in the Philippines within a total framework Victor N. Ordonez 30 thatand Auxiliary health training and development of the Faculty of Medicine at Khon Kaen University, Thailand Kawee Tungsubutra 33 paptta tzew guinea

Providing health services for rural populations in Papua New Guinea Goasa G. Damena 38

Summary of discussions Alexandre Dorozynski 43 List of participants 47

3 AN

Village Health Workers in Iran

Population: 36 million* attempt to provide a partial solution to this problem and to create a model for village Infant mortality rate: 139 per 1000/ yr health care, the Department of Community Crude birthrate: 45 per 1000/ yr Medicine at Pahlavi University Medical Crude death rate: 17 per 1000/ yr School in Shiraz undertook two pilot projects. Rate of population growth:3.1% per yr One was the training of "village health workers" (V HWs). VHWs are literate Per capita GNP: $490 village men or women who receive 6 months training in both preventive and curative *Al/ figures.from 1976 World Population Data health care, and upon completion of their Sheet of the Population Reference Bureau, Washington, D.C. training are sent to a village to provide basic health care, under the regular supervision of a physician. The second project involves the training of "middle level health workers" Hossain A. Ronaghy (behdars), men or women with a minimum of 9 years of education who are trained for 4 Department of Community Medicine, years. Following their training they live in Pahlavi University School of Medicine, small towns and large villages, supervise the Shiraz, Iran work of the VHWs, help train future VHWs, and handle patients referred from the villages by the VHWs. Iran, a fast- with a The Kavar Village Project population of 33 million, suffers from a shortage of trained health personnel. About In January 1973, to find out whether or half of its 12 000 physicians practice in not barely literate villagers could effectively , Iran's largest urban centre, with improve rural health in Iran, the Depart- most of the rest residing in other cities. This ment of Community Medicine undertook a leaves approximately 60% of Iran's popula- pilot study with IDRC's financial support. tion, those who live in the 65 000 villages A study site was chosen at Kavar, a small and rural areas, with little or no medical town about 35 miles southeast of Shiraz, to services and with a physician to population begin the training of VHWs. Located in ratio of 1:15 000. Kavar was a health corps station, one of about 400 similar health To help alleviate this great shortage, Iran centres found throughout rural Iran. (Health Corps is the is now importing foreign physicians to organization created to provide medical service to the rural areas. establish universal medical care, which is This has helped to some extent but the one of the principles of the problem still exists. Furthermore, there are revolution initiated by H.M. Sha- hanshah Aryamehr in 1964.) very few paramedical personnel: only about 5400 nurses and midwives and 9000 nurse/ These stations are staffed by recent midwife assistants currently practice in medical graduates who spend 18 months at Iran. the station in lieu of military service. Health corps stations seemed to be Given this health manpower situation, it the ideal site for VHW training. is obvious that the existing numbers of physicians and paramedics are inadequate It was realized that the VHWs would have for rural health care delivery in Iran. In an to be continuously supervised once their

6 training was completed and they were sent to the villages. The health corps physician was a logical choice for clinical supervisor, and the health corps station was also a logical choice, both as a training site and as a centre for continuing education of the A4' V H Ws. Furthermore, the health corps sta- 6 tions provide 400 nuclei in rural areas throughout Iran around which future VHWs could be placed, thereby greatly wei4" expanding the number of villages where health care would be available. in Other determining factors selecting Dr Ronaghy and colleagues at Pahlavi Uni- Kavar as the study site were a lack of any versity, Shiraz other available health care in the area, reasonable proximity to the city of Shiraz, and the administrative and supervisory physiology, , communicable dis- resources available. eases, VHW-patient relationship, maternal and child health and , and Prior to the selection and training of the rural . VHWs, baseline surveys were conducted to determine disease prevalence and the avail- Selection of the VHW Trainees ability of literate villagers and medical care. Epidemiological studies in Fars province The philosophy of the project from the as provided data on disease incidence among beginning was to involve the villagers rural village populations as well as indica- much as possible in decisions and overall tions of the feasibility of providing primary participation. Therefore, a total of 33 health care through the use of auxiliaries villages surrounding Kavar were visited and with very basic training. It was shown that the village "head man" (Kadkhodah) or most of the complaints at the village mobile head of the village council of each village clinic were fairly simple and that an aux- was consulted about the presence in his iliary health worker was capable of ad- village of a literate man or woman who equately treating most of the cases and might be a suitable V HW candidate. The then revisited, and all can- referring the remaining 10% to the medical villages were centre. didates were given literacy tests. A group of 27 top candidates was then In addition, a random-sample knowledge, selected and all were tested for physical and attitudes, and practices (K AP) study of 200 mental fitness; they were personally inter- households about individual and public viewed to determine their attitudes toward village health was conducted. Census data the project goals, family planning, tra- on births, deaths, marriages, divorces, im- ditional medicine as compared with modern migrants, emigrants, and total population, medicine, and their reasons for wishing to were also gathered. join the project. Finally, 16 VHWs from 16 Based on the data obtained from the villages were chosen. They represented a studies, the behavioural objectives to be met wide range of ages, personalities, and by the VI-Ms were developed. Objectives socioeconomic backgrounds. There were 11 were specified in six areas: communicable men and 5 women, and they ranged in age disease control; environmental health; nu- from 16 to 45 years. trition; community education; maternal and As a result of the evaluation of early child health and family planning; and experiences, trainees are now selected on a treatment. These behavioural objectives merit basis rather than by village author- then provided the basis for curriculum ities, and will not necessarily be located in planning and the content of the Persian their home villages when they complete learning material to be prepared for the training. This change was designed to course. The subjects covered included remove the VH Ws from the influence of growth and development, anatomy and village authorities and to lessen the like-

7 lihood of their involvement in local political Although diagnosing and treating pa- and family disputes that might hamper their tients was not a major objective of the ability to function as VH Ws. program, patient screening in the village (treating only minor problems and referring Training Method the rest to a physician) was seen as quite Once assembled in Kavar, the VHWs important. The students rotated from group began, in August 1973, an intensive 6-month to group on a weekly basis. In this way all training course. The major objective of the the students had experience in each of the course was to prepare the VHWs for four areas. preventive and educational work in their The final 3 months of training were respective villages. Of particular importance devoted to clinical skills. Although pre- were and basic , nutrition, vention and education were considered family planning, immunization, environ- more important, it was unlikely either would , and communicable disease be effective without all of the VHWs seeing control. These subjects were taught by staff and treating sick patients. Villagers are members from the Department of Com- primarily interested in being taken care of munity Medicine, medical personnel from when they are sick; they are not likely to the Health Corps, and the project training respect someone who talks to them but director. In each case, theory and practice provides no relief for their ailment, however were integrated, so that every day the minor. Given this fact, the main rural students had an opportunity to apply in the clinical problems were identified and the field or in the clinic what they learned in the VHWs were taught ways to assess them and classroom. to know whether a patient should be treated The students were extremely enthusiastic in the village or referred to a physician in and learned at a much faster rate than had Kavar or Shiraz. been anticipated. They all lived together in a In addition to seeing and rented house in Kavar, where meals were treating patients at the health corps station provided and where esprit de corps de- (under the close supervision of the health veloped among them. The trainees received corps physician), the VHWs made numerous field 500 Rials (U.S. $7.50) per month as expense visits to nearby villages. The money. They also helped the school by purpose of these visits was performing various tasks. primarily to learn practical methods of improving village hygiene and sanitation. Classes were taught in the rented house, They sampled supplies, carried out while practical and clinical work was done at sanitation inspections, and visited the the nearby health corps station. The stu- schools and other village centres for inspec- dents were divided into four groups of four tion and education. students each. One group worked with the midwife attached to the health corps family Trainees' skills and knowledge were eval- planning clinic, who taught maternal and uated periodically throughout their 6 child health and family planning. Another months through written examinations and group worked with the health corps aide in observation. A committee of physicians the treatment room, where he demonstrated observed VHW trainees in clinical and field sterile technique, methods of giving injec- settings and evaluated their competence in tions, burn treatment, wound dressing, and history-taking and physical examination, other first-aid skills. All of these were recognition of symptoms, planning for practiced by the students until they became treatment, administration of first aid, ed- proficient. ucation of patients, VHW-patient relation- A third group worked with the health ship, education of villagers, data collection, corps station assistant, whose training was and inoculation technique. in pharmacology, who taught them indica- tions, contraindications, dosages, and side Field Work effects of drugs. The fourth group remained Throughout the 6-month training phase, with the health corps physician, who ex- periodic visits to the villages and meetings in plained history-taking, physical examina- Kavar were used to familiarize the villagers tion, and patient evaluation. with the aims of the project and to establish

8 A health worker examining a child in one claw villages ofthe Kavar project

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9 working arrangements for the VHWs. All 9152. The percentage of females between project villages found clinic space and the ages of 15 and 44 who were using family provided miscellaneous equipment accord- planning methods increased from 8.8 to ing to what the villagers could afford. 21.4. Project funds provided basic medical sup- In addition, the VHWs have been able to plies and other necessary items that the motivate the villagers to make much needed villagers were unable to supply. sanitation improvements, including con- The first class of 16 VH Ws (supported by struction of sanitary toilets and improve- funds from ID RC) completed their training ment of existing ones; separation of animal in March 1974 and were sent to villages quarters from human living quarters; de- surrounding Kavar. A second group of 30 velopment of clean water sources (pumps students (supported by funds from the and wells) and having boiled government of Iran) began training in the when it cannot be obtained from a clean fall of 1974, and assumed their responsibil- water source; and improvement of existing ities as full-fledged VHWs in September bathhouses or construction of new ones 1975. where needed. Health education programs conducted by the VHWs have Depending on the size of the village, focused on improvements in personal hygiene, such as VHWs spend between 1 and 6 hours a day in more the clinic, when patients are seen and treated frequent and regular bathing, as well as the (or are referred to the health corps station introduction of handwashing with soap after using physician; eventually referrals will be made the toilet. to the middle level workers), and are Overall, indications are that the VHWs instructed in preventive measures to avoid a are highly productive and well accepted in recurrence of their illness. Following their the villages they serve and that the extension treatment activities, VHWs make home and of the V H W concept is not only feasible but village visits for follow-up care, to discuss would provide a strong foundation for family planning, sanitation, and nutrition Iran's developing health care delivery sys- with villagers, and to supervise sanitation tem. A four-tiered system is envisioned, with projects. physicians living in cities seeing those patients referred In addition, the VHWs, as part of their by the health corps phys- ician, who will ongoing responsibilities, keep detailed rec- in turn see those patients referred by the ords on the number of patient visits, and the behdars. The health corps physician will also supervise age, sex, diagnoses, and treatment of pa- the behdars' activities, while the behdars will tients. Information is also recorded on their supervise and see sanitation, health education, family plan- patients referred by the VHW. Physicians would ning, and other preventive activities, and on therefore comprise the upper two levels, and the two births and deaths in their villages. A auxiliary groups the lower two levels of the physician visits each VHW once a week for region- alized system of supervision and evaluation of clinical per- health care, which does not at present formance, while the VH Ws' nonclinical exist but that will hopefully be created in the activities are supervised by the training future. director. The evaluation reports serve as a basis for the topics covered at the monthly continuing education meetings of the VHWs in Kavar. The VHWs also return to the training centre for a 2-week refresher course each summer. Conclusion Evaluation studies indicate that the VHWs are well accepted by the people and that they are influencing the health practices of the villagers. During the VHWs' first 6 months in the field, patient visits to clinic facilities numbered 4875 of a population of VHWs are productive and well accepted

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