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Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems Graphic Design: www.creapixel.ch Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems

This piece of work has been commissioned by the Global Health Workforce Alliance (the Alliance), a partnership hosted by the World Health Organization (WHO), as part of its mandate to implement solutions to the health workforce crisis. In preparing the report, the Alliance is grateful to Zulfiqar A. Bhutta (Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan), Zohra S. Lassi ((Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan), George Pariyo (Makerere University School of Public Health, Kampala, Uganda) and Luis Huicho (Universidad Peruana Cayetano Heredia, Universidad Nacional Mayor de San Marcos and Instituto de Salud del Niño, Lima, Peru.

3 Global Evidence of Community Health Workers CONTENTS

List of Tables 6 Preface 8 Acknowledgements 9 List of Acronyms 10 Executive Summary 11 Core Report 17 Background 17 Methods 19 Main Findings from Global Systematic Review 26 and Country Case Studies Discussion and Way forward 28 References: 48 Annex I: 52 Global Systematic Review 52 References 205 Annex II: 230 Country Case Studies 230 References 384

5 List of Tables

Table 1: Recommendations – CHW Core Typology – characteristics of included studies and Table 2: Recommendations – Typology of Nutritional characteristics of outreach workers Health CHW Table 16: Malaria Control Interventions – Characteristics Table 3: Recommendations – Typology of Maternal and of Included Studies and characteristics of Newborn Health CHW outreach workers

Table 4: Recommendations – Typology of Child Health Table 17: Tuberculosis Control Interventions – CHW Characteristics of Included Studies and characteristics of outreach workers Table 5: Recommendations – Typology of Malaria Control CHW Table 18: HIV/AIDS Prevention and Control Interventions – Characteristics of Included Studies and Table 6: Recommendations – Typology of TB DOTS CHW characteristics of outreach workers

Table 7: Recommendations – Typology of HIV/AIDS Care Table 19: Mental health Interventions – Characteristics CHW of Included studies and characteristics of outreach workers Table 8: Ongoing Trials/ Studies Table 20: Non-Communicable Diseases Prevention Table 9: Nutrition Interventions – Description of Studies Interventions – characteristics of included and characteristics of outreach workers studies and characteristics of outreach workers

Table 10: Maternal health interventions – Characteristics Table 21: TCHWs Knowledge, attitude and practices as- of included studies and characteristics of sessment studies – characteristics of Included outreach workers Studies and characteristics of outreach workers

Table 11: Birth and Newborn Care Preparedness – Table 22: List of interventions delivered by CHWs Characteristics of Included Studies and characteristics of outreach workers Table 23: Criteria for Recommending CHW typology from Global Systematic Review Table 12: Promotion of Breastfeeding – Characteristics of Included studies and Table 24: Evidence from Cochrane Systematic Reviews characteristics of outreach workers Table 25 CHW Program in selected eight countries Table 13: Neonatal health – Characteristics of Included Studies and characteristics of outreach workers Table 26: Performance Evaluation of LHWs – Pakistan

Table 14: Childhood illnesses and immunization Table 27: CHW Program Functionality Assessment – characteristics of Included Studies and Tool (CHW-PFA) – Pakistan characteristics of outreach workers Table 28: Community Health Worker Functionality Table 15: Other Primary Health Care intervention Matrix – MCH Interventions – Pakistan

Global Evidence of Community Health Workers Table 29: Performance Evaluation of SSs – Bangladesh Table 45: CHW Program Functionality Assessment Tool (CHW-PFA) – Mozambique Table 30: CHW Program Functionality Assessment Tool (CHW-PFA) – Bangladesh Table 46: Community Health Worker Functionality Matrix – MCH Interventions– Mozambique Table 31: Community Health Worker Functionality Matrix – MCH Interventions – Bangladesh Table 47: Scoring Chart for Functional CHWs.

Table 32: CHW Program Functionality Assessment Tool Summary of CHW Program Functionality (CHW-PFA) – Thailand Assessment Across Selected Countries Table 48: Table 33: Community Health Worker Functionality Summary of CHW Program Functionality Matrix – MCH Interventions – Thailand Assessment Across Selected Countries

Table 34: Performance evaluation of CHWs – Brazil Table 49: Summary of CHW Contextual factors across eight selected countries Table 35: CHW Program Functionality Assessment Tool (CHW-PFA) – Brazil

Table 36: Community Health Worker Functionality Matrix – MCH Interventions – Brazil

Table 37: Performance evaluation of CHWs – Haiti

Table 38: CHW Program Functionality Assessment Tool (CHW-PFA) – Haiti

Table 39: Community Health Worker Functionality Matrix – MCH Interventions – Haiti

Table 40: Performance evaluation of CHWs – Ethiopia

Table 41: CHW Program Functionality Assessment Tool (CHW-PFA) – Ethiopia

Table 42: Community Health Worker Functionality Matrix – MCH Interventions– Ethiopia

Table 43: CHW Program Functionality Assessment Tool (CHW-PFA) – Uganda

Table 44: Community Health Worker Functionality Matrix – MCH Interventions – Uganda

7 Preface

Health workers represent the very foundation deployment and use. Also, recruitment criteria, of heath systems. The shortage of health wor- training content, certification process, supervi- kers is unanimously accepted as one of the key sion, incentives and professional advancement of constraints to the provision of essential, life-saving community health workers have been examined, interventions such as childhood immunizations, providing concrete and actionable recommenda- safe pregnancy and childbirth services for mothers, tions in all these domains. and access to treatment for AIDS, tuberculosis and The key findings of this study provide a clear malaria. The World Health Report 2006 argued direction for policy makers on the design and that community health workers (CHWs) have the management of CHW programmes: potential to be part of the solution to the human 1) CHWs should be coherently inserted in the resource crisis affecting many countries. CHWs wider health system, and this cadre should be provide a variety of functions, including outreach, explicitly included within the HRH strategic plan- counseling and patient home care and represent ning at country and local level; 2) village health a resource to reach and serve disadvantaged po- committees in the community should contribute pulations. There has been mounting evidence to to participatory selection processes of CHWs; demonstrate the positive potential of community 3) the pre-service training curriculum should in- health workers in improving equitable access to clude scientific knowledge about preventive and care and health outcomes. basic curative care; Scaling up community health workers is one 4) CHWs should continually assess community of the strategies enshrined in the Kampala health needs and demographics; Declaration and the Agenda for Global Action. 5) CHWs should have established referral proto- It is against this backdrop that the Global Health cols with formal health services and social service Workforce Alliance (the Alliance) in collabora- agencies; tion with United States Agency for International 6) CHWs should benefit from regular and conti- Development (USAID), commissioned this global nuous supportive supervision and monitoring. systematic review to address some unanswered Priority areas for further research were also questions on role of community health workers, identified. and policies required to optimize the impact of related programmes and strategies in the context The Alliance believes that implementing these of health workforce planning and management. recommendations has the potential to contribute Along with this, eight in-depth country case stu- to an equitable and cost-effective scale up of ser- dies in sub-Saharan Africa (Ethiopia Mozambique vice coverage, and lead to tangible improvements and Uganda), South East Asia (Bangladesh, in health outcomes, particularly in the context of Pakistan and Thailand) and Latin America (Brazil Millennium Development Goals. and Haiti) were conducted. The case studies were I would like to conclude by expressing the sin- undertaken with the specific purpose of corrobo- cere appreciation of the Alliance to USAID, the rating and validating the findings of the review. Consultants and the Advisory Committee for their In particular attention was paid to the different valuable support and contribution in undertaking types of community health workers and the servi- the review and preparing the report. ces they provide, the typical pitfalls of community health workers programmes, and the enabling Dr. Mubashar Sheikh systems factors, conversely, that must be put in Executive Director place to maximize the potential benefit of their Global Health Workforce Alliance

Global Evidence of Community Health Workers Acknowledgements

The authors would like to thank the Global Health Bureau from WHO country office Mozambique. Workforce Alliance for entrusting them with this important piece of research. They would further like to thank Dr Maimoona Azhar Salim, Research Officer, Division of Maternal The authors would also like to thank numerous and Child health, Aga Khan University, Pakistan, persons from diverse public and private orga- who accompanied the research and writing pro- nizations for their hospitality and support in cess. Moreover, they extended their sincere appre- providing contacts, information, sharing docu- ciation for the medical students (Salimah Valliani; ments and insights into the functioning of the Salima Bhimani; Arif Valliani) for their assistance in country-specific CHW Programs, and those we literature screening and retrieval. interviewed in person, by telephone or through electronic communication: Dr Zahid Larik, Dr Iqbal Lehri, Dr Rashid Jooma, Dr Zareef Khan, Dr Majeed Memon, Dr Assad Hafeez, Ministry of Health Pakistan; Prof Anwar Islam, Dr Koasar Afsana, and Dr Taskeen Chowdhury from BRAC, Bangladesh; Dr Tahmeed Ahmad ICDDRB; Dr Felix Rigoli, Dr J Paranaguá de Santana and Augusto Campos from PAHO Brazil; Prof Maria Fátima de Sousa from Universidade de Brasília and Núcleo de Estudos em Saúde Pública; Ena Galvao & Christian Morales from WHO/PAHO Haiti; Dr Lambert Wesler from Zanmi Lazante, Haiti; Dr Wesler, Jude Jean, two public health nurses in LasCahobas and Boucan Carre; Gregory Jerome from Haiti; Dr Keseteberhan Admasu Berhane; Abaseko Hussein Mohammed, Woldemariam Hirpa, and Dr Tizita Hailu, from Ethiopian Federal Ministry of Health; Dr Fatoumata Nafo-Traoré, Dr Gebrekidan Mesfin, Dr Sofonias Getachew, and Martha Teshome from WHO country office for Ethiopia; Kora Tushune from Jimma University, Ethiopia; Dr Flavia Mpanga from UNICEF Uganda; Dr Benjamin Sensasi from WHO Uganda; Jessica Anguyo from AMREF Uganda; Richard Okwi from MoH Uganda; John Mukisa from UNACOH Uganda; Tom Lakwo from MoH Uganda; Nantume Sophie Mawejje from TASO Uganda; Sengendo from Uganda Community Based Health Care Association (UHBHCA); Dr. Elizeus Rutebemberwa, Makerere University, Uganda. Dr Leonardo Chavane from MOH Mozambique; Dr Benzerroug from WHO Mozambique; Dr Antoine

9 List of Acronyms

AIDS Acquired Immunodeficiency Syndrome ARI Acute Respiratory Infections ART Anti Retroviral Treatment BLDS British Library for Development Studies BRAC Bangladesh Rural Advancement Committee CHW Community Health Worker CHW-PFA Community Health Worker- Program Functionality Assessment CM Community Mobilizer DOTS Directly Observed Treatment Support EmOC Emergency Obstetric Care GDP Gross Domestic Product GNI Gross National Income HAART Highly Active Anti Retroviral Treatment HIV Human Immunodeficiency Virus IMCI Integrated Management of Childhood Illnesses IPT Intermittent Presumptive Treatment KAP Knowledge, Attitude, and Practices KMC Kangaroo Mother Care LBW Low Birth Weight LHWP Lady Health Workers Program MDG Millennium Development Goal MoH Ministry of Health MNCH Maternal, Newborn and Child Health NCD Non-Communicable Disease NGO Non-Government Organization NS Non Significant ORS Oral Rehydration Salts or Oral Rehydration Solution ORT Oral Rehydration Therapy PACS Programa de Agentes Comunitários de Saúde PC Peer Counselor PMTCT Prevention of Mother to Child Transfer RCT Randomized Controlled Trial STI Sexually Transmitted Infections TBA Traditional Birth Attendant TB Tuberculosis TT Tetanus Toxoid UNFPA United Nations Population Fund WHA World Health Assembly WHO World Health Organization

Global Evidence of Community Health Workers Executive Summary Methodology Human resources for health crisis is one of the For the systematic review, a comprehensive search factors underlying the poor performance of of studies was performed in several data sources, health systems to deliver effective, evidence-based without language restrictions, focusing on studies interventions for priority health problems, performed in developing countries. Eligible stu- and this crisis is more critical in developing dies included randomized, quasi-randomized and countries. Participation of community health before/after trials which had relied upon CHWs in workers (CHWs) in the provision of primary community settings. In addition, other less rigo- health care has been experienced all over rous study designs like observational (cohort and the world for several decades, and there is an case-control) and descriptive studies were also amount of evidence showing that they can reviewed to understand the context within which add significantly to the efforts of improving the they were implemented, the typology of health health of the population, particularly in those care providers, the types of intervention delivered settings with the highest shortage of motivated and reported results. Studies were included if (a) and capable health professionals. they detailed the role of CHWs and (b) if the outcomes consider-ed are those related to reaching With the overall aim of identifying CHWs programs the health and nutrition MDGs like child morta- with positive impact on Millennium lity, maternal mortality, combating HIV/AIDS, TB, Development Goals (MDGs) related to health malaria, among other target health problems. or otherwise, a global systematic review was The main comparison was between CHW inter- undertaken of such interventions, as well as ventions compared to no intervention or routine eight in-depth country case studies in Sub- care; or one form of CHW intervention compared Saharan Africa (Ethiopia Mozambique and with another form. Uganda), South East Asia (Bangladesh, Pakistan and Thailand) and Latin America (Brazil and For country case studies, a review of published Haiti). The focus was on key aspects of these and unpublished reports was conducted on spe- programs, encompassing typology of CHWs, cific country experiences with CHWs, and also a selection, training, supervision, standards for direct contact with key personnel overseeing the evaluation and certification, deployment -pat program was made through electronic corres- terns, in-service training, performance, and pondence and country visits. The primary level of impact assessment. For impact indicators, the evidence on impact derived from country specific focus was on those related to maternal and assessment of CHW programs and from objective child health, HIV/AIDS, TB and malaria, as well evaluation data (where available). The evidence as on those related to mental health and non- was also triangulated from the global systema- communicable diseases. In addition, building tic review to the specific programs and types of on the systematic review and the country case CHWs in the selected countries. In addition to that, studies, draft recommendations was develop for stakeholders familiar with program management recruitment, training and supervision criteria for and evolution were also contacted for specific CHWs programs to address the health MDGs, for inputs. In this process, information was assembled further regional and global consultation among related to: program descriptions, job descriptions, stakeholders, and for their eventual adaptation or official descriptions of the role of the CHWs and in varied contexts. the process followed to identify and recruit them; records identifying numbers of trained CHWs, dates of recent trainings, and documents describing training content and process as well as the supervision or monitoring process; and records

11 of current numbers of CHWs. Following the These country case studies demonstrate the assembly of information from multiple sources, participation of the respective governments a USAID supported CHW Program Functionality and the NGOs in financing and implementa- Assessment Tool (CHW-PFA) was utilized to tion of their policies for the CHW programs. assess the functionality of the CHW programs Results confirm that CHWs provide a critical across these countries. The CHW-PFA proposes link between their communities and the health twelve programmatic components for a CHW and social services system. Communities across program to be effective. all the countries that we studied recognized the value of CHWs as a member of the health Key Findings delivery team and therefore have supported the utilization and skill development of CHWs. The review of CHWs across the globe provided These case studies further speak out the achie- us an interesting and diverse picture of the cur- vements of their CHW programs in relation to rent scenario in outreach services of health care their modeling and level of commitment from workers. There is a wide range of services offered their human resource. The region lagging far by the CHWs to the community, ranging from behind the MDG targets is Africa especially the provision of safe delivery, counseling on breast- Sub-Saharan Africa. Various factors have been feeding, management of uncomplicated child- identified to be responsible. These include ina- hood illnesses, from preventive health education dequate human resource especially work force on malaria, TB, HIV/AIDs, STDs and NCDs to their who are dying with HIV/AIDS and poor remune- treatment and rehabilitation of people suffering ration for their work leading to high drop outs, from common mental health problems. The lack of supervision, and equipment and drug services offered by CHWs have helped in the supplies needed to provide essential maternal, decline of maternal and child mortality rates child and reproductive health services and and have also assisted in decreasing the burden those required to control and treat potentially and costs of TB and malaria. However, the cove- preventable infectious diseases. rage by such programs and the overall progress towards achieving the MDG targets is very slow. Based on the review and the gaps identified in The growing consensus regarding this current the existing CHW programs and the services pace of progress, especially in the low-income rendered, various recommendations are made countries, is that it relates to fragile health and regarding their recruitment criteria, training economic systems. content, certification process, ongoing and refresher training, supervision, incentives and Country case studies identified a wide range of professional advancement. Although it is re- CHW programs with different mix of CHW typo- cognized that varying contexts are important, logy. For example, Uganda Village Health Teams attention to specific criteria and issues could program has short duration of training with pre- potentially improve the working of CHWs and ventive and basic curative tasks for CHWs, with a help scaling up key interventions in relation relatively strong supervision system, and within to MDG targets. These are detailed in the main a weak health system, while, on the other hand, Report and the summary messages below re- Pakistan’s Lady Health Workers (LHW) Program present major points for consideration. has long duration training programs, with promotional, preventive and basic curative tasks for CHWs, with a relatively strong supervision sys- Limitations of the study tem, and within a relatively weak health system. The review identified a number of limitations.

Global Evidence of Community Health Workers Firstly, most of the reviewed studies when im- on the promotive, preventive, curative and re- plemented, neglected to document the com- habilitative aspects of care related to maternal, plete description and characteristics of CHWs newborn and child health, malaria, tuberculosis, deployed, especially the level and amount of HIV/AIDs as well as other communicable and supervision provided to those workers, which non-communicable diseases. Other training could have helped us in identifying the im- content and training duration may be added portance of this factor and its association with pertinent to the specific intervention that the other outcomes. Additional information on the CHW is expected to work on as detailed in main initial level of education of CHWs, provision of report. refresher training, mode of training: balance of practical/ theoretical sessions would have The CHW programs should also give attention provided greater assistance in understanding to both the content and the timings of delive- the threshold effect, if any, of these factors on ring interventions at the planning stage. CHW performance in community settings. Importantly, community ownership and super- The CHW programs should regulate a clear se- vision of CHWs is a key characteristic which is lection/deployment procedure (ideally engage insufficiently described and analyzed in availa- community in planning, selecting, implemen- ble literature. ting, and monitoring) that reassures appointing those who certify the course completion and Secondly, studies related to the role of CHWs in pass the writing or verbal exam at the end of HIV/AIDS prevention and care, mental health training. and food security and nutrition were scarce. Government should take responsibility in ma- Thirdly, few evaluation studies/reports were at king a transparent system for selection and de- scale and none had followed an a-priori experi- ployment and further quality assurance of the mental design or impact assessment process. regulated set system. Key messages on integration of On scaling up a CHW program, decision makers should consider how to link them up with the CHWs at national level wider health system. Planning, production and deployment: The programs should be coherently inserted Attraction and retention in the wider health system, and CHWs should Community preparedness and engagement is be explicitly included within the HRH strategic a vital element that is relatively rarely practiced. planning at country and local level. From the outset, program should develop village health committees in the community that Given the broad role that many CHWs play in can also contribute in participatory selection primary care, a program must assure that a core processes of CHWs.1 set of skills and information related to MDGs be provided to most CHWs. Therefore, the curricu- CHW programs should be based in and respond lum should incorporate scientific knowledge to community needs. In practical terms, such about preventive and basic medical care, yet programs should continually assess community relate these ideas to local issues and cultural health needs and demographics, hire staff from traditions. They should be trained, as required, the community who reflects the linguistic and

13 cultural diversity of the population served, and third party evaluation could be recommended promote shared decision making among the in every 4-5 years, which would generate a neu- program’s governing body, staff, and commu- tral and free from bias findings. nity health workers. The outline of the country plan of action to CHW programs should also ensure a regular and develop and improve CHW program(s) should sustainable remuneration package that is com- be finalized by a working group of relevant plemented with other rewards and incentives. multiple stakeholders, including identification of resources needed, indicators and targets, and CHW programs should also provide opportuni- monitoring tools, and formally authorized by ties for career mobility and professional develo- the Ministry of Health pment. These should include opportunities for continuing education, professional recognition, Finally, sustained resources should be available and career advancement. This can be through to support the program and workers therein. specific programmatic opportunities or access to educational and training scholarships. Knowledge gaps requiring The CHW programs should support provision further study of requisite and appropriate core supplies and There is a remarkable dearth of information on equipment to enable appropriate functionality the cost-effectiveness of CHW programs. of such workers. Studies are needed to assess whether the CHW Performance management programs promote equity and access. The CHW programs should also ensure that the Studies are required to assess the effectiveness performance management is based on mini- of paid workers versus voluntary workers. mum standardized set of skills that respond to community needs and are context specific. Further analysis is required on the effectiveness of different models of remuneration/ payment/ The programs should have established referral incentivization of CHWs across different tasks protocols with community-based health and and settings. social service agencies. Studies are needed to evaluate quality of care The programs should have regular and conti- and effectiveness of health care provided by nuous supervision and monitoring systems CHWs as compared to professional health care in place and supervision should be taught to providers in the fields of health education, be undertaken in a participatory manner that promotion and management of specific health ensure two-way flow of information. Moreover, problems.2 both external and internal evaluations need to be carried out on regular basis to improve Studies are also required to compare the ef- the services and analyze the need of various fectiveness of promotive/preventive strategies logistics, supplies and training according to the compared to curative interventions delivered requirements. Ideally, programs should evaluate by CHWs for maternal and newborn health. their own performance on annual basis, while a

Global Evidence of Community Health Workers Given the global burden, specific studies on the That consultation should involve interactive potential role of CHWs in HIV/AIDS prevention debates that draw attention to key aspects of and care, as there is very limited empirical infor- the community component and planning pro- mation on this. cess, help clarify issues and address practical questions related to operationalization of these Further research is needed on how CHWs are findings. linked to the wider health system (e.g. in terms of referrals, supervision) and the impacts of the GHWA should organize theme-focused work- cadre on the health system. shops with existing CHW programs, to facilitate more interaction and generate quality output Further systematic reviews are also required and in the long run, facilitate follow-up visits on factors affecting the sustainability of CHW in these countries to provide technical support interventions when scaled up; the effectiveness and guidance for CHW programs, including of different approaches to ensure program sus- operational research. tainability; and the cost-effectiveness of CHW interventions for different health issues.2 GHWA should also facilitate in undertaking studies related to cost-effectiveness of CHW Additional analysis is required on the volume interventions, potential role of CHWs in HIV/ of work and type of activities and hence the AIDS prevention and care, functional needs of number of CHWs required for such tasks.3 An CHWS for MDG specific interventions etc. example of this type of analysis is provided by a study in Bangladesh which assessed how many GHWA should also take responsibility for additional health workers would be needed to publishing country specific CHW program eva- implement IMCI protocols. However, further luations and reports, and as much as possible, studies are needed to determine the CHW utilizing innovative, quasi-experimental designs workforce needed and their functional needs to assess impact of such programs. for MDG specific interventions.

Research is also required to identify innovative mechanisms of maintaining the sustainability of CHW programs. Recommendations on how GHWA can utilize the Report/Findings The findings from this report should be disseminated to policymakers at country level, to health care delivery organizations, and to organizations in charge of developing HRH programs. As an initial step, an international consultation on CHW study and a global review would facilitate this exchange.

15 Action Plan

Gathered existing information

Performed situation analysis (Collect additional information if needed) Already done Already GHWA Specific Country specific

Review Results (Global Consultation)

Set country priorities

Update CHW programs based on recommended criteria

Define indicators with targets

Further actionsFurther required and integrated monitoring tools

Develop a strategic plan within national HRH CHW plan

Global Evidence of Community Health Workers Core Report

Background The year 2000 marked an important event or health technologists. According to a report when 189 countries signed the UN Millennium by World Health Organization (WHO) 2006, 57 Declaration which translated into the eight countries, from Africa and Asia are facing shorta- Millennium Development Goals (MDGs). Three ges of health care workforce, and an estimated out of those eight are directly related to health, 4,250,000 workers are needed to fill in the gap.18 namely: Although several countries in Latin America have experienced sustained economic growth within 1 Reducing child mortality by two-thirds from the last few years, much social inequality and base levels of 1990; health inequities remain in the region, between 2 Reducing maternal mortality by three quarters and within countries. This is reflected in an ine- from base levels of 1990; and quitable distribution of health workers, with 15 countries in the region having less than 20 to 3 Combating HIV/AIDS, malaria and other 25 health workers for every 10,000 inhabitants, diseases. considered the minimum density for making a difference in health indicators. Shortage of However, progress on achieving these targets health personnel contributes to weaker health is far from the expectations, especially for the systems and the overall burden of disease in low-income developing countries. Despite these countries parallels the maldistribution of considerable evidence from recent reviews health workforce crises countries.19 of interventions that can impact on maternal, newborn and child health and survival, a major It is for reasons of achieving a wide range of the issue is the availability of trained health workforce population with cadres other than traditional to scale up these interventions in population health workers, that many countries have explo- settings.4-14 It is well recognized that critical red alternative strategies. An important strategy shortage of physicians and indeed misdistribu- towards attaining the health related MDGs is tion underlies poor access to skilled care and investing in cadres of CHWs, and this has been commodities by populations in need.15 This adopted by many African and Asian countries.20 recognition parallels the awareness that a range CHWs are community based workers that help of community health workers (CHWs), both individuals and groups in their own commu- skilled and semi skilled, can play a major role in nities to access health and social services, and community mobilization and deliver a range of educate community members about various commodities. health issues.21, 22 WHO has elaborated the definition of CHWs as“(they) should be members Given the limited resources available for scaling of the communities where they work, should be up interventions to reach the MDG goals, two selected by the communities, should be answera- major barriers have been identified. One, the ble to the communities for their activities, should critical need for health systems strengthening be supported by the health system but not neces- has been underscored16 and key shortages of sarily a part of its organization, and have shorter health care workers identified, which ought training than professional workers”. 23 to be addressed by innovative strategies such as development of alternative cadres and task During the 1980s, CHWs were considered a cor- shifting.17 Health care workers are personnel nerstone for primary health care, as envisioned whose activities are aimed to improve health, by the Alma Ata Declaration, but its importance and traditional trained health care workers declined in the 1990s with a changing focus on include cadres of doctors, nurses, midwives alternative vertical programs and service delivery

17 models. It is now evident that this change in di- program.30 These factors can be alleviated by rection was misplaced and given the increasing certified training and supportive supervision, interest in integrated primary care and the reco- along with other incentives (financial and non- gnition of the enormous mismatch between di- financial) to keep CHWs satisfied and motivated sease prevalence and optimal care,24 there has to perform their duties well. Furthermore, efforts been a rekindling of interest in the importance geared to standardize training and certification of CHWs. This interest is related to potential re- for CHW programs, could further provide a allocation of interventions and specified tasks career pathway and enable them to effectively from more specialized to less specialized health contribute to their communities. A recent study care workers (also called “task shifting”).25 by Kash et al.30 have concluded that certified CHWs are potentially an important health task While CHWs may not replace the need for force towards improving access to health care sophisticated and quality health care delivery and social services and improve utility of resour- through highly skilled health care workers, they ces to the underserved. could play an important role in increasing access to health care and services, and in turn, A large number of countries, many in the high improved health outcomes, as an effective link burden countries of South Asia and sub-Saha- between the community and the formal health ran Africa, are off target for reaching the MDGs system, and as a critical component in the set for the year 2015. One of the mechanisms to efforts for a wider approach that takes into ac- effectively reduce this gap is by improving the count social and environmental determinants of mechanisms and channels for delivering the health. Successful examples are evident by the interventions with a potential to improve the efforts of the Bangladesh Rural Advancement health and nutrition status of the mothers and Committee (BRAC), Bangladesh for setting up a children. The important role of formally trained CHW program based on cumulative experience health professionals like doctors and nurses in and learning.26 Brazil is another example where primary care and community settings is well- CHWs provide coverage to over 80 million recognized. There is a shortage of such staff in people.27, 28 Ethiopia is currently training about many countries which has emerged as a major 30,000 workers with emphasis on maternal and limitation in the delivery of useful maternal and child health, HIV and malaria. Similar programs child interventions. With appropriate training, are also being considered in other developing some of these tasks can be successfully perfor- countries like India, Ghana and South Africa. In med by CHWs and other cadres of workers like Pakistan, a huge public sector program for trai- traditional birth attendants, and lay health wor- ning and deploying Lady Health Workers (LHWs) kers. Engaging CHWs could provide improved has been in place since 1994 and has been ex- access to the basic essential health services and panded to cover over 70% of the rural popula- commodities, and could also influence commu- tion with a work force exceeding 90,000.29 nity demand creation. The role of CHWs, if any, in facilitating delivery of various interventions in For CHW programs to effectively perform, it is community and primary care setting is to im- vital to lay due emphasis on training and su- prove MDG outcomes in a subject of increasing pervision. Prior experiences have documented public health interest but has not been syste- that low interest/use by the government, in- matically analyzed. consistent remuneration, inadequate staff and supplies and lack of community involvement We undertook this review to evaluate the impact are key factors to negatively impact the CHW of global experience of CHWs in delivering the

Global Evidence of Community Health Workers Methods Global Systematic Review Criteria for considering studies for this systematic review. health related MDGs and components thereof. According to WHO, CHWs should be members This was accomplished through a systematic of the communities where they work, should be review of available literature and in-depth case selected by the communities, should be answe- studies of large CHW programs in both the pu- rable to the communities for their activities, blic and private (NGO) sector in eight countries should be supported by the health system but representing various parts of the developing not necessarily a part of its organization and have world. shorter training than professional workers.31 Therefore, the types of health care providers included encompassing village health workers, Objectives lady health workers/visitors, birth attendants, The specific objectives of the systematic review etc. We restricted our review to CHWs (either included paid or unpaid) undertaking activities related to achieving the health and nutrition activities Assessment of the evidence base of the impact and wherever possible, targeting disorders/ and effectiveness of global experience of CHWs conditions of direct relevance to related MDGs. in delivering care related to health and nutrition It was recognized that many CHWs in develo- MDGs. Special focus was paid on the ped countries had significantly higher levels of o Typology of CHWs education, training, experience and support as o Training practices compared to comparable cadres in developing o Supervisory practices countries. To ensure comparability of experience o Standards for evaluation and certification from various settings, we set an a priori criterion o Deployment patterns that CHWs should have received training in o In-service training some manner in relation to the interventions and targets, but excluded those with formal Undertaking case studies to evaluate the ty- professional or paraprofessional grooming, or a pology, impact, and performance assessment degree from tertiary learning centre. of the practices of CHWs deployed at scale in 8 countries across the world, two being in Our first level of evidence derived from- ex Latin America (Brazil and Haiti), three in Africa perimental designs and evaluations of CHWs (Ethiopia, Uganda and Mozambique), and in various settings. We thus identified and three in South Asia (Pakistan, Bangladesh and reviewed randomized, quasi-randomized and Thailand). before/after trials which had relied upon CHWs in community settings. In addition, other less ri- Based on the above, the development of an gorous study designs like observational (cohort analytical summary and draft recommendations and case-control) and descriptive studies were for recruitment, training and supervision criteria also reviewed to understand the context within for CHW programs to address the health MDGs which they were implemented, the typology of for regional and global consultation among health care providers, the types of intervention stakeholders. delivered and reported results. Studies were included if (a) they detailed the role of CHWs Prepare the framework for finalization of recom- and (b) if the outcomes considered are those mendations for consideration and adaptation related to reaching the health and nutrition by stakeholders MDGs like child mortality, maternal mortality, combating HIV/AIDS etc. The main comparison was between CHW interventions compared to

19 no intervention or routine care; or one form of CHW intervention compared with another form. Box 1 is a list of alternative names used for outreach workers globally.

Global Evidence of Community Health Workers Box 1: Alternative Names for Outreach Worker Bangladesh Shasthyo Sebika Bangladesh, India, Greece & Gambia Village Health Workers Peru Agente Comunitario de Salud Pakistan Lady Heath Workers India Saksham Sahaya Brazil Community Health Agents Brazil Agente comunitário de saúde Brazil Visitadora Burkina Faso Women Group Leaders Burma Maternal Health Worker Bangladesh Community Nutrition Worker India Anganwadi Workers India Maternal & Child Health Promotion Workers India Community-based Workers Nepal Female Community Health Volunteer Ethiopia Village Malaria Worker Nepal and China Maternal Child Health Workers Ecuador, Colombia, Nicaragua Voluntary Malaria Workers United States & Mexico Promotoras de Salud Madagascar, Ghana, & Bolivia Nutrition Volunteers Community Egypt Raedat Health Worker Haiti Accompagnateurs (CHWs) India Community Health Volunteer Iran Behvarz India Village Health Guide Senegal Nutrition Worker Latin America Colaborador Voluntario Uganda Community Drug Distributor Kenya Village Health Helper Indonesia Kader Posyandu Ethiopia Mother Coordinator Mali Village Drug-Kit Manager South Africa Lay Health Worker Uganda Community Reproductive Health Worker United States Lay Health Visitor England Mental Health Workers England Postnatal Support Worker United States Community Volunteer United States Community Health Advocates Unites States Community Health Aide Guatemala Village Health Promoters Guatemala Rural Health Worker Nicaragua Brigadistas Bangladesh Community-based Skilled Birth Attendant Traditional Pakistan Dai Birth Malaysia Bidan Kampong Attendant Bangladesh Skilled Birth Attendants (TBAs) Guatemala Traditional Midwives Egypt Dayas Pakistan Community Volunteers Community Nepal & India Facilitator Mobilizer Bangladesh Female Peer Facilitator (CMs) India Change Agents India Doot Brazil Peer Educators Peer Counselor Brazil Lay Counselor (PCs) England Volunteer Counselor United States Volunteer Peer Counselor England Peer Support Worker

21 Methods for literature search, information sources, abstraction and synthesis worker*» OR «primary health care» OR «Task All the evidence available, relevant to the role Shifting» OR «community based interventions» of CHWs in achieving the health and nutrition OR «Female village health worker*» OR «village related MDG targets around the world, was health worker*» OR «birth attendant*» OR «tra- systematically analyzed. The following sources ditional birth attendant*»]. Language restric- of information were used to search literature for tions were not applied and our search strategy review: included relevant Library of Congress Subject 1 All available electronic references libraries of in- Headings, and MeSH terms. dexed medical journals and analytical reviews Studies in languages other than English were 2 Electronic reference libraries of non-indexed included after relevant translation. The abstracts medical Journals (and the full sources where abstracts not availa- 3 Non-indexed journals not available in electronic ble) were screened by two authors to identify libraries studies adhering to our objectives. Any argu- ment on selecting studies between these two 4 Pertinent books, monographs, and theses authors was resolved by a third reviewer. After 5 Project documents and reports retrieval of the full texts of all the studies that meet the inclusion/exclusion criteria, each study The following principal sources of electronic was double data abstracted into a standardized reference libraries were searched to access form. The key variables elicited were study the available data on CHWs studies: Cochrane setting, location, study design, participants, in- Reference Libraries, Medline, PubMed, Popline, tervention delivered, outcome effects and type World Bank’s JOLIS search engine, British Library of outreach workers involved. Since the objec- for Development Studies BLDS at IDS as well as tive of this systematic review is to assess the the IDEAS database of unpublished working effectiveness of CHWs in delivering care related papers, Capacity Project website, HRH Global to health and nutritional MDGs, special focus Resource Center, Google and Google Scholar. has been laid in extracting information related Detailed examination of cross-references and to CHWs, their educational requirement for se- bibliographies of available data and publications lection as outreach worker, training content and to identify additional sources of information modalities (didactic, practicum, experiential etc), were also performed. In particular, this search training duration, certification, refreshers / on- was also extended to review the gray literature going training, key competencies, specific role in non-indexed and non-electronic sources. The and tasks assigned, supervision and monitoring, bibliographies of books with sections pertai- incentives (if any), population coverage, impact ning to CHWs were also searched manually to of CHW programs/ evaluation. All final studies identify relevant reports and publications. were entered into the Endnote XI database.

The following search strategy was modified Country Case Studies for the various databases and search engines. Two interrelated approaches were used to gather [«Community Health Aides» [Mesh] OR «Primary information on the CHWs program from each of Health Care» [Mesh] OR «community health the selected country. First, we conducted a re- worker*» OR «lady health worker*» OR «village view of published and unpublished reports on health volunteer*» OR «village health guide*» the countries experiences with CHWs. Second, OR «lay health worker*» OR «mid level health we made a direct contact with key personnel,

Global Evidence of Community Health Workers overseeing the program, through electronic 4 On-going Training: On-going training is provided correspondence and country visits. to update CHW on new skills, reinforce initial training, and ensure he/she is practicing skills Our primary level of evidence derived from eva- learned. luation reports of CHWs in selected countries. We thus identified and reviewed all published 5 Equipment and Supplies: The requisite equipment or unpublished reports which considered CHWs and supplies are available when needed to deliver in the community settings. We also included the expected services. evidence, pertinent to CHWs from selected ei- 6 Supervision: Supervision is conducted on a re- ght countries, identified from global systematic gular basis to carry out administrative tasks and review. We also contacted stakeholders, who to provide individual performance support (fee- are familiar with how the program is managed dback, coaching, data-driven problem-solving). or supported and the regions within which it functions, to get a deep insight about program 7 Performance Evaluation: Evaluation to fairly as- functionality through country visits and/or email sess work during a set period of time. correspondence. In this process we congrega- 8 Incentives: A balanced incentive package that ted information related to: program descrip- includes financial incentives, such as salary and tions, job descriptions, or official descriptions of bonuses and non-financial incentives, such as the role of the CHW and the process followed training, recognition, certification, uniforms, to identify and recruit the CHW; records identi- medicines, etc. that is appropriate to the work fying numbers of trained CHWs, dates of recent expectations. trainings, and documents describing training content and process; documents that describe 9 Community Involvement: The role that commu- the supervision or monitoring process; records nity plays in supporting a CHW. of current numbers of CHWs etc. 10 Referral System: A process for determining when referral is needed, a logistics plan in place for After assembling information from multiple transport and funds when required, a process sources, USAID’s CHW Program Functionality to track and documented referrals. Assessment Tool (CHW-PFA)32 was utilized to assess the functionality of the CHW programs 11 Professional Advancement: The possibility for across these countries. The CHW PFA proposes growth, advancement, promotion and retire- twelve programmatic components for a CHW ment for a CHW. program to be effective. These components are:32 12 Documentation, Information Management: 1 Recruitment: How and from where a community How CHWs document visits, how data flows to health worker is identified, selected, and assigned the health system and back to the community, to a community. and how it is used for service improvement. 2 The CHW Role: The alignment, design and clarity of role from community, CHW, and health system Functionality Rating: perspectives. For each of the 12 components listed above, 3 Initial Training: Training is provided to the CHW to four levels of functionality are described that prepare for the role in MCH services delivery and range from non-functional (Level 0) to highly ensure he/she has the necessary skills to provide functional as defined by suggested best prac- safe and quality care. tices (Level 3). These levels describe situations

23 commonly seen in CHW programs and provide presented some national or NGO driven CHW enough detail for assessor to identify where that programs in the form of “CHW Snapshots” ap- program fall within that range. Level 3, the hi- pearing randomly in annex I. We also undertook ghest level, provides an accepted best practice case studies in eight representative countries for each component. Because each of these from Latin America, Africa and Asia, with high components is equally necessary for a program burden of diseases, to understand the typology, to succeed a CHW program must be rated at least experience, training needs, program roll out and level 2 in each of the 12 components in order to assessments of CHWs to-date. be considered minimally functional. Moreover, a set of widely accepted programmatic and cli- Based on our findings from global systematic re- nical elements were also considered to evaluate view and country case studies, we constructed a their role in MCH. A ‘functional’ CHW providing typology of CHWs, taking into consideration the MCH services must deliver at least one of the expert opinion and the context and diversity key MCH classified by antenatal, childbirth, early of training programs, while acknowledging the post-partum and early childhood periods in the existing limitations in the available information MCH care-continuum. and in the methods used (Functionality assessment tool, desk review and key informants Scoring of MCH Intervention: interviews during country visits). MCH roles Interventions are grouped by categories which includes antenatal care, birth and newborn care, postpartum and newborn care, family planning, PMTCT, etc. One complete intervention requires a check mark in the column titled YES – indicating full implementation of the intervention at that program level. The scores from CHW program functionality assessment matrix and MCH intervention matrix are sum- med up separately and reported in the score card.

Data Analysis For global systematic review, the studies were categorized based on interventions relevant to health and nutrition related MDGs and then analyzed by the type of outreach workers and study design employed in order to explore the impact and effectiveness of global experience of CHWs in delivering healthcare. This helped us in outlining the typology, training and supervision needs, tasks and feasibility of developing and deploying CHWs as a way towards the achievement of the MDG targets. We have also

Global Evidence of Community Health Workers Structure of Report

Global Systematic Recommendations Review (published & CHW Typology Analysis = key unpublished papers - Educational level Findings and Gaps & reports) - Recruitment - Training Country specific - Monitoring & Supervision - Incentives - Evaluation Country Case Study - - Deployment CHW programs (country - Documentation & visits + CHW-PFA +Key Experts Opinion Information System informant’s interviews)

Input Process Output

25 Main Findings from Global Systematic Review and Country Case Studies

Global Systematic Review Summary CHWs were employed to deliver a wide range They promoted antenatal, intrapartum and of interventions that were arranged into groups, postnatal care, initiation of early and exclusive each containing studies that used broadly simi- breastfeeding, promoted use of colostrums and lar methods to influence a single health care growth monitoring of children. outcome. Their role in preventive medicine can be assessed from the emphasis that they lay in their 1 Nutritional interventions communities regarding appropriate nutrition 2 Maternal Health interventions and to remain healthy. They also emphasized on usage of condoms and change in sexual 3 Birth and Newborn Care Preparedness behavior, in HIV prevalent communities. In fact, Interventions some were trained in the social marketing of 4 Promotion of breastfeeding condoms. Besides advocating preventive strategies they 5 Neonatal Health Interventions also offered treatment for uncomplicated ma- 6 Childhood Illnesses and Immunization laria, pneumonia and treatment compliance Interventions was ascertained in case of TB and anti-retroviral therapy of HIV as DOTS. 7 Primary Health Care Interventions 8 Malaria Control Interventions 9 Tuberculosis Control interventions 10 HIV/AIDS Prevention and control Interventions 11 Mental Health Interventions 12 Interventions related to Non-Communicable Diseases (NCDs) 13 Knowledge, attitude & practices of community health workers

Global Evidence of Community Health Workers Country Case Studies 1 Typology of CHW programs system, within a relatively strong health system: Short to intermediate duration training pro- The Village Health Volunteers Program (VHV) grams, with preventive and basic curative tasks in Thailand for CHWs, with relatively strong supervision ac- 7 Long duration training programs, with mostly tivities, and within a weak health system: Haiti promotional and preventive tasks, and very res- Zanmi Lazante’s Community Health Program tricted and basic curative tasks for CHWs, with a 2 Long duration training programs with preven- strong supportive supervision, and within a re- tive and basic curative tasks for CHWs, with a latively strong health system, such as the Family relatively weak supervision system, and within a Health Program (FHP) in Brazil. weak health system: Ethiopia Health Extension Program (HEP) & Mozambique Agentes Polivalentes Elementares (APE) Program. 3 Short duration training programs with preventive and basic curative tasks for CHWs, with a relatively strong supervision system, and within a weak health system: Uganda Village Health Teams. 4 Long duration training programs, with promotional, preventive and basic curative tasks for CHWs, with a relatively strong supervision system, and within a relatively weak health system: Pakistan’s Lady Health Workers (LHW) Program. 5 Short duration training programs, with mostly promotional, preventive and basic curative tasks for CHWs and with a relatively strong supervision system, within a relatively strong health system: BRAC in Bangladesh 6 Short duration training programs, with mostly promotional, preventive and basic curative tasks for CHWs and with a relatively weak supervision

27 Discussion and and social services system. Communities across Way forward all the countries that we studied recognized The intentions underlying this global review the value of CHWs as a member of the health was to assess the role of CHWs in the interven- delivery team and therefore have supported tions related to the MDGS and to bring forth the the utilization and skill development of CHWs. image of how various countries in the world These case studies further speak out the achie- are running their CHW programs through our vements of their CHW programs in relation to country case studies. their modeling and level of commitment from their human resource. The region lagging far The review of CHWs across the globe provided behind the MDG targets is Africa especially us a vivid picture of the current scenario in the sub-Saharan Africa.39 Various factors have outreach services of health care workers. There been identified to be responsible. These include is a wide range of services that are offered by inadequate human resource especially work the CHWs to the community from safe delive- force who are dying with HIV/AIDS, lack of su- ries, counseling on breastfeeding to the mana- pervision, and equipment and drug supplies gement of uncomplicated childhood illnesses, needed to provide essential maternal, child and from preventive health education on malaria, TB, reproductive health services and those required HIV/AIDs, STDs and NCDs to their treatment and to control and treat potentially preventable in- rehabilitation of people suffering from common fectious diseases. mental health problems. The services offered by them have helped in the decline of maternal There has been long and unresolved debate and child mortality rates and have decreased about what functions one CHW can effectively the incidence of TB and malaria. However the carry out, coupled with concerns about how overall progress towards achieving the MDG many tasks a CHW can realistically perform.1 targets is very slow. The growing consensus re- An in-depth analysis of the CHWs contributions garding this current pace of progress, especially and their outcomes in various interventions has in the low income countries is due to the fragile led us to identify various gaps in the effective health and information systems. Their role in the working of these health workers.30 The PHC community has also been quantitatively analy- workers provided basic health care and appro- zed in other systematic reviews that offered en- priate referrals where needed. They increased couraging evidence of the value of integrating health awareness and promoted preventive maternal and newborn care and other health health behaviors. Their services however, were related interventions in community settings found to be fully utilized where the area of their through a range of strategies that work, many of deployment was in the rural vicinity. Roles and which can be packaged effectively for delivery responsibilities that CHW were fulfilling in rela- through a range of community health workers tion to MDGS, as evident from global literature (CHWs).2, 33-38 and national programs, were maternal and child health care, TB care, malaria control, HIV/AIDS Our country case studies, on the other hand, care, with very less reports can be found about demonstrate the participation of the respective the use of CHWs in food security and nutrition. governments and the NGOs in financing and implementation of their policies for the CHW The role of nutrition workers, in small scale pro- programs. Results from these country case jects, was mainly related to counseling and ad- studies confirm that CHWs provide a critical vocacy in community. While, on the other hand, link between their communities and the health in large CHW programs, they were involved in

Global Evidence of Community Health Workers iron/folate supplementations, counseling on practices. Their major efforts had to be directed maternal nutrition, promotion of growth moni- towards behavioral change of the community toring and weighing of newborns, provision of to convince them for the provision of adequate community based management of acute malnutrition to the pregnant women, to avoid pre- nutrition using ready to use therapeutic foods. lacteal feed in newborn and give colostrums Studies under our review also identified low and exclusive breastfeed for at least 4-6 months. education in CHWs as a main factor that hin- Inadequate supplies of equipment and drugs dered them in carrying out the advocacy skills were another barrier in the way of their tasks properly. On the other hand, there were studies accomplishment. They were trained for growth that highlighted the importance of CHW super- monitoring but at instances unavailability of vision and refresher training. Some programs physical weigh balance did not allow them to experienced challenges in which supervisors fulfill their job. Apart from inadequate supply were not involved which later diminished when of drugs and equipment, lack on ongoing and program involved supervisors. Keeping in view, refresher training was another major barrier in the current transition in dietary pattern, we proper functionality of CHW when adequate found a complete absence of CHW’s role in life time was not allocated for practical aspect du- style modification, physical activity and dietary ring their initial training. Studies in which CHWs changes particularly from large scale CHW pro- performed their services under the supervision grams, while, it was only found in small scale and attended monthly meetings were able to programs from developed countries. bring about positive impact and their standing in the community increased with updated Almost all of the CHWs driven interventional knowledge. studies showed a significant impact on -redu cing maternal, perinatal and neonatal mortality We, on the other hand, also assessed CHW pro- and improvement in perinatal and postpartum grams against MNCH interventions list prescri- service utilization indicators. In most of these bed by USAID, which showed that none of the studies they were trained and deployed as program delivered all the interventions sugges- maternal and child health care providers and ted. CHWs in these programs mainly complied reproductive health workers. They promoted on delivering antenatal care, postpartum care, the concept of antenatal, intrapartum and pos- immediate newborn care and immunization tnatal care, exclusive breastfeeding, maternal services in community with special emphasis and child nutrition, immunizations and family on counseling and referring cases to the health planning. The newborn care providers amongst facilities. But very few programs focused on re- these CHWs were trained to teach kangaroo cognizing and referring maternal and newborn mother care for LBW babies and monitor growth complications, prevention of post partum he- for children under-five years of age. Apart from morrhage, providing kangaroo mother care for delivering general health related promotional low birth infants, community based treatment interventions, these health workers were also of pneumonia, other referral services for severe involved in the preventive and therapeutic illness among children. Looking at the variety of maternal, newborn and childhood illnesses tasks under MNCH domain, CHWs are facing job interventions. They managed uncomplicated stresses which are leading to high attrition rates. common childhood illnesses and identified LHWs (Pakistan) in one study reported that low those requiring referral to higher health facility. socio-economic status and long travelling dis- However, the major barriers that came in the way tances for work, inconsistent medical supplies, of their services included traditional beliefs and inadequate stipends, lack of career structure

29 and not being equipped to communicate ef- expansion of ART services. The HIV epidemic fectively with families were the main factors for has drastically increased the demand for health job dissatisfaction and attrition.40 In addition, services, yet a growing number of health wor- BRAC Shasthyo Shebika identified factors -res kers in high prevalence regions are themselves ponsible for their dropouts as low income and dying or unable to work as a result of HIV/AIDS. small profit gains from selling medication and The role of CHWs in reducing the incidence of contraceptive methods.41 HIV however has not been very significant partly because HIV was not found to be the major fo- Globally, the incidence of malaria has been de- cus of CHW training programs in most parts of clining but especially in the sub-Saharan region the world despite of it being a part of MDGs. The malaria, which is preventable and controllable, role of CHWs pertaining to HIV was restricted to still continues to take millions of lives. The role creating awareness and providing ART using of malaria workers in the literature reviewed DOTS. From global systematic review, hardly 17 was to promote use of insecticide treated nets studies were found which described the role of and provide treatment for uncomplicated mala- CHWs related to HIV/AIDS out of which just 1 ria. While, from country case studies, their main study revealed that the concept of PMTCT was role was found in counseling and referral for conveyed to the CHWs and both the mother insecticide bed nets, IPTp treatment, and rapid and the HIV exposed newborn were treated diagnostic test. Only two programs, Ethiopia with single dose of medicine. And a single study Health Extension Program and BRAC Bangladesh reported the CHWs’ rehabilitative role towards have trained their CHWs for rapid diagnostic HIV/AIDS patients in the form of psychosocial tests and treatment. The CHWs working in this support. Whereas, none of the program from domain often faced shortage in supply of new our country case studies delivered all the inter- malaria drugs and insecticide treated bed-nets ventions (as per USAID PMTCT interventions) re- preventing them from offering services in their lated to assessment and treatment of HIV/ AIDS true capacity. Since in many studies, CHWs were in mothers and newborns. Only two programs local farmers or drug distributors from the com- (Brazil and Haiti) among all, included training munity, they were, in principle, always accessi- for PMTCT interventions which was restricted ble to the villagers, who had been motivated to counseling and referral. These observations through health education to consult the CHW reveal that the CHWs in general were not gi- for any fever episodes.1 Key problems in these ven a comprehensive training on the issue of interventions revolved around the limited scope HIV-prevention, treatment and rehabilitation. of the CHWs’ practice and their ambiguous role CHWs were not armed with the supportive and within the health care system.1 More specifically, rehabilitative strategies that would help them Delacotte et al. observed that CHWs wanted ease the life of HIV patients who are generally to be more than symbolically remunerated for living with the social stigma related to the di- their services; they were eager to receive further sease. Owing to its socioeconomic impact and training so as to expand their scope of practice, the multi-system diseases introduced by HIV/ and they wanted to become a formal part of the AIDS in a person like multi-drug resistant TB and health structure.1,42 other infections, the issue of HIV/AIDS deserves special attention in terms of preventive, thera- In combating HIV as a goal set in MDGs, there peutic and rehabilitation strategies. has been a decline in the incidence of newly affected HIV positive people. The number of Another intervention area that seems ne- deaths from HIV has also decreased with the glected and where the CHWs can create a

Global Evidence of Community Health Workers contexts, therefore our recommendations are based on core as well as for different types of difference is that of mental health. The current interventions carried out by CHWs, which is living standards with global economic crisis and definitely not suggesting having different types unemployment rates have led to a number of of CHWs. Attention to the following criteria and mental health problems in the society the most issues could potentially improve the working of common being anxiety and depression. These CHWs and help scaling up key interventions. problems tend to further deteriorate the health and socioeconomic situation and may even lead Education to loss of life in the form of crimes and suicide, if left unattended. Despite of these facts, the Setting up stringent post-primary or secondary sphere of mental health illnesses has not been education criteria as a pre-requisite for beco- given its due importance. We recommend that ming a health worker does not sound practical this intervention be galvanized into the preven- when it comes to meeting the health care needs tive and rehabilitative strategy of primary health of less privileged communities far removed care as well as every MDG related intervention. from health care facilities. However, keeping criteria of primary education and incorporating On the whole, factors limiting the range and adult education comprising of basic arithmetic, quality of CHWs impacts are identified as below reading and writing should be considered into and are further described in the recommenda- the training curriculum of the CHWs to ensure tion section.3 proper documentation, referrals and records keeping of the supplies. Moreover, CHWs who Shortage of basic drugs and irregular supply of are involved in case management should be vaccines and commodities (e.g. condoms) strictly scrutinize for their education level. In an ideal situation for giving a fair chance, candidate Inadequate and irregular supervision with at least primary level education should be Lack of equipment and non-functional equipment given a preference. Insufficient initial and continuing education Recruitment criteria Low status and remuneration of CHWs All the studies and CHW programs, that we Inadequate linkages with health system. reviewed, emphasized that CHWs should be chosen from the communities they will serve Based on our review and the gaps identified in and that communities should have a say in the the existing CHW programs and the services selection of their CHWs. As far as the selection of rendered by them in terms of MDGs, we are able the CHW is concerned, we would recommend to make the following recommendations regar- that they should be directly chosen by the hou- ding their recruitment criteria, training content, seholds that they will work with. Neither health certification process, ongoing and refresher trai- or other officials, nor even community leaders ning, supervision, incentives and professional should make this choice alone. CHWs should advancement (Table 1). There is a wide range of always be answerable to the local community different CHWs, performing an even wide range that they volunteer to serve.1 We also reviewed of tasks. A typology is therefore not easy. One from BRAC example that villages initiated village simple distinction, however, is that between ge- health committees which also help and are res- neralist and specialist CHWs like MNCH workers, ponsible for selecting CHW candidates. However, nutrition workers, TB and HIV/AIDS workers etc. most studies reported that CHWs were chosen We also recognize the importance of varying or selected “by the communities themselves”.

31 *Volunteers members who volunteer (community few hours a week)(full time CHWs) Salaried Table 1 Key Community Health Worker competencies :

center local health community and by final selection and willingness on motivation Interview: and numeracy Test: resident-permanent community - from the local -18-40years of age Applicant must be cadidates to join for interested radio channel or local newspaper in - Advertisement workers health community of potential identification Involvement in Community Recruitment on literacy on literacy Recommendations - CHW Core Typology to judge schooling level primary criteria tional Educa- mental health for activities promotion of -educational and personal hygiene for- educational activities water , sanitation hygiene, group with emphasis onpediatric on oral & dental - educational activities habits dietary community on family & - educational activities methods on family planning - educational activities delivery after & mothers of newborns - monitoring promoting breastfeeding mother preparation for delivery, and symptoms, on feeding orientating and follow-up, signs identifying risk and household visits for- periodic prenatal care at the health facility of prenatal promotion of importance - identification of pregnant & women pregnancy - prevention of STD/AIDS, premature diseases - promotion of oral rehydration for diarrheal - promote exclusive breastfeeding pregnant women - routine immunization of children and - growth of children monitoring - visits households - confidentiality communication skills - interpersonal - organizational skills - leadership of medical services - knowledge management - crises - coordination of services to access resources- ability didactic,interactive sessions Refresher: every 6 months once Ongoing: month per 6 months On-the-job: 6 months Initial: Core training: key Role : Training content, duration & role (initial & ongoing) CHW Contextual Factors a certificate awarded with should be they on-job training on completion of awarded with title should be they of initial training and completion on passing exam initial training Exam after Certification Certification process & evaluation every 5 year every in evaluation external evaluation annual internal Evaluation: 20-25 CHWs 1 supervisor: Supervisors supervision supervision Monitoring Monitoring Volunteer/ employment Full time arethey poor that view in keeping Salaried OR volunteers * salaried based incentives (if possible) for their family for themselves and Free health coverage ceptives methods allow to sale contra minor ailments medication for allow to sale Performance General or - the next level.the next required to reach and experience education level of minimum sor on completion career as supervi to advance their Should be offered development pathway & Career - Referral system health TBAs and between linkages system

Global Evidence of Community Health Workers Community preparedness and engagement is leaders and district health officer. Other recruit- a vital element that is relatively rarely practiced. ment criteria may be added pertinent to the From the outset, program should develop vil- specific intervention that the CHW is expected lage health committees in the community that to work on as mentioned below. can also contribute in participatory selection processes of CHWs. MNCH workers: Workers for MDGs 4 and 5 should preferably be Although, the countries scored highest (PFA- female, married and children with not less than 3) in program functionality assessment on 5 years of age, as they have lower tendency following best practice for recruitment of their for migration. Moreover, they have their own CHWs, but difference were found on the nature experience of dealing with issues related to and selection checklist. It is recommended that pregnancy and motherhood and taking care of CHWs should be recruited for training on the their own children when they were sick. During basis of standard and transparent criteria for interview, they should particularly be assessed selection. An advertisement in the most acces- for their own acceptance and attitude towards sible local newspaper or local radio channel family planning. should be possibly made for walk-in interviews of interested candidates. Since being a perma- TB and HIV/AIDS Workers: nent resident of that locality is the most impor- For TB and HIV workers, preference should be gi- tant criteria for selection, therefore, evidences ven to those who are former drug user, or those confirming their residency must be strictly and who themselves suffered from tuberculosis and stringently examined during their first assess- HIV/AIDS and have completed their treatment ment, followed by cross confirmation of their regimens. Preference can also be given to those educational certificate and work experience who have taken care of a family member suffe- (if any). The assessment may include a test for ring from tuberculosis or HIV/AIDS. This would literacy and numeracy as well as interviews to specifically work in areas with high burden of assess aptitude, competence and motivation. TB and HIV /AIDS diseases like Africa, and where Candidates should be thoroughly gauged for a large number of outreach workers are dying their interest for voluntary work (depending from same condition. Their experience and on local national program), and serving their courage for the fight against disease can give a own community even in situation of no mone- motivational light to others. tary rewards. It is also recommended that some process for community buy-in and ownership Training content of this screening and selection process be ins- Almost all the studies described the training tituted, free from political interference, so that modality and content but the extent of training, the most suitable candidates are identified and type of training, and timings of training varied there is local accountability. dramatically across the studies. Training courses varied from several hours to several days to In summary, while the selection of CHWs from even several months. Training is in many cases local communities is common practice, partici- conducted by professional health members, patory selection processes remain an ideal that or, in the case of NGO-driven programs, by the is relatively rarely practiced, particularly in large- NGOs themselves.1 CHWs across all the country scale programs.43 The final selection should profiles and global review, were delivering pro- be proposed by community (or village health motional, preventive and therapeutic interven- committee) with the consensus of community tions with very few studies identified with their

33 *Volunteers members who volunteer (community few hours a week)(full time CHWs) Salaried Table 2: Key Nutrition Worker competencies center local health community and by final selection and willingness on motivation Interview: and numeracy Test: resident-permanent community - from the local -18-40years of age Applicant must be cadidates to join for interested radio channel or local newspaper in - Advertisement workers health community of potential identification Involvement in Community Recruitment on literacy on literacy

Recommendations – Typology of Nutritional Health CHW to judge schooling level primary criteria tional Educa- vitamin A deficiency - treatment for clinical sings of children malnourished - treatment of severely and monitoring parasitic disease - timely treatment for infectious and for - ORT diarrhea for mothers and children deficiency prevention of anemia and Vitamin A - micronutrient supplementation for women and lactating for intake pregnant- improved dietary - improved hygiene and sanitation for children - iron and folic acid supplementation feeding for 6-24 months next - appropriate complimentary for first 6 months - promotion of exclusive breastfeeding therapeutic interventions: 2 weeks On-the-job: 1-2 weeks Initial: Promotive, preventive and key Role : Training content, duration & role (initial & ongoing) CHW Contextual Factors a certificate awarded with should be they on-job training on completion of awarded with title should be they of initial training and completion on passing exam initial training Exam after Certification Certification process & evaluation every 5 year every in evaluation external evaluation annual internal Evaluation: 20-25 CHWs 1 supervisor: Supervisors supervision supervision Monitoring Monitoring Volunteer/ employment Full time arethey poor that view in keeping Salaried OR volunteers * salaried of a child for a year growth monitoring child malnourished of severally identification Performance General or incentives the next level.the next required to reach and experience education level of minimum sor on completion career as supervi to advance their Should be offered development pathway & Career - Referral system health TBAs and between linkages system

Global Evidence of Community Health Workers role in rehabilitative services especially with specifically for CHWs rather than using training chronic diseases and HIV/ AIDS. Majority of the packages developed for facility-based workers.1 studies under our review found positive impact As suggested, CHWs should at least be edu- of their interventions on health and nutrition cated up to primary school; therefore, course outcomes. Studies particularly attempted to should be developed in simpler language, and evaluate the sensitivity, specificity and predic- incorporate more illustrations and more inte- tive values reported better diagnosis and case ractive components for less-educated CHWs.44 management by CHWs, confirming the tho- These days CHW’s role has been enhanced for roughness and appropriateness in the training therapeutic interventions, in which they dia- modality and training content. Looking at the gnose and treat infectious diseases in children diversity of interventions they deliver in com- specifically acute respiratory infections. They munity, they should be classroom trained for at are mostly given algorithms for proper iden- least 6 months with an additional 6 months of tification and management, which are better hands-on-training which gives practical flavor for literate workers but are less understood by to their theoretical lessons. illiterate workers who mostly rely on memory. In such case, keeping in view the educational level Approaches to training have changed over the of CHWs, visual or pictorial cue cards should be years. While in the past it was too theoretical and utilized. too classroom-based, while in today, competence-based approaches are usually used. However, Furthermore, continuing or refresher training is it is recommended that didactic training be as important as initial training. A number of stu- given with ample interactive sessions including dies have found that if regular refresher training small group discussions, role plays and field is not available, acquired skills and knowledge activities. This type of learning is usually more are quickly lost and that, on the other hand, effective especially where the CHWs are either good continuing training may be more impor- illiterate or less educated. Also the simulations tant than who is selected.1 Curtale et al. suggest as in role plays would help CHWs tackle real life that “three additional training days provided situations more efficiently. In this approach, the regularly to the CHV every year, will result in skills and competencies required of the CHW are improved quality of service with consequent defined and usually expanded into steps and increased utilization”.45 standardized procedures required for a specific skill. Given the broad role that many CHWs will play in primary care, it is recommended that a core The ideal location of training, where CHWs will set of skills and information related to MDGs be have sufficient opportunity to practice, varies provided to most CHWs. These include informa- by CHW program. In order to get hands on trai- tion on major causes of MNC ill health and morning experience, programs recommend that it tality, TB, HIV/ AIDS, its prevention, treatment should be conducted in community rather than and rehabilitation. Other training content and in health facilities. In other contexts like mana- training duration may be added pertinent to gement of sick children, training may take place the specific intervention that the CHW is expec- in the facilities so that they get more opportu- ted to work on as mentioned in CHW core and nities to demonstrate skills in a real-life situation MDGs specific typology. and to practice newly learned skills.1 Because CHWs have limited formal education, programs should develop training materials and activities

35 *Volunteers members who volunteer (community few hours a week)(full time CHWs) Salaried Table 3: Key Maternal and Newborn Health CHW competencies

center local health community and by final selection and willingness on motivation Interview: and numeracy Test: of age less than 2 years - children with not preferably-Married resident-permanent community - from the local -18-40years of age Applicant must be cadidates to join for interested radio channel or local newspaper in - Advertisement workers health community of potential identification Involvement in Community Recruitment on literacy on literacy

Recommendations – Typology of Maternal and Newborn Health CHW to judge schooling level primary criteria tional Educa- oral antibiotics, - treatment of neonatal pneumonia with - home care infants of low-birth-weight traditional materials) - cord care (cleaning & avoiding the use of signs requiring referrals - recognizing and danger sick newborns (thermoregulation) - temperature control in newborn care and newborn preparedness - birth - HIV/STI screening - prevention of mother to child transfer attendance birth - skilled for ANC and PNC services - facilitate access to health maternal - deworming - healthy timing and spacing of delivery preventive treatment prevention- malaria and Intermittent - Tetanus Toxoid immunization - iron/folate supplementation - adequate diet Maternal and Newborn: therapeutic interventions: 1-2 months On-the-job: 4 weeks Initial: key Role : Promotive, preventive and Training content, duration & role (initial & ongoing)

CHW Contextual Factors a certificate awarded with should be they on-job training on completion of awarded with title should be they of initial training and completion on passing exam initial training Exam after Certification Certification process & evaluation every 5 year every in evaluation external evaluation annual internal Evaluation: 20-25 CHWs 1 supervisor: Supervisors supervision supervision Monitoring Monitoring Volunteer/ employment Full time arethey poor that view in keeping Salaried OR volunteers * salaried - ensuring birth wt birth - ensuring complication and newbor - Referral of maternal - Providing ENC for delivery mothers - Brining identification - Pregnancy Performance General or incentives the next level.the next required to reach and experience education level of minimum sor on completion career as supervi to advance their Should be offered development pathway & Career - Referral system health TBAs and between linkages system

Global Evidence of Community Health Workers system linkages between and TBAs health system Referral Referral - Career Career pathway & pathway development Should be offered Should be offered advance their to as supervicareer sor on completion of minimum education level and experience reach to required the next level. incentives General or Performance Performance - identification of sick newborn – completion of essential immunization salaried volunteers * volunteers OR Salaried keeping in view that poor they are time Full employment Volunteer/ Volunteer/ Monitoring supervision Supervisors 1 supervisor: 20-25 CHWs Evaluation: annual internal evaluation external evaluation in every 5 year & evaluation process Certification Exam after initial training on passing exam and completion of initial training they should be with title awarded on completion of on-job training they should be with awarded a certificate CHW Contextual Factors CHW Contextual

& role (initial & ongoing) & role Training content, duration duration content, Training Promotive, preventive and preventive Promotive, key Role : Role key Initial: 4 weeks On-the-job: 1-2 months interventions: therapeutic Children: breastfeeding - appropriate - essential newborn care - hand washing complimentary- appropriate feeding iron (6-24 months) adequate - vitamin A supplementation - oral rehydration - zinc therapy age - full immunization for strategies - malaria prevention - deworming monitoring - growth of childhood and treatment - prevention illnesses Educa- tional criteria primary level schooling to judge to Recommendations – Typology of Child Health CHW of Child Typology – Recommendations

on literacy Recruitment

Community in Involvement identification of potential community health workers - Advertisement in local newspaper or radio channel interested for join to cadidates be must Applicant of age -18-40years the local - from community -permanent resident -Married preferably with not - children less than 2 years of age Test: and numeracy Interview: on motivation and willingness final selectionby and community local health center

Child Health CHW Health Child competencies Key Table 4: Table *Volunteers (community members who volunteer few hours a week) Salaried hours a week) (full time CHWs) few (community members who volunteer *Volunteers

37 Competencies relevant for CHWs rendering services in the far This is an extremely important area and de- flung areas especially those with geographical pendent upon the primary focus of the CHW constraints as in mountainous or desert areas so program, may include a blend of promotive, that the CHWs can perform outreach functions. preventive, therapeutic and rehabilitative services. While CHWs have played a significant role Supervision in various promotive, preventive and therapeu- Supervision and support are two pillars on tic MNCH services, there is great potential for which a strong and successful program set its playing a major role in the screening, recogni- base.1 It is equally acknowledged, however, that tion and subsequent rehabilitation of patients supervision is often among the weakest links in with TB, STIs, NCDs, HIV/AIDS and selected di- CHW programs. Among studies we reviewed, sabilities. It is recommended that the rehabilita- we found that small-scale projects were succes- tion component also be added to their training sful because they handled to institute effectual curriculum. support and supervisory system for CHWs, often including a significant amount of supervision Certification & Appointment and oversight by the community itself.1 National Certification after training and promotion after programs, on the other hand, are rarely able to some years of service as CHW supervisor can achieve this consistently. Evaluations have do- also act as an incentive and keep CHWs actively cumented the flaw of monitoring and support involved in pursuit of professional advance- in national programs, which are often irregular ment. A clear salaried post must be earmarked or nonexistent.1 In the nastiest cases, CHWs do for CHWs. Too often CHWs have been identified not even know who their supervisors when the as “community volunteers” and given a below programs had a clear supervisory system.46 In minimal wage under that consideration. This few CHW programs, we found that supervisors dichotomy should be removed and a clear were formal health staff from the health services, appointment/deployment strategy should be who, however, may not understand the CHWs available to those who certify the course com- or their own role properly and furthermore may pletion and pass the writing or verbal exam resent the additional task.46 The CHW programs at the end of training. The CHWs recruited for without supervision system have shown gaps training and deployment should sign a bond in program functionality in terms of inadequate for completing the training and service contract documentation and linkages with overall health of certain time period, failing to do which they system. should be held liable to a penalty. This will help reduce the dropout rates and ensure a sense of We would therefore recommend that super- commitment to service with responsibility well visors should be the members of community, before the CHW is into making. who again should be selected according to the set criteria. They should be trained and equip- Deployment ped with supervisory skills. Clear strategies and CHWs should always be posted in the areas that procedures for supervision and the activities they belong to so to assure maximal local enga- with which supervisors will be charged should gement and ownership. However, it is recogni- be well defined. The skills need to be taught so zed that given health worker needs, there may that health personnel, CHWs and community be exceptions. In that event, CHWs should be health committee members know what is ex- provided with safe and secure housing as well pected of them as supervisors.46 Supervisors as local transport as needed. This is particularly should be supportive and available to offer help

Global Evidence of Community Health Workers system linkages between and TBAs health system Referral Referral - Career Career pathway & pathway development Should be offered Should be offered advance their to as supervicareer sor on completion of minimum education level and experience reach to required the next level. incentives General or Performance Performance - identification of suspected case - sales of insecticide bed nets treated salaried volunteers * volunteers OR Salaried keeping in view that poor they are time Full employment Volunteer/ Volunteer/ Monitoring supervision Supervisors 1 supervisor: 20-25 CHWs Evaluation: annual internal evaluation external evaluation in every 5 year & evaluation process Certification Exam after initial training on passing exam and completion of initial training they should be with title awarded on completion of on-job training they should be with awarded a certificate CHW Contextual Factors CHW Contextual

& role (initial & ongoing) & role Training content, duration duration content, Training Promotive, preventive and preventive Promotive, key Role : Role key Initial: 1 weeks On-the-job: 2-3 weeks interventions: therapeutic for drugs with effective treatment - prompt suspected t all people especially children malaria have cost insecticide low access to - increased children especially for bed nets, treated and women women pregnant for - protection intermittent prophylaxis/ regular (e.g. treatment). preventive of malaria- Community-based treatment or Test with Rapid (testing Diagnostic malaria per for treatment presumptive national guidelines.) Educa- tional criteria primary level schooling to judge to Recommendations – Typology of Malaria Control CHW of Malaria Control Typology – Recommendations

on literacy

Recruitment

Community in Involvement identification of potential community health workers - Advertisement in local newspaper or radio channel interested for join to cadidates be must Applicant of age -18-40years the local - from community -permanent resident Test: and numeracy Interview: on motivation and willingness final selectionby and community local health center

Malaria control CHW control Malaria competencies Key Table 5: Table *Volunteers (community members who volunteer few hours a week) Salaried hours a week) (full time CHWs) few (community members who volunteer *Volunteers

39 where needed rather than policing and keeping Nutrition workers: an eye whether CHWs are on duty or are carrying Weighing scale, growth monitoring chart, Iron/ out the required amount of work.3 Supervision Folate, ORS, Anti-helminthics, pictorial material should be taught to be undertaken in a participa- for teaching tory manner. Top-down mechanistic supervision emphasizes the social distance between supervi- MNCH workers: sor and supervisee and leads to communication Iron/ folate, TT vaccine, anti-helminthics, family breakdowns and ultimately to program damage. planning methods, ORS, growth monitoring The guidelines for supervision should include a charts, weighing scale, antibiotics for case list of supervisory activities. The most important management, insecticide treated bed nets etc, element of supervision is ensuring the two-way pictorial material for teaching flow of information. It is also vital that the supervi- Malaria workers: sor acts as a role model so that their behavior can insecticide treated bed nets, malaria drugs, and be copied. It is also recognized that experienced rapid diagnostic test materials, pictorial material and competent CHWs may be allowed further for teaching training and opportunities for skills development to rise to a level of supervisors.47 In an ideal and TB and HIV/AIDS Workers: BCG vaccines, TB realistic situation, one supervisor should head 20 drugs, ART drugs for HIV /AIDS, condoms, picto- to 25 CHWs which allows strong supervisory sys- rial material for teaching tem as evident from lady health worker program (Pakistan) and BRAC (Bangladesh). Incentives Keeping in mind the dearth of health workers Equipment and Supplies and the rising need of CHWs to meet the health Issues such as the reliable provision of transport, care demands, it is imperative to prevent dro- drug supplies and equipment have been identi- pouts from training programs. CHWs are poor fied as another weak link in CHW effectiveness.1 people, living in poor communities, and thus The result is not only that they cannot do their require income. From the global and country job properly, but also that their standing in com- case studies review we found that programs munities is undermined. Failure to meet the ex- pay their CHWs either a salary or an honorarium pectations of these populations (with regard to and almost no examples exist of sustained com- supplies), destroys their image and credibility. If munity financing of CHWs.1 Even NGOs tend to CHWs are used in programs that have drug treat- find ways of financially rewarding their CHWs. ment at their core, such as TB DOTS or HAART, Moreover, control on attrition can be achieved the situation becomes more critical but most with regular and performance based financial programs include the need for supply of drugs incentives and hiring CHWs as full time em- and/or equipment, including transport.1 Ideally, ployees rather than part time volunteers.1 They supplies and equipment should be organized should also be given a wage if they work as full through district or regional dispensaries, and col- time, and those working as part time should be lected and delivered by CHWs.1 In cases where given small incentives for their work. We would villages are very remote to the central health make a strong recommendation for ensuring the centre, village dispensaries can be established CHWs be paid adequate wages commensurate to cater for the drug needs of the populations.48 with their work load and timings. Performance Equipment and supplies may be added perti- incentives could be the other pay back option, nent to the specific intervention that the CHW is which can also motivate them to work with full expected to work on as mentioned below. determination. Moreover, in kind awards, such

Global Evidence of Community Health Workers as an identification pin, can provide a sense of centive for career development. pride in their work and increased status in their communities.1 In cases where possible, free Documentation, Information System and health coverage for themselves and for their fa- Referral System mily should be provided. In the end, we would In many programs, health facility workers who recommend that CHWs should be given pay for come into most contact with CHWs are not performance to keep them stimulated.43 We involved in the planning, implementation, mo- have also proposed some basic MDGS specific nitoring and evaluation of these programs.1 A performance based incentives for CHWs. proper linkage is therefore required to be created with health system right from the planning Nutrition workers: of introducing the CHW program in some vici- identification of severally malnourished child, nity to the implementation of actual program. monitoring growth of a child over the period of CHWs should be properly linked in to how they 1 year. would be referring a case to the health centre and how the documentation would take place MNCH workers: to prevent duplication in case report. pregnancy identification, bringing mothers for institutional deliveries, providing essential new- Evaluation born care, referral of a complicated pregnancy It is necessary to keep up with the changing case, ensuring taking birth weight, identifica- demands of the health care needs of com- tion of sick newborn, completion of essential munity in terms of both supplies and services. immunization. Moreover, the effect of the additional workload Malaria workers: on the trained CHWs also need to be monitored, identification of suspected case. to ensure that the they are not being overbur- dened and that there is no detrimental effect on TB and HIV/AIDS Workers: the provision and supervision of services to the completion of DOTS therapy for a cure of TB, community. As such both external and internal identification of symptomatic case, identifica- evaluations need to be carried out on regular tion of HIV positive pregnant women, leading basis to improve the services and analyze the monthly support group meeting with HIV/ AIDS need of various logistics, supplies and training patients. according to the requirements. We would recommend that programs should evaluate their Professional advancement own performance on annual basis, while a third Professional advancement is another way out for party evaluation could be recommended in controlling attrition among CHWs and ensuring every 4-5 years, which would generate a neutral continued interest and enthusiasm. In addition and free from bias findings. We would make a to potential rise to the level of supervisors men- special plea for publishing such evaluations and tioned above, other opportunities for career as much as possible, utilizing innovative, quasi- development and additional training must be experimental designs to assess impact of such provided. Some countries are actively explo- programs. ring distance education and support programs for CHWs. Career enhancement opportunities Self-Protection of CHWs should be offered on completion of minimum While delivering health care to the community education level and experience required to these CHWs are themselves at risk of contac- reach the next level and may be used as an in- ting infectious diseases. They are especially at

41 *Volunteers members who volunteer (community few hours a week)(full time CHWs) Salaried Table 6: Key TB DOTS CHW competencies

center local health community and by final selection and willingness on motivation Interview: and numeracy Test: ted TB treatment who have comple- Preferably people resident-permanent community - from the local -18-40years of age Applicant must be cadidates to join for interested radio channel or local newspaper in - Advertisement workers health community of potential identification Involvement in Community Recruitment on literacy on literacy

Recommendations – Typology of TB DOTS CHW to judge schooling level primary criteria tional Educa- symptomatic case -DOTS to cure TB identification for resistance strains -early transmission and emergence of drug - DOTS for infectious case to prevent - BCG immunization for children Tuberculosis: and rehabilitative interventions: once Ongoing: month per 4 weeks Initial: key Role : Promotive, preventive, therapeutic Training content, duration & role (initial & ongoing)

CHW Contextual Factors a certificate awarded with should be they on-job training on completion of awarded with title should be they of initial training and completion on passing exam initial training Exam after Certification Certification process & evaluation every 5 year every in evaluation external evaluation annual internal Evaluation: 20-25 CHWs 1 supervisor: Supervisors supervision supervision Monitoring Monitoring Volunteer/ employment Full time arethey poor that view in keeping Salaried OR volunteers * salaried symptomatic case - identification of for cure of TB DOTS therapy - completion of Performance General or incentives the next level.the next required to reach and experience education level of minimum sor on completion career as supervi to advance their Should be offered development pathway & Career - Referral system health TBAs and between linkages system

Global Evidence of Community Health Workers system linkages between and TBAs health system Referral Referral - Career Career pathway & pathway development Should be offered Should be offered advance their to as supervicareer sor on completion of minimum education level and experience reach to required the next level. incentives General or Performance Performance - identification of HIV pregnant positive women - leading monthly support group meeting with HIV/AIDs patients salaried volunteers * volunteers OR Salaried keeping in view that poor they are time Full employment Volunteer/ Volunteer/ Monitoring supervision Supervisors 1 supervisor: 20-25 CHWs Evaluation: annual internal evaluation external evaluation in every 5 year & evaluation process Certification Exam after initial training on passing exam and completion of initial training they should be with title awarded on completion of on-job training they should be with awarded a certificate CHW Contextual Factors CHW Contextual

& role (initial & ongoing) & role Training content, duration duration content, Training key Role : Role key Promotive, preventive and preventive Promotive, Initial: 4 weeks per month Ongoing: once interventions: therapeutic HIV /AIDS: sex and other safe - condom promotion health promotion TB and education on information - Provide community increase awareness and HIV to and their of both infections inter-relationship, case finding in - Intensify tuberculosis of high HIV prevalence, areas - Building HIV support in the groups social and psychological community for rehabilitation. PMTCT: timing and spacing of pregnancy - Healthy women pregnant to - antibody testing and mothers ARVs/HAART- prophylactic ARVs/HAART- prophylactic infants to - early infant diagnosis (CPT) therapy preventive - Cotrimoxazole Educa- tional criteria primary level schooling to judge to Recommendations – Typology of HIV/AIDS Care CHW of HIV/AIDS Care Typology – Recommendations

on literacy

Recruitment

Community in Involvement identification of potential community health workers - Advertisement in local newspaper or radio channel interested for join to cadidates be must Applicant of age -18-40years the local - from community -permanent resident people Preferably AIDs or those have taken who have family of any care member with AIDS Test: and numeracy Interview: on motivation and willingness final selectionby and community local health center

HIV/AIDS Care CHW Care HIV/AIDS competencies Key Table 7: Table *Volunteers (community members who volunteer few hours a week) Salaried hours a week) (full time CHWs) few (community members who volunteer *Volunteers

43 the risk of air borne and blood borne diseases on the overall performance and impact of the while treating TB patients and while conducting program. Also, where the need of alternative deliveries and must therefore receive available health providers is more pressing, task shifting preventive vaccines such as Hepatitis B, H1N1 with CHWs assuming basic curative tasks should vaccine etc. We also strongly recommend that be implemented and evaluated. they should be armed with appropriate tools and training to safe practices and prevention Short duration training programs, with mostly strategies against common communicable di- promotional, preventive and basic curative tasks seases such as TB, hepatitis and HIV. for CHWs and with a relatively strong supervision system such as BRAC in Bangladesh and Up till now we recommended some general and VHV in Thailand are associated with increased MDGs specific CHW typology, their entry and coverage and utilization of health services and training criteria, certification and deployment with certain improved health outcomes, and pathways, core functions etc., which might not should be implemented in other settings. Such work in all scenarios. Therefore, we finish by ma- programs have been implemented in contexts king recommendations based on the evidence with relatively strong health systems and have of what works and what not in different settings, been effectively linked to the health system. building on the constructed typology, on the global review of evidence, and on the country Short to intermediate duration training pro- case studies. grams, with preventive and basic curative tasks for CHWs, with relatively strong supervision acti- Long duration training programs with a content vities, and implemented by NGOs within a weak mostly promotional and preventive, and also health system, have shown to have impact on aimed at understanding social and environmen- infant mortality in the area of influence of invol- tal determinants of health, strongly supervised, ved NGOs (Haiti). Their impact when implemen- with CHWs playing basically a role of empower- ted at scale is not known. ment of the community and health promotional and preventive activities improve health of the Limitations population and should be replicated in other settings. This type of program seems to work on The review identified a number of limitations. the condition that CHWs activities are organized Firstly, most of the reviewed studies when im- as part of a wider health team and on the condi- plemented, neglected to document the com- tion that programs are effectively linked to the plete description and characteristics of CHWs public health system that is able to provide effi- deployed, especially the level and amount of cient stewardship and financing, and that consi- supervision provided to those workers, which ders health as a basic human right that should could have helped us in identifying the im- be available to all citizens, free at the point of portance of this factor and its association with use. There is no evidence on whether this mo- other outcomes. Additional information on the del could be equally effective when delivered initial level of education of CHWs, provision of by private providers. Several years of schooling refresher training, mode of training (balance as a selection and recruitment criterion seems of practical/ theoretical sessions) would have unpractical, and alternatively, basic schooling provided greater assistance in understanding or literacy as a minimum requirement should the threshold effect, if any, of these factors on be attempted, while taking care of monitoring CHW performance in community settings. and evaluating the effect of such modification Importantly, community ownership and super-

Global Evidence of Community Health Workers Key messages on integration of CHWs at national level

Planning, production and deployment: population served, and promote shared decision ma- The programs should be coherently inserted in the king among the program’s governing body, staff, and wider health system, and CHWs should be explicitly community health workers. included within the HRH strategic planning at country CHW programs should also ensure a regular and sus- and local level. tainable remuneration package that is complemented Given the broad role that many CHWs play in primary with other rewards and incentives. care, a program must assure that a core set of skills CHW programs should also provide opportunities for and information related to MDGs be provided to most career mobility and professional development. These CHWs. Therefore, the curriculum should incorporate should include opportunities for continuing educa- scientific knowledge about preventive and basic me- tion, professional recognition, and career advance- dical care, yet relate these ideas to local issues and ment. This can be through specific programmatic cultural traditions. They should be trained, as required, opportunities or access to educational and training on the promotive, preventive, curative and rehabi- scholarships. litative aspects of care related to maternal, newborn and child health, malaria, tuberculosis, HIV/AIDs as The CHW programs should support provision of requi- well as other communicable and non-communicable site and appropriate core supplies and equipment to diseases. Other training content and training duration enable appropriate functionality of such workers. may be added pertinent to the specific intervention Performance management that the CHW is expected to work on as detailed in The CHW programs should also ensure that the perfor- main report. mance management is based on minimum standardi- The CHW programs should also give attention to both zed set of skills that respond to community needs and the content and the timings of delivering interven- are context specific. tions at the planning stage. The programs should have established referral proto- The CHW programs should regulate a clear selection/ cols with community-based health and social service deployment procedure (ideally engage community in agencies. planning, selecting, implementing, and monitoring) The programs should have regular and continuous that reassures appointing those who certify the course supervision and monitoring systems in place and completion and pass the writing or verbal exam at the supervision should be taught to be undertaken in a end of training. participatory manner that ensure two-way flow of Government should take responsibility in making a information. Moreover, both external and internal transparent system for selection and deployment and evaluations need to be carried out on regular basis further quality assurance of the regulated set system. to improve the services and analyze the need of various logistics, supplies and training according to the On scaling up a CHW program, decision makers should requirements. Ideally, programs should evaluate their consider how to link them up with the wider health own performance on annual basis, while a third party system. evaluation could be recommended in every 4-5 years, Attraction and retention which would generate a neutral and free from bias Community preparedness and engagement is a vital findings. element that is relatively rarely practiced. From the The outline of the country plan of action to develop outset, program should develop village health com- and improve CHW program(s) should be finalized by mittees in the community that can also contribute in a working group of relevant multiple stakeholders, participatory selection processes of CHWs.1 including identification of resources needed, indica- CHW programs should be based in and respond to tors and targets, and monitoring tools, and formally community needs. In practical terms, such programs authorized by the Ministry of Health should continually assess community health needs Finally, sustained resources should be available to sup- and demographics, hire staff from the community port the program and workers therein. who reflects the linguistic and cultural diversity of the

45 vision of CHWs is a key characteristic which is to explore the impact of deploying CHW with insufficiently described and analyzed in availa- suggested typology on achieving MDGs. ble literature. Secondly, studies related to the role of CHWs in HIV/AIDS prevention and care, During the course of undertaking this review, we mental health and food security and nutrition found dearth of data on the cost effectiveness were scarce. Lastly, there were few evaluation of CHW programs. Although it was not the aim studies/reports at scale and none had followed of this review, but economic studies should ac- an a-priori experimental design or impact asses- company trials to establish the cost effectiveness sment process. of different CHW interventions, because CHWs are more accessible and acceptable to clients in their communities, and they are expected to Conclusion and Areas improve the overall coverage of services as well as equity. Studies are needed to assess whether for Further Study the CHW programs promote equity and access; The UN Secretary General Ban Ki-moon said: and to evaluate the effectiveness of paid workers “Time is short. We must seize this historic mo- versus voluntary workers. Moreover, studies are ment to act responsibly and decisively for the needed to evaluate the effectiveness of CHWs as common good”. He used these words to stron- compared to professional health care providers gly urge the governments to work constructi- in delivering interventions in the fields of health vely for a high level meeting in September 2010 education, promotion and the management of 2 to review their country’s progress towards the disease. MDGs. With just six years left to meet the MDG 2015 deadline a gigantic responsibility rests on Given the global burden, specific studies on the shoulders of governments to upscale health the potential role of CHWs in HIV/AIDS pre- and nutrition interventions and provide adequa- vention and care are particularly required, as te funding and support to their health systems there is very limited empirical information on to fulfill the pact they signed way back in 2000 this. Analysis on the effectiveness of different as the UN Millennium Declaration. Induction of models of remuneration/ payment/ incentiviza- more workforces into the programs as CHWs tion of CHWs across different tasks and settings and supervisors with ascertained commitment needs to be examined. Studies are also required can greatly help us achieve MDG targets. It is to compare the effectiveness of promotive/ expected that increased emphasis on the issue preventive strategies compared to curative in- of HIV in the training module of a CHW, field terventions delivered by CHWs for maternal and experience before deployment, better super- newborn health. Further systematic reviews are vision, switching them from volunteers to full also required on: factors affecting the sustaina- time paid health care workers and regular eva- bility of CHW interventions when scaled up; the luation can lead to a stronger outreach system effectiveness of different approaches to ensure of healthcare delivery and could eventually help program sustainability; the cost-effectiveness of meet the MDG targets. CHW interventions for different health issues; and factors that determine the effectiveness of We constructed a core and MDGs specific CHW CHW interventions in different settings. An addi- typology from the evidences and gaps identi- tional analysis is required on the volume of work fied from global systematic review and country and type of activities and hence to determine 3 case studies. The next step which is required is the number of CHWs required for such tasks. An example of this type of analysis is provided by a

Global Evidence of Community Health Workers study in Bangladesh which assessed how many additional health workers would be needed to implement IMCI protocols.49 However, further studies are needed to determine the CHW workforce needed and their functional needs for MDG specific interventions. Further research is also needed on how CHWs are linked to the wider health system (e.g. in terms of referrals, supervision) and the impacts of the cadre on the health system. Moreover, research is required to identify innovative mechanisms of maintaining the sustainability of CHW programs.

47 References: 1 What works for children in South Asia: 9 Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong Community Health Workers P, Starrs A, Lawn JE RH, Wilczynska-Ketende K, http://www.unicef.org/rosa/community.pdf. Hill K. Continuum of care for maternal, newborn Kathmandu, Nepal UNICEF 2004. and child health: from slogan to service delivery. Lancet. 2007;370:1358-1369. 2 Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community 10 Bhutta ZA, Ali S, Cousens S, et al. Interventions to health care for maternal and child health and the address maternal, newborn and child survival: management of infectious diseases. Cochrane what difference can integrated primary health Database of Systematic Reviews 2010;Issue 3. care strategies make? Lancet. 2008;372:972- Art. No.: CD004015. DOI: 10.1002/14651858. 989. CD004015. 11 Adam T, Lim SS, Mehta S, et al. Cost effectiveness 3 Abbatt F. Scaling up health and education analysis of strategies for maternal and neonatal workers: community health workers: literature health in developing countries. British Medical review London DFID, Health Systems Resource Journal. 2005;331:1107. Centre March 2005. 12 Graham WJ, Cairns J, Bhattacharya S, Bullough 4 Jones G SR, Black RE, Bhutta ZA, Morris SS,. CHW, Quayyum Z, K R. «Maternal and perinatal Bellagio Child Survival Study Group. How many conditions.» 2006. Disease Control Priorities in child deaths can we prevent this year? . Lancet. Developing Countries. 2nd ed. New York: Oxford 2003;362:65-71. University Press; 2006

5 Darmstadt GL BZ, Cousens S, Adam T, Walker N, 13 Haws RA, Thomas AL, Bhutta ZA, Darmstadt GL. de Bernis L,. Lancet Neonatal Survival Steering Impact of packaged interventions on neonatal Team. Evidence-based, cost-effective interven- health: a review of the evidence Health Policy tions: how many newborn babies can we save? and Planning. 2007;22:193-215. Lancet. 2005;365:977-988. 14 Bhutta ZA, Darmstadt GL, Lawn R, Goldenberg R. 6 Campbell OM, Graham WJ. Lancet Maternal A global review of interventions to address still- Survival Series Steering Group. Strategies for births. BMC Pregnancy and Child Birth. 2009. reducing maternal mortality: getting on with what works. Lancet. 2006;368:1284-1299. 15 Bhutta ZA, Soofi SB. Community based newborn care: are we there yet? Lancet. 2008;372:1124- 7 Engle PL, Black MM, Berham JR, et al. International 1126. Child Development Steering Group. Strategies to avoid the loss of developmental potential 16 Travis P, Bennett S, Haines A, et al. et al. in more than 200 million children in the deve- Overcoming health-systems constraints to loping world Lancet. 2007;369:229-242. achieve the Millennium Development Goals. Lancet. 2004;364(9437):900-906. 8 Bhutta ZA, Ahmed T, Black RE, et al. Maternal and child Undernutrition Study Group. What works? 17 World Health Organization. The global shortage interventions for maternal and child undernutri- of health workers and its impact. . WHO Fact tion and Survival. Lancet. 2008;371:417-440. sheet 302. 2006.

Global Evidence of Community Health Workers 18 Fraser B. Human resources for health in the te of evidence on programmes, activities, costs Americas. Lancet. 2007;369(9557):179-180. and impact of health outcomes of using health workers. Geneva: World Health Organization; 19 Haines A, Sanders D, Lehmann U, et al. 2007. Achieving child survival goals: potential contribution of community health workers. Lancet. 28 Rocha R SR. Evaluating the Impact of Community- 2007;369:2121-2131. Based Health Interventions: Evidence from Brazil’s Family Health Program. Discussion Paper 20 Earp JA, Falx VL. What lay health advisors do: Series. IZA DP No. 4119. Discussion Paper No. an evaluation of advisors activities. Cancer 4119. Bonn, April 2009. Practionor 1999;7(1):16-21. 29 Oxford Policy Management. Lady Health Worker 21 Rosenthal EL. A summary of national commu- Programme: External Evaluation of the National nity health advisor study. Baltimore, MD: Annie Programme for Family Planning and Primary E Casey Foundation; 1998. Health Care 1999-2002: Final Report: Oxford Policy Management March 2002. 22 World Health Organization. Strengthening the performance of community health workers in 30 Kash BA, May ML, Tai-Seale M. Community health primary health care: a report from a WHO study worker training and certification programs in the group. Geneva: World Health Organization; United states: findings from a national survey. 1989. Health Policy and Management. 2007;80(1):32-42.

23 Kurowski C, Wyss K, Adbulla S, Mills A. Scaling 31 Lehman U, D S. Community health workers: up priority health interventions in Tanzania: the what do we know about them? World Health human resource challenge. Health Policy and Organization Planning. 2007;22(3):113-127. http://www.who.int/hrh/documents/commu- nity_health_workers.pdf 24 World Health Organization. Taking stock: health accessed on 14.10.2009; 2007. worker shortages and the response to AIDS. Geneva: World Health Organization; 2006. 32 Crigler L, Hill K. Rapid assessment of community health worker programs in USAID priority MCH 25 Standing H, Chowdhury AM. Producing effective countries USAID Health Care Improvement knowledge agents in a pluristic environment: Project 2009. what future for community health workers? Social Science and Medicine. 2008;66(10):2096- 33 Lassi ZS, Haider BA, Bhutta ZA. Community- 2107. based intervention packages for preventing maternal morbidity and mortality and impro- 26 Macinko J, Guanais FC, Souza MdFMd. ving neonatal outcomes. Cochrane Database of Evaluation of the impact of the family health Systematic Reviews 2010 [Submitted]. program on infant mortality in Brazil, 1990-2002. Journal of Epidemiological Community health. 34 Lassi ZS, Haider BA, Bhutta ZA. Community- 2006;60(1):13-19. based intervention packages for preventing maternal morbidity and mortality and impro- 27 World Health Organization. Community Health ving neonatal outcomes.: International Initiative Workers: what do we know about them? the sta- for Impact Evaluation.; March 2010.

49 35 Panpanich R, Garner P. Growth monitoring in 44 Management of sick children by community children. Cochrane Database Syst Rev. 2000;2:1- health workers. http://whqlibdoc.who.int/pu- 11. blications/2006/9789280639858_eng.pdf. Geneva, Switzerland World Health Organization 36 Dale J, Caramlau IO, Lindenmeyer A, Williams and UNICEF January 2006. SM. Peer support telephone calls for improving health Cochrane Database of Systematic 45 Curtale F, Siwakoti B, Lagrosa C, LaRaja M, Guerra Reviews. 2008; Issue 4. Art. No.: CD006903. DOI: R. Improving skills and utilization of community 10.1002/14651858.CD006903.pub2. health volunteers in Nepal. Social Science and Medicine. 1995;40(8):1117-1125. 37 Dyson L, McCormick FM, Renfrew MJ. Interventions for promoting the initiation of 46 Lehman U, Sanders D. What do we know about breastfeeding. Cochrane Database of Systematic them? The state of the evidence of program- Reviews. 2005;Issue 2. Art. No.: CD001688. DOI: mes, activities, costs and impact on health 10.1002/14651858.CD001688.pub2. outcomes of using community health workers http://www.who.int/hrh/documents/commu- 38 Volmink J, Garner P. Directly observed therapy nity_health_workers.pdf. Geneva: World Health for treating tuberculosis. Cochrane Database of Organization January 2007. Systematic Reviews. 2007(4). 47 Haines A, Sanders D, Lehmann U, et al. Achieving 39 Achieving the Millennium Development Goals child survival goals: potential contribution in Africa 2008. of community health workers. The Lancet. 2007;369(9579):2121-2131. 40 Khan Z, Iqbal Z, Rahman A. Job stress among community health workers: a multi-method 48 Ofosu-Amaah V. National experience in the use study from Pakistan International Journal of of community health workers: a review of cur- Mental Health System 2008;2(15). rent issues and problems Geneva: World Health Organization 1983. 41 Khan SH, Chowdhury AMR, Karim F, Barua MK. Training and retraining Shasthyo Shebika: 49 Khan MM, Ahmed S, Saha KK. Implementing IMCI reasons for turnover of community health wor- in a developing country: estimating the need for kers in Bangladesh. The Health Care Supervisor additional health workers in Bangladesh; 2000. 1998;17(1):37-47.

42 Delacollette C, Stuyft PVd, Molima K. Using community health workers for malaria control: experience in Zaire. Bull World Health Organ. 1996;74(4):423-430.

43 Bhattacharyya K, Winch P, LeBan K, Tien M. Community health worker incentives and disin- centives: how they affect motivation, retention and sustainability Virginia: BASICS II for the USAID October 2001.

Global Evidence of Community Health Workers 51 Annex 1: G l o b a l S y s te m a t i c Review

For global systematic review, the studies were out of which 326 papers (266 original studies) categorized based on interventions relevant passed the eligibility criteria for inclusion. Among to health and nutrition related MDGs and then these 326 papers, 240 papers described the role analyzed by the type of outreach workers and of CHWs in delivering interventions, 40 studies study design employed in order to explore the trained TBAs and evaluated the impact of their impact and effectiveness of global experience training, and nineteen studies utilized peer of CHWs in delivering healthcare. This helped us counselors, while 7 described the role of com- in outlining the typology, training and supervi- munity mobilizers. As far as study designs are sion needs, tasks and feasibility of developing concerned, 87 were cRCTs/RCTs, 42 were Quasi and deploying CHWs as a way towards the RCTs, 34 were prospective before-after interven- achievement of the MDG targets. We have also tion studies and 147 were descriptive studies. presented some national or NGO driven CHW Box 2 presents the included studies according programs in the form of “CHW Snapshots” ap- to country and continent where it was actually pearing randomly in this report. conducted. During our search we also identified six ongoing studies which matched our eligibi- Description of included studies lity criteria and are described in table 8. The defined search strategy identified 136,996 studies from multiple search engines (Figure 1). 1060 studies were retrieved for full text review,

Box 2: Included studies by continent and country Asia n Africa n Europe n America n Australia n

Bangladesh 30 Burkina Faso 6 England 3 Bolivia 4 Australia 1 Burma 3 Cameroon 2 Ireland 1 Brazil 10 New Zealand 2 China 2 Egypt 1 Netherlands 1 Canada 2 India 35 Ethiopia 6 Scotland 1 Colombia 2 Iran 2 Gambia 7 Turkey 2 Ecuador 2 Indonesia 2 Ghana 5 Guatemala 6 Iraq 2 Guinea 1 Haiti 5 Korea 1 Madagascar 1 Latin America 1 Laos 1 Mali 2 Mexico 2 Malaysia 1 Malawi 3 New England 3 Nepal 11 Mozambique 1 Nicaragua 1 Pakistan 19 Nigeria 5 Peru 4 Palestine 1 Kenya 8 United States 56 Philippines 2 Rwanda 1 Thailand 8 Senegal 1 Vietnam 2 Sierra Leon 1 South Africa 7 Swaziland 1 Tanzania 8 Uganda 10 Zaire 1 Zambia 2 Zimbabwe 1

Global Evidence of Community Health Workers Figure 1: Search Flow diagram

Search Strategy Identified 136,995 studies PubMed = 67166 Popline = 27938 Google Scholar = 18400 Science Direct = 19238 Cochrane Trial Register = 4253 Gray literature Capacity Project = 312 Excluded 136099 papers HRH Global Resource Center = 162 from first screen World Bank JOLIS = 78 BLDS = 22 IDEAS = 49

1060 were retrieved for full text review 735 Excluded: 40 review papers and 705 did not meet the inclusion criteria

326 Papers (266 original papers) included for review

6 ongoing studies (not included in analysis)

By type of outreach worker By design By Target MDGs

CHWs 240 cRCT / RCT 87 MDG 1: Nutrition

TBAs Quasi RCT 42 MDG 4: Child Health

Community mobilizers 7 Pre/post 34 MDG 5: Maternal Health 75

Peer counselors 19 Descriptive 147 MDG 6: Malaria/TB/HIV/NCD /Mental health / NCDs 97

53 Anticipated Anticipated end date Dec 2010 Dec 2011 01/01/2010 01/06/2010 01/01/2010 Trial Trial registration number NCT00675389 NCT00850915 ISRCTN96256793 ISRCTN45752079 ISRCTN87820538 - - Outcomes suppression Virologic at 6 months at failure Virologic intervals time all ARTfrom initiation measured Adherence pill counts by TB , inci incidence of events, dence of adverse TB-related incidence of in householdsymptoms of proportion contacts household contacts star discontinuing IPT, ting IPT, adhering IPT treatment to Neonatal mortality rate. deliveryAntenatal, and uptake. postnatal care exclusive of duration The rate its and breastfeeding at 6 months Psychological at 3 and 6 months distress Neonatal mortality rates, stillbirth maternal rates, Sepsis ratios, mortality management - - - Patients in communities communities in Patients without peer educators. In care, line with routine cases index eligible send to requested are their contacts the to evaluation clinic for does group control The an interven not receive benefit areas Control tion. service health the from activities of theprovision Newborn for Initiative City mater Health: improved at care newborn and nal maternityhealth posts, general hospitalshomes, and tertiary hospitals. arm control The a similar will receive number of visits routine breastfee counseling for different ding through Workers. Lady Health group control The does not receive an intervention. Control arm Control - - In - - Interventions Peer health workers Peer Table 8: Ongoing Trials/ Studies Trials/ 8: Ongoing Table community health workers. workers. health community Experimental arm Experimental Workers Health Peer Experimental A: Intervention: on ART who PLWHA themselves are good ART demonstrated adhe have peersThe at least 6 months. for rence and patients ~15-20 for responsible are visit the patients in expected to are their homes once every two weeks. Workers Health Peer Experimental B: and Mobile Intervention: Phone the peer health workeraddition to inter phone mobile a adds arm this vention, the hou In the intervention group, TB/HIV sehold contacts of enrolled home at visited are patient co-infected by isoniazid at 300mg (5 offered They are 6 once daily for children) mg per Kg for of their HIV-status. regardless months, commu will convene Facilitator maternal explore to nity groups Groups issues. health neonatal and will meet once or twice monthly action through research and move is of the facilitator role The cycles. groups, activate & strengthen to support them in identifying problems, plan possible solutions andhelp to implementation & monitoring of in the community. solution strategies seven receive will arm intervention The sessions of this maternal focused breastfeeding promote to approach Workers. Lady Health through monthly will be convening CHWs in which they will groups women’s problems the prioritize identify, and implementand then develop their success. and evaluate strategies for care will be trained to CHWs vulnerable newborn infants. -

rd - Participants General population status with HIV positive and older Years 15 population birth who give Women gives who woman any or is area study the in birth a participant.potentially age range would The 49 years. be 12 to Married, consenting wo men, aged 17 – 40 years. in their 3 Pregnant; trimester of pregnancy of repro Women infantsductive age, of age. under a year Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs cRCT cRCT cRCT cRCT cRCT Study Study design 2 3 4 5 1 Study / Study country Ronald Uganda & Chakaya Klinkenberg Kenya Osrin et al.2008 India Rahman Pakistan Costello Nepal

Global Evidence of Community Health Workers Anticipated Anticipated end date completed Trial Trial registration number NCT00518856 - Outcomes perinatalNeonatal, & sepsis related mortality cost effec successful tiveness, nevirapine of delivery HIV to prophylaxis exposed deliveries Active Comparator TBAs TBAs Comparator Active current with continuing of practice standard Control arm Control Interventions Experimental arm Experimental attendants birth traditional Training version of the neonatala modified (NRP) and by protocol resuscitation sepsis identify to ability their improving antibiotics in the field. and initiate Participants TBA trained in deliverysafe Outreach Outreach worker TBAs cRCT Study Study design 6 Study / Study country Gill Lufwanyama, Zambia

55 Results According to WHO, CHWs should be members Maternal, Neonatal and Child health of the communities where they work, should interventions be selected by the communities, should be o Maternal health interventions answerable to the communities for their activi- o Breastfeeding promotion interventions ties, should be supported by the health system o Birth and Newborn Care Preparedness (BNCP) but not necessarily a part of its organization interventions and have shorter training than professional o Neonatal health interventions workers.7 o Childhood illnesses and immunization interventions CHWs were first formally introduced in 1970s and 80s after Alma Ata declaration for the initiation Other Primary health care promotion and provision of primary health care services at interventions grass root levels to entire population.8 However, they gained their popularity due to the shortage Malaria control interventions of human resources for health care.8 They not only support in the promotional and prevention Tuberculosis control interventions activities but also take part in the management and treatment of illnesses.8,9 HIV/ AIDS prevention and control interventions

CHW programs have been said to be able to Mental Health interventions provide three major benefits: health benefits including improvement in health indicators, Other non communicable diseases prevention utilization of health services and changes in interventions behaviours directly related to health; non- health benefits to individuals including infor- Nutritional Interventions mational benefits, cultural appropriateness and the promotion of autonomy; and non-health Background social benefits which can include community The first seven Millennium Development Goals empowerment sustainability and economic are directly or indirectly linked with the activities benefits. While now being acknowledged as a of the health and nutrition. There are many sy- potential important tool in improving health, nergies among these goals and related activities, CHW programs are often held back by unrealistic and nutrition underlies achievement for most expectations, poor initial planning, problems of of the health MDGs, so working for all MDGs at sustainability and the difficulties of maintaining the same time, such as education, water and quality.10 sanitation, and gender is likely to be the most effective way of achieving progress in health Studies according to MDGs and nutrition goals. Every year, it is estimated that under nutrition contributes to the deaths In this global systematic review, we grouped and of about 5.6 million children under the age of analyzed selected studies according to health five.11 One out of every four children under related MDGs. Studies are clustered according five or 146 million children in the developing to the following categories: world is underweight for his or her age, and at increased risk of an early death. When nutrition Nutritional interventions falls short, damage is done to individuals and to society. When pregnant women are not ade-

Global Evidence of Community Health Workers quately nourished, their babies are born at low (Table 9A and Table 9B). Those recruited were weights, putting their survival at risk. When girls mostly locals from the community.12-16 They are undernourished, their future ability to bear were trained using didactic mode of trai- healthy children is threatened. Under-nutrition ning12-15 and the training content varied from and micronutrient deficiencies can lead to de- health education on nutritional requirements of velopmental delays throughout childhood and mother and child12-14 to the counseling related adolescence, making individuals less produc- to nutritional consumption with limited finan- tive as adults. Prevention and control of under cial resources.15 nutrition is possible through simple community based interventions lead by community wor- In Hossain et al., children were weighed and their kers. We therefore included studies that initiated care giver was counseled on health, family plan- community based nutrition interventions by ning, breast feeding, caring practices, personal community workers and monitored their results hygiene and the use of iodized salt.13 Children in creating an impact on improving nutritional who did not gain weight in three consecutive health of community. months were enrolled in a supplementary feeding program and provided standard packets Community Based Evidence of food.13 However the intervention did not show any impact on evaluation by pre/post A total of ten studies were reviewed to assess intervention questionnaire as compared to in- the impact of nutrition related interven- terventions where only counseling on nutrition tions involving the CHWs in the community was provided.12,15,16 The CHWs in the Staten et

CHW Snapshot 1 Village Health Workers Program Bhutan

Program overview Bhutan initiated its Community health workers program in 1979 with the name of village health workers program. Their basic idea was to build a link between community and health service utilization. Through this program the concept of primary health care was disseminated and includes improvement in basic hygiene and sanitations prevention of vaccine preventable diseases and other preventive and promotive aspects of health.

Operational aspects and considerations Village health workers were selected if they were found confident, Village Health Workers, Bhutan trusted and popular in the community, living permanently in the Training 12 days training community and had a good personal hygiene and health care and Supervision BHU staff community participation. Their role in the community is to pro- Incentive voluntary and only receive vide health education towards better health care, including family financial benefit during training planning, provide simple first aid treatment for emergencies and minor illnesses, notification of the outbreak of any epidemics in the community, recognizing danger signs and symptoms of serious and chronic patients, playing an important role in outreach clinics and expanded program of immunization and referral to the nearest health centre. They are also expected to participate in any development activities in the community, for example electricity and water programs.

Coverage and effectiveness Village health workers have been recognized as a positive force in the community at all levels, including the National Assembly. There is a great demand for VHW training from those communities which do not have VHWs, either, because no-one was trained before or, to replace the drop-outs. However, as the program is totally dependent on donors, even maintaining the network of close to 1,300 VHWs is becoming a challenge. Source: Unicef 2004 18

57 Conclusion al. organized bi-monthly walks and encouraged Overall the role of CHWs involved in nutritional the participants to find walking partners and intervention was promotive in nature and had support each other in health improving goals17 a preventive baseline strategy. They promoted and also encouraged each other to increase health education with positive impact on ma- their fruit and vegetable intake.17 The CHWs ternal and child health, thus contributing to the who participated in the Tandon et al. conducted achievement of MDG goal 4 and 5 targets. We nutrition program for the preschool children, found that simple promotive interventions lead pregnant women and lactating mothers.12 The to create an impact on the nutritional status effectiveness of this intervention were evalua- of children, pregnant women and society as a ted by the outcomes of counseling which did whole. not create an impact on the nutritional status of children as evident by 0.1% decrease in severe malnutrition cases over the period of 8 years.12Health education on topics like hygiene, proper positioning of infant while feeding and adequate nutrition was the domain of CHWs in Zuvekas et al.19 The CHWs in Winchagoon et al. monitored growth of children and managed diarrhea using oral rehydration solution.14

In an intervention by Winch et al., the CHWs provided dispersible zinc tablets in 14-tablet blister packs for children under five years of age.20 The Macharia et al., cross-sectional study on the other hand provided region specific data on the nutrition status in the world.21 Only the CHWs in Tandon et al., were paid honorarium12, which did not seem to have impact on their working as compared to other studies where the health workers were just volunteers.15-17

Other contextual factors related to CHWs were poorly reported in the included studies. The educational levels of these CHWs, their actual recruitment process and duration of training, refresher and supervision provided were mostly missing in these studies.

Thus we cannot comment on the effect of these factors on overall performance of CHWs and their impact on nutritional outcomes.

Global Evidence of Community Health Workers CHW Snapshot 2 BRAC – Bangladesh Nationwide Shastho Shebika Program

Program overview The BRAC was formed in 1972 and has been supporting CHW program since 1977. The BRAC program has trained community health workers who are known as 56 Shastho Shebika and is responsible for treating the essential 10 diseases: anemia, cold, diarrhea, dysentery, fever, goiter, intestinal worms, ringworm, scabies and stomatitis. They sell medications for these ailments for a nominal fee. Each CHW is responsible for approximately 300 households and visits about 15 households each day. In addition to treating the 10 diseases and referring patients, the Shastho Shebika work in many different programs (treatment of tuberculosis cases through directly observed therapy, control of diarrheal disease, immunization, family planning and prevention of arsenic poisoning), encourage people to seek care at BRAC and government clinics, and assist at satellite clinics that focus on antenatal care and immunization.22

Operational aspects and considerations Shastho Sebika, Bangladesh The 56 Shastho Shebika are women chosen by the community and Education Few years of schooling are members of the BRAC-sponsored village organizations. Shastho Training 18 days basic and 3 days Shebika are volunteers, they support themselves through the sale TB management training of commodities provided by BRAC, such as oral contraceptives, Refresher One day each month birth kits, iodized salt, condoms, essential medications, sanitary Supervision Shastho Kormi napkins and vegetable seeds. The Shastho Shebika use a system Incentive Sales of medication of verbal referral.23

Coverage and effectiveness BRAC have achieved extensive coverage and have been associated with marked improvements in women and children’s health. Oral rehydration therapy was first used clinically for diarrheal illness in Bangladesh, and BRAC was the first organization to implement a community-based program promoting oral rehydration therapy on a wide scale. Reductions in neonatal, post-neonatal and infant mortality were observed in study districts after the introduction of the oral therapy extension program. Source: WHO/Unicef 200624

59 - - - Outcomes increase an showed groups intervention three All in self-reported weekly of moderate- minutes with no significant activity, physical to-vigorous Significantly groups. between the differences comprehensive the received who women more health edu intervention counseling, of provider eating to cation, and CHW support progressed with compared vegetables per day, fruits and five counselingparticipants only provider who received counseling plus health education. or provider Respiratory mainly upper respiratory illness, illness, common than diarrhealwas more disease at baseline children During 6%, respectively). follow-up, (54% vs. in the intervention communes had approximately half the respiratory illness experienced those in by = 0.5; p .001) comparison communes (AOR 11.4% in intervention (<-3 z-scores) WAZ low Severe low Moderate (NS) control in 12.1% to compare areas 35.2% in inter and ,<-2 z-scores) (> 3 z-scores WAZ Severe (NS) control in 36.3% to compare areas vention areas intervention in 11.6% z-scores) (<-3 HAZ low HAZ (NS) Moderate low 12.4% in control to compare 27.5% in intervention and ,<-2 z-scores) (> 3 z-scores low (NS) Severe 27.6% in control to compare areas 1.0% % in intervention com WHZ (<-3 z-scores) areas WHZ (> 3 (NS) Moderate low 1.1% in control to pare (NS) 13.4% 14.3% in control and ,<-2 z-scores) z-scores intervention infants had a higher mean daily feeding solids at least four likelyfrequency be fed (more to = 4.35, 95% CI =1.96, 10.00), higher (OR times a day more a receive to likely (more diversity dietary diet OR = 3.23, 95% CI 1.28, 7.69), anddiverse the by suggested foods likely be fed more to were = 10.00, 95% counselors such as bananas (OR non-intervention to 2.78, 33.3) compared infants A study of the nutritional weight-for- status (by non-ICDS the in children the of estimations) age malnutrition in severe a drop populations showed 8.4% between 1976 and 1985. 19.1% to from ICDS the in 1985 in malnutrition of status The of years 8 and years 3-5 after populations 6.3% 6.4% to from implementation decreased Participants women over age 50 over women oldless than 3 years and their children 25mothers (5 to months old children) of 6-59 Children months of age infants aged 5-11 months under children of age 6 years Years of Years study 24 months 24 months 60 months 12 months 96 months Control arm Control was intervention No arm control to delivered no intervention armin control areas control in Children * care routine receive did not receive the intervention not was service ICDS areas in control initiated - - Interventions Table 9A: Nutrition Interventions – Description of Studies 9A: Nutrition Interventions Table Experimental arm Experimental (1) provider interventionThree groups: and counseling provider (2) counseling, counse health education, or (3) provider health education, and CHW support.ling, assess if community-basedto partici patory intervention could significantly neonatal mortality. undertookreduce monitoring and promotion growth counseling, growth session, provided conducted monthly nutrition education session program and rehabilitation with mothers of malnourished received carer the & weighed, was Child counseling on health, family planning, caring practices, personal breastfeeding, salt. All or & the use of iodized hygiene weight gain the required who failed to monthly weighing consecutive in three in a supplementarywas enrolled the given were They program. feeding molasses and oil) pulses, (rice, food packets. in standard was given An intervention study using monthly nutrition education delivered locally trained counselors by at services education and nutrition Anganwadi through the village level each of which was run by centers, a local part-time worker female Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs RCT Study Study design RCT Quasi RCT Quasi RCT Quasi RCT 25 17 13 15 Study / Study country et Staten al.2004 USA Arizona, et Sripaipan 2002 al. Vietnam Rural et Hossain al.2005 Rural Bangladesh et Kilaru al.2005 India India

Global Evidence of Community Health Workers - Outcomes birth reduction in low had the greatest group 36% between 1992 and 1994 i.e. weights, areas other BRAC from women to compared symptoms diarrhea with presented children of 27% community and 14% to health centers CHWs to with diarrhea of (29%) children andsimilar percent and community CHWs to presented symptoms fever with diarrhea 17% and 29% of children health center and community health CHWs to and ARI presented 27% and 29% of children respectively centers CHWs to presented ARI and fever diarrhea, with respectively. and Community health centers supplementation of school children iron Weekly being extended. in 2000, and is now was piloted deficiency iron address to Other utilized strategies improvement dietary fortification, food include and complementary public health measures (46.5%) of stunting in the project area prevalence The was slightly higher than among the non-project area preva in difference was no significant There (42.1%). wasting and underweightlence of stunting, between and non project area. the world vision project area on nutrition at area given were 12 presentations on health education topics schools; 11 call-in shows on the local public access channel; aired were Participants pregnant women, pregnant adolescent girls, children under children of age 5 years and children women betweenChildren 6 – 59 months adolescents children and elderly Years of Years study 24 months 5 months in the year 2000 2 months 24 months - - Control arm Control No intervention was pro areas vided in Non BRAC Interventions Experimental arm Experimental bass monthly on house each visited CHWs education and conducted and provide education health and nutrition monthly meetings and managed growth less ages children by sessions monitoring mothers andthan 2 yrs and educated Pregnant malnourishment. identified care, monthly antenatal received women education and nutrition assessment. provided packs were Dispersible zinc tablets in 14-tablet blister community and drug kitsthrough health centers CHWs. managed by CHWs. by meetings and individual counseling provided Village part integral an as implemented been has improvement Nutritional of primary and community extending health care development services government beyond include community to participation. of has been a crucial feature Utilization of village health volunteers supplementation has been the major iron Universal the program. volunteers health village using women, pregnant for strategy schedule and care encourage continuation of the antenatal to health service by approach providers. a preventive encouraging dispensed along with multivitamin Iron tablets (60 mg dose) were ANC schedules to according mineral tablets monthly or bimonthly, specific data on the nutrition situation in the region provide is any and establish whether there area Project Vision World from the non-operationalarea difference significant to Maine uses CHWs at Lubec, MedicalRegional Center CHW pro The the health of community. promote community’s the to services providing on focuses gram most needy: and the elderly. adolescents, children, Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs Study Study design Quasi RCT Compa- crossrative sectional survey Cross sectional survey Compa- rative cross- sectional surveys Cross sectional 16 20 21, 26 19 14 Study / Study country etWinch al.2008 Bougouni, Mali Winchagoon Winchagoon 2002 Thailand Macharia et al.2005 Kenya et Zuvekas al.1998 USA Lubec, Chowdhury & Mahmud Mymensingh, Bangladesh

61 - mode Evaluation Evaluation Questionnaires Questionnaires assessing for the effec oftiveness counseling Effectiveness Effectiveness assessed by outcomes the of counseling coverage Incentive Incentive (if any) Honorarium paid Supervision - key compe-key tencies coun Provided health seling, education, and support social behavior for change. Nutrition counseling Nutrition counseling Nutrition and education services ANC, health education, and nutrition assessment. - - - Role support information, Provided walks bimonthly organized & they encouragedwhere participants find walking to partners, build friendships, and support each other in improvement health their Also encouraged to goals. vegetable & fruit their increase consumption incrementally child Home visits made, coun giver and care weighed seled on health, family plan caring feeding, breast ning, hygiene personal practices, salt and the use of iodized monthly filledCollected on feeding questionnaire and behavior, and child care weighed study infants were SECA the using time, this at for developed solar scales, messages Conveyed UNICE developmen to: related foods local appropriate tally these of preparation & frequency; feeding foods; Complementary feeding breastfeeding; by followed bottles. of feeding avoidance nutritionConducted program (under children preschool for women, old), pregnant 6 years and lactating mothers. Monthly household visits to nutrition monitoring, for assessment and health education Refreshers Refreshers / Ongoing training Certification Table 9B: Characteristics of outreach workers of outreach 9B: Characteristics Table Duration Training Training Content Didactic trained They were under Bangladesh Integrated Nutrition Project Training Didactic nutritionist by Trained & pediatrician, related feeding appropriate to of an infant. Also be mindfultrained to of constraints in terms householdof available financial limited food, decision resources, making capacity and privilege within the family structure while counseling the community members Training Didactic and healthCounseling education related consumption ofto fruits & vegetables every day. - Recruitment Recruitment Criteria >50 yr old bilingual, introduce whowomen, could pro vide outreach, translation services from Workers community Locally trained counselors Community workers Education 16 17 13 15 12 Study Study et Staten al.2004 (F) CHWs et Hossain al.2005 CHWs et Kilaru al.2005 CHWs Tandon 1989 (F) CHWs Chowdhury & Mahmud CHWs

Global Evidence of Community Health Workers mode Evaluation Evaluation coverage Incentive Incentive (if any) Supervision key compe-key tencies Maternal and child health activities care Primary health servicescare Role Activities included growth Activities included growth diarrheamonitoring, management using oral (ORT), therapy rehydration women identifying pregnant them to and encouraging services care antenatal attend as topics on education Health how hygiene, proper as basic an correctly to hold and feed nutrition infant and proper Refreshers Refreshers / Ongoing training Certification Duration - Training Training Content Didactic trained on essential health knowledge and specificassigned pro and preventive tasks with amotive on maternal focus and child health and nutrition. Recruitment Recruitment Criteria Selected the from community Education 19 14 Study Study Winchagoon 2002 CHWs Zuvekas et al.1998 CHWs

63 Maternal Health Interventions Background and outreach workers are reported in Table 10A The inclusion of maternal health in the millen- and Table 10B. The types of CHWs involved in nium development goals in itself reflects the the interventions studied, related to maternal gravity of the issue. The targets set are reduction health are the community health workers in the maternal mortality ratio by three-quarters (CHWs), the community mobilizers (CMs) and between the years 1990-2015, and universal ac- the traditional birth attendants (TBAs). In 16 stu- cess to reproductive health services by the year dies CHWs alone or in combination with TBAs 2015. Several indicators that are set to monitor and CMs delivered the interventional packages the progress towards meeting the MDGs are related to maternal health, while in 6 studies maternal mortality ratio, proportion of births only TBAs delivered maternal health interven- attended by a skilled birth attendant, coverage tions in community. Out of 42 included studies of emergency obstetric care, proportion of de- in this section, only seven were conducted in sire for family planning, adolescent fertility rate, high income country (USA). contraceptive prevalence rate and HIV prevalence amongst 15-24 year old pregnant women.27 Almost all of the CHWs driven interventional studies showed a significant impact on -redu According to the joint report of WHO, UNICEF, cing maternal, perinatal and neonatal mortality UNFPA and the World Bank in the year 2005 on and improvement in perinatal and postpartum maternal mortality estimates, the sub-Saharan service utilization indicators In most of these Africa and the south Asia account for the 86% studies they were trained and deployed as ma- of the maternal mortality rate in the world.28 ternal and child health care providers and repro- The efforts made to reduce the maternal morta- ductive health workers. A review of the litera- lity ratio were focused at providing skilled birth ture from various parts of the world shows that attendant, who would have midwifery skills.27 introduction of skilled birth attendant reduced .32-37 These skills include conducting normal delive- direct obstetric mortality The utilization of ries, recognizing danger signs if any, provide antenatal care was found to be availed by 90% initial management and appropriate referral to of the pregnant women in a survey conducted 38 the health care facility.27 In the areas where the by Navaneetham and Dharmalingam in India. maternal mortality burden is high, intrapartum period is not the only domain that needs to be Most of workers were selected from the commu- 32, 39, 40 taken care of. The role of antenatal and post- nity. While some of them were required natal care, family planning, and safe abortion to have a few years of schooling for recruitment 40-43 39 cannot be undermined in the improvement of as CHWs or TBAs , the CHWs participa- the maternal health scenario and reduction in ting in the intervention presented by Teela et maternal mortality rate.29 al, were required to have 4 months of medical training prior to their recruitment, but since the study was descriptive qualitative we could not

Community-Based Evidence analyze it against studies where extensive medi- Total of 44 studies were identified that delive- cal training was not required. However, we com- red interventions related to maternal health pared studies in which CHWs were educated improvements. There were 12 quasi RCTs, 5 (studies which failed to mentioned education prospective before and after intervention stu- were assumed that educational level was not dies, 3 comparative cross sectional studies and their condition for recruitment) and found that rest were descriptive cross sectional qualitative all these studies showed a positive results on or quantitative studies. Characteristics of studies uptake of family planning methods concluding

Global Evidence of Community Health Workers that educated workers usually have positive modalities like theoretical lectures with field attitude towards family planning methods and training,34, 39, 45, 47, 60, 61 only theoretical lec- in turns results in positive impact towards using tures, 41 or didactic training sessions alone.32, family planning. 44 37, 40, 43, 46, 48, 51, 54, 56-58, 62 In Begum et al the training also included field visits for two days CHWs were provided training based on various per week.33 In the intervention by Douthwaite topics like clean and safe deliveries,32, 33, 36, the CHWs were trained for 3 months initially 39, 45-55 family planning,32, 34, 40, 41, 43, 48, 56, and then took 12 months of in-service training 57 immunization,48, 58 recognition of obstetric in primary health care while the study focused complications and referral.51-53, 57 In some of their role in family planning services and their the interventions the CHWs were trained to impact on uptake of family planning methods.43 offer Emergency Obstetric Care (EmOC).34, 59 Refresher training was also offered59 and in one In an intervention by Xu et al. the CHWs were of the interventions related to maternal health trained to manage high risk pregnancies.35 The the skilled birth attendant took three months of duration of training varied between 6 hours 54 advanced course on management of complica- to 6 months.41, 47 The training content was de- tions in mother and newborn.47 These skilled livered to the participants using various training birth attendants were in Bangladesh and were

CHW Snapshot 3 Community Health Agents Program, Brazil Program overview In 1988 the Brazilian government launched the Unified Health System (Sistema Unico de Saúde), with the declared aim to provide universal health services to Brazilians, which was evolved from primary health care initiative (community health agents’ program) in the northeastern state of Ceará. The basic initial focus was on universal coverage but later on during 1990s program expanded its horizon into the Family Health Program (Programa Saúde da Família) that encompassed integrated components like promotional and preventive activities and curative and health care, using a family health team of workers assigned to a specified geographic area. The standard team comprises of one physician, one nurse, nurse aides’ and 4-6 community health workers. Community health agents are responsible for home visits, in which they collect demographic, epidemiological and socioeconomic information of each assigned family, promote healthy practices, and link families to health services. Their activities ensure the implementation of a community component in IMCI.30

Operational aspects and considerations Community Health Agents, Brazil These CHWs are selected from the community where program is Education Primary School implemented and are selected by the program. Ninety Five percent (95%) of these workers are women and are supervised by a nurse Training 8 weeks residential course + 4 who also works full-time in the basic health unit, as part of the family weeks field work health team. The program uses a team approach for referrals of sick Refresher Monthly & quarterly children. A unique operational aspect of the program is that CHWs Supervision Nurse are paid health professionals. The state government is paying the Incentive voluntary and only receive salaries of CHWs on agreement of municipal government to also provides a salary for a nurse supervisor.30, 31

Coverage and effectiveness Program gained its coverage drastically; when the program was initiated there were approximately 35 participating municipalities with 1500 CHWs. In 1998, 150 municipalities joined hands and 8000 CHWs were deployed in communities. The initiative was expanded in 1994 to the family health program, a team approach to primary health, and adopted at a national level. In 2001, there were 13,000 family health program teams covering 3,000 municipalities, with an estimated coverage of more than 25 million people. Currently there are more than 30,000 family health teams and more than 240,000 CHWs across the country, covering about half of the Brazilian population. Program activities include expanded vaccination coverage, promotion of breastfeeding, increased use of oral rehydration salts, management of pneumonia and growth monitoring. The extended coverage of the Program has been associated with declines in the infant mortality rate.31

65 certified by the Bangladesh Nursing Council at the end of their training.47 Most of them were CHWs were supervised during these interven- deployed in the rural areas.33, 39, 46, 53, 60, 61 tions by the government teams 34, 45, or by midwives, community health nurse and doctors,51, Several competencies were developed in these 60 or by the female paramedic supervisors.33, 47 CHWs during the interventional training. Some In Shaheen et al. proper monitoring and super- developed counseling skills to increase utiliza- vision could not be done due to deterioration tion of the prenatal and postnatal services.36, of political conditions in Palestine.62 In Pakistan 55, 63 In an intervention by McCormic et al. the the CHWs were supervised by the Lady Health CHWs were specifically trained to encourage Supervisors43 and in the intervention by Yadav the use of prenatal services by people in lower et al. in Malaysia, the supervision was done by income communities.64 Immunization of pre- the nurses.55 gnant women with tetanus toxoid was also done in a few interventions.32, 34, 48 Most of these health workers were working as volunteer and a few were paid meager salaries The role of the CHWs as such was well-oriented as incentives43, 48, 53 while just the transport with the indicators set to achieve the MDG Goal cost was covered in Yadav et al. intervention.55 5 targets. They were promoting the utilization Salaried TBAs in Bailey et al. 199453 did not crea- of antenatal and postnatal care.55, 61 In the ted an impact of increasing the usage of health intervention of Shaheen et al. the CHWs also care services in women, while Swaminathan spread awareness on breast and cervical cancer et al. 198648 did find an impact on increasing prevention by teaching breast self-examination health care service utilization among women and doing pap smears.62 Which relates to the when their TBAs were given a monthly stipend. sexual health component of the MDG Goal 5. Thus it shows that providing wages or salaries In this regard, they encouraged preventive be- to these outreach workers did not have any im- havior towards HIV,56 the details of which shall pact on improving the maternal health. be discussed in the section on HIV. The CHWs also recognized anemia in pregnant women Evaluation of the CHWs, trained in the inter- and managed it with iron and folate supple- ventions was done in a few studies. The impact mentation.32, 65 They also counseled mothers of their training was assessed by prospective regarding their nutritional needs.48, 55 In case of surveys by interviewing people from covered parasitic infections they provided curative care households.40, 41 In the Williams and Yumkela for deworming the patient34 and also provided intervention, the impact of CHWs was evaluated chemoprophylaxis for malaria.45 They made by the WHO and the UNICEF.51 referrals, after providing initial management, in case any complications arise.39, 45-47, 60 Our disaggregated analysis on quasi-randomized study designs revealed that there were two In an intervention by Douthwaite et al. the CHWs studies in which CHWs were linked with TBAs called Lady Health Workers were exclusively and integrated with health system (Greenwood evaluated for providing family planning servi- et al. 199045; Foord 199560) and delivered inter- ces.43 In another intervention by Stanback et ventions. Greenwood 199045 found a significant al. the CHWs not only emphasized on the need impact on decreasing neonatal deaths, and of family planning but also provided DPMA increasing institutional deliveries possibly with injections using single-use, auto disposable the reason that TBAs trained for 10 weeks were syringes.40 directly supervised by CHWs and training team,

Global Evidence of Community Health Workers while in Foord 1995,60 they were supervised by must be trained to play an intermediary role in health care providers like doctors midwives etc. connecting these two extreme levels of health working in health centers which might required care provision structures. to be tighten up by linking them with CHWs working in that area.

Conclusion The maternal health concerns all over the world can only be addressed with effective training, monitoring and supervision of the CHWs who reach out to the communities at the grass root level. The important finding from analysis signifies that CHWs education (at least 6 yrs of schooling and above) must be stringently followed criteria for selection. They should be linked with local TBAs and health system and

CHW Snapshot 4 Rural Primary Health Care in Iran Program overview In 1970s, based on the experience of Azerbaijan province, where a research project around delivering primary health care in the province had been conducted, a network for the delivery of primary health care was developed for the whole country. At the beginning the whole focus was on the rural areas but steadily it spread into the urban areas as well. The most basic unit of service delivery is the health house which covers an average of 1200 to 1600 people. This is staffed by a community health worker known as a behvarz. Usually there will be two behvarz in each health house, with one being male and one being female. Every health house covers one main village and one or more satellite villages. The health house is responsible for: maternal and child health care, family planning, case finding, and follow up of infectious diseases (TB and Malaria), mental health problems and, more recently, other chronic illnesses such as Diabetes and Hypertension, limited symptomatic treatment, environmental health, and occupational health 66.

Operational aspects and considerations The community health workers (behvarz) are selected by the com- Behvarz, Iran munity and trained at the Behvarz Training Centre which exists in Education Secondary School each district. Their health team comprised of physician, among Training 2 years training whom one physician works as an administration and another super- Supervision Physician vises Behvarz and see the patients referred by them in their health houses. Source: Primary Health Initiative66

67 - - Outcomes 3% reduction in direct obstetric mortality 1-5%) (CI: per year No impact of intervention on maternal mortality 33% reduction in neonatal deaths 56% neonatal deaths No impactlate of intervention on still births 56% Increased in institutional deliveries by ANC in intervention arm 89.6% and in control arm during 76.1% Complication pregnancy and during postpartum period in intervention arm arm 62% Institutional66% and in control deliveries 12% in intervention arm arm & 0.4% in control duringComplication delivery in intervention in inter armarm 20% PMR 17% and in control 0.4% same i.e. arms were and control vention in intervention Deliveries SBAs by arm were was 32% area 52% while in control No impact of intervention observed on maternal mortality No impact of intervention observed stillbirths reducing for No impact of intervention perinatalobserved deaths reducing for using contra 28% of married were women 15% of married to women compared ceptives group in control in the same age group with Second the CHW was associated home visit by in the likelihood a substantial increase of visiting the 40 (49.1% of interventionMCH clinic on day group mothers, group 35.6% of control mothers versus with second visit was also associated The p<0.05). support the husband to by increased provided 40 (51.0% of interventionvisit the clinic on day group 29.0% of control husbands versus group likelihood as increased p<0.05), as well husbands, communication about timing of husband-wife of next pregnancy (86.0% of intervention group couples discussed timing of next pregnancy p<0.05). couples, group 77.0% of control versus Participants Women of Women age reproductive women Pregnant women Pregnant women Pregnant women Pregnant Married women of 15-44 years parity women Low in postpartum period - - Years of Years study 72 months 36 months 15 months 24 months 14 months - - - - Control arm Control did Comparison area MCH-FP ser not have vices and was provided services*with routine have Non- PHC areas deliveryroutine service outlets like health fa cilities and hospitals Routine services govern by provided ment health care facilities and hospitals not were SBAs trained and commu nity was provided care* with routine Services provided were government by health centre In areas, control services not were CHWs by provided was group IControl care routine receiving Interventions Table 10A: Maternal health interventions – Characteristics of included studies – Characteristics health interventions 10A: Maternal Table Experimental arm Experimental sick for (referrals MCH-FP areas delivery for safe kit,cases, & folate iron management family planning, mothers, of obstetric complication etc) Government of Gambia implemented regarding TBAs OHC service and trained for referrals clean deliveries at home, delivery of antenatal and promotion among mothers and post care enhanced complication for TBAs Trained danger mothers for teaching referrals, accessibility health Improved to signs. servicescare and trained hospital care appropriate doctors and nurses for management, distributed home based maternal and neonatal action records Skilled Birth (SBAs) Trained Attendants ANC, PNC, newborn who delivered and counsel mothers resuscitation newbornmanagement care for pregnant registered TBAs, Trained anemia and treated women, referred identified and infection, obstetric problems all potential services providing were CHWs family planning regarding Basic service delivery model includes recently a CHW to home visits by after delivery. 2-3 days women delivered During the second home visit CHW about their day the women reminded postpartum40 clinic visit for and care the importancehighlighted and benefits and cervicalof contraception, and breast and prevention. cancer awareness Outreach Outreach worker CHWs TBAs CHWs TBAs TBAs TBAs CHWs CHWs CHWs Study Study design Quasi RCT Quasi RCT Quasi RCT Quasi RCT Quasi RCT Quasi RCT Quasi RCT 68 41 70 32, 67 46 39 60, 69 Study / Study country Ronsmans 1997 Matlab, Bangladesh Greenwood et al.1990 Gambia, Africa Alisjahbana 1995 Rural West-Java, Indonesia Bhuiyan 2005 Rural Bangladesh Foord 1995 Rural Gambia Zeighami et al.1977 Iran Shaheen et al.2003 Bank West & Gaza, Palestine

Global Evidence of Community Health Workers - Outcomes Ninety-five of community-worker percent clients with services, and “highly satisfied” or “satisfied” were on side-effects. information 85% reported receiving Mean number of obstetric visits in intervention arm (P < 5.6 in control to was 6.6 as compare group in intervention0.05) number of times women arm visit doctors was higher in intervention to was told (P <0.05) 94% of women control to arm as compare in intervention contraceptive arm by was told arm (P<0.05) 79% in control to methods as compare community by visited health women Pregnant visits earlier than other agents began prenatal and lab tests, visits, prenatal had more groups, counseling more and received clinical exams, supplementation. and iron on breastfeeding incidence of postpartumThe complications in after the intervention, for decreased controlling after the On the other hand, tervention community. most less likely recognize to were TBAs intervention did not rates and referral maternal complications, The likelihood of using health significantly. increase who among women servicescare six-fold increased was and no increase TBAs, by not attended were TBAs. by observed attended among those who were was 1 group in postpartumappointment percentage it was 76% 2 it was 84% and in control 79%, in group 65,000 babies referred over delivered needing medical care 21,000 women 4.8 / 1000 to from Maternal deaths reduced births1.5/ 1000 live after training Stillbirths 76.9 / 1000 birthsdeclined from 46.2/ 1000 to births number of ANC after training Average 2.9 after training Average 1.3 to from increased 2 after training 1 to from PNC visits increased Participants Women of Women age reproductive mothers with under children of age 3 years mothers pregnant mothers pregnant mothers pregnant mothers pregnant mothers pregnant - Years of Years study 12 months 48 months 18 months 36 months 4 months 12 months 24 months - Control arm Control Routine services governmental from health centers no interventions to was provided group control by care routine facilities health care in their area areas in control TBAs not trained were group-wo Control not men who were at home. visited Interventions -women were visited at home visited were -women Experimental arm Experimental DMPA provide to CHWs Trained injections using single-use autodisable active workersThese were syringes. of pills and condoms providers and they provided trained CHWs services maternal care prenatal levels root mothers at grass to and women visited trained CHWs which included care prenatal provided breastfeeding clinical exams, lab tests, supplementation counseling and iron TBAs’ in increase trained to were TBAs detection of obstetric complications them or women for and referral and danger signs must recognize a hospital on their own. go to 1 Group & on child care information and given as encouragement to as well self care, keep the postpartum appointment. at home visited 2-womenwere Group attend them to encouraging but only for postpartumthe clinic for examination. Skilled birth essential Trained who counseled; provided attendants childbirthobstetric skills care, and post-partum in antenatal for care and her newborn;requiring the woman - identified complications their households and neighbors on women, motivated referral; women pregnant skilled for need for and care attendance the management of childbirth trained for were TBAs Outreach Outreach worker CHWs CHWs CHWs TBAs CHWs TBAs TBAs Study Study design Quasi RCT Quasi RCT Quasi RCT Quasi RCT Quasi RCT pre/post pre/post 42, 53 40 65 71 61 47 33 Study / Study country Stanback et al.2007 Nakasongola, Uganda Zhang 2004 areas Rural of China et Cesar al.2008 Rio Grande, Brazil Bailey et al.1994 Rural Guatemala et Moore al.1974 New Orleans, USA Ahmed & Jakaria 2009 Bangladesh Begum 1987 DistrictsRural (Bongra, & Tongi Dhaka) Bangladesh

69 - - Outcomes in 53% decline in NMR (P=0.004). Improvement birth skilled by attended birth institu attendants, in Banke 52% of women districttional deliveries. While 11% in Jhapa PPH, from prevented were 1 4 maternal deaths from were During 1995 there (maternal mortality195 pregnancies of 335/100 000), during were 1998 (post-intervention), there In no maternal deaths. 1993 no deliveries took were but in 1998 there place at the polyclinic, serious 946 deliveries at the clinic without any the method of delivery, The complications. and the incidence of low incidence of prematurity, birth did not change significantly weight Infant mortality births 60/1 000 live from decreased rate births. 37/1 000 live to Over 95% of both samples but a higher proportion breast-feeding, initiated of the post-intervention sample reported breast- 32%, P = longer than 6 months (41% vs. for feeding in the use of apparent were 0.0005). No differences improved. but immunization rates clinics, under-5 Maternal mortality in intervention reduced areas births 151/ 10 000 live from 37 per 10 000 live to births, while maternal mortality areas in control births 93 / 10 000 live 99/ 10 000 to from decreased Distribution methods was higher of contraceptive TBAs. untrained to compare TBAs among trained checkups antenatal was for of women Registration 6% to compared group TBAs 39% among trained TBAs PNC among trained group. TBAs in untrained 8% in untrained group. to was 13% compare group hospital in trai to of women of referrals Proportion 9% were TBAs 12% while in untrained were TBAs ned TBAs in trained women to Toxoid Tetanus was 52% while in untrained 25% group are Workers served Lady Health by Women likelyreversible to use a modern more significantly in communities not servedmethod than women = 1.50, 95% CI: 1.04–2.16, (OR the Program by various for after p =0.031), even controlling household and individual characteristics. Participants Pregnant women Pregnant women pregnant mothers pregnant mothers pregnant women Pregnant age Reproductive population group 6 months Years of Years study 24 months 30 months 36 months 12 months 36 months Control arm Control Interventions Experimental arm Experimental management of PPH with Misoprostol, Health messages, TT home visits Postnatal doses, women, for Iron-folate interventionsThe clinics included the establishment of antenatal the opening of maternity health centers, at the district’s the introduction low-risk deliveries, for facilities at the polyclinic support clinic, of a family planning clinic and breast-feeding children’s clinics, (well-baby) under-5 pediatricians for from and the emergency care, outpatient services and children’s the local community. from introduction of health agents recruited of the organization into introduced Changes were staff training obstetric emergencies, for maternal care and health education of families community their performances and evaluated TBAs trained not been trained with those who were kit a maternity of charge free trained and given were TBAs and after which they voluntarily work in maternal and child health, family planning and nutrition in the community evaluation was performedCHWs of the determine the effect to methods contraceptive reversible modern of uptake the on Program Outreach Outreach worker CHWs CHWs CHWs TBAs TBAs CHWs Study Study design pre/post pre/post pre/post Compa- cross rative sectional vs. Trained untrained TBAs Compa- rative cross sectional. TTBA vs. UTBA Compa- cross rative sectional study LHWP vs. non LHWP 34 48 43 35 56 72 Study / Study country Mc Pherson et al.2007 Nepal Rural Emond et 2002 al. Felipe Camarão, Brazil 1995 Xu Beijing, China Swaminathan et al.1986 Andhra Pradesh, India Douthwaite et al.2005 Pakistan Benara & Chaturvedi 1990 Bassi Bhanpurkalan & Sirsi, India

Global Evidence of Community Health Workers - - - Majority reported rela that positive of MHWs and other project tionships between themselves village leaders and TBAs), and (HWs providers success critical community for members were When askedof about the future of the project. ‘‘We the MOM project, one MHW exclaimed: must continue until no maternal death!’’ training TBAs odds of intrapartum due to referral 1.95 (95% CI: 0.92-4.16) odds of postpartumwere training was 1.04 (95% CI: 0.34- TBAs due to referral decreased training also shown TBAs of 312) effect 65% (95 CI: 4-875) of placenta by in retention Outcomes Injectable family planning increased methods for 4632 2007-08 Oral 347 in 2006-07 to from 6540 in 2006-07 from increased contraceptives 90 to from 35027 in 2007-08 IUD increased to usability time Condom increased 228 in a year’s time. 70348 in a year’s 38107 to from maternal health servicesImproved leading to reduction in maternal mortality 380 in from of institutional rate 90 in 2007. increased 1993 to 97.7% in 2007 PNC 20% in 1971 to deliveries from of birth, Nadu within two days is Tamil by given PNC within 42 days 87.2%, and 91.3% receive 50. TBAs, by to attended 22.7% of deliveries were a nurse or trained by attended 2% of deliveries were no-one and 2.4% by a doctor, 5.4% by midwife, in the area refugees MMR among Afghan The births 291 per 100 000 live from in improved The births 102 per 100 000 live 2000 to in 2004. proportion births of refugee skilled by attended to 67% in 2007. 5% in 1996 from staff increased from increased coverage care prenatal Complete 90% in 2006, and postnatal coverage 49% in 2000 to 85% in 2006 27% in 2000 to from than trebled more proportionThe of births in the health delivered 83% in 2007 6% in 1999 to facility from increased with high satisfaction levels. deli hospital was 57% Attempted to Referrals to hospital 3% referred very difficult and if found la duringComplication delivery of Prolong & referral 32% hospital 17%. Immunizationbor case to referral pregnant women women pregnant women pregnant Participants mothers women & pregnant mothers pregnant mothers pregnant women Pregnant and children women Pregnant women Pregnant - - - 16 months Years of Years study 24 months 168 months 48 months 24 months - - Control arm Control Interventions ‘‘Mobile Obstetric Maternal Health Worker’’ (MOM) project, em Worker’’ Obstetric Maternal Health ‘‘Mobile essential access to increase a community-basedto approach ployed maternal health services including emergency obstetric care to then regressed trained and data were were TBAs with training and maternal identify the factors associated assess the impact to And evaluated of the use outcomes. intra and post partum in ante, techniques care of improved on maternal and perinatal morbidity and mortality Experimental arm Experimental By an intervention offering mix that included maternal and newborn HIV/AIDS, and immunization. nutrition and micronutrients, care, babies and encourage deliver trained to were CHWs and counsel during perinatal and post natal period community data from trained and then qualitatively were TBAs health was conducted and of reproductive women from people i.e. trained communityIRC members established EmOC centers, linked motherhood, primaryon safe with education health care of pregnancy and the importanceon danger signs of skilled system the health information and improved attendance, such as features model involves new The culturally sensitive vertical and bench for deliverya rope position, inclusion of family and traditional birth in the delivery attendants process was conducted and evalua training program 3 years after their training was performedTBAs tion of CHWs TBAs Outreach Outreach worker CHWs CHWs TBAs CHWs CHWs TBAs qualitative qualitative survey Cross- sectional Qualitative survey Prospec- Cross tive sectional surveys Cross sectional Cross sectional Study Study design cross sectional Descriptive reported National Surveys 36 57 59, 58 50 37 51 75 Teela et Teela al.2009 73, 74 Burma Smith et al.2000 Ghana Study / Study country Diakite et al.2009 Guinea Padmanaban et al.2009 Nadu, Tamil India Gabrsch et al.2009 Ayacucho, Peru & Williams Yumkela 1986 Leon Sierra Bisika 2008 Malawi et Purdin al.2009 Hangu, Pakistan

71 - Changes in attitudes with respect to adolescent Changes in attitudes with respect to sexuality adolescents. and contraception by communication between adults and Improved Changes in adolescents and between agencies. the availability and accessibility of contraception. Some improvement in the overall knowledge in the overall Some improvement 52%. of 44% to a score of maternal health from causes of observed to Changes were with regards 47%) and HIV/ pregnancy complications (29% to motherhood (76% to safe to AIDS as the threat in the early increase was a significant There 90%). booking care 37.7% in antenatal (18.7% in 2004 to 2006) and the utilization of a skilled at attendant delivery SMPs advice by 49.8%). Referral (33.3% to rate the first line facilities (referral home to from with a compliance of (66%) received 52.9%) was well Outcomes care prenatal Of for enrolling the 599 women only 52 during the intake the study, period for the start contact had an outreach before of extensive field activity. despite care prenatal January 1997 – October From 1997 promotorus conducted 18-20 presentations in Brownsville January 1997 – October per month From 1997 each and Matamoros in Brownsville promotorus 400-500 home visits per month made approximately adolescent Changes in attitudes with respect to Changes in attitudes toward sexuality. com Improved adolescents. contraception by munication between adults and adolescents Changes in the availability and between agencies. and accessibility of contraception. visited 2,669 patients who have Contacted services care acute for the emergency room appointments of 73 prenatal follow-up for rate in 1995 70 percent in 1996 up from percent women Sixty-three (269) of pregnant percent did so in their first trimester. care using prenatal Thirty in their care (128) sought prenatal percent (32) began percent second trimester and only seven trimester. in their third care prenatal receiving youth and youth adolescents Pregnant women Pregnant Participants Women registered registered Women care prenatal for at clinics women pregnant and youth adolescents high risk pregnant with infants women women Pregnant - - - - - 24 months Years of Years study 10 months - - - - Control arm Control Interventions Logan Heights Family Health Center located in San Diego, has two in San Diego, located Health Center Heights Family Logan of sexually active youth on the protection that focus CHW programs and education peer counseling. organization parental through CHWs were tested and assessed a community-based tested were CHWs motherhood intervention, was safe their main role delivery promote to with a skilled attendant Experimental arm Experimental trained and sent in communitycommunity for health works were services use of prenatal encouraging communities in low-income Muno A CHW program, Community Health Center’s Brownsville from (health promoters) Muno (Hand-in-Hand), uses promotorus community conduct border to home visits to Texas/Mexico this prenatal and help them gain access to women identify pregnant array of health the community educate on a comprehensive care; services clients to in the community. available conditions; and refer in San located Health Center Heights Family Logan on that focus has two CHW programs California, Diego, parental through of sexually active youth the protection and education peer counseling. organization Medicaid Comprehensive Syracuse Community Health Center’s case-management provides services ManagementCase program to Its with infants. and women AmeriCorps women high-risk pregnant pa to Community Health Corps members: work on projects related tient services; patients about the importance educate of preventive and collectiprimary system; use a managed care to and how care projects. work on communityvely health education and awareness Alabama Health ServicesWest the Home in Alabama operates community-based home visits by which provides program Visitor the through support women that: 1) provide pregnant to CHWs new for provided care perinatal that appropriate period; 2) ensure skills; parenting borns; the mother appropriate 4) ensure 3) teach communication between the home and health provider; and 5) as evaluating patients. the home situation of at-risk by sist the provider CHWs CHWs Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs Cross Cross sectional survey Study Study design Cross sectional survey Cross sectional Cross sectional Cross sectional Cross sectional Cross sectional 64 19 19 19 19 19 76 Mushi 2007 Mtwara, Tanzania Study / Study country McCormic et al.1989 Harlem, USA Zuvekas et al.1998 Brownsville, USA Zuvekas et al.1998 San Diego, USA Zuvekas et al.1998 Onondaga, USA Zuvekas et al.1998 West Alabama, USA Zuvekas et al.1998 San Diego, USA

Global Evidence of Community Health Workers - - Project activitiescommunity increased participationProject was seen in in maternal health. An increase birthknowledge of danger signs, planning, and transport of pregnant timely referrals, as in support as well hospitals, to women with women More VHWs. of and retention using the community- are obstetrical problems based transport hospitals. get to to system likelyto more significantly were TBAs Trained and then untrained. delivery, practice hygienic diffe 19%, P <0.0001). No significant (45% vs. of postpartum in the rates rence infections. Outcomes knowledgeable more on danger were TBAs Trained during pregnancy and childbirthsigns and were with complications to women likely refer more to TBAs. untrained to compared a health facility, births 2.1 live declines to Fertility rate per level. replacement which is below women 71% 15% to from increased rate Contraceptive 81% of the time complication was detected referred and out of which 43% were evaluation of this training is unde Formal available. rway not yet are but results Around care antenatal received 90% of all women > 4 ANC visits received 70% of all women place at 50% of all deliveries took Around 70% of all deliveries were institutional level undertaken skilled by birth attendant skilledDeliveries from birth increased attendant from decreased TBAs 40% and from 23% to from 47% t o 19% MMR of 452 / 100 000 deliveries (27 deaths) observed. Obstructed labor was the main cause of maternal death. general population TBAs Participants pregnant women pregnant women Pregnant women Pregnant TBAs Married women women Pregnant women Pregnant - 18 months 18 months Years of Years study 42 months 36 months 72 months 12 months 70 months 24 months Control arm Control Interventions Qualitative data from group interviews and program data from interviews data from group and program data from Qualitative and use of in development assess progress used to CBRHP were community transport level and support systems the village for health workers (VHWs) and postpartumTBAs with untrained compared were TBAs trained among the two groups then compared were infections Experimental arm Experimental trained and untrained traditional birth (TBAs) attendants in complications developing for with danger signs identifying women during pregnancy and childbirthpractices as their referral as well of maternal and child health/family planning intensification and servicesinformation mobile motivation through service of a village level and creation teams outreach TBAs and delivery CHWs through system TBA training. the impact evaluate of the To TBAs of training Evaluation utilization was surveyedMode of maternal health care in India deliveries and advised mothers on antenatal attended TBAs to nursing care and postnatal issues also provided care on baby babies and new mothers some basic steps indentify high risk women, all pregnant registered trained to TBAs the health facilities to and evacuate referrals provide pregnancies, with all the necessary pregnancy and delivery to equipment related Outreach Outreach worker TBAS CHWs TBAs CMs TBAs TBAs CHWs TBAs TBAs CHWs TBAs - Cross Cross sectional survey Cross sectional Cross sectional Cross sectional Cross sectional Descriptive compara cross tive sectional survey Study Study design cross sectional Cross sectional survey 55 80 81 79 54 52 77 78 38 Study / Study country Hussein & Mpembeni 2005 Mkuranga, Tanzania Bhiromrut 1990 Narativas, Thailand Bailey & Coombs 1996 Verapaz, Guatemala Yadav 1987 Yadav Kerian, Malaysia Wollast et Wollast al.1993 Burkina Faso Ahluwalia et 2003 al. Northwestern Tanzania Goodburn et 2000 al. Bangladesh Foster et Foster al.2004 Guatemala Navaneetham & Dharmalingam 2002 Southern India

73 - mode Evaluation Evaluation Evaluation onEvaluation rate mortality years 3 after of implemen this of tation program coverage Incentive Incentive (if any) - Supervision Governments training team Supervision mid from CHNs wife, and doctors key compe-key tencies Maternal health Maternal health Maternal health Maternal and neonatal care. Resuscitation and Safe home hygienic deliveries - - - Role Immunized with women TT contra and provide on door steps. ceptives delive hygienic Conducted riesantenatalon advised and also and postnatal care of chemoprophylaxis gave women pregnant malaria for Reported identified pre she births the and gnancy the interviewers, to attended ideally within 24 hrs antenatal Delivered and and postnatal care counseled mothers for newborn management care pregnant of Registration in antenatal women of treatment programs, anemia and infections Refreshers Refreshers / Ongoing training Certification Duration 10 weeks 10 weeks - - - Table 10B: Description & Characteristics of Outreach workers of Outreach 10B: Description & Characteristics Table

Training of Training These These Training of Training Training Training Content Didactic trained were CHWs on delivering services during twi ce-monthly home Immunizedvisits. withwomen provide TTand contraceptives on door steps. Theory and practicum at women Deliver home and given andantenatal and postnatal care advised them for health to referrals facility and trained chemopro give to of malaria phylaxis Didactic in detectionTBAs of pregnancy complications and taking appropriate action (referral) Theory and prac ticum in detectionTBAs of pregnancy complications & referral providing Theory and practicum provide to Trained treat care, antenatal anemia, infections and identification of emergency cases &complicated to and their referral tertiary centre care Recruitment Recruitment Criteria Selected by villages Selected by villages Selected from community Education Illiterate 32, 67 68 46 39 60, 69 Study Study Ronsmans 1997 (F) CHWs Green- wood et al. 1990 (F) CHWs (F) TBAs Alisjahbana 1995 (F) TBAs Bhuiyan 2005 (F) TBAs Foord 1995 (F) CHWs

Global Evidence of Community Health Workers mode Evaluation Evaluation Interviewed people from covered households Prospective surveys coverage Incentive Incentive (if any) Salaried Supervision midwives, CHNs and doctors Proper monitoring and supervision be not could done due to deteriorating political conditions. key compe-key tencies of Provision vaccination, health education and contraceptive education Maternal health - - Role of identification Early women pregnant servicesCurative for eye and ear colds, common card Kept a record infections, of those interviewed and of duration estimate noted use. of contraceptive the women to Explained importance of conducting a family the clinic, 40 visit to day maternal planning methods, breast feeding, breast care, self-exam and newborn during 1st home visit and care health to visit ensured facility 40 after delivery. day by DPMA provided They injections their com to on emphasized munities, the importance of family planning methods and pro Educational motional activities - Refreshers Refreshers / Ongoing training Oral exami nation to certify them as workers Certification Duration 6 months 2 weeks

- - They training on preventive, on preventive, Training Training Content PRACTICUM to required were mid accompany the during wives village visits; their assiststask was to in home deliveries. trai Theoretical ning and familycurative planning benefits, servicespreventive like immunization visits etc, baby well training Didactic provide to how On counseling and are that services the to tailored parityneeds of low to Trained women. do pap smears and examination. breast Didactic training theywhere trained to were DMPA provide injections their to communities using single-use auto disable syringes. and Theoretical practical and on prenatal postpartum services on Trained emphasizing the of importance visits, prenatal breastfeeding and counseling, folate iron supplementation - Recruitment Recruitment Criteria positive attitude to family wards planning From community Education of6 years education of years Few schooling read Can 65 42, 61

Study Study (F) TBAs Zeighami et al.1977 41 CHWs (M & F) Shaheen et al.2003 70 (F) CHWs Stanback et al.2007 40 CHWs (M & F) Zhang 2004 CHWs etCesar al.2008 CHWs et Bailey al.1994 53 CHWs

75 mode Evaluation Evaluation coverage 1 TBA per 2298 1 population Incentive Incentive (if any) Supervision female paramedics Supervisors receive monitored Ministryby of Health & Population, Health Family Division and District Health Assistant Assistant & supervisor paramedic key compe-key tencies Maternal health Counseling skills, Essential obstetrical skills and neonatal care Maternal and child health Maternal and neonatal health - - - Role Make postpartum visits to and encourageeducate a healthy to return them to and state pre-pregnant baby a healthy have to and women Visited in indentified pregnancies During their the community. home visits they also identi pregnan fied complicated women cies and referred in case of complication Community-level antenatal contact. Strengthening existing services like basic care obstetric emergency (BEOC), management of complications and EPI. Used aseptic technique, Used aseptic technique, advised mothers on nutrition and importance of colos longer counseled for trums, feeding duration of breast - Refreshers Refreshers / Ongoing training After spending 9 months as community- based SBA they undergo 3 months advance course on mngtt of complica I in tions, mother and newborn skilled birth attendants theby Bangladesh Nursing Council Certification Duration 6 months - 3 months training - - - Health visits were visits were knowledge Training Training Content and theoretical practical counseling for essential obstetric skills child care, antenatal in birth and post-partum the woman for care and her newborn, -identifying complica referral, tions requiring women, motivate their households and neighbors on skilledneed for and care attendance women pregnant for Theory and practicum education & inter includingventions and folate iron supplementation, deworming and of TT, recognition SBA danger signs, emer attendance, gency obstetrical and essential care newborn care. Class lectures, demonstrations, and field two for organized in each week days - Recruitment Recruitment Criteria to Willingness and servestay the com munity with midwifery services TBAs, selected TBAs, through interviews Education no formal education 34 71 47 33 Study Study etMoore al.1974 CHWs Ahmed & Jakaria 2009 (F) TBAs Mc Pherson et al.2007 (F) CHWs Begum 1987 (F) TBAs

Global Evidence of Community Health Workers mode Evaluation Evaluation Oxford Policy Oxford Management evaluation coverage 1: 1000 population Incentive Incentive (if any) Rs. 3oo per Rs. month and each 2 for Rs. delivery Supervision health Female workers and health assistants Lady health supervisors Maternal and child health services key compe-key tencies PHC services - - - - Role Made visits with the feeding, message of breast- causes & mngtt of diarrheal & respiratory and diseases, Promote HIV. of prevention well clinics, antenatal visit to immu Clinics and for baby and advised nization and, go for hypertensive adults to monitoring and treatment encourage to was role Their examination, antenatal for management of high risk & streamlined pregnancies, system information every wo Register pregnant natal antenatal, man, provide provide care, postnatal and TT immunization, PHC servi family planning services,ces, maternity kits.provide contraceptive of Uptake methods Identification of pre of recognition gnancies, complication, referrals, , growth family planning, monitoring &immunization Refreshers Refreshers / Ongoing training Refreshers given were Certification Duration 1month 15 months 2 weeks - - Health Trained Training Training Content Didactic on an Education breast care, tenatal causes feeding, and management of diarrheal and diseases, respiratory encouraging health seeking infant for behavior and and in elderly, of HIV prevention women Educated about maternal health issues trained They were behavior for to change communi makecation to sure and theirwomen of families aware servicesimproved Didactic and practical Didactic 3 for andmonths of12 months in-service training Didactic duringon care partum,ante intrapartum and postpartum period Recruitment Recruitment Criteria 4 months of medical training previously Education of8 years schooling 35 56 48 43 57 82 Study Study Emond et 2002 al. CHWs 1995 Xu CHWs & Cordon Fonseca- Becker 2004 CMs Swaminat han et al.1986 (F) TBAs Douth- etwaite al.2005 (F) CHWs et Teela al.2009 59, 73, 74 (F) CHWs Smith et al.2000 CHWs

77 mode Evaluation Evaluation WHO and UNICEF coverage Incentive Incentive (if any) Transport cost Transport - Supervision Nurse/ from midwives health facility Monthly mee tings where they shared experiences Nurses supervised of ministry by social affairs key compe-key tencies Maternal health Maternal and child health workers pregnancy and child birth procedure - - Role maintainedWorkers and system information women pregnant register provide and counsel and family planning methods awareness raising PHC, including regarding health reproductive Identify pregnancies, provi Identify pregnancies, and clean deliveryded safe compli and recognized cation and danger sings Identified pregnancies, ANC and PNC provided riskpregnancies high identify the health to and evacuate facility during complication - Refreshers Refreshers / Ongoing training re 2 week course fresher Certification Duration training 3 day 3 weeks training 6 hours of training 1 month training - Safe Safe They were They were Trained Trained to deliver to Training Training Content Didactic training family planning for information Didactic motherhood Didactic clean and safe for deliverypractices for of and recognition complication during delivery Didactic iden trained to tify risk good factors, and transfer hygiene cases. Complicated training Practical taught on They were simple hygienic procedures, cleanliness and basic nutrition education and Theoretical practical trained TBAs learntbabies, asepsis and simple obstetrical manipulations and with also provided clean delivery kit, Recruitment Recruitment Criteria of Panel nurses and midwives recruited them from community Education 58 37 54 79 51 55 Study Study Diakite et al.2009 CHWs et Purdin al.2009 CHWs (M & F) & Williams Yumkela 1986 (F) TBAs et Foster al.2004 TBAs Yadav 1987 TBAs et Wollast al.1993

Global Evidence of Community Health Workers Birth and Newborn Care Preparedness Interventions Background post studies and 1 comparative cross sectional study. Several of these studies CHWs and /or TBAs Ninety-eight percent of the four million annual to provide care at community level and few of neonatal deaths occur yearly in middle and these studies utilized community mobilizers for low income countries, and two-thirds or more delivering these interventions in conjunction of these deaths occur in the first week of life.83 with TBAs and CHWs. Substantial improvement Despite large reductions in mortality for children was observed in reducing perinatal and neona- under 5 years of age, neonatal mortality remains tal mortality and increasing service utilization largely unaltered, and now contributes to over services like institutional deliveries, deliveries by one-third of total mortality of children under skilled birth attendants. However, Manandhar et five.83, 84 The precise contribution of various al.87 reported substantial impacts of interven- causes of neonatal deaths is difficult to ascer- tions in reducing maternal mortality. tain since the vast majority of births and deaths occur in homes, and are thus poorly reported The CHWs and the TBAs recruited in these inter- and categorized.85 ventions were from the local community88-98. Their training ranged from 3 days to 6 weeks, In an effort to improve outcomes for both mo- while in Bhutta et al. 200892 & Bhutta et al. thers and their newborn infants, the “Mother- 200997, CHWs were already trained by govern- Baby Package” was introduced by the WHO in ment and were given additional 6 days of trai- 1994.86 The “Mother-Baby Package” consists of ning on birth and newborn care preparedness. a set of interventions considered essential to The training imparted to them for interventions maternal and newborn health. These include were mostly didactic in nature.88-92, 95-98, 101-104 interventions such as antenatal registration The training content included birth and new- and care, iron/folate supplementation, tetanus born care preparedness messages, provision of toxoid immunization, prevention and manage- essential newborn care, clinical assessment of ment of STIs and HIV in endemic areas, treat- the neonates, promotion of exclusive breastfee- ment of underlying medical conditions such as ding and referral to hospital of newborns with malaria and hookworm infestation, nutritional danger signs95, 96 and management of the sick advice, ensuring clean delivery, presence of a neonates with an IMCI adopted algorithm.91 trained birth attendant at delivery, recognition They were trained to provide home-treatment and management of maternal and neonatal of serious infection with oral chloroquine.95 In complications, neonatal resuscitation, early and an intervention by Bhutta et al. 2009, the CHWs exclusive breast-feeding; and prevention and were trained to provide bag and mask resuscita- management of neonatal hypothermia and in- tion in case of birth asphyxia.97 The TBAs in this fections including ophthalmia neonatorum and study were also trained to recognize low birth cord infections. weight babies, provide them care and refer to the CHWs for further management.97 In another Community-based evidence: study, the CHWs were trained for appropriate We identified 25 studies that were undertaken immunization of the infant and in the use of oral 101 in community settings and included a compre- rehydration solution in case of diarrhea. hensive birth and newborn care preparedness plan rather than solitary interventions (Table In an intervention by Bhutta et al. 2008, empha- 11A and Table 11B). Among these studies there sis was laid on adequate maternal nutrition, iron were 11 RCTs, 4 quasi RCTs, 6 prospective pre/ and folate use and rest during pregnancy and promotion of early breast feeding and colos-

79 CHW Snapshot 5 CARE Community Initiatives for Child Survival, Siaya, Kenya

Program overview In 1995, CARE Kenya implemented the Community Initiatives for Child Survival in Siaya after the completion of original project which was ended in 1999. In 2003, second phase of wide-ranging intervention package aimed at improving child and maternal health in the Siaya district.99 Community health workers in this district were trained to treat children with multiple diseases by using simplified IMCI guidelines. Promotion of family planning, immunization and AIDS prevention are also included in the education package. The CHWs are assigned to 10 households in their community. The supply of drugs in this program is based on the Bamako Initiative. Community-based pharmacies are established and serve as resupply points for the CHWs’ drug kits. The CHWs sell the drugs to community members and use monies from sales to buy more drugs to restock their kits in a revolving fund scheme.99

Operational aspects and considerations Community Health Workers, Kenya The CHWs are selected by the community and trained to use the guidelines to classify and treat malaria, pneumonia and diarrhea/ Training 3 weeks initial training dehydration concurrently, and use flow sheets to assist in the ap- Refresher One week plication of these algorithms.100 CHWs provide verbal referral, and Supervision Field staff referred cases are taken to the front of the line to receive treatment Incentive None at facilities.

Coverage and effectiveness Every two years, CDC in the United States evaluates the performance of CHWs. The recent evaluation demonstrated that 85% of the cases that the CHWs treat are classified as malaria, acute lower respiratory infection or diarrhea. CHWs adequately treated 90.5 per cent of malaria cases, but they had difficulty in classifying and treating sick children with pneumonia. Four years after the implementation of the project, a reduction 49% in the child mortality rate was noted. Source: WHO/Unicef 200624

trums administration.92 They were also trained supervised studies did not show greater impact to provide treatment of neonatal pneumonia on the outcomes. with oral trimethoprim-sulphamethoxazole.92 This intervention showed significant reduction The CHWs involved in the interventions rein still births, NMR and MMR.92 It also showed viewed promoted the utilization of antenatal, improvement in institutional deliveries and ini- postpartum and neonatal care with recognition tiation of early and exclusive breast feeding.92 of danger signs in the neonates of the community.91, 92, 94, 96, 97, 103, 104 They also provided Refresher training sessions were held related to treatment of infections with oral Chloroquine e management of maternal and newborn com- 95 and with oral trimethoprim-sulphamethoxa- plications in most of the interventions reviewed zole in case of neonatal pneumonia.92 In case in this regard and showed a greater impact in of diarrhea they provided the neonate oral the outcomes of those interventions91, 93, 94, rehydration solution101 and would also offer 96, 97 as compared to those without refresher immunization services.92 Their role therefore training.101 Some of the interventions were can be perceived to be in compliance with the supervised by the regional supervisors.95-97 In achievement of the MDG targets in reducing un- the Bolam et al. CHWs were supervised by its der- 5 mortality. Besides this they also provided principal investigators.101 However as compa- emergency obstetric care to the mother in case red to the studies without any supervision, the of any obstetric complication and promptly re-

Global Evidence of Community Health Workers Conclusion ferred where needed.91, 94 The CHWs in Bhutta The percentage neonatal mortality contributes et al.2009 intervention resuscitated case of birth to the under-5 mortality ratio demands active asphyxia using bag and mask resuscitation, while participation from the health care teams and the TBAs in the same intervention were trained the community to bring a decline in these to offer mouth-to-mouth resuscitation.97 The preventable deaths. The interventions reviewed Barnes-Boyd et al. intervention worked at the have shown that the financial incentives did not improvement of psychological well being of the affect the working of the CHWs, and as such the mothers, social support and the overall impact outcomes of those interventions. However, the on the baby.90 additional training which demands active involvement from the CHWs, did seem to reinforce A few of the CHWs involved were paid sti- the positive outcomes of the intervention.92 pends92, 96, 98 or transport cost.97 However this did not affect the outcome as compared to the studies where the CHWs were all volunteers.91, 94, 95

81 Outcomes No impact of intervention on mortality of 18 – 41%) (CI: mothers 30% reduction in PMR 31% reduction in still births 17 – 43%) 29% (CI: 17-38%) 39% reduction reduction in NMR (CI: complication duringin hemorrhage related in referrals 21- 53%) 50 % increased pregnancy (CI: in emergency(19 – 91%) obstetric care 7 – 53%) 44% reduction in NMR (CI: initiation breastfeeding improved OR seekingHealth care qualified provider from facility OR2.9 (CI: Project to 2-4.44) Referral 2.98 (CI: seeking1.91-4.41) Health care unqualified from 53-79%) 69% (CI: to decreased providers No impact of intervention on maternal mortality 29% reduction in Still births 11- 43%) 31% reduction (CI: (CI: 13 – 45%) 28% reduction in PMR in NMR (CI: in institutional deliveries, 15-39%) Improvement breastfeeding initiation of early and exclusive of intervention observedNo improvement in reduction in maternal mortality in intervention 50% reduction in NMR (CI: groups. and control in early31-64%) among these 41% decline occurred neonatal period 16 – 59%) and 68% decline (CI: neonatal period 15-88%) 47% in late (CI: occurred 27 – 62%) 45% reduction in (CI: reduction in PMR still births 5-55%) 59% reduction in complication (CI: 51 – 67%) & 50% labor (CI: prolonged due to 4-74%) complication (CI: decline in eclampsia related in initiation of early Improvement breastfeeding Participants Pregnant women Pregnant All married women age of reproductive Married of women age reproductive Married of women age, reproductive and older women adolescent girls Stakeholders, community leaders, women, pregnant their immediate family members, neighbors and relatives Years of Years study 14 months 30 months 12 months 24 months 16 months - Control arm Control not trained were TBAs and did not receive delivery kits. Routine care LHWs by was delivered Comparison arm the usual received health services provided the government, by and non-government and pri organizations Refresher providers. vate government training for workers was provided. Routine care* LHW training program continued as usual, refresher with regular but no attempt sessions, link LHWs was made to Special with the Dais. training in basic and newbornintermediate to all was offered care public-sector staff arm received Control the usual services of and governmental non-governmental area the in organizations - Interventions Experimental arm Experimental services improved for TBAs all Trained care antenatal enhanced referrals, for and postpartum and provided visits, were TBAs them with delivery kits. Workers also linked with Lady Health in the community (LHWs) interventions arm received Home care birthfor and newbornprepared care acid supplementation, iron/folic ness, & community care enhanced referrals group through mobilized arm were and women meetings with pregnant training community Refresher leaders. health government to was provided workers in both the intervention groups on birth women Counsel and newborn made postnatal visits preparedness, care sick newborns. for enhanced referrals for in the interventional LHWs arm were additional training after their given linked with usual training & they were training for given Dais (who were newborn & immediate resuscitation of nutritional newborn promotion care), enhanced antennal BNCP, counseling, and postnatal visits + training in basic newbornwas and intermediate care to all public-sector staff offered of essential newborn Provision enhanced birthcare, preparedness, plus thermoregulation referrals along with all other intervention Table 11A: Birth and Newborn Care Preparedness – Characteristics of Included – Characteristics Studies 11A: Birth Preparedness Care and Newborn Table Outreach Outreach worker TBAs CHWs CMs CHWs TBAs CHWs CHWs CMs TBAs CHWs Study Study design cRCT cRCT cRCT cRCT cRCT 94 95 92 108, Study / Study country Jhokio et al.2005 Larkana, Pakistan Baqui et al.2008 105-107 , Rural Bangladesh Bari et al.2008 Tangail, Bangladesh Bhutta et al.2008 Hala, Pakistan Darmstadt et al.2008 109 Uttar Pradesh, India

Global Evidence of Community Health Workers - - Outcomes No impact of intervention on maternal mortality 20% reduction in still births 10-29%) 16% reduc (CI: tion in perinatal mortality 9-23%) 12% reduction (CI: in neonatal mortality 1-22%) No impact (CI: on early neonatal mortality No impact observed in neonatal mortalitylate at in receiving 24% increase least one ANC observed in 5-48%) 22% increase (CI: birth skilled by attendance 4-44%) (CI: attendant No impactMMR on reducing NMR reducing interventionobservedin of impact No (no impact on Early NMR) NMR and late No impact on intervention observed in stillbirthsreducing and perinatal deaths observed No improvements in service delivery and newbornoutcomes care No impactMMR on reducing 33 – 55%) 45% reduction in NMR (CI: 55% reduction in early NMR (43 – 64%) No impact observed NMR in Late No impact observed stillbirths in reducing 19 – 42%) (CI: 31% reduction in PMR twice) (91% visited High of antenatal coverage 0 or 1) home on days and postnatal (69% visited practices Indicators of care visitations was achieved. and knowledge of maternal and neonatal danger mortality Adjusted ratio in hazard improved. signs the intervention the comparison to arm, compared 0.87 and baseline at 0.80–1.30) CI: (95% 1.02 arm,was Primary(95% CI: 0.68–1.12) at endline. causes of birth (49%) and prematuritydeath were asphyxia (26%) Absence of an early 11.3, 95% CI: 6.7, CHW visit (OR: of pre-lacteal18.9) and feeding 2.8, 95% CI: 1.3, (OR: fee a with having associated significantly 5.9) were visit. On adjusted first-week at a late ding problem absence of an early 11.4, 95% CHW visit (OR: analysis, 2.5, 95% (OR: of prelacteal CI: 6.7, 19.3) and feeding association significant have CI: 1.1, 5.7) continued to visit. persisting at late problem with feeding Participants Pregnant women women Pregnant and whole community of 15-49 women of age years of 15-49 women of age years All married of women age reproductive 15–49 years (i.e., women Pregnant - Years of Years study 36 months 36 months 36 months 24 months 24 months - - - Control arm Control on LHWs Trained community mobiliza building tion through promo support groups, tion and use of clean delivery kits, recognition of neonatal illness and TBAs and care for referral linked with LHWs were was not group Control with participrovided patory learning groups Health committees clusters in control give to formed were Community a in the design voice and management of local health services. in care standard arm the control trained No CHWs or deployed - Interventions = Along with the basic training = along with the basic training Experimental arm Experimental LHWs they received group) control (for additional training on recognition and referral, of high risk pregnancies management of Birth serious Asphyxia, LBW bacterial infants. infections, TBAs they received group) control (for of LHW additional training on promotion at birthsattendance and resuscitation mouth) of newborn(mouth to Implemented a participatory learning and action cycle in which they identify then formulate & prioritize problems, monitored & implemented and strategies group + process the evaluated finally and two according was again divided into or not asphyxia for TBAs the trained to Implemented a participatory learning women’s developing cycle, through they identify & prioritize where groups maternal and newborn health problems the implemented in their community, the results and evaluated strategies, In the intervention arm, commu nity health workers identified pregnant home made two antenatal women; birth promote visits to and newborn postnatal made four preparedness; care care preventive negotiate home visits to practices assess newborns and to for a to sick neonates illness; and referred compliance. hospital and facilitated who made two antenatal CHWs Trained postpartumand three home visits to and supportpromote practices for birth and newbornpreparedness care (BNCP) and newbornincluding care support breastfeeding for Outreach Outreach worker CHWs TBAs CMs TBAs CMs TBAs CHWs CHWs Study Study design cRCT cRCT cRCT cRCT cRCT 113 97 114 110 111, 112 Study / Study country Bhutta et al.2009 HALA Pakistan Azad et al. 2010 Rural Bangladesh et al. Tripathy 2010 Jharkhand & Orissa, India Darmstadt et 2010 al. Mirzapur, Bangladesh Manan et al.2005 Sylhet, Bangladesh

83 - - Mothers in groups A and B (received health A and B (received Mothers in groups likelyeducation at birth) slightly more were use contraception at six months after birthto C and D (no with mothers in groups compared health education at birth) ratio 1.62, 95% (odds no other were There confidence intervalto 2.5). 1.06 regards groups with between differences significant or immunization. infant care, infant feeding, to No impact of intervention observed in differences of mortality observed Improvement in institu tional deliveries or conductedskilled by birth feeding initiation of earlyattendant, breast observedImprovement in initia tion of early breastfeeding Outcomes infant health (breastfeeding to related behaviors and contraception appeared and infant check-up) by participation be influenced to in the program IMR in experimental arm was 3/1000 and in comparison armbirths was 5/1000 live PNMR among experimental arm was 2/ 1000 and in comparison armbirths was 5/ 1000 live no impact was observed in 2 arms in health problems in experimentalimmunization rates arm was 77% while in comparison arm it was 63% (P<0.001) 27-56%) 25% (CI: 63% reduction in PMR (25.3% rates in breastfeeding increase 50.3% post intervention) to pre increased Essential newbornpreparedness care in early initiation of 20-30%. No improvement from in skilled (P 0.06) No improvement breastfeeding birth at birth attendants (0.55) Odds of breastfeeding messages was 4.2 (P<0.001) when exposed to delivery skilled for Planning from birth 26% (P<0.001) to increased attendant women admitted to to admitted women Griha hospital Prasuti delivery for residing in study areas women Pregnant mothers Pregnant and family members Participants First time expectant First mothers African American families women pregnant women pregnant women pregnant birthgiven within 12 months 18 months 24 months 20 months Years of Years study 18 months 60 months 36 months 24 months 36 months - - Control group did not group Control these health receive education teaching and counseling standard Received health government Child and Integrated Development Services rou Available was utilized tine care area in control Control arm Control was Routine care areas in control provided did comparison group advocate not had any their counseling for - - Interventions health education immediately health education immediately : at three months only The The months only : at three : at birth only Group A: Group after birth months later and three B Group C Group infant feeding, were covered topics of of diarrhea,treatment recognition respiratory acute in young infection the importanceinfants, of immu nization, and the importance of contraception after the puerperium. and CMs who deli CHWs Trained intervention, antenatal birthvered disposable delivery kit,preparedness, postnatal interventionnewborn care, , of CHWs Increased coverage and providers trained health care TBA, use of clean delivery kit, and postnatal visits antenatal Experimental arm Experimental of education consisted antenatal The Session topics 2-hour. eight daytime included health during pregnancy, pregnancy nutrition, for preparing childbirth, childbirth, motherhood and communication, infant feeding, health and health, women’s infant care and contraception after the birth. community trained health workers were maternal and health on advocacy, issues and community internship was was there at the end was employed advocacy which received one group and trained advocate from information keychaincontaining plan, Birthpreparedness of mother and newborn, care danger sings on antenatal, on birth of JPIEGO focused preparedness, MNH program of danger sings recognition Impact of women group diagnosing, designing, imple designing, Impact diagnosing, group of women and evaluating community-basedmenting, solution maternal and perinatalto health problems CHWs CMs CHWs CHWs Outreach Outreach worker CHWs CHWs TBAs CHWs CMs CHWs CHWs RCT Quasi RCT Quasi RCT Study Study design Quasi RCT quasi RCT pre/post pre/post pre/post 90 . 101 89, 117 103 104 93, 115. 116 102 Bolam et al.1998 Khatmando, Nepal Baqui et al. 2008 Uttar Pradesh, India Syed 2006 Rural Bangladesh Study / Study country & Say Turan 2003 Istanbul, Turkey Barnes-Boyd et al.2001 Chicago, USA O’Rourke et al.1998 Inquivisi, Bolivia McPherson et al.2006 Siraha, Nepal Moran et al.2006 Rural Burkina Faso

Global Evidence of Community Health Workers - - Outcomes (29%) and men (31%) of women Almost a third some aspect exposed to were in the follow-up activities66% and messages. of the program’s that severe recognized of exposed women 31% in the to compared bleeding is dangerous, baseline and 51% of exposed men recognized to compared bleeding, the danger of severe (93%) in Exposed women 22% in the baseline. likelyto more significantly were the follow-up prenatal should receive that a woman believe a skilled than non-exposed from care provider in the baseline (66%) (72%), and women women in acceptance of of increase percentage The 37% to immunization (From Toxoid tetanus supplements 76%) and the ingestion of iron 36%) Maternal 1% to deaths de (from 0.4% (P=0.053) 1.5% to from creased with a traditional clinic-based When compared multi-disciplinary (MDP) using health program Mothers the Resource Program professionals, of high-risk ado a higher percentage reached 45.6% MDP clients 75.5% RMP vs. lescents (e.g., a higher old or under), promoted aged 17 years 32.6% 53.1% RMP vs. (e.g., care of prenatal level the before care prenatal MDP clients beginning in fourth month of pregnancy), and resulted the MDP but that favored pregnancy outcomes 93.5% MDP 89.8% RMP vs. comparable (e.g., were at birth). 2500 grams over client babies were Occurred in home births 76% perinatal deaths. perinatalRisk deaths among home births ratio for was 3.29 (95% CI: 1.28-9.22) as compared via skilled those delivered birth to attendants at dispensaries and clinics TT immunization of 4 + shots in intervention areas TT areas. 17.8% in control to 31.2% compare were 93% &75% in intervention were coverage areas PNC visits in intervention areas areas in control LBW areas among was 53% and 9% in control areas intervention was 27% while in control areas in intervention was 63/1000 live 32% PMR areas births it was 84/1000 population areas and in control birthsNMR in intervention was 49/1000 live areas it was 34/1000 population areas and in control birthsSBR in intervention was 42/1000 live areas it was 38/1000 population areas and in control Participants Pregnant women Pregnant women Pregnant mothers teen and her family women Pregnant pregnant women pregnant - Years of Years study 24 months 48 months During1990 24 months - - Control arm Control Interventions Experimental arm Experimental develop encouraged families and communities to CHWs emergency help make seek plans (Eps) to timely decisions to of an obstetrical or neonatal in the event qualified medical care and the plans detailed maternal danger signs The emergency. necessary childbirth for preparations both at the family level be on hand, much money needs to how (knowing go, to where and who will takeof the house other children) care Mothers recognize & their home birth taught to were attendants selected& take maternal &neonatal life- action resolve to Community mobilization effortswere problems. threatening in transport delays reduce emergency to to obstetric designed use of family planning increase units and to referral care maternal bleeding and newborn sepsis was enhanced (RMP) supports disadvantaged Mothers Resource Program The who are home visitors the use of para-professional through teens in race and socio-economic the teens similar to In status. addition early and encouraging pre the program into teens recruiting to mothers teen provides Mothers the Resource Program natal care, and their families with practicalcommunity help and increases infant mortality regarding and adolescent pregnancy. awareness In this study perinatal mortality was observed among those delivered at home vs. delivered women via trained skilled birth attendant. trained TBAs were trained for promotion of ANC and PNC promotion trained for were TBAs trained early and exclusive services, of complications, awareness nutrition institutional delivery, promoting breastfeeding, LBW and neonates for supplement and education, care home deliveries, hospitals Safe to children severe refer manage compli knowledge of sick neonates, of signs of the referral care, antenatal promote cations at home, nutritionsick newborns supplementation. clinics, to Outreach Outreach worker CHWs CHWs CHWs TBAs CHWs TBAs CHWs - Study Study design pre/post pre/post compara cross tive sectional survey Compa- Cross rative sectional Study Trained UTBA vs. pre/post 82 119 118 98 88 Study / Study country & Cordon Fonseca- Becker 2004 Guatemala et Fullerton al.2005 Uttar Pradesh, India Julnes et al.1994 Richmond, Newport and News, Norfolk, USA et Walraven 1995 al. Kwimba, Tanzania Hadi & Ahmed 2005 Rural Bangladesh

85 mode Evaluation Evaluation Follow up Follow LHWdone by who asked Data presented the from project MIS coverage 1 TBA per 1 1000-5000 population 1 CHW per 4000 population 1 CM per 18000 population 1 CHW per 4000 population Incentive Incentive (if any) Unpaid Supervision Field The Supervisors Suboptimal practices included lack of disinfection care, cord of delivery unhygienic instruments, of newborns, and lack lack of weighing or vitamin K. prophylaxis administration of eye - key compe-key tencies Antepartum, intrapartum and post partum care, Emergency Obstetrical Neonatal Care; care care Perinatal Emergency care Obstetrical Management of childhood illnesses Maternal and child health - - pregnant women pregnant - Role all pregnant Register LHW. and inform women visit to asked were They & pregnancyeach woman signs dangerous for check to encourage women & to seek to with such signs emergency obstetrical care. BNCP, promote ANC visits to acid supple folic iron& home postnatal mentation assess newbornsvisits to on and seventh the first, third, or of birth,days & referred sick neonates. treated of birthdisseminated newborn-care and messages preparedness change com (a) Behavior munication, (b) identification newborns sick of referral and and (c) in the community, of neonatal strengthening in health facilities. care Refreshers Refreshers / Ongoing training 1 days 3-4 refresher times during the study Refresher training sessions for management of maternal and newborn complications Management of maternal and newborn complications Certification Duration 3 days training 6 weeks 1 month - - - - They The trainingThe Traditional birth conducted most deliveries. (Dayas) attendants Traditional breastfeeding for except was rare, Advice Training Training Content and Didactic Practicum ante on trained were partum, intrapartum, and postpartum care; conduct to how a of use delivery; clean the disposable delivery wo kit; refer when to emergencymen for and obstetrical care; of the newborn. care supervised Hands-on training included skills develop provision BCC, ment for of essential newborn clinical assess care, & neonates, of ment management of sick with an IMCIneonates algorithmadopted Didactic They held group the meetings for dissemination of BNCP messages. CHWs The Didactic. carry trained to were out bi-monthly pregnancy surveillance and made home-visits and the in the third eighth month of counselpregnancy to families on (BNCP). the CHWs delivery, After made home-visits to evidence-promote based domiciliary new identify and to born care sick newborns, and refer home-treatment of serious with infection oral co-trimoxazole. Table 11B: Characteristics of Outreach Workers in Birth and Newborn Care Preparedness activities in Birth Preparedness Care and Newborn Workers of Outreach 11B: Characteristics Table TBAs Recruitment Recruitment Criteria from TBAs community Recruited from community Recruited from community Resided in the population they would serve qualitative Education These had CHWs a minimum of 10th grade education 94 95 96 105- Darmstadt 2008 Egypt Cairo, Study Study et Jhokio al.2005 (F) TBAs Baqui et al. 2008 107 (F) CHWs CMs (M & F) et Bari al.2006 (F) CHWs

Global Evidence of Community Health Workers - mode Evaluation Evaluation External eva done luation and found coverage 1 CHW per 1000 population Incentive Incentive (if any) Approxi- mately US$ 30 per plus month local travel costs. of Cost transport & meals Supervision Regional program supervisor - key compe-key tencies Essential maternal and newborn care, contracep advise andtive immunization services Basic resuscitation immediate and newborn care. Role conducted community sessions group education They should liaise closely with Dais and medical staff at basic health units or rural growth monitor to centers antenatal provide and to advice contraceptive care, and immunization services. Encouraged health maternal and newborn of recognition education, newborn danger sings Supported in LHWs conducting 3-monthly sessions education group establish an& helped to transport emergency mothers for fund and newborns. Refreshers Refreshers / Ongoing training Certification Duration Standard 18 months training from government and 6 days extra training this study for 3 days - - - Trained Trained Trained Training Training Content to TBAs Trained referral promote hospital for to newborns with danger signs. Didactic. Standard curriculum included: of ANC; Promotion use in and folate iron Immediate pregnancy, newborn Cord care; of Promotion care; breastfeeding. exclusive curriculum:Additional of adequate Promotion maternal nutrition and Early breastfeeding rest; & colostrum admi nistration; thermore care Home gulation; low-birth-weight of of Treatment infants; neonatal pneumonia with oral trimethoprim- sulphamethoxa sick Recognizing zole; newborns and danger Training requiring; signs counseling in group & communication strategies and Theory practicum in basic newborn Dais, for care which included basic resuscitation immediate and newborn care. and Theory practicum in basic newborn Dais, for care which included basic resuscitation immediate and newborn care. - Recruitment Recruitment Criteria from Women local commu with at nities, least 8 years of formal education and 6 months of training deliver to in healthcare the home Education At least 8At ofyears schooling 92 Study Study (F) TBAs et Bhutta al.2008 (F) CHWs TBAs (Female) CMs (Female)

87 mode Evaluation Evaluation two door-to- door inquiries Surveys. evaluation of the coverage $30-40/ month 1 CHW per 7000 population Incentive Incentive (if any) Transport Transport cost - Supervision supervised a regional by super program were who visor for responsible 6–7 Saksham Sahayaks (CHWs) Lady health worker supervisors trained CHWs 1 supervisor everyfor 3 facilitator key compe-key tencies Maternal and child health Maternal and neonatal health and resuscitation Maternal and neonatal health and resuscitation - - - Role Essential newborn care, , feeding breast Thermal care, reco danger sign counseling, change ma behavior gnition, nagement and trust building at birthAttendance Routine postnatal visit for the mother and newborn within 48 hours after birth care antenatal of Promotion deli To LHWs. sessions led by conduct & care, perinatal ver of presence the in delivery LBW recognize LHW & to infant & sick newborn, provide further for LHWs refer and care management and referral. meetings monthly Organize obstetric and address to perinatal problems - - Refreshers Refreshers / Ongoing training Regional program supervisors had daily monthly re group fresher sessions monthly re group fresher sessions were arranged in which problems encountered were discussed and resolved Certification Duration 7 days training 5 days 3 days

- - they They were They were Training Training Content Theory and practicum of combination A and classroom-based ship-basedapprentice field training on knowledge, attitudes, and practices related essential newbornto within the care behavior community, change management, and trust-building and Didactic practicum of highRecognition risk pregnancies, of Recognition referral. domiciliary manage ment of birth asphyxia bag and maskby & bac resuscitation. as perterial infections preventive protocol of LBWcare infants and Theory practicum trained on were of LHW promotion of births;attendance newborn resuscitation mouth);(mouth to maternal standardized post-partum care Didactic brief training ingiven perinatal health issues ------Recruitment Recruitment Criteria Recruited the local from community in proficient communi &reaso cation ning skills, CHWs Local trained by LHW national program working in commu nity were recruited TBAs Local com from munity were recruited Nominated ad leaders, by vertisement, after which all can potential were didates interviewed Education 12 years of more or education of8 years education 97 87, 87, 108, 108, Study Study et Bhutta al.2009 (F) CHWs (F) TBAs Manan- dhar et al. 2004 120-122 CMs (F) Darmstadt Darmstadt et al. 2008 109 (F) CHWs

Global Evidence of Community Health Workers mode Evaluation Evaluation coverage 1 CHW per 4000 population Incentive Incentive (if any) 1 CHW per 4000 population - Supervision A female trainer observed trainee each while CHW assessing new a breastfee ding mother, using a structured checklist. monitored weekly the during trial two by principal investigators - key compe-key tencies feeding Breast guidance, counseling, motivation, ne gotiation and demonstration Maternal and newborn health Mother & newborn care Role visits partum post Early 3, 4 to 1 to between days To 7 of birth.5 and 6 to best practices ensure with feeding breast to regard first educationConducted discharge before session the hospital and from second education session the in conducted was three home mothers’ months after delivery promote ANC visits to newborn-care and birth &folic iron preparedness, acid supplementation postnatal home visits to the on newborns assess and seventh first, third, of birth,days &referred sick neonates. or treated Refreshers Refreshers / Ongoing training Refresher training was on organized needing areas improvement in assessing & supporting breastfeeding mothers. Refresher training sessions for management of maternal and newborn complications Certification Duration 21 days 6 weeks

- - - - - Training on Training . Trained for for Trained . Training Training Content and Didactic practicum essential newborn care, which included an 8-h module on breast & counseling feeding a by support, followed 6-h practical session on observation & assess ment of breastfeeding and a 4-h practical session on counseling. covered Topics importance included of & basic features Training breastfeeding. methods included hands-onlectures, demonstration & with practical exercises postpartumreal-life mothers breastfeeding & video-guided lessons. Didactic exclusive of promotion appro feeding, breast priate immunization of infant, knowledge of oral rehydration solution in case of signs infant diarrhea, suggesting pneumonia and uptake of postnatal family planning. Hands-on supervised included Training skills for development behavior-change com munication, provision of essential newborn clinical assess care, and ment of neonates, management of sick with an IMCIneonates algorithmadopted Recruitment Recruitment Criteria CHWs from recruited community fluent in the two local languages, Nepali and Newari Recruited from community Education 114 101 Study Study Manan et al.2005 (F) CHWs Bolam et al.1998 CHWs Baqui et 2008 al. 115 93, (F) CHWs

89 mode Evaluation Evaluation evaluated obstetricby behavior and before the after intervention Their effectiveness was evaluated and pre by andpost tests a household survey. coverage 1 CM per 18000 population - Incentive Incentive (if any) Hourly mini wage mum payment without benefits Supervision Maternal and newborn health key compe-key tencies Mother & newborn care & Maternal newborn health Community health education with special emphasis on maternal-child health issues. Health education and counseling deliveries home Inter-personal counseling skills with individuals and towards groups desired for behavior - Role of birthdisseminated newborn-care and messages preparedness antenatalConducted education sessions for expectantfirst-time mothers a supportive develop rela To tionship with the mother and model problem-solving to improve helped to This skills. well- psychological mothers’ being and their perceived of social support.level the on awareness Create and issues of reproduction danger family planning, and self-caresigns and to receive to women encourage TBAs delivery from care deliveries safe Conducted knowledge increasing members community of and practice of beneficial and by household behaviors the use of maternal increasing and newborn health services Refreshers Refreshers / Ongoing training Management of maternal and newborn complications Maternal Child Health Advocates Certification - Duration 6 months +3 ad 2 days ditional days - - - - - They held antenatal edu antenatal Training Training Content Didactic meetings for group of dissemination the BNCP messages. Didactic topics Session cation. included health during nutrition, pregnancy, childbirth, for preparing childbirth, motherhood & communication, infant feeding, infant women’s health, & care health & contraception after the birth. and Training Didactic Trained field experience of concepts the in community health, health prevention practices and promo tion, social problems infant impact that health and maternal- child health issues trained to they were knowledgeincrease of contracep reproduction, signs danger use, tive and of complications, improve (b) self-care, newbornimmediate care, the per increase and (c) whocentage of women delivery from receive care trained birth attendants ma trained for were TBAs nagement of childbirth on counseling for Trained small for techniques individuals and groups and the use of BPP tools. Key on four chain focus of birth-plan¬ning:areas - Recruit- ment Criteria Recruited from community Residents of the serving commu reliability, nity, and literacy, history of volunteering service Education Literate selected from community TBAs local 90 89, 103 CMs CMs (M & F) TBAs (F) Study Study & Turan 2003Say 102 CHWs (F) Barnes- et Boyd al.2001 CHWs O’Rourke et al.1998 117 (F) CHWs Mc et Pherson al.2006 (F) CHWs

Global Evidence of Community Health Workers mode Evaluation Evaluation coverage Incentive Incentive (if any) Paid health providers (community midwives) supervised TBAs Supervision visited CHWs once them every 3-4 months. - key compe-key tencies maternal and care neonatal use of BPP. by andCounseling intrapersonal communica tion skills Communication skills desired for andbehavior neonatal care Maternal and newborn health Nurses - - - Role one-on-one Provided pregnant with counseling families their and women on key messages focused on birth-preparedness and readi-ness complication of danger and recognition using a flip-chartsigns Pregnant of identification interview antenatal women, the of weeks two before interviewdelivery, at 48 & delivery after hours interviewsfollow-up after of delivery. 4 weeks mothers and teen provides To their families with practical communi help and increases infant regarding awareness ty adolescent and mortality Also acts as a pregnancy. andliaison between the teens public agencies. the relevant re women, pregnant Register intra danger sings, cognized partum neonatal & immediate including resuscitation, care and skinthermal control care. Refreshers Refreshers / Ongoing training Certification Duration days Two training 1 day - - Training Training Content the for care care; antenatal mother &newborn during and after delivery; danger and in women signs newborns; and financial preparations logistical and delivery, pregnancy, for & postnatal period. on counseling Trained for techniques and small groups individuals and the use of BPP tools. hands-on problem- approach solving Knowledge of birth package,preparedness readiness complication and recognition of danger signs trained by were TBAs and mid Physicians were they and wives, behavior trained for change communication and essential newborn management care Training Didactic assist to Trained and adolescent parents the with families their non-medical dimen sions of pregnancy and child care. provide to Trained intrapartumantenatal, and early postnatal Recruit- ment Criteria TBAs local were selected women the from community serveto as resource mothers for pregnant teens Education 104 98 88 96 CMs CMs (Female) Study Study Moran et al.2006 (F) CHWs Hadi & Ahmed 2005 (F) TBAs et Julnes al.1994 (F) CHWs Darmstadt 2008 (F) CHWs

91 Promotion of Breastfeeding Background Each year about 10.8 million children die be- eleven were conducted in high income coun- cause of preventable causes and almost all from tries, 128,129,130,131,132,133,364 seven in middle in- poor countries.123 Most of these deaths can be come countries134,135,136 and five from lower in- reduced through universal coverage of simple come countries. 137,138,139,140,141 Interventions interventions like breastfeeding and estimates in Quinn et al. 2005137 were delivered in three predict that improved breast-feeding practices study sites (countries) Madagascar, Bolivia and could save the lives of 1.5 million children per Ghana. Studies included 10 RCTs, 3 Quasi RCTs, year.124 The World Health Organization and 3 pre/post studies, and 1 comparative cross UNICEF recommend exclusive breastfeeding sectional study (Table 12A & Table 12B) in which for first six months of life and appropriate com- breastfeeding was either promoted by peer plementary foods after six months along with counselors or volunteers from community. breastfeeding until two years and beyond.125, 126 However, exclusive breastfeeding and ap- In some studies breastfeeding was initiated propriate complementary feeding are far from during the antenatal period usually during optimum. In developing countries rate of ex- hospital visits by pregnant women. During pos- cusive breastfeeding ranges between 30-50%, tnatal period most interventions were delivered while equally unsatisfactory rate for complimen- during home visits by CHWs but occasionally tary feedings has been observed.127 Low rates were delivered by telephone. This was the main of breastfeeding brings along a high burden mode of delivery in Dennis et al.130 and Graffy of childhood illness like recurrent diarrhea, ARI, et al.142 In some cases breastfeeding counseling and other infections resulting to poor nutritional was done during both antenatal and postnatal status of children. Several studies done in deve- period.138,139 loped countries have consistently shown that duration of breastfeeding has been associated In the included studies, CHWs were particularly with reduced risks of childhood/adolescent playing a role of peer counselors selected from obesity and some chronic diseases in adulthood. community, except in two cases where the na- The major challenge is now how to improve the ture of their interaction with mother or women breastfeeding practice to ensure universal cove- was not clearly defined.129,133 Peer counselors rage. Studies done in developing countries have were usually women from community and had shown that effective breastfeeding counseling previous experience of breastfeeding their own can improve the rate of exclusive breastfeeding children and were more extensively trained then substantially. An important aspect of communi- CHWs. Our disaggregated analysis on results re- ty-based breastfeeding promotion is the home vealed no difference in the impact of outcomes based peer counseling, which involves training and both of these workers managed to create a lay health workers to contact and advice peers positive result in increasing early and exclusive from the same community. The peer counse- breastfeeding rates. ling intervention further improves its rate. We therefore have separately analyzed the effect Few studies clearly mentioned their training of promotion of breastfeeding counseling by part and the certified programs and boards CHWs on breastfeeding rates, a subset indicator which had accredited them for lactation of MDG. program.131,142Agrasada et al.134 and Morrow et al.136 found improvements in exclusive Community-based evidence breastfeeding rates as compared to Graffy et al.142 A large proportion of these studies provi- Twenty three studies were identified, of which ded one to one counseling at mother’s homes.

Global Evidence of Community Health Workers On the other hand, few studies used telepho- In a few studies CHWs were paid and were gi- nic counseling mechanism for promotion of ven a monthly wage ranging from USD 12 per breastfeeding130, 142 The main objective of all hour131 to USD 100-120 /month,135 but this sa- these studies was to promote breastfeeding by lary did not show an added benefit in increasing clarifying their misconceptions and improving initial and exclusive breastfeeding rates.131, 134, their understanding on direct advantages of 135, 138 breastfeeding.

In Morrow et al.136 breastfeeding education Conclusion based on six visits was compared with three Improved breastfeeding rates plays a major visits counseling, and significant results were role for achieving health and nutrition rela- found in 6 visits breastfeeding education, with ted to MDGS goals. Breast feed is the first and the reason that women obtained information at most important food in newborns life can help each phase of their breastfeeding, and with time them protect against major infections through became comfortable with their peer volunteers strengthening defense mechanism. Many and started sharing with them all the problems preventable deaths among neonates can be related to breastfeeding and started following averted through proper and timely initiation their guidance effectively. In another study, and continuation of breastfeeding. CHWs show breastfeeding counselor was compared with promising benefits in breastfeeding rates as counselors trained for general care; it was found compared to usual care. Their contextual factors that rates of excusive breastfeeding among wo- in increasing the rates of breastfeeding by mo- men counseled by breastfeed counselors were thers only had an impact when they were pro- higher as compare to general care counselor. fessionally trained by accredited body. However, the additional training and mode of training

CHW Snapshot 6 CARE Peru Enlace and Redes Program Program overview CARE Peru, in close collaboration with both the ministry of health and community health promoter associations and committees (APROMSA and COPROMSA), has supported community health workers program through the child survival projects Enlace (1996–2000) and Redes (2000–2004). Within this program, the CHWs are responsible for case management of diarrhea and acute respiratory infection and refer cases needing care at higher facilities. The CHWs are also responsible for mapping out the population, but they identify and track households with young children and pregnant women 143.

Operational aspects and considerations The comunitarios de salud, both men and women, are selected by Community Health Workers, Peru the communities in which they serve. Each health centre under the ministry of health is responsible for training its corresponding Refresher Regular meetings community health workers. Supervision and support are provided Supervision Promoter association by facility-based ministry of health personnel, as well as promoter associations. Through both active and passive detection, CHWs locate and refer cases to the nearest health facility.

Coverage and effectiveness During the Enlace program, more than 70 per cent of individuals in need of facility-based care were referred from communities with referral slips, and approximately 50 per cent of these referred cases were counter-referred to the CHW for follow-up. Over the five years of this project, the follow-up visits (counter-referrals) of CHWs increased from 40 per cent of sick children monitored at baseline to 81% monitored during the final evaluation. Source: WHO/Unicef 200624

93 demands active involvement of CHWs with community though direct visitation to women did seem to reinforce the positive outcomes of the intervention.

Global Evidence of Community Health Workers - - - Outcomes at the end of infants breastfed Proportion of 5 months was > 70% in the intervention areas. <10% in control to compare areas breastfeeding interventionThe exclusive increased introduction the delayed 0.044), = p 19.4%; vs. (24.7% substituted infants time the increased and formula of bottle milk (bottle 33.4% in the to breastfeeding p interventionthe in 20.1% and group; group control When comparing the frequency of artifi= 0.00002). of breast all other forms versus cial breastfeeding + partial), predominant the (exclusive+ feeding in 39% rates intervention breastfeeding increased were (RR = 0.61; CI 95%: 0.50–0.75); 15% of children artificialreduction) from feeding (absolute risk free mothers in the peer supportMore than in the group at 3 months breast-feed continued to group control 66.9%, p = and did so exclusi post partum (81.1% v. relative 40.3%, p = 0.01) Breast-feeding (56.8% v. vely 1.10 (95% confidence intervalrisk were [CI] 1.01–2.72) and 1.13 (95% CI 1.00–1.28) at 8 weeks at 4 weeks, post partum1.21 (95% CI 1.04–1.41) at 12 weeks 79% were rates breastfeeding exclusive 3 months, At (381) in the intervention and 48% (197) in the control ratio 4·02, 95% CI 3·01–5·38, communities (odds 7-dayThe diarrhea was lower prevalence p<0·0001). in the intervention communities than in the control at 3 months (0·64, 0·44–0·95, p=0·028) and 6 and mean weights The (0·85, 0·72–0·99, p=0·04). or and the proportionlengths, with weight-for-height at age 3 months of 2 or less, Z scores height-for-age groups. much between and 6 months did not differ Participants Pregnant women women Pregnant aged 16–35 years, than with no more 3 living children mothers who birthhad given In-hospital, breast- primiparous, of women feeding had 16 yrs of age, birtha singleton at 37 wks gestation in &resided or later the local region mothers of infants - - Years of Years study 15 months 50 months - Control arm Control recruited No PCs were group. control for group control The no specific received They were intervention. seek out instructed to their local health service facility in case of any health problems. to allocated Women had group the control the conven access to tional In hospital & community postpartum support services such by as those provided hospital-based nursing and medical staff Routine services at provided were sites. the control - Interventions Table 12A: Promotion of Breastfeeding – Characteristics of Included – Characteristics studies of Breastfeeding 12A: Promotion Table Mothers in intervention taught arm were on correct positioning of breastfeeding, breastfeeding early and exclusive Experimental arm Experimental mothers at trained and visited PCs were 10 times during and postnatal antenatal They mothers and key family period. members about importance of exclusive early breastfeeding, breastfeeding, and post prelacteal discouraging positioning and proper lacteal foods further they advised of breastfeeding, nutrition diet. mothers of healthy the peer support to allocated Women all of the conventio had access to group nal support services group that control being paired in addition to was availing, and they were with a peer volunteer, support to given and education related these counselors through breastfeeding and nutrition workersTBA, CHWs in the intervention counsel communities to at breastfeeding exclusive mothers for assessed Worker multiple opportunities. on the benefits information and provided age 3 At breastfeeding. of exclusive mothers & infants were and 6 months, a member of the at home by visited ascertain to study team to exposure the details of counseling sources, different instances of and any counseling received, disease in the infant past 3 months. PCs Outreach Outreach worker PCs PCs CHWs RCT Study Study design cRCT RCT cRCT 138 130 139, 135 Leite et al. et al. Leite 2005 Fortaleza, Brazil Study / Study country Haider et al.2000 Dhaka, Bangladesh Dennis et al.2002 Toronto, Canada Bhandari et al.2003 144 Haryana, India

95 - Outcomes 3 months post partum,At breastfeeding exclusive 50% of three-visit, was practiced 67% of six-visit, by mothers (intervention vs. and 12% of control Groups – visit, p=0·02). three vs. p<0·001; six-visit controls, (p=0·02) was significantly Duration of breastfeeding than in controls, longer in intervention groups intervention infants had than control and fewer an episode of diarrhea (12% v s 26%, p=0·03). and 73% Group 97% in the Control 3 months, At had not exclusively counseling group in the Peer risk [RR] =1.33; 95% CI, 1.14-1.56) (relative breastfed likelihoodThe of during 24 hours. the previous the first throughout breastfeeding nonexclusive Control for the higher 3 months was significantly (99% vs. Group Counseling than the Peer Group likelihoodThe 79%; RR=1.24; 95% CI, 1.09-1.41) diarrheal 1 or more episode in infants of having Group Counseling was cut in half the Peer 38%; RR=2.15; 95% CI, 1.16-3.97). (18% vs. counseled 44% of the breastfeeding 6 mo, At 7% childcare-counseledmothers, mothers and none of the mothers in control breastfeeding exclusively were group Offering supportfeeding did not signifi in breast feeding breast of any the prevalence cantly increase (65% (218/336) in the intervention six weeks to group; and 63% (213/336) in the control group risk 1.02, 95% confidence intervalrelative to 0.84 1.24). Survival months confirmed four analysis up to nor time to feeding that neither duration of breast significantly differed feeds introduction of formula and interventionbetween control groups. for initiation of breast did not differ groups IThe 69.0% (747/1083) in the interventionfeeding: and 68.1% (896/1315) in the control group odds ratio 1.11 adjusted cluster groups; (95% confidence intervalto 1.43). 0.87 - - Participants Included were Included were in mothers residing whose study area child was youngest of age < 5 years Expectant mothers, less than 32 weeks gestation and consi dering breastfeeding mothers with > vagi 18 years, a LBW nally delivered & intended singleton breastfeed to considering Women feeding. breast All pregnant women Years of Years study 21 months 18 months 19 months 40 months 5 months - - - - Control arm Control mothers Control-group with lactation problems their to referred were No physicians. own of other sources coun breastfeeding available seling were in the community to assigned Women (CG) group the control conven only received tional breastfeeding education prena Women’s the tally from Ambulatory Health Services clinic staff of group control mothers who did not counseling receive No support provided group control to in the control Women received clusters care, antenatal standard which included usual and ad information on midwives vice from without feeding, breast community input from peer support workers. - In the Interventions Experimental arm Experimental six visits intervention group visited mothers were group, six-visit in the first pregnancy, in mid and late 2, 4, and 8 post partum and weeks week mothers visits interventionthree group in the pregnancy, in late visited were week,first week 2 postpartum. & peer breastfeeding Exclusive counseling Support 3 offering daily perinatal home visits, prenatal 9 postpartumvisits, and home visits, counseling as needed. telephone receiving intervention groups Two one by home based counseling visits, counselors trained in breastfeeding counselors the other by counseling, trained in general childcare once women visited Counselors birth postnatal before and offering support or further telephone by home the antenatal At visits if requested. the women visit the counselors gave a contactand two leaflets. card peer supportAn antenatal worker ser comprisevice planned to a minimum of two provide contacts to with women and support information, advice, from gestation 24 weeks’ approximately clinic or at home within the antenatal Outreach Outreach worker PCs PCs PCs PCs PCs Study Study design RCT RCT RCT RCT cRCT 136, 131, 148 142 129. Study / Study country et Morrow al.1999 1425 San Pedro Martir, Mexico Chapman et al.2004 146, 147 New England et Agrasada al.2005 Manila, Philippines Graffy et al.2004 & London south Essex, England MacArthur et al.2009 Birmingham, England

Global Evidence of Community Health Workers - Outcomes discharge the research who received Women the pack, with those who received compared likely prolong pack, more to commercial were (P = .004, one-tailed), to breast-feeding exclusive at 4 months postpartumbe partially breast-feeding the daily use delay (P = .04, one tailed), and to impact a positive of the breastfeeding toward Trends evident but weak, activities promotion were postpartum. 7-10 days gone by and largely with compared 24% in the CG hospital discharge, At with breastfeeding, 9% in the PC had not initiated breastfee nonexclusively 56% and 41%, respectively, and 73% in the PC 97% in the CG 3 months, At ding. risk [RR] =1.33; (relative breastfed had not exclusively The 95% CI, 1.14-1.56) during24 hours. the previous throughout breastfeeding likelihood of nonexclusive CG for the higher the first 3 months was significantly 79%; RR=1.24; 95% CI, 1.09-1.41). than the PC (99% vs. less likely than their PC were Mothers in the CG 52%; counterparts in at 3 months (33% vs. remain to likelihoodThe of having RR=0.64; 95% CI, 0.43-0.95). diarrheal1 or more episode in infants was cut half 38%; RR=2.15; 95% CI, 1.16-3.97). in the PC (18% vs. all duration for median breastfeeding The in the peer support women was 2 days group group the control for 1 day to compared and the Kaplan–Meier survival the plot shows slightly breastfeeding peer support overall group with no statistically group, longer than the control test (P = 0.5). by log rank difference significant the proportion breastfeeding delivery, At initiated 23% of the intervention subjectswere and of postnatal 6 weeks At 20% of the control. period the proportion in intervention areas it was 8% area was 10% and in control - Participants delivered women delivered African-American WIC participants 18 yrs or older, gestation age or of 32 weeks healthy younger, and absence of any medical condition hyperten (diabetes, sion, HIV/AIDS or using illegal drugs) of 28 weeks women of gestation from general practice in Scotland women Pregnant 7-10 days Years of Years study 16 months 3 months 4 months 24 months - Control arm Control Routine counseling hospital staff by did not group control interventions receive did not group Control interventions receive normal breastfeeding support commu by the first for nity midwife they were Plus 10 days. breastfeeding given support and groups workshops breastfeeding area in control Women teaching was given at health center - Interventions Received normal breastfeeding support normalReceived breastfeeding 2 peer supporters was as in control. each mother and they to assigned period mothers in antenatal visited Intervention comprised peer women, counseling of pregnant support mothers and of breastfeeding raising activities local awareness Experimental arm Experimental first intervention,The research consisted counseling, breast-feeding 40-mi 20- to of an individualized postpartumnute counseling session a trained counselor, in the hospital by eight scheduled telephone by followed the counselor when calls from of age infant was 5, 7, 14, 21, 28 days of age. and 6, 8, 12 weeks the single and combined evaluated We a motivational of introducing effects four video and peer counseling into WIC clinics on breastfeeding matched initiation and continuation at 7-10 days the peer counseling to assigned Women home 3 prenatal offered were group 9 postpartumvisits, and home visits, daily in-hospital visits during postpartum peer the assigned hospitalization, from the routine counselor (in addition to support the by breastfeeding received During the prenatal group). control with an was provided the woman visits, opportunity a breastfeeding watch to family was also encouraged to The video. participate in the education, especially supportthe person expected to the mothers could The after delivery. woman contact phone if they the mothers by problems breastfeeding urgent had any peer assigned The between visits. the mother-infant counselor also visited startingpair at least once a day within 24 hours after delivery as and continued for hospitalized long as the dyad remained PCs PCs Outreach Outreach worker PCs PCs PCs RCT Quasi RCT Study Study design RCT RCT RCT 150 132 133 133 Muirhead et 2006 al. Urban Scotland Mclnnes et al.2000 Glasgow, USA Study / Study country et Frank al.1987 USA Boston, et Frank al.1987 USA Boston, Anderson 2005 et al. 147 USA

97 - - Outcomes Eighty-two of intervention percent compared initiated women group of control with 31 percent Mean duration of breastfeeding breastfeeding. was women intervention group for and control 4 weeks, At respectively. 5.7 and 2.5 weeks, of intervention of 56 percent and 10 percent still breastfeeding. were women group control The results show that the training was most show results The CHW recommendations powerful predictor. 60.25, p-0.000), (OR and of on breastfeeding knowledge (OR=1.92.49, breastfeeding ‘perfect’ (in the age bracket CHWs Younger p=0.000). likelyto more significantly were 29 years) 20 to make on exclusive correct recommendations p=0.0304). (OR=3.02, breastfeeding within one hour of birth infants breastfed increased intervention 34% pre 78% post intervention to from in 24 hours increased breastfed infants exclusively intervention 46% pre 68% post intervention to from within one hour of birth infants breastfed increased intervention 56% pre 74% post intervention to from in 24 hours increased breastfed infants exclusively intervention 54% pre 65% post intervention to from within one hour of birth infants breastfed increased intervention 32% pre 40% post intervention to from in 24 hours increased breastfed infants exclusively intervention 68% pre 79% post intervention to from hospital-training interventionThe a high achieved in the hospitals, breastfeeding (70%) of exclusive rate was not sustained at home and 10 but this rate exclusively of age only 30% infants were days in breastfeeding patterns of exclusive The breastfed signi 10–180 differed days for the two trial groups preva ficantly (p_0·0001), with a mean aggregated home visits assigned lence of 45% among the group none. assigned the group with 13% for compared their child. breastfed 25% failed to problems They identified common breastfeeding breast nipples, sore breast milk”, “insufficient as Participants Pregnant women Pregnant pregnant pregnant women, grandmother and other decision makers such as grand fathers and husbands Pregnant women Pregnant mothers delivered a baby partially breast infants fed women pregnant - - Years of Years study 24 months 36 months 24 months 24 months 5 months of 2 weeks up follow Control arm Control no significant breastfeeding programs promotion In arm, control no training was CHWs to provided - Interventions volunteers taught a series of in-home, taught a series of in-home, volunteers one-to-one diet lessons about healthy and maintained and breastfeeding, contact answer informal to Experimental arm Experimental The training of health workersThe on breast and lactation management is to feeding enable them make correct breastfeeding mothers. to recommendations who disseminated CHWs Trained a combination of messages through interpersonal communication strategies community (health worker mother, to mother), mother to worker mother, to activities and communitygroup mobilization, and mass media (Radio, were Women and print).television, small- and large-group through reached activities, one-on-one counseling in breastfeeding promoted they and homes groups via songs performed women’s by and community &musical troupes, such as local theater, mobilization events celebrating and festivals health fairs, & child health days. breastfeeding the hospital-based compare main objective The was to intervention (BFHI training of maternity staff) with a combined hospital-based and community-based intervention (BFHI training primaryThe measure outcome and postnatal home visits). birth from 6 months. to breastfeeding of exclusive was rates CHWS individually counseled by mothers were who their infants aged 1-12 weeks breastfeed to diarrhea with acute been admitted have their communities to returned training CHWs After and started supportingpeers breastfeeding PCs Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs CHWs PCs - Quasi RCT Study Study design Quasi RCT pre/post pre/post pre/post compara cross tive sectional Cross sectional survey Qualitative survey 147 128 133 133 133 136 148 141 Schafer et Schafer al.1998 USA Iowa, Study / Study country Davies- Adetugbo et al. 1997 Osun, Nigeria Quinn et al.2005 Madagascar Quinn et al.2005 Bolivia Quinn et al.2005 Ghana et Coutinho 2005 al. Brazil Haider et al. 1997 Dhaka, Bangladesh Nakhunda et al.2006

Global Evidence of Community Health Workers - mode Evaluation Evaluation Effectiveness Effectiveness of counse ling assessed using a 5-point Likert scale coverage 1 PC for 12- 1 PC for 25 mothers Incentive Incentive (if any) (£16 [US$22.50] per month). US$4 for home each about visit, US$100–120 per month - Supervision perforTheir was mance at monitored least thrice over studythe total period two by breastfeeding supervisors. Supervision provided were Growth monitoring ntechniques were reading supervised sending before workers for workfield - - engorgement, mastitis and poor positioning at the breast. mastitis and poor positioning at the breast. engorgement, They further observed were that most of these problems The correct at the breast. eased by positioning of the baby their communities. by easily accepted peer counselors were someone within their have to happy mothers were The problems. community helping them with their breastfeeding key compe-key tencies Counseling skills encou for ragement of feeding. breast and Prenatal postpartum counseling onCounseling feeding breast mo Counseled benefits thers and proper of method feeding breast Growth monitoring and breastfeeding counseling - - - Role They mothers &key family importance about members breastfeeding, of exclusive discou early breastfeeding, post and prelacteal raging and proper lacteal foods positioning of breastfeeding, mothers advised they further nutrition diet. of healthy the on mothers visited They birth, from 5th day 15th, 30th, 60th, 90th and 120th Contact the new mother within 48 hours after as and discharge hospital the as thereafter frequently mother deemed necessary materials various Used were communication for clinics, doctors’ for posters workers,for a flip books recom with feeding card a counseling mendations, guide on solving common difficulties, breastfeeding and a mother-and-child card cli handed out at Antenatal nics or at the first home visit. Refreshers Refreshers / Ongoing training periodic training the activity logs distributed during the orientation session were reviewed in relation the peerto volunteer interactions. Certification Duration (4 h10 days Worked daily) Part-time 20 hours 2.5hours 3 days - - - - - Table 12B: Description & Characteristics of Outreach workers of Outreach 12B: Description & Characteristics Table orienta information All members of of members All Training Training Content Didactic demons role and trations WHO/UNICEF play breastfeeding counseling course and used book were King’s taught Were guides. as demonstrations andby and included. play role theory-practice trai ning trained were this group on a course adapted Breastfeeding from training course Didactic and Interactive tion session was to the peerdevelop telephone volunteers’ support and referral skills; incorporated various such topics as breast-feeding general benefits, breast-feeding information Didactic and hands-on training indi in counseling of viduals or groups mothers on the benefits of breastfee exclusive on ding and feed demand based on an adaptation of the Manual IMCI Training On Breastfeeding Counseling, - Recruitment Recruitment Criteria with Women breastfeeding experience, willingness help otherto mothers breastfeed, personal experience in breastfeeding is associated with the Milk Bank at the Federal University of Ceará´ previous breastfeeding experience of at least 6 months’, a positive breast-fee ding attitude health and nutrition workers - Education leastAt 4 years schooling, postseconda ry education 135 138 130 Iganga, Uganda Study Study Haider et al. 20000 PC (F) et Leite al.2005 PCs (F) Dennis et al. 2002 PCs Bhandari et al.2003 139, 144 PCs

99 mode Evaluation Evaluation An exit exit An at interview 6 months post partum Evaluated positive by outcome coverage Incentive Incentive (if any) $12 per hour & receive health care on working 20 hr/wk transport cost paid during & training home visit - - Supervision supervised of staff by La Leche of League Mexico and the physi cian study coordinator Supervised experienby ced peer counselor 6 3 to for months A certified lactation counselor - key compe-key tencies feeding Breast counseling Prenatal, perinatal and postpartum counseling exclusive for feeding breast telephone and counseling as needed. Counseling exclusive on feeding breast and child care Breastfeeding counseling directlyWorked with the an clinicstenatal and counseled breast early for feeding. - Role pregnant to visits Home the on focused women breast benefits of exclusive especially during feeding, the of positioning illness; “latching on” infant and home visit, daily 1 prenatal 3 postpartumperinatal visits, telephone and visits, home contact as needed. counselors breastfeeding The the of mothers informed benefits of exclusively infants up to breastfeeding mothers assisted & mo, 6 & managing in preventing problems. breastfeeding contact a women the Gave leaflets two and card during visit and antenatal support postnatal offered or further telephone by home visits if requested. of activities of log a Kept who had reached women gestation, then24-28 weeks Also 36weeks. at around who up women followed to feeding breast initiated postnatal support.give individualized Offered postpartum 40-minute 20- to counseling session in a trainedthe hospital by by followed counselor, telephone scheduled eight the counselor calls from Refreshers Refreshers / Ongoing training biweekly case review meetings with program director Accredited Accredited counselors for the National Trust. Childbirth Certification Duration 30 hours 40 hours 8 weeks - - training classroom classroom Training Training Content and Didactic practicum of 1 week consisted 2 months of classes, in lactation clinics and with mother-to-mother andsupport groups, of observation1 day and demonstration visiting expertsby Didactic Topics training. were covered and anatomy breast manage physiology, ment of breastfeeding, counseling techniques, cultural and related and social factors DidacticInteractive On Training Didactic counseling techniques promoting for feeding. breast Training Didactic Unicef the on based friendlybaby breast management feeding and addressed course, and cultural beliefs barriers to appropriate the local population. - - Recruitment Recruitment Criteria aged 25–30 andyears they did not necessarily previous have personal breastfeeding experience. community whowomen breast have a child for fed a minimum of 6 months posi previous personaltive breastfeeding experience themselves breast have their child fed Education high-school high-school formal education 133 136, 136, 148 142 129 Study Study Morrow et al. 1999 145 PCs Chapman et al.2004 146, 131, 147 PCs Agrasada et al. 2005 PCs Graffy et al. 2004 PCs Mac Arthur et al. 2009 PCs et Frank al.1987 PCs

Global Evidence of Community Health Workers - mode Evaluation Evaluation Postnatal Postnatal question were naires used to the assess of impact counseling. Evaluated after 4 months of coverage Incentive Incentive (if any) Supervision key compe-key tencies Breastfeeding counseling Encouraged feeding breast counselingby mothers Encouraged feeding breast counselingby mothers counseling in breastfeeding - - - Role pregnant of Counseling supportwomen, of breast mothers and local feeding activities. awareness-raising monthly meeting 3 hrs each for of series a taught one-to-one in-home, lessons about healthy diet and breastfeeding, discussions group Focused mothers lactating with and grandmothers messagesDisseminated a combination through of interpersonal strategies Communication activities and com (group munity mobilization, and televi mass media (Radio, sion, and print). Included grandmothers & fathers audiences secondary as behaviors promote to supporting mothers to optimally breastfeed Refreshers Refreshers / Ongoing training Certification Duration 9 hrs - -

and . And four . And four Training Training Content Didactic training skills enable them to breast promote to support to and feeding mothers feeding breast 2 days sessions. evening Didactic training included gene Topics ral nutrition, advanta ges of breastfeeding, of management basic listening breastfeeding, and communication skills, and goal setting. Training Didactic Course feeding Breast for manual modified a non-Hospltal based primary selling, care Short-term practical training heavy on counseling/ negotiation and skills communication frontline and health for workers community aimed at training numbers to large counteract attrition Recruitment Recruitment Criteria mothers who had at least 1 child under 5yrs of age, had breastfed at for a baby least 3months 2 written references and security wasvetting carried out Breastfeeding experience of at least 3 months Health workers staff from government offices and NGOs along with community- based volunteers Education 128 137 137 137 150 Study Study Mclnnes et al.2000 132 PC s(F) Muirhead et al. 2006 Urban Scotland et Schafer al.1998 PC s(F) Davies- Adetugbo et al.1997 141 CHWs Quinn et al.2005 Madagascar CHWs Quinn et al.2005 Bolivia CHWs Quinn et al.2005 Ghana CHWs

101 mode Evaluation Evaluation Once every two weeks, a supervisor observed each peer counselor coverage Incentive Incentive (if any) - Supervision Each peer counselor would a by be visited supervisor every andtwo weeks a monthly mee all. ting held for key compe-key tencies BREASTFEEDING COUNSLING AND MANAGEMENT OF BREASTFEEDING PROBELEMS - Role mothers pregnant Recruited visit each at and follow-up for information offer they would mo For about breastfeeding. breastfeed, thers planning to the peer counselor offered help the mother withto after the birth.breastfeeding - Refreshers Refreshers / Ongoing training peerThe counselors and supervisors held monthly meetings where reports and challenges by peer coun selors were discussed and possible solutions agreed. Certification Duration 18 hrs Training Training Content Interactive, Didactic training and Practicum twowas run by lactation consultants. Answer Breastfeeding MohrbacherBook by was usedand Stock material. as reference Recruitment Recruitment Criteria 24–35 years and old, must have a breastfed child who was less than years old. five Also had to be literate in Lusoga, the local and language, acceptable theto community. Education Study Study Nakhunda et al.2006 140 PC s(F)

Global Evidence of Community Health Workers Neonatal Health Interventions Background The likelihood of death of a child under five years ted in rural areas of South Asian countries of age, born in a developing country is over 13 (Pakistan,159 India160-164 and Bangladesh165) times that of a child born in an industrialized (Table 13A & Table 13B). The interventions re- country.153 The Sub-Saharan Africa accounts for viewed on community health workers’ role in about half of the under five child mortality in neonatal health have shown positive outcomes the developing world.154 There has been some where the trained CHWs were used to outreach decline in the under five mortality but that is far the sick children of the community.159, 162, 166, below the MDG target for Goal 4 i.e., to reduce 167 The types of outreach workers involved in the under five mortality rate by two-thirds.154 these activities were the CHWs, TBAs, and CMs. The educational level of the CHWs was gene- According to Walsh et al., pregnancy-related rally poorly described. The TBAs involved in the illnesses and complications during pregnancy Saleem et al. were all literate159 while those and delivery are associated with a significant in Bang et al. were illiterate.161 The CHWs in impact on the fetus, resulting in poor pre- other interventions reviewed had a few years of gnancy outcomes leading to greater health schooling.162, 163, 167 risks for the infant.155 These health risks include childhood illnesses, disability or even death.155 In developing countries, almost two-thirds of The training modalities used were mostly didac- 163-165, 167 births occur at home and only half are attended tic and sometimes in combination 159, 161, 162 by a trained birth attendant.156 Of the 136 mil- with practicum. The training in Bang 170 lion babies born every year, approximately 3.2 et al. was hands-on, workshop based training. million are stillbirths and four million are neo- The training content focused on management natal deaths, 98% of which are in developing of birth, birth asphyxia, hypothermia, manage- countries. The first week of life is a particularly ment of LBW babies, recognition of danger signs 159, vulnerable period, with 60 to 70% of neonatal in neonates and breast feeding problems. 161-163, 167 deaths occurring within the first seven days The CMs trained in the Dongre et al. after birth.157, 158 intervention were trained to identify newborn danger health signs and promptly refer as per The reduction in child mortality is achievable the country specific adaptation of IMCI to ensure 164 by ensuring full coverage of immunization household-to-hospital continuum of care. programs, exclusive breastfeeding for 6 months, scaling up of vitamin A and nutritional supple- In Sloan et al. BRAC CHWs (government trai- ments, prevention and effective treatment of ned nutrition workers) delivered interventions diarrhea, pneumonia, malaria and other infec- related to nutritional counseling and taught tious diseases, hand washing and using safe and Kangaroo-Mother-Care to mothers. These CHWs clean drinking water.154 These tasks are do-able were provided frequent refreshers and supervi- with the appropriate and active engagement of sion but despite of providing close monitoring the CHWs.154 and supervision and frequent refreshers, intervention did not create an impact on reducing neonatal deaths and infant mortality.165 Community Based Evidence We identified nine studies including 2 RCTs, 3 We identified 6 studies in which CHWs delivered quasi- RCTs, and 4 before/after trials that descri- preventive and therapeutic interventions for im- bed interventions to improve neonatal health proving neonatal health. Among these Bang et outcomes. All of these studies were conduc- al.1994 and Bang et al.1999 particularly trained

103 CHWs to identify and treat neonatal infection seen in health care seeking and uptake of im- and provided referrals where necessary. Both munization services in newborns. CHWs in these of these studies found substantial reduction studies were extensively trained to create a link of up to 24% in neonatal deaths and declined between TBAs and local health center. In Daga pneumonia specific neonatal deaths by over et al. CHWs were also given a remuneration of 40%. In these projects CHWs along with TBAs Rs 50 per month.163 were trained to make visits and identify sick neonates who require treatment with antibio- Neonatal resuscitation was another major in- tics.162, 166 In Bang et al.1993, illiterate TBAs tervention which was utilized to manage birth were trained to count respiratory rate through asphyxia for the improvement and reduction “Breath counter” and sand timer to identify ta- of neonatal deaths. In Bang et al. the TBAs were chypnoea.161 Workers involved in the treatment trained to manage birth asphyxia via mouth- and management of neonatal infections were to-mouth, tube – mask or bag-mask resuscita- closely supervised by a physician162 and by tion.167 Since TBAs involved in these interven- field supervisors161 and therefore managed to tion were illiterate, therefore they were given avert neonatal mortality and more particularly extensive 3 days hands on training to manage pneumonia specific neonatal mortality. those babies who failed to cry or breathe at birth and undertook drills every 2 months to refresh Dongre et al. and Daga et al. trained CHWs to their practice.167 Extensive training along with assess and refer sick newborns and they created incentive of $1 per case showed up an impact referral mechanism with health systems.163, 164 of reducing neonatal mortality by 70%.167 In these studies significant improvement was

CHW Snapshot 7 Female Community Health Volunteers Nepal Program overview The Female Community Health Volunteer (FCHV) Program in Nepal was started in 1988 by the Ministry of Health and Population in order to improve community participation. In the mid-1990s a “population based” strategy was adopted in 28 districts whereby additional FCHVs were recruited leading to a current total of nearly 50,000 FCHVs in Nepal and 97% of them are in are in the rural areas 168. FCHVs play an important role in contributing to a variety of key public health programs, including family planning, maternal care, child health, vitamin A supplementation and immunization coverage.

Operational aspects and considerations Female Community Health volunteers, Nepal The CHWs are chosen from community; they work for community Training 5 days and refer sick cases to the nearest health facility. Refresher 2 days after 2-3 months Coverage and effectiveness The program is currently operates in 17 of 75 districts in the country. As of 2001, there were more than 9,000 community health workers trained in pneumonia case management. Many partners help maintain the program, and it is estimated that a much larger proportion of pneumonia cases are treated in program areas. The Nepal Demography and Health Survey (NDHS 2006) indicates that about 10% of children with ARI in CB-IMCI districts go to FCHVs compared with 19% of children who go to government rural facilities. Only 13% of treatment FCHVs failed to treat any children over six months due to lack of medicines. Evidence from districts that have all treatment FCHVs is that 88% of FCHVs treat successfully if trained. The 2006 NDHS survey found that 90% and 84% coverage for vitamin A and deworming, respectively. Source: WHO169 and WHO/Unicef 200624

Global Evidence of Community Health Workers Conclusion The evidence based review of the interventions MDGs related intervention. However, their per- described above shows that the extensively trai- formance can be enhanced through vigorous ned CHWs were able to manage preventive and training, supervision and pay for performance therapeutic care in compliance with the MDG incentives. But at the same time, we need to 4 targets.154 The TBAs were equally competent create a system where these TBAs should be in managing neonatal infections and birth coupled with literate health workers who can asphyxia through antibiotics and resuscitation liaise on with the health system for maintaining respectively.159, 163 Despite the fact that they proper referral feedback mechanism for achie- are illiterate and were a part of informal health ving better outcomes as evident in included system, we cannot ignore their role in delivering studies.

105 Global Evidence of Community Health Workers Outcomes skin among experimental infection arm arm was 22% was 16% while in control neonatal deaths in experimental arm was arm it was 2% 0% while in control NMR = OR adj 1.060, 95% CI: 0.761–1.477 IMR = OR adj =1.039, 95% CI: 0.770–1.40 5-38%) 94% 24% reduction in NMR (CI: pneumonia reduction in CMR due to 59-81%) 70% reduction in NMR (CI: 46-68%) 49% (CI: 56% decline in PMR reduction in still births 31-66%) (CI: pneumonia specific mortalityto 44% reduced neonatal mortalitywhile total 20% to reduced After birthAfter trained in the Essential were attendants was no significant there course, Newborn Care of neonatal death baseline in the rate reduction from after birth all causes in the 7 days riskfrom (relative 0.99; 95% confidence intervalwith training, [CI], 0.81 was of perinatal 1.22) or in the rate death; there to reduction of stillbirth in the rate a significant (RR 0.88; P=0.003) 0.69; 95% CI, 0.54 to with training, seeking seen in health care improvements Significant sick newborns for providers private health care from Participants pregnant women pregnant (>7 months) all late gestation and postpartumrecently and women their families women Pregnant women Pregnant neonates neonates women pregnant - Years of Years study 7 months 35 months 84 months 42 months 24 months 36 months - - Control arm Control used saline wipes were of chlorhexidineinstead in controlled Women servedarm were with community nutrition not workers who were CKMC trained for these In areas control the done by tasks were health ser government vices & the Integrated Child Development Service (ICDS) workers areas in control TBAs not additio were TBAs nally trained as in intervention arm, but they did receive usual training from sources government services provided were government by health facilities Interventions Table 13A: Neonatal health– Characteristics of Included health– Characteristics Studies 13A: Neonatal Table The government started government The Integrated (BINP), which Nutrition Program became the National Nutritionlater advice & (NNP), provided Program women. pregnant supplementation to community nutrition In this study BINP’s CKMC to teach trained to workers were participants In the intervention group breastfeed taught to They were villages. and on demand. exclusively, promptly, Experimental arm Experimental The women. identified pregnant TBAs chlorhexidine wipe was used by vaginal cervix, & applied on entire TBAs & vagina was also external the neonate genitals, wiped after delivery within 6 hrs of birth TBA and village HCW, paramedics, Train in administration of antibiotics and counseling in mother and newborn care TBA training on the impactAssessed of and home based neonatal resuscitation education on neonatal mortalitycare trained to were and CHWs TBAs pneumonia and treat diagnose with antibiotics neonates local instructors trained birth rural communities from attendants Democratic Republicin six countries of Congo, (Argentina, Health World India,Guatemala, and Zambia) in the Pakistan, course (which focuses Essential NewbornOrganization Care thermoregulation, resuscitation, neonatal care, on routine [skin-to-skin] of the small care care, “kangaroo” breast-feeding, in a in Argentina) and common illnesses) (except baby, Pediatrics Neonatal of Academy version of the American modified basic resuscitation). (which teaches Resuscitation Program about newborn women danger sings birthEducate seeking, and conduction health care preparedness, of monthly village based meeting CHWs Outreach Outreach worker TBAs CHWs TBAs CHWs TBAs CHWs TBAs CMs cRCT Study Study design cRCT Quasi RCT Quasi RCT Quasi RCT pre/post pre/post 166 159 164 74 165 160 Sloan et al. Sloan et al. 2008 & Sylhet Dhaka, Bangladesh Study / Study country Saleem et al.2007 Karachi, Pakistan Bang 1999 170-173. Gadchiroli, India Bang 2005 Gadchiroli, India Bang et al.1993 Gadchiroli, India Carlo et al. 20101 Argentina, Democratic Republic of Congo, Guatemala, India, Pakistan, and Zambia et Dongre al.2009 Rural Wardha, India

107 Outcomes ANC registration increased from 467 in 1987 to 467 in 1987 to from increased ANC registration in immunization and 630 in 1989. improvement reportedbeneficiaries in immunization was also Participants pregnant women women pregnant and newborns Years of Years study 36 months Control arm Control Interventions Experimental arm Experimental and warmth, resuscitation, providing trained for were TBAs foot length less than 6.5 with of a baby referral identification and and TBAs make also trained to a link between were cm. CHWs each newborn and they visited health system. on birth the for need hospitalization to in case found assessment and referral Outreach Outreach worker TBAs CHWs Study Study design pre/post 163 Study / Study country Daga et al.1993 IndiaRural

Global Evidence of Community Health Workers mode Evaluation Evaluation Evaluation done in the next workshop 2 months later coverage Incentive Incentive (if any) Small stipend $7.50 a month was CHW given $1.00 per case Field supervisors visited later homes and the Verified records. - Supervision By study supervisor was physician A withentrusted field supervi sion fortnightly BRAC supervisors field Trained supervisors field Trained supervisors - key compe-key tencies Postpartum Infection in control mother and neonate Management of birth LBWasphyxia, infants and feed breast counseling Diagnosed and treated neonatal sepsis Breastfeeding counseling +KMC Measurement indicators of and the ma nagement of birth asphyxia. of Diagnosis pneumonia - - Role de &hygienic safe Conducted livery using the kits provided as chlorhexidine used and neonate the was, wipe vaginal was also wiped after delivery within 6 hours of birth tookMade home visits, examined mother history, the weighed child, and child each week, and managed minor illnesses and pneumonia in the neonates. Managed birth asphyxia, birth birthpremature or low and hypothermia, weight, problems. breast-feeding community- teach To based kangaroo mother all expectant to andcare postpartum in women the intervention villages home-based Provided newborns in care neonatal with birth or asphyxia or no cryweak at birth de hygienic safe Conducted newbornlivery and offered case record Completed care. andincluding clinical signs of effects Side symptoms, and up, follow treatment in of treatment outcome every case diagnosed. - Ongoing training monthly CKMC trai refresher ning sessions drills practiced on dummy dolls every 2 months Certification Duration 3 days Table 13B: Characteristics and description of outreach workers and description of outreach 13B: Characteristics Table Trained the the Trained They were They were Training Training Content Didactic and practicum training and conductto safe clean delivery and use of chlorhexidine wipes andas vaginal use in neonates. for and Theoretical practicum histories take to CHWs women, of pregnant of process the observe examine neonates, labor, findings. and record color given were Workers various of photographs visual for neonatal signs female The reference. trainedalso workerswere in case management of pneumonia in children, including neonates. Didactic CKMC teach to Trained or the pregnant to postpartum women trained on and were nutritional counseling Workshop Hands-on based to trained in how atmanage a baby birth to and how manage those who crynot did breathe or at birth following by an algorithm. Didactic and practicum trained and hygienic in safe delivery and better of the neonates; care Recruitment Recruitment Criteria TBAs Skilled who had conducted at least five deliveries per month whoThose willing were work were to chosen as village health workers. community nutrition workers were VHWs resident ofwomen the village birthLocal attendants Education Literate Village withwomen 5–10 years of school education 10 years 5 to of schooling Illiterate 160 165 166 Study Study Saleem et al.2007 159 TBAs Bang 1999 170-173. CHWs Sloan et al. 2008 CHWs Bang 2005 CHWs Bang et al. 1993 (f)TBAs

109 mode Evaluation Evaluation Evaluated by a by Evaluated and pretested predesigned questionnaire 3years after paying by home visits nce performa was observed after 1 yr after their deployment coverage 1 CHW per 1000 population 50 per Rs. months Incentive Incentive (if any) Supervision supervised villageby coordination committees Lot using Quality Assurance Sampling (LQAS) technique key compe-key tencies Behavior change communication(health seekingcare behavior), and health education newborn assessment and referral Role Community mobilization, health education efforts, of danger recognition referral and prompt signs house hold visit on day of assessment delivery, of hospital to newborn, referral Ongoing training Certification Duration 3 months

Essential course clinical course in Training Training Content 3-day practice sessions and demonstrations train all birthto attendants 3-day Newborn course Care 3-day the Neonatal Resuscitation Program Didactic trained CMs were ‘Community Led by ChildInitiatives for Survival CLICS program on identification of signs danger newborn referral and prompt under household and community IMNCI (country specific adaptation of IMCI) to household-to- ensure hospital continuum (HHCC). of care Didactic trained on assessment and of sick referrals newborn hospital to a link and create TBAS and between Health system Recruitment Recruitment Criteria village based CLICS doot selected were village from chosen by community Education of years few schooling 163 174 164 Study Study Carlo et al. 2010 Dongre Dongre et al. 2009 CMs et Daga al.1993 (F) CHWs

Global Evidence of Community Health Workers Childhood Illnesses and Immunization Interventions Background all were from lower or middle income countries. Approximately 29,000 children under the age (Table 14A and 14B). of 5 years die each day, 21 every second. More than 70% of 11 million child deaths occur The CHWs involved in these interventions were mainly from preventable diseases like mala- mostly local residents 181-186 while some were ria, diarrhea, neonatal infections, pneumonia, from the neighborhood.177, 178, 187 Some of the preterm delivery or lack of oxygen at birth.175 CHWs had a few years of schooling,183, 184 while Some of the deaths occur from measles, teta- the ones involved in Fisher et al. intervention nus, HIV/ AIDS, while malnutrition and lack of had high school education.178 All of these stu- safe water and sanitation contribute to half of dies with literate CHWs found significant results all these children’s deaths. These deaths oc- on study outcomes. cur mainly in developing countries while sub Saharan Africa has the higher rates. The global The training modality used to train these CHWs effort for averting these deaths, countries joint was mostly didactic 177, 178, 183-185, 187-192 while their hands and signed a pledge to ensure a Arifeen et al. and Ali et al. used didactic and two-third reduction in child mortality by 2015 practical approach to train their CHWs.181, 182 and the effort and goals are listed under the MDGs. Research and experience have shown The training content included identification that six million of the almost 11 million children and management of a wide range of childhood who die each year could be saved by low-tech, illnesses like acute upper respiratory tract infec- evidence-based, cost-effective measures such tions,180, 182, 187, 189, 190 pneumonia,161, 183, 192 as vaccines, antibiotics, micronutrient supple- diarrhea,181, 194 asthma178 and uptake of immu- mentation, insecticide-treated bed nets and nization services. .176, 177, 179, 186, 188, 189, 195 The improved family care and breastfeeding prac- intervention by Kelly et al. dealt with common tices.175 Training of health workers in countries childhood illnesses,100 while the one by Cesar with IMCI implementation have been shown to et al. trained CHWs in treatment of scabies, have positive effects. Furthermore, they have infection by helminthes and in use of anti-py- also shown promising results in promoting the retic agents.184 The CHWs in the Alderman et al. uptake of immunization in children. intervention were trained in deworming treatment and micronutrient supplementation.195 In this section we have reviewed all the evidence of CHWs driven intervention for improving child A total of 3 randomized control trials were ex- health and illnesses through identification and clusively based on delivering education related management of diseases and promoting the to promotion of immunization against common uptake of childhood immunization. We have illnesses among children. The Pence et al. trial separately reported evidence based results of showed positive outcomes of immunization studies pertinent to malaria in malaria control services by reduction in the rates of infant, early section. and late child mortality.188 The CHWs involved in this study visited households to talk about Community Based Evidence hygiene and child immunization and made community aware of their availability for treat- A total of 33 studies were reviewed related to ments and referrals.188 The CHWs in the Barnes the role of CHWs in dealing with childhood ill- et al. were involved in immunization outreach, nesses. Among these 5 studies were conducted tracking and follow-up in the community.176 in high income countries,176-180 and remaining The Rodewald et al. on the other hand, was de-

111 signed to reduce missed immunizations and the practice of exclusive breast feeding and 70% role of CHWs here was to prompt parents for the correct treatment of all illnesses among children immunization of their children.177 The CHWs in by the CHWs.181 some other studies as well played their part in the promotion of immunization.179, 186, 189 The CHWs working in most of the interventions were volunteers and only those working in The CHWs involved in the treatment of acute Cesar et al., Chopra et al. and Perry et al. were respiratory infections could recognize and dif- paid a meager financial incentive which did not ferentiate between no pneumonia, pneumonia seem to have an impact on the working of the and severe pneumonia and could also provide volunteers as compared to the studies where its management.161, 181, 183, 192, 194 The Fisher CHWs were unpaid.184, 186, 196 et al. intervention focused on counseling and management of asthma, use of asthma control- Of all the interventions only a few were su- ling and relieving medications as well as beha- pervised. Supervision was done by project vior modification for better outcomes of treat- physicians,181 or by a nurse and psychologist ment.178 The CHWs in the Arifeen et al. adhered as in Fisher et al.178 or by health care staff like to the IMCI case management strategies for the nurses.185, 189, 192 However, supervision also treatment of pneumonia.181 This intervention did not seem to effect the outcomes of these also laid special emphasis on malnutrition of studies as compared to those where the CHWs children and counseled mothers for breast were not supervised. feeding. Their outcomes showed increase in the

CHW Snapshot 8 Village Drug Kits, Bougouni, Mali Program overview A village drug kit in southern Mali was implemented by the Malian government in 1990 in which gerent de caisse phar- maceutique, or village drug-kit manager were trained who used to manage a kit containing eye ointment, paracetamol, oral rehydration salts, alcohol, bandages, Chloroquine tablets and Chloroquine syrup. Ant malarial treatment is given pre- sumptively. In limited areas, zinc treatment for diarrhea is also distributed and sulfadoxine-pyrimethamine is provided as intermittent presumptive treatment for pregnant women.

Operational aspects and considerations Village drug-kit managers are selected by the villages they serve, ge- Village drug-kit managers, Mali nerally by a committee of village leaders. In community they counsel and manage the drug kit. The CHWs are provided with visual aids Education Usually illiterate to help them explain to caregivers how to administer Chloroquine Training 35 days literacy classes and one to children in various age groups, and describing the symptoms, week malaria treatment classes such as convulsions and difficulty breathing that require immediate Refresher One each month referral to a health facility. Training Village committees

Coverage and effectiveness An evaluation of this CHW initiative found that the drug kits were successful in increasing the availability of Chloroquine at the village level.193 In household interviews, parents reported that 42% of children in the intervention group were referred to the community health centre by the drug-kit manager, versus 11% in the comparison group (OR = 7.12, 95% CI: 2.62–19.38).193 This intervention is now implemented in all the village drug-kit programs established by Save the Children in collaboration with the local health services. Source: WHO/Unicef 200624

Global Evidence of Community Health Workers Conclusion The CHWs involved in the childhood illnesses related intervention made a great contribution towards the achievement of Goal 4 of the MDGs by promoting exclusive breastfeeding and preventive care through immunization and hygiene. Their role in identifying and treating pneumonia is also a great contribution towards bringing down the figures of under-5 child mortality rate.

113 Global Evidence of Community Health Workers Outcomes was 24% in ill and taken health provider Children to Correct areas intervention and 5% in control areas was management of all illness among children areas 70% in intervention and 4% in control areas than younger in children breastfeeding Exclusive 6 months in intervention was 76% and in control milk and complementary was 65% Breast areas aged 6-9 months was among children feeding areas 68% in intervention and 57% in control areas 13% while in in intervention were areas Wasting was 14% Stunting in intervention areas control was 57% was 50% while in control areas the 3 months of randomization to Within had at least 89.6% of parents asthma coach group, contact1 substantive with the coach, an proportionThe of 21.1 contacts per parent average was 35 of 96 (36.5%) in hospitalized are of children and 55 of 93 (59.1%) in the coach group the Asthma parental for (P=.01), controlling group usual care sex, and hospitalization education and child age, prior the index hospitalization. in the year to observedReductions were in infant (6 and early child (20 percent), percent), mortality child (41 percent) late Significantly more intervention children were were intervention more children Significantly up-to-date with their vaccination series than controls group in the control 54%; P = .03). Children (75% vs. a vaccine for likely be late 2.8 times more to were than intervention ratio = 2.8; P .02). (odds children In of longer than addition, an immunization delay of predictor was a significant at enrollment 30 days (odds ratio = 2.6; P=.02) final immunization delay levels immunization coverage Complete 76%; 74%; prompting-only, control, were: tracking/outreach-only 95%; and combined 95%. tracking/ with prompting, outreach - Participants children between 2 children 5 years months to of 2-8 children of age years less than Children of age 5 years less Children with than 2 years, a no-shows for booked appoint ment, & overdue a vaccine for months 12 to 0 ages Years of Years study 60 months 24 months 60 months 7 months 18 months - Control arm Control not deployed were CHWs receiving and they were * care routine No intervention for group control A comparison area servicesreceives standard to according MOH guidelines. were children Control notified of immuniza tion status at enrollment no but received further contact until the conclusion of follow-up no intervention was this group to given - - - - - Interventions Experimental arm Experimental com provide trained to were CHWs munity case management of non- pneumonia and diarrheasevere cases severe for and referrals basic asthma reinforced Coaches education and encouraged key mana home visits through gement behaviors parent’s to and phone calls tailored adopt management to readiness practices and emphasizing a nondirec supportivetive styleand (cooperative and choices). accepting of feelings interventionThe implements both and establishes close approaches links between the MOH nurse and community leaders and volunteers. talk about They visit households to child immunization, and other hygiene, make and to the com health issues, available that they are munity aware and referrals. basic treatments for Immunization tracking, and outreach, commu by provided were follow-up follow-up throughout nity volunteers In the first intervention, tracking with The (tracking/outreach). outreach second intervention was a program missed immunization reduce to opportunities in the (prompting) primary offices. In the third care intervention tracking with outreach provided were and prompting Table 14A: Childhood illnesses and immunization – characteristics of Included illnesses and immunization Studies 14A: Childhood Table Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs Study Study design cRCT RCT cRCT RCT RCT 188 178 176 177 Study / Study country et Arifeen al.2009 181,197 Matlab, Bangladesh et Fisher al.2009 Louis, St. USA et Pence al.2005 Kassena- Nankana, Ghana Barnes et al.1999 York, New USA Rodewald et al.1999 York, New USA

115 - Outcomes impactThe of intervention status on cognitive ages varieddevelopment as a function of children’s showing children with younger at recruitment, were There of home intervention. beneficial effects associated development no changes in motor with intervention During the study period, status. gained skillschildren competence in interactive became more and their parents during feeding, but differences during Feeding, controlling with intervention not associated status. were 85%. 60 to from Immunization rose coverage (P <0.005). Which was 20% higher than control of assessment, classification mean percentage The performed procedures correctly and treatment each child was 79.8% (range 13.3—100%). Offor at least one who required the 187 children only a health facility, to or referral treatment (including all treatments Prescribed 38.8% were the guidelines. by recommended referral) found in were differences No significant between areas these health measurements midwives. by visited LHV and areas by visited in the the end of study children At likely have more to were intervention group all of their primaryreceived immunizations, daily. to be read and to to, be read to of 260 (34%) the 763 patients in A total 306 (40%) of the 763 in auto group, control 284 (37%) of the 760 in outreach dialer group, and 293 (38%) of 764 in the combination group, the vaccination series. completed group among interventionALRI death rate areas per yr and in control was 6.42/ 1000 children per year 11.82/ 1000 children were areas Participants children under five children less than children of age , 5 years women pregnant and mothers time mothers First with infant <1 old. year born children 1year over > 5 years Children Years of Years study 12 months 6 months 2 months 24 months 16 months 24 months 60 months Control arm Control No interventions No interventions No interventions arm this in the control my was given care community midwives no interventions and in some usual care, instances non-automated system recall postcard CHWs No training to - - - - Interventions Experimental arm Experimental services received All children in a multidisciplinary and nutrition growth A community clinic. based agency the home intervention.provided schedu were in the HI group Families 1 for Visits weekly home receive led to supervised home visitors, lay by year The a community by health nurse. intervention maternal sup provided child port parenting, and promoted and for use of informal development, advocacy. and parent mal resources, homes and referred visited CHWs They also targeted clinics. to children who failed to those children immunization schedules. complete correct for analyzed were CHWs identification and treatment of children Community health workers were were they identified and trained, communitythey then sent to where at risk and not identified children health institution. that not attending They guided their family and given on immunization them teaching problems and child health related trained and to Community mothers were (early program child development deliver language development, as a child, reading play) through development cognitive trained to workersoutreach were the impactevaluate of reminder immunization in call on low an inner city population identify both to CHWs Trained ARI cases from active and passive re and provide households, cases severe to ferrals Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs CHWs CHWs Study Study design RCT RCT RCT RCT RCT RCT Quasi RCT 201 202 203 182 198 199 200 Study / Study country Black et al. 2003 Baltimore, USA Brugha & Kevany 1996 Urban Ghana et al. Rowe 2007 Siaya, Kenya Gokcay et 1993 al. Urban Turkey Johnson et 1993 al. Urban Ireland et LeBaron 2004 al. Urban USA Ali et al.2001 Matlab, Bangladesh

Global Evidence of Community Health Workers - - - pneumonia specific mortality in the intervention rate and about 80% was 40% less in the neonates area of infancyless in the second month and rest area. with the control compared (12-23 months that children the study revealed had higher coverage of age) in the index group measles and in the percentage OPV, DPT, in BCG, 66%, P = 0.0001) (84% vs. of fully immunized their children it to give 94% said they would 76% in the control vs. with diarrhea, if available, 37% of the (P =0.0001). In the index group group to according reportingchildren ARI symptoms, co-trimoxazoleCHVs by given were the mothers, Just group. < 1% in the reference to compared 3%, in the less, and even 22% in the index group had GMCs at the time of survey, group reference (P = 0.001). was significant though the difference Outcomes ALRI specific mortality in infants intervention was 15/1000 All was 10/1000 and in control cause specific infant mortality in intervention was 53/1000 and 55/1000 ALRI areas and control specific child mortality among interventiongroup was 7/1000 All area was 4/1000 and in control cause specific child mortality among intervention areas was 21/1000 and 28/1000 in control group in the interven of getting one infection Probability was 0.884 (95% CI: 0.4 – 1.95) P=0.76 tion group under 5 in Immunization among children rates 160/1000 while it was to intervention reached areas Immunization area among 40/ 1000 in control 323/1000 in up to reached population of 5-14 years intervention while it was 36/1000 in control areas age had an immu 15 years over Population area 37/1000 while it was up to reached nization rate areas 9/1000 in control under 5 motality reduced from 32/ 1000 chil under 5 motalityfrom reduced in intervention 29/1000 children to area dren area 35/ 1000 in control 40/ 1000 to and from specific mortality 12 Pneumonia reduced from in intervention / year areas 10 /1000 children to areas. 12 / 1000 in control 14 to and from children below below children of age 5 years below children of age 5 years Participants Children under Children 5 years under Children of age 5 years General population under children 5 years 24 months 24 months Years of Years study 24 months 4 months 24 months 24 months - Routine treatment was Routine treatment govern by provided ment health facilities any by not covered intervention Control arm Control areas in control Children health by treated were dispensaries or center, private practitioners was group Control care routine given Routine services by facilities governmental Routine services governmental from health centers Interventions Extensive health education was in the intervention on provided area suspectwhen to pneumonia in a child care. seek immediate to and where intervention,The which included activities, and curative preventive was carried the out through existing Primary Health Care (PHC) utilizing CHVs structure, Experimental arm Experimental administer trained to were CHWs suspected sulphamethaxaole for otitis media pneumonia or acute health center to referring before detect serious trained to ARI were CHWs and to sponging by initial care and given health center of cases to advice referral Immunization CHWs counseling by each home every visited CHWs 6-8 health education and gave weeks of and prevention on recognition them with antibiotic and ARI, treated a higher level them to referring CHWs TBAs CHWs TBAs CHWs Outreach Outreach worker CHWs CHWs CHWs CHWs Quasi RCT Quasi RCT Study Study design Quasi RCT Quasi RCT Quasi RCT Quasi RCT 183 161 189 179 187 190 Bang et al.1993 Gadchiroli, India Curtale et al.1995 Nepal Study / Study country Khan et al.1990 Abbottabad, Pakistan Congsuviva- twong et al 1996 Pattani, Thailand Stewart et al.1970 Okla, USA Mtango & Neuvians 1986 Bagamoyo, Tanzania

117 - - Outcomes In 1988, the infant mortality was 83 per 1,000 rate the IMR had When this project was implemented; deaths per 65 per 1,000, or seven to been reduced Duringyear of intervention, the first only two year. one child died and year, following The died. children indicates This two deaths occurred. year, in the third years. 4.2 times in three by that the IMR was reduced performanceThe of cases by on correct treatment prior follow trained 4 – 6 weeks to were weeks AWWs after up one year followed than group up was better the completion of training (81.8% and 47.9% respec the performance the same time, At tively). on correct during improvement significant showed treatment up (47.9% and 83.8% respectively). the second follow in odds ratio of being underweightThe children for villages after introduction of the program intervention was 0.83 (95% CI 0.69, 1.00), after and village trends regional for controlling household characteristics. treated 60, 000 patients per month were on average 30/1000 to from decreased under 5 years children 18/1000 Children’s weight for age, weight for height, and for weight age, for weight Children’s during the significantly age improved height for of intervention regardless 12-month study period, had better in the Home group Children status. child- time and more language over receptive in the than children oriented home environments impactThe of intervention status clinic-only group. varied development as a function on cognitive of Children with younger ages at recruitment, children’s of home intervention. beneficial effects showing development no changes in motor were There with interventionassociated During the study status. gained skills children period, compe in interactive became and their parents duringtence feeding, but differences during feeding, controlling more with intervention not associated status. were Participants Children with mean Children age 12.7 months under children 5 years under Children of age 5 years under Children of age 3 years under children 5 years Years of Years study 12 months 108 months 12 months 24 months 36 months Control arm Control No intervention was arm control to delivered - Interventions Experimental arm Experimental services received All children in a multi disciplinary and nutrition clinic. growth intervention maternal The provided child support parenting, and promoted and use of informal development, advocacy. and parent resources, formal made weekly visits and distributed CHWs medicine like analgesics, and drugs against helminthes scabies. ointments, antipyretics, and the supervisory workers Anganwadi (AWWS) The staff The WHO package. IMCI training using 5 days given were using standardized AWWs up visits to supervisors follow gave of 2nd batch WHO material. from adapted up forms follow after training in IMCI. up 4-8 weeks was followed AWWs community which in turn mobilized communities, Organized monitoring growth health and nutrition workers provide to services children all mothers of young and counseling to and women encourage pregnant in selected communities, such as antenatal health care seek preventive to caregivers with health personnel and coordinate and postnatal care deliveryfor of essential health services, such as vaccination, deworming supplementation and micronutrient in close were field they trained and sent to were CHWs contact with health facilities staff. Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs Study Study design RCT pre/post pre/post pre/post multiple surveys 184 191 195 204 185 Study / Study country Black et al. 1995 USA et César al.1998 Itapirapua Paulista, Brazil Chaudhary et al.2005 Haryana, India Alderman et al.2008 Senegal Ghebreyesus et al. 1999 Tigray, Ethiopia

Global Evidence of Community Health Workers ORS advice was adequate. Oral antibiotic use ORS advice was adequate. among dysentery was satisfactory (75 per cent). malnutrition as of severe prevalence overall The This health workers by high. was quite diagnosed the use of mid-arm be due to circumference may A Vitamin malnutrition. severe as a criterion for poor supply of was due to This low. use was quite workersThe vitamin A during the study period. its dietarygave often; however, advice more was not assessed during this study. effectiveness Measles managed in most cases. was adequately Most medication by commonly prescribed and Chloroquine, was paracetamol, CHWs of the workers Many did not attended antibiotics. and supervisioncontinuing education program, was also irregular. 2 years in the previous Outcomes instructed on treatment 90% of all mothers were while 45% of upper respiratory infections, regimens complied with the treatment participated 108, and 114 CHWs One hundred, in the evaluations in 1998, 1999, and 2001, proportionsThe treated of children respectively. anti malarial, (with an antibiotic, “adequately” depending solution, or referral, oral rehydration 57.8%, were disease classifications) on the child’s children for 35.5%, and 38.9%, respectively, classification and 27.7%, 77.3%, with a severe with a children for and 74.3%, respectively, classification. CHWs (but not severe) moderate 90.5% of malaria cases (the treated adequately classification). most commonly encountered 92% immunization coverage observed92% immunization coverage in intervention (P <0.001) areas 73% in control to compared areas mortalityUnder-five was 58% less in the HAS service and mortality area, children for 12–59 months of age was 76% less children under children 5 years less than children of age 5 years Participants mothers aged Children 3-59 months CHWs of under 5 years age children - - 24 months Years of Years study 6 months 48 months 48 months Control arm Control Interventions Workers were given training in the management of diarrhea given were Workers Ballabgarh sent to were referral requiring and ARI. Children and performed histories, evaluation. took physical CHWs They also performed and treatment diagnosis symptomatic of ARI. Experimental arm Experimental teach and trained to recruited Community health aides were when they had an their children for care to mothers how upper respiratory (URI) infection intervention trained and they related delivered were CHWs immunization level to Community health worker (CHW) used an algorithm were CHWs common childhood illnesses. managing for observed sick outpatient and inpatient children managing with and their management was compared at a hospital, that of an expert clinician who used the algorithm mortality the under-five Study compares in the Hospital Albert (HAS) Primary Service Health Care Schweitzer an HAS provides Haiti in general. with that for Area of community-based system primaryintegrated health services, and communitycare hospital care development CHWs CHWs Outreach Outreach worker CHWs CHWs CHWs CHWs - - cross cross sectional compara cross tive sectional survey cross cross sectional Cross Cross sectional survey Study Study design compara cross tive sectional Prospective cross sectional survey 180 100 194 186 205 Anand et al 2004 Haryana, India Fagbule & Kalu 1995 Rural Nigeria Study / Study country et Cauffman al.1970 Los Angeles, USA Chopra & Wilkinson 1997 SouthRural Africa Kelly et al.2001 Siaya, Kenya Perry et al.2006 196, 206 Haiti

119 - - - Outcomes of anaemia (Hb prevalence The < 11 g/dl) in these was 87%, 79%, 74% and 52%, respectively. groups anaemia (Hb of severe < 7 g/dl) was prevalence The sensitivityThe 24%, 11%, 10% and 2%, respectively. 79% 60% to anaemia ranged from of the HCS for The sensitivity to 94%. and specificity59% from 24% anaemia ranged from severe of the HCS for to 100% 63% and the specificity97% to from child survivalThe in implemented programme Chokwe districtMozambique, of Gaza province, bed net use (80%), for high coverage achieved with diarrhea children for therapy oral rehydration care-seeking(94%) and prompt trained from Evidence with danger signs. children for providers a 66% reduction in indicated this system from infant mortality and a 62% reduction in under-five mortalityThe surveymortality. reductions showed mor of 49% and 42% in infant under-five leading causes of death The respectively. tality, malaria (30%), were verbal by autopsies identified neonatal causes (17%) and pneumonia (21.3%). Community-based management of pneumonia compared number of cases treated doubled the total Over with districts with facility-basedonly. treatment com the female by treated half of the cases were was phased program The munity health volunteers. under-five 69% of Nepal’s and now 14 years in over pneumonia treatment. population has access to The proportionsThe correctly managed by of children health workers with longer duration of preservice 83·7% 57·8% (n=43) versus training in Brazil were those with shorter(n=61) for duration of training 32·6% (n=134) (p=0·008), and 23·1% (n=47) versus those with longer Tanzania, (p=0·03) in Uganda. In than did those duration of training did better with shorterassessment duration in integrated asses (mean index of integrated of sick children 0·88 [0·13]; p=0·004). Insment 0·94 [SD 0·15] vs. Bangladesh, both categories of health worker did recorded We much the same in all clinical tasks. in clinical performance in difference no significant countries. all the other clinical tasks in four Participants children under children of age 5 years aged 2 children 2 years months to and a sample of women pregnant under children of age 5 years under children 5 years - Years of Years study 3 months 45 months 20 years - - Control arm Control Interventions Experimental arm Experimental the clinical performance of health workers with longer duration of preservice of training (those with >4 years post-secondary in the other education in Brazil or >3 years countries) and shorterthree duration (all other health workers qualitywith calculated of care We clinical care). providing of assessment, classification, and management indicators Every IMCI guidelines. to child according of sick children the IMCI-trained health workerwas examined twice, by supervisor. a gold-standard being assessed and by takenall consenting parti from blood samples were Finger-prick compared the HCS were from Haemoglobin (Hob) levels cipants. portable haemoglobinometer a HemoCueTM from with results community-basedThe child survival ensured programme of all households with coverage equitable and universal groups’, ‘care 173 organizing of age by under 5 years children trained through who were each consisting of 10—15 volunteers role methods of instruction song, culturally appropriate (drama, of her neighbou ten to was assigned Each volunteer etc.). play, ring provide households and conducted monthly home visits to vital events. register the caretaker and to health education for selected as were community health volunteers Female manage childhood pneumonia at to the national cadre working A technical community using oral antibiotics. level local experts officials, composed of government group and donor partners a embarked develop to on a process and expand it nationally. pilot the approach to strategy Outreach Outreach worker CHWs CHWs CHWs CHWs Study Study design cross sectional cross sectional cross sectional Program description 207 192 209 208 Study / Study country Huicho et 2008 al. Bangladesh, Brazil, Uganda and Tanzania Lindblade et al. 2006 western Kenya Edward et al. 2007 Gaza, Mozambique et Dawson al.2008 Nepal

Global Evidence of Community Health Workers mode Evaluation Evaluation Hospitalization data was used the evaluate to effectiveness - coverage Survey was was Survey repeated years 2 after of imple mentation of program per 1 CHWs 500 inhabitants Incentive Incentive (if any) 1 CHW per 2200 population - - Supervision field supervi sors respon 5-9 sible for + regular VHWs project by visits physicians Nurse and psychologist Health post staff key compe-key tencies IMCI management Asthma management Case Management for strategies pneumonia and Children maternal health services Role case IMCI to Adaptation and management strategies form. use of structured referral counseling, Asthma administration of asthma medications and controlling medications reliever asthma and asthma monitoring management and Detection dataof ARI [Collected of distribution spatial on health practitioners] deliver in to role Their immunization, antenatal maternal nutrition, care, health education and malaria control Refreshers Refreshers / Ongoing training -managing children in both and first-level referral-level Facilities - Extensive mo nitoring and supervision Certification - Duration 10 days training in case manage ment and in5 days counseling 3 months 90 days training 24 days - in - trained deployed deployed they were they were Trained and Trained trained Training Training Content and Didactic Practicum of supplies with commoditie essential emphasis Special on pneumonia and malnutrition Didactic covered contents disease asthma the asthma action process, communication plans, social techniques, support, and behavior change strategies Didactic counseling, for follow education, up and diagnosis trained They were identify children, to their parents prompt Didactic and Practicum an ARIon diagnosing as no pneumonia, pneumonia, and pneumonia severe treat to Trained pneumonia, fur were they thermore and also trained safe deliberyhygienic Didactic training immunization, family nutri ORT, planning, tion and first aid care Didactic deliveringtrained to health education and management of common illness maternal to related and child health - - Recruitment Recruitment Criteria Recruited the from population Recruited neigh from bourhood Recruited neigh from bourhood Recruited the from community the From neighborhood Recruited village from Table 14B: Description & Characteristics of Outreach workers in Childhood illnesses and immunization in Childhood workers of Outreach 14B: Description & Characteristics Table Education High school College education Illiterate 10 years 182 178 188 161 189 183 181, 181, Study Study Arifeen et al. 2009 197 CHWs (female) et Fisher al.2009 (F) CHWs et Pence al.2005 (M) CHWs Rodewald et al.1999 177 (F) CHWs Ali et al.2001 (F) CHWs et Bang al.1993 (F) TBAs et Curtale al.1995 (F) CHWs et Khan al.1990 (F) CHWs

121 mode Evaluation Evaluation This qualityThis control at consisted yrs least of five coverage 1 CHW per 1000 population Incentive Incentive (if any) $140/month Supervision homeLay visitors supervised aby community health nurse. Supervisory ICDS at staff 1 supervisor responsible 20-25 for workers key compe-key tencies ARI detection and treatment Childhood illness recognition and treatment Role Identified cases with ARI, management with in antibiotics and referrals case of serious illness identify visit each household, age of years 5 under children educate household, from mother about the sings and of childhoodsymptoms of treatment and infection pneumonia among children home-visitingThe program as awas developed partnershipnegotiated between families and Home interventionists. asking began by visitors families about their strengths, and priorities, andneeds, then worked with them to an individualized develop family service plan with specific goals and objectives visits weekly made CHWs medicine distributed and like antipyretics, analgesics, against drugs and ointments, helminthes and scabies. approximately Followed per week 410 children households, Visit health and provide nutrition counseling Refreshers Refreshers / Ongoing training Certification Duration 2 days training was an There eight-session training program 3-4 hours each day 5 days for - - - - - trai - - They were were They Trained on Trained Training Training Content WHO Didactic receommended was curriculum were They developed. detect ARI trained to didactic training health provide ned to mothers to education of ARIabout symptoms of pneu and treatment monia with antibiotics didactic training health and children’s nutrition, infant and development,toddler activities promote to develop children’s child ment, parent interaction, behavior management, building, relationship relationships family (including violence), child & family advo problem-solving cacy, &com strategies, resources munity and services. Didactic and diagnose to how diarrheatreat and respira infectious tory diseases , infant immunizations and health seeking from health services for serious illnesses Didactic provide to trained nu basic health care, preventive and trition servicesand curative Recruitment Recruitment Criteria from neighborhood the from community Local residents Accepted theby community Education 3-10 yrs of formal school education

184 191 19’0 187 Study Study Congsu- vivatwong et al 1996 CHWs Mtango & Neuvians 1986 (F) CHWs Black et 1995 al. 204 etCésar al.1998 Itapirapua Paulista, Brazil CHWs (M & F) Choudhary et al.2005 (F) CHWs

Global Evidence of Community Health Workers mode Evaluation Evaluation coverage 1 CHWs per 100 homesteads Incentive Incentive (if any) $ 10/day - Supervision supervised aby person with doctorate in commu nity and psychology Nurse incharge key compe-key tencies Malaria control CHW facilitators - Role if a child missed out a vaccination then the outreach worker attempted contactto a family counseling, They provided and monitored screen and delivered children community effective mo bilization programs Refreshers Refreshers / Ongoing training Every month they had a meeting theywhere shared reports Refresher given were Certification Duration 3 days training 4 months - - - - - trained to Training Training Content training 3 week on MCH , com skills munication and home visits training of weeks 4 Didactic exclu promote breastfeeding, sive andadequate timely complimen tary hygiene feeding, micronu behaviors, trient intervention, malaria for treatment Diagnosis Didactic treatment and of malaria training onGiven of management diarrhea and ARI given They were training on promo and preventive tional, servicescurative - Recruitment Recruitment Criteria interviewed regional by family develo pment nurse Selected by community Accepted theby community Education primary school graduates college educated Read and write

194 201 202 203 185 186 Study Study Gokcay et al. 1993 Urban Turkey Johnson et al. 1993 Urban Ireland LeBaron et al. 2004 Urban USA Alderman et al.2008 195 (F) CHWs Ghebre- yesus et al. 1999 (F) CHWs Anand et al 2004 CHWs (M & F) Chopra & Wilkinson 1997 (F) CHWs

123 mode Evaluation Evaluation coverage 1 CHW per 400-500 population Incentive Incentive (if any) Paid Supervision Health staff care key compe-key tencies Monitors were to recruited supervise these CHWs of Treatment pneumonia Role They provided peer to peer peer to They provided assist education, health with clinic activities and higher to referral provide promote and care of level in community involvement implementation planning, and evaluation of services was task main Their healthy promote to and provide behaviors services in their villages Refreshers Refreshers / Ongoing training Certification Duration - - Training Training Content Trained to provide provide to Trained immunization, family expand planning, safe and care prenatal delivery practices, the preven promote of tion and treatment childhood diarrhea Didactic training of Management childhood pneumo treatment and nia with oral antibiotics - Recruitment Recruitment Criteria Identified byIdentified wor technical king group Education 190, 192 Study Study Perry et al.2006 196, 206 (F) CHWs et Dawson al.2008 (F) CHWs

Global Evidence of Community Health Workers Primary Health Care Interventions Background Community participation and utilization of and nutrition of mother and children.212 They CHWs are essential components of the primary were also trained to provide chemoprophylaxis health care model. CHW can undertake various of malaria and purpose and preparation of oral tasks, including case management of childhood rehydration solution.212 They were evaluated by illnesses (e.g. pneumonia, malaria, and neonatal their research team who reported their degree sepsis) and delivery of preventive interventions of success.212 The CHWs involved in Omer et such as immunization, promotion of healthy al. were trained in primary health care services, behavior, and mobilization of communities. family planning methods and provision of sup- In this section we have basically pooled up all plies, nutritional counseling, treatment of com- those studies that have implemented primary mon ailments like diarrhea, malaria, ARI, TB and health care interventions related to maternal, intestinal parasites.213 They were also trained to newborn and child health and nutrition related provide DOTS and disseminate awareness regar- interventions. ding preventive measures against HIV.213 These CHWs received a monthly stipend of Rs 3600 Evidence from Community per month, which seemed to have a moderate impact in the outcomes of this intervention as Based Health worker projects compared to the studies where the CHWs were We found 12 studies related to the role of CHWs all volunteers.213 in the overall primary health care interventions (Table 15A & Table 15B). The CHWs recruited in A study conducted by Sauerborn et al. assessed these interventions were mostly literate210-212 the service utilization of health care workers however those mentioned in the oxford policy as compared to other health facilities.215 The management and Omer et al. had 8 years of for- outcomes of the study showed that 69% of mal school education.213, 214 The CHWs involved the population approached CHW for primary in Wayland et al. also had age criteria for selec- health care.215 The CHWs involved in Bukhari tion and were supposed to be at least 18 years & Gupta were village health guides who were old for participation in the intervention.212 trained to deliver primary health care facilities in the community.216 The role of CHWs in Couper The training modality used to impart knowledge et al. encompassed maternal and child health to the CHWs involved in promotion of primary care, family planning, case finding, and follow health care was mostly didactic210-212 while up of infectious diseases like TB and malaria and practicum was an added modality in the Omer mental health problems.66 They were also trai- et al. and Oxford Policy Management report.213, ned to provide limited symptomatic treatment 214 The training content was pertinent to basic of diabetes and hypertension and addressed health care. In Hill et al. the CHWs were trained the issues of environmental and occupational to promote community participation in health health.66 In Zuvekas et al. the CHWs provided education, water and sanitation.210 The CHWs community health care to the fellow farm wor- involved in Edpuganti et al. were trained to kers, increased awareness of preventive health provide health education related to diarrhea, behaviors and promoted early enrollment of purpose and preparation of oral rehydration pregnant women for prenatal care.19 solution, infant nutrition, usage of birth control and growth monitoring of children.211 The Kauffman & Myers trained the CHWs in the fundamentals of primary health care including The Wayland et al. trained CHWs in the preven- health promotion and disease prevention.215 tion of rabies and counseling on breastfeeding The CHWs in Reis et al. promoted use of ORT and

125 Conclusion vitamin A supplements to prevent dehydration The CHWs involved in primary health care played and blindness due to insufficient consumption their role in health promotion and preventive of vitamin A.217 health education. They also provide treatment for minor ailments and injuries as a therapeutic intervention. In the studies reviewed financial incentive was paid only in one intervention which seemed to have a moderate impact on its outcome as compared to those where the CHWs were working as volunteers.

CHW Snapshot 9 China Bare Foot Doctors Program overview In 1968, China introduced the program of bare foot doctors as a national policy under the guidance of Red Flag.63 The program was aimed at providing services, including immunization, delivery for pregnant women, and improvement of sanitation. They not only prescribed antibiotics and western medicine but also performed simple surgical operations. Training of barefoot doctors varied and their recruitment depended on a candidate’s political attitude and local relationship rather than educational background.

Program constraint and limitation In 1980, after the collapse of reform in the health care system, from Bare Foot Doctors, China cooperative medical system to a payment-based system of medical care in rural areas. In that era bare foot doctors lost their institutional Education secondary school and financial support and in 1985 their title got canceled by the mi- Training 3-6 months nistry if health and some of them became village doctors. Source: Zhang & Unsculd 200863

Global Evidence of Community Health Workers - Outcomes the establishment of PHC system Following in 1983, infant mortality 134/1000 from dropped 69/1000 in 1992–94 the PHC in 1982–83 to 91/1000 in the non-PHC 155/1000 to villages & from Between the same period. 1982 & 83 villages over aged 1–4 children for &1992–94, the death rates 28/1000 in the PHC villages & 42/1000 to from fell 38/1000 in the non-PHC villages. 45/1000 to from In 1994, when supervision of the PHC system infant mortalityhas weakened, in the PHC rates risen 89/1000 in 1994–96. to villages have Community had lack of knowledge in the sources causes of diarrhea, purpose of ORT, of infant nutrition, usage of birth control and purposechildren. of weighing 9% care, prenatal 12% of population received 13% on immu counseling, breastfeeding receive nization, 18% on diarrhea and ORS preparation, 9% on nutrition and 5% on respiratory infections malaria promotion activities were undertaken activitiesmalaria promotion were given 0.006% time health education sessions were 47% of minor ailments were 5% times treatment activities time family planning promotion were performed 17% times and immunization 4% time reportedNo outcome her 61% likely stop to were in exposed group Women colostrum, 60% gave work during pregnancy, routine her newbornmilk after likely breast feed 60% more to birth, liquid other than twicelikely introduce more to moths, the age of four child before milk to breast LHWs not exposed to who were women to compare Participants general population general population mothers and under children population five general population General population general population Years of Years study 180 months 2 months 1 months 4 months 12 months Control arm Control intervention areas with compared were PHC were where areas not developed Interventions Experimental arm Experimental for Each of them was responsible supervisionthe supplies, and the continuing education of the village health workers (VHWs) and trained birth (TBAs) attendants in about 5 EPI and They provide PHC villages. maternal and child health services perform trained to they Health agents were their task in field, and provide visit household under their coverage trained to were infant diarrhea, to purpose of ORT, them health education related nutrition, usage of birth children. and they also weighed control in 1991. CHW program a nationwide Brazil implemented de Agentes (Programa called PACS goal of this program, The for PHC coverage improve Comunitárias de Saúde), is to women in low-income and pregnant under five children During these visits the CHW should measure households. and children women the nutritional status of pregnant When the CHW under the age of two in each household. woman a malnourishedencounters child or pregnant family members the and educate them for she registers on various during health topics their monthly visits primary deliver trained to village health guides were health facilities in the community care Every one main village and or health house covers for health house is responsible The villages. satellite more case finding, family planning, maternal and child health care, diseases (TB up of infectious and follow and malaria), mental illnesses other chronic recently, more and, health problems and Hypertension,such as Diabetes symptomatic limited health, and occupational health. environmental treatment, focused Over NGOs have the last decade GOP and several One initiative in the health sector. on improvement attention accessibility primary and to women improve to for health care were in which LHWs LHW, for is the National program children services family planning and PHC and provide for recruited Table 15A: Other– characteristics of included studies intervention Primary Health Care Table Outreach Outreach worker TBAs CHWs CHWs CHWs CHWs CHWs CHWs Study Study design Quasi RCT pre/post cross sectional Retro- spective cross sectional study Cross sectional Cross sectional 210 216 211 212 213 66 4 Study / Study country Hill et al.2000 Farafenni, Gambia Edpuganti 1995 Pacatuba, Brazil Wayland 2002 Brazil Rural Bukhari & Gupta India Couper 200 Iran Omer 2002 Pakistan

127 - Outcomes cove promotion Vaccination is about 70%, Coverage usage: Contraceptive under five, rage: 67% of children 50% of all 20% of all users modern contraceptives, emergency case in previous LHW seen and referred Indicators of population served months. three by off than National figures slightly better were LHWs with 168’5 users had 1710 encounters CHAs services for migrants for made 687 referrals CHAs dentist, social service at the health center, performed CHAs 3 11 liaison encounters etc. agency, and the health center between the migrants administered CHAs staff and various agencies. to migrants. basic first aid on 402 occasions their CHW only m 8.8% of consulted Villagers in 69% the family contacted CHWs mild diseases, primaryfor In the case of serious care. diseases, identify and which the CHW was supposed to passed the CHW m 96 5% the villagers by refer, 34% of all mothers weighed were 76% of all children 40% on immunization, advised of growth, were 36% in family planning and 48% diarrheas distributed vitamin A. management. 81% were Majority of villagers did not know about CHWs had used their services.and only few suggest that special intervention Findings using indigenous and nonprofessional programs, preventive workers, can increase outreach service poverty utilization by groups. Participants General population general migrant population General population General population general population school Pre from children poverty families. - - Years of Years study 36 months 12 months 2 weeks 23 months - - Control arm Control Interventions Experimental arm Experimental of National lady health workersEvaluation program Health Aide Camp Northwest Michigan Health Service’s persons farm workers uses migrant as health-resource Program community health care provide camps to in the migrant farm early workers enrollment and promote among fellow the health of migrant improve care; intoprenatal of women be of preventive awareness families; and increase CHWs population. the migrant and general health for haviors household survey was carriedA representative out in order of other sources to study the utilization of CHW in relation to health care use of ORT and vitamin A supplements to promoted CHWs secondary dehydration diarrhea to prevent and blindness insufficient consumption of vitamin A. sue to and disease trained in health promotion were CHWs and fundamentals of PHC prevention one two groups, divided into families were Initially, workers. Outreach with and one without outreach workers were (neighborhood health coordinators) They were and health education. trained in prevention of the poverty specific subgroups to then assigned the importance ser teach population to of preventive use these services. persons to motivate vices and to Outreach Outreach worker CHWs CHWs TBAs CHWs CHWs CHWs CHWs Study Study design Cross sectional Cross sectional Cross sectional cross sectional study cross sectional Qualitative Compa- rative cross- sectional surveys 220 19 217 215 219 Study / Study country OPM Evaluation 214, 218 Pakistan Zuvekas et al.1998 Michigan, USA Sauerborn et al. 1989 Burkina Faso Reis et al.1991 Indonesia Kauffman & Myers 1997 Thailand et Colombo 1979 al. Portland, USA

Global Evidence of Community Health Workers mode Evaluation Evaluation community were members interviewed Researchers toevaluated degree report of success OPM evaluation coverage 1 CHW per 1000 population Incentive Incentive (if any) Rs. 3600 / Rs. month - Supervision Community health nurses local supervi the and sors the at officials SecretaryState of Health Lady health supervisor key compe-key tencies were They trained in close liaison with nurses TBAs and Childhood illnesses health education and prophylaxis of malaria PHC They are serviceprovider Role health and provide Visit to education related diarrhea, purpose of ORT, of usage nutrition, infant birth and they control children. also weighed to people how Teaching make oral rehydration immunizingsolution (ORS), malaria providing children, etc. prophylaxis, treatment of provision of common ailments, participate in immunization of provision campaigns, nutritional and family planning counseling, post and care antenatal growth of women, natal care monitoring of children Refreshers Refreshers / Ongoing training monthly meeting with supervisor theywhere their share experiences Certification Duration 2 months written exam 18 months -

- - Table 15B: Description & Characteristics of Outreach workers of Outreach 15B: Description & Characteristics Table Trained in Trained They health Training Training Content Didactic trained to were communityprovide participation in health education, water and sanitation Didactic to education related of purpose diarrhea, in feeding, breast ORT, of usage nutrition, fant birth and they control children. also weighed Didactic basic healthcare. continuing Attended workshops education (e.g. topics on specific rabies prevention, are They breastfeeding) eight work to required Monday hours a day, pass Had to Friday. to didactic and practical trained onthey are primary ser health care family planning vices, methods and provision nutritionalof supplies, treatment counseling, of common ailments like malaria, diarrhea ARI, tuberculo disease, parasites intestinal sis, in and involve etc. treatment, DOTS preventive disseminate against HIV measures Recruitment Recruitment Criteria Health agents the from community local From neighborhood Recruited the from community Education Literate of8 years school 210 211 212 213 Study Study et Hill al.2000 Farafenni, Gambia Edpuganti 1995 CHWs Wayland 2002 Rural Brazil CHWs Omer 2002 (F) CHWs

129 mode Evaluation Evaluation OPM evaluation coverage 1 CHW per 1000 population Incentive Incentive (if any) Rs. 3600 / Rs. month Supervision Lady health supervisor key compe-key tencies PHC They are serviceprovider Role of treatment of provision participate ailments, common in immunization campaigns, of nutritional andprovision family planning counseling, post and care antenatal growth of women, natal care monitoring of children coordinators of role The information provide was to selected educate and to the chosen persons regarding They were services. preventive encourage andexpected to the obtain to people motivate services within the Kaiser- program. Permanente Refreshers Refreshers / Ongoing training monthly meeting with supervisor theywhere their share experiences Certification Duration 18 months 6 months Training Training Content practical and didactic trainedthey are on primary health services,care family planning methods and of supplies, provision nutritional counseling, of common treatment ailments like malaria, diarrhea disease, ARI, tuberculosis, parasites intestinal in and involve etc. treatment, DOTS preventive disseminate against HIV measures workers Outreach (neighborhood health were coordinators) trained in prevention and health education Recruitment Recruitment Criteria local From neighborhood from neighborhood Education of8 years school Study Study OPM Evaluation 214 8F9 CHWs Colombo 1979 et al. 220

Global Evidence of Community Health Workers Malaria Control Intervention Background Malaria currently kills up to 3 million people cruited in the Delacollete et al. and Deressa et al. per year worldwide and a child somewhere in were literate,227, 237 while those in the Rubesh the world every 30 seconds, most of them chil- II et al. 1990 intervention were both literate dren in sub-Saharan Africa.221 The disease also and illiterate.239 The training modality used to contributes significantly to anaemia among train these CHWs included didactic approach in children which is a major cause of poor growth 12 studies224-231, 233-235, 237, 238, 240 as well as and development. Malaria during pregnancy is didactic along with practicum in 3 studies.223, also associated with severe anaemia and other 235, 241 The training provided to the CHWs in the illness in the mother and contributes to low Kroeger et al. was workshop based.232 birth weight among newborn infants which is one of the leading risk factors for infant morta- Refresher training was provided in few of the lity and poor growth and development. Yet the interventions. The Kouyate et al. provided just disease is absolutely treatable and highly pre- one refresher course during the study period, ventable. Therefore, the international commu- 223 while in Delacollette et al. there used to be nity has vowed malaria part of its MDGs to make a monthly meeting with the project coordina- appropriate investments and interventions to tor.227 The refresher training in Pagoni et al. was bring this disease under control. Malaria is truly Conducted by the core group of mothers229 and a disease of poverty, which is badly affecting by the malaria treatment study team in Mayxay the poor who live in malaria-prone rural areas et al. intervention.241 In some studies refresher in poorly-constructed dwellings that offer few training was provided from time to time after barriers against mosquitoes. Despite malaria’s the volunteers had spent some years working shocking role in illness, lives, and economic in the community.235,236 The refresher training costs,222 measured are not taken as vigorously had an impact on the outcomes of interventions as it should be. Malaria’s preventable and trea- as compared to the studies which did not have table cycle of illnesses can be altered through refresher or on-going training. This is evident simple measures by community volunteers. We from high number of self reported Chloroquine therefore reviewed all the interventions applied treatment and more referrals in Kouyate et al. to control and prevent malaria through simple and from decrease in malarial cases in interven- community based interventions by CHWs. tion arm in Delacollette et al. and Pagoni et al. Community Based Evidence The peer counselors (PC) in the Kidane & Morrow 2000 helped neighbor group mothers There are total of 29 studies identified that recognize and treat symptoms and also to re- delivered intervention related to malaria pre- cognize the adverse effects of treatment if they vention and control in community (Table 16A & might occur 224. These PCs were supervised Table 16B). Among these identified these, seven by the CHWs from the community 224. The were RCTs, five were quasi RCTs, eight were proper monitoring and supervision of PCs and pre/post design while three were comparative educating neighbor group mothers resulted in cross sectional studies. Studies targeted general reducing under five mortality by 40% (P <0.003). population, children under 5 years of age and The CHWs in most of the interventions were pregnant women for malarial treatment. trained to provide treatment of uncomplicated malaria with Chloroquine. 223, 228-231, 233, 235- The CHWs in a total of 21 studies identified un- 237, 240 However additional training on how to der the domain of malaria were mostly residents take thick film and refer to health centre if fever of the community.223-238 The health workers re- not treated in 3 days.227 They were supervised

131 by the nurse in-charge of health centre.227 The The CHWs involved in this intervention were CHWs in Sievers et al. intervention were also unpaid but provided free medical services at trained in laboratory monitoring and checking government hospitals.235 Their role was to hemoglobin of all the children with malaria.230 spread health education related to malaria pre- Those involved in Mayxay et al. were also invol- vention, to make blood smears, offer presump- ved in the Laboratory diagnosis of malaria.241 tive treatment and maintain patient record.235 The CHWs involved in Das et al. distributed Since the nature of study was a cross sectional Chloroquine, free of charge to all fever cases234 survey so we could not report the effectiveness while in the Mbonye et al. the CHWs dealt with through comparison, but it does show that they the chemoprophylaxis of malaria in the pre- collected blood smears of 15% and 30% of the gnant women.225 population in Thailand and Latin America respectively. They identified 9% and 47% of all the The intervention carried out by Okanurak & cases of malaria in Thailand and Latin America Ruebush II was conducted in two parts of the respectively.235 world, namely Thailand and Latin America.235

CHW Snapshot 10 Anganwadi Workers (Village Health Guides) – India Program overview The CHW scheme in India was introduced in 1977 with the aim of providing health services at the doorsteps. The titles of community health worker has been changed over time from community health workers in 1977 to village health guides (Anganwadi workers) in 1981. 242, 243 In 2002 the village health guides scheme was completely sponsored by family welfare program.

Operational aspects and considerations village health guides are the people from community and their main Anganwadi Workers, India goal is to provide curative, preventive and promotive health care at Education minimal schooling door steps and to involve rural people in the provision, monitoring Training 3 months and control of basic health services, and to create resource person trusted by the local population who could provide link between Supervision community primary health center and the local community. They devote and Incentive Rs. 50 per month work for at least 3 hours per day. 242, 244 and basic medicines of Rs. 50

Constraints in Sustainability village health guides program is functional since last 25 years and the program comes under the state government and they are getting financial support from central government, but none of these are willing to take an ownership for the its sustainability. The program has encountered number of difficulties, among which is the initiation of perceiving themselves as village medical practioners. Source: Unicef 200418

Global Evidence of Community Health Workers Similarly the intervention by Kroeger et al. was HOMAPAK which resulted in 10% improvement conducted in three countries namely Ecuador, in the community effectiveness of malarial treat- Colombia and Nicaragua.232 The CHWs involved ment. In these studies mothers were supervised in this intervention were trained to diagnose by community workers for proper identification and treat uncomplicated malaria.232 After ini- and treatment of children at their homes. tial training, the refresher training workshops were conducted once a month by the research Conclusion team.232 This intervention seemed to have a positive impact on the outcomes as compared The interventions related to the malaria preven- to the studies which did not have frequent tion have shown positive outcomes especially and regular refresher workshops as evident by in studies with regular supervision. The role of increased knowledge of malaria in intervention CHWs in outreaching the community to reduce group by 33-61% as compared to the control. the incidence of malaria has been very effective through their awareness campaigns, laboratory The CHWs involved in Kolaczinski et al. inter- diagnosis and treatment that they provided for vention provided their services in the internally uncomplicated malaria. displaced persons (IDP) camp using color coded HOMOPAK according to age of the child.238

In Nsungwa-Sabiiti et al. CHWs actually trained mothers and provided them with 3 days pre packaged Chloroquine and other medicines as

CHW Snapshot 11 Community Health Workers – Sri Lanka Program overview In Sri Lanka the concept of community health workers started back in 1915 after involving teachers and village leaders work voluntarily. The initiation was introduced by Rockefeller Foundation who campaigned of hookworm infection control. Service organization such as family planning association started to train volunteers in 1970s from 60 in 1973 to 40, 000 in 1987. From 1976 onwards, the Health Education Bureau developed its volunteer program and trained 100,000 volunteers.

Operational aspects and considerations Volunteers were supposed to be from community and they were the Community Health Workers, Sri Lanka educated males and females from rural areas. Their primary task was Education educated to provide health communication message and liaise on with com- Training 3 months training munity and health care providers. Each volunteer is responsible for 10 households. Their training differed from areas to areas.245 There Supervision none were no material incentive for either health staff or volunteers and the means of the cost of the program is very low.

133 CHW Snapshot 12 Thailand Buddhist Monks (Village Health Volunteers) Program overview The Malaria Division of the Thai Ministry of Public Health started the Village Voluntary Malaria Collaborator program in 1961. The volunteers used to provide presumptive treatment with sulfadoxine-pyrimethamine 235, 236 but such treatment was phased out at the end of 2001. Volunteers are also trained to provide education about malaria prevention methods, chemical and biological vector control practices, writing of reports, and community motivation techniques.

Operational aspects and considerations Malaria volunteers are selected using a variety of methods. They Village Health volunteers, Thailand are chosen from an established group in the community, identified Education Compulsory education by a malaria field officer in collaboration with the village leader, Training 1-2 days or selected by community leaders at a community meeting. The majority of volunteers are males over 30 years old and farm as their Refresher periodic main occupation. 235, 236 Training takes place over one to two days, Supervision Program officer with periodic refresher training. Topics covered during the training Incentive Free care at government include: general information about malaria, such as basic epidemio- facilities and certificate logy, prevention, and signs and symptoms; vector control, including of recognition spraying and biological control; management of malaria, including blood slide collection and preparation, and presumptive treatment; completion of patient records; and sensitization of the community.246

Coverage and effectiveness In 1990, there were approximately 40,000 malaria volunteers in Thailand. The volunteers took 15% of all the smears used for epidemiological surveillance. Case detection by volunteers was, however, less efficient than in clinics, with only 9% of the volunteers’ smears positive, in comparison with 54% of smears positive at the malaria clinic and 26 per cent positive through other passive detection. Source: WHO/Unicef 200624

Global Evidence of Community Health Workers - - Outcomes episodes of fever treatment Self-reported CQ health centers to as referrals at home as well to Compared the study period. over increased of anemia the prevalence baseline findings, 16%, p < 0.0001) and malaria para (29% vs. falciparum of P. such as prevalence meters and palpable spleens was parasitaemia, fever no differences were but there at follow-up lower between the intervention group and control mortalityUnder-5 40% by was reduced in the intervention localities (95% CI from p<0·003) t test, 29·2–50·6%; paired The intervention The with significant was associated in knowledge requiring increases of danger signs reported qualitythe CHW, by of Counseling referral, in the home. and correct administration of CQ in the reported that 42.1% of children Parents the CHC by to referred were intervention group with 11.2% in the comparison the CHW compared ratio = 7.12, 95 % CI 2.62-19.38). (odds group For the months of April, June and August June and August the months of April, For season),deltamethrin impregnated (rainy malaria prevalence bednets did not reduce malaria overall prevalence but the significantly, all months of the study was significantly for 2 MH = 9.17, P 0.002). (chi reduced efficacy protective The varied between 0% and 70% when looking only at the postintervention between intervention and control differences was 40.8% protection average The groups. incidence of when considering a four-month clinical malaria attacks and 28.3% when consi dering a two-week malaria incidence. Participants children aged children 6–59 months under children 5 years under children of age 5 years of ages children 0-15 years general population Years of Years study 24 months 24 months 3 months 12 months 12 months Control arm Control arm received Control * care routine mother In areas control not trained. were group of control CHWs their also received training but standard not given they were additional training on counsel & referral no interventions no interventions - Interventions Table 16A: Malaria Control Interventions – Characteristics of Included – Characteristics Interventions Studies 16A: Malaria Control Table Experimental arm Experimental types of workers:Three health workers leaders; and the group (nurses); women takers main care (usually the mothers) the women Thereafter, trained. were leaders trained mothers on correct group and CQ Thus, malaria management. pre-packedparacetamol were in plastic age-specificbags in four doses each with a specific color and containing pictorial to guidelines according guidelines national malaria treatment nei teach trained to mother were recognize mothers to ghbor-group children in their under-5 symptoms of malaria, give to that might be a result course of Chloroquine the appropriate Chloroquine share to their age, for possible recognize and to properly, the drug. reactions from adverse the skillsImprove of the village drug kit counsel parents managers to on correct home administration of and (ii) increase (CQ), Chloroquine to of sick children the referral community health centers. bed deltamethrin treated household to nets given bed deltamethrin treated household to nets given Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs Study Study design RCT cRCT cRCT cRCT cRCT 248 248 223 193 247 224 Study / Study country Kouyaté et al.2008 Farafenni, Gambia Kidane & Morrow 2000 Tigray, Ethiopia et Winch al.2003 Bougouni, Mali Mouou- Somo et al. 1995 West South Cameroon Koreger et 1995 al. eucador Koreger et 1995 al. Colombia

135 - - Episodes of malaria cases decreased significantly significantly Episodes of malaria cases decreased at home (+16%) treated cases were and more (+16%). Malaria cses in intervention CHWs and by to arm decreased mortality49% reduction in children and 73% reduction in attacks of clinical malaria Outcomes episodes with associated incidence of febrile The season the rainy malaria parasitaemias throughout of splenomegaly and parasitae and the prevalence determined season were mia at the end of rainy who slept under bed aged 1–9 years in 233 children who did not. Bed nets were nets and in 163 children in the study cohort,used correctly the children by but direct observations that a significant showed a period left during their nets for number of children in the difference was no significant There the night. other incidence of clinical attacks malaria or in any malariometric between the 2 groups. measurement 10% in the intervention to arm compared arm malaria. developed 22.4% in control of malaria prevalence episodes decreased The 160 (17.6%) of 909 (P 906 (49.5%) of 1830 to from < 0.001) with the new delivery and from system 13 (13.1%) of 99 (P < 0.001) 161 (39.1%) of 412 to proportion was a lower There with health units. birthof low 6.0% with the new delivery weight 8.3% with health units (P < 0.03) versus system pro in the accumulated 13.5% improvement portion of patients Anti malarial drug efficacy in the community in a 10.4% improvement resulted of malaria treatment effectiveness General population 3-59 children months of age Participants General population women Pregnant Under 5 children 24 months 48 months Years of Years study 4 months 6 months 21 months 18 months In arm, no control specific malaria control effort was undertaken not trained workers were malaria treatment for group in control Control arm Control not treated nets were in no treatment areas control ITTp was provided health center through area in control Children care routine was given - - Interventions In control areas CHWs provided provided CHWs In areas control of malaria and also treatment patient to referrals provided community health workers treated during rainy with fever all children seasons with Chloroquine Experimental arm Experimental permethrin treatment bed nets of existed trained CHWS conduct to massm meetings with vil lage elders and issue bednets with insecticide and treatment people community resource Train In Uganda, distribute IPTp. to consists of two therapeutic IPTp tablets of 500 mg doses of SP (three + 25 mg pyrimethamine) sulfadoxine mothers and educated Volunteers a 3-day course of pre-pacprovided kaged plus sulfadoxine/ Chloroquine pyrimethamine tablets (HOMAPAK) CHWs CHWs Outreach Outreach worker CHWs CHWs CHWs CHWs Quasi RCT Quasi RCT Study Study design cRCT cRCTl Quasi RCT Quasi RCT

250 240, 225 226, 249 227 Delacollette et al. 1996 Katana, Zaire Menon et al.1990 253 Farafenni, Gambia Study / Study country et al. Snow 1987 Rural, Gambia Rowald et 1996 al. Baghicha & Kagan, Pakistan et Mbonye al.2008 Mukono, Uganda Nsungwa- Sabiiti et al.2007 251, 252 West Ugandan, Uganda

Global Evidence of Community Health Workers Outcomes use of community The health workers (CHWs) 26.1% (p < 0.05), while 0% to from increased 9.4% from in the homes decreased self-treatment 0% (p < 0.05) after the implementation of to medicine Use of patent the CHW strategy. 17.9% (p 44.8% to from dealers also decreased was implemented. < 0.05) after CHW strategy 4712 in 1990 to from All malaria cases decreased 5.6% was 1990 malariain of Proportion 1995. in 2612 6.09% in 1995 (95%CI: 5.2 – 7.0) (95% CI: 4.9 – 6.2) to The percentage of suspected malaria percentage admissions The laboratory- during that were greater confirmed was the pre-intervention the to period (80.4%) relative post-intervention periodratio (48.1%, prevalence p-value < [PR]: 1.67; 95% CI: 1.39 – 2.02; chi-squared with laboratory- admitted 0.0001). Among children confirmed malaria, the risk of high parasitaemia was higher during the pre-intervention to period relative the post intervention period (age-adjusted PR: 1.62; p-value = 0.004) Risk95% CI: 1.11 – 2.38; chi-squared greater than twofold anemia was more of severe during the pre-intervention period PR: (age adjusted p-value = 0.08) 2.47; 95% CI: 0.84 – 7.24; chi-squared Neonatal mortality 37 /1000 from increased birthslive births. 49/ 1000 live to Slight decline observed in post neonatal mortality 73 from i.e. births. 67 /1000 live to Early childhood mortality 18 per 1000 children 25 to from reduced knowledgeThe of malaria etiology and symptoms in the interventionwas 33-61 % better group Knowledge of the group. than in the control increased doses of Chloroquine recommended Colombia but 93% in Ecuador, (34% in significantly not in Nicaragua) and correct use of Chloroquine of malaria episodes also in the treatment 85% in Colombia) (26% in Ecuador, improved - Participants Adult population ex Adult ladies cept pregnant under Children of age 7 years under Children of age 5 years infants Neonates, and children General population Years of Years study 6 months 12 months 12 months 27 months 24 months 24 months 12 months - - Control arm Control was Routine care provided Interventions Experimental arm Experimental treat trained to were CHWs The cases of fever only uncomplicated the all other cases to refer and to or general hospital health centre of mothers in every group village and supplying a core Training community health workers with essential anti malarial drugs specially packed in age-specific bags containing a full course of treatment. malaria. of uncomplicated diagnosis They used a simple algorithm for of 551 pediatric examined a total admis review record The identify 1) laboratory-confirmedsions to malaria, by defined thick smear examination, 2) suspected malaria, defined as with malaria consistent in the absence and symptoms fever and 3) all-cause cause, of an alternate admissions Phosphate Chloroquine provided CHWS were malaria for treatment provide to two phases of the intervention: were (I) the training of There village health workers, and (2) community In workshops. interven malaria mainly to and related were tion communities the topics other common health problems. communities to in the control two phases of the intervention: were (I) the training of There village health workers, and (2) home visits community the village health workers by Inmeetings organized intervention malaria mainly to and in related were communities the topics other common health problems. communities to the control two phases of the intervention: were (I) the training of There village health workers, and (2) home visits community the village health workers. In by interventionmeetings organized malaria mainly to and in related were communities the topics other common health problems. communities to the control Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs CHWs CHWs Study Study design Quasi RCT pre/post pre/post pre/post pre/post pre/post pre/post

228 232 229, 232 230 231 232 Study / Study country Onwujekwe et al.2006 Enugu State, Nigeria et Pagoni 1997 al. 254 Sourou, Burkina Faso et Sievers al.2008 Kayonza, Rwanda Spencer et al.1987 Seradidi, Kenya Koreger et 1996 al. Eucador Koreger et 1996 al. Colombia Kroeger et al.1996 Nicaragua

137 - - CHWs collected 15% population blood smears CHWs detected 8.8% of all malarial were infection mortality49% reduction in children and 73% reduction in attacks of clinical malaria case fatalityThe and proportionate rate mor 20.8% and 90.9% malariatality were ratio for in the Hospital. respectively, in August, had 93.3% – 98.4%) of their children 95.0% (CI: their age and the correct dose for received pack. the blister 52.3% of caretakers had retained correct self-reporting, Assuming the overall 93.9% – 98.7%). was 96.3% (CI: adherence Outcomes from Malaria decreased significantly prevalence 13.6% (281/2,068) in December4.0% 2004 to (80/2,019) in December 2006. Malaria incidence 25.7/1,000 than 50%, from more by decreased population at risk in the second half of 2004 12.3/1,000 in the second half of 2006. to Mean annual incidence of 331.8 cases per 1,000 The population during the three-year study period. was reduced (AFD) fever morbid due to days average 5.9 ± 2.1 in the experimental villages 1.6 ± 0.1 from to at 5.0 ± 1.0 in the check villages. while it remained 1 h training 64 village health volunteers After (VHVs) laboratory with no previous rural Laos, from performedexperience, two malaria rapid diagnostic accurately. and OptiMALTM) (ParacheckPfTM tests collected in PHC and Number of mosquitoes not statistically different. non-PHC villages were in the appre found were mosquitoes The ciable numbers in 4 months of the year (Geometric mean = 32.5, 95% CI: 18.2-57.3) General population 3-59 children months of age general population under Children of age 5 years Participants General population General population general population general population - Over more Over more than 30 years more over than 40 years 2 months 1 months Years of Years study 33 months 24 months 10 months - Control arm Control Interventions CHWs responsibility was to take responsibility was to patient information, CHWs treatment presumptive and administer blood smears, with Pyrimethamine-sulfadoxine with suspected residents to malarial those with high risk illnesses or to behaviors. network collaborator was built in which CHWs volunteer take trained and they blood to patient information, were of malaria treatment presumptive and administer smears, of suspected and training on health education, diagnosis Sulfadoxine-Pyrimethamine by malaria cases and treatment (SP), breeding reduction of mosquito source cases, of severe referral consumed cases, and reporting of treated registration sites, of deaths and assessment the registration anti malarial, status of the epidemic in their particularoverall areas Distribute pre-packaged plus Sulfadoxine Chloroquine of charge free Pyrimethamine (HOMAPAK®) children. caretakers of febrile to Experimental arm Experimental (NMCP) was launched using Program National Malaria Control national The community-based monitoring of malaria cases.. insecticide-treated supported bed net (ITN) campaign, by on the importance media campaign an intensive of malaria use of artemisin and the widespread derivatiand ITN use, at the basis of such a success were treatment, for ves distribution of selected for villages were from Volunteers and the selection villagers Chloroquine was made either by servicesThe were of the volunteers or head of the village. and voluntary Chloroquine free absolutely in nature. cases. all fever to of charge free was provided by prepared and thin stained blood smears were Thick microscopic for later the same finger-prick from VHVs the houses VHVs’ at rapid tests with positive examination. Patients 3 days; (25 mg/kg with oral Chloroquine over treated were the district to clinic, referred Lao national guidelines), or were (above) with either oral Chloroquine treated they were where or sulphadoxine-pyrimethamine single dose (25/1.25 mg/ kg) plus or oral artesunate 3 days) (4 mg/kg for once a day mefloquine (15 mg/kg 1, 10 mg/kg 2). on day on day in PHC areas was implemented Malaria program control nets and targeted insecticide where impregnated was used. chemoprophylaxis CHWs CHWs CHWs CHWs Outreach Outreach worker CHWs CHWs CHWs TBAs CHWs - - - - retrospec cross tive sectional retrospec cross tive sectional cross sectional survey cross sectional Study Study design Pre/post Compa- rative cross sectional compara cross tive sectional study compara cross tive sectional PHC with nonPHC

238 233 234 237 241 255, 237 246 Soma, Okanurak & Ruebush II 2001 Thailand Okanurak & Ruebush II 2001 Latin America et Deressa al.2005 Oromia, Ethiopia Kolaczinski et al.2006 Gulu, Uganda Study / Study country et Thang al.2009 Vietnam Das et al.2008 Orrisa, India et Mayxay al.2004 Laos Rural et Lindsay al.1993 256 Gambia

Global Evidence of Community Health Workers Outcomes by detected 10% of all malaria cases were the static over in 1987 which remain volunteers 1990 9% in the year and was around years of 10 an average treated counters illiterate 12 per treated patients per months while literate 36% of the population treated month,. illiterate 30% of the population treated while literate Participants general population general population Years of Years study 48 months 24 months Control arm Control Interventions Experimental arm Experimental malaria program collaborator trained for were CHWs detect the case malaria trained to and treat were 28 CHWs Outreach Outreach worker CHWs CHWs Study Study design Cross sectional pre/post

239 236 Study / Study country Okanurak & Sornmani 1992 Thailand Rubesh II et 1990 al. Guatemala

139 mode Evaluation Evaluation coverage 1 CHW per 15 mothers Incentive Incentive (if any) They earned money after selling out drugs Supervision supervision their localby health workers key compe-key tencies malaria anddiagnosis treatment Supervised CHWs by Supervised from team by TCBMCP the - Role were: main roles The of health staff, Training leaders and group women of Sensitization mothers; communities; Drug supply leaders, group women to fund Supervisionrevolving of health workers and leaders group women inKept track of and Record, births all of format monthly and of drug and deaths, help neighbor To supply. and mothers recognize group of malaria symptoms treat its recognize to also and if they effects may adverse make appro Would occur. needed. where priate referrals collected the monthly reports on births, deaths, the of out and in migration and referrals, community, drugs whether checked and shortwere and reported any Supervisedproblems. mother as acted and coordinators affairs social for executive of the local community. Refreshers Refreshers / Ongoing training one refresher the course over study period Certification Duration 5 days - Table 16B: Characteristics and description of outreach workers and description of outreach 16B: Characteristics Table Health Trained to Trained Training Training Content and Didactic Practicum and malariaEducation management. Didactic neighbor group teach recognize mothers to in theirsymptoms that children under-5 of might be a result the give to malaria, course appropriate for of treatment share to their age, properly, Chloroquine pos recognize and to reactions adverse sible the drug. from Recruitment Recruitment Criteria permanent residency in the sub- age village, 30–50 years From community Education Mother coordinators 223 224 Study Study et Kouyaté al.2008 CHWs Kidane & Morrow 2000 PCs CHWs

Global Evidence of Community Health Workers - - mode Evaluation Evaluation OPM evaluation interven Post tion survey to theevaluate effectiveness of CHWs Assessed using a survey was performed afterone year the imple mentation coverage - - Incentive Incentive (if any) Received only symbo lic monetary reward. commis Paid sion on drugs to allowed keep O.6 US cents for each bag Supervision district health team on a monthly basis. Supervised nurse Inby of HC charge Supervised nurse the by the from dispensary - - key compe-key tencies Chemoprop- of hylaxis malaria in pregnant women. Provided treatment of Malaria and offered it under directly observed therapy of Treatment uncomplica malariated of Treatment uncomplica malariated and record of keeping drug supply - - Role iron gave Distributed IPTp, acid supplementa and folic and infor tion, deworming, nutrition. mation on proper anti-malarial in twoprovided age-specific, colour-coded pack a red formulations, infants aged 2—23 for pack months and a green those aged 2—5 years. for Chloroquine provided Quickly for treatment phosphate episodes of fever isolated Take malaria). (presumed to HC refer thick film and in 3days if not cured of patient clinical Kept record data, cost of drug and treatment provided supplies, unable patient if visit home by cases Referred them. reach to the to fever persistent with or hospital that health centre the sick person. to was nearest drugs of supply the held sell instructed to and were mothers the to treatments the provided request, upon child did not need Referral. monthly returns, Compiled of number the indicating each age group. bags sold for Refreshers Refreshers / Ongoing training Monthly meeting project with coordinator of the project Refresher training by the core of group mothers Certification Duration 1 week 3 days 2 weeks 1 month - - - in-service trai Training Training Use Training Training Training Content training Didactic of recognition on illness symptoms, advising mothers on HOMAPAK of use the and health facilities, and on keeping registers. treatment Didactic ning at health centre in the use of simple algorithmtreatment and early fever for and ma recognition nagement of malaria Didactic only treat trained to cases uncomplicated refer and to of fever theall other cases to general or centre health hospital within town. Didactic of a simple algorithm of diagnosis for malaria.uncomplicated Didactic Training Training Didactic Module included dangers of malaria in pregnancy; malaria in pre prevention gnancy; the benefits of SP and its side-effects; taking blood samples count and parasite for hemoglobin analysis; taking the baby’s and estimatingweight; gestational age - Recruitment Recruitment Criteria Community resource people. villa Local gers/ farmers selected community members Workers the from community Education Literate 228 225 226, 229, 229,

Study Study et Mbonye al.2008 CHWs Nsungwa- Sabiiti et al.2007 252 251, CHWs Dela- collette et al.1996 227 CHWs Onwu- jekwe et al.2006 CHWs Pagoni et al. 1997 254 CHWs

141 mode Evaluation Evaluation census and of registration vital events research The observers team workshops the &evaluated and problems achievements of health promoters. coverage Incentive Incentive (if any) Supervision Supervised by the research the and team health staff of ministry of health. - Malaria anddiagnosis treatment key compe-key tencies Management of uncompli malariacated Malaria anddiagnosis treatment - - - Updated census file withUpdated migrations and deaths births, and reported monthly records the malaria to provincial the electronic station where Also census file was managed. in health promotion involved activities. and malaria control Role withManaged children malariauncomplicated those with and referred illness and dehydra severe Laboratory hospitals. tion to including monitoring, checking admission all children hemoglobin for with suspected malaria. Chloroquine Provided the for phosphate of malaria, treatment identify chil households, Visit illness and with febrile dren medication Chloroquine treat workshop based Provided the communitytraining to malaria. to related home visits and orga PMade communitynized meetings Refreshers Refreshers / Ongoing training Weekend training workshops held were once a month I or 2by members of the research team Certification Duration - . they were were they Didactic Training Training Didactic use rapidtrained to to tests, diagnostic slides blood take the administer and malaria to treatment patients according results the test to Training Training Content Training Didactic distributetrained to anti-malarial within each five of children to village of age or less withyears symptoms and fever withconsistent malaria.uncomplicated regimens therapeutic All accordance in were with Rwanda Ministry of Health guidelines training Didactic treat to Trained malariauncomplicated with Chloroquine Didactic treat to trained how illness withfebrile Chloroquine Didactic and works training based hop on community based malaria control Volunteer Volunteer malaria workers healthVillage workers Recruitment Recruitment Criteria Community workers Volunteer village health helpers Health Local promoters Malaria volunteers Education 232 233 230 231 240, 232 232 Kroeger et et Kroeger al.1996 Nicaragua CHWs etThang al.2009 CHWs Study Study etSievers al.2008 CHWs et Spencer al.1987 CHWs Menon et al.1990 253 (F) CHWs et Kroeger al.1996 Ecuador CHWs et Kroeger al.1996 Colombia CHWs

Global Evidence of Community Health Workers - mode Evaluation Evaluation Impact was was Impact evaluated based on the changes observed in days, fever para incidence, incidence site parasite and prevalence. on Evaluated the basis of performance. coverage Incentive Incentive (if any) Unpaid Unpaid. Provided medical free services at government hospitals and centres. Supervision Monitor at Phalanxes District Clinic. Supervised by malaria field officer on a weekly basis. Supervision carried out Pas by - key compe-key tencies Distributed Chloroquine, charge of free all fever to cases. Laboratory diagnosis of malaria malaria dia andgnosis treatment Provision of malaria of treatment under malaria supervision - - - - Role Chloroquine provided those patients whoto treat them for approach ‘fever fill up a ment and to the and sheet’ treatment ta number of Chloroquine with Volunteers blets given. no educational background supplied with pre- were packed tablets in colored pouches plastic disposable age classes. different for thick and thin Prepared later stained blood smears for examination. microscopic If with a patient returned they would symptoms, and to the test repeat according or refer, retreat condition. the patient’s to on awareness Spread made prevention, malaria offered blood smears, and treatment presumptive maintained patient record of treatment and diagnosis cases malaria uncomplicated of severely referral with SP; ill patients; community mo bilization on environmental mngtt & health education on malaria transmission, &the control prevention, diagnosis early of importance & weekly& treatment, repor ting of their performances. Refreshers Refreshers / Ongoing training follow-up and re- by teaching the malaria treatment study team Refresh course organized time to from the after time volunteers been have working for some years. Certificate Certificate Malariafrom & Division Ministryfrom of Public Health in the 2nd year of service. Certification Duration 1 week 1hr 1-2 days 3days - - on on Includes Includes Training Training Content training Practicum included training in blood collection, performance & inter tests rapid of pretation and making malaria was held in smears, the Lao language and Didactic Practicum ongeneral information malaria transmission, prevention, symptoms, prepare to how thick blood smears, presump administer and treatment tive patient the complete Alsoreport forms. trained in motivational for techniques activities antimalarial in the community. Didactic training health education, of suspecteddiagnosis malaria cases and Sulfadoxine- by treatment Pyrimethamine (SP), severe of referral reduction source cases, breeding of mosquito and registration sites, cases, reporting of treated consumed antimalarial, of deaths and registration assessment of the overall status of the epidemic Didactic Training Didactic based on thediagnosis of malariasymptoms and on Chloroquine administration as in theprescribed National Anti-Malaria group through Program discussion sessions and demonstrations - Recruitment Recruitment Criteria Volunteers selected by villagers or head of the village and some malaria workers also included. Chosen on their to willingness participate. Selection themade by malaria field officer and the village headman. Community malaria workers selected from Epidemic- affected peasant asso ciations (Pas). Education literate –capable of and reading writing 234 241 246 246 Study Study Das et al.2008 CHWs Mayxay et et Mayxay al.2004 CHWs Okanurak & Ruebush II 2001 Thailand CHWs Okanurak & II Ruebush 2001 Latin America CHWs Deressa et al.2005 237 CHWs

143 mode Evaluation Evaluation Evaluations carried out performance evaluation people in community aksed were report to differences & literate in illiterate coverage Incentive Incentive (if any) Unpaid basic remuneration (per diem). pin Reward Supervision Monthly Record by screened surveyor supervision evaluators by every 8 weeks key compe-key tencies skills to manage malaria illness in IDP camps malaria and control and treatment management detection and treatment of malaria - - Role of dose correct the provided and color coded HOMAPAK®, the age of child recorded trained to they were health education provide they the community, to increase to trained also were oncommunity awareness malaria and prevent to how get treatment to where made visits at community as household and they were re the family to ked inform to port malaria these workers to Refreshers Refreshers / Ongoing training were refresher after provided working for some time Certification Duration 1-2 days training 1 week orientation & 2 days training - Training Training Content Didactic training On coded color- of provision according HOMAPAK age of the child to to and giver his/her care of record maintenance training didactic 6 subjects. covered subjectsThis included general information about malaria, malaria prepare to how control, a think blood slide, drug distribution and report writing and mo tivation of community theyhome volunteer at to trained how were report,fill to and how days three administer treatment presumptive were and malaria of a bookletgiven for dosage schedule - Recruitment Recruitment Criteria Community drug distributors established community and groups, then that community decided commu from nity through community poll Education illiterate and literate 236 239 Study Study Kolaczinski et al.2006 238 CHWs & Okanurak Sornmani 1992 CHWs Rubesh II et al. 1990

Global Evidence of Community Health Workers Tuberculosis Control interventions Background Tuberculosis (TB) is known to afflict mankind adults with clinical and culture positive TB in 11 since ancient times. With the arrival of che- studies,260-270 only children and general popu- motherapy and establishment of short course lation in 7 studies.271, 272 Type of CHWs working treatment regimen in 1970s and 1980s, it was for TB prevention and treatment were mostly believed that TB would surely be conquered volunteers from the community and in few pla- soon. Steady declines in case notifications were ces they were one to one peer and individuals observed in most of the developed countries in who themselves got treated with anti-TB.265, 271 early 80s,257 while no such declines were seen In Clarke et al. consumers themselves selected in most developing countries. Before it could the CHWs.273 have eradicated completely a reversal of the declining trend started with the emergence of Educational level of CHWs was not mentioned HIV/ AIDs disease. Consequently, TB was decla- in any of the study, while 3 studies mentioned red a global emergency by the World Health that their CHWs were illiterate members from Assembly (WHA) in 1991 and a frame work for the community.267, 268, 269 In all included stu- TB control was developed in the form of DOTS dies CHWs were the members from local resi- (the internationally recommended strategy for dence. They all received didactic training except TB control).258 The principle target of MDGs in Phomorphub et al. in which CHWs were gi- for TB control adopted in the year 2000 is to ven practicum training in addition to classroom ensure that the incidence rate of TB is declining teaching.275 When the number screened by by 2015. The supplementary targets are to halve CHWs in Phomorphub et al. was compared with the prevalence of TB and TB mortality rates by those diagnosed by health center or hospital 2015 as compared to 1990. The ultimate goal is staff, their performance was better than health to eliminate TB by 2050, when the annual inci- center but poor than hospital staff.275 dence should be less than one case per million population. Content of training varied between studies. In Shargie et al. CHWs distributed leaflets and To control TB, the DOT strategy was introduced discussed symptoms of TB at community gain late 1990s.259 In this section we will be fo- thering, plus they also screened population at cusing on the intervention delivered by CHWs monthly diagnostic outreach clinics.260 While in their community to achieve a part of MDG in some other studies CHWs or family members goal-6. trained as promoter delivered and monitored TB DOTS therapy.261, 262, 265, 268-271, 273 Community-based evidence In Clarke et al. and Walley et al.262 the direct Twenty six studies were included in this group observations therapy strategy by CHWs was that delivered interventions related to manage- compared with family members. Both of these ment of tuberculosis in the community. Studies studies showed that cured rates were higher included twelve RCTs, 2 quasi-RCT, 2 pre/post among CHWs arm as compare to family mem- design, and other cross sectional or comparative ber arm. cross sectional studies (Table 17A & Table 17B). all of these studies were from lower or middle Training of these workers varied from 2 days as income countries except two which were from in Niazi & Al Delamimi intervention266 to 30 days high income country i.e. USA.19, 269 in Chowdhury et al.267 Studies that utilized BRAC CHWs were provided with close monitoring and The participating consumers included only supervision267-269 while only Chowdhury et al.

145 Conclusion reported that their CHWs were provided with The interventions related to the tuberculosis refresher training once a month.267 prevention have shown positive outcomes especially in studies with regular supervision of Workers from BRAC areas were given small CHWs in TB DOTS program. The role of CHWs remuneration of 125 Taka,269 sales of drugs267 in outreaching the community to the cure and transport cost.265 Disaggregated analysis rates of tuberculosis has been very effective showed that all these studies where CHWs were through their awareness campaigns, laboratory given remuneration for work had significant screening and treatment that they provided for tuberculosis cure rates. eradicating tuberculosis.

CHW Snapshot 13 Community Health Workers – Burkina Faso Program overview A pilot program in Burkina Faso sponsored by the National Centre for Malaria Control (Centre National de Lutte contre le Paludisme) relies on community health workers who supply anti malarial drugs at the community level. The CHWs sell the pre-packaged Chloroquine regimens to mothers under a cost-recovery mechanism, in accordance with Bamako Initiative principles. The CHWs are given the first stock of drug packages and are expected to sell the drugs at a pre-approved price.

Operational aspects and considerations Nurses from the health centers train core groups of mothers, village leaders and CHWs in symptom classification and correct dosage schedules. The core mothers and leaders are then responsible for sharing the messages with other members of the community. The CHWs and community leaders are responsible for providing advice about treatment and referral, acting as intermediaries between the health system and the community. Posters depicting the correct dosage of anti malarial by age are placed in the villages and are given to core mothers, village leaders and CHWs. Health centre nurses are responsible for supervision of the CHWs through monthly visits and reviewing the sales of packages. Referral is indicated for those patients with convulsions or other neurological complications and for those who are febrile 48 hours after treatment.229, 254

Constraints in Sustainability In a study evaluating this program, it was found that 59% of those children treated with pre-packaged tablets received the treatment over the recommended three days. The correct dosage packet for age was received by 52% of the children, with 31% under-dosed (given a packet for younger child) and 17% over-dosed (with packet for older child). Source: WHO/Unicef 200624 & Winch et al. 2005274

CHW Snapshot 14 Philippines- Barangay Health Workers Program overview The Barangay health workers or government trained health volunteers have been operating in rural villages in the Philippines since 1981. Being a vital part of the health system these CHWs were operating in all parts of the country. Functioning within the capacity of primary health care workers they epitomize health care as acceptable, affordable and accessible.276

Operational aspects and considerations These workers were recruited and selected and then adequately oriented to tackle malaria in community. They are female residents of community. And receive training from health center personnel to promote and give initial care for common ailments.

Constraints in Sustainability these workers are expected to deliver comprehensive care directed to common ailments prevailing in rural communities and nutritional activities like weighing children under six, maternal and child health services, family planning and immunization. With more than a dozen of task need to be performed by these workers their roles has been questioned. Source: BASICS II 277

Global Evidence of Community Health Workers - - - Outcomes TB were 159 and 221 cases of smear-positive in the interventiondetected groups, and control Case-notification in all age rates respectively. 124.6/105 and 98.1/105 person-years, were groups rates corresponding The (P = 0.12). respectively 207/105 and were in adults older than 14 years The (P = 0.09). respectively 158/105 person-years, symptom proportion of patients with >3 months’ duration was 41% in the intervention group (P<0.001). group with 63% in the control compared duration in the intervention symptom Pre-treatment with 3–20% in 55–60% compared by fell group In the intervention and control group. the control of patients 81% and 75%, respectively groups, (P = 0.12). treatment successfully completed Community DOTS and family-member DOTS achie and family-member DOTS Community DOTS (odds of 85% and 89%, respectively success rates ved fa to relative community DOTS ratio of success for 0·67 [95% CI 0·41–1·10]; p=0·09). mily-member DOTS, case-finding 63% with the com Estimated were rates munity and 44% with family-member DOTS. strategy Within the strengthened tuberculosis services, tuberculosis the the strengthened Within and family-member DOTS, health-worker DOTS, very gave strategies treatment self administered of 64%, 55%, and rates with cure similar outcomes, or treatment-completed and cure 62%, respectively, of 67%, 62%, and 65%, respectively. rates (LHW vs. similar outcomes achieved All groups 17.2%, 95% confidence clinic nurse: risk difference interval self Supervision 0.1–34.5; LHW vs. [CI] 15%, LHW 95%CI _3.7–33.6). New patients benefit from supervision clinic nurse: risk difference (LHW vs. self supervision24.2%, 95%CI 6–42.5, LHW vs. patients 39.1%, 95%CI 17.8–60.3) as do female clinic nurse 48.3%, 95%CI 22.8–73.8, (LHW vs. self supervisionLHW vs. 32.6%, 95%CI 6.4–58.7) The successful treatment completion rate in adult completion rate successful treatment The TB patients was 18.7% higher (P= 0.042, 95%CI than in the 0.9–36.4) in the intervention group TB cases for adult finding Case group. control was 8% higher (P = 0.2671) in the intervention group. the control to compared group Participants General population all new > 15 years of age patients with sputum smear-positive adults with new sputum-positive tuberculosis adult (> 15 years) who TB, with started a course of (new TB treatment and retreatment) new smear-positive new smear-positive TB patients adult Years of Years study 12 months 12 months 28 months 16 months 12 months - - Control arm Control In communities, control detected cases were case- passive through finding among sympto matic suspects reporting health facilities to arm, family in control was used member DOTS in which as a strategy drug taking supervised a household daily by member selected by the patient, with drugs the patient’s to provided supervisor every week. self-administered treatment In arm, self su control pervised patients visited the clinic once a week, or sent a family member collectto their drugs Patients in control arm in control Patients from TB DOTS received health facility where issued with they were for 1–4 sufficient drugs depending on weeks, the distance they live. - - Interventions Experimental arm Experimental Health workers held monthly diagnostic clinics at which they obtained outreach sputum micros sputum samples for TB suspects. In symptomatic from copy addition, trained community promoters distributed leaflets and discussed TB during house visits and of symptoms Symptomatic at popular gatherings. visit the encouraged to individuals were or a nearby health facility. team outreach In intervention arm Community DOTS was used in which drug takingstrategy supervised com a female daily by or a village munity health volunteer health worker with drugs provided the supervisorto every month. with direct observationDOTS health workers by of treatment with direct observationDOTS of family members by treatment In intervention arm, of attendance TB was expected 5 days patients with for new weeks the first 8 for per week re-treatment for patients (12 weeks per 3 days by patients), followed the continuation phase for week TB patients were issued with at TB patients were anti tuberculosis most 1 month’s chose And patients were treatment. the LHW from DOT receive to Table 17A: Tuberculosis Control Interventions – Characteristics of Included – Characteristics Interventions Studies Control Tuberculosis 17A: Table Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs Study Study design RCT cRCT RCT RCT cRCT 264 260 261 262, 273 Study / Study country et Shargie al.2006 & Lemo Hadiya, Ethiopia et Newell al.2006 Hills districts of Nepal et Walley al.2001 278 Rawalpindi, Pakistan Zwarenstein et al.2000 Town, Cape South Africa Clarke et al.2005 Western South Cape, Africa

147 - Overall, there was no significant difference in difference was no significant there Overall, between the two rates and cure conversion [M-H 0.62; pooled odds ratio (OR) strategies 95% confidence interval(CI) 0.23, 1.71 and OR ¼ 1.58; 95% CI 0.32, 7.88, respectively] a higher treatment showed interventionThe group default rate 76.7%), lower (94.2% versus success rate 10.0%) and higher smear conversion (0.8% versus 75.0%) (92.9% versus after the end of treatment rate trained personnel Home visiting by than controls. patient compliance with DOTS. improves significantly Outcomes in the cure difference was no significant There between direct observationand completion rate and family members [2% CHWs by of treatment to 7%), exact (95% CI 3% P ¼ 0.52]. A difference before-and-after comparison demons of outcomes completion rate and treatment that the cure trated a baseline of 27–67% following from improved implementation of community-based DOTS. were and treatment-completion rates Cure cohort higher in the DOT (76% and significantly (67% and 76%). group 84%) than in the control by therapy isoniazid preventive to Adherence injection drug users is best with supervised care. routine over adherence counseling improves Peer electronic monitoring of by as measured care, peer counseling and patients receiving pill caps, reported accurately their adherence. more and thirty hundred patients were smear-positive Two the intervention identified from and 88 patients from mean case detectionThe rate kebeles. the control was higher in the intervention than in the control In kebeles addition, more (122.2% vs 69.4%, p,0.001). identified in the intervention patients were females mean treatment The kebeles (149.0 vs 91.6, p,0.001). was higher in the interventionsuccess rate than in kebeles the control (89.3% vs 83.1%, p = 0.012) and patients (89.8% vs 81.3%, p = 0.05) females for more - - - - - General popu TB lation with General popu TB lation with Participants Adults or children or children Adults with diagnosed or smear +ve pulmo –ve nary tuberculosis; extrapulmonary or re tuberculosis lapse of previously tuberculosis treated ca all tuberculosis with ses presenting sputum smears acid-fast for positive bacilli (AFB) at least 18 years used injection old, had a drugs, tuberculin positive skin test TB patients with 7 months 6 months Years of Years study 26 months 14 months 16 months 17 months usual care no home visits Control arm Control member/carer Family supervision. A family was member or carer the by nominated become the patient to supportertreatment In group, the control drugs patients received 1 month of treatment for and after after diagnosis up visit. No each follow supervisiontreatment between was offered visits. follow-up assigned were Patients daily self- receive to isoniazid administered care. with routine no intervention - - Interventions Health volunteers from community from Health volunteers community provide trained to were TB people with to based DOT community selected from women serve trained to as volunteers were homes and promoted visited TB treatment of adherence Experimental arm Experimental Community health worker super vision. Community health workers supportersacted as treatment with the patient visiting every for day direct observation of treatment TB patients In the intervention group, the choice of selecting given were community staff, either health centre or family members health volunteers as supervisors staff (health centre homes: twice per the patients’ visited month during the initial 2 months and once per month of treatment, 4 months. during the remaining receive to assigned were Patients directly observed isoniazid pre twice therapy weeklyventive with peer counseling and education. in the intervention trained HEWs We kebeles identify suspects, to on how directly collect sputum, and provide HEWs The observed treatment. in the intervention kebeles advised people with productive duration or more cough of 2 weeks the health posts attend to CHWs CHWs Outreach Outreach worker CHWs CHWs CHWs CHWs RCT RCT Study Study design RCT RCTl RCT RCT

279 282 271 265 280 281 Lwilla et al. et al. Lwilla 2003 Rural Tanzania Mohan et 2003 al. Iraq Study / Study country et Wright al.2004 Lubombo, Swaziland Kamohan- tanakul et al.1999 Thailand Chaisson et 2001 al. Baltimore, USA Datiko & Lindtjorn 2009 Southern Ethiopia

Global Evidence of Community Health Workers - The intervention group showed a higher treatment a higher treatment showed interventionThe group default rate 76.7%), lower (94.2% versus success rate 10.0%) and higher smear conversion (0.8% versus 75.0%) (92.9% versus after the end of treatment rate trained personnel Home visiting by than controls. patient compliance with DOTS. improves significantly at home were patients treated for rates Cure versus 68.6%), (83.7% than controls better significantly 14.0%). Smear was compliance (100.0% versus so too in inter better significantly were rates conversion at all stages. with controls cases compared vention For TB patients. 2873 adult collected for Data were rates cure treatment TB patients, smear-positive higher in the intervention (Guguletu) area were (Nyanga) 50%, P area (58% vs. than in the control 35%, cases (47% vs. retreatment = 0.0378) and for similar. were success rates P = 0.0791), treatment Outcomes In the phase-two 3497 (90%) of 3886 cases analysis, 12-month treatment. In identified had accepted all of 1741 identified cases accepted phase three, 2833 (81·0%) and 1496 the 8-month regimen. respectively, (85·9%) in phases two and three, 336 (9·6%) and 133 (7·6%) died. cured; were Following the implementation of CB-DOTS, treatment treatment the implementation of CB-DOTS, Following TB pulmonarysuccess among new smear-positive 74% (RR 1.3, 95%CI 56% to from cases increased interruption 1.2–1.5, P < 0.001) and treatment 1% (RR 16.5, 95%CI 6.1–44.7, 23% to from decreased difference was no significant There P < 0.001). and after the in the proportion of deaths before new 14% for (15% vs. implementation of CB-DOTS new 29% for and 38% vs. pulmonary, smear-positive and extra-pulmonaryTB cases) smear-negative In the BRAC area, each cured patient cost the each cured In area, the BRAC US$ 52, while successfully treated health system US$ 48 each. However, patients cost the system was higher, cost per patient cured overall the total at US$ 64 (Tablethe 4). In area, the government US$ 77, 70, and were equivalent figures in completion rate Treatment 96, respectively. patients was 62.5% in the BRAC sputum-negative The area. and 87.5% in the government area was 83.3% in the success rate treatment overall area. and 82.7% in the government area BRAC - General popu TB lation with TB newly diagnosed patients Tuberculosis patients Participants General population Tuberculosis patients general adult population 6 months 10 months 12 months Years of Years study 84 months 24 months 12 months - no home visits attended group control the local health centre treatment for No interventions arm control to Control arm Control - Interventions Adolescents from commu from Adolescents become a peer trained to nity were health counselors and provided TB families for education to were interventionThe group TB patients daily at visited the 2-month initial home for trained members of phase by Federation Women’s the Iraqi via CHW program TB control in an area was delivered Experimental arm Experimental has been implemented TB program Since 1993, a national Both BRAC strategy DOTS WHO recommended based on the (5), regimens use the same treatment TB programs and national on the use of community mainly relies health workersbut BRAC directly observed deliver to (DOT) therapy (CHWs) while the health complexes mostly through DOT provides government The communityThe health workers about distributed information village organiza especially through the community, to tuberculosis cases of pulmonaryThey also detected tion meetings and posters. cough of 4 weeks’ up individuals with chronic & followed tuberculosis, duration or longer and collect two early-morning sputum samples. As part of routine tuberculosis control programme operations, to to operations, programme part control As tuberculosis of routine and acceptability the effectiveness of community-based measure (TB)tuberculosis using the directly observed care treatment, implementation of The TB control. short-course for strategy (DOTS) with active participation strategy of local communities in the DOTS supervision the option of treatment providing in the community is known(CB-DOTS). in Uganda as community-based DOTS CHWs CHWs CHWs Outreach Outreach worker CHWs CHWs CHWs RCT Quasi RCT quasi- RCT Study Study design pre/post pre/post cross sectional study (BRAC with areas Government areas) 267 283 284 269 266 285 Morisky et 2001 al. Urban USA Niazi & Al-Delaimi 2003 Baghdad, Iraq Dudley et 2003 al. Town, Cape South Africa Study / Study country Chowdhury 1997 et al. Rural Bangladesh et al. Adatu 2003 Kiboga, Uganda Islam et al.2002 Rural Bangladesh

149 - Outcomes or four Among the 66 patients who completed (55) were 83 percent months of therapy, more Five at the completion of treatment. cured probably died while receiving of these 66 patients (8 percent) treatment of the time to predictors The therapy. hematocrit (hazard a low or death were failure confidence interval,to 4.09; 95 percent 1.35 ratio, ratio, body-mass index (hazard 12.36) and a low confidence interval,to 11.53) 3.23; 95 percent 0.90 including 44 (6%) TB, of diagnosed 55 (8%) were proportionsThe of smear- cases. smear-positive health VHV, by cases among those screened positive 6.7%, 3.4% and 12.9%; were and hospital staff center TB proportions corresponding The for respectively. proportionsThe 8.4%, 5.1%, and 12.9%. cases were 2.5%, 21.7%, and 14.6% cases were of smear-positive A, B and C, respectively. the Region those from for their detection rate is 30% and cure rate is about 95% rate is 30% and cure their detection rate Consistent cure rates of around 85% are testi 85% are of around rates cure Consistent program of the BRAC the effectiveness to mony in 1992 rates the cure approach and the DOTS 90% in 1997 to was 81% while it increased had malnutrition of the children percent Forty-five 29% had severe or anemia at the time of diagnosis, cavitary or (defined as bilateral findings radiographic disease), and 13% had extra pulmonary disease. hospitalized were of the children percent Forty-five initially because of the severity Adverse of illness. no but children, observedthe of 42% were for events _5 days. for suspension of therapy required events children) 38 of (36 Ninety-five children the of percent 1 child (2.5%) cures, or probable cures achieved therapy from and 1 child (2.5%) defaulted died, Participants TB patients TB population TB population with General TB General population under Children of age 15 years - - - Years of Years study 84 months 48 months Between 1997 compa success red &failure of 1992 rates with 1997 48 months - Control arm Control Interventions Experimental arm Experimental the who then go into trained their CHWs BRAC TB to treatment and provide level root grass strategy WHO DOTS patients through the proportions (TB)this study compared of tuberculosis cases part under a project launched in lower detected of southern (VHV), type screener [village health volunteer 1) by Thailand and hospital staff]; staff, health center region by and 2) results of community based therapy for multidrug-re of community for results based therapy in a poor section sistant tuberculosis of Lima, Peru For the first decade of operation, the BRAC program relied on program the first decade of operation, BRAC For 1995 an 8-month but from regimen, a 12-month treatment CHW identifies The short-course was introduced. regimen cough and sends samples of sputa to people with chronic acid-fast-bacilli- The laboratorya local BRAC microscopy. for CHW The immediately. treatment to brought cases are positive the government. from free received the drugs, provides performedCHWs drug sensitivity of the child’s testing or suspected on the basis of isolate tuberculosis a child with household for of clinical symptoms presence Tuberculosis, contact multidrug-resistant with documented was performed a supervised and initiated individualized tuberculosis multidrug-resistant for regimen treatment Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs - Study Study design cross sectional survey Retro- spective cross sectional Cross sectional compara cross tive sectional study 12 months regimen 8 vs. months Retros- pective case series

275 286, 272 270 268 Ravichan- daran 2003 Rural Bangladesh Study / Study country Mitnick et al.2003 287 Lima, Peru Phomorphub et al.2008 Southern Thailand Chowdhury 1999 Rural Bangladesh Drobac et Drobac al.2006 Lima, Peru

Global Evidence of Community Health Workers - - Outcomes as grow continues to of CHWs role The of extend care beyond their responsibilities and prevention and affected the infected education in the communities studied. pulmonary new smear-positive two stra patients, For used until the 1) the strategy compared: were tegies 2 months of hospita end of October 1997, involving and 2) a new of treatment, lisation at the beginning 1997, in November introduced decentralised strategy the choice of in- or out- given in which patients were during the first 2 months of treatment. patient care 1740 persons (78%) for Read PPD results X-ray for readings 142 positive Referred homeless 125 PPD positive (8.3%) Referred (12%) tests TB positive Read 44 X-ray people for TB cases on 33 through Successfully followed Of the 1811 TB patients, 1215 (67%) were treated treated 1215 (67%) were TB patients, Of the 1811 726 (60%) received among these, under DOT; and 489 (40%) community- clinic-based treatment community-based offered Patients based treatment. (99%) likely accept DOT more to were treatment (60%, P clinic-based treatment than those offered new smear- for success rates Treatment _ 0.001). significantly TB cases were and retreatment positive with community-based higher among those treated clinic-based DOT. to compared DOT Participants CHWs Tuberculosis patients general homeless population TB population Years of Years study 2 months 12 months 24 months - Control arm Control Interventions Experimental arm Experimental as their responsibilities grow continues to of CHWs role The and and affected of the infected extend care beyond education in the communities studied. prevention stra assess the cost and cost-effectiveness of new treatment To new in pulmonary introduced for patients, tegies tuberculosis pulmonary new smear-positive two strategies patients, 1997. For used until the end of October 1) the strategy compared: were 2 months of hospitalization at the beginning 1997, involving introduced strategy and 2) a new decentralized of treatment, the choice of given 1997, in which patients were in November during the first 2 months of treatment. care in- or out-patient Alameda County Health Care for the Homeless Program operates an operates the Homeless Program for Alameda County Health Care to carryout by CHWs case-management staffed program outreach California homeless people of Alameda County, activities for Patients were offered DOTs when they presented to out- when they presented DOTs offered were Patients was provided DOT an initial diagnosis. patient clinics for using CHWs in the clinic or community, Outreach Outreach worker CHWs CHWs CHWs CHWs Study Study design cross sectional cross sectional Cross sectional cross sectional survey 19 288 289 290 Study / Study country Khan et al. 2002 Rawalpindi, Gujranwala, Sahiwal, Pakistan et al. Floyd 2003 Lilonwe, Malawi Zuvekas et al.1998 California, USA Cavalcante et al. 2007 Rio de Janeiro, Brazil

151 mode Evaluation Evaluation Evaluated success by rate coverage Incentive Incentive (if any) No incentives Supervision - key compe-key tencies Treated symptomatic patients and encouraged visit to them the outreach or ateam nearby health facility. Ensuring treatment of completion TB Counseling com ensured pliance with complete the TB of treatment TB Assuring treatment compliance Role Held monthly diagnostic clinics at which theyoutreach samples sputum obtained from sputum microscopy for TB suspects. symptomatic Also trained community leaflets distributed promoters of symptoms discussed and TB during house visits and at popular gatherings. the tuberculosis, discussed and roles process, treatment in successful responsibilities of side-effects treatment, of importance the and drugs, advice seeking immediately facility the treatment if from side-effects Discussion arose. flipcharts by supported was for and leaflets designed Reminders strategy. each subsequent all on given were the health facility. visits to direct observation of health workers by treatment in as DOT, care Provided case of self-supervision a mentoring played LHWs & patient the visiting role, and monitoringencouraging adherence treatment LHWs cases, all In regularly. non- treatment addressed through promptly adherence of particularizeda process were motivation. LHWs in a unique position to TB patients’ understand the & consider situations, life problems. individual patients’ Refreshers Refreshers / Ongoing training Certification Duration 6 days 1-week five (25 h weekly) training during the off-peak season - Table 17B – Characteristics and Description of outreach workers and Description of outreach 17B – Characteristics Table training Orientation Training Training Content Didactic on case-finding, procedures, diagnostic coordination, outreach handling of sputum interviewspecimens, and techniques, record-keeping. strategy, the DOTS process the treatment and its duration, the of communityrole supervisors in ensuring treatment tuberculosis completion, the side tuberculosis of effects process the and drugs, patients for of referring their management. Didactic DOTS by provided supervisor Training Didactic modules Training included becoming tuberculosis, an LHW, (including health family HIV/acquired immune-deficiency first [AIDS]), syndrome and home-basedaid, within TB focus care. primary & health care community develo pment principles Recruitment Recruitment Criteria health worker everyfrom centre DOTS hHealth workers farmAdult dwellers selected suitable farm-dwelling peers for training as HealthLay Workers Education

260 261 262, 273 Study Study et Shargie al.2006 CHWs et Newell al.2006 CHWs et Walley al.2001 278 et Clarke al.2005 Western South Cape, Africa CHWs

Global Evidence of Community Health Workers - mode Evaluation Evaluation Outcome as Outcome sessment was undertaken laboratoryby examination of sputum by technician by Evaluated rate cure by Evaluated rates, cure treatment compliance coverage 1 CHW per 200 households Incentive Incentive (if any) transport transport allowance Transport available small profit the from drugs of sale 100takka/ completed / regimen patient 25 /case Taka Supervision Professional health educator supervised BRAC by physicians and field staff - - key compe-key tencies Monitored treatment adherence and notified to defaulters the diagnos tic centre. TB, of Treatment common fever, respira acute tory infections , diarrhea, Immunization, family planning, deworming Role supervision to Provided patients taking drugs TB of treatment for treatment as Acted patient the with supporters direct for day every visiting observation of treatment. homes: the patients’ Visited the during month per twice initial 2 months of treatment, and once per month during 4 months. the remaining and given counseling were monthly supply of isoniazid also 300 mg tablets were They also met with given. twice counselor peer the of month first the during and once a monththerapy Arrange monthly thereafter. support meetings group treatment DOTS Provided patient ascertain to TB of health compliance; gave patient the to education about family his/her and TB and its transmission. treatment and control Tb diseases infectious some of improvement with along and sanitation. of water Refreshers Refreshers / Ongoing training per1 day month of in-service training Certification Duration 2 days 15–30 days - To They were were They Training Training Content and didacticPracticum Clinic-based training run on sessions were support to how and TB treatment, observe adhe and recording Treatment a on rence Supporter card. Didactic training treatment TB provide under supervision treatment assure and compliance. taught to they were provide and counsel And patients. drugs to arrangealso to monthly support meetings training Didactic TB of the problem in general and on of the the treatment close and disease supervision of DOTS DIDACTIC detecting trained for followed TB patients, provide and them TB drugs. them Trained to interview TB interview to Trained patients on treatment Recruitment Recruitment Criteria Community healthlay workers Rural health motivators the from community selected by Iraqi local counsel Community former injection drug user Trained members of the Iraqi Women’s Federation Selected BRAC from organization. Edu- cation Illiterate 264 264 265 280

281 282 266 267 Study Study Zwarenstein et al.2000 CHWs Datiko & Lindtjorn 2009 Southern Ethiopia Lwilla et al. et al. Lwilla 2003 Rural Tanzania Mohan et al. 2003 Iraq Kamohan- et tanakul al.1999 CHWs Chaisson 2001 et al. 279 & Niazi Al-Delaimi 2003 (F) CHWs Chowdhury et al. 1997 (F) CHWs

153 mode Evaluation Evaluation The role of role The was CHWs evaluated and cure by treatment success TB. of evaluated by consistent rates. cure coverage Incentive Incentive (if any) 125 Takas 125 Supervision Supervised BRAC by paramedics Supervised area by manager Supervised nurses. by key compe-key tencies Developing patient compliance to TB treatment acid- The fast-bacilli- cases positive brought are treatment to immediately. Close monitoring treatment for compliance and improved rates. cure TB surveillance and treatment - - Role observed new patients the drugs duringswallow while months, 2–3 first the retreat patients undergoing the for observed were ment the initial After period. entire patients period, month 2–3 collected drugs once a week the home of CHW from people identifies CHW cough and with chronic sends samples of sputa laboratory a local BRAC to CHWThe microscopy. for received the drugs, provides the government. from free operational Provide support the program for implementation and would patient related also generate and data information all doses received Provided outside the health center was dosing Twice-daily hours. observed per week 6 days of course the throughout for also monitored treatment, on daily basis events adverse patient out- Supervised sur and provided treatment effects. adverse for veillance suspectedScreened and cases of tuberculosis cases. up positive followed Refreshers Refreshers / Ongoing training Certification Duration - - specially Training Training Content Didactic training Didactic of treatment the on illnesses common including tuberculosis ope to Trained under specificrate guidelines technical Didactic training provide to Trained close monitoring with children to multi-drug resistant tuberculosis Didactic trained in outpatient & sur treatment adverse for veillance multi to related events TB drug resistant Didactic and practicum includedtraining topics TB general knowledge about symptoms, infectivity, (cause, & treatment, transmission, DOT of roles prevention), and TB drugs, anti- observer, methods of self-protection. people with screen to Trained TB symptoms suspected Recruitment Recruitment Criteria Community locals who Women received training BRAC from healthVillage workers community health worker community health worker healthVillage workers Illiterate mostly unschoo- led Education 275 272 286, 269 268 270 Study Study Chowdhury 1999 (F) CHWs Ravichan- daran 2003 CHWs et Drobac al.2006 CHWs et Mitnick al.2003 287 CHWs Phomorphub et al.2008 CHWs Islam et al.2002 Rural Bangladesh

Global Evidence of Community Health Workers mode Evaluation Evaluation coverage Incentive Incentive (if any) Supervision Supervised twoby nurses and an administrator key compe-key tencies theImprove TB of care patients by - Role services health Provided &health education through home-based and outreach communities the in follow-up they serve. Mainly involved and in health promotion education, immunization, & sa of water improvement nitation, and family planning. Refreshers Refreshers / Ongoing training Certification Duration underwent underwent Training Training Content Didactic a training program teach to designed to them how the in care TB provide focusing community, and TB control on administration. DOT Recruitment Recruitment Criteria Selected through a written andtest interviews. Edu- cation 290 Study Study et Cavalcante al.2007 CHWs

155 HIV/AIDS Prevention and control Interventions Background HIV/AIDS alone has taken more than 20 million in nature 44, 294-300, 302, 304, 306 except for the lives, roughly 500,000 children younger than 15 Sanjana et al. where the training was based on years died of the disease in 2008, and children theory and practicum, related to concepts and accounted for 13% of new infections in 2004 methods of HIV counseling and testing and (640,000 cases).291 Women accounted for nearly then testing of skills under supervision of an 50% of more than 37 million people living with experienced counseling and testing (CT) pro- HIV worldwide and for 60 % in sub-Saharan vider.305 Certificate of completion of training Africa. The HIV and AIDS pandemic threaten the was provided to these peer counselors.305 The progress of many of the other MDGs, as it has TBAs in Wanyu et al. and Perez et al. were given severe health consequence for individuals, fa- additional training on Prevention of Mother to milies, and communities. At the same time HIV Child Transfer (PMTCT).302, 303 In Wanyu et al. and AIDS slower the nation growth and act to 99% of the women were tested for HIV and 88% damage social capital and lower GDP growth. In of the mothers and 86% of newborns were trea- some studies annual reductions of GDP growth ted with single dose of medicine.302 In another of about 2-4% have been noted in the countries study CHWs were trained to administer medi- highly affected by HIV.292 cations to patients in their homes as DOTS and also counsel the patient and contacts on stigma In resource-limited settings, the CHW approach related to HIV and TB300 while in Zachariah et has regained credibility in the last few years al. the CHWs were trained to counsel HIV/ AIDS through its support of HIV/AIDS care, in par- patients for adherence to anti-retroviral therapy ticular voluntary testing and counseling and (ART), anti-TB treatment and home-based care treatment adherence support for people on HIV activities.44, 295 In Koenig et al. patients were also and TB treatment.293 These emerging issues of provided with emotional support as a rehabili- multi-drug resistant TB and HIV make commu- tative measure, apart from administering DOT- nity health education and treatment adherence HAART.295 The CHWs in Ross et al. were trained support imperative. Therefore, in this section we in the social marketing of condoms294 while have assessed the role of community based in- those in Nasreen et al. worked for creating mass tervention and the quality of CHWs in providing awareness of HIV/AIDS in the community.298 In these interventions through evidence based Sox et al. and Mock et al. CHWs performed Pap researches from all parts of the world. Smear in the community for STI detection.296, 297 The CHWs, TBAs and the PCs all promoted Community Based Evidence preventive strategies294, 298, 304 against HIV and counseled for treatment adherence in the pre- We identified 17 studies which portrayed the sence of disease.44, 300 The role of TBAs studied role of CHWs in the prevention and control of in a cross-sectional survey reported that they HIV and STIs (Table 18A & 18B). The types of provided obstetric care to HIV positive pregnant health workers involved in these studies were women and HIV exposed newborn301 while in CHWs,44, 294-300 TBAs301-303 and PCs.294, 304- another study their level of awareness on princi- 306 Those recruited in these studies were either ples of PMTCT of HIV were tested.303 The female health workers,294, 300 community educators,304 sex workers enrolled as PCs in Benezaken et al. volunteers44, 305 especially those with some gathered data on the number of condoms sold background training in HIV/AIDS305 or female weekly with detailed mapping of the “prosti- sex workers.306 tution spots” in town, carried out preventive education assessment with 100 clients about The training imparted to them was didactic ‘prostitution as work’, their motivation to seek

Global Evidence of Community Health Workers Conclusion female sex workers, child prostitution and their The CHWs, TBAs and PCs proved to be an im- views on the project.306 In this study, the results portant tool for the dissemination of awareness of pre/post questionnaires show that there was related to HIV/AIDS. Their contributions can be a significant change in behavior after awareness estimated from the increasing number of mo- of HIV prevention methods, i.e., 95% from pre- thers and newborns getting medications and viously 75% of the clients had changed their from the change in sexual behavior resulting sexual behavior to prevent STIs/AIDS.306 from prevention awareness on STIs and HIV/ AIDS.

CHW Snapshot 15 Indonesia Community Health Workers Program overview Indonesia developed a framework in 1976 and started training and deploying community health workers with the title KADER in West Java, Indonesia as a pilot project. In kader method trainer train trainee in exactly same manner as they were trained by their trainer. By 1977 it was clear that kader should become an official component of Indonesian rural health system.307

Operational aspects and considerations They are trained on role playing using counseling cards to practice Community health Workers, Indonesia counseling or teaching precisely as trained village health promoter. Education Compulsory education These counseling cards include diagnostic algorithms and treatment Training few days methods. One kader usually worked with 10-15 households and the training lasted for few days to few weeks. Their task involved treat- Refresher periodic ment of number of common illnesses, weighing of children under Incentive none 5 years of age, nutrition, family planning and health education including environmental hygiene and sanitation, and development of community health insurance scheme and referrals of serious cases. 78

Coverage and effectiveness the survey in 1978 revealed that coverage of kader in Indonesia was up to 85% and 91% of the population had used kader for illness care during previous 18 months and 87% reported hat they had visited their home in last 18 months.78, 307

157 - - Outcomes in boys, occurred conversions HIV sero Only five ratio (intervention rate in girls the adjusted whereas comparison) versus was 0.75 [95% confidence interval 0.34, 1.66]. Overall at (CI) HSV2 prevalence 11.9% in male and 21.1% female were follow-up participants, ratios of 0.92 prevalence with adjusted 0.83, 1.32), respectively 0.69, 1.22) and 1.05 (CI (CI Knowledge regarding AIDS was in Knowledge regarding in interventioncreased arms. Overall, the mean proportionOverall, in the of women increased test participating villages who had a Pap During the 0.48 at follow-up. 0.44 at baseline to from the mean proportionssame periods, in the compa 0.39 (p= 0.37). 0.42 to from rison villages decreased to sexual behavior changed you you Have STD/AIDS? 111 75.0 132 94.7 < 0.001 prevent 29 done yet? had an anti-HIV test you Have use condoms 19.6 64 46.0 < 0.001 Did you 62 41.9 107 78.0 < 0.001 last week? Testing increased among women in both the among women increased Testing combined intervention 81.8%; P<.001) (65.8% to and media-only 75.5%; P<.001) groups, (70.1% to in the combined intervention more but significantly women in the more (P=.001). Significantly group obtained their first combined intervention group or obtained one after an interval test of more Pap 67.3%, (became up-to 45.7% to than 1 year date; respectively; P<.001) than did those in the media- 55.7%, respectively; (50.9% to only group P=.035) For all patients placed on ART with and without For community support, and alive those who were 96 and 76%, respectively continuing ART were (P < 0.001); death was 3.5 and 15.5% (P< 0.001) and on alive risks (with 95% CI) for relative The ART 1.26 (1.21—1.32), death 0.22 (0.15—0.33) Women at any age at any Women high risk population (sex workers) Participants Adolescents. Adolescents. > 14 years Aged General adult population Women HIV positive patients positive HIV 12 months 72 months Years of Years study 46 months 24 months 30 months 20 months - - Control arm did not Control additional receive services CHWs from Control arm Control No intervention in areas control Routine government health services prevailed com in addition to munity development and home-based care the program by initiated media-based education only Community in control Community in control arm did not receive community support Interventions : received information, education information, : received CHWs were trained for risk assessment, trained for were CHWs history taking, patient education, in and tests, examination, Pap breast disease tests sexually transmitted infor the use of condoms, promote trained to PCs were sex workers and their clients about STD/ ming female cost condoms at low also resold have educators AIDS. Peer sex workers special with suspected STD to and referred medical consultation at the project outpatient clinics for headquarters, weekly and to supervised activities. Experimental arm Experimental intervention components: The had four community activities; led, teacher sexual health education in peer-assisted 5–7 of primaryyears school; training and Supervision of health workers provide to sexual health services; ‘youth-friendly’ condom social marketing. and Peer Arm 1 and communication comprising that includes drama and video shows HIV testing, lessons on condom use, and STD treatment HIV spreads how seeking Arm behavior B: received education the same information, and communication combined STD management with improved health worker lay outreach plus media based education intervention)(combined Community in intervention arm community supportreceived from community health workers Table 18A: HIV/AIDS Prevention and Control Interventions – Characteristics of Included – Characteristics Interventions Studies and Control 18A: HIV/AIDS Prevention Table CHWs PCs Outreach Outreach worker CHWs CHWs CHWs CHWs Quasi RCT pre/post Study Study design cRCT RCT RCT Quasi RCT 306 304 297 294 296

44 Sox et Sox al.1999 Alaska, USA Benzaken et al.2007 Amazon, Brazil Study / Study country Ross et al.2007 Mwanza, Tanzania Mitchell et al.2002 Rural Uganda Mock et al.2006 Clara, Santa USA Zachariah et al.2007 Thyolo, Malawi

Global Evidence of Community Health Workers - Lay counselors provide up to 70% of counseling up to counselors provide Lay The servicesand testing at health facilities. lay for rates error lower revealed data review workers, in health care to compared counselors, registers. completing the counseling and testing HIV service 400 20 to from utilization increased PHC model after the implementation of HIV- advice HIV and AIDS 31% gave TBAs 31% of family planning 7% gave check baby Outcomes 76.4% of patients were 24 months of ART, After with compared successes, classified as t treatment When 64.1% at 12 months and 46.1% six months. of ART baseline examined the predictors we success, community health and all three support initiatives on ART effect afterhad a positive six outcomes patient characteristics whereas had little months, patients with the support Six months later, effect. or support group CHW, buddy, of a treatment the impact whereas of ARThad better outcomes, of two After years baseline health had diminished. community treatment, support as again emerged the most important success. of treatment predictor Of 4,055, about 99% (4,023) had heard the total (P < 0.001) higher A significantly about HIV. proportion (about 51%) said that of respondents then he/she should with HIV, infected if anyone not continue the occupational activities with the Majority population got others. of AIDS-aware TV (52%). BRAC by (72%) followed from information other by (94%) followed mentioned BRAC CSWs of information NGOs (68%) as the main source super receiving 120 patients were over a year, Within than 200 tuberculosis with ARVs. More vised therapy receiving DOTS. identified and began patients were - lay counselors lay General population postnatal care clients with a child months 12 than less Participants Patients with HIV Patients adults and adolescents, internal migrants, drug-users and bro thel-based CSWs general population - 1 months 12 months Years of Years study 36 months 3 months 14 months - Control arm Control Interventions Quantitative and qualitative data were collectedmeans of by data were and qualitative Quantitative semi structured interviews counselors in each all active lay from of the facilities and a facility manager or counseling supervisor services counseling and testing overseeing and clients. model depends on communityThe health workers (ART) who supervise therapy (CHWs) antiretroviral and communityincluding active case outreach, provide populations to marginalized finding and outreach contacts/relationship Information on the last delivery, obste care, HIV and AIDS, antenatal THP, TBAs, with and counseling on safe post-partumtric care, care, HIV exposed newborn babies. for infant feeding Experimental arm Experimental usually buddy’, ‘treatment identify a to requested are Patients of the patient’s who is aware someone living in their household, issues. assist him/her with adherence status and who is willing to the signs education sessions, buddy attends treatment The ART begin with the patient, and reminds consent to together and supports. the patient once ART Patient has commenced. also include the supportmobilization and empowerment of which groups, Peer-support PLWHA. fellow an AIDS patient by the facilitate patients on ART, for generally not exclusively are enhance or impede adherence, discussion of factors that may issues, and other psychosocial disclosure, events, such as adverse and education. health promotion for and also act as forums was initiated community-basedThe HIV/AIDS education program of HIV/AIDS among community awareness increase in 2002 to of HIV/ components include 1) mass awareness Five people. AIDS in the community including couple education, 2) awareness raising among adolescents in secondary as in schools as well HIV and AIDS among the high-risk 3) preventing the community, and drug-users, CSWs populations comprising brothel-based such as transport HIV among internal migrants, 4) preventing workers, and 5) supporting the people living with HIV/AIDS to and sexually transmitted HIV infection, of tuberculosis, Diagnoses visits; and detailed encounter the number of prenatal infections; health, etc.) reporting service by women’s (pediatrics, PCs CHWs TBAs Outreach Outreach worker CHWs CHWs CHWs - - cross cross sectional survey Cross sectional Cross sectional survey Study Study design Prospective Cohort cross sectional evaluation study retros pective observatio nal study 308 305 301 299 300 298 Sanjana et al.2009 Zambia Mukherjee & Eustache 2007 Maitha, Haiti et Pelzer al.2009 Town, Cape South Africa Study / Study country et Wouters 2009 al. state, Free South Africa Nasreen 2005 Distrcits (Khulna, Madaripur, Jamalpur, and Faridpur) Bangladesh et Walton al.2004 Haiti

159 Outcomes decline in injectingSignificant was risk behavior baseline for from at 18-month follow-up noted locations. outreach from the IDUs recruited 45% of TBAs interviewedTBAs knew the principles45% of of with known a woman and 8% delivered PMTCT Women year. status in previous HIV-positive less likely have to at home were who delivered than one ANC service more received or have to had contactcompared with a health centre (91.0% vs. in a health centre who delivered women who 63.6% of the women 72.6%; P < 0.001). Also, had the opportunity in a health centre delivered choose the place of deliveryto 39.4% to compared at home (P < 0.001). who delivered of women 8000 scale-up,over Inyear of program the first 1050 were and over HIV, for followed patients were HAART to was Adherence HAART. with DOT treated excellent: very were high, and clinical outcomes gain and with weight all patients responded than 5% and fewer functional capacity, improved side effects. medication changes due to required among a subset of patients load was tested Viral that 86% had undetectable showing viral loads The role of CHWs continues to grow as grow continues to of CHWs role The of extend care beyond their responsibilities and prevention and affected the infected education in the communities studied. 99% of all women were tested for HIV. 88% of women HIV. for tested were 99% of all women with treated mothers and 86% of newborn were single dose of medicine. pregnant women pregnant general population Participants HIV patients CHWs pregnant pregnant pregnant 3 months after 1 year scale up Years of Years study 18 months 36 months - Control arm Control No intervention in areas control - - Interventions Trained TBAs are defined as those who have received a short-received defined as those who have are TBAs Trained sector the modern to health care course of training through their skills in possession of a badge or upgrade [35] and were certificate which has been issued on completion of her training. TBA was that she of an untrained recruitment criterionThe for ago than a year not more a woman delivered should have of the survey the date trained. and was not formally before program in the contextHAART of a comprehensive was provided (TB), tuberculosis of HIV, disease (STD) the sexually transmitted health services and women’s and prevention, project, treatment the medical facility was At each site, year. in the first sites at four and a network as needed, hired were additional staff renovated, (community health workers)of accompagnateurs was established serve villages to the surrounding throughout as a link with the directly observed (DOT) provide and to treatment community, Experimental arm Experimental workers IDUs from outreach recruit The various interven and provide the street Apart level. the tions at the street from face-to-face education about acquired immunodeficiency(AIDS) syndrome and its transmission, these individuals on with information provided are Bleach and decontamination of syringes. the outreach distributed by condoms are on medical and social pro Advice team. blems and service also are information workers and outreach facilitate provided, the use of addictionservices. treatment been trained as com individuals have of lay hundreds munity home-based health workers provide to care sick or dying HIV/AIDS clients in rural areas. to In 2002 TBAs were trained to provide prevention to mother to child mother to to prevention provide trained to were TBAs In 2002 performingHIV transmission services, testing, including counseling, and administration of single-doseoral rapid HIV tests, Nevirapine be taken their newborn. to in labor & to women, HIV positive to TBAs CHWs Outreach Outreach worker CHWs CHWs TBAs Compa- cross rative sectional trained TBA vs. Untrained TBAs descriptive Study Study design cross sectional cross sectional cross cross sectional study

303 302 310 295 309 Koenig et al. 2004 Haiti Study / Study country Kumar et al. 1998 Madras, India Johnson & Khanna 2004 Nyanza, Kenya Perez et Perez al.2008 Mashonaland East, Zimbabwe Wanyu et Wanyu al.2007 rural Cameroon, Africa

Global Evidence of Community Health Workers mode Evaluation Evaluation The The was impact evaluated in a cohort of 9645 adolescents. Evaluated houseby houseto & KAP serological surveys coverage Incentive Incentive (if any) Incentives Incentives included rainboots, rain coats, seed grain, fertilizer farms, for &bicycles. Supervision supervised quarterly Supervised aby community nurse. - key compe-key tencies community- based condom promotion Inculcated HIV and STD treat ment seeking in thebehavior community services PHC and HIV counseling Creating and awareness counseling of HIV - Role Community mobilization annual youth by followed around focused health weeks competitions interschool and performances local by twice-yearly groups, youth at health health days youth and quarterlyfacilities, video discussions to linked shows all open to that were community members. information, Provided education & communication comprising drama and video lessons includes that shows HIV testing, on condom use, and STD HIV spreads how seekingtreatment behavior visits house-to-house Made ‘home-based equipped with a drugs basic containing kit’ care & supportive condi material for tions including diarrhea, fever, common skin conditions & oral that signs’ ‘risk Detected thrush. a community to merit referral nurse or a health facility AIDS HIV/ of awareness Mass in the community including adolescents education, couple as well as schools secondary in preventing in the community, HIV and AIDS among the high- risk populations comprising and CSWs brothel-based HIV preventing drug-users, among internal migrants, such as transport workers, people the to supporting and living with HIV/ AIDS Refreshers Refreshers / Ongoing training Certification Duration 1 week 2weeks - - Table 18B: Characteristics and description of outreach workers and description of outreach 18B: Characteristics Table Training Training Content trained in the social marketing of condoms. of family provision The services planning case improved and management of STI, and also in the provi friendlysion of youth sexual health services. training Didactic in giving Trained lessons on condom general HIV- use, andinformation and HIV spread testing, in local STD treatment language Luganda. theoretical formal curriculumThe training various covered aspects linked to adherence HIV/AIDS, ART, counseling for treatment anti-TB and home-based (HBC)care activities Didactic, used flip charts and videos. Correct knowledge re HIV/AIDS, STI. garding Recruitment Recruitment Criteria five to Four peryouth village were elected by their peers to Two health four workers per government facility Community educators Community volunteers Education 294 304 44

298 Study Study et Ross al.2007 PCs CHWs Mitchell et al.2002 PCs et Zachariah al.2007 CHWs Nasreen 2005 CHWs

161 - mode Evaluation Evaluation CT record keeping was asevaluated a qua lity assurance measure. data maintained were TBAs by checkedcross healthby facility staff data maintained were TBAs by checkedcross healthby facility staff coverage Incentive Incentive (if any) Supervision Supervised anby experienced CT provider. nurse supervisor nurse supervisor - - - key compe-key tencies AIDS quality and treat care ment of STIs, TB treatment Critical inter face between patient, community and the CBS. care Obstetric of HIV posi pregnant tive andwoman HIV exposed newborn HIV counseling and, testing administration of drugs Role of tuberculosis, Diagnoses and sexuallyHIV infection, the infections; transmitted visits; number of prenatal and detailed encounter reporting servic by post-test and pre provided HIV counseling as well as HIV testing Supervised antiretroviral (ART)therapy and provided community outreach, including active case to finding and outreach populations. marginalized HIV counseling, they provided performed rapid oral fluid andHIV antibody test, Nevirapine administered the mother and baby, to Refreshers Refreshers / Ongoing training Certificate on provided successful completion of both theoretical and practical training Certification Duration 2 weeks theory and 4weeks practicum - on

Training Training Content Theory and Practicum component classroom of the training includes instruction as role-playsas well & case studies for understandingbetter of the concepts of methods and HIV counseling and Practicum testing. included counseling skills&testing under of supervision the an experienced CT provider. Training Didactic administer trained to medications to homes their in patients provide (DOTS); as education prevention to communities, to & stigma minimize the clinic to refer to TB possible HIV and contacts or those at infection. risk for Not trained in this study rather their towards attitudes of HIV HIV and care mother andpositive studied. newborn were Didactic training additional training on was given and HIV PMTCT Didactic training side-effect manage ment o and referral - Recruitment Recruitment Criteria selected among volunteers preference to was given those with ofsome level background training in HIV/AIDS. Community outreach workers from recruited existing lists traditio the of nal health practitioner office TBAs existed in community was selected Edu- cation Literate 299 301 302 305 300 Study Study et Walton al.2004 CHWs Sanjana et et Sanjana al.2009 Zambia PCs Mukherjee Eustache & 2007 CHWs et Pelzer al.2009 TBAs et Wanyu al.2007 (F) TBAs

Global Evidence of Community Health Workers mode Evaluation Evaluation coverage Incentive Incentive (if any) $1500 Supervision Vietnamese aswoman coordinator key compe-key tencies of Awareness of principles of HIV PMTCT HIV/TB worker Preventive health education and early detection and of Breast cervical cancer. Role attitude knowledge, on Tested to and practice with regards HIV/AIDS especially in regard and women pregnant to the HIV exposed newborn chart flip the used LHWs the 20-minute to 15- a give to about cervicalpresentation testing cancer and Pap and distributed booklets, posters, cards, reminder calendars & reminder ART for support Community patients in the public sector that continuum a represents formalized more from stretches paid) community(even health informal to workers (CHWs) activities, including voluntary people livingsupport for groups or with HIV/AIDS (PLWHA) members of their social act to volunteer who networks The buddies. treatment ARV as have initiatives these of roles are but time, with broadened the generally oriented towards and supportcare of PLWHA, rather than AIDS prevention of health or the promotion examination, Pap Breast smears and other STD tests, Refreshers Refreshers / Ongoing training Certification Duration 3 2 sessions, hours each 22 hrs didactic Instructions, 16 hrs practical, 16 hrs of field supervision Training Training Content Trained for procedures procedures for Trained LHW to and approaches received LHWs outreach Vietnamese-language booklets and charts flip use in their outreach to of causes the explain to the and cancer cervical procedure. testing Pap Didactic, practicum and work.field instruction on risk assessment, history taking, patient education, 16 follow-up; &indicated hours of skills acquisition examination, in breast in and STI tests tests, Pap outpatient hospital the department; and up 16 hours of fieldto supervision in their clinics village respective within 1month of training Recruitment Recruitment Criteria 18 Above of age years from Person patient household Education 308 303 297 296 Study Study et Perez al.2008 (F) TBAs et Mock al.2006 (F) CHWs et Wouters 2009 al. etSox al.1999 CHWs

163 mode Evaluation Evaluation coverage Incentive Incentive (if any) Supervision key compe-key tencies HIV counseling - - Role data gathering on the number of condoms sold of mapping detailed weekly, in town, spots” “prostitution education asses preventive sment interviews with 100 sample) clients (convenience as work”, “prostitution about female seek to motivation their sex workers, child prostitution, and their views on the project the visits, daily the During ob accompagnateurs serve the patients taking their and they thenmedications, dose second the leave either later of medication or return that dose as well. deliver to Refreshers Refreshers / Ongoing training Certification Duration weeks 1-2 training - - - trained Female Female Didactic concerning the impor tance of confidentiality Support emotional & Also the patients. for the regarding training & presentation clinical & HIV of management including the pro TB, medications of use per & their side-effects Training Training Content Didactic ease workers, sex communicative on abilities and interest in the prevention practices planning sex other the among workers of the town and their clients CHWs the of number A HIV!AIDS the for recruited Home-Based Care previously have program with other been CHWs such organizations, the for Association as and SupportFormation of Development (AFAD) and CARE Kenya- that workorganizations with environmental com sanitation, educate munities about proper sanitation, and help to diseases treat and prevent cholera, (such as measles, In infections). and eye home-based training care learn the CHWs sessions, a variety of information methods HIV/AIDS, about care and prevention, of of management and the sick and dying. Recruitment Recruitment Criteria selected from community the from for health staff Edu- cation higher oflevel education 295 306 310 Study Study Benzaken et al.2007 PCs (F) Johnson & Khanna 2004 et Koenig 2004 al.

Global Evidence of Community Health Workers Mental health Interventions Background The MDGs practically define health efforts in the Lester et al., were psychology graduates.315 The 21st century, but they apparently ignore non- training content was mostly didactic,312, 314, communicable diseases such as mental health. 316 while the modality was didactic and practi- In developing countries, conditions related to cum in Lester et al.2007315 and the one used in mental health rank the top among all as physical Barnet et al. was didactic and interactive, using health also relies on mental fitness of individual. role-plays, play activities and social and cultural Mental health alone is the most important cause outings in the community.313 The disaggrega- of sickness, disability and premature mortality ted analysis showed training with didactic and and it contributes to the increased chances of interactive mode had an impact on the outco- reducing the incidence of mother breastfee- mes of mental health313 as compared to those ding their children and decreased likelihood where the mode of training was only didactic. of seeking out care for physical illnesses.311 Although mental health has not been given its In most of these studies CHWs were trained due significance in chalking out the Millennium on content related to neonatal behavioral Development Goals, but it has clear implications assessment,312 psychological counseling for in achieving targets like eradication of extreme depressed mothers,314 parenting behavior313, poverty and hunger, reduction of mortality in 314, 316 and mental health counseling skills.315 children and improvement of maternal health. Some of them provided individual as well as family counseling.313 In this way they played The complete absence of mental health from an important role to prevent mothers from the MDGs reinforces the position that mental depression which would eventually affect both health has little role to play in major health the maternal and child healthcare promoting development agendas. In this review we have psychosocial development of children.312 particularly included studies that have delivered mental health interventions to understand the They also provided rehabilitative support to the role of outreach worker in community mental already depressed mothers314 and to the peo- and psychosocial health. ple with common mental health problems.315 Training of CHWs for mental health counseling Community Based Evidence was meant to develop their core competency in psychological counseling,312, 314, 316 howe- We found paucity of studies which have applied ver, Morrell et al. study mentioned that their mental health interventions in the community; CHWs were awarded with national vocational therefore we merged studies specifically focused qualification at the end of their training316 but on mental health of the community along with even that extensive training failed to create an those that promoted parent child interaction impact on improving mental health outcomes and bonding. We found 8 RCTs, 1 quasi-RCT and at six weeks of intervention. two cross sectional studies in the section (Table 19A & 19B). Supervision of the CHWs was done by the community non-profit organization in Barnet et al.313 The community health workers involved in the however in Lester et al. CHWs attended 1 hour interventions of mental health were mostly of individual clinic supervision every week from residents of the local village312, 313 however, a psychologist and also had ongoing training non-residents were also involved in an interven- on a daily basis.315 This ongoing training was tion by Rehman et al.314 These CHWs had a few conducted by the support groups as in service years of schooling312, 314 while those trained in curriculum refreshers for the CHWs in Barnet et

165 al. 313 When level of supervision and provision by re-interviewing the mother,312, 314 some of refresher in Barnet et al. was compared with mothers were issued questionnaires at 6 weeks other studies (in which proper supervision and and 6 months postnatal.316 The CHWs in Lester refresher training was missing), it was found that et al. intervention were evaluated from patient it had a significant impact on improving paren- primary care records.315 However none of these ting behavior, however no improvement was evaluations made a reinforcing impact on the seen in parenting stress or mental health.313 outcomes of mental health interventions.

Most of the CHWs worked as volunteers in the interventions reviewed,315 however the ones who participated in Barnet et al. were paid $200 per year and this showed a positive impact on the mental health outcomes in the community.

Several methods were used to evaluate the performance of the CHWs working under the domain of mental health. Some were evaluated

CHW Snapshot 16 Home Based Care Services – Tanzania Program overview Home based care model came into existence in Tanzania as a result of pilot project implemented during 2005/2007 in 57 communities. The prime aim of this program is to identify practical solutions to specific problem that older carer face. The model is a community based approach to support older care givers and is based on components to collect baseline information, training of old carer for home based care, initiating support groups for home based care, peer counselor, and for self advocacy, and linking them to support services 318. Operational aspects and considerations Home based carer was selected based on their willingness to work Home Based Carer, Tanzania and participate in community activities and who is acceptable to community. The main component which is focused during selection Education basic level of literacy is that they should have a previous experience of caring to sick child Training 21 days and have good interpersonal skills and ability to provide feedback and reports. They are trained on the national AIDS control program curriculum for training community home-based care services providers as antiretroviral and DOTS. They were trained on general awareness about HIV/ AIDS, parenting skills general hygiene and sanitation, communication and negotiation skills, psychological support skills, reducing pain, nutritional needs and counseling skills, and proper and timely referrals. Source: Scholl 1985318

Global Evidence of Community Health Workers Conclusion The impact of mental health in the development of a society cannot be underestimated. It is essential especially for the maternal and newborn healthcare and adequate growth of the children. The interventions reviewed in this regard have shown that the training modality especially those trained in classroom teaching along with interactive sessions had a positive impact on their results.313 Also external evaluation, financial incentives and regular refresher training sessions for the CHWs can help achieve desired health objectives.313, 315

CHW Snapshot 17 Nicaragua Brigadistas Program overview In 1981, Nicaraguan ministry of health began training community health workers called as brigadista de salud, or health brigadier. They trained two types of workers one called as “jornada brigadistas” who were recruited to provide manpower for the national health campaigns and the second group was called “primary health care brigadister” and they perform variety of curative and preventive tasks 318. Operational aspects and considerations these workers are typically chosen from community in which they Nicaragua Brigadistas work and given a modest amount of training and perform variety of preventive, promotive and sometimes curative tasks and are ultima- Training few days tely accountable for community. Some workers works full time while Supervision nurse auxiliary other work as part timer. Incentive paid

Coverage and effectiveness in 1983, jornada workers found in all 97 health areas while PHC workers were found in 33 of 97 health areas. Source: Scholl 1985318

167 - - - Outcomes 97 (23%) of 418 and 211 (53%) 400 6 months, At mothers in the intervention groups, and control major depression met the criteria for respectively, 0·22, 95% CI 0·14 to odds ratio (OR) (adjusted weight-for-age in differences The 0·36, p<0·0001) infants in the for Z scores and height-for-age at 6 months not significant were two groups −2·16, p=0·3, −0·86, p=0·7 and −2·03 vs. (−0·83 vs. −0·8, p=0·3 or 12 months (−0·64 vs. respectively) −1·36, p=0·07, respectively). and −1·10 vs. There was no impact of interventionThere on maternal mood signifi demonstrated the home visitation group up at follow- scores behavior parenting cantly better no (P=.01) but showed group than did the control or mental health. stress in parenting differences found were of harsh parenting levels Lower among mothers in he enhanced home visitation condition than among those in the unenhanced of Prevalence conditions. home visitation or control of mothers who were abuse (percentage physical duringyear was 26% in the control abusive) the first condition, 23% in the unenhanced home visitation condition, and 4% in the enhanced home visitation in families that greatest were condition. Benefits A linear pattern of child. included a medically at-risk fea for child health; as program found benefits was for child health increased benefits added, were tures At six weeks there was no significant improvement improvement was no significant there six weeks At in the intervenin health status among the women in the intervention women The group tion group. verywere satisfied with the supportworker visits. Patients in intervention practices had a higher mean Patients of general satisfactionlevel than those in control of 8.3, scores group between practices (difference 95% confidence intervalto 15.3, P = 0.023). = 1.3 in mental health did not differ two The groups or use of the voluntary scores symptom sector. Postpartum mothers aged Adolescents at > 12-18 years 28wks gestation or who had delivered in the a baby past 6 months at Families riskmoderate of Child abuse, expecting the birth of a child or having given recently birth a child. to Participants Married women (aged 16–45 years) trimester in their 3rd with perinatal depression aged >17 women delivered years baby a live 18 to 65 years 65 years 18 to of age with a of a diagnosis new or ongoing common mental health problem 6 months 42 months 24 Years of Years study 24 months 35 months Women in control area area in control Women CHWs by not visited were area in control Women CHWs by not visited were did not group Control interventions receive Control arm Control In group the control untrained health workers made an equal the number of visits to mothers depressed Routine service provided arm control to No intervention for group control - Interventions Table 19A: Mental health Interventions – Characteristics of Included – Characteristics 19A: Mental health Interventions studies Table Interventions were delivered in women’s in women’s Interventions delivered were hour. an for lasted session each and home In the interventions they tried improve to of children development psychosocial the from recruited were Volunteers community implement and trained to curriculuma parenting during weekly Each volunteer home visits. with one teenager. was paired that servedHome visitors as facili in making assisting parents tators, a causal appraisal of the possible giving an identified care for reasons a strategic and in designing problem Conducted the future. plan for 20 home visits in one year Experimental arm Experimental primaryIn the intervention group, deliver trained to health workers were The intervention.the psychological intervention of a session consisted in the last every 4 weeks for week sessions three month of pregnancy, in the first postnatal month, and nine 1-monthly sessions thereafter 10 home visits in the first Up to three postnatal month of up to a communityhours duration by postnatal support worker. in intervention areas patients were in intervention patients were areas with anxiety management for provided people with common mental health assessment, information, problems, referral onward if required screening the voluntaryto sector and support for and mental health promotion. self-help, CHWs CHWs CHWs Outreach Outreach worker CHWs CHWs CHWs Quasi RCT iRCT RCT Study Study design cRCT RCT cRCT 319 315 312 313 314 316 Cooper et Cooper al.2002 Khayelitsha, South Africa Barnett et al.2002 Baltimore, USA Bugental et 2002 al. California, USA Study / Study country Rahman et al.2008 Gujar Khan & Kallar Syedan, Pakistan Morrell et al.2000 Netherlands Lester et Lester al.2007 Birmingham, England

Global Evidence of Community Health Workers Both home-visited women and controls made Both home-visited and controls women Home-visited women child care. good use of well- (p = 0.002), use of sick-child care made greater greater The most of which was appropriate. among was concentrated use of sick-child care with or high family stress, mothers with moderate had closer relationships. whom home visitors Outcomes did not interventionThe groups and control at measures on the psychosocial significantly differ made by were Comparisons at 34 weeks baseline. The analysis of covariance using the baseline scores. stress had lower at 34 weeks intervention group (means 16.5 vs 18.4, p = group than the control scores trait anxiety (means 35.2 vs 39.4, p = 0.04) 0.02), lower mood (means 6.6 vs 8.1, p = 0.02). and less depressed the intervention was higher for Self group esteem interventionThe (means 34.9 vs 32.5, p = 0.008). smoking alter failed to but the intervention women (p = did report use of community more resources less likely skip to 0.02) and were meals (p = 0.03) on effect program overall was no significant There and use of for desire risk mothers’ or on at-risk any was a There community services risks. address to reduction of poor mental in one measure significant health at one agencyreduction and a significant alcohol use and repeated in maternal problem partnerincidents of physical families violence for Home in the model. ≥75% of visits called for receiving risks and parental recognize often failed to visitors seldom linked families with community resources. Mothers that were Mothers that were expecting first or second child, 20-26weeks were were pregnant, at least 16yrs. Participants women recruited recruited women an antenatal from clinic and general practice surgeries < 20 who were gestation weeks & either single or in a relationship the partnerwhere was unemployed at risk Families child abuse for and neglect 14 Years of Years study 8.5 36 months - Control arm Control did not group Control interventions receive did not group Control interventions receive routine Received maternity and pae including diatric care nutrition and social services, occasional public health visits by nurses and delivery at university hospital - Interventions Experimental arm Experimental in the intervention group Women weekly calls telephone received All their pregnancy. throughout interviewed were initially and women gestation. 8 check-off at 34 weeks be askedquestions to weekly. health care to women Referred was medical problem if there provider seek to and encouraged women community assistance from agencies. an indivi guided by Home visits were dual family support plan(family goals them). Supervisor achieve to and steps identify keyand home visitor issues stress examining the family’s by checklist assessment and concerns. of concern They decided what areas the home visitor for appropriate were with the family in addition address to the family. by goals nominated to and supervision home visitor The the goals at least every to 2 referred by updated the goals were months, and family everythe visitor 6 months. develop sought to Home visitors with families, trusting relationships emotional primarily Provided mothers. and support mothers, to listening by Provided understanding. showing help eg rides clinics, to concrete information provided babysitting on pregnancy and infant care, and enhanced mothers informal social networks helping formal by mothers access community resources child stamps, food such as housing, what to They responded etc. care, cope they needed to mothers felt discussed and encouraged better, contraception, talked about infant mothers to and listened feeding description of childs minor illnesses CHWs Outreach Outreach worker CHWs CHWs RCT Study Study design RCT RCT 320 321 Dawson et Dawson 1989 al. USA Study / Study country Bullock et 1995 al. New Zeeland Duggan et 2004 al. USA Hawaii,

169 - - - Outcomes intervention ef l)ad a significant only professional Interventionfect, anxiety state successfully lowering a value comparable with the moderately to levels Changes in anxiety for anxious mothers. levels minimal an interventionmothers not receiving were In the high anxiety sub-groups, there the study. over those anxietywas a 19% reduction in state for levels intervention, a 12%reduc a professional receiving interven a non Professional those receiving tion for A planned tion and a 3% reduction in the controls. contrast analysis determined that only professional intervention intervention effect, l)ad a significant anxiety a value state to successfully lowering levels anxious mothers. comparable with the moderately signifiant parental parental signifiant in the care intervention group. (p=000001) Participants Primiparous women women Primiparous on screened (were anxietytrait and state in the measures post-partum period pregnant pregnant women Years of Years study 12 months - Control arm Control were groups Control 12 for also reviewed months after being randomly selected. - Interventions Resource mothers provided parenting parenting mothers provided Resource experience and knowledge local to associated hazards community reduce to with rural adolescent pregnancy Experimental arm Experimental on screened were women Primiparous and trait anxietyin the state measures post-partum period; sub-groups of hi anxious ghly anxious (n =89), moderately (n = 29), and minimally anxious 29) derived and subsequently mothers were high-anxietyThe mothers interviewed. professional a to assigned randomly were intervention, a non-professional and to was reviewed intervention their progress 12 months. the following over CHWs Outreach Outreach worker CHWs cross cross sectional Study Study design Observa- tional Prospective Cohort 322 323 Heins et al. Heins et al. 1987 Carolina, USA Study / Study country Barnett & Parker 1985 Sydney, Australia

Global Evidence of Community Health Workers - - mode Evaluation Evaluation Evaluation done by re-inter viewing the mother. question were naires six at issued andweeks six months Effectiveness evaluated patient from care primary records Evaluated the from view mother’s coverage Incentive Incentive (if any) Voluntary $200 per year - - Supervision received of hour 1 individual clinical super vision each a from week psychologist Supervised theby commu nonprofit nity organization - key compe-key tencies inCounseling the perinatal depression Competence of in care maternal infant young and children mental health counseling emotional support and counseling Provided individual and family counseling, case mana gement, and coordinated linkages with community when agencies problems identified were - - Role sessions with mo Conducted inther every 4 weeks for week the last month of pregnancy, rst fi the in sessions three nine and month, postnatal 1-monthly sessions thereafter first the in visits home 10 postnatal month of up to hours duration three defined in Roles were with the national accordance Liaised with primaryguidance. statutory members, team &care & services, sector non-statutory patients for services specialized managed in PHC who are advices specific Gave on aspects of infant sleep regi management(e.g. men, crying, during feeding) and postnatal visits antenatal home of hrs 1.5 weekly made andvisits with the teenager other family members until with first birthday, the child’s continue untilan option to second birthday. the child’s Refreshers Refreshers / Ongoing training ongoing training on a release day basis. Support groups conducted as as in-service curriculum refresher - achieved their national vocational qualification Certification Duration 8 week plus12 weeks prac 3 weeks tice-based induction 16 hours - - trai using Table 19B: Characteristics and description of outreach workers and description of outreach 19B: Characteristics Table Trained in the the in Trained Training Training Content Didactic training the psy deliver ned to interventionchological mothers depressed to Didactic children of young care and intra-personal skills and Didactic Practicum included all Training the knowledge, skills, and attitudes required in their job description. Training Didactic Neonatal Behavioral Schedule Assessment the sensitize to infant’s her to mother individual capacities & sensitivities. Didactic training and counseling skills development through of a mentoring and supportiverelationship. discuss to Trained infant development, in age-engaging feeding appropriate activities,or play role-playing age- discipline, appropriate and taking social and cultural outings in the community. - - Recruitment Recruitment Criteria Non residents of that village psychology graduates Community workers older than 21 years recruited the local from community announce via ments, newspaper advertise and ments, churches. Screened their criminal background Education Secondary school graduates Limited schooling

316 315 313 Study Study Rahman al.2008 et 314 CHWs Morrell et al.2000 CHWs et Lester al.2007 CHWs Cooper et al.2002 312 CHWs et Barnet al.2002 Baltimore, USA CHWs (female)

171 mode Evaluation Evaluation coverage Incentive Incentive (if any) Supervision key compe-key tencies - Role in the unenhanced Parents home visitation condition home visitation received Home the with consistent (Duggan visitation program with2004) supplemented regarding information existing community services. in the enhanced Families informa condition received tion on existing community services, combined with the in used methods Start andHealthy program a brief attribution ally based discussion problem-solving visit each of start the at by appraisal followed (causal appraisal). problem-focused as served visitors Home parents assisting facilitators, in making a causal appraisal for of the possible reasons giving an identified care a and in designing problem the future. plan for strategic intervention Professional acomprised assistance from social worker experienced in working with mothers and each social workerchildren, six subjects. being Allocated Refreshers Refreshers / Ongoing training Certification Duration 30 hours - - Training Training Content the social Guidelines for worker suggested the to: attention of support;provision specific anti-anxiety the pro measures; motion of self-esteem and confidence; a reduction in intensity mother-infant the of interaction (if appro priate), and promotion of mother father and father-child interaction. covering Training infant birth, pregnancy, nutrition, safety, care, child development, resources community and family life. Were trained in Were home methods the National through Teachers as Parents by Trained program. Teachers as Parents in National Center Two City California. trainers: one Caucasian and one Latino Recruitment Recruitment Criteria Social workers Edu- cation 12 grade 319 322 Study Study Bugental et 2002 al. Barnett Barnett & Parker 1985 Dawson 1989 et al. 321 Source: Scholl 1985318

Global Evidence of Community Health Workers Interventions related to Non- Communicable Diseases (NCDs) Background Non-communicable Diseases (NCDs) such mostly locals from the community.296, 327-332 as heart attack, stroke, cancers, diabetes, and The CHWs in Thompson et al. were either diabe- common injuries account for the vast majority tic themselves or had a family history of diabetes of all global deaths, but still do not lay in the and were required to have good interpersonal domain of millennium development goals. skills to participate in the intervention.329 Those Several of the MDGs are acting as determinants recruited in the Gary et al. intervention were all of NCDs like lower levels of education leads local high school graduates, but had no prior to engagement in unhealthy life style and in training in health care327 while those in the turns results in developing NCDs.324 Likewise, Sankaranarayanan et al. were university gradua- environment health hazards are associated with tes.333 In another study from Pakistan CHWs causing respiratory diseases and some types had 8 years of schooling and were recruited in of cancers. NCD also impose severe costs on the pattern of how CHWs are selected for na- national health-care systems and economies tional LHW program.328 The training modality as a whole.325 NCD prevention is still not featu- used in all of the studies was didactic.327-335 red as a priority in most national public health The CHWs in the Krieger et al., Jafar et al. and agendas. It is therefore essential to move from Gary et al. interventions were trained to counsel programs to treat NCDs to risk factor prevention patients to adopt preventive care and adhere to and initiatives for health promotion at every le- the treatment of hypertension.327, 334 328 They vel (individual, family, community and national). were taught the risk factors for cardiovascular Thus, primary control and prevention of NCD diseases and trained to conduct blood pressure risk factors could help strengthen, rather than measurement. 327, 334 328 The CHWs involved in compete, with health-care interventions for Fedder et al. intervention were trained in case infectious diseases and reproductive health.326 management of diabetes, like glucose monito- During our review we found many studies in ring, medications, emergencies and complica- which CHWs focused delivering interventions tions, besides their training in the management related to prevention of NCDs and majority of of hypertension.330 In Thompson et al. the them were from developed countries. Most of CHWs were given 30 hours training in the mana- the NCDs driven interventions are targeted in gement of diabetes mellitus and depression329 developed countries as they have already or are while Ingram et al. intervention focused on trai- in phase of achieving targets related to MNCH ning the CHWs in inculcating self-management and communicable diseases. behavior in the diabetics.332 In another study reviewed, the CHWs were trained in prevention Community-Based Evidence strategies against lead poisoning.331 In Solomon et al. the CHWs were trained in the diagnosis of We also found the role of CHWs in delivering in- trachoma, its treatment with azithromycin and terventions related to other non communicable proving information of the possible side effects diseases like hypertension, diabetes and cancer. of the drug.335 on the other hand in Forst et al., We reviewed 25 studies that came across while farmers in the field were given education rela- searching for studies particularly related to ted to protective eye care measures and were MDGs and included in this review to evaluate distributed eye wear. 337 their dynamic roles in provision and management of non-communicable health problems The educational level333 328 and the training (Table 20A & Table 20B). content both seemed to have a positive impact on the outcomes of all the interventions The CHWs recruited in these interventions were reviewed. In Thompson et al. having a personal

173 experience of managing own illness or so- pression,329 lead poisoning,331 oral cancers,333 meone else in the family with diabetes resulted and protective eye care in farmers.321 They in producing highly significant results through also offered therapeutic service as in case of decreasing the levels of HBA1C in the people trachoma where they treated the disease using under their coverage. When educational level azithromycin.335 of CHWs in Gary et al. and Sankaranarayanan et al. were compared with studies which did Most of the studies under review of NCDs had not mention education level of CHWs at all, we CHWs, who worked as volunteers, however found no added advantage in the outcomes those in Fedder et al. and Jafar et al. were given achieved, in fact in studies where CHWs were stipends.330 328 However the financial incentive selected base on their educational level failed or the lack of it did not seem to have any impact to show any impact on their study outcomes. on the outcomes of these interventions. On the other hand, regular bi-weekly supervi- Conclusions sion of the health workers not only served as on-going training but also provided an oppor- The CHWs can play a great role in promoting tunity to assess the problems encountered in preventive healthcare strategy in the commu- the development of health seeking behavior of nity. The outcomes of interventions make it the community.329, 330 This contributed to the evident that they can counsel patients towards significant reduction in the glycosylated hemo- health seeking behavior and provide them mo- globin of the diabetics in the community329 and tivation necessary for treatment compliance. It in the decline of total emergency room visits by is therefore imperative to the achievement of 40%.330 MDGs that the CHW can be deployed to the regions farther from the reach of physicians. The role of CHWs in relation to the MDGs was oriented towards promotion of health seeking behavior in the community. They promoted preventive strategies with regards to hypertension, 327, 330, 334 328 diabetes,329, 330, 332 de-

CHW Snapshot 18 Nigerian Community Health Workers Program overview In 1982, the institute of child health and primary health, Lagos designed a primary health care service model for rural population. The model decided to base the services in the villages by developing a cadre of volunteer village health workers who will be utilized for referral. Supply and supervision. Home Based Carer, Tanzania Operational aspects and considerations Education no criteria Initially village health committees were developed and those com- Training 3 weeks mittees nominated volunteers for training in accordance with criteria Refresher 2 refresher courses designed. These volunteers were recruited if they managed to show a permanent residency in that community and had a responsible Supervision community health assistant attitude. The courses covered curative, preventive and promotional (mid level PHC worker) activities. Incentive sales of drugs Source: Weerakon & Jiffry 1989336

Global Evidence of Community Health Workers CHW Snapshot 19 South African Community Health Workers Program overview Implementation of community health workers program initiated in 1970s and 1980s following alma ata declaration. In 2002 the year was marked in the history o South Africa as the year of volunteer and a rapid growth was seen with the range of lay workers, home based carer, lay counselors, DOT supporters etc. and term community health workers was introduced under the umbrella concept of lay workers in the health sector and national CHW policy framework was adopted in 2003338 where these workers were all brought under the banner of an Expanded Public works Program (EPWP). In 2006, training standardization and accreditation of CHW came into existence.

Operational aspects and considerations Recruitment and selection occurred mostly through calls for volunteers and sometimes via community-based organization and Community health Workers, South Africa often through involvement of health facility staff. They are expected Supervision nurses to work half a day and 20 hours per week. In 2005/06 the national Incentive R1000 per month department of health allocated USD 10 million for their training and involving them in HIV/AIDS and TB care and support activities. 14 CHWs were linked with each primary health facility center in their community. Source: Schneider et al. 2008 339

175 Global Evidence of Community Health Workers Outcomes up by follow up increased enhanced follow The Follow usual care. to 39% (95% CI: 14- 71% Relative 65% Of by completed in Participants up visits were intervention 47% in usual care. to arm compared Compared to the Usual care group, the NCM group, the Usual care to Compared had modest declines and the CHW group group (0.3 and 0.3%, respectively), in HbA1c 2 years over had a and the combined NCM/CHW group decline in HbA1c (0.8%. P _ 0.137). After greater follow-up and/or baseline differences adjustment for showed the combined NCM/CHW group time, in triglycerides (_35.5 mg/dl; P _ improvements to compared blood pressure, 0.041) and diastolic (_5.6 mmHg; P =0.042). group the usual care was significantly blood pressure in systolic decrease (10.8 mm Hg in the HHE and GP group greater 12.8 mm Hg]) than in the GP-only, [95% CI, 8.9 to (5.8 mm or no interventionHHE-only, groups 7.7 mm Hg] in each; P < 0.001). 3.9 to Hg [CI, in the cancer registry, Of the 63 oral cancers recorded in the and 16 were in the intervention group 47 were of 56.1 and yielding incidence rates group, control in the intervention20.3 per 100,000 person-years program The respectively. groups, and control detectionsensitivity of oral cancer was 76.6% and for value was the specificity predictive 76.2%; the positive 72.3% In the intervention group, oral cancer. 1.0% for 12.5% in in Stages I2II, as opposed to of the cases were case fatality were rates 3-year The group. the control 14.9% (7 of 47 patients) in the intervention group group. and 56.3% (9 of 16 patients) in the control The high-intensity group improved significantly significantly improved high-intensityThe group in its pediatric intensity than the low group more quality-of-life (P=.005) and score asthma caregiver health services urgent asthma-related use (P=.026). in the declined more days symptom Asthma although the across-group high-intensity group, reach statistical significance did not difference triggers actions (P= .138). Participant reduce to in the high-intensity group. generally increased - - patients with type 2 diabetes hypertensive pa tients with 40 years of age and above adult population Participants Persons with Persons blood elevated (140 mm pressure or 90 Hg systolic mm Hg diastolic) s of chil 4-12 year with asthma dren 24 months 24 months 36 months Years of Years study 28 months 24 months Participants assigned to to assigned Participants the usual medical care continued group (control) their on-going from care health professionals own arm CHWSin control not and GPS were trained and they were servicesreceiving from local health facilities did not group control intervention any receive Control arm Control in the usual- Participants advised were group care see a health care to follow-up. for provider without a provider Those a list of public given were & community clinics usual care received - - Interventions The NCM was a registered nurse with NCM was a registered The in training to degree a baccalaureate NCM be a certified educator. diabetes 45-min face-to-faceinterventions were contacts. clinic visits and/or telephone direct patient care, She provided management, education, counseling, and physician referrals, up, follow- which included and prompting, feedback changes & implemen advising regimen orders. ting changes under physician’s hyper screen trained to were CHWs the selected patients from tensive communities and modify their and diet, exercise on healthy behavior smoking were cessation and then GPs and pharmacological also trained for interventionsnon pharmacological Subjects in the intervention group of screening 3 rounds will receive consisting of oral visual inspection trained health workersby at 3-year intervals. Subjects in the intervention and screening, offered were group of oral those with lesions suggestive leukoplakia, submucous fibrosis, for referred or oral cancer were physicians examination by Experimental arm Experimental a health workersThe followed sequence of activities standardized a client: telephoning until they reached 3 times), mailing a postcard (up to asking contact the client to the health making a home visit, and worker, contacting persons who alternate might know the location of client. Community health workers in-home environmental provided education, supportassessments, and resources. change, behavior for either to assigned were Participants 7 receiving a high-intensity group or visits and a full set of resources a receiving a low-intensity group resources. single visit and limited CHWs CHWs CHWs Outreach Outreach worker CHWs CHWs Table 20A: Non-Communicable Diseases Prevention Interventions – characteristics of included studies Interventions Diseases 20A: Non-Communicable Prevention Table RCT cRCT cRCT Study Study design RCT RCT 334 340 327 333, 328 Gary et al.2003 California, USA Jafar et al. 2009 Karachi, Pakistan Sankarana- et rayanan al.2000 341 Kerala, India Study / Study country Krieger et al.1999 USA Seattle, Krieger et al.2005 USA Seattle,

177 - - The LHW_ME group increased receipt of mammo receipt increased LHW_ME group The in the past 2 years and mammography ever graphy 82.1%, p_0.001) while 91.6% and 64.7% to (84.1% to 79.0%, did not. Both ME (73.1% to the ME group 85.5%, p_0.001) p_0.001) and LHW_ME (68.1% to but the of CBE ever, receipt increased groups increase. greater had a significantly LHW_ME group In CBE within 2 years. similar for were results The LHW_ME was significantly multivariate analyses, with four outcomes, for all than ME effective more mammography ORs of 3.62 (95% CI_1.35, 9.76) for ever; mammography 3.14 (95% CI_1.98, 5.01) for CBE ever; 2.94 (95% CI_1.63, 5.30) for within 2 years; CBE within 2 years. and 3.04 (95% CI_2.11, 4.37) for Outcomes diabetes Interventions improved group group. control to compared control the follow-up to of 319 individuals responded A total data survey Medical rate). records (69% response for 9 testing since randomization verified hepatitis B participants(6%) of the 142 experimental group and participants group (P = 0.04). 3 (2%) of the 177 control a higher proportion of individuals in follow-up, At the experimental arm than individuals in the control arm knew razors by that hepatitis B can be spread (P = 0.07). (P\0.001) and during sexual intercourse with ocular injuries, VHWs 1365 people reported to eligible of whom 374 with corneal abrasions were Of 368 (98.5%) abrasions healed treatment. these, for 2 patients had mild localised without complications. out the ointment, 2 dropped reactions to allergic developed and 2 patients in the placebo group culture-negative cornealmicroscopic stromal drops. week with natamycin that healed in 1 infiltrates (n 27) expe with IGT/IFG diagnosed Those weight loss after screening rienced significant Study (5?2 (SD 6?6) Vanguard and during the weight loss Significant P,0?01). t test paired kg, Study among Vanguard duringoccurred the all participants P,0?001). (21?3 (SD 3?6) kg, women aged women >40 years Participants Patient with Patient diabetes General Population with Patients traumatic corneal abrasion patients with diabetes 36 months Years of Years study 24 months 6 months 18 months 24 months Control arm Control Own going care patient own from health professionals did not group Control interventions receive No treatment media received education only No interventions arm control to - - - Interventions Experimental arm Experimental intervention given were Patients acti diet, physical to related blood vision care, care, foot vity, blood glucose self monitoring, to adherence control, pressure medications and appointments, and smoking cessation referrals, and sixty hundred individuals Four for been tested who had never identified from hepatitis B were community-based surveys of Chinese and Washington, conducted in Seattle, These British Columbia. Vancouver, to randomly assigned individuals were health worker a hepatitis B lay receive intervention or a direct mailing of activityphysical educational materials with either 1% chloramphe treated ointment nicol and 1% clotrimazole or 1% chloramphenicol and a times a placebo ointment three doctors and Patients, 3 days. for day treatment. blinded to were VHWs Media targeted received Both groups interventionThe group Education. two LHW educational received calls. sessions and two telephone A pilot study (Vanguard Study) cohort of 160 participants weighed were and during MCHW intervention, before with fiftyand compared particitwo before immediately pants weighed interventionparticipants1143 with and area. the same geographical from CHWs Outreach Outreach worker CHWs CHWs CHWs CHWs RCT Study Study design RCT RCT RCT RCT 346 345 344 342 343 Nguyen et Nguyen 2009 al. USA Study / Study country et al. Vetter 2004 USA et al. Taylor 2009 Seattle, Washington USA and Vancouver, Canada Srinivisan et 2006 al. South India Simmons et 2008 al. New Zealand

Global Evidence of Community Health Workers - - - Outcomes Analysis of variance that the demonstrated intervention on post main effect had a significant baseline intervention for adjustment controlling indicating score (P=.01).Using a cutoff scores of experimental maladjustment, the percentage in the maladjustment range children group after the interven baseline to10% fellfrom19%at children group of control tion; the percentage 15% from in the maladjustment range rose 21% after the intervention.at baseline to The primary results were a significant decrease primarydecrease The a significant were results after pressures and diastolic in mean systolic of intervention,both levels and a significant of individuals with in the percentage increase no Surprisingly, high blood pressure. controlled observedwere results between in differences of interventionthe 2 levels intensity of In recognition the intervention community, between significantly increased tests screening pre- and post intervention surveys: CBE, 50 to smear, 79%; and Pap 59 to 85%; mammography, all). Receipt of screening 78% (P 0.001 for 22 to significantly: also increased tests to 70% CBE, 44 69% (P 5 0.006); 54 to (P 0.001); mammography, 66% (P 0.001). Best-fitting 46 to smear, and Pap prein adjusting for models, regression logistic also tervention covariates, and significant rates odds ratios [9]. statistically significant showed Vietnamese Only about half (50 and 53%) of .0001). the intervention (P, for effect women de and post-interventionPre- questionnaires self-reported use of eyewear greater monstrated in all blocks after the intervention (P<0.0001), change the greatest with Block A showing B (P<0.0001) and C (P¼0.03); this to compared was supported field observations. by Block A in knowledge improvement the greatest showed training content. to on questions related (ER) visits declined emergency room Total hospitals declined 40%; ER admissions to by hospital admissions; and 33%, as did total by 27%. declined by Medicaid reimbursements - general population women Vietnamese farmers patients with type 2 with or wi diabetes thout hypertension Participants children aged 7 children with 11 years to mellitus, diabetes sickle cell anemia, cystic fibrosis, to or moderate asthma. severe - 39 months 48 months 36 months Years of Years study 12 months - No interventions arm control to no interventions Control arm Control did not group Control interventions receive Interventions Community health workers were Community health workers were trained and certified in blood pressure education and management, monitoring, social supportcounseling, mobilization, up. and communityfollow outreach workersLay conducted 56 sessions on 86 on cervicalgeneral States, cancer, Surveys can- cancer. and 90 on breast conducted were 373 women of 306 to Further, cervical develop in to cancer. the study women Vietnamese communities in 1992 and 1996. Experimental arm Experimental “experienced by provided program, The specialists, and child life mothers” contacts, face-to-included telephone and special family events. face visits, 786 workers on 34 farms were divided into three intervention three 786 workers divided into blocks: on 34 farms were farm and training to workers; eyewear (B) protective provided CHWs (A) farm but no training to workers; eyewear (C) provided eyewear CHWs farmwas distributed to workers and no training. with no CHW present ascertain had on the quality of life that trained CHWs the effect To with utilization of Medicaid enrollees of healthcare and level (QOL) weekly alternated home CHWs DM, with or without HTN. Healthcare. understand the need to patients to visits and phone contacts teach to regi and behavioral both their therapy follow to their illnesses, control a primary visits to maintain appropriate and to practitioner. mens, care CHWs CHWs CHWs CHWs Outreach Outreach worker CHWs - RCT Quasi-RCT pre/post compara cross tive sectional study Study Study design RCT 337 329 347 348 349 Levine et al. et al. Levine 2003 USA et al. Bird 1998 California, USA et al. Forst 2004 Michigan, USA et Fedder al.2003 Baltimore, USA Study / Study country et al. Cheroff 2002 Baltimore, USA

179 - The volunteers’ diagnostic sensitivity for sensitivity diagnostic for volunteers’ The active trachoma was 63%; their specificity was to ‘‘decision their the household level, 96%. At was correct in 83% of households treat’’ Outcomes model findings suggest that a church-based The the participationof social influence can leverage of minority in cervical women cancer control, underserved access to provide Hispanic women activities and sustain cancer control in particular, of an intervention the life program. beyond Mean decreased childhood blood lead levels improved behaviors and selected preventive Yuma, Random in blood glucose measurement 201 mg/dL, and, 224 mg/dL to from dropped 197 mg/dL from dropped in Santa Cruz, levels 151 mg/dL. Among high-riskto participants in 137 mg/ 151 mg/dL to from BP fell systolic Yuma, 84 mg/dL. 100 mg/dL to from BP fell dL, & diastolic Among-high risk participants in Santa Cruz, systolic 139 mg/dL, & diastolic 153 mg/dL to from BP fell 91 mg/dL. 102 mg/dL to from fell blood pressure their physicians had visited 51.5%of those referred 65.6% within 6 to increasing 4 months, within 2 to 1.17 per ratio [OR], Older age (odds 12 months. to 1.17 per education (OR, additional decade), more levels higher blood cholesterol additional level), 1.19 per additional 0.51 mmol/L), previous (OR, a knowledge 1.34), and receiving (OR, of level with associated significantly 1.24) were (OR, reminder completion, whereas likelihood of referral greater counseling was not. the type providing of educator proportionThe of patients with commu with significantly increased nity volunteers 25% in 2002), even time (13% in 2000 to in the absence of financial incentives General population in households Participants All women ages All women & older 21 years aged children 1-6 years patients with Diabetes adults males, poor and young, less educated TB patients with - 1 months Years of Years study 24 months 36months 36 months 21 months - - Control arm Control Interventions Experimental arm Experimental protective for women educational sessions to CHWS provided health reproductive monthly meetings, who then attended health advisors, lay Trained indivi activities, and educated planned and engaged in outreach of 5.4 education/ outreach duals in their social networks (average activities intervention per month). During they the 2-year period, made nearly 27000 contactsthan 5000 hours and spent more Topics community education efforts.22 TEAL-related conducting the importance of lead, included sources of blood lead screening, in grass playing hand washing, lead sources, removing for strategies rather than in dirt good nutrition, & housecleaning. or mine tailings, model included a five-weekdiabetes The series of free participantseducation classes that assisted in gaining the knowledge and skills necessary control active, be physically to of takeand be aware medications, blood sugar, diet, monitor the model was use of commu to Central complications. nity health workers conductparticipate — or to outreach, individual support.in patient education, and provide the treat trachoma and to diagnose trained to were CHWs of also informed They were disease using azithromycin. possible side-effects. Under supervision, each the drug’s and if necessary then examined, volunteer treated éducation, components included physicien Principal or A lay and follow-up. community based screenings, counseling and referral provided educator professional Half of the subjectsadvice. with high blood cholesterol see their physician to a reminder received levels strategy DOTS given patients were CHWs Outreach Outreach worker CHWs CHWs CHWs CHWs CHWs - cross cross sectional survey Study Study design compara cross tive sectional cross sectional survey cross sectional study Cross sectional cross sectional 332 335 350 331 352 351 Solomon et al.2001 Daboya, Ghana Study / Study country Davis 1994 Los Angeles, USA Kegler & Malcoe 2004 Oklahoma, USA Ingram et al.2005 Yuma and Santa USA Cruz, Singh et al. 2004 Haryana, India Havas et al. et al. Havas 1991 Massachusetts, USA

Global Evidence of Community Health Workers - - - Outcomes that understanding in interventionmore group smoking causes and human papillomavius cervical cancer Testing increased among women in both the among women increased Testing combined intervention 81.8%; P<.001) (65.8% to and media-only 75.5%; P<.001) groups, (70.1% to in the combined inter more but significantly never (P=.001). Among women group vention women more significantly screened, previously (46.0%) in the combined intervention group than in the media-only (27.1%) obtained group women in the more (P<.001). Significantly tests obtained their first combined intervention group or obtained one after an interval test of more Pap (became up-to-date;than 1 year 67.3%, 45.7% to respectively; P<.001) than did those in the media- 55.7%, respectively; (50.9% to only group P=.035). ages 40 and breast Seventy-six of women percent and cervical among uncover cancer screening for non-English- lower significantly 89%). Rates were and evaluate develop to designed based research such speaking (56 Latinas and Chinese women and mammography), for and 32%, respectively, unders previously insights regarding maintenance mammograms (three tudied popular screening variations in the past 5 years) and multiple study 7% (non-En from proven The challenges. design glish-speaking of 53% effectiveness Chinese) to (Blacks). smears in pre and Pap mammography Vietnamese Vietnamese American women general women population Participants Women in Women community 36 months 36 months Years of Years study 60 months - - Control arm Control Interventions lay health worker plus media-based education lay outreach intervention)(combined or media-based education only. health workersLay met with the combined intervention Papanicolaou promote 4 months to 3 to twice over group chan measure to used questionnaires We testing. (Pap) testing. knowledge, and Pap ges in awareness, Experimental arm Experimental health workers lay by women to education outreach in the community The Breast and Cervical Breast The Intervention Cancer Study was a control Area Bay interventionsled trial of three in the San Francisco health worker 1996: (1) cercommunity-based lay 1993 to from system; training and reminder (2) clinic-based provider outreach; of abnormal screening follow-up for and (3) patient navigator and a description of the interventions Study design results. of a household survey reported along with baseline results are aged 40–75 languages among 1599 women, conducted in four CHWs CHWs Outreach Outreach worker CHWs cross cross sectional cross sectional Study Study design cross sectional 297 354 353 Mock et al. Mock et al. 2006 USA Hiatt et al. 2001 California, USA Study / Study country Lam et al. 2003 California, USA

181 Global Evidence of Community Health Workers mode Evaluation Evaluation coverage Incentive Incentive (if any) salaried Supervision Contact activities were with monitored a computerized tracking system. key compe-key tencies blood pressure measurement and linkage with health facility and client pressure blood measurement and linkage with health facility and client - - Role conducted BP measurements, medical to referral provided assistance in and, care locating a provider; took appointments at health appointment issued center; letter; reminder follow-up the whether determine to new a kept; was appointment each missed appointment for 3); andappointment (up to barriers reducing in assistance referral through care to preventive CHW facilitated The schedule to offering by care mo appointments and visits, participantnitored and family adherence reinforce behavior, recommenda treatment to social support, mobilize tions, feedback, physician & provide which included reporting on as such problems identifiable readings high blood pressure exercise, (diet, pharmacologic and smoking loss, weight cessation) and pharmacologic interventions, prescription appropriate and low-cost of use preferential drugs, generic of single-dose drug regimens, visits follow-up scheduled blood pressure, guided by the stepped-care approach achieve titrating drugs to for and blood pressure, target satisfactory consultation with patients, sessions for treatment of explanations appropriate of use and communication strategies. Refreshers Refreshers / Ongoing training - BP measu rement specialists Certification Duration 100 hours 6 weeks - Table 20B: Characteristics and description of outreach workers and description of outreach 20B: Characteristics Table Training Training Content training Didactic on hypertension, the cardiovascular factors risk system, cardiovascular for communitydisease, Didactic skills development preventive in training to adherence care, recommen treatment of reporting and dation identifiable problems. Didactic training on changebehavior of communication and diet, exercise smoking cessation - - Recruitment Recruitment Criteria predomi nantly Black (12/14) low income neighborhood in enrolled college part and had time, no formal training in health care the before study. the from same com munity and hiring as per lady health program Pakistan Education a local high school graduate of8 years schooling 328 334 327 Study Study Krieger et al. 1999 CHWs Gary et al. 2003 (F) CHWs Jafar et al. 2009

183 mode Evaluation Evaluation coverage 3500-4000 population Incentive Incentive (if any) Paid Paid workers provided bus MTA an pass and a monthly stipend $45 (from $75,to based on caseload) for incidental expenses incurred. Supervision key compe-key tencies oral cancer counseling and screening of oral cancers in community Developing Health seeking behavior - - - Role Dor door survey to and iden tify patients with traumatic corneal abrasion using a taught in training technique household andthey visited them training related given they also ant tobacco, to performed of oral screening visual inspection of anatomi oral cancers andcal benign them to referrals provide the of extenders as Acted be to facilitate medical staff patient using change, havior walking counseling, centered and a classes, diabetes club, educational group psycho depression. for home weekly Alternated visits and phone contacts to understand patients to teach their control the need to both follow to illnesses, and behavioral their therapy maintain and to regimens, a visits to appropriate primary practitioner. care - Refreshers Refreshers / Ongoing training Biweekly meetings pro vided ongoing instruction and support on topics by requested the promoters, the duration for of the project, including 12 hours on depression. Bi-weekly supervision meetings were held in which new patient assignments given, were were forms distributed and collected, and problems addressed. Certification Duration - - Training Training Content 10 sessions of general Didactic training on facilitation, de group cision making, popular education methods, making presentations, communication, and Subsequently, analysis. 30 they received hours of training in management diabetes TTM.and the Trained to identify to Trained corneal abrasions didactic training trained they were anti tobacco give to health messages to community suring their household visits to Training Didactic trainingReceived illnesses, in chronic identification, resource and case management. initial training wasThe and covered 40 hours, to related topics many medi (eg, diabetes emergencies cations, glucose &complications, monitoring), and to high blood pressure - - - Recruitment Recruitment Criteria in Fluent English having ordiabetes a fa having mily member with diabetes, possessing good inter personal skills, required have to community experience demons to theirtrate commitment service,to & to either reside in, or be able to, travel to the catchment area. Edu- cation High school education university gradates

344

333, 330 Study Study et Srinivisan 2006 al. Sankarana- et rayanan al.2000 341 CHWs (M & F) et Fedder al.2003 CHWs Thompson et al.2009 329 CHWs

Global Evidence of Community Health Workers - mode Evaluation Evaluation Collabora- tively developed quantita andtive qualitative instruments coverage 40/ 27000 contacts Incentive Incentive (if any) Supervision key compe-key tencies Role - - - Refreshers Refreshers / Ongoing training community edu cation efforts: included Topics of lead, sources importance the of blood lead screening, for strategies lead removing hand resources, playing washing, ratherin grass than in dirt or mine tailings, & nutrition, good housecleaning. pro to vide outreach, of recruitment assist participants, participants in incorporating self-management into behaviors their lifestyles, ongoing & offer support and follow-up. were They trained to anddiagnose trachoma. treat also They were of theinformed si possible drug’s de-effects. Under supervision, each volunteer then examined, and if necessary treated Certification Duration 8 hours on sources sources on Training Training Content training exposure lead of and lead poisoning strategies prevention by Training Didactic the hospital in each a CDEcounty provided classes, facilitate to and care, in diabetes work individually with participants trained to were CHWs trachomadiagnose disease the treat to and using azithromycin.

- Recruitment Recruitment Criteria respected people to whom others turned for advice and help) were from recruited the Native American community Promotores indige are thenous to communities in which they work Education 332 335 331 Yuma Yuma Study Study Kegler & Malcoe 2004 et Ingram al.2005 and Santa USA Cruz, et Solomon al.2001 Daboya, Ghana

185 mode Evaluation Evaluation coverage Incentive Incentive (if any) Supervision key compe-key tencies Role Refreshers Refreshers / Ongoing training Certification Duration 2 hours daily for 2 weeks training Training Training Content promote safety promote in the measures farmers including wear eye - Recruitment Recruitment Criteria in interest Heath, have leadership & communi cation skills, demonstrated respect for farm workers Edu- cation and read write Spanish 337

Study Study et al. Forst 2004

Global Evidence of Community Health Workers Knowledge, attitude and practices of community health workers Background A CHW is a frontline public health worker who is functional status had significantly changed for a trusted member of the community served and outreach activities, health education, environ- is the backbone of the primary health care.355 mental health, MCH activities, EPI, birth and The importance of CHWs in the provision of deaths registry, curative patients, school health, health services cannot be overlooked because referrals and epidemic control.368 In Darmstadt they are the solitary means of house-to-house et al. physicians independently evaluated all the access of health system for the provision of neonates seen by the CHWs and the outcomes basic health care and serve as a liaison between of this study showed that the sensitivity of CHWs’ health/social services and the community to evaluation of a very severe disease was 75% and facilitate access to services and improve the specificity was 98%.364 In another study by Hadi quality and cultural competence of service deli- et al. the assessment and management of ARIs very. They also build individual and community by CHWs was assessed against the gold standard capacity by increasing health knowledge and of physician assessment and diagnosis.362, 363 self-sufficiency through a range of activities The sensitivity of the diagnosis by the CHWs was such as outreach, community education, infor- found to be 68% while the specificity was 95% mal counseling, social support and advocacy. as compared to the diagnosis of a physician.362, Therefore, only those CHWs who have good 363 The management of sick children according knowledge, positive attitude and proper skills, to IMCI protocol and the role of CHWs was also can help the community regarding primary studied in another cross sectional survey and it health care and family planning. was found that a significant number of CHWs were needed to meet the time requirement by In the systematic search for the global evidence IMCI protocols.361 of CHWs, we also identified set of studies in which their training and practices were eva- In Falle et al. the TBAs were trained and then luated and reported in the form of Knowledge, evaluated on their antenatal support and de- attitude and practices (KAP) studies. livery of the baby. They were trained to make antenatal visits and convey advice on diet and Community Based Evidence nutrition, immunizations (TT) and conduct safe delivery and counseled on reducing the We reviewed a total of 19 studies which as- workload during pregnancy.357 The outcomes sessed the knowledge, attitude and practices of of this study showed that the trained TBAs were the CHWs (Table 21A & Table 21B). The types of more likely to wash hands with soap before health worker involved in the studies reviewed delivery and use a clean delivery kit, and advice 356, 357 .358-368 are TBAs and the CHWs The CHWs feeding colostrums to the newborn.357 in Darmstadt et al. were educated up to secon- 364 dary school or higher while some had had a Similarly the TBAs in another study were first trai- 362 357 few years of schooling or were just literate. ned in newborn care and then their knowledge The training modality used where the CHWs and training was tested before and after trai- 357, 359, 360, 364, were being trained was didactic ning.356 The after training assessment showed 367 356, 358, along with field work in few of them. statistically significant reduction in perinatal and 361-363, 365 neonatal deaths among deliveries conducted by TBAs.356 The functional status of the CHWs in Ayele et al. was assessed after providing them with refresher The CHWs in Afsar et al. were assessed on their 368 training of 5 days. It was observed that their primary health care delivery, family planning

187 services, maternal and child health care and significant improvement in the performance referral practices.360 The outcomes of this study skills after learning from a pretested self learning showed that the CHWs made 76.4% successful educational module with simulation method.365 referrals.360 In another study Afsar et al. found In Nigeria the Oganfowora & Daniel were inter- that only 4% of the patients referred visited viewed by a self-administered questionnaire to government facilities, the rest preferred private test their knowledge on neonatal jaundice, its physicians and in-formal practitioners.359 causes, treatment and complications and the results of this study showed that only 51% of the The knowledge, attitude and skills of the CHWs respondents had correct knowledge of neonatal with a job experience of more than 24 months jaundice and only 55% of them had adequate revealed that their knowledge was above 36%, knowledge of its effective treatment.366 attitude score above 88% and skill assessment score above 86%. The variables included in this In Zietz et al. it was found that the CHWs deve- study were home visits, antenatal care, family loped the competency to correctly classify ARI, planning, newborn care, vaccination, growth and their average score improved from 60% to monitoring, common diseases, medicines and 83%, in a pre/post study after training them to referrals.358 The CHWs in Mohanty et al. showed use the WHO ARI guidelines.367

CHW Snapshot 20 Pakistan Lady Health Worker Program Program overview In 1993, government of Pakistan started a National Program for Family Planning and Primary Health Care and soon the program began to employ a cadre of salaried, female CHWs, called lady health workers, to provide health education, promote healthy behaviours, supply family planning methods and provide basic curative services. Their duties include monitoring the health of pregnant women, monitoring the growth and immunization status of children, and promoting family planning. The lady health workers are provided with a kit that contains materials such as bandages, scissors, cotton, a thermometer, health education posters and a child scale. The kit also contains contraceptives and drugs, including contraceptive pills, condoms, paracetamol tablets and syrup, eye ointment, oral rehydration salts for diarrhea, Chloroquine for malaria and antibiotics for respiratory infections.214 Lady Health Workers, Pakistan Operational aspects and considerations Education 8th grade Lady health workers are all women; 70 per cent are under the age of Training 3 months initial training 35 years, and 72 per cent are currently married or have been married. Refresher One week each month The written requirements for a lady health worker are to be female, Supervision Lady Health Supervisor educated to 8th grade, a permanent resident where she will serve, Incentive Rs. 1600 / month 20 to 50 years of age and preferably married. Their training covers the basics of primary health care and comprises both classroom and clinical practice.214, 369 A supervisory visit to the lady health worker’s community takes place every month, and monthly meetings are held at the health facility. According to an evaluation 80% of the workers had supervisory visits in last 30 days.214 The lady health worker is responsible for recording information about births and deaths in the community, use of family planning methods, immunization of children, diagnosis and treatment of her clients, and pregnancies and care provided. She also refers her clients to next-level facilities if they need further care.

Coverage and effectiveness The program is currently employing approximately 69,000 lady health workers each being responsible for approximately 1,000 individuals. This coverage equals approximately one fifth of the entire population of Pakistan and one third of the target population of the program. External evaluation of LHW program occurs periodically in every 3-5 years and up till now 3 evaluations have been conducted. Program has achieved vaccination promotion coverage of 67% of children under five, modern contraceptive usage of 20% and overall indicators of population served by LHWs were slightly better off than National figures. Source: WHO/Unicef 200624 & Winch et al. 2005 274 & Unicef 2004 18

Global Evidence of Community Health Workers Conclusion The review of studies on knowledge, attitude and practices of the CHWs has brought us to the conclusion that basic training and then refresher trainings can significantly improve the working of CHWs and TBAs and thereby make a significant contribution to the health care system of the community.

189 - Outcomes their functional changed status significantly activities, health educations, outreach for health, MCH activities, EPI, Birthenvironmental patients, curative deaths registered, registries, and epidemic control school health, referrals, CHWS diagnosis of pneumonia was 67.6% CHWS diagnosis Agreement and 95.2% specific. sensitive was 0.67. and physician between CHWs The in 1998-1999. evaluated were CHWs identified 221 (18.9%) health volunteers kind, ARIs of any while the as having children the identified 263 (22.6%) children physicians diagnosis sensitivityestimated of volunteer was 67.7%, with the specificity being 95.2%. collect time needed to information average The including the physical the IMCI approach, for be about to was found checkup of sick children, a significant represents IMCI strategy 16.3 minutes in the time input of health workers. increase of Using the additional time input requirement somewhere employ IMCI, Bangladesh needs to between 2,700 and 4,100 health workers in rural these additional cost of employing The areas. 4.0 million US health workers 2.6 to will be around health of total 1.5 percent about one to dollars, sector budget of the Government Bangladesh used clean cord-cutting instrument (89%) Trained delivery (74%), were before and hand-washing likely wash more to were TBAs Trained common use a clean delivery, hands with soap before delivery-kit, colostrum and advise feeding of 347 patients interviewed,Out of a total 265 (76.4%) re unsuccessful were (23.6%) 82 while successful were analysis showed regression Multivariate logistic ferrals. OR, 2.96; CI: 1.44- (Adjusted that objection referral to OR, 1.25; CI: 1.34- (Adjusted before referred 5.52), never OR, (Adjusted before site the referral 6.90), not visited 4.04; CI: 2.50-6.08) and no knowledge meet of who to OR, 1.30; CI: 1.01-2.96) (Adjusted site at the referral with unsuccessful referral. the factors associated were CHWs evaluation of very disease was 75% and CHWs severe specificity of 98%. PPV was 57% and NPV was 99% - children 3-60 children months between children < 60 to 3 years inclu months were ded in the study under children of age 5 years women Pregnant General population Participants CHWs Neonates - 3 months during 1998 12 months 2 months Years of Years study 6 months - - CHWs were not given not given were CHWs training and the refresher with not provided were monthly supervision Control arm Control Interventions CHWs were given training and then their assessment given were CHWs against tested were children of ARI in communitydiagnosis over assessment and diagnosis. of physician gold standard work as the frontline used communityBRAC health volunteers health The trained in 1992. were level roots at the grass force but to ARIs, detect expected cases and treat to were volunteers nearby health clinics. cases to and complicated severe refer and the paramedics seekingthe CHWs All children from care the survey the study. over the sample for months constitute time-inputThe survey requirement was carried out at the CHW home during their routine CHWs by treated Children only. level Since IMCI is a facility- not included in the sample. visits were provided medical care based illness management strategy, should not be included in estimating the costs at doorstep evaluated trained and then they were were TBAs faci health care different to patients referred interviewed were the LHWs lities by Experimental arm Experimental received trained CHWs previously and were course of 5 days refresher monthly supervisiongiven was looked higher functional status providing for and and symptoms breastfeeding evaluated CHWs during of illness in neonates household visits at signs disease with severe 0, 2, 5, and 8. Neonates postnatal days communityPhysicians to based hospital. referred were CHWs. seen by all neonates independently evaluated CHWs CHWs CHWs CHWs CHWs Outreach Outreach worker CHWs CHWs - Table21A: CHWs Knowledge, attitude and practices assessment studies – characteristics of Included assessment Studies and practices attitude Knowledge, CHWs Table21A: validation study cross sectional survey cross sectional survey Compa- cross rative sectional TTBA vs. UTBA Cross sectional Study Study design compara cross tive sectional cross sectional study

361 357 360 368 364 362 363 Hadi 2001 Rural Bangladesh Hadi 2003 Rural Bangladesh khan et al.2000 Matlab, Bangladesh et Falle al.2009 Sarlahi, Nepal et Afsar al.2003 Karachi, Pakistan Study / Study country et Ayele al.1993 Illubabor, Ethiopia Darmstadt et al.2009 Rural Bangladesh

Global Evidence of Community Health Workers - - - - Outcomes govern visited Only 4% of patients referred private visited having the rest ment facilities, practitioners and in-formal physicians Eighty-five percent of respondents indicated respondents indicated of Eighty-five percent somewhat/verythat they were likely to family, friends, from this information receive somewhat/very while 73% were or neighbors, the CHWs from information likely receive to Knowledge of lady health workers was 88% and above 36%, attitude score above 86%. skill above assessment score two The most important the irregular factors are supply of drugs and selection and unreliable commu be trained for people to of the wrong nity health workers. Other like factors, inadequate community support supervision, and inadequate contributors. many entioned by were of 242 partograms in labor were A total of women period; 76.9% of them were a 1-year over plotted Community health extensioncorrectly plotted. 193 (79.8%) partogramsworkers plotted (CHEWs) 49 (20.2%). plotted and nurse/midwives sensitivityThe and specificity of the commu nity health worker was 3.8% and 99.4% diagnosis and positive rate false positive The respectively. 55.6% and 44.4%, respectively. values were predictive predictive and negative rate false negative The 10.3% and 89.7% respectively. value were intervention prior the period year to (one Pre training) and post intervention after period year (one was a statistically that, there the training) showed reduction (p<0.05) in the perinatal deaths significant 2) among the 3) and neonatal deaths (10 to (11 to after the training. TBAs deliveries conducted by in improvement was a significant There the performance skills between interven (p <0.001) groups tion and control general population LHWs CHWs CHWs CHWs TBAs CHWs Participants General population - - 7 months 12 months 12-36 months July 2005 - Years of Years study 1 months - - - Control arm Control Interventions In 1992, the Center for Healthy Communities in Dayton, Ohio in Dayton, Communities Healthy In for 1992, the Center people indige train as Advocates to a program developed be working. the communities in which they would nous to from has been evaluated of the program effectiveness The the perspectives: the Community Health Advocates, three of the community at which the managers/ directors sites work,CHAs work. & the clients with whom CHAs than with a job experienceWorkers of more Lady Health interviewed assess their knowledge,24 months were to attitude and skills, their job to in terms of variables according antenatal variablesThese included home visits, description. vaccination, growth newborn care, family planning, care, medicines and referrals common diseases, monitoring, self learning educational module with simula Pretested in interventiontion method was introduced group Experimental arm Experimental by the facilities health care different to patients referred interviewed were LHWs This study was conducted to identify the factors associated identify the factors study was conductedThis associated to performancewith low of community health workers health workers deliveryFifty-six offering services in primary use the trained to facilities were health care after evaluated 7 months partogram and were communityThe health workers identified nine subjects as against an educa was compared This dementia. having of dementia made in accordance diagnosis tion adjusted protocol. group with the 10 ⁄ 66 dementia research conducted and then knowledge training were and practicesTBAs and after training before newbornwas tested to care related CHWs CHWs CHWs CHWs CHWs CHWs CHWs Outreach Outreach worker CHWs - Cross Cross sectional Cross sectional Cross sectional descriptive Cross sectional study Cross sectional Compa- rative cross sectional. TTBA vs. UTBA compara cross tive sectional study Study Study design Cross sectional survey 356

358 370 365 359 371 372 373 Rodney et al.1998 USA Ohio, Khan et al.2006 Kohat, Pakistan Stekelenburg et al. 2003 Kalabo, Zambia et al. Fatusi 2008 Osun, Nigeria Jacob et al. 2006 India Satischandra et al.2009 Karnatka, India Mohanty et al.1994 Varasani, India Study / Study country et Afsar al.2005 Karachi, Pakistan

191 - - Statistically significant differences between pre- between and differences Statistically significant oral seen regarding were ostintervention program health knowledge among both health workers number of shared The (p<0.05). and women Frequency per family decreased. toothbrushes Self- and fl ossing increased. of toothbrushing effi cacy increased. assessment of oral hygiene Changes in practices and personal skills improved to services access Women had more self-effi cacy. (p<0.000) regularly (p<0.000) and used them more Outcomes a correct defi gave Only 51.5% of the respondents 75.8 % knewthis nition of NNJ. examine for to how condition while 84.9 % knew at least two of its major only 54.5 % had Also, causes in our environment. namely, knowledgeadequate treatment of effective blood transfusion. and exchange phototherapy for to hospitals babies Rather affected than referring management, 13.4 %, 10.4 % and 3 of the proper natu drugs, participants with ineffective treat would respectively. and herbal remedies ral phototherapy 100% 71% to from of 88% (ranging An average ARI formalized had received groups) the three for Only 59% (in a training duringyear. the previous reported groups) the three 74% for range of 48% to a case of ARI during evaluated the month having identification for the study mean score preceding was only 10%, & the mean score of danger signs knowing of ARI cases was for the correct treatment classification of for score average The only 34%. 83%, while the average 60% to from ARI improved 76% 34% to from rose ARI treatment for score of assessment, classification mean percentage The performed procedures correctly and treatment each child was 79.8% (range 13.3—100%). Offor at least one who required the 187 children only a health facility, to or referral treatment (including all treatments prescribed 38.8% were the guidelines. by recommended referral) CHWs Participants CHWs CHWs CHWs - 12 months Years of Years study 1 months 1 months - Control arm Control Interventions Experimental arm Experimental interviewedCommunity health workers were in this area which questionnaire means of a self-administered by and knowledge on awareness of neonatal jaun focused and complications. treatment dice and its causes, WHO ARI guidelines of taking use trained to were CHWs of evaluation, disease classification, assignment physical history, use of medication, education mothers about site, treatment keeping and record and patient follow home therapy appropriate assess changes was conducted including 36 communityA study to sample of homemaker health workers and a representative living in 3- to 39 years and mothers aged 25 to women literate in the city dwelling of Rio6-room Grande da Serra, southeastern Data on oral health knowledge, self-reportedBrazil. practices, and personal skillsself-examination, oral hygiene, regarding number of number of people living in the same household, and dental serviceindividual and collective toothbrushes, access collected using structured interviews.and utilization were In 1995, the non-governmental CARE initiated organisation trained CHW program The district. in Siaya a CHW program collect on clinical assess (i.e. information to volunteers <5 years children and treat diagnose and symptoms), signs the CARE Management to of the Sick Child old according WHO/UNICEF (MSC)version of the a modified guidelines, the assessed for on they were later Then IMCI guidelines. of multiple interventionseffect practices. on healthcare CHWs Outreach Outreach worker CHWs CHWs CHWs cross cross sectional survey Study Study design Cross sectional survey Pre/post cross sectional survey

367 200 374 366 Frazão & Frazão Marques 2009 Rio Grande da Serra, Brazil Study / Study country Ogunfowora & Daniel 2006 Ogun state, Nigeria et Zeitz al.1993 Bolivia et al. Rowe 2007 Siaya, Kenya

Global Evidence of Community Health Workers - mode Evaluation Evaluation their functionality was assessed after 6 months Evaluation done throughout the training, and their of assessment neonates five at the hospital was evaluated they before started field work. their assessment & diagnosis was checked gold standard (physician) diagnosis The treatment and exami were the by ned research BRAC physicians. coverage Incentive Incentive (if any) - - Supervision monthly supervision 1 supervisor CHWs 6 for met who them fortnightly 6 hours for study trained physicians super were these vising CHWs of group physicians and para-pro with fessionals experience in managing and treating ARIs. - - - key compe-key tencies Counseling regarding feeding. breast Managed and up followed fast breathing, oral thrush, bac localized terial infection, diarrheas with dehydration and diarrhea without dehydration ARI assess ment and management examination of pneumonia coun cases, ting respiration advice on rate, patient care, use of card, referral group target identification, and record keeping. - Role that sure make to Observed is technique feeding breast Managed and appropriate. conditions minor up followed transportfacilitated and disease severe. where referred assigned they visited household with children and assessed dia ARI and provided gnosed them to treatment their visited Volunteers household(100-120assigned housholds/CHW) monthly and diagnose, identify, to with ARIs. children treat - Refreshers Refreshers / Ongoing training 5 days refresher Supervisor conducted refresher training fortnightly Paramedics BRAC from rou provided tine refresher training to volunteers once a month Certifi- cation Duration 36 days 4 months 3 to - - - - Table 21B: Description & Characteristics of Outreach workers of Outreach 21B: Description & Characteristics Table sessions, videos videos sessions, already trained already Training Training Content Didactic and practice on sick newbornand healthy babies Manual content: surveillance pregnancy antenatal ®istration; counseling on prepared birthness for and new managementborn care; at birth,of the neonate including resuscitation; continuing essential newborn routine care; assessment neonatal and illness classification; of management and the to according illness Mirzapur CHW clinical algorithm, including the hospital. to referral Field and Didactic work. selected were CHWs ARI and trained for detection and manage ment at community. work field and Theory BRAC’s in training basic included content offices. physio and anatomy basic logy of respiratory organs, classification of ARIs, analysis of the causes and factors that contribute to and signs these infections, of pneumonia,symptoms examination referral keeping. and record - Recruitment Recruitment Criteria Recruited local through advertiseDi dactic ments all were 20–40 female, old. years trained CHWs selected were Selected from among the local area - Education Educated secon to dary school certification or higher. Most of them had of5 years schooling 363 368 Study Study Ayele et al. 1993 Darmstadt et al.2009 364 (F) CHWs Hadi 2001 362 (F) CHWs Hadi 2003

193 mode Evaluation Evaluation coverage Incentive Incentive (if any) Supervision - key compe-key tencies of Diagnosis dehydra tion and measuring vital sings of patients Antenatal support delivery and of baby of referral patients theto appropriate health facility Role obtain to Used questionnaire about all the sickinformation range age the in children and 5 years, of 2 months to examination, did physical management of sick child and advising counseling of mothers was recorded. placenta the baby Delivered During and cut the cord. provided visits, antenatal advice on diet and nutrition, immunizations (TT), and the workloadreducing during pregnancy. Delivery of primary health family planning care, services and maternal and child health care. Refreshers Refreshers / Ongoing training afterRefreshers 12 months Certification Duration 3 days 3 days - to - involved in involved Informtion on Training Training Content health by Trained district NGOs, centre, office health public to on issues related deliverysafe and care antenatal didactic sessions and practical deliveries in the PHC facilities participated which in the training, the by conducted was of most investigators, specialist were whom obstetricians engaged in usingconsistently the partogram and training health workers in their trainingThe practices. partogramthe utilized WHO. by produced Didactic and practi cum classification of illness conditions according IMCI module to Training Didactic PHC at the provide Trained level. roots grass essen provide to tial maternal and child health & family planning services, management of common ailments of family and provision planning material and health education. Recruitment Recruitment Criteria reported delivering at least one withinbaby the 3months prior to recruitment. resident Local Lady Health Workers Edu- cation Literate

361 360 357 372 Study Study et khan al.2000 CHWs et Afsar al.2003 (f)CHWs Falle et Falle al.2009 TBAs (female) et al. Fatusi 2008

Global Evidence of Community Health Workers - mode Evaluation Evaluation KAP assess includedment home visits, Post-test evaluation was done Evaluation done at 3, 6 and 9months after training. to Evaluation judge their knowledge. was test post conducted their test to knowledge coverage Incentive Incentive (if any) Supervision - - key compe-key tencies Appropriate and referrals building patient com pliance with it Primary health and care appropriate referrals care, Perinatal breastfeeding counseling Newborn and & care infant management of diarrhea. Identification neonatal jaundice ARI mana gement in children - - - Role Delivery of primary health family planning servicescare, and maternal and child health Management of common care. appropriate and ailments needed where referrals pro home visits to Paid family care, vide antenatal immunization planning, of monitoring growth and treatment for and infants of common ailments deliveryconducted safe care newborn provided and correct advised practices. practices, breast-feeding and immunization infor the mothers. mation to Identified and managed LBW did growth babies, monitoring of infants, gave and diarrhea managed taking body tempe ORT, of sick and referral rature, identify neonatal To provide to and jaundice management. appropriate take to trained were they cases manage and history IMCI algorithm to according - Refreshers Refreshers / Ongoing training training rein content during forced visits monthly 5 months the after training. Refresher was training for given anda day ARI outdated management was training refreshed Certifi- cation Duration ------for ap for Training Training Content Didactic training patient referral propriate Didactic and Practicum in , antenatal Trained family planning, care, vaccina newborn care, monito tion, growth common diseases, ring, medicines and referrals. Didactic and Practicum onincluded topics of conduc techniques deliveryting safe and newborn practices. care Didactic and Practicum included Topics and mana recognition gement of LBW babies, of monitoring growth management infants, of diarrhea and ORT, taking body tempera system. and referral ture, the by CHWs Trained of Boliviagovernment ARI WHO to according management standards Recruitment Recruitment Criteria resident Local Lady Health Workers Lady Health Workers with a job experience than of more 24 months Anganwadi workers belonging two ICDSto blocks Education

359 358 365 367 Study Study et Afsar al.2005 (f)CHWs et Khan al.2006 CHWs (female) Satischandra et al.2009 356 TBAs (female) et Mohanty al.1994 Varasani, India Ogunfowora & Daniel 2006 366 CHWs et Zeitz al.1993 CHWs

195 mode Evaluation Evaluation coverage Incentive Incentive (if any) volunteer Supervision key compe-key tencies monthly group meetings - Role of childhooddiagnoses standard to illness acrodding criteria using flip charts and with drugs then treatment work included:Their & information providing improve contribute to manage to ability people’s health; help oral health team identify the most vulnera to more of need in families ble specifi c oral health actions; access &utilization &improve dental of PHC thus delayed the need & reducing care consultations urgent for - Refreshers Refreshers / Ongoing training of re 6-15 days those to fresher weak found Certification Duration 10 days theory and 5 days of clinical practice 36-hour - - The Training Training Content was manual The through developed steps: the following of cation identifi common oral health the in conditions community; formu lation of questions issuesabout relevant the community;to question selection into and grouping thematic blocks; of design general the manual; and of evaluation CHW ma reading proposed terials and illustrations Lectures, role playing playing role Lectures, + practicum trained CHW program assess to volunteers collect(i.e. information &on clinical signs diagnose symptoms), <5 children and treat to old according years the CARE Management of the Sick Child (MSC) a guidelines, version ofmodified WHO/UNICEF the (IMCI) guidelines Recruitment Recruitment Criteria in the reside community Edu- cation 7alteast ofyears schooling 374 Study Study et Rowe 2007 al. 200 Frazão & Frazão Marques 2009

Global Evidence of Community Health Workers Short summary of the global review It is said that health workers are the backbone ractive sessions,130, 140, 148 practicum and field of health care delivery. There are over 59.8 mil- work.296, 362, 363 The training was certified only lion health workers in the world, two-thirds of in few of the studies and most of them were de- which provide health services and the remai- ployed in rural areas where health care facilities ning one-third are management and support were not easily accessible. After their training in workers.375 The main task of a health worker the interventions, they developed several com- is to share knowledge and teach people pre- petencies which ranged from behavior modifi- ventive methods and self-care of common cation counseling as in promotion of exclusive diseases so that they are tackled earlier with breastfeeding with consumption of colostrums better outcomes.376 Owing to the strength of by the newborn,92, 101, 130, 138, 139 antenatal the healing power of belief, many CHWs respect care,14, 38, 47, 129, 213, 214, 301, 357 family planning, their people’s traditions and build on them, hel- 213, 216, 294, 358, 377 anxiety management in de- ping them use the safe traditional remedies and pressed mothers315 and immunization of both gradually switching them to modern medicine the mother and the child,41, 48, 51, 56-58, 356, 357 by increasing their level of awareness.376 to the sample collection and lab diagnosis of malaria,235, 241 TB260, 265 and pap smears.62, 296 In this systematic review, we evaluated the role These CHWs were well trained to provide DOTS of CHWs in various communities of the world for TB213 and ART44, 300 to ensure treatment and assessed their compliance with the achie- compliance, and could also treat uncomplicated vement of health and nutrition related MDG malaria228-231, 237 and ARIs in children.362, 367 targets, mainly Goals 4, 5 and 6. The clustering The CHWs involved in the maternal and birth of included studies as mentioned earlier was and newborn care preparedness interventions based on different subsets of these MDGs. The were also capable of providing emergency obs- assessment of CHWs’ role in various interven- tetric care34, 37 and manage birth asphyxia by tions across the globe revealed that few years bag-mouth and mouth-mouth resuscitation39, of formal school education or more had a 97 besides being able to conduct safe and hy- better impact on the working of the CHWs as gienic deliveries.45, 47, 51, 60 was evident from the attitude of CHWs towards family planning43 and from the management of Their role in relation to the MDG targets has childhood illnesses by CHWs who had had a few been versatile (Table 22). They were agents of years of formal schooling.177, 178, 183 Similarly the health education in the community to prevent educated CHWs involved in the primary health them from STDs, malaria, TB and other non- care interventions showed effective performan- communicable diseases.89, 90, 101, 161, 164, 187, ce in their outreach services like breastfeeding 196 They promoted antenatal, intrapartum and and colostrums counseling, antenatal care, postnatal care,57, 94, 96 initiation of early and contraceptive usage and immunizations.213, 214 exclusive breastfeeding, promoted use of colos- This was also reflected by patient satisfaction in trums92, 101, 130, 138, 139 and growth monitoring an intervention where CHWs were psychology of children.14, 16, 57, 365 This promotive role graduates who participated in anxiety manage- played a significant role in bringing down ma- ment and treatment of common mental health ternal mortality32, 33, 94 and under-5 child mor- problems.315 tality rates in the communities they served.92, 94, 96, 378 Their role in preventive medicine can The training modality that seemed to be most be assessed from the emphasis that they laid effective amongst all that were used in the in- in their communities regarding appropriate cluded studies, was didactic training with inte- nutrition and to stay healthy. 12, 15-17 They also

197 - Monitoring of severely mal Monitoring of severely nourished children Complementary feeding Immunization age for of ARI with antibiotics Treatment care Cord timing and spacing of deliveryHealthy child transfer of mother to Prevention Emergency obstetric care TB cure to DOTS pregnant to Antibody testing & mothers women Dietary pregnant intake for & lactating women Hand washing Zinc therapy A supplementation Vitamin sick newbornsRecognizing & referrals immunization Toxoid Tetanus Birth and newbornpreparedness care Skilled birth attendance bed nets insecticide to treated Access Early identification of case symptomatic pregnancy of spacing & timing Healthy Early infant diagnosis emotional support mothers to BP monitoring strategies: Preventive and Blood sugar monitoring - Iron and folic acid supplementation Iron and folic Essential newborn care Oral rehydration Thermo-regulation in newborn Newborn preparedness care supplementation Iron/folate servi access to Facilitate ANC & PNC ces for Deworming case infectious for DOTS Building HIV support groups Anxiety management smears Pap Table 22: List of interventions delivered by CHWs CHWs by delivered 22: List of interventions Table Interventions related to: to: related Interventions breastfeeding Exclusive first 6 months for to: related Interventions Breastfeeding monitoring Growth Malaria strategies prevention of LBWHome care infants to: related Interventions diet Adequate treatment Intermittent preventive HIV/STI screening to: related Interventions of suspected malariatreatment cases children immunization for BCG sex promotion & safe Condom ARVs/ HAART infants to Prophylactic counseling Psychological of health seekingpromotion behavior Goal 1 Nutrition Goal 4 Health Child Goal 5 Health Maternal Goal 6 Malaria control control Tuberculosis HIV/AIDS prevention and control Mental health promotion NCDs prevention and control

Global Evidence of Community Health Workers emphasized on usage of condoms and change plete description and characteristics of CHWs in sexual behavior, in HIV prevalent communi- deployed, especially the level and amount of ties.306 Infact some were trained in the social supervision provided to those workers, which marketing of condoms.294 Besides advocating could have helped us in identifying the im- preventive strategies they also offered treat- portance of this factor and its association with ment for uncomplicated malaria, pneumonia other outcomes. This information would be of and treatment compliance was ascertained in great relevance to policy and practice. The dura- case of TB and anti-retroviral therapy of HIV as tion of training provided to CHWs was the only DOTS. As such the role and competencies of consistent information available from these CHWs were compliant with the MDG targets studies but on its own, did not reveal any addi- and did show up positive outcomes in the form tional impact on mortality outcomes. Additional of declining maternal and under-five children information on the initial level of education of mortality rates, decline in the incidence of ma- CHWs, content of training, provision of refresher laria, TB and HIV. training, mode of training, balance of practical or theoretical sessions, remuneration for work, The supervision and ongoing refresher training amount of activities performed by CHWs would of CHWs for performing their above mentioned have provided greater assistance in understan- roles had a positive impact on their performan- ding the threshold effect, if any, of these factors ce. Similarly the lack of incentives was found to on CHW performance in community settings. be one of the major reasons behind dropout Importantly, community ownership and super- rates. However, the provision of incentives vision of CHWs is a key characteristic which is in- provided better motivation to work. In some sufficiently described and analyzed in available studies the CHWs were promoted to the level literature. There was a large diversity in the inclu- of supervisor. ded studies that ended up having small number of similar studies in each group.379 Therefore we In various studies, a very strong referral system could not evaluate the impacts with the charac- was in place using which the health workers teristics of CHWs involved. There is thus a clear would refer complicated cases to nearby health need for additional research at an appropriate care facility after initial management.44, 193, 223, scale with detailed description of each interven- 224, 227, 237, 299 tion bundled in a form of package.

The diversity observed in the services of CHWs We also tried to look at the impact of CHWs is a testimony to the wide range of health care intervention on the outcome achieved accor- services that they are capable of extending to ding to those who were paid and those who the community. Several pitfalls and shortco- were unpaid. The major limitation we faced in mings were observed which acted as barriers evaluating this factor was the incomplete docu- to the outreach services of CHWs. However, mentation in the reviewed studies. Among all keeping in mind the significance of the role of 326 reviewed studies, only 32 mentioned that CHWs in the achievement of the MDGs makes it their CHWs were paid either in terms of salary or imperative to address these shortcomings and were getting reimbursement for their meals and come up with practical recommendations to transport cost. While, on the other hand, only 4 overcome these obstacles. studies reported that their workers were unpaid or working on voluntary basis. Comparison on Notably, most of the reviewed studies when im- this factor was therefore not promising, and plemented, neglected to document the com- results were meaningless.

199 We recommended CHW typology primarily from the evidence derived from global syste-

matic review (Table 23) and if the similar prac- . (3-4)

(2) tice has also been recommended from other Cochrane reviews (Table 24). The criteria have

We analyzed studies analyzed We and reports and CHW recommended typology from: Studies with strong designs and/or studies with findings significant (3-4) and evidence if positive from was available similar Cochrane reviews given importance to three main components: type of evidence, strength of evidence and existing evidence from Cochrane review. Thus, the recommendations for core contextual factors were made when the evidence was generated from studies with strong study design, with high CHWs contextual factors contextual CHWs typology CHWs *Recommended Recruitment Education content/ Training duration (initial and ongoing) Certification process Monitoring and supervision Volunteer/salaried Incentives pathways Career and advancement system Referral strength of evidence and when Cochrane review also suggested positive impact of community

health workers on particular MDG target.

= Evidence available available Evidence = 2

= Evidence not available available not Evidence = 1

Evidence available available Evidence reviews existing from

= Very strong (very significant <0.01) significant (very strong Very = 4

= Strong (significant <0.05) (significant Strong = 3

= Moderate (partially significant <0.1) significant (partially Moderate = 2

= Poor (insignificant >0.1) >0.1) (insignificant Poor = 1

Strength of evidence of evidence Strength studies) (from

= Cluster /randomized controlled trial trial controlled /randomized Cluster = 4

= Quasi-experimental Quasi-experimental = 3

= Prospective time series (before/after) series time Prospective = 2

= Descriptive Descriptive = 1 Type of evidence of evidence Type (study design) Table 23: Criteria for Recommending CHW typology from Global Systematic Review Review Global CHW typology Systematic Recommending from for 23: Criteria Table Recommendations were based on type of evidence, strength of evidence and if evidence were available from existing Cochrane reviews reviews existing Cochrane from available of evidence and if evidence based on type were strength of evidence, Recommendations were Studies related to to related Studies MDG-1 Nutrition MDG-4 Child Health MDG-5 Maternal Health *

Global Evidence of Community Health Workers - - - - Results both conducted countries. in developing studies included, Two no diffe In showed the nutritional status at 30 months in 500 children one, monitoring and those not. growth to between those allocated rence knowledge mothers’ other study examined whether counseling improved The months. chart, at four scores of the growth and reported test better in mammography with an increase support associated calls were Peer telephone in and 34% of women in the intervention with 49% of women group screening, since the start a mammogram receiving of the intervention group (Pthe control maintain to support peer telephone found Postnatal (Edinburgh mothers with postnatal depression peer supportThe symptomato depressive intervention decreased significantly 12). 6.23 (95% confidence interval ratio (OR) assessment (odds logy at the 4- week (CI) 1.15 27.84; P = 0.01). 6.23 (95% CI 1.40 to assessment (OR 33.77; P = 0.02)) and 8-week to the use of peer support patients with poorlyOne study investigated for groups between differences significant no were There diabetes. controlled self-efficacy,and body mass index. level for HbA1C, cholesterol rates breastfeeding low typically with USA the in incomes low on women) (582 studies Five compared rates initiation increasing on effect significant a had education breastfeeding showed (risk ratio (RR) 1.57, 95% confidence interval care to 2.15, P = 0.005). standard (CI) 1.15 to sessions education repeat informal needs-based, one-to-one, that showed analyses Subgroup in breast terms in of an increase effective education sessions are antenatal formal and generic, intention. of ethnicity and feeding incomes regardless on low among women rates feeding peer support informal Needs-based, and postnatal periods in the antenatal was also were women who in one study conducted among Latina be effective to shown 6.14, P < 0.00001). in the USA (RR 4.02, 95% CI 2.63 to considering breastfeeding Type of studies Type included RCTS and Quasi RCTs studies 2 Randomized trials controlled trials 11 Randomized trial controlled studies included 11 MDG 1 (nutrition) MDG 4 (breastfeeding) MDG 4 (breastfeeding) MDG targeted - - - Table 24: Evidence from Cochrane Systematic Reviews Reviews Systematic Cochrane from 24: Evidence Table Protocol Objectives routine of effects the evaluate To monitoring on: growth death, preventing to in relation child, The 1. for illness or malnutrition; and referrals medical specialist assessment medical care, social support or professional follow-up. nutritional to in relation mother, The 2. knowledge, anxietyabout the or reassurance health, and satisfaction with services. child’s of peer support assess the effects telepho To blood pressu (e.g. ne calls in terms of physical symptoms), depressive (e.g. psychological re), uptake (e.g. outcomes health behavioural and and other outcomes. of mammography) of interven the effectiveness evaluate To encourage women tions which aim to in terms of changes in the breastfeed to who startnumber of women breastfeed. to 382 381 380 Review REVIEW REVIEW REVIEW Review Review ID / year & Panpanich Garner 2009 2009 Dale et al. Dyson 2005 et al. Evidence from Cochrane Reviews Cochrane from Evidence

201 - - Results breastfeeding Antenatal components. type education with breastfeeding Any of antenatal being imparted information during pregnancy ineducation is defined as breastfeeding include home visiting basis, could be on an individual or group This a variety of forms. or clinic appointments specifically aimed peer education programmes programmes; or booklets;at impartingknowledge; Brochures electronic education breastfeeding fathers or not. prospective and could involve or a combination of these, programmes; Intervention: of newbornthat include the use care programs neonates antibiotics for of health existing level (vs. of a health education strategy the effectiveness compare To education), imparted country mothers or their family members in developing to com and health care, access to munity on neonatal mortality, neonatal morbidity, settings, used: the educational strategy to will conduct analyses according separate We cost. control one counseling vs. 1. One to control counseling vs. 2. Group control vs. combination of the above 3. Any counseling group one counseling vs. 4. One to in: qualityof LHWs evidence of moderate of the effectiveness Analyses found immunization childhood uptake 1.37; P = 0.0004);promoting (RR 1.22, 95% CI 1.10 to 1.61; P < (RR = 1.36, 95% CI 1.14 to initiation of breastfeeding promoting 1.39; P = 0.0004), and (RR 1.24, 95% CI 1.10 to breastfeeding 0.00001), any 4.44; P <0.0001); (RR 2.78, 95% CI 1.74 to breastfeeding exclusive (RR 1.22 (95% CI 1.13 to rates TB cure pulmonaryImproving usual care. to 1.31) P <0.0001), when compared 1.09; P = 0.99) completion (RR 1.00, 95% CI 0.92 to treatment TB preventive child morbidity 0.99; P = 0.03) and child mortality (RR 0.86, 95% CI 0.75 to (RR 0.75, 1.02; P = 0.07), 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 95% CI 0.55 to Increase the likelihood childhood ill of seeking for care 2.05; P = 0.20). ness (RR 1.33, 95% CI 0.86 to Unpublished results: a wide range of interventional covering included 19 studies, packages, review The of which included in the meta-analysis. 2008 trial) were 17 trialsBaqui et al. (and two subsets from reduction in maternal mortalityReview any did not show (RR 0.74; 95% CI: 0.51-1.07). reduction was observed significant in maternal morbidity (RR 0.75; 95% CI: 0.61- However, 0.92); neonatal mortality (RR 0.74; 95% CI: 0.66-0.82), stillbirths (RR 0.84; 95% CI: 0.74-0.96) and perinatal mortality (RR 0.80; 95% CI: 0.71-0.90) as a consequence of implementation of community-based interventional packages. to care It the referrals also increased 40% (RR 1.40; 95% CI: 1.19-1.65), complication by pregnancy related health facility for 94% (RR 1.94; 95% CI: 1.56-2.42). by of early the rates breastfeeding and improved Type of studies Type included randomized trials controlled Community-based controlled, randomized cluster-randomized or quasi-randomized trials. controlled RCTs Eighty-two studies Randomized and quasi-randomized trials controlled - (TB) MDG 4 (breastfeeding) MDG 4 (management of newborn sepsis) MDG 4 (management of newborn sepsis) MDG 4 (immunization and breast and feeding) MDG 6 and 4 MDG MDG 5 MDG targeted - - - - Objectives of ante assess the effectiveness To education for natal breastfeeding duration. breastfeeding increasing forms various of effectiveness the compare To peer example, education; for of antenatal didacticsupport, educational programme, booklets, etc, session, workshop, teaching or a combination of these interventions duration. breastfeeding increasing for of community determine the effect To the mana that address based programs to gement of neonatal sepsis compared include not do that programs similar on neonatal mortalityantibiotic treatment with confirmedin neonates or suspected countries. sepsis in developing of a health the effectiveness compare To of health existing level (vs. education strategy education), imparted mothers or their to countryfamily members in developing com munity on neonatal mortality, neona settings, and cost. health care, access to tal morbidity, interventions LHW of effects the assess To care health community and primary in the and health child and maternal on diseases. management of infectious of community- assess the effectiveness To based intervention packages in preventing maternal and perinatal mortality and health outcomes. morbidities; and improving 387 385 386 384 383 REVIEW Review Review ID / year Lumbiganon 2007 et al. PROTOCOL 2009 Zaidi et al. PROTOCOL 2009 et al. Thaver PROTOCOL 2010 et al. Lewin 2009 Haider et al. PROTOCOL

Global Evidence of Community Health Workers - - Results DOT and self administration in between was detected difference No statistically significant 1.21, random-effects (RR 1.02, 95% CI 0.86 to terms model; 1603 participants, of cure 4 trials) DOT with compared home at provided DOT location, by stratified When at clinic suggests a possible small advantage with home-basedprovided 1.18; 1365 participants, (RR 1.10, 95% CI 1.02 to 3 trials). cure for DOT DOT at a clinic between in clinical outcomes detected difference was no significant There provided a family member or community by health workerversus DOT (2 trials), or for a community a family member versus health workerby (1326 participants, 1 trial). no statistically drugs users found in intravenous prophylaxis small trials of tuberculosis Two DOT and self administration (199 participants, 1 betweentrial) or difference significant (108 participants, completion of treatment 1 trial). for DOT a choice of location for typesThese of interventions assessed will be separately of their susceptibility influenza. perceptions to interventions:patients’ increase to 1. Patient and up interventions:demand for increase 2. Administrative to take individuals or communities of vaccinations by 3. HCW interventions:HCWsusceptible to that elderly increase individuals are beliefs to and their patients; for themselves and safe influenza and that vaccination is effective 4. Societal interventions: frameworks or decisions that dif administrative such as increased betweenvaccination rates, societies and affect fer vaccination rates. increasing for HCWs to remuneration educational or counseling interventionAny alone or in combination with each other aimed in which education and/or Trials treatment. anti tuberculosis to adherence at improving other types by of interventionscounseling interventions confounded will be excluded. are on changing focusing Those types: interventions The include the following may Examples include mass media altering social norms. by condom use behaviors as social marketing the use of public opinion leaders, strategies, campaigns, as some interventionswell of social learning which employ strategies. - Type of studies Type included Randomized and quasi-randomized trials controlled trials 11 RCTs and quasi-ran cohortdomized, and case-control studies. Randomized trials controlled Randomized controlled before (RCTs), trials trials after and MDG 6 (TB) 6 MDG MDG 6 health(other problems) MDG 6 (TB) MDG 6 (HIV/AIDS) MDG targeted - - - - Objectives with self administration DOT compare To for options DOT or different of treatment active clinically for treatment requiring people of active disease. or prevention tuberculosis identify all interventions (patient, admi To and societal) to worker, health care nistrative, in those 60 influenza vaccination rates increase and older in institutions the community Education and of the effects evaluate To completion and counseling on treatment in people with clinical tuberculosis. cure assess the ef objective is to The of this review of structuralfects and community-level inter compa by condom promotion, for ventions assessing the or by ring strategies alternative with a control. compared of a strategy effect 389 391 388 390 REVIEW Review Review ID / year 2009 Volmink 2005 et al. Thomas PROTOCOL Volmink & M’Imunya 2007 PROTOCOL 2001 Myer et al. PROTOCOL

203 Assessment of CHWs roles in various interventions across the globe revealed: NOTE: [(a/b) suggests that out of ‘b’ many o Female sex workers (1/8) studies only ‘a’ times study (ies) reported that o Combination of didactic and interactive ses- component] sions, practicum and field work provided better understanding of topic and interven- MDG 4 and 5 tional content (13/77) o Behavioral therapy and counseling skills Receiving formal schooling had better impact (4/8) o Positive attitude towards family planning (2/3) o Proper management of childhood illnesses using algorithms (10/11) o Effective counseling skills for breastfeeding promotion (10/22) and immunization (6/9)

Workers who were female, married, and had children had a positive impact on o Promotion of breastfeeding à personal experience of feeding their own child (16/22) o Uptake of family planning (4/5)

Combination of didactic and interactive sessions, practicum and field work provided better understanding & intervention content (78/125)

Specialized certified training was associated with better results o On management of childhood illnesses (11/30) o Breastfeeding counseling (4/11)

Continuing training once in a month provided a platform (22/125) o For discussing field issues o Updating knowledge and skills o Refill drugs and supplies stock o Provision of incentives provided better motivation to work o Birth and newborn care preparedness intervention (4/7)

MDG 6 Recruitment advantages o Person with AIDS or those who have taken care of any family member with AIDS (9/40)

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353 Lam TK, McPhee SJ, Mock J, et al. Encouraging 362 Hadi A. Diagnosis of pneumonia by commu- Vietnamese-American women to obtain Pap nity health volunteers: experience of BRAC, tests through lay health worker outreach and Bangladesh Tropical Doctor. 2001;31:75-77. media education. Journal of general internal medicine. 2003;18(7):516-524. 363 Hadi A. Management of acute respiratory infections by community health volunteers: 354 Hiatt RA, Pasick RJ, Stewart S, et al. Community- experience of Bangladesh Rural Advancement based cancer screening for underserved women: Committee (BRAC). Bull World Health Organ. design and baseline findings from breast and 2003;81:183-189. cervical cancer intervention study Preventive Medicine 2001;33:190-203. 364 Darmstadt GL, Baqui AH, Choi Y, et al. Validation of community health workers’ assessment of 355 Declaration of Alma Ata. Paper presented at: neonatal illness in rural Bangladesh. Bull World International conference on Primary Health Health Organ. Jan 2009;87(1):12-19. Care, Alma-Ata, 6-12 September, 1978; USSR. 365 Mohanty N, Mohapatra SC, Srivastava PS, Gupta 356 Satishchandra DM, Naik VA, Wantamutte AS, JNP. The measurement of performance skills Mallapur MD. Impact of training of traditional of primary maternal child health workers-an birth attendants on the newborn care. Indian Indian experiment Indian Journal of Community Journal of Pediatrics. 2009;76(1):33-36. Medicine 1994;19(2-4):59-63.

357 Falle TY, Mullany LC, Thatte N, et al. Potential role 366 Ogunfowora OB, Daniel OJ. Neonatal jaundice of traditional birth attendants in neonatal heal- and its management: knowledge, attitude and thcare in rural Southern Nepal. Journal of Health, practice of community health workers in Nigeria Population and Nutrition. 2009;27(1):53-61. 2006;6(19).

358 Khan MH, Saba N, Anwar S, Baseer N, Syed S. 367 Zeitz PS, Harrison LH, Lopez M, Cornale G. Assessment of knowledge, attitude and skills of Community health worker competency in lady health workers Gomal Journal of Medical managing acute respiratory infections of child- Sciences 2006;4(2):57-60. hood in Bolivia. Bulletin of Pan American Health Organization. 1993;27(2):109-119. 359 Afsar HA, Younus M, Gul A. Outcome of patient referral made by lady health workers in Karachi, 368 Ayele F, Desta A, Larson C. The functional status Pakistan; 2005. of community health agents: a trial of refresher courses and regular supervision. Health Policy 360 Afsar HA, Qureshi AF, Younus M, Gulb A, and Planning. 1993;8(4):379-384. Mahmood A. Factors affecting unsuccessful referral by the lady health workers in Karachi, 369 PC-I. National Programme for Family Planning Pakistan. Journal of Pakistan Medical Association and Primary Health Care «The Lady Health 2003;53:521-528. Workers Programme 2003-08. : Government of Pakistan August 2003.

227 370 Rodney M, Clasen C, Goldman G, Markert R, CD004015. Deane D. Three evaluation methods of a community health advocate program Journal of 380 Panpanich R, Garner P. Growth monitoring in Community Health. 1998;23(5):371-381. children. Cochrane Database Syst Rev. 2000;2:1- 11. 371 Stekelenburg J, Kyanamina SS, Wolffers I. Poor performance of community health workers 381 Dale J, Caramlau IO, Lindenmeyer A, Williams in Kalabo district, Zambia. Health Policy. SM. Peer support telephone calls for impro- 2003;65:109-118. ving health Cochrane Database of Systematic Reviews. 2008; Issue 4. Art. No.: CD006903. DOI: 372 Fatusi AO, Makinde ON, Adeyemi AB, Orji EO, 10.1002/14651858.CD006903.pub2. Onwudiegwu U. Evaluation of health worker’s training in use of partogram Indian Journal of 382 Dyson L, McCormick FM, Renfrew MJ. Gynecology and Obstetrics 2008;100:41-44. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic 373 Jacob KS, Senthil Kumar P, Gayathri K, Abraham Reviews. 2005;Issue 2. Art. No.: CD001688. DOI: S, Prince MJ. Can health workers diagnose de- 10.1002/14651858.CD001688.pub2. mentia in the community? Acta Psychiatrica Scaninavica. 2007;116:125-128. 383 Lumbiganon P, Martis R, Laopaiboon M, Festin MR, Ho JJ, Hakimi M. Antenatal breastfee- 374 FrazãoI P, MarquesII D. Effectiveness of a com- ding education for increasing breastfeeding munity health worker program on oral health duration. Cochrane Database of Systematic promotion. Rev Saúde Pública. 2009;43(3) Reviews. 2007;Issue 2. Art. No.: CD006425. DOI:10.1002/14651858.CD006425. 375 WHO. The global shortage of health workers and its impact April 2006. 384 Zaidi AKM SM, Bhutta ZA, Thaver D. Community based management of neonatal sepsis in deve- 376 Werner D. Where there is no doctor: Macmillan; loping countries (Protocol). Cochrane Database 1985. of Systematic Reviews. 2009;Issue 1. Art. No.: CD007646. DOI: 10.1002/14651858.CD007646. 377 Chowdhury AMR. Rethinking interventions for women’s health Lancet. 2007;370:1292-1293. 385 Thaver D, Zaidi AKM, Owais A, Haider BA, Bhutta ZA. The effect of community health educational 378 Baqui AH, Rosecrans AM, Williams EK, et al. NGO interventions on newborn survival in deve- facilitation of a government community-based loping countries (Protocol). Cochrane Database maternal and neonatal health programme in ru- of Systematic Reviews. 2009; Issue 1. Art. No.: ral India: improvements in equity. Health Policy CD007647. DOI: 10.1002/14651858.CD007647. and Planning. 2008;23:234-243. 386 Lewin SA, Dick J, Pond P, et al. Lay health wor- 379 Lewin S, Munabi-Babigumira S, Glenton C, et al. kers in primary and community health care. Lay health workers in primary and community Cochrane Database Syst Rev. 2005;1. health care for maternal and child health and the management of infectious diseases. Cochrane 387 Lassi ZS, Haider BA, Bhutta ZA. Community- Database of Systematic Reviews 2010;Issue 3. based intervention packages for preventing Art. No.: CD004015. DOI: 10.1002/14651858. maternal morbidity and mortality and impro-

Global Evidence of Community Health Workers ving neonatal outcomes. Cochrane Database of Systematic Reviews 2010 [Submitted].

388 Volmink J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database of Systematic Reviews. 2007(4).

389 Thomas RE, Demicheli V, Jefferson T. Interventions to increase influenza vaccination rates of those 60 years and older in the community and in institutions. Cochrane Database of Systematic Reviews. 2005;Issue 2. Art. No.: CD005188. DOI: 10.1002/14651858.CD005188.

390 M’Imunya MJ, Volmink J. Education and counseling for promoting adherence to the treatment of active tuberculosis. Cochrane Database of Systematic Reviews. 2007;Issue 3. Art. No.: CD006591. DOI: 10.1002/14651858.CD006591.

391 Myer L, Morroni C, Mathews C, Tholandi M. Structural and community-level interventions for increasing condom use to prevent HIV and other sexually transmitted infections. Cochrane Database of Systematic Reviews 2001; Issue 4. Art. No.: CD003363. DOI: 10.1002/14651858. CD003363.

229 Annex 2: Country Case Studies

Country Case Studies After deriving out an evidence from a global systematic review, an in-depth country specific CHW program have been evaluated to further appraise the typology, impact, and performance assessment of the practices of CHWs deployed at scale in eight countries across the world. The eight countries investigated in this section were chosen based on their high burden of disease and low utilization of health services and most importantly with the reason that they are far off from reaching the targets of the MDGs set for the year 2015. To understand the typology, experience, training needs, program roll out and assessments of CHWs to-date, we also undertook case studies in eight representative countries from Latin America, Africa and Asia, with high burden of diseases. These countries have been selected on the basis of existing CHW programs in the public and non-governmental sector and include: 1 South Asia (Bangladesh, Pakistan, Thailand) 2 Latin America (Brazil and Haiti) 3 Africa (Ethiopia, Uganda and Mozambique)

Global Evidence of Community Health Workers Supervisor (post name) Lady Health Supervisor (LHS) KormiShasthyo (SK) health Village Sr. volunteer health Village Sr. volunteer (Senior health agents, Social workers, Doctors, HIV health nurses, Public Senior Nurses, program Accompagnateurs (Accompagnateur Leaders) CHWs Village workerhealth center Female (%) Female 100% 100% 700% 95% 50% 60% About 50% - Duration Duration of training 15 months 3 weeks 3 weeks 12 weeks 3 months - health agents, 2 weeks -accompa and gnateurs, 1 month-TBAs 6 months 10 days - Per HH/per Per 10,000 pop 100-200 HH / 1000 population 150-250 HH 5-15 HH 12.57 per 10,000 population (na tional average) 10/10,000 (Up a maximum to of six patients per CHW) ~1 /20.000 -* Numbers of Trained CHWs 92 957 78 000 80,000 240,000 > 1,600 < 1000 -* Year Year Initiated 1994 1977 1970 1994 1985 1978 2003 Table 25: CHW Program in selected countries eight 25: CHW Program Table - Local name Local CHW for Workers Lady Health SebikaShasthyo Health Village Volunteer comuni Agentes tarios de Saúde (Health agents, Women’s health agents, birth Traditional (matrons) attendants Accompagnateurs, monitors, Youth agents Agricultural Polivalentes Agentes Elementares Health Village CHWs Team CHW Program CHW Program Name Lady Health Program Worker Bangladesh Rural Advancement committee- CHW program Health Village Program Volunteer Saúde Programa da Familia santé Projeveye (Zanmi Lasante’s Community Health Program) Agentes Polivalentes Elementares Program Health Village and Teams Program CHWs Country Pakistan Bangladesh Thailand Brazil Haiti Mozambique Uganda

231 ASIAN Case-Studies

Pakistan – Lady Health Workers Program Bangladesh – BRAC Community Health Workers Thailand – Village Health Volunteer Program

Global Evidence of Community Health Workers 1. Pakistan – Lady Health Workers Program Socio-economical and Political sector is rarely taken into account while making the Health plans. Economic polarization as such background has resulted in greater health inequalities.8 The Pakistan is a profound blend of landscapes maternal mortality ratio is alarmingly high and varying from plains to deserts, forests, hills, and is estimated to be 320 per 100,000 live births.9 plateaus ranging from the coastal areas of the The burden of diseases and service utilization Arabian Sea in the south to the mountains of indicators has been summarized in Box 3. the Karakoram range in the north with arable land, water, and extensive natural gas and oil In order to cater to the health needs of larger reserves as country’s principal natural resources. masses of the country, one major initiative to The total population according to the World improve the accessibility to primary health care, Health Statistics 2008 is 161,000,000.1 taken by the Government, was establishment of the Lady Health Worker Program (LHWP). The demographic and health scenario in Pakistan is characterized by a high birth rate, Brief historical description of a comparatively low death rate and a conse- the LHW Program quent rapid growth in population. Total fertility rate per woman in 2007 is reported to be 4.1/ The Lady Health Worker Program originally woman.2 Estimated crude death rate is 7.1 per designed in the early 1990s, later conceived in 1000, in which there has been a steady decline 1993 and finally launched in April 1994 as a fe- from 16 per 1000 in 1970 to the current 7.1 per deral development program. The program was 1000.1 However the infant mortality rate is still originally officially called the Prime Minister’s very high and estimated to be 91 per 1000 live Program for Family Planning and Primary Health births.3 Care (PMP-FPPHC) and then later in 2000 was changed to the National Program for Family According to the World Health report 2004 the Planning and Primary Health Care (NPFP & PHC), total health expenditure in Pakistan per capita but it is typically referred to as Lady Health is $184 whereas the total health expenditure as Workers Program (LHWP)10 Under this program a % of GDP is just 0.6% as reported by Pakistan paid Lady Health Workers (LHWs) are recruited Social and Living Standards Measurement from local communities, especially in rural areas Survey 2004-05.5 The private financing of health of the country, to provide services for family care is estimated to be more than 75% as per planning and primary health care. WHO 2006 report.6 Why this program for review? Health System Overview In a developing country like Pakistan, outreach Over the last decade the Government of Pakistan workers are essential for the delivery of health and several non-government organizations care especially in the rural areas. Seventeen have focused attention on improvement in the percent of all those who consult for an illness health sector. In Pakistan the healthcare compri- report consulting the LHW first, and not a phy- ses of public and private set ups. However, the sician.10 They play an important and increasing private healthcare system serves the affluent role in the provision of preventive, promotive, of the country, where the proportion of popu- and curative health care services. The program lation below the national poverty line is 32.6%, has expanded manifolds since its inception and according to the UN report.7 Besides, the private as such there have been some substantial im-

233 Recruitment Process provements in the level of service delivery since The LHWs are the women residing in the same the previous evaluation, particularly for family community for which they are recruited, accep- planning services.10 Therefore reviews on this table to their communities, trained to deliver program are necessary to further increase the family planning services, to promote positive coverage of services, so that they reach all regis- health behaviors and deal with health problems tered clients in compliance with the Millennium of individuals and the community through a Development Goals. PHC approach.11 The Lady Health Selection committee, which comprises of medical officer in-charge First Level Care Facilities Workers’ Program (FLCF), women medical officer-FLCF, lady health According to latest Oxford Policy Management visitor/ female medical technician-FLCF, male report on evaluation of Lady Health Workers technician/ dispenser, member nominated by Program, there are now close to 90,000 LHW na- the local community preferably the local educa- tionwide.10 Since its last evaluation in May 2000 ted union, council Nazim/ counselor, first identify the LHWP has expanded rapidly. In view of its potential LHWs through contacting community wide scope of work in terms of the population organizations if active in the area and in areas and health problems covered, and widely ex- where community organizations do not exist, panded infrastructure, in terms of health facili- the committee meet with key members of that ties, staff, drugs and supplies etc. There is a need community, discuss and obtain their support for for the program to have an efficient information the program. Selection committee also dissemi- system, responding to the information needs nates information through print media, and of various decision making levels of the health local announcements.11 system.

Box 3: Burden of disease and service utilization indicators in Pakistan Maternal Mortality Ratio 1 320 Neonatal Mortality Rate 1 53 Infant Mortality Rate 1 73 U-5 Mortality Rate 1 90 HIV / AIDS prevalence (%) 2 86 Malaria incidence (per 1000 population)3 0.75 Tuberculosis incidence ( per 100 000 population) 4 181 Tuberculosis prevalence (per 100 000 population) 4 263 Proportion children immunized for Measles 1 80 Proportion of births attended by skilled health personnel 1 39 Contraceptive Prevalence Rate 1 30 Antenatal care coverage (at least once) 1 36 Unmet need for family planning 1 33

Sources: 1 United Nations Population Division 2007 2 United Nations Program on HIV/ AIDS 2002 3 National Malaria Control Program, Ministry of Health, Pakistan 2006 4 World Health Statistics 2008

Global Evidence of Community Health Workers Selection of LHW is based on the following years only if she is married), criterion:11 past experience in community development, female (preferably married), willing to carry out the services from her home permanent resident of the area (for which she (designated health house that ensures effective is recruited), linkage between the community and the public health care delivery system) minimum 8 years of schooling (preferably matriculate), The age, marital status, residence and level of education of current LHWs has been summari- should be between 20 to 50 years (up to 18 zed in Box 3:10

Box 3: Characteristics of LHW The final selection of the LHWs is made after careful scrutiny of the documents and the Age Distribution (%) residential status of the applicants and their 15-19 1.1 20-24 12.2 selection is approved on the recommendations 25-29 24.6 of council Nazim/ counselor and on approval 30-34 27.7 of Executive District Officer – Health (EDO-H). 35-39 15.7 LHWs are initially employed on contract for one 40-44 9.6 year but their services are likely to continue for 45+ 9.0 the life of the Program. The LHWs, at the time of Mean age 32.6 Mean age when recruited 25.5 recruitment, are required to provide a notarized affidavit stating that they would perform their Marital Status (%) duties to the satisfaction of their supervisors for Never married 25.6 at least one year after the completion of their Currently married 65.8 Widow/divorced/separated 8.6 full training and incase of failing the course, they will have to return the salaries and equipment Years LHW has resided in Village/Mohalla (%) (LHWS kit bag, weighing scales etc) they have 0-2 3.7 3-4 5.4 received. The LHWs selected are then supervised 5-20 31.6 closely to ensure provision of quality services to More than 20 8.6 the communities. Those who do not fulfill the Since birth 50.7 selection criteria or those not performing their Mean years resided 21.7 duties satisfactorily are liable to termination of Educational Level (%) contract by the District Head of the health de- Less than 8 years 0.7 partment i.e. EDO (H)/DHO.10 8 or 9 years 35.7 Matric (10-11 years) 44.4 Intermediate (12-13 years) 15.1 The LHW Role Graduate (14+ years) 4.1 The prime role of LHWs is to provide PHC servi- Mean education Level (1-5) 9.84 % with class certificate seen ces to the communities in her catchment area and confirmed 77.2 and to organize community by developing women groups and health committees in her area. Source: OPM LHWP Fourth She has to look after a population of 1000 indi- Independent Evaluation, (2008) vidual for whom she arranges meetings of these

235 groups in order to effectively involve them in especially pregnant and lactating mothers as family planning, primary health care and other well as anemic young children related community development activities. In these meetings they discuss issues related to Promote nutritional education with emphasis better health, hygiene, nutrition, sanitation and on breast-feeding and weaning practices, ma- family planning and emphasize their benefits ternal nutrition and macronutrient malnutrition towards improved quality of life. They also act as a liaison between formal health system and the Coordinate with EPI for immunization of mo- people and ensure coordinated support from thers against tetanus and children against six NGOs and other departments. LHWs routine preventable diseases and participate in various activities are:10 campaigns for immunization against EPI target diseases Register all family members in the catchment areas specially the eligible couples (married wo- Involve in the surveillance activities men age 15-49 years) during their visits to households , and maintain up to date information Carry out prevention and treatment of common ailments e.g. malaria, diarrhea diseases, acute Visit 5-7 households every working day and en- respiratory infections, tuberculosis, intestinal sure a re-visit every two months parasites, primary eye care, scabies, snake bites, injuries and other minor diseases using essential Keep in close liaison with influential women drugs and refer cases to nearest centers as per of her area including lady teachers, traditional given guidelines birth attendants and satisfied clients Involve in DOTS and malaria control programs Motivate and counsel clients for adoption and continuation of family planning methods Disseminate health education message on individual and community hygiene and sanitation Provide condoms, oral pills to eligible couples as well as information regarding preventive in the community and inform them about pro- measure against spread of AIDS per use and possible side effects and also refer clients needing IUD insertions, contraceptive Submit monthly progress report to incharge surgery and injectable to the nearest FLCF in health center containing information regarding the government or NGO sector all activities carried out by her including the home visits, number of family planning accep- Coordinate with local TBAs/midwives or other tors by methods and stock position of contra- skilled birth attendants and local health facilities ceptives and medicines for appropriate antenatal, natal and postnatal services The LHWs role in curative care is substantially larger in rural areas than in urban areas (0). As Undertake nutritional interventions such as was found in the Third Program Evaluation, anemia control, growth monitoring, assessing this is particularly true for rural women and common risk factors causing malnutrition and girls; around a fifth of females who had been nutritional counseling ill consulted a LHW, if they consulted any care provider. It is interesting to note that the urban/ Treat iron deficiency anemia among all women rural differences are not so pronounced in the

Global Evidence of Community Health Workers Integrated training: (initial 3 months training) current survey. However, having increased the The first phase of basic training is for five days a coverage of services during a period of program week for three months. In this period, the newly expansion should be recognised as a significant recruited LHWs are trained to cover the major achievement.10 PHC subjects, which include immunization, diarrhoea control, reproductive health including Initial Training of LHWs maternal and child health and family planning, nutrition, common ailments, personal hygiene The training of LHWs are conducted in two pha- along with education on community organiza- ses for a total of fifteen months using program tion and interpersonal communication skills.10 training manuals and curriculum, which is then followed by continual training at the health facility along with refreshers. Their 15 months trai- Task Based Training: ning course is divided into integrated training (12 months training) 10 and task based training. The second phase of training lasts for twelve months with three weeks of fieldwork followed

Box 4: Consultations with the LHW by sick individuals by place of residence 2000 2008-All LHWs Measure Urban Rural Urban Rural Individuals who were ill or injured in the previous fourteen days % who consulted the LHW – total 11 22 14.2 18.1 % who consulted the LHW – female 14 25 16.1 20.2 % who consulted the LHW – male 8 19 12.2 15.8 Individuals who were ill or injured in the previous fourteen days and who consulted any health provider % who consulted the LHW first - - 6.1 9.4

Children under 5 who were ill in the previous fourteen days and who consulted any health provider % with diarrhea who consulted the LHW 10 15 14.9 19.9 % with respiratory infection who consulted the LHW 12 19 15.6 23.5 Children under 5 who were ill in the previous fourteen days and who consulted any health provider % with diarrhea who consulted the LHW first - - 2.7 13.1 % with respiratory infection who consulted the LHW first - - 8.8 16.2 Children under 5 who were ill in the previous fourteen days and who consulted LHW % mothers reported that LHW gave advice about how to prevent diarrhea in future - - 38.7 60.1 Source: OPM LHWP Fourth Independent Evaluation, Quantitative Survey Data (2008).

237 by one week of classroom training each month. months training of LHWs.10 This training gives special emphasis to fieldwork and practical work on health center patients. Equipment and supplies This training builds on the first three months to strengthen the competence and skills of LHWs. The LHWs are basically provided with oral contra- The training is job specific, focused on carrying ceptive pills and condoms and with a limited out instructions/procedures related to the work range of inexpensive following essential drugs of LHWs. The training of LHWs is linked to their for those health problems that are common.10 scope of work, to the problems they have to sol- Paracetamol Tabs 500mg ve and to their ability to carry out specified tasks. The training is participatory and instrumental in Chloroquine Tabs 150mg the process of helping LHWs to develop new Mabendazole Tabs 100mg skills, acquire knowledge, and apply what they are learning to their day-to-day working envi- Oral rehydration solution ronment. During this phase, the LHWs also work Cotrimoxazole Syp. in their communities for three weeks and come to the training site for one week each month.10 Ferrous Fumerate 150mg + Folic Acid 0.5mg Cotton Bandages 4” x 3m On-going Training of LHWs Benzyl Benzoate Lotion All LHWs attend their respective health facility/ Paracetamol Syp 120mg/ml training center for one day each month to get refresher training on an identified topic. In ad- Chloroquine Syp 50mg/5ml dition, problems faced by LHWs in providing Piperazine Syp 500ml/5ml services are discussed with the trainers. LHWs Polymyxin “B” Sulphate Eye Ointment (4 Gram) also submit their monthly report, and collect supplies for one month. LHWs are not given any B.complex Syp Complex refresher trainings, but in latest LHW program Antiseptic Lotion PC-I report, this issue has been highlighted and they have planned to provide LHWs with 15 days List of Non-Drug Items training each year in addition to the continuing education. They have also planned to remune- Cotton Wool (250 Gram) rate these LHWs with Rs. 50 per day in addition Sticking Plaster 1” x 5m to salary to cover travel costs and refreshment etc.11 The summary of training duration and by Pencil Torch with Two Cells whom it was imparted has been summarized in Thermometer Clinical Box 5. Scissors Training of Trainers LHW Kit Bags containing weighing scale etc. Salter Scale with Trouser Trainers of LHWs are FLCF staffs who are trained by district trainers for a period of 9 days followed by 3 days of assessment workshop to ensure the Supervision quality of training. This training team is paid 20% The National Program for FP & PHC has an ela- of their current salary per month during the 15 borate and multi tiered supervisory system. The

Global Evidence of Community Health Workers Box 5 :Training of LHWs Proportion of LHWs who received initial (basic) training 99.8 Duration of initial training Less than two months 0.0 Two months 0.0 Three months 94.1 More than three months 5.8 Total 100.0 Mean number of months of initial training 3.1 Training was imparted by Medical doctor (male) 87.2 Medical Doctor (female) 16.5 Lady health visitor 68.7 Dispenser 24.5 Male medical health technician 16.4 Female medical health technician 4.5 Others 7.5 LHW training was given by any female trainers Source: OPM LHWP Fourth Independent Evaluation, (2008).

cadre of LHW Supervisors has been developed Age: 22-45 years to provide supervisory support to the LHWs on daily basis. The LHS uses a structured checklist Education (In order of preference): LHV/Graduate for monitoring purposes. The Program has a pro- or LHW Intermediate with one year experience vision for one LHS for 25 LHWs i.e. a ratio of 1:25 as LHW or Intermediate reference. At the Provincial level, Field Program Preferably one-year relevant experience Officers (FPOs) are employed on contract to monitor the program in two or three districts Local resident of the area and report back to the Federal, provincial or district level program implementation unit on LHS are employed on contract initially for one monthly basis. In the case of non-performance year but their services are likely to continue the District Health Officer (DHO) has the autho- for the life of the program. They are paid Rs. rity to end the LHWs contract. Feedback to the 3300 per month as training allowance for three DHO and the District Coordinator can occur via months and later on the same amount is paid the community, the health facility, other DOH as fixed salary. They are given an annual raise of professionals, the LHS and the Field Program Rs. 200 per month as an incentive. LHS are also Officer.10 provided with POL for the vehicles (800cc Pick- ups) on an average of 70 liters per month. Those LHS working without vehicles get Rs. 70 as fixed LHS are selected based on the following 10 criteria10: travel allowance per field visit day. Female LHS are trained for one year and their training is

239 Performance Evaluation carried out in following three phases The program has carried out 3 evaluations. The result showed that Program is having a significant 02 months training of trainer manual + 03 weeks impact on a range of health outcomes. Fourth LHS manual + one week practical training 3rd party evaluations are in process. The mean 03 months field/on job training (First two weeks number of households registered by the LHWs in the field and last two weeks of every month is highest in Punjab and lowest in Baluchistan. class room training) on LHS manual with more The lower number of households registered by emphasis on practical training with audiovisual LHWs in Baluchistan is understandable due to support and role-play. the scattered population in this province. It is also likely that LHWs will have lower number of 46 months training (first 3 weeks of every month individuals registered due to the hilly terrain and in the field and last week for class room training) a scattered population in AJK/NAs and in some more emphasis in practical training in the areas parts of NWFP. All provinces have some house- of EPI, pediatrics, Eye, midwifery/Gynae/ Obs. holds that are registered with the LHW but do not know they are registered, although this has The LHS are trained on specially designed curri- improved since 2000. The problem is smallest culum and they use the program checklist du- in Balochistan and largest in Punjab. In most of ring field visits. Specific checklist and feedback the activity measures, however, Balochistan and report for LHS are also developed. Their main Sindh show the poorest performance. Around functions are to: two thirds of LHWs in Balochistan and a third Provide support and guidance of LHWs in Sindh reported working less than 15 hours in the preceding week. Two thirds of Ensure adequate performance of LHWs regar- LHWs in Balochistan and a quarter of LHWs in ding delivery of primary health care and family Sindh saw less than 10 clients in that week.10 planning services In his report on evidence-led training and com- Assess the level of community participation munity tools for LHWs in Sindh, Pakistan, pu- and involvement in support of LHW and the blished in August 2002, K Omer et al concludes program that use of traditional craft items to communicate health messages to the non-literate masses Identify deficiencies in communication skills proved quite effective. Results showed that a Check whether the eligible couples have been woman shown a traditional ajrak with maternal registered and contacted regularly for motiva- and child health care messages, was 61% more tion and delivery of family planning services likely to avoid heavy routine work during pre- and to find out reasons for non-acceptance and gnancy, was 60% more likely to breastfeed the to assist in the motivation and service delivery infant and twice as likely to follow the exclusive of hard-core cases breastfeeding guidance.12 The additional supervision provided to the LHWs and their active Provide support and supervise skilled birth involvement due to the intervention also see- attendants med to improve their performance. The impact Carry out corrective measures to improve the of the LHWs efforts was noted to be greater in performance of LHWs as per given guidelines cases where either women had some degree of formal education or if their spouse was educated.12

Global Evidence of Community Health Workers In another study by Douthwiate et al. the role of percent and 27 to 46 percent coverage respecti- CHWs in promoting modern reversible contra- vely. The proportion of children fully immunised ceptive methods was assessed as compared has increased from 57 to 68 percent. Measures to the population not approached by LHWs. of exclusive breastfeeding have also improved, The study showed that women served by Lady although this area needs further investigation. Health Workers are significantly more likely to However, the improvement in the contraceptive use a modern reversible method than women prevalence rate is modest, having increased by in communities not served by the Program (OR only 3 percentage points. = 1.50, 95% CI: 1.04–2.16, p =0.031), even after controlling for various household and individual Some areas of LHWs performance have howe- characteristics.13 It also showed that continuous ver stagnated or even decreased. Knowledge of support and monitoring by the supervisors en- mothers regarding at least one way to prevent sured successful results.13 diarrhoea has reduced; and growth monitoring services continue to have a limited coverage.10 The comparison between the year 2000 and The factors identified, leading poor performan- 2008 surveys11 suggests a substantial improve- ce, are failures in supply systems of medicines ment in a number of the LHWP target indicators. and equipments, like that in growth monitoring The improvements in tetanus toxoid coverage have been unavailability of functional weighing (five or more doses) and attended deliveries are scale to the LHWs. Another factor affecting the particularly large, with increases from 14 to 33 performance of LHWs has been the irregularity

Table 26: Performance Evaluation of LHWs Program coverage Coverage is about 1 per thousand populations. 70% of the population is covered Preventive and promotive Vaccination promotion coverage: 68% of children under five service delivery Contraceptive usage: 36% of all users of modern contraceptives Curative service delivery 17.2% of all LHW seen and referred emergency case in previous fourteen days Support system for LHWs Recruitment: vast majority meet program selection criteria Training: and their performance 99.8% received introductory training Knowledge: 86.8% of LHWs given at least one correct answer Supplies and equipment: lack of stock, expired stock, missing stock Salaries: one third had not been paid for over three months Supervision and LHS: 85.3% reported supervisor meeting in last 30 days Support from FLCF: 50% doctors present and 50% facilities lacked important medicines and supplies on the day of survey LHW impact on health Indicators of population served by LHWs were slightly better off than National figures

LHW costs – current and Actual level of funding is much lower than the levels originally planned future

Source: OPM LHWP Fourth Independent Evaluation, (2008).

241 in the payments of salary and deduction in and to mothers for safe motherhood including salaries due to untold reasons.10 One out of ante natal, safe delivery and postnatal care. ten LHWs has been reported to charge for the LHWs achieve this by close coordination with services offered.10 the nearest health facility, TBAs and other skilled birth attendants including midwives.10 Incentives Professional Advancement During their initial training of three months they are paid Rs. 50 per day for first three months fol- Professional advancement and promotions are lowed by Rs. 1600 (approx USD 20) per month. offered to LHW to learn new skills to advance They are also given an annual raise of Rs. 100 their career as LHS and later on as Field Program as an incentive, whereas, their monthly salary is Officer (FPO) on completion of minimum edu- Rs. 3090 (approx. USD 38). Other incentive they cation level (intermediate to become an LHS receive is in the form of money which they earn and Masters in any field to become an FPO) and after selling contraceptives to their clients. They experience (1 year work experience as LHW to charge Rs. 3 per cycle of pills and Rs. 0.50 per become an LHS and 2 years work experience as condom. LHS to become an FPO) required to reach the next level. Hence, advancement is intended Community Involvement to reward good performance or achievement. There are no paths planned to retirement for Through the process of community organiza- LHWs.10 tion for PHC and family planning, members of the community are organized for participation Documentation and in health promoting activities. These activities include participation in:10 Information Management In view of its wide scope of work in terms of Decision making during project planning/pro- the population and health problems covered, ject implementation at the local level and widely expanded infrastructure, in terms Monitoring and evaluation of health facilities, staff, drugs and supplies etc. there is a need for the program to have an ef- Various primary health care services (e.g. immu- ficient information system, responding to the nization, improved sanitation etc) information needs of various decision making Possible approaches that are employed for levels of the health system. Procedures and initiating contact with community are through instruments are developed to collect data in advocacy and awareness raising activities and key areas having impact on the health status of by establishing organizations like health com- the communities through the LHWs. Data are mittees, women groups and through health passed on to the FLCF, district, provincial and care delivery outlets. federal level for compilation and analysis. The federal, provincial and district program implementation units are equipped with computers Referral System and printers for proper compilation and analysis One of the important functions of the LHW is of the reports on monthly, quarterly and annual referral of patients to the appropriate health basis. The federal, provincial and district PIUs are facility. LHWs provide motivation and referral linked through WAN or e-mail for timely and service to community for common ailments efficient transfer of data. LHW MIS system has

Global Evidence of Community Health Workers been placed for proper management of information; however, the HMIS in its present form is limited to the FLCFs, without incorporating the data from the community level. The different kinds of tools used by LHWs are: Map of community Family (Khandan) register Community chart Treatment and family planning register & Diary Mother and child health card Referrals slips Monthly report of LHW

243 3 3 3 2 2 Current Current Level/ Evidence 3 (best practice) community from Recruited If when possible. not possible, the community is consulted and agrees during the process selection. on recruitment community, Health system, the role/ and CHW design expectations and policies in place that support CHW Role and expectations role. CHW and clear to are for Process community. and discussion of update role/expectations in place CHW and community for Initial training is provided within the six all CHWs to months that is based on for CHW. defined expectations Some training is conducted in the community or with community participation. with is consistent Training health facility guidelines for community and health care in training. facility is involved On-going training is provided CHW on new skills, update to and initial training, reinforce he/she is practicing ensure is Training skills learned. tracked and opportunities in a consistent offered are all and fair manner to (not only some) CHWs All necessary supplies; no substantial stock-out periods. - - - CHW is not recruited from com from CHW is not recruited munity but the community is on the final selection.consulted defines (policies Health system but without exist) the CHW role community input. Role is clear CHW and communityto but little discussion of specific expectations. General agree between CHW, ment on role and community. health system, to Initial training is provided year within the first all CHWs does Training of recruitment. not include participation community from or health center. referral On-going training is provided Some super basis. on a regular up with coaching. visors follow have CHWs Functional Note: updated) been trained (or within the last 18 months. on ordered Supplies are basis although a regular Stock delivery can be irregular. out of supplies essential for defined CHW tasks occur at of x per year/mo a rate 2 - - 1 from CHW is not recruited community but the commu nity (reluctantly) accepts the identified CHW after selection. of CHW exists role No formal (no policies in place) General to expectations given are CHW (initial training) but CHW and not specific. are community do not always on role/expectations. agree Minimal initial training is etc). (1 workshop, provided works attend Some CHWs topics. hops on specific ad hoc visits Occasional, supervisorsby provide some coaching. Inconsistent supply and supportrestocking to formal No defined CHW tasks. re-ordering. for process - Table 27 – CHW Program Functionality Assessment Tool (CHW-PFA) – Pakistan (CHW-PFA) Tool Assessment Functionality 27 – CHW Program Table 0 community CHW not from and in the recruitment. no role plays upon Role is not clear or agreed community between CHW, health system. and formal No initial training is provided. No ongoing training is provided No equipment and sup provided. plies are Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional

Training provided to to provided Training Component Component Definition Recruitment a where and from How community health worker and selected, is identified, a community. to assigned CHW Role design Alignment, and clarity from of role and CHW, community, perspectives. system health Training Initial role for prepare CHW to in MCH services delivery he/she has the and ensure necessary skills provide to and quality care. safe Training On-going On-going training to CHW on new skills,update initial training, reinforce he/she is and ensure practicing skills learned. and Supplies Equipment equipment Required deliver and supplies to expected services.. 1 2 3 4 5

Global Evidence of Community Health Workers 3 3 2 2 Current Current Level/ Evidence - - - All necessary supplies; no substantial stock-out periods. 3 (best practice) Regular supervision visit every 1-3 months that includes reports,reviewing monitoring Data is of data collected. solving problem used for Supervisorand coaching. makes visits community, skills provides home visits, Supervisor CHW. coaching to is trained in supervision and has supervision tools evaluation least once/year At that includes individual performance (local eva luation) and evaluation of or monitoring data coverage evalua (national /program tion) Community is asked to on CHW feedback provide clear are There performance. good perfor for rewards and community mance, plays rewards. in providing a role and/or non-financial Financial partly are incentives based on good performance. Incentives balanced and in line with are expectations placed on CHW. Examples of non-financial that engage incentives workers might include (advancement, recognition, certification process) an activeCommunity plays in all supportrole for areas such as development CHW, feedback, providing of role, providing solving problems, establish helps to incentives, CHW as leader in community. - Regular supervision visit at least every months that three reports,includes reviewing monitoring of data collected and occasionally provide supportproblem-solving to Supervisors trained not are CHW. in supportive supervision but facility are based health workers. evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage data (national /program evaluation). Community is not on feedback asked provide to There performance. CHW’s good for some rewards are performance, such as small etc. recognition, gifts, incentive Some financial or non-financial provided. are incentives Examples of non-financial incen include occasional formal tives additional training, recognition, and other small incentives. significant Community plays in supportingrole the CHW groups, mother’s through CHW is widely networks, etc. for and appreciated recognized serviceproviding community. to 2 - 1 Supervision visits conducted times between two and three collect to reports/per year meetings at group data (or facility turn to in monitoring No individual perforforms). workmance supporton offered coaching) (problem-solving, evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage no rewards are There data. good performance. for provided incentives No formal but community recognition a reward is considered ICommunity is sometimes education) (campaigns, involved with the CHW and some people in the community recognize the CHW as a resource. 0 No supervision or regular evaluation occurs outside of by CHWs occasional visits to nurses or supervisors when or less). possible (1x/year evaluation of No regular performance CHW. by No financial or non-financial provided incentives with Community is not involved ongoing support CHW to Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional -

Component Component Definition Supervision Supervision conducted carry basis to on a regular tasks out administrative individual provide and to performance support data- (feedback, coaching, driven problem-solving). Evaluation Performance fairly to Evaluation assess work during a set period of time. Incentives salary Financial= and bonu ses Non-financial= training, certification,recognition, etc. medicines, uniforms, Involvement Community Role that community in supportingplays CHW. 6 7 8 9

245 1 2 2 Current Current Level/ Evidence - - 3 (best practice) CHW knows when to signs, client (danger refer etc) additional treatment, CHW and community know facility is and referral where plan for a logistics have (transport,emergencies with a funds) Client is referred slip of paper and information to CHW with a back flows and/ form referral returned or monthly monitoring. is (promotion) Advancement who performto CHWs offered an and who express well in advancement if the interest opportunity exists (advan cement might mean path to sector or change in formal opportunities are Training role) to learnto CHW new offered skills and advance their role to of them. CHW is made aware to is intended Advancement good performancereward or and is based on achievement, is fair evaluation. Retirement encouraged and incentives encourage to provided are at a set age. retirement document their CHWs and group visits consistently facilitymonitoring visits to who CHWs by attended are bring monitoring forms. Supervisors quality monitor of documents and provide CHWs/ help when needed. communities work with supervisor facility or referral use data in problem-sol to ving at the community. - - CHW knows when to refer CHW knows refer when to additional signs, client (danger CHW and etc) treatment, community know referral where facility is and usually have transportthe means to client with a slip of Client is referred tracked paper and informally by CHW (checking in with family, up visit) but information follow to CHW. back does not flow is (promotion) Advancement to CHWs sometimes offered for been in program who’ve Limited specific length of time. training opportunities offe are learn CHW to new skills to red Advancement advance role. to good reward to is intended performance or achievement, although evaluation is not (advancement might consistent sector or formal mean path to reti No path to change in role). CHWs is made clear to rement document their CHWs and group visits consistently facilitymonitoring visits to are who bring CHWs by attended Supervisorsmonitoring forms. qualitymonitor of documents help when needed. and provide do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 2 - - 1 client CHW knows refer when to additional treat signs, (danger CHW and communityment, etc) facility know referral where referral no formal is but have is not Referral process/logistics tracked community by or CHW is (promotion) Advancement to CHWs sometimes offered been in program who’ve specific length of time. for No other opportunities discussed with CHW. are to is not related Advancement performance or achievement. document their vi Some CHWs monitoring visits sits and group CHWs by facilityattended to are who bring monitoring forms. do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 0 in place: CHW system No referral might know to when and where plan client, but - no logistics refer the communityin place by for - information emergency referral is not tracked or documented advancement is No professional offered. documentation for No process management is followed or info Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional - Component Component Definition System Referral - for a process Is there determining when referral plan is needed logistics transport/payment for to facility a health care when is referral - how required tracked and documented Advancement Professional growth, possibilityThe for advancement, promotion CHW for and retirement Documentation, Management Information document CHWs How to data flows how visits, and the health system the commu back to it is used and how nity, servicefor improvement 10 11 12

Global Evidence of Community Health Workers Table 28 – Community Health Worker Functionality Matrix – MCH Interventions – Pakistan MCH INTERVENTIONS YES COMMENTS 1 ANTENATAL CARE A Iron folate supplements Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Maternal nutrition Counsel x Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment o C Counsel on birth preparedness/complication readiness x * (includes counseling to use skilled birth attendant) D Tetanus toxoid Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x E Deworm Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment o 2 CHILDBIRTH and IMMEDIATE NEWBORN CARE A Prevent Infection/Clean Delivery x (Hand washing, clean blade +/or clean delivery kit) B Provide Essential Newborn Care a. Immediate warming and drying x b. Clean cord care x c. Early initiation of breastfeeding x C Recognize, initially stabilize (when possible) and refer for maternal and newborn complications a. newborn asphyxia o b. sepsis, o c. hypertensive disorder o d. hemorrhage e. prolonged labor and post-abortion o complications D Prevent PPH: AMTSL or use of uterotonic alone o in absence of full AMTSL competency (e.g. oral Misoprostol) E Provide special care for Low Birth Weight newborns o (Kangaroo Care) 3 POST-PARTUM and NEWBORN CARE A Provide counseling on evidence-based maternal newborn health and nutrition behaviors a. clean cord care; o b. exclusive BF through 6 months; x c. thermal protection; hygiene; o d. danger sign recognition; o e. maternal nutrition, etc. o

247 MCH INTERVENTIONS YES COMMENTS B Assess for maternal newborn danger signs and provide o appropriate referral. C Provide Treatment for severe newborn infection (when o community-based treatment supported by national guidelines.) 4 EARLY CHILDHOOD A Infant and young child feeding, IYCF: x Provide counseling for immediate BF after birth; exclusive BF < 6 months; age-appropriate complementary foods B Promote growth monitoring, weighing infants and x recording progress C Provide community based management of acute mal- o nutrition (CMAM) using Ready to Use Therapeutic Foods (community-based recuperation of children with acute moderate to severe malnutrition without complications) D Community-based treatment of pneumonia o Counsel re recognition of danger signs, seeking care/ antibiotics o Assess and treat with antibiotics o Refer for antibiotics o Refer after treating with initial antibiotics G Community-based prevention and treatment of diarrhea x Counsel on hygiene x Counsel on point-of-use water treatment o Provide point-of-use water treatment o Refer point-of-use water treatment x Counsel on ORS x Provide ORS o Refer for ORS o Counsel on Zinc o Provide Zinc Refer for Zinc H Vitamin A supplements (twice annually children 6-59 months) x Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment I Effectively assess and recognize severe illness in chil- x dren (danger signs) with appropriate referral. j Counsel on immunizations x Mapping/tracking for immunization coverage o Provide Immunizations: -DTP x -polio and or measles x - +/- HIB o - Hep B o -Pneumovax o -Rotavirus o Refer for immunizations x

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS 5 FAMILY PLANNING/HEALTHY TIMING AND SPACING OF PREGNANCY A Counsel on HTSP/contraceptives x Provide contraceptives: o - condoms x - Lactation Amenorrheic Method (LAM) o - oral contraceptives x - depo o Refer for contraceptives: x - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - long-acting and permanent methods x Provide FP counseling +/ x - administer contraceptives (e.g.;Oral Contraceptives) 6 MALARIA (Optional - Dependent Upon Country) A Insecticide-treated mosquito nets to pregnant women and children Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o B Intermittent preventive malaria treatment (IPTp) Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o C Community-based treatment of malaria (testing with Rapid Diagnostic Test or presumptive treatment per antimalarial per national guidelines.) Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment o 7 PMTCT (Optional - Dependent Upon Country) A Healthy timing and spacing of pregnancy Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o B Antibody testing to pregnant women and mothers Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o C Prophylactic ARVs/HAART to pregnant women mothers Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o E Prophylactic ARVs/HAART to infants Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o

249 MCH INTERVENTIONS YES COMMENTS F Early infant diagnosis Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o G Pregnant HIV-infected women tracking Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o H HIV-exposed infant tracking Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o

Global Evidence of Community Health Workers Summary The LHWP, launched in Pakistan in 1991, as a there is a need to follow the program design concretion of the integrated health system, is with consistency for better outcomes and a a highly beneficial program for the community need to overcome shortcomings resulting from and has a major role to play in the provision of financial and supplies inadequacy. Despite of primary health care and in reduction of burden the incentives and chances for professional ad- of disease via preventive strategies and educa- vancement, 1 out of 10 LHWs charge their clients tion of the masses, especially in the rural areas. for their services and drop outs have also been The LHW program is composed by Lady Health observed. The reasons behind this were found Workers and Lady Health Supervisors that work to be the irregularity in the payment of salaries together, having families as their center of ac- to the LHWs the geographical constraints that tion. Each LHW is responsible for enrolling and make travelling for home visits difficult for them monitoring the health status of about 1,000 po- thus hampering their performance. pulations living in an assigned area, providing primary health care services, family planning Notwithstanding these challenges, LHW pro- and making referrals to other level of care as gram is indubitably a global example whose required. The LHW who is a member of commu- basic underlying principles can and should be nity and at the same time is a health professional implemented in different settings, irrespective paid by public sector. They are accountable for of the political and economic country level es- the health of their own community, and play a tablished systems, on the basic stipulation of liaison between community and health system. considering health as a fundamental right to Their main tasks involves preventive and pro- be offered by a public sector minimally able to motive activities related to maternal, newborn address the community needs. and child health, plus therapeutic activities in controlling diseases like malaria, tuberculosis and other communicable diseases. They also 2. Bangladesh – BRAC provide promotional and preventive messages Community Health to community members and are expected to timely identify family members at risk or with Workers Program early signs of diseases, and refer them for further Socio-economic and diagnosis and management. Political Context Based on these characteristics and through a Bangladesh is located in South East Asia between combined central government support and India and Burma having a total area of 143,998 strong local committeemen, the LHW program square kilometers with mostly flat alluvial plain expanded impressively, from a less than 20,000 and hilly areas in southeast region. It has a workers in 1995 to more than 90,000 workers all population of 156,050,883 which is growing at over the country in 2005-06, that are covering a rate of 1.3%.14 Children under the age of 14 currently about half of the Pakistani population. years comprise 36.4% of the population while only 4% of the population is under the age of 65 There are convincing evidences about the im- years.14 Majority of the population are between pact of the LHW program on health indicators the ages of 15-64 years. The total population sex when compared with national figures as regard ratio according to the 2009 estimates of Central to immunization coverage, modern methods Intelligence Agency is 0.93 males for every one for family planning utilization, antenatal cove- female.14 Although the rate of urban population rage, maternal, infant and child health. However

251 is increasing at 3.5% annually only 27.5% of the of public facilities at tertiary, secondary and total population resides in the urban areas.14 primary levels. However in reality there is a mix of public, private, NGO, and traditional providers Bengali is the dominant ethnic group with the operating with variable population reach and 98% population who usually converse in Bengali quality. Less than 20% of the curative health which is the official language whilst English is services are consumed from the public sector. also used by some as the mode of communi- cation14. Eighty three percent of the people are Traditional healers, quacks, qualified doctors Muslims and 16% Hindus.14 working privately, and NGOs also have their stake in the delivery of health services. Several The GDP of Bangladesh has increased from doctors are into dual practice, i.e., both public US$1300 to US$1500 from 2006 to 2009.14 and private.16 The private sector is the major Conversely 45% of the population is below po- provider of curative services for both poor and verty line in addition to 2.5% increase in annual rich, in both urban and rural areas.17 unemployment.14 Consequently, the life expectancy at birth is merely 60.25 years with female The public sector is underfunded yet has poor life expectancy is indistinctly higher than that absorptive capacity. The distribution of qualified of males.14 Moreover, the death rate is 9.23 for staff seems to be biased and retaining them in every thousand people yearly.14 The degree of rural postings is quite difficult. Ghost workers risk due of major infectious diseases is also high. in the public sector18 and mushrooming of These include food and water borne diseases private health care set ups are another serious such as bacterial and protozoal diarrhea, hepa- problems.19 titis A and E, and typhoid fever; vector borne diseases like dengue fever and malaria and water The professional medical associations are parti- contact disease which includes rabies.14 cularly opposed to make any attempts to tackle the human resource deficit in rural areas, such Health Systems Overview as by addressing the skills of semi-qualified providers who are mostly consulted by the rural Bangladesh is one of those low income coun- populations.19 tries which has made considerable progress in improving the health and nutritional status of Bangladesh Rural Advancement Committee its citizens during the last decade. In the poor (BRAC) is the largest national non-governmental households of the country however, the issues organization that incorporates semi-voluntary of preventable morbidity and mortality from CHWs. BRAC came into existence in 1972 as a poor maternal and child health, malnutrition, relief organization. After a year of working, as a communicable diseases are still major challen- relief team, realized that relief and reconstruc- ges to be tackled. At the same time, there are tion efforts would only be limited to disaster new concerns due to the rising rate of non- management measure. Thus in 1973, BRAC communicable diseases, from environmental adopted the community development ap- hazards such as air and water pollution and proach but due to the exploitation of the poor from behavioral causes such as tobacco use, by the rural elites, lack of education and health accidents and violence.15 care found their intervention to be insufficient. BRAC then switched to the Health, Nutrition and Bangladesh has a three tier health care service Population Programs in 1973 and a Non-Formal delivery system with a comprehensive network Primary Education Program in 1985. In health

Global Evidence of Community Health Workers care outreach services BRAC has been corrobo- married having children not below 2 years of rating with CHW programs in Bangladesh since age, 1977. It integrates essential health care and provides basic curative and preventive health care. few years of schooling, Shastho Sebikas (SS) is an alternative term used willing to provide voluntary services, for CHWs in Bangladesh. CHWs in Bangladesh are a class under primary health care approach. acceptable to community they serve, They are selected by the community and are Preferably, they should not be living near a local acceptable to them.20 health facility to avoid competition, and extend basic health facilities coverage to places far Besides designing interventions for the com- away from any health facility munity, BRAC also focused on the sustainability of the project and generated funds from both The SS Role donors as well as through its own support en- terprises and microfinance projects. SS works for 15 days a month, approximately six days a week and on an average two hours a day BRAC not only strengthened its roots in usually in afternoon, but they work quite exten- Bangladesh but also expanded globally. It has sively in the community. Their specific roles are been serving in Afghanistan since 2002, in Sri to: 22, 23 Lanka since 2004 and in Tanzania, Uganda and Perform health education and promotion activi- Southern Sudan since 2006. BRAC USA came into ties in five essential components that consist of being in year 2007, while the year 2008 marked water and sanitation, immunization, health and BRAC’s full-fledged operations in Pakistan. nutrition education, family planning, and basic curative services Recruitment Process Shasthya Sebika are recruitment from among Sell medicine, contraceptives, sanitary latrines, the active village based BRAC credit and develo- tube-wells and vegetable seeds 21 pment group called Village Organization (VO). Diagnose, treat and provide health education on VO is formed by the poor women in the village diarrhea, dysentery, fever, common cold, worm and this organization extends small loans to infection, gastric ulcer, allergic reaction, scabies members for income generating activities. and ringworm infection Initially village organization discusses and Identify pregnant women mutually nominates prospective SSs and then suggests nominated candidates to regional of- Encourage pregnant women to utilize services fice members. Based on the recommendations in government facilities forwarded by that organization, final selection is Visits women at 42 days of delivery done at BRAC regional office. In regional office, a general meeting is held to ratify the nomina- Give special care to Low Birth Weight (LBW) tion and finally the candidate has to undergo a babies selection interview. Selection of SS is based on Organize income generating activities the following criterion: Prepare and submit monthly progress report female (25-45 years), Works on DOTS program

253 Initial Training of SSs Supervision SSs are given fundamental and essential cura- Supervision of the SSs is done by the program tive training for a period of 4 weeks, amounting officers at BRAC, the Shasthyo Kormis (SKs). about four days per week at the regional office.16 SKs are paid health care workers associated They are trained on following common illnesses: with BRAC and have a minimum of ten years of anemia, angular stomatitis, common cold and school education. Each SK supervises 25 to 30 cough, diarrhea, dysentery, gastric ulcer, peptic SSs. An SK visits households three days a week ulcer, ringworm, scabies, and worm infestation.24 during which time she reviews the work done For specific programs such as DOTS, community by SS related to DOTS, family planning, and EPI based ARI, and safe motherhood interventions, motivation and maintenance of their registers. a subset of these workers are given additional In the remaining three days she provides ANC training as and where necessary. and PNC services to women, manages health forums and enrolls births. During this time she On-going Training of SSs also reviews the activities of SSs with regard to diverse services provided by the SSs. Thus, this For the next two years, they are provided with helps her supervise the SSs. Each SS is visited by refresher training sessions, once every month, a program officer (PO) at an average of three to conducted by the program organizers. Refreshers four times a month. The visit of 25% of house- are conducted in an interactive and problem holds by the PO is also a part of routine scree- solving way, in which problems encountered ning. SKs are selected based on the following during the month are discussed alongside the criteria:26 discussion of new health and nutrition aspects. This keeps the knowledge of the SSs updated experienced, about health innovations and management of selected from and by community, diseases, and most importantly, it gives the SSs willing to work, the motivation to continue the work.16 age 30-45 years Equipment and supplies These supervisors are given 2 weeks training on After training, SSs receive essential drugs, other basic curative care for some common illness, health commodities (e.g. contraceptives pills, family planning, MNCH, nutrition, immuni- condoms) kit, delivery kit, sanitary napkins, zation, water and sanitation, communicable soaps and iodized salt for performing their disease control, DOTS, ARI, communication, tasks in the community. These drugs and health supervision and monitoring. Supervisors are commodities are procured by BRAC in bulk and also paid with incentives of Tk.80 for providing then supplies to the SSs at lower-than-market antennal and post natal care services to women prices, which they sell with a small mark up.25 in community. The essential drug kit contains: Paracetamol Performance Evaluation Vitamins Performance evaluation of CHWs and their im- Antihistamines pact on service utilization has been observed in BRAC internal reports. Evaluation has shown Oral rehydration solution that 27, 28: Antacids CHW are well recognized in community and motivated Anti helminthics

Global Evidence of Community Health Workers Patient compliance has increased Providing essential newborn care Tk. 100 Service provision and utilization has been Refer from home for complication Tk. 100 increased Inform the SK for ensuring birth weight if delivered at home Tk. 30 They made several efforts to spread awareness of HIV/AIDS in the community and 94% of the Women receives ANC Tk. 5 for non VO member Community sex Workers (CSWs) reported that and Tk. 3 for a VO member the BRAC volunteers were their source of information.29 It has also been observed that there Community Involvement has been greatest reduction in low birth weight SSs perform their task in the community by in- 30 babies in the areas of BRAC volunteers . Their volving community in their tasks. They develop diagnosis of pneumonia was found to be 67.6% community level advocacy and support groups 31 sensitive and 95.2% specific. Their efforts in TB where they discuss issues and influence them control are reflected by treatment success rate to participate and help them in suggesting an 32 of 83.3%. action plan for specific problems and issues. SSs also involve community in identifying patients Incentives for referrals.34 They also enhance community SS works as a volunteers and receives no salary, awareness through interactive communications they basically earn income from the sale of drugs in the form of folk music, theatre. Furthermore, and health commodities and receive incentive SSs also aware local stakeholders about the com- from certain performance based tasks 25. munity issues through advocacy workshops. Incentive mechanism in BRAC was started in 1984 particularly for TB control program for Referral System detecting higher number of cases from the On identification of emergency case by SSs, community. Until previously, the program was they verbally refer the child to an existing heath based on voluntary mechanism and SSs were facility. Workers inform center’s health providers benefiting from the sales of medicines and about case pre hand through mobile phone commodities provided by BRAC and as a part of and then these workers ensure that these pa- non monetary reward, motivational factors like tients are transferred to facilities through proper enthusiasm to work for the betterment of the transport. They also follows patient at home on community was involved and social prestige their arrival to community after treatment.34 and fame were important inspirational factors that were involved. The subset of SSs who also Professional advancement works for DOTS program receives Tk. 150 for the patient who completed the treatment for TB Some CHWs accumulate experience and are under her observation.33 Under urban MNCH sometimes used to train others. There were program, CHWs are also provided with incen- no cases of retirement reported and at the tives for identification, referral and provision of moment there is no formal retirement plan for services.33 Following incentives are provided for them documented. specific MNCH tasks: Pregnancy identification Tk. 30 Brining mothers to delivery centers Tk. 100

255 Table 29: Performance Evaluation of SSs Program coverage Coverage is about 70%. Covered 46 districts out of total 64. Preventive and promotive Vaccination promotion coverage: 87% of children under five, CPR 62%, service delivery ANC (3 visits) coverage 62%, TT coverage 82%, under 5 vitamin A is 92% Curative service delivery Tuberculosis Completion rate over 90%, and success rate is 89% LHW services and the poor BRAC providing services to the poorest population of Bangladesh LHW impact on health BRAC impact and coverage is better off than national figures. TB prevalence in BRAC areas half the rate in other areas

Global Evidence of Community Health Workers 3 2 2 3 3 Current Current Level/ Evidence 3 (best practice) community from Recruited If when possible. not possible, the community is consulted and agrees during the process selection. on recruitment community, Health system, the role/ and CHW design expectations and policies in place that support CHW Role and expectations role. CHW and clear to are for Process community. and discussion of update role/expectations in place CHW and community for Initial training is provided within the six all CHWs to months that is based on for CHW. defined expectations Some training is conducted in the community or with community participation. with is consistent Training health facility guidelines for community and health care in training. facility is involved On-going training is provided CHW on new skills, update to and initial training, reinforce he/she is practicing ensure is Training skills learned. tracked and opportunities in a consistent offered are all and fair manner to (not only some) CHWs All necessary supplies; no substantial stock-out periods. - - - CHW is not recruited from com from CHW is not recruited munity but the community is on the final selection.consulted defines (policies Health system but without exist) the CHW role community input. Role is clear CHW and communityto but little discussion of specific expectations. General agree between CHW, ment on role and community. health system, to Initial training is provided year within the first all CHWs does Training of recruitment. not include participation community from or health center. referral On-going training is provided Some super basis. on a regular up with coaching. visors follow have CHWs Functional Note: updated) been trained (or within the last 18 months. on ordered Supplies are basis although a regular Stock delivery can be irregular. out of supplies essential for defined CHW tasks occur at of x per year/mo a rate 2 - - 1 from CHW is not recruited community but the commu nity (reluctantly) accepts the identified CHW after selection. of CHW exists role No formal (no policies in place) General to expectations given are CHW (initial training) but CHW and not specific. are community do not always on role/expectations. agree Minimal initial training is etc). (1 workshop, provided works attend Some CHWs topics. hops on specific ad hoc visits Occasional, supervisorsby provide some coaching. Inconsistent supply and supportrestocking to formal No defined CHW tasks. re-ordering. for process - Table 30 - CHW Program Functionality Assessment Tool (CHW-PFA) – Bangladesh (CHW-PFA) Tool Assessment Functionality 30 - CHW Program Table 0 community CHW not from and in the recruitment. no role plays upon Role is not clear or agreed community between CHW, health system. and formal No initial training is provided. No ongoing training is provided No equipment and sup provided. plies are Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Recruitment a where and from How community health worker and selected, is identified, a community. to assigned CHW Role design Alignment, and clarity from of role and CHW, community, perspectives. system health Training Initial to provided Training role for prepare CHW to in MCH services delivery he/she has the and ensure necessary skills provide to and quality care. safe Training On-going On-going training to CHW on new skills,update initial training, reinforce he/she is and ensure practicing skills learned. and Supplies Equipment equipment Required deliver and supplies to expected services. 1 2 3 4 5

257 3 2 2 3 Current Current Level/ Evidence - 3 (best practice) Regular supervision visit every 1-3 months that includes reports,reviewing monitoring Data is of data collected. solving problem used for Supervisorand coaching. makes visits community, skills provides home visits, Supervisor CHW. coaching to is trained in supervision and has supervision tools. evaluation least once/year At that includes individual performance (local eva luation) and evaluation of or monitoring coverage data (national /program evaluation) Community is feedback asked provide to on CHW performance. for clear rewards are There good performance, and community a role plays rewards. in providing and/or non-financial Financial partly are incentives based on good performance. Incentives balanced and in line with are expectations placed on CHW. Examples of non-financial that engage incentives workers might include (advancement, recognition, certification process) an activeCommunity plays in all supportrole for areas such as development CHW, feedback, providing of role, providing solving problems, establish helps to incentives, CHW as leader in community. - Regular supervision visit at least every months that three reports,includes reviewing monitoring of data collected and occasionally provide supportproblem-solving to Supervisors trained not are CHW. in supportive supervision but facility are based health workers. evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage data (national /program evaluation). Community is not on feedback asked provide to There performance. CHW’s good for some rewards are performance, such as small etc. recognition, gifts, incentive Some financial or non-financial provided. are incentives Examples of non-financial incen include occasional formal tives additional training, recognition, and other small incentives. significant Community plays in supportingrole the CHW groups, mother’s through CHW is widely networks, etc. for and appreciated recognized serviceproviding community. to 2 - 1 Supervision visits conducted times between two and three collect to reports/per year meetings at group data (or facility turn to in monitoring No individual perforforms). workmance supporton offered coaching) (problem-solving, evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage no rewards are There data. good performance. for provided incentives No formal but community recognition a reward is considered Community is sometimes education) (campaigns, involved with the CHW and some people in the community recognize the CHW as a resource. 0 No supervision or regular evaluation occurs outside of by CHWs occasional visits to nurses or supervisors when or less). possible (1x/year evaluation of No regular performance CHW. by No financial or non-financial provided incentives with Community is not involved ongoing support CHW to Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional - Component Component Definition Supervision Supervision conducted carry basis to on a regular tasks out administrative individual provide and to performance support data- (feedback, coaching, driven problem-solving). Evaluation Performance fairly to Evaluation assess work during a set period of time. Incentives salary Financial= and bonu ses Non-financial= training, certification,recognition, etc. medicines, uniforms, Involvement Community Role that community in supportingplays CHW. 6 7 8 9

Global Evidence of Community Health Workers 1 0 1 Current Current Level/ Evidence - - - 3 (best practice) CHW knows when to signs, client (danger refer etc) additional treatment, CHW and community know facility is and referral where plan for a logistics have (transport,emergencies with a funds) Client is referred slip of paper and information to CHW with a back flows and/ form referral returned or monthly monitoring. is (promotion) Advancement who performto CHWs offered an and who express well in advancement if the interest opportunity exists (advance for ment might mean path to mal sector or change in role) opportunities are Training to learnto CHW new offered skills and advance their role to of them. CHW is made aware to is intended Advancement good performancereward or and is based on achievement, is fair evaluation. Retirement encouraged and incentives encourage to provided are at a set age. retirement document their CHWs and group visits consistently facilitymonitoring visits to who CHWs by attended are bring monitoring forms. Supervisors quality monitor of documents and provide CHWs/ help when needed. communities work with supervisor facility or referral use data in problem-sol to ving at the community. - - CHW knows when to refer CHW knows refer when to additional signs, client (danger CHW and etc) treatment, community know referral where facility is and usually have transportthe means to client with a slip of Client is referred tracked paper and informally by CHW (checking in with family, up visit) but information follow to CHW. back does not flow is (promotion) Advancement to CHWs sometimes offered for been in program who’ve Limited specific length of time. training opportunities offe are learn CHW to new skills to red Advancement advance role. to good reward to is intended performance or achievement, although evaluation is not (advancement might consistent sector or formal mean path to reti No path to change in role). CHWs is made clear to rement document their CHWs and group visits consistently facilitymonitoring visits to are who bring CHWs by attended Supervisorsmonitoring forms. qualitymonitor of documents help when needed. and provide do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 2 - - 1 client CHW knows refer when to additional treat signs, (danger CHW and communityment, etc) facility know referral where referral no formal is but have is not Referral process/logistics tracked community by or CHW is (promotion) Advancement to CHWs sometimes offered been in program who’ve specific length of time. for No other opportunities discussed with CHW. are to is not related Advancement performance or achievement. document their vi Some CHWs monitoring visits sits and group CHWs by facilityattended to are who bring monitoring forms. do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. - 0 in place: CHW system No referral might know to when and where plan client, but - no logistics refer the communityin place by for - information emergency referral is not tracked or documented advan No professional cement is offered. documentation for No process management is followed or info Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional

- Component Component Definition System Referral - for a process Is there determining when referral plan is needed - logistics transport/payment for to facility a health care when is referral - how required tracked and documented Advancement Professional growth, possibilityThe for advancement, promotion CHW for and retirement Documentation, Management Information document CHWs How to data flows how visits, and the health system the commu back to it is used and how nity, servicefor improvement 10 11 12

259 Table 31 - Community Health Worker Functionality Matrix – MCH Interventions MCH INTERVENTIONS YES COMMENTS 1 ANTENATAL CARE A Iron folate supplements Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Maternal nutrition Counsel x Provide commodity or intervention/Assess and treat x Refer for commodity, intervention, or treatment x C Counsel on birth preparedness/complication readiness x * (includes counseling to use skilled birth attendant) D Tetanus toxoid Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x E Deworm Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x 2 CHILDBIRTH and IMMEDIATE NEWBORN CARE A Prevent Infection/Clean Delivery x (Hand washing, clean blade +/or clean delivery kit) B Provide Essential Newborn Care a. Immediate warming and drying x b. Clean cord care x c. Early initiation of breastfeeding x C Recognize, initially stabilize (when possible) and refer for maternal and newborn complications x a. newborn asphyxia x b. sepsis, x c. hypertensive disorder x d. hemorrhage e. prolonged labor and post-abortion x complications D Prevent PPH: AMTSL or use of uterotonic alone x in absence of full AMTSL competency (e.g. oral Misoprostol) E Provide special care for Low Birth Weight newborns x (Kangaroo Care) 3 POST-PARTUM and NEWBORN CARE A Provide counseling on evidence-based maternal newborn health and nutrition behaviors a. clean cord care; x b. exclusive BF through 6 months; x c. thermal protection; hygiene; x d. danger sign recognition; x e. maternal nutrition, etc. x

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS B Assess for maternal newborn danger signs and provide x appropriate referral. C Provide Treatment for severe newborn infection (when x community-based treatment supported by national guidelines.) 4 EARLY CHILDHOOD A Infant and young child feeding, IYCF: x Provide counseling for immediate BF after birth; exclusive BF < 6 months; age-appropriate complementary foods B Promote growth monitoring, weighing infants and o recording progress C Provide community based management of acute mal- o nutrition (CMAM) using Ready to Use Therapeutic Foods (community-based recuperation of children with acute moderate to severe malnutrition without complications) D Community-based treatment of pneumonia x Counsel re recognition of danger signs, seeking care/ antibiotics x Assess and treat with antibiotics x Refer for antibiotics x Refer after treating with initial antibiotics G Community-based prevention and treatment of diarrhea x Counsel on hygiene o Counsel on point-of-use water treatment o Provide point-of-use water treatment x Refer point-of-use water treatment x Counsel on ORS o Provide ORS o Refer for ORS o Counsel on Zinc o Provide Zinc o Refer for Zinc H Vitamin A supplements (twice annually children 6-59 months) Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x I Effectively assess and recognize severe illness in chil- x dren (danger signs) with appropriate referral. j Counsel on immunizations x Mapping/tracking for immunization coverage o Provide Immunizations: o -DTP o -polio and or measles o - +/- HIB o - Hep B o -Pneumovax o -Rotavirus x Refer for immunizations

261 MCH INTERVENTIONS YES COMMENTS 5 FAMILY PLANNING/HEALTHY TIMING AND SPACING OF PREGNANCY A Counsel on HTSP/contraceptives x Provide contraceptives: o - condoms x - Lactation Amenorrheic Method (LAM) - o oral contraceptives x - depo o Refer for contraceptives: x - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - long-acting and permanent methods o Provide FP counseling +/ - administer contra- x ceptives (e.g.;Oral Contraceptives) 6 MALARIA (Optional - Dependent Upon Country) A Insecticide-treated mosquito nets to pregnant women and children Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Intermittent preventive malaria treatment (IPTp) Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x C Community-based treatment of malaria (testing with Rapid Diagnostic Test or presumptive treatment per antimalarial per national guidelines.) Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x 7 PMTCT (Optional - Dependent Upon Country) A Healthy timing and spacing of pregnancy Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o B Antibody testing to pregnant women and mothers Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o C Prophylactic ARVs/HAART to pregnant women mothers Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o E Prophylactic ARVs/HAART to infants Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS F Early infant diagnosis Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o G Pregnant HIV-infected women tracking Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o H HIV-exposed infant tracking Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o

263 Summary The health system in Bangladesh was crippled facilities run by NGOs. There is also consistent after partition from Pakistan in 1971. At that evidence about clearly positive impact of NGOs time the health system of Bangladesh was community based programs on reduction of facing weak leadership, governance, and ac- TB and malaria morbidity and mortality and on countability, and thus was unable to provide reduction of infant and child mortality, and on minimum and decent level of health services to maternal and reproductive health indicators in the majority of their citizens. BRAC initially came their catchment areas. into existence in 1972 as a relief organization, but after working for years they realized that The valuable effort of BRAC CHW program has relief and reconstruction efforts would only be now been replicated in many regions of Africa, limited to disaster management measure. Thus USA, UK and South Asia. Amongst all these BRAC then switched to the Health, Nutrition and BRAC Afghanistan has been functional since last Population Programs in 1973 and has been cor- 7 years which was initially started in response to roborating with CHW programs in Bangladesh the conflict in Afghanistan and the flood of retur- since 1977. The initiative and commitment of ning refugees in 2002. By implementing the ho- CHWs from BRAC in taking responsibility of local listic strategy we have developed in Bangladesh implementation of health and nutrition services and adapting it to suit the local context, BRAC across the country allowed an impressive expan- Afghanistan quickly became the largest and sion of the program, from a number of CHWs most sustainable of all the development orga- less than 1,000 in 1990 to more than 78,000 in nizations in the country with program in 23 of 2008 in place currently. Each CHW is responsible the country’s 34 provinces and nearly 895,000 for following up 150-200 households. The CHW people are benefiting from the program. receive training that privileges the determination and understanding of social, economic and With all these success, program is also facing environmental characteristics of the commu- some local difficulty of high drop-outs that nity, as well as epidemiological profile. They also need to be effectively discussed and addressed receive promotional and preventive aspects to assure the sustainability of the program. The of health, so that they are in good position of primary motivation to become a CHW is the providing influential counsel to community economic incentive, with the meager income members, for identifying timely family members earned by their activities, it is difficult to retain at risk or with health problems and refer them them in the system and the drop-out rate is fair- to the health facility for further assessment and ly high. The Shasthya Sebika work extensively in management, if considered pertinent. Their role the community and drive their motivation not in community health promotion is significant, as only from the financial incentive but also from they are community members carefully selected the prestige that they gain in the community. with the participation of community members An escalation in their financial incentives can and BRAC leaders. improve their performance and as such the primary health care scenario of the country. From the very outset, BRAC has provided consistent evidence about the positive impact on an increased coverage of health care for MNCH, nutrition and TB, malaria patients through home-based directly observed therapy strategy conducted by CHWs, and also an increased trust of community members on health

Global Evidence of Community Health Workers 3. Thailand – Village Health Volunteer Program Socio-economic and Political Context des, i.e., the rate has dropped to 8 per 1000 in The United Kingdom of Thailand is a moun- year 2006.36 The system has been developed in tainous country in the Southeast Asia, lying such a way that the primary health care is roo- southeast of Burma, bordering the Andaman ted in the local communities and the volunteers Sea and the Gulf of Thailand.35 It has a total area play an important role to prevent the disease of 513,120 square kilometers.35 The total po- in the first place through preventive health pulation of the country is 63,444,000,36 which education.36 is growing at the rate of 0.6%.35 Majority of the population (70.5%) are between the ages 15-64 In the year 2003, health care system in Thailand years35 and the life expectancy in Thailand at has been decentralized to provinces and the birth is 73.1 years35 while the death rate is 7.3 districts as a result of Health System Reforms.39 deaths per 1,000 population.35 The program with its appreciable outcomes36 deserves a full functionality assessment. The most dominant ethnic group of the country is Thai followed by Chinese, comprising 75% and 14% of the total population, respecti- The Village Health Volunteers vely.35 Amongst them 95% of the people are Program (VHVs) Buddhists.35 The official language of the nation The VHV program has been launched in Thailand is Thai35 and the country has a literacy rate of at a national level after the Alma-Ata conference 92.6%35 where the government spends 4.2% of in 1978.40 The two types of CHWs involved in GDP on education.35 the primary health care are VHVs and the Village Health Communicators (VHCs).40 Almost all The GDP per capita of the country is $8,400,35 the villages in Thailand had trained VHVs and and the total expenditure on health as % of GDP VHCs by the year 1986.40 The CHW scheme (2006) is 3.5.36 The World Bank listed Thailand’s then became the most important activity of economy as the lower middle income eco- the National Primary Health Care program with nomy.37 Thailand’s economic growth has fallen the objectives of reaching out majority of the sharply due to political crises that are there since population with low cost, equitable and easily 2005 35 and currently 10% of the total popula- accessible healthcare.40 In 1994, these two roles tion lives below poverty line.35 have been merged together and only VHVs are trained.41 Health Systems Overview Thailand has a multi-layered health care system Recruitment Process beginning from self-reliant, self-care at the fa- The VHVs are the respected members from mily level to that of care offered by a medical Thai village where they work. During the early specialist.38 The dominant provider of the health years of the system, VHVs were selected by the care is the public sector although for profit and primary health care centre officer using a “so- not for profit private sectors also have their cial matrix” method to identify potential VHVs role in delivery of health services.38 There are 4 through informal surveys. This method involved attending physicians per 10,000 population36. selecting individuals who were respected by The country has a very strong primary health the community and had the social skills neces- care system with CHWs as its backbone and it sary to engage community members, including has proven its success by a cut down of 80% in good listening, communication and inter-per- infant mortality rate during the last three deca- sonal skills as well as motivation to help others.

265 The selected VHVs were usually village leaders background. 86.9% have no more than basic or other respected villagers. primary school education. Only 7.3% were college graduates and 1.0% holds a bachelor Selection of VHV is based on the following degree. 51.1% were farmer and 13.4% worked criterion:41 as waged labor.42 Able to read and write, The VHV Role Live and work in the village, Every village in Thailand has at least one VHV, Have shown regular participation in the village who in turn are responsible for 5 to 15 house- health community development program, holds.39 The responsibility of VHV is to promote Be trusted by village members, health and intervene in treating minor health Have one’s own occupation to earn a living, problems. Their health promotive activities range from advocating simple preventive measu- Live in a house easily accessible to villagers, res to fostering wider health related community Not to be government official or village development in areas such as literacy, housing, headman sanitation and water supply and their health interventions activities range from providing basic The candidates who fulfill the above require- drugs and oral rehydration solution to endorsing ments are approved by a government official and teaching family planning and conducting (Provincial Health Officer) after going through routine childhood growth measurements.43 the following selection process: Some important responsibilities of VHVs are Public advertisement is posted by a primary to:41 health care centre for a specified period Demonstrate a good role model in self-care Completed application is received Disseminate health information through com- Official assignments are given by the district munity radio health officer (who also serves as the supervisor) after the basic training is completed Provide a health information corner in the public health center An informal pre-selection process is also fol- Meet with public health workers on the sur- lowed in which potential VHVs are selected and veillance system of communicable diseases in encouraged to apply by their village leaders and the community the primary health care centre staff. This pre- selection helps ensure the acceptability of the Educate the villagers on self and family preven- VHV in the village once officially appointed by tion of communicable diseases the provincial level. Senior VHVs also assist with Provide information on disease outbreak the selection of new ones. VHVs often serve immediately for life, once selected, and children of VHVs are encouraged to participate once their parents Test blood for malaria and test specimen for eventually retire. parasite when suspected Provide basic health care Existing volunteer workforces were found to be comparatively low educational and economic Transfer the patient to an appropriate health centre

Global Evidence of Community Health Workers Survey and collect sanitation and environment children aged 1 ½ to 2 years data and send it to the district health worker Urge parents to take their children for dental Raise awareness on environmental care management Suggest to the villagers to avail the dental ser- Improve public water supply vice when having a dental problem Cooperate with community leaders and orga- Supply and sell toothbrush, toothpaste and nize health promoting activities medication Survey and collect data on children aged 0-5 Provide knowledge on mental health to years, pregnant women, and post partum villagers women Support to establish a society for the elderly Inform the villagers on vaccine-preventable and provide knowledge on physical and mental disease health of elderly persons Cooperate with public health workers in organi- Organize mental-health-promoting activities zing vaccination point Provide knowledge on AIDS to villagers on pre- Weigh children aged 0-5 years every three vention and control months and compare the children’s weight with Organize activities to promote National AIDS standard and record Day Measure nutrition intake of children every two- Supply condoms for villagers three months Survey villagers aged 40 and above for diabetes, Spray iodine in salt for the villagers high blood pressure and vision problems Promote selling of iodized salt in the Mobilize villagers to improve the environment community and to reduce accidents Supply concentrate iodine water to the Publicize on how to select good quality villagers products Promote prenatal care Demonstrate a good role model in buying pro- Recommend to mothers to breastfeed till the duct showing registration number and expiry child is at least four months old date and in reading the medical labels Suggest to the mother to bring her child for a Cooperate with community leaders to ensure medical checkup at the health centre that only good quality products are sold. Follow up pregnancy, and post-pregnancy and Cooperate with the village committee in moni- ensure that the infant gets a medical check-up toring the environment and to set up an envi- Provide knowledge on family planning ronment protection club. Suggest use of medication and herbal medication Supply and sell basic-needs medication Promote the “My first toothbrush” campaign in

267 Initial Training of VHVs Village health volunteers are trained in primary other VHVs and briefs them on any training or health care aspect for 7 days and later on, spe- communication received.39 cialized on-the-job training is provided for 15 days.41 They are trained for motivation sessions, Performance Evaluation concepts of primary health care, prevention of disease including water supply, sanitation, There is no formal evaluation and monitoring immunization and other controls, treatment system placed to assess the quality and impact of health problems including first aid, sympto- of village health volunteers’ work. However matic and supportive treatments and herbal studies have shown that the case detection of medicine, promotion of health including nutri- tuberculosis done by the VHVs was compara- tion, reduction of mental stress and family plan- ble to the trained staff of the hospital and the ning.44 They are trained in the form of lectures, health center.45 Currently, they are providing a demonstration and discussions by volunteered coverage to 12 million household in Thailand.46 professionals from medicine, nursing and public The knowledge and performance of VHVs are health fields. evaluated by questionnaires and visits by professionals while they are practicing in the community and are also re-evaluated when they On-going Training of LHWs are on their refresher training.47 However VHVs To sustain and upgrade the VHVs’ knowledge, reported a decline in the use of their services regular meetings are held at the district health in regions bordered by urban areas where quite office level. These meetings provides an oppor- advanced health facilities were available to the tunity for refresher training, communication villagers.41 There is also a current shift in their and networking among VHVs, health officials role to potential areas of work such as preven- and health professionals. tion of domestic violence, alcohol consumption control, and caring of the elderly. Equipment and supplies More health activities were found in the villages The VHVs are provided with simple non-pres- where the VHVs had a higher level performance cription medicines that are effective in treating than in the villages where the VHVs had lower common illnesses. They also promote herbal level of performance.46 medications as an important way to address health problems and the drug shortage.41 Incentives Supervision There is no monetary incentive provided to the VHVs, except for free health services for themsel- VHVs work under the direct supervision of a ves and their immediate family members. More primary health care officer at the sub-district specifically, VHVs are exempted from the annual level, whereas the district health officer serves a fee that is required for the universal coverage of second-level supervisor. There is no formal eva- health care or what is called the “30-baht heal- luation or performance monitoring to assess the thcare scheme”.48 They also have full and free quality of VHVs work. Each village has a lead VHV access to health services at the district hospital. who organizes the other VHVs into a team, and, They also have special quotas for VHV families in effect also serves as an informal supervisor. to apply to government nursing. As a part of They are usually the senior-most among VHVs non monetary reward, VHVs receive public rein the village. The VHVs leader also supervises cognition from both the community as well as

Global Evidence of Community Health Workers the formal health sector. They also experience enhanced social standing, greater respect from their community and personal satisfaction, and some of them have also been elected to the local government. VHVs are treated as part of the formal health system, and the district health services use them in the out-patient department at health centers, when there is a surge of work or a personnel shortage. Furthermore, VHVs are also acknowledged for their work in various ways. The “best VHV of the year” is selected and announced annually at a national ceremony attended by all VHVs in the country on the 20th of March, which is designated as “Village Health Volunteer Day” to celebrate and recognize their work. Community Involvement Whenever the health system requires community involvement, especially with regard to prevention and health promotion activities, the VHV is designated to communicate the messages and mobilize the community to participate and suggest in developing an action plan.

Referral System VHV knows when to refer a client and know where referral facility is but have no formal referral process is place and referral is not tracked by community or VHV. Professional Advancement The system encourages young village health volunteers for further education and provide them grants to study and return as public health officers.39

269 3 3 3 2 2 Current Current Level/ Evidence 3 (best practice) community from Recruited If when possible. not possible, the community is consulted and agrees during the process selection. on recruitment community, Health system, the role/ and CHW design expectations and policies in place that support CHW Role and expectations role. CHW and clear to are for Process community. and discussion of update role/expectations in place CHW and community for Initial training is provided within the six all CHWs to months that is based on for CHW. defined expectations Some training is conducted in the community or with community participation. with is consistent Training health facility guidelines for community and health care in training. facility is involved On-going training is provided CHW on new skills, update to and initial training, reinforce he/she is practicing ensure is Training skills learned. tracked and opportunities in a consistent offered are all and fair manner to (not only some) CHWs All necessary supplies; no substantial stock-out periods. - - - CHW is not recruited from com from CHW is not recruited munity but the community is on the final selection.consulted defines (policies Health system but without exist) the CHW role community input. Role is clear CHW and communityto but little discussion of specific expectations. General agree between CHW, ment on role and community. health system, to Initial training is provided year within the first all CHWs does Training of recruitment. not include participation community from or health center. referral On-going training is provided Some super basis. on a regular up with coaching. visors follow have CHWs Functional Note: updated) been trained (or within the last 18 months. on ordered Supplies are basis although a regular Stock delivery can be irregular. out of supplies essential for defined CHW tasks occur at of x per year/mo a rate 2 - - 1 from CHW is not recruited community but the commu nity (reluctantly) accepts the identified CHW after selection. of CHW exists role No formal (no policies in place) General to expectations given are CHW (initial training) but CHW and not specific. are community do not always on role/expectations. agree Minimal initial training is etc). (1 workshop, provided works attend Some CHWs topics. hops on specific ad hoc visits Occasional, supervisorsby provide some coaching. Inconsistent supply and supportrestocking to formal No defined CHW tasks. re-ordering. for process Table 32 - CHW Program Functionality Assessment Tool (CHW-PFA)-Thailand Tool Assessment Functionality 32 - CHW Program Table 0 community CHW not from and in the recruitment. no role plays upon Role is not clear or agreed community between CHW, health system. and formal No initial training is provided. No ongoing training is provided No equipment and supplies provided. are Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Recruitment a where and from How community health worker and selected, is identified, a community. to assigned CHW Role design Alignment, and clarity from of role and CHW, community, perspectives. system health Training Initial to provided Training role for prepare CHW to in MCH services delivery he/she has the and ensure necessary skills provide to and quality care. safe Training On-going On-going training to CHW on new skills,update initial training, reinforce he/she is and ensure practicing skills learned. and Supplies Equipment equipment Required deliver and supplies to expected services. 1 2 3 4 5

Global Evidence of Community Health Workers 0 0 2 3 Current Current Level/ Evidence - All necessary supplies; no substantial stock-out periods. 3 (best practice) Regular supervision visit every 1-3 months that includes reports,reviewing monitoring Data is of data collected. solving problem used for Supervisorand coaching. makes visits community, skills provides home visits, Supervisor CHW. coaching to is trained in supervision and has supervision tools. evaluation least once/year At that includes individual performance (local eva luation) and evaluation of or monitoring coverage data (national /program evaluation) Community is feedback asked provide to on CHW performance. for clear rewards are There good performance, and community a role plays rewards. in providing and/or non-financial Financial partly are incentives based on good performance. Incentives balanced and in line with are expectations placed on CHW. Examples of non-financial that engage incentives workers might include (advancement, recognition, certification process) an activeCommunity plays in all supportrole for areas such as development CHW, feedback, providing of role, providing solving problems, establish helps to incentives, CHW as leader in community. - Regular supervision visit at least every months that three reports,includes reviewing monitoring of data collected and occasionally provide supportproblem-solving to Supervisors trained not are CHW. in supportive supervision but facility are based health workers. evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage data (national /program evaluation). Community is not on feedback asked provide to There performance. CHW’s good for some rewards are performance, such as small etc. recognition, gifts, incentive Some financial or non-financial provided. are incentives Examples of non-financial incen include occasional formal tives additional training, recognition, and other small incentives. significant Community plays in supportingrole the CHW groups, mother’s through CHW is widely networks, etc. for and appreciated recognized serviceproviding community. to 2 - 1 Supervision visits conducted times between two and three collect to reports/per year meetings at group data (or facility turn to in monitoring No individual perforforms). workmance supporton offered coaching) (problem-solving, evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage no rewards are There data. good performance. for provided incentives No formal but community recognition a reward is considered Community is sometimes education) (campaigns, involved with the CHW and some people in the community recognize the CHW as a resource. 0 No supervision or regular evaluation occurs outside of by CHWs occasional visits to nurses or supervisors when or less). possible (1x/year evaluation of No regular performance CHW. by No financial or non-financial provided incentives with Community is not involved ongoing support CHW to Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional - Component Component Definition Supervision Supervision conducted carry basis to on a regular tasks out administrative individual provide and to performance support data- (feedback, coaching, driven problem-solving). Evaluation Performance fairly to Evaluation assess work during a set period of time. Incentives salary Financial= and bonu ses Non-financial= training, certification,recognition, etc. medicines, uniforms, Involvement Community Role that community in supportingplays CHW. 6 7 8 9

271 1 1 0 Current Current Level/ Evidence - - - 3 (best practice) CHW knows when to signs, client (danger refer etc) additional treatment, CHW and community know facility is and referral where plan for a logistics have (transport,emergencies with a funds) Client is referred slip of paper and information to CHW with a back flows and/ form referral returned or monthly monitoring. is (promotion) Advancement who performto CHWs offered an and who express well in advancement if the interest opportunity exists (advance for ment might mean path to mal sector or change in role) opportunities are Training to learnto CHW new offered skills and advance their role to of them. CHW is made aware to is intended Advancement good performancereward or and is based on achievement, is fair evaluation. Retirement encouraged and incentives encourage to provided are at a set age. retirement document their CHWs and group visits consistently facilitymonitoring visits to who CHWs by attended are bring monitoring forms. Supervisors quality monitor of documents and provide CHWs/ help when needed. communities work with supervisor facility or referral use data in problem-sol to ving at the community. - - CHW knows when to refer CHW knows refer when to additional signs, client (danger CHW and etc) treatment, community know referral where facility is and usually have transportthe means to client with a slip of Client is referred tracked paper and informally by CHW (checking in with family, up visit) but information follow to CHW. back does not flow is (promotion) Advancement to CHWs sometimes offered for been in program who’ve Limited specific length of time. training opportunities offe are learn CHW to new skills to red Advancement advance role. to good reward to is intended performance or achievement, although evaluation is not (advancement might consistent sector or formal mean path to reti No path to change in role). CHWs is made clear to rement document their CHWs and group visits consistently facilitymonitoring visits to are who bring CHWs by attended Supervisorsmonitoring forms. qualitymonitor of documents help when needed. and provide do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 2 - - 1 client CHW knows refer when to additional treat signs, (danger CHW and communityment, etc) facility know referral where referral no formal is but have is not Referral process/logistics tracked community by or CHW is (promotion) Advancement to CHWs sometimes offered been in program who’ve specific length of time. for No other opportunities discussed with CHW. are to is not related Advancement performance or achievement. document their vi Some CHWs monitoring visits sits and group CHWs by facilityattended to are who bring monitoring forms. do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. - 0 in place: CHW system No referral might know to when and where plan client, but - no logistics refer the communityin place by for - information emergency referral is not tracked or documented advan No professional cement is offered. documentation for No process management is followed or info Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional

Global Evidence of Community Health Workers Table 33 - Community Health Worker Functionality Matrix – MCH Interventions MCH INTERVENTIONS YES COMMENTS 1 ANTENATAL CARE A Iron folate supplements Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Maternal nutrition Counsel x Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment o C Counsel on birth preparedness/complication readiness x (includes counseling to use skilled birth attendant) D Tetanus toxoid Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x E Deworm Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment o 2 CHILDBIRTH and IMMEDIATE NEWBORN CARE A Prevent Infection/Clean Delivery x (Hand washing, clean blade +/or clean delivery kit) B Provide Essential Newborn Care a. Immediate warming and drying o b. Clean cord care o c. Early initiation of breastfeeding o C Recognize, initially stabilize (when possible) and refer for maternal and newborn complications o a. newborn asphyxia o b. sepsis, o c. hypertensive disorder o d. hemorrhage e. prolonged labor and post-abortion o complications D Prevent PPH: AMTSL or use of uterotonic alone o in absence of full AMTSL competency (e.g. oral Misoprostol) E Provide special care for Low Birth Weight newborns o (Kangaroo Care) 3 POST-PARTUM and NEWBORN CARE A Provide counseling on evidence-based maternal newborn health and nutrition behaviors a. clean cord care; o b. exclusive BF through 6 months; x c. thermal protection; hygiene; o d. danger sign recognition; o e. maternal nutrition, etc. o

273 MCH INTERVENTIONS YES COMMENTS B Assess for maternal newborn danger signs and provide x appropriate referral. C Provide Treatment for severe newborn infection (when x community-based treatment supported by national guidelines.) 4 EARLY CHILDHOOD A Infant and young child feeding, IYCF: x Provide counseling for immediate BF after birth; exclusive BF < 6 months; age-appropriate complementary foods B Promote growth monitoring, weighing infants and x recording progress C Provide community based management of acute mal- o nutrition (CMAM) using Ready to Use Therapeutic Foods (community-based recuperation of children with acute moderate to severe malnutrition without complications) D Community-based treatment of pneumonia o Counsel re recognition of danger signs, seeking care/ antibiotics o Assess and treat with antibiotics o Refer for antibiotics o Refer after treating with initial antibiotics G Community-based prevention and treatment of diarrhea Counsel on hygiene x Counsel on point-of-use water treatment x Provide point-of-use water treatment o Refer point-of-use water treatment o Counsel on ORS x Provide ORS x Refer for ORS o Counsel on Zinc o Provide Zinc o Refer for Zinc H Vitamin A supplements (twice annually children 6-59 months) Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x I Effectively assess and recognize severe illness in chil- o dren (danger signs) with appropriate referral. j Counsel on immunizations x Mapping/tracking for immunization coverage o Provide Immunizations: x -DTP x -polio and or measles o - +/- HIB o - Hep B o -Pneumovax o -Rotavirus x Refer for immunizations

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS 5 FAMILY PLANNING/HEALTHY TIMING AND SPACING OF PREGNANCY A Counsel on HTSP/contraceptives x Provide contraceptives: o - condoms x - Lactation Amenorrheic Method (LAM) o - oral contraceptives x - depo o Refer for contraceptives: x - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - long-acting and permanent methods x Provide FP counseling +/ - administer contra- x ceptives (e.g.;Oral Contraceptives) 6 MALARIA (Optional - Dependent Upon Country) A Insecticide-treated mosquito nets to pregnant women and children x Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment B Intermittent preventive malaria treatment (IPTp) o Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment C Community-based treatment of malaria (testing with Rapid Diagnostic Test or presumptive treatment per antimalarial per national guidelines.) x Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment 7 PMTCT (Optional - Dependent Upon Country) A Healthy timing and spacing of pregnancy x Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment B Antibody testing to pregnant women and mothers o Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment C Prophylactic ARVs/HAART to pregnant women mothers x Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment E Prophylactic ARVs/HAART to infants x Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment

275 MCH INTERVENTIONS YES COMMENTS F Early infant diagnosis x Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment G Pregnant HIV-infected women tracking x Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment H HIV-exposed infant tracking x Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment

Global Evidence of Community Health Workers Summary Thailand’s PHC system, one of the oldest and diseases like avian H5N1 from the published stu- most successful in the world, grew from a 1966 dies. In addition, the decentralization of health pilot program to a full-fledged program of care system in Thailand has proved the inherent universal health care in 1980. Supporting the sustainability of the CHW program which conti- concept of community involvement, the Village nues to show improvement in the health sce- Health Volunteer (VHV) is the backbone of this nario of the country by consistently decreasing health care delivery system. Thailand, which is at the burden of diseases prevalent in the country. high risk of major infectious diseases, the preva- However, the referral system needs to be further lence of HIV in the country and the occurrence strengthened and the formal evaluation of the of H5N1 avian influenza makes it mandatory to CHWs should also be done on a regular basis have a strong grass root level health care inte- to further improve their performance. We also gration program which connect people in the recommend that the funding of CHW program community to formal health care system. The which at times become insufficient to run trai- village health volunteer program in Thailand ning programs be increased keeping in view the was started in 1970 with the aim of training 1% crucial role played by the VHVs in the country’s of the population as CHW managed to train and preventive and curative health care system. deployed one volunteer in each village.

There are many factors that has contributed in the sustainability of the program and that includes: the perceived high value paid to these village health volunteers by the government as well as the community for their work and the way they were chosen with full consensus of community in their selection process. Furthermore, they are also been empowered by the district level and public health matters that directly affects the community. Though volunteers receive modest or no financial remuneration, they receive in- kind incentives and acknowledgement as well as social standing. It appears that membership in a nationwide network, fulfillment of their aspirations to help others, and security gained for their family members in terms of receiving health care benefits and some advantages in educating their children are enough to sustain the system. It has also been identified that many of these retired volunteers have been replaced by their own offspring or relatives which help in supporting the program.

There is convincing evidence about the impact of the VHV worker program on health indicators such as malaria control, management of Tuberculosis and HIV/AIDs and other infectious

277 L A T I N - A M E R I C A N Case-Studies

Brazil – Programa Saúde da Familia Haiti – Zanmi Lazante’s Community Health Program

Global Evidence of Community Health Workers 4. Brazil - Programa Saúde da Familia improved water source is 91%, and literacy rate is 89%,50 figures all substantially better than Socio-economic and political years ago, but still hiding huge disparities. context Brazil is the largest country in South America Health System overview with 191.6 million inhabitants, and covering The pattern of mortality in Brazil has changed around half of the total surface area of the sub- markedly over the years, with a decline in some continent. It is politically and administratively infectious diseases and a resurgence of others, organized in 26 states, 5,561 municipalities, and and with a sustained increase in the frequency the Federal District, seat of the federal govern- of some non-communicable diseases, such as ment. There are five political and geographical heart disease (most notably cerebrovascular regions: North, Northeast, Southeast, South, diseases and ischemic heart diseases), diabetes, and Center-west. cancer, and deaths attributable to violence, particularly during the period 1996-2004.51 The Brazilian constitution establishes three independent branches: legislative, executive, and During the same period, childhood deaths due judicial. Brazil has a democratic system relying to diarrheal disease and acute respiratory infec- on general elections for a President and for tions have dropped substantially. Infants’ deaths legislative representatives. Judges and other ju- have seen a decrease of 34%, the largest reduc- dicial officials are appointed after passing entry tions being from meningitis (86.3%), HIV infec- exams. The President is both head of state and tion (69.8%), and intestinal infections (65.1%). head of government of the union and is elected Similarly, the proportion of infant deaths due to for a four-year term, with the possibility of re- perinatal causes increased from 57.0% in 1996 election for one additional term. to 61.2%. In 2004, the risk that a child would die before reaching the age of 1 year was 2.23 times Brazil is an upper-middle-income country, with greater in the Northeast than in the South.50 The an average GNP of US$ of 5,920 and an estima- states with the highest and lowest rates, respected 22% of the population below the national tively, were Alagoas (47.1 per 1,000 live births) poverty line. It has made substantial advance- and Santa Catarina (13.6 per 1,000 live births). ments in poverty fighting in the last years.49 However, several inequalities still persist, with In 2004, the average country maternal mortality 59 million Brazilians living on less than two dol- was estimated in around 76 deaths per 100,000 lars a day, with North and North East parts of the live births, whereas the figure was 44 deaths per country concentrating the poorest segments 100,000 live births in the Federal District and 84 of the population, and showing comparatively deaths per 100,000 live births in Mato Grosso do worse health, education and economic indica- Sul. More than half (61.4%) of maternal deaths tors that need further improvement.49 were due to direct obstetric causes, notably eclampsia and antepartum hemorrhage, and According to the Human Development Report important indirect causes (such as preexisting 2005, Brazil ranks 63rd in the classification of conditions complicating pregnancy that in- countries based on the human development clude infectious diseases, diabetes, anemia, and index.50 Life expectancy at birth is 72 years, cardiovascular disorders).51 infant mortality rate is 19 per 1,000 live births, child malnutrition prevalence is 4%, access to It is within the above described health profile

279 that the Brazilian health systems exists. It basi- of special services, such as indigenous health cally faces the challenges of a country charac- care. Other parts of the federal government also terized by an epidemiological and nutritional provide health services directly, notably the sys- transition, and persisting inequalities in the tem of university hospitals, health care facilities social determinants of health. operated by the Ministry of Education, and the armed forces health services. The SUS carries The health sector in Brazil comprises a complex out ongoing functions of coordination, plan- network of services encompassing both pu- ning, linkage, negotiation, monitoring, control, blic and private suppliers and financers.51 The evaluation, and auditing, which are incumbent private sector includes for-profit providers and on the three levels of government. nonprofit charitable organizations. The private system of health plans and insurance covers There are three major sources of funding for about 24.5% of Brazilians, 44% of the privately the Brazilian health system: the Government covered population being primary beneficiaries (through taxes and social security contributions of health plans and 56% dependents of primary collected by the three spheres of government), beneficiaries.51 Most of the clientele of the pri- companies, and families.51 The World Health vate system reside in the cities of the Southeast Organization estimates that in 2004 total health and South regions. The private system unde- spending in Brazil amounted to 7.9% of GNP.52 rwent considerable growth during the 1990s, Private expenditure accounted for 51.9% of that especially in the second half of the decade. total, and out-of-pocket spending by families The public health sector, to which access is accounted for nearly 64% of private expen- universal, is the sole provider of health care diture. For 2006, the total health expending coverage for 75% of the population, in addition (public and private, all categories) was nearly to providing public health services for the entire 90 billion dollars, which represented about 8% population. Some of the population covered by of the GDP. Private spending on health inclu- private health plans also uses the services of the des expenditures by families and companies, Unified Health system (Sistema Unico de Saude, the latter through the provision or purchase SUS), especially for highly complex or costly of insurance plans or through health plans for procedures or treatments. Private contractors, their employees and their dependents, such including both nonprofit and for-profit entities, coverage being voluntary, not mandatory. In deliver through federal, state, and municipal 1996, 9% of consumer spending by families government networks and SUS. The SUS inclu- was devoted to health (37% for drug purchases, des subsystems at the level of each state (state 29% for payment of health plans and insurance, SUS) and each municipality (municipal SUS). By and 17% for dental services). Spending by the law, municipalities have primary responsibility richest segment of the population represented for providing health care and services to their a significant portion of total health expenditure, respective populations, with technical and fi- while spending by the poorest decile constitu- nancial assistance from the federal government ted only a very small fraction. According to the and the states. Nationally, the SUS is managed Periodic Family Budget Survey, the three weal- by the Ministry of Public Health, which has thiest deciles accounted for 68% of total health primary responsibility for regulatory and coor- spending, while the poorest 30% accounted for dination functions and plays a major role in just 7%.53 There are also qualitative differences financing of the system. The Ministry retains di- in expenditure by the richest and poorest seg- rect responsibility for some areas, such as health ments: while drugs constitute the main item of education, research, tertiary care, and delivery expenditure for the latter, among the highest-

Global Evidence of Community Health Workers income deciles, health plans accounted for an reform, Primary Health Care was chosen by increasing proportion of spending, although in the Ministry of Health as the way to reach with all income deciles spending on drugs accounted quality health services the neediest segments, for a considerable proportion of total health ex- and eventually the whole Brazilian population, penditures.51 In particular, in the poorest decile, and therefore Family Health Program (Programa 54% of health spending went to the purchase Saúde da Familia, PSF) was launched in Brazil of drugs and 6% to payment for health plans, in 1994, in a context of active decentralization while in the wealthiest decile 24% of spending and intense mobilization of municipal health was for drugs and 33% for health plans.51 secretaries from all over the country in favor of basic care. Brief historical description of the In the late 1980s, Brazil converted its federal CHW Program public health financing system to a single natio- The PSF was chosen as the target Program for nal health fund. In the mid-1990s, it instituted this present country case study because it is a per capita payment for primary care services by far the most important health care initiative that was distributed directly to municipalities, in the country since several decades ago, and a reform that caused vast improvement in the because it is a comprehensive health care deli- equity of the health care system. This capitation very channel that emphasizes promotional and system was later enhanced by the PSF, through preventive health activities performed mainly which the Federal Government transferred ad- by CHW, while also paying attention to health ditional funds to the municipalities that agreed facility-based care through other health pro- to implement a proactive primary health care fessionals. In addition, the activities of the CHW model, provided resources were spent for program, the predecessor of the current PSF, agreed purposes and municipalities fulfilled have spanned more than four decades now and their agreed obligations. The PSF therefore is ba- was a valuable experience on which PSF built sically implemented by the municipalities across for accomplishing its objective of providing the country, in coordination with the Ministry of integral and universal health. Another reason is Health, which has mainly a stewardship role. that the PSF implementation reached impressive expansion since its inception in 1994, and The PSF targets provision of a broad range of there is compelling evidence about its positive primary health care services, delivered through impact on several health indicators. a Family Health Team (Equipo de Saúde Familiar) composed by at least one family doctor, one The main health reform in Brazil was performed nurse, one assistant nurse, and six community since 1988 through the development of the health agents or CHW,56, 57 although the num- Brazilian unified health system (Sistema Unico de ber of CWs within each team varies at each Saúde, SUS). This system was conceived on the municipality level. Some expanded teams in principle of health as a basic right of all citizens, due places also include one dentist, one assis- and with the aim to reach universal coverage, tant dentist, one dental hygiene technician, emphasizing decentralization, equity, commu- and social work professionals.56, 57 Each team nity participation, integration, shared financing is in charge of a specific geographical area, among the different levels of government, and working actually in the Basic Health Units and complementary participation of the private in the households themselves. The team is then sector.54, 55 Shortly afterwards, as a concrete responsible for enrolling and monitoring the way to making operational this fundamental health status of the population living in the

281 assigned area, providing primary care services, the PSF is a package designed by the Ministry of and making referrals to other levels of care as Health, and its implementation requires volun- required. Each team is responsible for following tary adhesion of a municipality administration, about 3,000 to 4,000 and a maximum of 4,500 preferably with support from the state govern- people. ment. Officially, the responsibilities across the different spheres of government are defined The PFS started in a few municipalities, reporte- in the following way:58 a) Federal Government: dly in the poorest ones, but municipality cove- elaborates the basic health goals of national rage expanded in a sustained way to more than policy; co-finances the system of “basic health ninety percent in about fifteen years, as part of attention;” organizes the formation of human an explicit effort from the central government resources in the area; proposes planning and and due to strong local initiatives. Thus it is es- control mechanisms, regulates and evaluates timated that currently PSF covers more than 85 the system of “basic health attention;” and main- million people across the country. tains a national database; b) State Government: follows the implementation and execution of the The key characteristics of the PSF include: i) to PSF; regulates the inter-municipal relationships; serve as an entry point into a hierarchical and coordinates policies of human resources quali- regional system of health; ii) to have a definite fication in the state; co-finances the program; territory and delimited population of respon- helps in the execution of the strategies of the sibility of a specific health team, establishing system of basic health care; and c) Municipality liability (co-responsibility) for the health care of Government: defines and implements the mo- a certain population; iii) to intervene in the key del of the PSF; hires the labor force for use in the risk factors at the community level; iv) to per- program; maintains the management network form integral, permanent, and quality assistance; of basic health units; co-finances the program; v) to promote education and health awareness maintains the information system; and evaluates activities; vi) to promote the organization of the the performance of the basic health care teams community and to act as a link between diffe- under its supervision. rent sectors, so that the community can exercise effective control of actions and health services The PSF has built in a significant proportion on and develop strategies for specific health inter- the valuable lessons from The CHW Program ventions; and vii) to use information systems to (Programa de Agentes Comunitários de Saúde: monitor decisions and health outcomes.58 PACS) that had been active in Brazil for more than 40 years, by going beyond those activi- In fact, the PSF has been conceived as a fe- ties based in health facilities, relying for this on deral program, and the responsibility of its CHW as an important part of the family health implementation rests on each municipality. team. Thus in the Brazilian PSF, the cadre of For an effective implementation therefore, an CHWs is integrated into the ministry of health adequate coordination is required between the hierarchy, with strong links to health facilities different government levels. Ideally, the concep- or other health agents, but also accountable to tion of the program should involve all three their communities. The PACS was developed by levels of government (municipality, state, and the former Fundacao SESP (Servicos Especias central government). However, and this is also a de Saúde Publica) about 50 years ago, with the demonstration of its flexibility, there are stories aim to reach poorest people, living mostly in of local implementation without support or remote and rural areas of Brazil. In those places interference of the state government.58 In brief, where there are only PACS, the situation can

Global Evidence of Community Health Workers The CHW Role be considered as transitional through the de- The CHW should be well familiarized with the finitive establishment of the PSF.59 community where he/she will work. His/her work starts with the household registration and Recruitment Process (selection a detailed information recollection, including family composition, basic facilities (such as committee, selection criteria) water and sanitation), schooling, literacy, job situation and income of household members. Compulsory requirements for being eligible as a This information will allow him/her the identifi- CHW (profile): cation of household members needing priority To have demonstrated leadership and solidarity attention, such as infants, children, pregnant spirit; women, malnourished, members with diseases such as hypertension, diabetes and other To have 18 years old or more; conditions. This household information should To be literate (reading and writing); since 2004, a be updated periodically, both for feeding the minimum of 8 years of schooling is required, due Basic Care Information System and for serving to a high demand for the CHW position and with as an orientation to CHWs activities. Specifically, the aim of increasing the quality standards; the update of the information is made by the CHW on a yearly basis, and whenever a family To be resident of his/her own community by at arrives from another place or moves to another least 2 years; geographical location. To have enough available time for performing the assigned activities; Other specific activities of CHWs include: To take responsibility for the follow-up of maxi- Work with families of defined geographic areas mum 150 families or 750 individuals of the Participate in the demographic diagnosis community Participate in the definition of socioeconomic The selection process: level of community members The CHW candidates do not need to have pre- Participate in the identification of cultural and vious health knowledge, because if selected, religious characteristics of families they will be trained and permanently supervised Determination of risk micro-areas by his/her assigned nurse instructor/superior. Visits to risk micro-areas The CHWs are choiced through a public selec- To adequate frequency of household visits tion process with a strong presence of commu- whenever there are situations needing special nity members. The corresponding municipality, attention with support of the State Health Secretariat, conducts the process. The Municipal Health Update the families’ information sheet Council, as a way to guarantee transparency, Perform surveillance of children considered at accompanies this process. Candidates are as- risk sessed for their aptitude, posture, and attitudes, during simulated community problems. Follow-up children 0-5 years old, through measurement and registration of weight, height, growth and development monitoring Promote routine immunization of children and

283 pregnant women, encouraging their visit to of outbreaks or occurrence of conditions nee health facilities ding compulsory notification Promote exclusive breastfeeding through edu- cative activities Perform promotion and prevention activities for the elderly Monitoring of diarrheal diseases and promotion of oral rehydration Identify persons with psychological or physical impairment, orientating their families for Monitoring of acute respiratory infections, identifying danger signs and asking the referral of providing support at home pneumonia suspicious cases to referral health Incentive community members for acceptance facilities. and social insertion of persons with psychologi- Monitoring of dermatoses and parasitosis in cal or physical impairment children Orientate families and communities for preven- Orientation of adolescents and their families in tion of endemic diseases prevention of STD/AIDS, premature pregnancy Perform educational activities for environmental and drug misuse preservation Identify and orientate pregnant women on im- Perform activities for increased awareness of portance of prenatal care at the health facility families and communities on human rights Perform periodic household visits for prenatal Promote community participation in actions follow-up, identifying risk signs and symptoms, related to improved quality of life orientating on feeding and mother preparation for delivery, and promoting breastfeeding Perform other activities related to CHWs tasks, to be further defined during local planning Monitoring of newborns and mothers after delivery Supervise together with families and encourage treatment compliance at home by persons with Performance of educational actions for preven- TB, leishmaniasis, AIDS, diabetes, hypertension, tion of cervix and breast cancer, encouraging and other chronic diseases period examinations at health facilities Performance of educational activities on family Initial Training of CHWs planning methods The central level of the MoH proposes the trai- Perform educational activities on menopause ning curriculum as a national reference, and the Perform educational activities on family and Ministry of Education approves it. Then each community dietary habits municipality prepares its own specific training program, according to its particular epidemiolo- Perform educational activities on oral and den- gical profile, social and economic context. Initial tal hygiene, with emphasis on pediatric CHWs training consists of an 8-week residential group course, with an additional 4 weeks of strictly supervised fieldwork. However, training is a Perform active search of carriers of transmissible gradual and continuous process that is adapted diseases according to needs emerging during the daily Support epidemiologic enquiries, investigation work. Nurses at the nearest public clinic provide training, with the assistance of staff from the

Global Evidence of Community Health Workers State Health Secretariat based in the capital. The trally coordinated and funded by the Ministry of whole Family Health Team also participates in Health, and the technical arm is the Fundacao the training process. Oswaldo Cruz, in Rio de Janeiro. Teachers are senior nurses who already have the experience Initially, CHWs receive orientation for home of having been nurses of the PSF. There are cur- visits and family census, including information rently more than 3,100 senior nurses at national on cultural background of communities, so- level. Basic content of training of trainers cour- cioeconomic conditions of the work area, and ses include themes as health and education communication techniques. context, health and work, and the understanding of social determinants of health. The feasi- Then they are trained in specific themes on how bility of establishing a MA in Professional Health to follow and orientate the group of women Education is being currently considered, as a and children, considered a priority target for step forward that should strength the profile of health care, with emphasis on identification and health professionals of the PSF. prevention of risk situations. Finally, a year ago it was established UNASUS, a Gradually, the training is extended according to national level strategy that brings together aca- the array of problems of the community: fight of demic institutions and health services, with the endemic conditions, elderly care, adolescents, aim to establish and consolidate a critical mass attention of groups with special needs, impor- of Family Health Specialists through an ad-hoc tance of basic sanitation, amongst others. training process of health professionals, with an initial emphasis on members of the PSF. This On-going Training of CHWs initiative, thought to work as an open university, is offering about 52,000 positions for applicants After the initial 12-week period, ongoing educa- to the specialization course. tion is provided during local monthly and quarterly meetings. This training is oriented toward local concerns of the agents or clinical family Equipment and supplies health team. Standardized training is provided Basic equipment and supplies: whenever new practices are instituted, such as - A distinctive dress and ID badge care for acute respiratory infections or procedu- - A Clipboard res for reporting causes of deaths. - A format of Basic Care Information System - Bicycle, canoe or ship, if the CHW needs to Training of Trainers reach remote places - Scale for weighing children at home Training of trainers (nurses) consists of a basic - Chronometer to verify respiratory rate training module of 80 hours. Trainers can also - Thermometer perform a further specialization program of 540 - Tape measure -Educational material h, offered at the municipality level and at state level through the Technical Schools. This extended course has a semi-presential modality. Supervision Nurses fulfilling this specialization requirements Periodically, the instructor/supervisor (a nurse) course receive a title of Specialist in Professional brings together the CHWs, to evaluate their work Health Education, which has national level and to reorient their activities. Alternatively, as recognition. This specialization program is cen- for example, in Ceara, a nurse-supervisor visits

285 each agent under her charge at least once a Monthly follow-up of diagnosed pregnant wo- month to review problem cases and collect men resident in micro-areas: 100% services data. In addition, one of the nine staff Monthly follow-up of diagnosed hypertensive members of the agent program at the central patients resident in micro-areas: 100% office meets with each municipal supervisor every 2 to 4 months. Monthly follow-up of diagnosed diabetic patients resident in micro-areas: 100% Each nurse of the PSF generally spends half of Monthly follow-up of diagnosed TB patients her time supervising an average of 30 CHWs, resident in micro-areas: 100% doing bookkeeping, distributing supplies, and compiling data for the health agents program. Monthly follow-up of diagnosed leprosy pa- During the other half of her time she staffs tients resident in micro-areas: 100% a clinic.60 However, where there are many Proportion of children younger than 4 months agents, the nurses increasingly work full-time as old with exclusive breastfeeding: increasing supervisors. trend

As part of the evaluation process of CHWs, a Proportion of deaths in children younger than 1 working group must be established, composed year old: decreasing trend by representatives of partners in charge of Proportion of deaths due to diarrhoea in chil- CHWs enrollment (the municipality and civil dren younger than 1 year old: decreasing trend society organizations), in order to follow-up and Proportion of deaths due to respiratory infec- guarantee the accomplishment of the goals tions in children younger than 1 year old: de- established in the contract. creasing trend During the evaluation process of performance Number of deaths in children younger than 1 of CHWs in relation to goals and activities de- year old: 0 fined, the following criteria are considered for each micro-area: Accomplishment of CHW requirements and attributions: 100% Proportion of families enrolled in each micro- area: 100% Performance Evaluation of the Mean monthly number of domiciliary visits per- PSF formed by CHW to each family enrolled in the micro-area: 1 Various external evaluation efforts of PSF have been published. One of them resorted to an eco- Systematic update of family enrollment in the logical design, using longitudinal secondary data micro-area: 100% sources.61 It documented coverage of PSF from Follow-up of children 0-5 years old resident in 1990 to 2002 and variation of infant mortality micro-areas: 100% during the same time period, and then explored possible association between coverage of PSF Proportion of children younger than 2 years and infant mortality, controlling for contextual weighed: 100% factors, including state level measures of access to clean water and sanitation, average income, Proportion of children younger than 1 year old women’s literacy and fertility, physicians and nur- with updated immunization: 100% ses per 10 000 population, and hospital beds per

Global Evidence of Community Health Workers 1000 population. Additional analyses controlled on reductions in mortality throughout the age for immunization coverage and tested interac- distribution, but mainly at earlier ages. It further- tions between PSF and proportionate mortality more found that municipalities in the poorest from diarrhea and acute respiratory infections. regions of the country benefit particularly from According to this report, from 1990 to 2002 IMR the program. For these regions, implementation declined from 49.7 to 28.9 per 1000 live births. of the program is also robustly associated with During the same period average Family Health increased labor supply of adults, reduced ferti- Program coverage increased from 0% to 36%. lity, and increased schooling. A 10% increase in PSF coverage was associated with a 4.5% decrease in IMR, controlling for all As for the direct impacts, the results of the other health determinants. The authors conclu- study showed that implementation of the PSF ded that the PSF is associated with reduced IMR, was significantly associated with reductions suggesting it is an important, although not uni- in mortality before age 1, between ages 1 and que, contributor to declining infant mortality in 4, and between ages 15 and 59. Particularly, Brazil. municipalities eight years into the program are estimated to experience a reduction of 5.4 per A more recent study analyzed the direct and in- 1,000 in mortality before age 1, as compared direct impacts of Brazil’s Family Health Program to municipalities not covered by the program. at country level and in different regions of Brazil, The estimated impacts are driven mostly by by crossing municipality level data with the reductions in mortality due to perinatal period Brazilian National Household Survey from 1995 conditions, infectious diseases, endocrine and through 2003, and controlling also for contex- metabolic diseases, and respiratory diseases.62 tual factors such as presence of other public health policies, education infrastructure, and In relation to changes in behavior that may immunizations in each assessed municipality.62 be determined from improvements in health, The authors also explored other possible sour- the analysis concentrates on the two poorest ces of variation in the effects of the program, regions of the country.62 The study found that such as initial level of mortality and geographic eight years of exposure to the program are as- region. The main sources of variation used to sociated with a 6.8 percentage point increase in identify the effects of the program included dif- the labor supply of adults between 18 and 55, ferent timing of adoption across municipalities a 4.5 percentage point increase in the school and different time of exposure. enrollment of children between 10 and 17, and a 4.6 percentage point reduction in the Direct impacts were related to the effects of the probability that women aged between 18 and program on health outcomes. Indirect impacts 55 experience a birth over a given 21 month refer to the effects of the program, through interval.62 changes in health, on household behavior related to child labor and schooling, employment of The PSF seems to be most effective in the adults, and fertility. In the analysis of the health North and Northeast regions of Brazil, and impacts of the program, the unit of observation also in municipalities with a higher fraction of is a municipality at a point in time. In the analy- rural population, and lower coverage of public sis of the impacts of the program on individual health infrastructure (access to treated water behavior, the unit of observation is an individual and sewerage system).62 For example, a munici- within a municipality at a point in time. The pality eight years into the program is estimated study found consistent effects of the program to experience a reduction in infant mortality of

287 15 per 1,000 in the North and 14 per 1,000 in the effective tool for improving health in poor areas, Northeast, as compared to the 1993 national although a formal cost-effectiveness study was average of 27 for this variable. not performed. On the other hand, the yearly cost of main- Incentives taining a PSF team has been estimated to be between US$ 109,610 and US$ 173,400 in 2000. In Brazil, the CHWs are considered sui generis On the assumption that each team coverage employees of the ministry of health, selected capacity reaches about 3500 individuals, this with an active participation of the community, would correspond to a yearly cost between US$ paid by the public sector, and accountable both 31 and US$ 50 per individual covered.58 The to their communities and to the public sector. authors concluded that the evidence suggests They are in charge of actively making the sur- that the Family Health Program is a highly cost- veillance of the whole social, economic and

Table 34 - Performance evaluation of CHWs Program coverage (%) >90% of Brazilian municipalities, and more than 85 million people (Ref: 15), or about half of Brazilian population. Preventive and promotive Vaccination promotion coverage (%): 100 % of children under five in the service delivery assigned area of each CHW Contraceptive usage: there is not a specific goal of the PSF for CHWs for this particular aspect. Curative service delivery % of all CHW seen and referred emergency case in previous three months : 100% Support system for CHWs Recruitment: approximate proportion that meet program selection cri- and their performance teria: variable from municipality to municipality Training: 100 % CHWs received introductory training Supplies and equipment: provided regularly. No stock problems Salaries: all CHWs receive regularly their salaries Supervision: 100 % CHWs attend monthly a supervisory meeting. CHW services and the poor Approximate overall poor coverage of the program: (%): hard to estimate. Although initially focused on poorest regions of the country, the PSF is currently aimed at reaching all the Brazilian population. With 30,000 Family Health Teams active across the country, it currently covers half of the Brazilian population. CHW impact on health Indicators of population served compared with national figures? Difficult to ascertain. The average current coverage is more than 95% of country municipalities, but this hides great disparities from municipality to municipality (there are still municipalities with less than 10% coverage)

CHW costs – Actual level of funding is increasing compared with the originally current and future planned budget, but is not enough due to the magnitude of expansion of the PSF.

Global Evidence of Community Health Workers social situation of families, and of serving as a formation, has been able to integrate CHWs into link between the community and the health its primary health care services and has institu- system. As health professionals, whose role in tionalized Community Health Committees as the PSF is so important, CHWs receive a financial part of the municipal health services to sustain incentive, earning the official national minimum social participation, meaning that community wage, which is about US$ 112 per month. This participation does not become an alternative is about twice the average local monthly in- but an integral part of the state’s responsibility come for rural workers, but the specific amount for health care delivery. With decentralization, varies in fact from municipality to municipality, municipalities are now responsible for delivery through negotiations between CHWs associa- of health services at primary level. Municipalities tions and municipalities. The Ministry of Health are also in charge of actively ensuring the exis- pays them, but there is a co-financing between tence of Community Health Committees, incor- federal government, state, and municipal go- porating in this way the voice of community vernment levels. Importantly, selection and members. Public service regulations regarding participation of the state government in salary the national advertising of civil service posts have payment prevents local politicians from mani- been amended to ensure that health agents pulating the program. Central funding has also come from and serve their own communities. been key to the local leaders’ accepting the Moreover, one of the key characteristics of the program, which employs 30–150 local residents PSF is that it is explicitly committed to promote per municipality. the organization of the community and to act as a link between different sectors, so that the A unique operational aspect of the both the community can exercise effective control of ac- PACS and PSF is the way they have been intro- tions and health services and develop strategies duced into new municipalities. In the PACS the for specific health interventions. state government would pay the CHWs’ salaries only if the municipal government agreed to pro- Referral System vide a salary for a nurse supervisor, contributing thus to the assembly of the Family Health Team, The CHW performs a monthly visit to each family and avoiding to promote isolated activities of in his/her catchment area, and on a daily basis CHWs. Similarly, in the PSF a municipality must whenever he/she finds a member at risk or sick. apply to the federal government and agree to In this last case, he/she immediately reports the partial financial responsibility for the program. finding to the nurse auxiliary or to the nurse of This scheme ensures local commitment before the family health team, for further evaluation. the government initiates the program in that Depending on the severity of the case, a referral area. The program generally employs 30 to 150 to the nearest health facility may be formally local residents per municipality as CHWs. They made, with the CHW accompanying the patient are paid out of central state funds, making the and permanently maintaining the contact with program attractive to local leaders. the family. Once the patient is discharged, the CHW continues the follow-up until the resolution of the problem, maintaining the link between

Community Involvement the health system and the family and the com- A key challenge for assuring the sustainability munity. The CHW keeps a written record of each of CHW programs lies in institutionalizing and family at risk and of those patients referred for mainstreaming community participation. The further assessment and treatment. Such a writ- PSF, which is part of a large-scale political trans- ten record is monthly presented by the CHW to

289 the family health team. By interacting on a sys- the PSF think that encouraging the systematic tematic basis with the same families, through promotion of CHWs by the PSF would risk them a close supervision by a nurse, and in coordi- becoming employees of the public sector, wi- nation with the Family Health Team, CHWs are thout real incentives for working with a genuine able to detect early symptoms that may require interest in their communities, and thus it would a more specific type of care, but they are also jeopardize the very basic tenets of PSF. This instrumental in increasing the accountability of trade-off between the programmatic needs of the health system to the community, and also the PSF and the legitimate aspirations of CHWs in empowerment building and maintenance for professional development is an important of the community with regards to the health as challenge that needs to be faced adequately. a right. The network of PSF professionals, once established in a certain area, can be used to Documentation and implement any type of health intervention that demands some degree of coordination across Information Management large areas or different agents (immunizations, The PSF maintains an information system aimed campaigns against endemic conditions, etc). at monitoring decisions and health outcomes. Data related to implementation of the program Professional Advancement at the municipality level are available from the Brazilian Ministry of Health, through its Basic The CHW is a unique professional, who is aimed Attention Department (“Departamento de at working only for the PSF. Therefore, there are Atenção Básica”). These data provide the date of no mechanisms for promoting them to nurse implementation in each municipality (starting auxiliaries or nurses, or other health specialist from 1996). The Family Health Team, including titles. Of course each individual CHW is free to the CHW, is required to systematically collect pursue any professional development path, and and report geographical, demographic, and most frequently, the previous training and expe- health information on the assigned families, and rience gained is an asset that allows him/her to also to use such information for monitoring their achieve his/her expectations. Although there is own activities and performance, so as to make an official referential national minimum wage for the adjustment decisions deemed pertinent. CHWs, they are organized locally, and nationally, and are therefore empowered for negotiating However, there are remaining challenges. with national and local authorities the range of Currently the information systems at health salaries at each local setting. In addition, there facilities that are part of the PSF have Internet are performance-based financial incentives for access, and allow access to data integrated to a the family health team at some municipalities. unified database of the Ministry of Health. There The issue of professional advancement has are available indicators on the health team been largely discussed, and the decision of not activities and on management. The under-re- promoting it as a program is based on the fun- gistration has decreased in the last years, but damental philosophy of PSF of building a strong there is still resistance of health workers to use family health team with empowered, motivated the information systems, as they are perceived and passionate CHWs, committed not only to the as being basically related to management and health of the community to which they belong, financing support systems, and not related to but also and more generally, contributing to the clinical activities. There are ongoing efforts at development of citizenship and of human and municipality level for developing software that social capital. Champions and implementers of should allow registration of data useful for both

Global Evidence of Community Health Workers managing and evaluation of clinical activities, including the development of a digital clinical record.

291 3 3 3 3 2 Current Current Level/ Evidence Although significant significant Although has been progress made along the in defining years this of CHW, the role is still a challenge needing further improvement 3 (best practice) community from Recruited If when possible. not possible, the community is consulted and agrees during the process selection. on recruitment community, Health system, the role/ and CHW design expectations and policies in place that support CHW Role and expectations role. CHW and clear to are for Process community. and discussion of update role/expectations in place CHW and community for Initial training is provided within the six all CHWs to months that is based on for CHW. defined expectations Some training is conducted in the community or with community participation. with is consistent Training health facility guidelines for community and health care in training. facility is involved On-going training is provided CHW on new skills, update to and initial training, reinforce he/she is practicing ensure is Training skills learned. tracked and opportunities in a consistent offered are all and fair manner to (not only some) CHWs All necessary supplies; no substantial stock-out periods. - - - CHW is not recruited from com from CHW is not recruited munity but the community is on the final selection.consulted defines (policies Health system but without exist) the CHW role community input. Role is clear CHW and communityto but little discussion of specific expectations. General agree between CHW, ment on role and community. health system, to Initial training is provided year within the first all CHWs does Training of recruitment. not include participation community from or health center. referral On-going training is provided Some super basis. on a regular up with coaching. visors follow have CHWs Functional Note: updated) been trained (or within the last 18 months. on ordered Supplies are basis although a regular Stock delivery can be irregular. out of supplies essential for defined CHW tasks occur at of x per year/mo a rate 2 - - 1 from CHW is not recruited community but the commu nity (reluctantly) accepts the identified CHW after selection. of CHW exists role No formal (no policies in place) General to expectations given are CHW (initial training) but CHW and not specific. are community do not always on role/expectations. agree Minimal initial training is etc). (1 workshop, provided works attend Some CHWs topics. hops on specific ad hoc visits Occasional, supervisorsby provide some coaching. Inconsistent supply and supportrestocking to formal No defined CHW tasks. re-ordering. for process Table 35 - CHW Program Functionality Assessment Tool (CHW-PFA)-Brazil Tool Assessment Functionality 35 - CHW Program Table 0 community CHW not from and in the recruitment. no role plays upon Role is not clear or agreed community between CHW, health system. and formal No initial training is provided. No ongoing training is provided No equipment and supplies provided. are Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Recruitment a where and from How community health worker and selected, is identified, a community. to assigned CHW Role design Alignment, and clarity from of role and CHW, community, perspectives. system health Training Initial to provided Training role for prepare CHW to in MCH services delivery he/she has the and ensure necessary skills provide to and quality care. safe Training On-going On-going training to CHW on new skills,update initial training, reinforce he/she is and ensure practicing skills learned. and Supplies Equipment equipment Required deliver and supplies to expected services. 1 2 3 4 5

Global Evidence of Community Health Workers - 3 3 3 3 Current Current Level/ Evidence With progressive progressive With empowerment asso of CHWs they are ciations, in a better now ask for position to salariesbetter - All necessary supplies; no substantial stock-out periods. 3 (best practice) Regular supervision visit every 1-3 months that includes reports,reviewing monitoring Data is of data collected. solving problem used for Supervisorand coaching. makes visits community, skills provides home visits, Supervisor CHW. coaching to is trained in supervision and has supervision tools. evaluation least once/year At that includes individual performance (local eva luation) and evaluation of or monitoring coverage data (national /program evaluation) Community is feedback asked provide to on CHW performance. for clear rewards are There good performance, and community a role plays rewards. in providing and/or non-financial Financial partly are incentives based on good performance. Incentives balanced and in line with are expectations placed on CHW. Examples of non-financial that engage incentives workers might include (advancement, recognition, certification process) an activeCommunity plays in all supportrole for areas such as development CHW, feedback, providing of role, providing solving problems, establish helps to incentives, CHW as leader in community. - Regular supervision visit at least every months that three reports,includes reviewing monitoring of data collected and occasionally provide supportproblem-solving to Supervisors trained not are CHW. in supportive supervision but facility are based health workers. evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage data (national /program evaluation). Community is not on feedback asked provide to There performance. CHW’s good for some rewards are performance, such as small etc. recognition, gifts, incentive Some financial or non-financial provided. are incentives Examples of non-financial incen include occasional formal tives additional training, recognition, and other small incentives. significant Community plays in supportingrole the CHW groups, mother’s through CHW is widely networks, etc. for and appreciated recognized serviceproviding community. to 2 - 1 Supervision visits conducted times between two and three collect to reports/per year meetings at group data (or facility turn to in monitoring No individual perforforms). workmance supporton offered coaching) (problem-solving, evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage no rewards are There data. good performance. for provided incentives No formal but community recognition a reward is considered Community is sometimes education) (campaigns, involved with the CHW and some people in the community recognize the CHW as a resource. 0 No supervision or regular evaluation occurs outside of by CHWs occasional visits to nurses or supervisors when or less). possible (1x/year evaluation of No regular performance CHW. by No financial or non-financial provided incentives with Community is not involved ongoing support CHW to Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Supervision Supervision conducted carry basis to on a regular tasks out administrative individual provide and to performance support data- (feedback, coaching, driven problem-solving). Evaluation Performance fairly to Evaluation assess work during a set period of time. Incentives salary Financial= and bonuses Non-financial= training, certification,recognition, etc. medicines, uniforms, Involvement Community Role that community in supportingplays CHW. 6 7 8 9

293 3 2 3 Current Current Level/ Evidence explained As this above, particular type of professional advancement is not promoted the PSF as by for a program, the explained fundamental reasons - - - 3 (best practice) CHW knows when to signs, client (danger refer etc) additional treatment, CHW and community know facility is and referral where plan for a logistics have (transport,emergencies with a funds) Client is referred slip of paper and information to CHW with a back flows and/ form referral returned or monthly monitoring. is (promotion) Advancement who performto CHWs offered an and who express well in advancement if the interest opportunity exists (advance for ment might mean path to mal sector or change in role) opportunities are Training to learnto CHW new offered skills and advance their role to of them. CHW is made aware to is intended Advancement good performancereward or and is based on achievement, is fair evaluation. Retirement encouraged and incentives encourage to provided are at a set age. retirement document their CHWs and group visits consistently facilitymonitoring visits to who CHWs by attended are bring monitoring forms. Supervisors quality monitor of documents and provide CHWs/ help when needed. communities work with supervisor facility or referral use data in problem-sol to ving at the community. - - CHW knows when to refer CHW knows refer when to additional signs, client (danger CHW and etc) treatment, community know referral where facility is and usually have transportthe means to client with a slip of Client is referred tracked paper and informally by CHW (checking in with family, up visit) but information follow to CHW. back does not flow is (promotion) Advancement to CHWs sometimes offered for been in program who’ve Limited specific length of time. training opportunities offe are learn CHW to new skills to red Advancement advance role. to good reward to is intended performance or achievement, although evaluation is not (advancement might consistent sector or formal mean path to reti No path to change in role). CHWs is made clear to rement document their CHWs and group visits consistently facilitymonitoring visits to are who bring CHWs by attended Supervisorsmonitoring forms. qualitymonitor of documents help when needed. and provide do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 2 - - 1 client CHW knows refer when to additional treat signs, (danger CHW and communityment, etc) facility know referral where referral no formal is but have is not Referral process/logistics tracked community by or CHW is (promotion) Advancement to CHWs sometimes offered been in program who’ve specific length of time. for No other opportunities discussed with CHW. are to is not related Advancement performance or achievement. document their vi Some CHWs monitoring visits sits and group CHWs by facilityattended to are who bring monitoring forms. do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. - 0 in place: CHW system No referral might know to when and where plan client, but - no logistics refer the communityin place by for - information emergency referral is not tracked or documented advan No professional cement is offered. documentation for No process management is followed or info Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional

Global Evidence of Community Health Workers Table 36 - Community Health Worker Functionality Matrix – MCH Interventions MCH INTERVENTIONS YES COMMENTS 1 ANTENATAL CARE A Iron folate supplements Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x B Maternal nutrition Provides counsel and refers if he/she identifies a Counsel x nutrition problem or risk Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment x C Counsel on birth preparedness/complication readiness x (includes counseling to use skilled birth attendant) D Tetanus toxoid Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x E Deworm Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x 2 CHILDBIRTH and IMMEDIATE NEWBORN CARE A Prevent Infection/Clean Delivery o CHW provides counseling and education on (Hand washing, clean blade +/or clean delivery kit) prenatal care, safe delivery and need of immediate newborn care at a health facility, but does not provide any care intervention B Provide Essential Newborn Care CHW provides counseling and education on a. Immediate warming and drying o prenatal care, safe delivery and need of imme- o diate newborn care at a health facility, but does b. Clean cord care not provide any care intervention c. Early initiation of breastfeeding o C Recognize, initially stabilize (when possible) and refer for maternal and newborn complications o CHW provides counseling and education on o prenatal care, safe delivery and need of imme- a. newborn asphyxia diate newborn care at a health facility, but does b. sepsis, o not provide any care intervention c. hypertensive disorder o d. hemorrhage e. prolonged labor and post-abortion o complications D Prevent PPH: AMTSL or use of uterotonic alone CHW provides counseling and education on o prenatal care, safe delivery and need of imme- in absence of full AMTSL competency (e.g. oral diate newborn care at a health facility, but does Misoprostol) not provide any care intervention E Provide special care for Low Birth Weight newborns CHW provides counseling and education on (Kangaroo Care) o prenatal care, safe delivery and need of immediate newborn care at a health facility, but does not provide any care intervention 3 POST-PARTUM and NEWBORN CARE A Provide counseling on evidence-based maternal newborn health and nutrition behaviors x a. clean cord care; x b. exclusive BF through 6 months; x c. thermal protection; hygiene;

295 MCH INTERVENTIONS YES COMMENTS d. danger sign recognition; x e. maternal nutrition, etc. x B Assess for maternal newborn danger signs and provide appropriate referral. x C Provide Treatment for severe newborn infection (when community-based treatment supported by national o guidelines.) 4 EARLY CHILDHOOD A Infant and young child feeding, IYCF: x Provide counseling for immediate BF after birth; exclusive BF < 6 months; age-appropriate complementary foods B Promote growth monitoring, weighing infants and x recording progress C Provide community based management of acute mal- o nutrition (CMAM) using Ready to Use Therapeutic Foods (community-based recuperation of children with acute moderate to severe malnutrition without complications) D Community-based treatment of pneumonia x Counsel re recognition of danger signs, seeking care/ o antibiotics x Assess and treat with antibiotics o Refer for antibiotics Refer after treating with initial antibiotics G Community-based prevention and treatment of diarrhea x Counsel on hygiene x Counsel on point-of-use water treatment o Provide point-of-use water treatment x Refer point-of-use water treatment x Counsel on ORS o Provide ORS x Refer for ORS x Counsel on Zinc o Provide Zinc x Refer for Zinc H Vitamin A supplements (twice annually children 6-59 months) Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x I Effectively assess and recognize severe illness in chil- x Although the CHW is not expected to make a specific classification or - dia dren (danger signs) with appropriate referral. gnosis, he/she should recognize danger signs and make the corresponding referral j Counsel on immunizations o Mapping/tracking for immunization coverage x Provide Immunizations: -DTP o -polio and or measles o

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS - +/- HIB o - Hep B o -Pneumovax o -Rotavirus o Refer for immunizations x 5 FAMILY PLANNING/HEALTHY TIMING AND SPACING OF PREGNANCY A Counsel on HTSP/contraceptives x Provide contraceptives: o - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - depo o Refer for contraceptives: x - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - long-acting and permanent methods o Provide FP counseling +/ - administer contra- o ceptives (e.g.;Oral Contraceptives) 6 MALARIA (Optional - Dependent Upon Country) A Insecticide-treated mosquito nets to pregnant women and children Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x B Intermittent preventive malaria treatment (IPTp) Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x C Community-based treatment of malaria (testing with Rapid Diagnostic Test or presumptive treatment per antimalarial per national guidelines.) Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x 7 PMTCT (Optional - Dependent Upon Country) A Healthy timing and spacing of pregnancy Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x B Antibody testing to pregnant women and mothers x Counsel o Provide commodity or intervention/ Assess and treat x C Refer for commodity, intervention, or treatment Prophylactic ARVs/HAART to pregnant women mothers x Counsel o

297 INTERVENTIONS YES COMMENTS Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment E Prophylactic ARVs/HAART to infants Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x F Early infant diagnosis Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x G Pregnant HIV-infected women tracking Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x H HIV-exposed infant tracking Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x

Global Evidence of Community Health Workers Summary Brazil has experimented significant social, eco- phical area, performing their activities actually nomic and health changes in the last years, with in the basic health units and in the households substantial reductions in country average po- themselves. The team is specifically responsible verty, improvements in life expectancy at birth, for enrolling and monitoring the health status of and reductions in several health indicators. the population living in the assigned area, pro- Important inequities persist, however, which viding primary health care services, and making need to be addressed if the gains are to be sus- referrals to other levels of care as required. Each tained. In 1988 the Brazilian government laun- team is responsible for following about 3,000 to ched the Unified Health System (Sistema Unico 4,000 and a maximum of 4,500 people. de Saúde), with the declared aim to provide universal health services to Brazilians, empha- The CHWs receive a training that privileges the sizing decentralization, equity, community par- determination and understanding of social, eco- ticipation, integration, shared financing among nomic and environmental characteristics of the the different levels of government, and comple- community, as well as the epidemiological pro- mentary participation. Primary Health Care was file. They also receive training on promotional considered to be key tool in achieving the goal and preventive aspects of health, so they are in of universal access to health care, and it was a good position for providing influential council made operational through the implementation to community members, for identifying timely of the Family Health Program (Programa Saúde family members at risk or with health problems da Família, PSF) in 1994. The PSF was conceived and refer them to the family health team for fur- as an integral approach to community health ther assessment and management, if deemed needs, with a particular emphasis on promotio- pertinent. The CHWs follow-up closely those nal and preventive activities and with an equity families at risk and those with a sick member, lens, prioritizing first the poorest regions of the providing support, counseling, supervising and country. The initiative and committment of encouraging treatment compliance, whenever municipalities for taking responsability of local needed. The role of the CHWs within the Family implementation of PSF across the country al- Health Team is seemingly critical, as they are lowed an impressive expansion of the program, community members carefully selected with from a few municipalities covered in 1994, to participation of community members, the mu- more than 95% of all municipalities with PSF in nicipality, and the Ministry of Health. The parti- place currently, although this figure hides great cipation of the CHWs in the team facilitates an disparities, as there are still municipalities with integral approach to health, with an increased less than 10% of PSF coverage. understanding of social determinants, linking more closely the whole Family Health Team The PSF has been implemented as an initia- to an empowered community demanding for tive aimed to provide a broad range of primary more and better health, but also taking respon- health care services, delivered through a Family sibility for adopting healthy life styles. Health Team (Equipo de Saúde Familiar), composed by at least one family doctor, one nurse, The PSF started in 1994 in a few pilot munici- one assistant nurse, and a variable number o palities and then has reached an impressive community health agents or CHW in each mu- expansion, having currently about 30,000 family nicipality. Some expanded teams also include health teams and more than 240,000 CHWs that one dentist, one assistant dentist, one dental cover half of the country, whereas the other half hygiene technician, and social work professio- is still basically covered through the traditional nals. Each team is in charge of a specific geogra- health facility-centered model. Although the

299 PSF initially prioritized the poorest regions of by a public sector minimally able to address the the country, it is not to be conceived as an in- community needs. tervention for poor people, but as an innovative integral promotional and preventive health model aimed at covering the entire Brazilian popu- 5. Haiti - Zanmi Lazante’s lation instead. There is compelling evidence on Community Health Program PSF impact on health indicators such as infant, child mortality and maternal health, as well as Socio-economic and on behavioral indirect household outcomes political context including increased child schooling, reduction of female fertility rate and improved adult labor Haiti is one of the poorest countries in the enrolment. These improvements can be attribu- world and reportedly the poorest country in the ted in a substantial proportion to a wide country Western hemisphere,63 and it has suffered seve- level implementation to PSF, although other ral decades of social unrest and political instabi- health and crosscutting interventions have also lity. Despite several efforts made, vast segments surely played an important role. Remaining of the population remain poor and this situation challenges for sustaining and further increasing has even worsened, as well as inequalities in this implementation at scale of PSF and for access to basic services such as health and edu- improving quality are huge, however, including cation. Due to this gloomy situation, the United among others a still “medicalized” narrow and Nations placed a special peace keeping force vertical training of CHWs and other members of (MINUSTAH) in the country in 2004, and they are the family health team, with a still relatively weak still in place now. Security has improved since emphasis on social determinants of health and then, although crime and violence continue on health understood as a fundamental right undermining Haiti’s development.63 to be demanded by empowered communities and provided by the government, a continued Haiti is a mountainous country. It has about 9.6 resistance of powerful health professional million inhabitants, 5 million of whom live in ru- corporations to the PSF innovative approach, ral areas.64 Some social indicators are among the difficulties in enrolling capable and committed weakest in the world in Haiti,63, 65, 66 including family doctors, nurses, CHWs and other health a GNI per capita of only US$560, life expectancy professionals, and trade-offs between mana- at birth of 60 years, infant mortality rate of 60 for gerial objectives of keeping solid family health every 1,000 live births, 2.2 percent of HIV preva- teams with minimal leakages and legitimate lence among the population (aged 15-49), and expectations of CHWs for further professional literacy rate of 43 percent. Haiti ranks 146th out development. There are also several local dif- of 177 countries on the United Nations Human ficulties that need to be openly, honestly and Development Index, and 54 percent of Haitians effectively discussed and addressed to assure live on less than US$1 a day and 78 percent on the sustainability of the program. less than US$2 a day.

The PSF is undoubtedly a global lesson whose The country has been hit very recently by soaring basic underlying principles can and should be world prices for food and fuel, followed by natural adopted in different settings, irrespective of the disasters such as tropical storms and hurricanes political and economic country level prevailing since August 2008, which took the lives of several systems, on the basic condition of considering hundred people and left about a tenth of the total health as a basic human right to be provided population needing humanitarian assistance.63

Global Evidence of Community Health Workers Health systems overview Haiti has witnessed recently three successive The Haitian health system includes the public years of economic growth since 2004, when sector (Ministry of Public Health and Population the economy contracted by 3.5 percent, and is and Ministry of Social Affairs); the private for- still set to post modest growth for the country’s profit sector (all health professionals in private 2008 fiscal year. However, growth estimates for practice); the mixed nonprofit sector (Ministry fiscal year 2009 and beyond are being revised of Health personnel working in private insti- downwards to reflect the impact of the recent tutions (NGOs) or religious organizations); the natural disasters.63 private nonprofit sector (NGOs, foundations, associations); and the traditional health system.65 According to a recent World Bank country brief, A number of central bureaus execute the health Haiti requires continued strong support from programs (except AIDS and tuberculosis, directly its international partners for relief, recovery, and under the Office of the Director General). There rebuilding, and to safeguard the considerable are also 10 directorates (one for each depart- progress made since 2004.63 This country brief ment and for the Nippes Coordination), under states that Haiti has improved economic and so- which come the UCSs. Due to the country’s cial stability, democratically elected a president political problems, there has been no recent and parliament and launched wide-ranging progress in health legislation. The Ministry of reforms, particularly in the area of economic Health coordinates all health system institu- governance, notably in budget formulation, tions. This sector has been unable to assume its execution and reporting.63 leadership role in the recent past, as the economic embargo directed resources toward the Although there is currently an apparent stabi- nonprofit sector. The health services reach 60% lity, the political situation is always volatile, and of the population. rapid changes in leadership affect governance, continuity of policy-making and progress in all In 2000, after irregularities in legislative elections sectors. Haiti still struggles with major political, were reported, the US and European Union im- economic and social challenges. An always-weak posed an economic embargo and more than leadership and governance jeopardizes pre- US$ 500 million of blocked loans were earmar- sence of state across the country and provision ked for health, education, water and roads.66 of even basic services, which are in a significant During the following five-years period, the only extent in the hands of civil society organizations. aid coming from these regions for health was As a dramatic illustration, barely 55.2 percent of channeled through non-governmental organi- the Haitian population has access to an impro- zations, further weakening the already crippled ved water source, while almost 70 percent does health system in Haiti.66 Thus it is not surprising not have direct access to potable water. Water that the Haitian government spends less than supply is intermittent in virtually all urban areas, US$2 dollars per capita on health per annum. whereas in rural areas access to water becomes Moreover, less than 40% of health expenditures a real prowess during the dry season. Moreover, occur in the public sector,67 and the remaining only 27 percent of the country has access to 60% of health expenditures occur in the private basic sewerage, and 70 percent of households sector, including both the for-profit and not-for- in Haiti have either rudimentary toilets (34.9 profit health sectors.67 Notably, of the private percent) or none at all (34.7 percent). It is not sector spending, 70% is out-of-pocket expendi- difficult therefore to imagine that fecal contami- ture, which is a tremendous barrier to healthcare nation of the water supply is a leading cause of in one the most impoverished countries of the disease in Haiti. world.

301 According to a recent PAHO report, there are the country, and points to a problem that should only 371 health posts, 217 health centers and be taken into account by the government, do- 49 hospitals in Haiti.68 It is estimated that 40 % nors and the private sector, if the objective of of the population relies on traditional medicine, strengthening the health system is to be effecti- mostly in rural areas. vely pursued in practice.

Haiti lacks evidently the minimal financial, infras- Currently the World Bank is in the preparatory tructural, and human resources to deliver basic phase of a two-year program of non-lending preventative health and medical services to its technical assistance for Haiti to improve the citizens.69 It has only 25 doctors, 11 nurses, and capacity and effectiveness of nutrition-related one dentist per 100,000 people, a paltry figure programs that address the negative impact of when compared even with the least developed severe and chronic malnutrition among the countries in Latin America. most vulnerable on human and social capital development. There are ongoing discussions Community Health Workers on how to involve CHWs in this program so as to take advantage of their experience. However, Programs in Haiti the level of involvement of the Ministry of Health The role of CHW is critical in a country like Haiti, is rather weak, and therefore the prospects of with a weak public sector unable to provide the constructing strong and sustainable links with necessary amount of capable and motivated the public health system through this program health workers to vast segments of the popu- seem to be very limited, unless the presence of lation, particularly to rural areas such as central public sector is effectively increased, and real Haiti. Not surprisingly, as an alternative to the actions aimed at strengthening the health sys- failing public health system in the country, tem in the long-term are taken. non-governmental organizations that cover a substantial proportion of health care provision We chose Zanmi Lazante’s CHW Program for have resorted to CHWs, in the attempt to com- a full functionality assessment because it is by pensate the deficiencies of the formal system. far the most consistent effort that relies on the participation of CHWs for providing access of A review of the National Health System Reform health care to poor rural and remote areas of Strategic Plan 2005-1010 from the Ministry the country. of Health and Population (Plan Stratégique National pour la Réforme du Secteur de la Santé Brief historical description 2005-2010 –Ministère de la Santé Publique et de la Population),70 shows that CHWs are barely of the Zanmi Lazante’s CHW mentioned. Another document of the Ministry Program in Haiti 71 of Health on a Minimum Health Package, Zanmi Lasante was founded in 1985 by a group considers the role of the various types of CHWs of Haitians and Dr. Paul Farmer of Partners In active in the country, but fails to specify what Health, a non-governmental organization affi- the relationship of CHWs Programs is with the liated with the Harvard Medical School. Partners wider health system, in particular of those ini- In Health (PIH) (or Zanmi Lasante in Haitian tiatives run by NGOs and faith organizations. Creole) founded the Clinique Bon Sauveur (CBS) This reflects surely the weak stewardship of the in 1985. Partners In Health is a non-govern- public sector for bringing together the various mental organization affiliated with the Harvard sub-systems and delivery channels operating in

Global Evidence of Community Health Workers Medical School that has been at the forefront of Agricoles). The CHWs thus have become a criti- HIV service provision in Haiti since the first case cal interface between patient, community and of HIV was detected in Haiti’s central plateau the CBS in Haiti. in 1986. It has done so within a framework of wider primary health care services for the range Recruitment Process of public health problems affecting low-income households. We emphasize from here onwards on Health Agents as they constitute the most important CHWs have served to bridge gaps in access to cadre of CHWs of Zanmi Lasante, and unless care that arise from lack of communication for otherwise stated, when we talk of CHWs we are patient follow-up and long distances for pa- referring to Health Agents. CHWs are chosen by tients to travel for health problems. CHWs are lay patients or their communities, thus the hiring people who are selected by the community to policy involves a strong communal component. be trained and employed as health agents. Such It happens that more than one candidate may cadres had been involved in directly observed be eligible for final selection. In such cases, administration of tuberculosis treatment since members of the community get together and the mid 1980s in Haiti. In 1999, modeled after the elect one of them. This is an informal process successful outpatient treatment of tuberculosis, that involves a lot of discussion and negotiation access to highly active antiretroviral therapy in case the selection of a health agent is in play. (HAART) was expanded through a community- The process of selecting an accompagnateur based program called the HIV Equity Initiative. A is less complex as it only involves the program cadre of CHWs was trained to administer HAART nurse, the social worker and the HIV or TB to patients in their homes as directly observed patient. Moreover, due to the particular vulne- therapy (DOT). The CHWs were also trained to rability of women in face of the HIV epidemic, provide preventive education to communities, more than fifty percent of accompagnateurs to minimize stigma and to refer to the clinic are women. Given the demographics of Zanmi possible HIV and TB contacts or those at risk for Lazante’s CHWs workforce, they have an innate infection. understanding of the socioeconomic and health concerns of the communities they serve. Later on, Zanmi Lasante has expanded its network of lay community members serving General Requirements: as CHWs, involving them in a wider range of The CHW must be an adult (usually over 18 years activities such as encouragement of voluntary of age) and preferably literate. HIV testing, HIV, TB and other chronic diseases treatment supervision, health education, edu- Since the CHW is in daily contact with patients cational and psychological support to families in their homes, he or she should live in or close of affected patients, reproductive health, and to the community served; having lived in the assessment and management of maternal community for a specific number of years is and child health problems. This network the- often required. refore includes currently several groups of The CHW should have a background that is si- CHWs with different names and roles (Health milar to the background of the patients so that Agents: Agents Sante; Women’s Health Agents: they feel comfortable sharing their concerns. Agents de Femmes; Youth Monitors, The This also enables the CHW to have first-hand Accompagnateurs, Traditional Birth Attendants: knowledge of the problems and obstacles pa- Matronnes; and Agriculture Agents: Agents tients face every day. In some cases, CHWs are

303 The CHW Role themselves HIV positive or former TB patients. CHWs have traditionally been used in the deli- They frequently know someone who has HIV or very of tuberculosis medicines and in national TB in their community. vaccination strategies in Haiti. Less often have CHWs been used in the management of chro- Motivation and character are critical requi- nic medical illnesses such as HIV, diabetes and rements. A CHW must be a trustworthy and chronic heart failure. Depending on the spe- respected member of the community, with a cific subgroup of CHWs involved and on the strong desire to help the needy and a strong education they receive, their responsibilities sense of empathy with those who are vulnerable range from general preventive services to the and sick. A CHW’s work is not only focused on provision of drugs and medicines and health improving health status, but also on social jus- education and agricultural techniques. tice and solidarity with the community, through working to support affected individuals and Broadly speaking, Zanmi Lazante’s CHWs in Haiti households and reduce social isolation. serve as counselors, educators, treatment supervisors, and advocates experienced in identifying Interviewing CHW candidates: the needs of their communities. They: The clinical team usually interviews people who wish to become CHWs to see if they meet the Provide home-based care above requirements. Team members that may Provide psychosocial support to patients under- be involved in the interview process include going treatment doctors, nurses, social workers or program managers. The candidate may be asked to take a Act as the link between the patient and the basic literacy test. He/she may also be called health center upon to read a medication label or write his/ Carry out active case-finding her name, to distinguish medications by color and size and to count the number of pills in a Educate the community on a variety of health month’s supply. In some specific programs, topics preference is given to candidates who are extremely poor and could therefore particularly use In fact, however, as we already outlined above, the additional income and skills-training. As sta- Zanmi Lazante’s CHWs network includes several ted previously, given the specific vulnerabilities groups, with different names, training profiles of women in face of the HIV epidemic, women and roles. may be preferentially selected. Health agents (Agents Santé, Ajan Santé in Pairing a patient with a CHW creole) are the most educated and provide Patients themselves play an active role in selec- basic health services, vaccination, health edu- ting CHWs. In the case of an established pro- cation, family planning, and hygiene education, gram, a patient may already know a CHW in his collect socio-demographic information about community, and may even have been referred communities can provide basic treatment for to the health center by him/her. If the patient malaria, diarrhea and other non-complex health does not know any CHW, or doesn’t feel com- problems. fortable with the one(s) he/she knows, then the clinical team suggests another possible candi- Women’s health agents (Agents de Femmes, date from those CHWs who live in the vicinity Ajan Fanm in creole) focus on reproductive of the patient. health counsel, and provide modern contra-

Global Evidence of Community Health Workers ceptive methods except Norplant and surgical provision of health care services, are a key com- methods. They are also involved in support ponent of Zanmi Lazante’s network. PMTCT mothers by providing psychosocial support and the provision of HIV prophylaxis. Initial Training of CHWs

The Accompagnateurs are focused on HIV,AIDS, Organization: and TB. They are in charge of directly observed Before they begin supporting patients, CHWs retreatment (DOTS) for HIV/TB, and provide psy- ceive an orientation from the clinical staff at the chological support to families. These tasks have health center as well as participate in a rigorous been expanded to other diseases, and they also training program designed by Sanmi Lazante. supervise treatment compliance for chronic Its current curriculum for CHWs comprises 15 diseases, making sure that patients comply units, with a focus on AIDS and tuberculosis. with anti-diabetes and hypertension drugs, for The training is tailored to be given over seven instance. consecutive or separate days. Each training day consists of 6.5 hours of training, 1 hour for Youth monitors provide education and peer lunch, and two 15-minute breaks. The number support to young groups on HIV, sexually trans- of participants varies according to need; 25 par- missible diseases (STDs), sexual issues and other ticipants or fewer are ideal. All participants are reproductive health problems such as early provided with meals and a stipend. Trainers and pregnancy. facilitators are drawn from the staff at the health centers and should have experience in training Traditional birth attendants (TBA) (Matronnes) or education to ensure that they are knowled- play an active role in the referral of pregnant geable about and competent in participatory- women at any stage of their pregnancy, but pro- based learning and training methods suited vide also HIV drugs as part of the prevention of to low-literate adult learners. Regardless of the maternal-to-child transmission of HIV (PMTCT) specific content areas covered, the primary to mothers. They are trained to recognize signs objective of CHW training is consistent: to instill and symptoms of pregnancy complications and a sense of solidarity and social justice in suppor- accompany affected pregnant women to the ting patients, households and the community. clinics. Specific training goals include: Agricultural agents (Agents Agrikol in creole) teach agricultural techniques to communities Providing correct information about treatment, and educate them on how to improve their prevention, and risk factors for HIV, TB, malaria, production. Community members are suppor- and other infectious and chronic non-transmis- ted for to produce nuts for instance, and selling sible diseases. them. In this way consumption of nutritious Defining the roles and responsibilities of CHWs. products is promoted, along with and increased family incomes. This activity of agricultural Helping CHWS recognize and reduce stigma agents is key, because most of CHWs trained and discrimination in their communities. by Zanmi Lasante are farmers, and HIV and TB Developing CHWs’ competence in active case patients go back to their communities and they finding for diseases and social needs. are expected to be reinserted in the productive activities, mainly agriculture. Agricultural agents Helping CHWs improve their skills related to effec- therefore, even if they are not directly related to tive communication and psychosocial support.

305 Directing CHWs to additional resources or peo- expert patients. Modules include HIV, TB and ple at the health center and in the community, STDs topics as well as psychological matters, who can guide or assist their work. counseling and individual and group support, and daily monitoring of patients through the Training principles: accompagnateurs’ form. Based upon adult learning principles, the CHW training curriculum presented here incorpo- On-going Training of CHWs rates a variety of participatory approaches to teaching and learning that build upon the exis- Continuing education: ting knowledge, skills, and experiences of the After the initial program, CHWs participate in on- participants, including: going monthly education sessions for one year and beyond, with additional training in areas Large- and small-group activities and such as nutrition, malaria, pediatric HIV/AIDS, discussions diarrhoeal disease, family planning, active case- Role plays finding, worms and parasites, chronic diseases, first aid, the role of traditional healers, and oral Case studies hygiene. Health center staff or other available Brainstorming teachers lead trainings. Panel discussions Shadowing a CHW: Peer teaching After completing his/her initial training, the new CHW joins a veteran CHW in conducting According to the specific group of the network, patient visits. This provides a practical, hands-on discussion and teaching topics and issues offe- learning experience and helps the new CHW red during initial training vary in length, modules develop a support network of fellow CHWs. and even locations of training. Health agent is the group who receives the most advanced trai- In fact, the process for on-going training is ning in diverse issues, from infectious diseases also quite different from one group to another. to hygiene and sanitation, and includes com- Health agents and women’s health agents meet munication skills, counseling and reproductive on a monthly basis for programmatic follow-up. health and preventable diseases for children These meetings serve as an opportunity for and vaccination. Women’s health agents focus continuing education. New topics or refresh- on reproductive health and HIV/AIDS. Youth ment courses are taught. Accompagnateurs monitors address youth issues, sexuality and receive refreshment courses on a yearly basis as responsible behavior in the era of STDs and their group makes the majority of ZL network civic actions. TBAs are trained in danger signs of CHW. recognition and referral of women in labor and beyond. Agricultural agents address agricultu- On-going training characteristics for Youth ral techniques for improving production, grow, Monitors, TBAs, and Agricultural Agents has to harvest and education including nutrition mat- do with refreshment courses and discussions of ters. Initial training for Accompagnateurs is very new matters that are not systematically taught participatory, comprising various methodolo- in initial training such as hygiene, new agricultu- gies from theory presentations to discussions, ral techniques, sexuality, STIs or new monitoring case studies, and visits to patients with expert and evaluation issues that may arise from donors accompagnateurs, and often testimonies of such as new forms and new indicators to report.

Global Evidence of Community Health Workers Training of Trainers which supervision activities and continuing training are provided together. In addition to Training of trainers (TOT) has not been formally that, unplanned and planned field supervision offered to CHWs until recently. In 2009, formal visits are carried out by the each level of su- TOT was delivered to a group of CHW among pervision. Unplanned supervision visits during the best ones. The Training center is committed health posts and vaccination day are provided to carrying out more TOTs targeting this group. as well. Historically, CHWs have been directly supervised by clinical staff, usually a doctor or Equipment and supplies nurse involved in the care of HIV or TB patients. As Zanmi Lazante programs have grown, there Supplies are provided to each CHW according was increasing awareness on the need for more to their respective responsibilities and compe- formal supervision structures that take advan- tencies. The stocks are provided mainly on a tage of the experience and skills of more senior monthly basis. CHWs. Recently, the role of Accompagnateur Health agents: dressing kits, flip chart and flyers Leader has been introduced at several of the for education, vaccines (Polio, DTP, TT, BCG), sy- program sites. ringes, ORS, weigh scales, centimeters, thermo- meters, boots, rain coats, road to health charts, CHW leader (Accompagnateur Leader): Most data collection forms, monthly and daily report often, the leader is an existing CHW who has forms, and irregular provision of phone cards been chosen based on the high quality of his/ Women’s health agents: pills, boots and rain her work, leadership qualities and standing in coats, data collection forms Youth monitors: flip the community. The length of time the CHWhas charts, raincoats, and pens Accompagnateurs: been working as an accompagnateur and his/ boots, raincoats, pens, data collection forms her level of education are also factors taken in Agricultural agents: agricultural materials, flip consideration for their promotion to CHW lea- charts TBAs: boots, rain coats, a delivery kit ders. The number of CHWs supervised by each (clean gloves, scalpels, cotton, gauzes and refer- CHW leader varies. In Haiti, a CHW leader may ral forms). oversee up to 50 CHWs.

CHWs receive monthly stocks of specific sup- Roles and responsibilities of the Accompagnateur plies or commodities such as condoms, SROs, Leader:The primary responsibility of the CHW Iron, Folate, and vitamin A. Vaccines, however, leader is to ensure that the CHWs are visiting are provided the day before or the same day of their patients daily, administering medications vaccination, as cold chain may be a major issue correctly, and vigilantly monitoring patient in Haiti. health. The leader also helps the clinical team by answering patients’ questions, joining the Supervision team on patient visits, and identifying problems The supervisory system is built involving all between CHWs and patients. Another point of levels of hierarchy of each institution. It starts supervision is at the pharmacy, which CHWs from the head of the Commune (city) to public visit regularly to pick up medications for their health nurses, HIV program nurses/ Social wor- patients. Pharmacy logs and interactions with kers to Senior Health Agents/Accompagnateurs the pharmacist are important points of super- to the rest of each group. The system is orga- vision. The CHW leader and other members of nized around the monthly meetings during the health center identify problems between CHWs and patients through unannounced visits

307 to patients’ homes. When a conflict does arise, it is doubtful that Haiti will reverse the gloomy the CHW is called to the health center to discuss health situation that most of their citizens’ face. the situation. CHW leaders meet regularly with health center staff to exchange information and Incentives discuss common issues. CHWs meet monthly with health center staff for ongoing training and All the groups within the network are paid in to discuss any problems or concerns. addition to other social benefits. Monthly salary ranges from USD 50 -130. Agents Sante are full- time employees (8 hours a day, five days a week),

Performance Evaluation and receive a monthly payment of about US 100 There are several assessment publications on (one USD=40 goudes). Agents de Femmes focus Zanmi Lazante’s CHW Program impact. They on reproductive health) mostly offer counseling basically show an increased coverage of health on family planning, and provide some methods: care for HIV/AIDS and TB patients, specifically condoms, pills. Very few of them can give in- increased coverage of voluntary HIV testing jections of Deproprovera. Full-time Monthly and HIV/TB treatment adherence in Zanmi salary: 75. The Accompagnateurs work on a Lazante’s influence areas, through home-based part-time basis (about 1-3 hours a day, 7 days directly-observed therapy strategy conducted a week, because they should not work more by CHWs, and also an increased trust of com- than 30 minutes for each patient they visit, as munity members on health facilities run by they need to move long distances from one committed and capable organizations such as patient to the next one), receive a payment that Zanmi Lasante and other NGOs. There is also ranges between USD 40-60/month, depending consistent evidence about a clearly positive on the number of patients they see. Matronnes impact of NGOs community-based programs (TBS): they work part-time and receive a case-by on reduction of TB and HIV morbidity and case payment that is US 5 for each institutional mortality, and on reduction of infant and child delivery. Agricultural agents are full-time em- mortality, and on maternal and reproductive ployees and are paid the equivalent of US $ 100 health indicators in their catchment areas.72-77 a month, almost the same as CHWs. Youth mo- These findings highlight the fact that more nitors are part-time and school fees are paid for than 20 years experience of work with CHWs in them, as well as training and provision of some Haiti constitutes a unique potential on which to equipments. build for scaling up and for strengthening the Haitian health system. However, to date there is Community Involvement not yet compelling evidence about the overall impact of CHWs Programs on Haiti key health CHWs are local people selected by community indicators at country level. Improved levels of members and ZL staff. They have an innate un- coordination between NGOs, the stimulus of the derstanding of the local population. They are not vital stewardship role of the public sector, the only focused on HIV care but community health critical need of strengthening capacity, gover- and serve as liaisons between the community nance and accountability of the public sector, and clinics, which helps to prioritize needed ser- and an effective tackling of social determinants vices beyond clinical care, such as water projects of health including factors such as poverty and and vaccination campaigns. CHWs attend clinic external debt, all must constitute long-term staff meetings bringing a community voice to objectives for the effective and sustainable de- decision making, from planning events such livery of health services in Haiti. Without them, as World AIDS Day to structuring clinic visits.

Global Evidence of Community Health Workers Employing local residents creates trust between the community and clinic, decreases stigma Professional Advancement and generates self-confidence in community members. Professional advancement still needs to be improved and better structured. CHWs who have demonstrated a good performance re- Referral System cord are promoted to positions of supervision The referral system is very active and all groups (Accompagnateur Senior). refer to the clinics. Referral forms are available between sites. CHW refer to the clinics and of- Additional incentives for advanced CHWs may ten accompany the patients to make sure that reach a 30% of their salary when they become they get the care they need. Feedback is most supervisors. A motorcycle is also provided for often provided to them, facilitating in this way each site for supervision. In addition they receive follow-up of patients. In brief, a CHW refers to calling cards for about US $15 a month. the clinics any patient suffering with any kind of disease. All referrals are made through written referral forms that are completed by CHWs. Documentation and

Table 37 – Performance evaluation of CHW program Program coverage (%) 15% (About 1.2 million people –Overall population 9 million) Preventive and promotive Vaccination promotion coverage: 90%. Proportion of children with basic service delivery vaccination: 80% Contraceptive usage: 24% of all users of modern contraceptives Curative service delivery 100 % of all CHW seen and referred emergency cases in previous three months Support system for CHWs Training: 98% who received introductory training Knowledge: 95 % of and their performance CHWs given at least one correct answer Supplies and equipment: Few lack of stocks. No expiration of stock was reported in the last 5 years. Salaries: example: 100% paid over three months Supervision: Each CHW supervisor makes a visit at least once a month to all the CHWs under his/her supervision. Public health nurses supervise once a week at least a major CHW health post. A doctor, like the nurse, supervises once a week a CHW health post or mobile clinic. 0% facilities lacking important medicines and supplies on the day of survey CHW services and the poor Approximate overall poor coverage of the program: 90% CHW impact on health IIndicators of population served compared with national figures? 1.2 millions In Central Plateau and half of the Artibonite region. CHW costs – Actual level of funding is enough than originally planned? More funds current and future are needed to support the program. The program grew so fast that actual level of funds is not sufficient.

309 Information Management Monthly data collection forms are provided to health agents. Daily and monthly forms are also given to all the other groups. Forms to collect information about health posts, special vaccination days, and routine vaccination are handled as well. Accompagnateurs handle forms to report on HIV drugs, adverse reactions and any remark they may have.

Recently, Zanmi Lazante has set up a web-based medical record system linking remote areas in rural Haiti.78 It comprises an information system and medical record to support HIV treatment and it is used to track clinical outcomes, laboratory tests, and drug supplies and to create reports for funding agencies. Future work will focus on refining the system and developing a core data set and functions to support other HIV treatment projects, including incorporation of data representation and exchange standards. It is acknowledged that common standards for creating computerized guidelines are also important to allow sharing of knowledge between projects and information systems.

Zanmi Lazante is aware that HIV treatment does not occur in isolation, and that the infrastructure this organization has developed in central Haiti is augmenting the care of other acute and chronic diseases, including tuberculosis and heart disease. The similar web based tuberculosis electronic medical record in Peru provides important support for treatment, drug supply, and research with more than 2,500 complete patient records entered to date. Zanmi Lazante has been planning to make our HIV-EMR available to other organizations once it is complete, using an open source model for software distribution.

Global Evidence of Community Health Workers 3 2 2 3 3 trained in and Youth Youth and Monitors be specific topics specific groups such as groups related to MCH to related Remember that Current Current Level/ Evidence Accompagnateurs Accompagnateurs 3 (best practice) Recruited from community from Recruited If when possible. not possible, the community is consulted and agrees during the process selection. on recruitment community, Health system, the role/ and CHW design expectations and policies in place that support CHW Role and expectations role. CHW and clear to are for Process community. and discussion of update role/expectations in place CHW and community for Initial training is provided within the six all CHWs to months that is based on for CHW. defined expectations Some training is conducted in the community or with community participation. with is consistent Training health facility guidelines for community and health care in training. facility is involved On-going training is provided CHW on new skills, update to and initial training, reinforce he/she is practicing ensure is Training skills learned. tracked and opportunities in a consistent offered are all and fair manner to (not only some) CHWs All necessary supplies; no substantial stock-out periods. - - - CHW is not recruited from com from CHW is not recruited munity but the community is on the final selection.consulted defines (policies Health system but without exist) the CHW role community input. Role is clear CHW and communityto but little discussion of specific expectations. General agree between CHW, ment on role and community. health system, to Initial training is provided year within the first all CHWs does Training of recruitment. not include participation community from or health center. referral On-going training is provided Some super basis. on a regular up with coaching. visors follow have CHWs Functional Note: updated) been trained (or within the last 18 months. on ordered Supplies are basis although a regular Stock delivery can be irregular. out of supplies essential for defined CHW tasks occur at of x per year/mo a rate 2 - - 1 from CHW is not recruited community but the commu nity (reluctantly) accepts the identified CHW after selection. of CHW exists role No formal (no policies in place) General to expectations given are CHW (initial training) but CHW and not specific. are community do not always on role/expectations. agree Minimal initial training is etc). (1 workshop, provided works attend Some CHWs topics. hops on specific ad hoc visits Occasional, supervisorsby provide some coaching. Inconsistent supply and supportrestocking to formal No defined CHW tasks. re-ordering. for process Table 38 - CHW Program Functionality Assessment Tool (CHW-PFA) - Haiti (CHW-PFA) Tool Assessment Functionality 38 - CHW Program Table 0 community CHW not from and in the recruitment. no role plays upon Role is not clear or agreed community between CHW, health system. and formal No initial training is provided. No ongoing training is provided No equipment and supplies provided. are Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Recruitment a where and from How community health worker and selected, is identified, a community. to assigned CHW Role design Alignment, and clarity from of role and CHW, community, perspectives. system health Training Initial to provided Training role for prepare CHW to in MCH services delivery he/she has the and ensure necessary skills provide to and quality care. safe Training On-going On-going training to CHW on new skills,update initial training, reinforce he/she is and ensure practicing skills learned. and Supplies Equipment equipment Required deliver and supplies to expected services. 1 2 3 4 5

311 3 2 2 3 financial and all aspects of non-financial Zanmi Lasante’s Zanmi Lasante’s incentives, both incentives, Current Current Level/ Evidence program involves involves program - 3 (best practice) Regular supervision visit every 1-3 months that includes reports,reviewing monitoring Data is of data collected. solving problem used for Supervisorand coaching. makes visits community, skills provides home visits, Supervisor CHW. coaching to is trained in supervision and has supervision tools. evaluation least once/year At that includes individual performance (local eva luation) and evaluation of or monitoring coverage data (national /program evaluation) Community is feedback asked provide to on CHW performance. for clear rewards are There good performance, and community a role plays rewards. in providing and/or non-financial Financial partly are incentives based on good performance. Incentives balanced and in line with are expectations placed on CHW. Examples of non-financial that engage incentives workers might include (advancement, recognition, certification process) an activeCommunity plays in all supportrole for areas such as development CHW, feedback, providing of role, providing solving problems, establish helps to incentives, CHW as leader in community. - Regular supervision visit at least every months that three reports,includes reviewing monitoring of data collected and occasionally provide supportproblem-solving to Supervisors trained not are CHW. in supportive supervision but facility are based health workers. evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage data (national /program evaluation). Community is not on feedback asked provide to There performance. CHW’s good for some rewards are performance, such as small etc. recognition, gifts, incentive Some financial or non-financial provided. are incentives Examples of non-financial incen include occasional formal tives additional training, recognition, and other small incentives. significant Community plays in supportingrole the CHW groups, mother’s through CHW is widely networks, etc. for and appreciated recognized serviceproviding community. to 2 - 1 Supervision visits conducted times between two and three collect to reports/per year meetings at group data (or facility turn to in monitoring No individual perforforms). workmance supporton offered coaching) (problem-solving, evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage no rewards are There data. good performance. for provided incentives No formal but community recognition a reward is considered Community is sometimes education) (campaigns, involved with the CHW and some people in the community recognize the CHW as a resource. 0 No supervision or regular evaluation occurs outside of by CHWs occasional visits to nurses or supervisors when or less). possible (1x/year evaluation of No regular performance CHW. by No financial or non-financial provided incentives with Community is not involved ongoing support CHW to Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Supervision Supervision conducted carry basis to on a regular tasks out administrative individual provide and to performance support data- (feedback, coaching, driven problem-solving). Evaluation Performance fairly to Evaluation assess work during a set period of time. Incentives salary Financial= and bonuses Non-financial= training, certification,recognition, etc. medicines, uniforms, Involvement Community Role that community in supportingplays CHW. 6 7 8 9

Global Evidence of Community Health Workers - 3 2 3 But with concerning for little irregularity be sent to CHW be sent to mal feedback to to mal feedback Current Current Level/ Evidence - - - 3 (best practice) CHW knows when to signs, client (danger refer etc) additional treatment, CHW and community know facility is and referral where plan for a logistics have (transport,emergencies with a funds) Client is referred slip of paper and information to CHW with a back flows and/ form referral returned or monthly monitoring. is (promotion) Advancement who performto CHWs offered an and who express well in advancement if the interest opportunity exists (advance for ment might mean path to mal sector or change in role) opportunities are Training to learnto CHW new offered skills and advance their role to of them. CHW is made aware to is intended Advancement good performancereward or and is based on achievement, is fair evaluation. Retirement encouraged and incentives encourage to provided are at a set age. retirement document their CHWs and group visits consistently facilitymonitoring visits to who CHWs by attended are bring monitoring forms. Supervisors quality monitor of documents and provide CHWs/ help when needed. communities work with supervisor facility or referral use data in problem-sol to ving at the community. - - CHW knows when to refer CHW knows refer when to additional signs, client (danger CHW and etc) treatment, community know referral where facility is and usually have transportthe means to client with a slip of Client is referred tracked paper and informally by CHW (checking in with family, up visit) but information follow to CHW. back does not flow is (promotion) Advancement to CHWs sometimes offered for been in program who’ve Limited specific length of time. training opportunities offe are learn CHW to new skills to red Advancement advance role. to good reward to is intended performance or achievement, although evaluation is not (advancement might consistent sector or formal mean path to reti No path to change in role). CHWs is made clear to rement document their CHWs and group visits consistently facilitymonitoring visits to are who bring CHWs by attended Supervisorsmonitoring forms. qualitymonitor of documents help when needed. and provide do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 2 - - - 1 client CHW knows refer when to additional treat signs, (danger CHW and communityment, etc) facility know referral where referral no formal is but have is not Referral process/logistics tracked community by or CHW is (promotion) Advancement to CHWs sometimes offered been in program who’ve specific length of time. for No other opportunities discussed with CHW. are to is not related Advancement performance or achievement. document their Some CHWs monitoring visits and group by facilityattended visits to are who bring monitoring CHWs do CHWs/communities forms. ef no and analyzed data see not fort use data in problem-sol to ving at the community is made. 0 in place: CHW system No referral might know to when and where plan client, but - no logistics refer the communityin place by for - information emergency referral is not tracked or documented advancement No professional is offered. documentation for No process management is followed or info Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional

313 Table 39 - Community Health Worker Functionality Matrix – MCH Interventions MCH INTERVENTIONS YES COMMENTS 1 ANTENATAL CARE A Iron folate supplements Counsel o Provide commodity or intervention/ Assess and treat Refer for commodity, intervention, or treatment x B Maternal nutrition Note that CHW are also involved in some as- Counsel o pects of the treatment as they have to follow- Provide commodity or intervention/Assess and treat x up the treatment prescribed at the clinics. Refer for commodity, intervention, or treatment C Counsel on birth preparedness/complication readiness x (includes counseling to use skilled birth attendant) D Tetanus toxoid Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x E Deworm Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x 2 CHILDBIRTH and IMMEDIATE NEWBORN CARE A Prevent Infection/Clean Delivery x Mostly TBAs and Health agents (Hand washing, clean blade +/or clean delivery kit)

B Provide Essential Newborn Care a. Immediate warming and drying x b. Clean cord care x c. Early initiation of breastfeeding x C Recognize, initially stabilize (when possible) and refer for maternal and newborn complications o a. newborn asphyxia o b. sepsis, o c. hypertensive disorder o d. hemorrhage e. prolonged labor and post-abortion o complications D Prevent PPH: AMTSL or use of uterotonic alone in absence of full AMTSL competency (e.g. oral o Misoprostol) E Provide special care for Low Birth Weight newborns (Kangaroo Care) x

3 POST-PARTUM and NEWBORN CARE A Provide counseling on evidence-based maternal newborn health and nutrition behaviors This is the critical role of TBAs and x a. clean cord care; Women’s Health Agents. x b. exclusive BF through 6 months; x c. thermal protection; hygiene;

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS d. danger sign recognition; x e. maternal nutrition, etc. x B Assess for maternal newborn danger signs and provide appropriate referral. x C Provide Treatment for severe newborn infection (when community-based treatment supported by national o guidelines.) 4 EARLY CHILDHOOD A Infant and young child feeding, IYCF: x Provide counseling for immediate BF after birth; exclusive BF < 6 months; age-appropriate complementary foods B Promote growth monitoring, weighing infants and x recording progress C Provide community based management of acute mal- x nutrition (CMAM) using Ready to Use Therapeutic Foods (community-based recuperation of children with acute moderate to severe malnutrition without complications) D Community-based treatment of pneumonia x Counsel re recognition of danger signs, seeking care/ x antibiotics x Assess and treat with antibiotics x Refer for antibiotics Refer after treating with initial antibiotics When they have to refer for ORS, it oc- G Community-based prevention and treatment of diarrhea curs only in case they have a stock out Counsel on hygiene x of ORS in the community Counsel on point-of-use water treatment x Provide point-of-use water treatment x Refer point-of-use water treatment x Counsel on ORS x Provide ORS x Refer for ORS x Counsel on Zinc o Provide Zinc x Refer for Zinc H Vitamin A supplements (twice annually children 6-59 months) x Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment I Effectively assess and recognize severe illness in chil- x dren (danger signs) with appropriate referral. Counsel on immunizations x j Only Health Agents are authorized to Mapping/tracking for immunization coverage x provide immunization routinely. Some Provide Immunizations: members of other groups if they are -DTP x deemed competent to do so. -polio and or measles x - +/- HIB o - Hep B o

315 MCH INTERVENTIONS YES COMMENTS -Pneumovax o -Rotavirus o Refer for immunizations x 5 FAMILY PLANNING/HEALTHY TIMING AND SPACING OF PREGNANCY A Counsel on HTSP/contraceptives x Provide contraceptives: x x - condoms Some competent senior CHWs - Lactation Amenorrheic Method (LAM) x can provide Depo - oral contraceptives x - depo x Refer for contraceptives: x - condoms x - Lactation Amenorrheic Method (LAM) x - oral contraceptives x - long-acting and permanent methods x Provide FP counseling +/ - administer contra- x ceptives (e.g.;Oral Contraceptives) 6 MALARIA (Optional - Dependent Upon Country) A Insecticide-treated mosquito nets to pregnant women and children o Counsel o Provide commodity or intervention/ Assess and treat x B Refer for commodity, intervention, or treatment Intermittent preventive malaria treatment (IPTp) o They are active in the distribution o of impregnated bed nets in the Counsel communities Provide commodity or intervention/ Assess and treat x C Refer for commodity, intervention, or treatment Community-based treatment of malaria (testing with Rapid Diagnostic Test or presumptive treatment per antimalarial per national guidelines.) Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x 7 PMTCT (Optional - Dependent Upon Country) A Healthy timing and spacing of pregnancy Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x B Antibody testing to pregnant women and mothers Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x C Prophylactic ARVs/HAART to pregnant women mothers Counsel x Provide commodity or intervention/ Assess and treat o x

Global Evidence of Community Health Workers INTERVENTIONS YES COMMENTS Refer for commodity, intervention, or treatment E Prophylactic ARVs/HAART to infants Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x F Early infant diagnosis Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x G Pregnant HIV-infected women tracking Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x H HIV-exposed infant tracking Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x

317 Summary Haiti faces a dramatic lack of a minimal strength efforts in place in Haiti and playing an effective of the state to accomplish its responsibilities stewardship role, each organization will continue for providing essential education and health executing its own agenda, while countless citi- services to the great majority of Haitian citizens will continue suffering as a consequence. zens. Non-governmental organizations have There is no way of turning a CHW Program, no been instrumental in providing such services matter how successful has been in its particular to poorest areas in Haiti, most notably for a ti- geographical catchment area, into a country mely diagnosis and treatment of HIV/AIDS and level example of successful health delivery if the TB, utilizing for these activities the potential of country health system is dysfunctional, and in community members themselves. this task the government responsibility is essential, but donors and private providers need also Several decades of valuable experiences with to take seriously their own participation quota. CHWs in Haiti are in place for helping to build a functional health system at country level. It is up Coordinated CHW Programs like Zanmi to the international community, to government Lasante’s, if they are effectively inserted into spheres and to civil society members to turn the wider health system activities, have a real this accumulated capacity into effective health potential for making a difference. It is within interventions for all Haitians. CHWs Programs the broader Haitian social, economic and health implemented by capable and commited non- system context that we present here the expe- governmental organizations such as Zanmi rience and contribution of Zanmi Lasante’s CHW Lasante’s have provided consistent evidence Program. about the positive impact on an increased coverage of health care for HIV/AIDS and TB patients, specifically on coverage of voluntary HIV testing and HIV/TB treatment adherence in the NGOs influence areas, through home-based directly-observed therapy strategy conducted by CHWs, and also an increased trust of community members on health facilities run by NGOs. There is also consistent evidence about a clearly positive impact of NGOs community-based programs on reduction of TB and HIV morbidity and mortality, and on reduction of infant and child mortality, and on maternal and reproductive health indicators in their catchment areas.

The evidence clearly shows that it is feasible to expand such experiences. There is not excuse for not doing so. It is not enough to have patchy success stories. Without country level sustained scaling up of effective interventions there is no hope for a real change in the quality of life of Haitians. Without a full presence of the public sector in the health sector reform, coordinating efficiently the diverse public and private

Global Evidence of Community Health Workers 319 AFRICAN Case Studies

Ethiopia – Health Extension Program Uganda – Uganda Village Health Teams Mozambique –Agentes Polivalentes Elementares Program

Global Evidence of Community Health Workers 6. Ethiopia - Health Extension Program George W. Pariyo (Dept of Health Policy, Planning Under 5 mortality fell from 204 per 1,000 live and Management, Makerere University School births in 1990 to 119 per 1,000 live births in 2007. of Public Health) & Kora Tushune (Dept of However, up to 47% of the under five children Community Medicine, Jimma University) experience moderate to severe stunting. Socio-economic and Economic and social reforms have been undertaken and the economy registered an impres- political context sive double digit growth rate in recent years, ac- Ethiopia is a Sub-Saharan African country loca- companied by falling poverty rates and a 83.4% ted in the Greater Horn region of East Africa. It increase in net enrolment in primary school. 79 has an area of 1.1million km2 and shares borders with five countries: Kenya to the South, Somalia Life expectancy at birth is estimated at 53 years. and Djibouti to the East, Eritrea to the North and Only 42% of the total population has access to The Sudan to the West. It is an ancient civilization improved drinking water sources, while only with recorded history of more than 300 years. 8% of the rural population was using improved sanitation facilities by 2006. By 2007, only 10% Ethiopia is a federal republic that has nine states of children under five with fever were estimated and two city administrations. It is further divi- to be accessing antimalarial drugs. There is an ded into 819 woredas (districts) and more than estimated HIV prevalence rate of 2.1% in the 15,000 kebeles (sub districts), 10,000 of which population age-group 15-49 years.80 are rural and 5,000 urban. The country is diverse in its climatic, ethnic, cultural and religious Health Systems Overview make up all of which have implications for the organization of the health system. A substantial The national health system is organized in four part of the country has challenging topography tiers with primary health care unit (PHCU) - full of ragged mountains and arid and semi-arid consisting of one health center and five satellite areas that are difficult to access and expensive health posts that serve a population of 5,000 to cover with infrastructural development. being the first tier interfacing the health system with the community. Next is the district hospi- Though the country has a long history of inde- tal that serves a population of 250,000 and the pendence, internal conflicts and civil wars punc- third is a zonal hospital that covers a population tuated by occasional drought and famine have of 1 million. The final tier is a specialized referral had a detrimental effect on socio-economic hospital that serves a population of 5 million development of the country. With a population (figure 1). of nearly 80 million people and a population growth rate of 2.9%, Ethiopia is one of the poor The health system is generally considered weak, countries in sub-Saharan Africa with low indica- underfunded, inequitable and inefficient. The tors of development. The majority of its people infrastructure is underdeveloped and facilities (85%) live in rural areas where infrastructure is poorly staffed. poor, 23% of the population live on less than $1 per day. It has a GNI per capita of $ 220 (2007), The health system suffers from shortage, mal- total adult literacy is 36% and net enrollment/ distribution and gender imbalance of the health attendance in primary schools is 45%. The workforce. The motivation and performance of economy is dependent on primary agricultural the workforce working in the public sector is products. low. As a result the performance of the system

321 is also poor. The health sector has a 20 year sec- The health status of the Ethiopian population is tor development strategy divided into a series also a reflection of the reality described above: of five-year rolling plans called Health Sector Infant mortality rate is 77 per 1,000 live births; Development Program (HSDP), and is currently maternal mortality ratio is 673 per 100,000 live implementing HSDPIII (2005/6-2009/10). births; under-five mortality stands at 123 per 1,000 live births; coverage of deliveries attended Health services are financed from four main by skilled staff (6%); antenatal attendance (27%) sources: Government (federal and regional) and access to post-natal services (11%). The 28%; multilateral and bilateral donors (through EPI coverage is estimated at 81%, the increase grants and loans, nongovernmental organi- mainly attributable to the recently implemented zations (NGOs) - international and local) 37%; health extension program. Seventy to eighty and private contributions (e.g., out-of-pocket percent of health problems are preventable, spending) 31%. Per capita health expenditure is occurring mainly due to infections and nutritio- US$7.14 and health expenditure is estimated at nal disorders. Access and utilization is very low US$522 million p.a. (5.6% of GDP). especially among rural and vulnerable groups of the population. Malaria, Acute respiratory

Figure 1: Organization of the health care system in Ethiopia Health Service Delivery System of Ethiopia

SPECIALIZED REFERRAL HOSPITAL 5million population

ZONAL HOSPITAL (ZH) 1000000 population

DISTRICT HOSPITAL (DH) 250000 population

PRIMARY HEALTH CARE UNIT (PHCU)25000 population or 5000HHs 1 health center 5 health posts 10 HEWs 100 VCHWs (2 HEWs 20 VCHWs per kebele for 5000 population or 1000HHs)

Global Evidence of Community Health Workers infections and helminthiasis are the top causes major breakthrough in terms of equitable access of outpatient visits whereas deliveries, malaria to PHC during the socialist regime and even in and bronchopneumonia are the leading causes the immediate aftermath of its downfall in 1991. of admissions.81 However the foundation for the Health Service Extension Program (HEP) can be traced back to The administration of the health services is the National Health Policy of the country that decentralized along a federal system of govern- was issued in 1991. The Policy gave emphasis to ment that was introduced in Ethiopia following prevention aspects of health service and promo- the 1991 overthrow of the socialist government. ted self-reliance as a way forward for Ethiopia. The federal ministry of health (FMOH) has taken Following the Policy the country adopted a 20- up the roles of policy making, regulation, tech- year Health Sector Plan as part of the national nical support and standardization of services development strategy of the country. The plan while Regional Health Bureaus (RHB), which is is further divided into five-year rolling plans cal- accountable to respective state governments, led Health Sector Development Plan (HSDP).82 assumed the role of provision of services and management of the workforce and health The Health Extension Program (HEP) was star- facilities. ted in 2004 during the second five year plan (HSDP II 2002/03-2004/05) after evaluation of Ethiopia Health the implementation of the first five year plan (HSDP I) revealed that necessary basic health Extension Program services had not reached the people at the Even though the importance of improving the grass roots level as envisaged and desired, due coverage of basic health services was recogni- to the nature of services being given by the zed much earlier in Ethiopia the significance health system and the health service indica- of PHC strategy received emphasis after the tors especially those related to MDGs were not Alma Ata Declaration of 1978. The earlier shift showing improvement or the improvements towards socialist ideology in the country also were negligible at the best. To implement the favored the adoption of PHC. Two years before HEP government launched a strategy known as the adoption of PHC, in 1976 The Revolutionary Accelerated Expansion of Primary Health Care Democratic Program of the socialist regime had Coverage (AEPHCC) that guided the investment also endorsed primary care, rural health services, plan. The strategy document was a blue print prevention and control of common diseases, for government investment in construction of self reliance and community participation as a health posts and health centers and investment policy direction of the new Ethiopia. in the workforce including the Health Service Extension Workers (HEWs). In spite of early adoption of PHC and deployment of CHWs, who were the key workforce, Health service extension program is “a package the achievements were not as expected pri- of basic and essential promotive, preventive marily because of challenges faced by similar and selected curative health services, targeting programs in many other developing countries; households in the community, based on the i.e., constrained resources and institutional en- principles of primary health care to improve vironments, problems of sustaining a volunteer the health status of families with their full par- workforce, logistics and supply chain difficulties, ticipation, using local technologies and the training and supervision needs and the required skill and wisdom of the communities”. It forms multi-sectoral support. As a result there was no the bottom part of the national health system

323 Recruitment Process mainly focusing on preventive aspects of health HEWs are recruited for the training from the services and promotion of healthful living in community in which they live and would serve the community. The HEP was initiated from after completing the training. The criteria used high level political leadership of the country, to select HEWs are that they have to: inspired by the enhanced implementation and Be female of 18 years of age and above performance of agricultural extension program. The philosophy behind the program is that Complete grade 10 secondary education with a households can produce their own health like grade good enough to allow them to join voca- they produce agricultural outputs for their tional training, TVET (1.6-1.8 grade points) consumption provided they are given the right Be from the target community information, supported in health actions and mobilized. As a result communities, households Respected by the community (recommenda- and individuals are empowered to take care of tion from the village) and willing to live in and their own health in the spirit of ownership and serve the community after the training self-reliance.83 A member nominated by local community, representative. Selection is done by a committee The package (HEP) is implemented by the comprised of woreda (district) health office, Health Extension Workers (HEWs), who receive capacity building and education offices. training for one year. HEWs are a new cadre of community based health workers in Ethiopia. The above criteria are reconsidered in recruit- They are selected by the community in which ment of the pastoralist HEWs due to problem they live (in collaboration with wereda adminis- of finding persons who have reached the 10th tration), to provide, after completing one year grade in general, and especially among wo- training, promotive, preventive and selected men in particular. As a result the educational curative health services to the community of requirement is reduced to 6th – 8th grade; their origin based on the values and principles training duration reduced to six months and of primary health care. Two HEWs are deployed gender criterion is also relaxed to allow men to in every village with population of 5000. They be recruited where it is difficult to find women are supported by a number of volunteer CHWs due to educational or cultural situation of the selected by the community with ratio of one community. VCHW for every 250 population. The CHW Role This program was selected for review as it is the main officially recognized nationwide CHW According to the implementation guidelines program that Ethiopia has developed and is of the Health Service Extension Program (HEP) implementing. It is the only CHW program that health service extension workers are expected is well structured, and with clear curriculum and to carry out responsibilities in four major areas; training materials agreed on by all the partners. a) administrative duties, b) promotive and pre- All other programs are rather ad hoc in nature ventive activities, c) basic treatment and referral and not nation-wide, and are being phased out services, and d) essential IEC activities which are or should work under overall co-ordination of cross-cutting. the HEP. 84 Administrative duties HEWs are responsible for:

Global Evidence of Community Health Workers collecting and recording basic demographic excreta disposal, solid and liquid waste mana- and health related information of the kebele gement, safe water supply and handling, food hygiene, environmental sanitation, pest and ro- planning, coordinating and leading the HEP in dent control, prevention and control of malaria kebele in collaboration with kebele administra- and TB, prevention and control of HIV/AIDS and tion, the community, voluntary health workers STD (VHWs) and partners train community members in becoming health availing and managing inputs for implementa- promoters tion of HEP strengthening the implementation of the refer- mobilize communities and organize campaigns ral system and to promote health services understand and implement policies, strategies ensuring the availability of registers and forms and the Health Sector Development Plan (HSDP) and using them of the FMoH. establishing and strengthening the documentation and filing system Basic treatment and referral services HEWs also provide Basic curative and referral requesting medicines, medical equipment and services which include to: supplies in a timely manner, collecting them, re- gistering in accordance with official guidelines relieve pain, managing medicines and medical equipment treat common health problems such as mala- carefully in order to avoid damage or waste, and ria, diarrhea, intestinal parasites, trachoma and report expired and unwanted medicines to the scabies, Woreda Health Office (WrHO). Refer cases beyond their capacity to the nearest health centre. Preventive and promotive activities Under this the HEW roles include: IEC activities organize, train and coordinate volunteer com- Another important task of a HEW is IEC activities munity health workers (VCHWs) which are cross-cutting in nature and included in nearly all other roles of the HEW. They are conduct regular house-to-house visits tailored to the local socio-cultural situation of identify defaulters and help them use services the community to convey health messages using inter-personal communication, role plays, implement and/or support vaccination, family folklore, poetry, proverbs, demonstrations and planning, health and nutrition, complementary the like. Theses duties and responsibilities which feeding, feeding the sick child, growth monito- are categorized in four areas are prepared and ring, identification of nutritious foods, nutrition delivered in 16 packages each having its own counseling for pregnant women, and lactating guideline booklets prepared in different langua- mothers, distribution of micronutrients (Vitamin ges. Box 6 shows the 4 components of the HEP A and zinc), prenatal care, intra-partum and and the 16 packages implemented by HEWs. post-partum and newborn care, infant and integrated maternal and newborn child health care, adolescent reproductive health services, disease surveillance, personal hygiene, human

325 These services are provided to the target com- Identifying sicknesses and referring to the next- munity using three modalities. These are: level health facility Providing appropriate treatment for children Health post based services and other members of the community Health education Vitamin A supplementation for the target Vaccination to mothers and children groups Clean delivery and postnatal care and Health education and demonstration in counselling schools Child growth monitoring and nutritional Training and regular meeting with volunteer counselling community health workers (VCHWs) Malaria prevention and control activities where Documentation, compiling records, files and needed reports Treatment of trachoma using tetracycline eye Displaying health information using graphs and ointment and counselling on face washing charts and posting them on the wall Prevention and control of scabies Antenatal Care Treatment of diarrhoea using ORS Delivery and postnatal care

Box 6 : Components and packages of the Ethiopian health extension program. HEP Components Health Service Packages Hygiene and Environmental Sanitation Excreta disposal Solid and liquid waste disposal Water supply and safety measures Food hygiene and safety measures Healthy home environment Control of insects and rodents Personal hygiene Family Health Service Maternal and child health Family planning Immunization Nutrition Adolescent reproductive health Disease Prevention and Control HIV/AIDS and sexually transmitted infections (STIs) and TB prevention and control Malaria prevention and control first aid emergence measures Health Education and Communication (cross- Crosscutting (Advocacy,Social mobilization, IEC/ cutting component) BCC (IPC & counseling), Community conversation and Social marketing

Global Evidence of Community Health Workers Immunization Monitor child growth and counsel on child Growth monitoring feeding Family Planning Assess nutritional status of children and pregnant women and counsel Nutritional advice, vitamin A supplementation Drain and eradicate mosquito breeding sites in Diagnosis and treatment of malaria malaria areas Treatment of eye and skin infections with Observe use of bednets and demonstrate pro- ointment per use Health education Provide treatment to patients with malaria First aid and referral of difficult cases Treat trachoma with tetracycline ointment and counsel on face washing HEWs generally spend about 25% of their time at the health post conducting facility-based ser- Prevent and control scabies vices and use about 75% of their time outside Treat diarrhoea with ORS and other homemade the health post delivering family and commu- fluids nity packages. Identify sick family members abd refer to next level health facility Family packages These include training of model families (2hrs/ Provide vitamin A supplementation day, total 96hrs) and home visit (4-6HH/day. Provide first aid treatment Model families are selected and trained in three phases graduating at the end of the training. Follow up of HIV/AIDS and TB patients All families in the kebele are eventually reached Provide training, support and encouragement with the training as a result of rounds of training for community health workers and coordinate sessions. During home visits HEWs provide the their activities following services: Facilitate care and support for HIV/AIDS patients Educate and demonstrate household waste ma- and facilitate support for orphans and vulnera- nagement, personal hygiene and other health ble children practices Assist families on how to use and properly han- Community based health packages dle latrines These deal with communication of health information to the community using traditional and Communicate and demonstrate how to keep indigenous community associations which in the home and compound clean the Ethiopian situation are called “idir”, “mahber” Advise to separate human quarters from where and “ekub”, and community based organizations animals stay such as schools, women and youth associations and religious institutions. As part of this effort Provide family planning services HEWs carry out community mobilization, com- Provide antenatal, intra-partum and postnatal munity-based organization mobilization and care services and counselling provide services at 3-4 outreach sites. Services Demonstrate essential newborn care practices HEWs provide at the outreach setting are:

327 Initial Training of CHWs Health education After recruitment the HEWs are sent to one of Vaccination of mothers the technical and vocational training schools (TVETS) in the country for one year training, in Family planning services case of agrarian HEWs. The HEP was designed Antenatal care and counselling to use about 40 such training schools in various parts of the country to train HEWs for agrarian Child growth promotion and nutritional and pastoralist communities. Once they are counselling back to their communities, the HEWs then Nutritional assessment of pregnant women and train volunteer CHWs that can support them in counselling providing the services to the households and individuals. Malaria prevention and control activities where needed Recently the government has launched a variant Treatment of trachoma using tetracycline oint- of HEP for urban setting which trains registered ment and counselling on face washing nurses for three months before deployment to urban communities. The HEP for urban setting Prevention and control of scabies has just started and the first batch of trainees is Treatment of diarrhoea with ORS still undergoing training. Identification of sick children or members of the Agrarian HEWs are trained for one year, 30% of family and referring to the next-level facility the time in theoretical courses and 70% of the Vitamin A supplementation for the target time in practical training including apprenti- groups ceship attachment to health centers and project First aid attachment to the community. Attachment to health facilities and community is for about three Health education and demonstration in months. The training syllabus and breakdown is schools shown below:

Box 7: Content and Structure of Training Program for HEWs Course Structure of Health Service Extension Workers Theoretical training Practical training Community documentation Practical works Family health care Models training Disease prevention and control Group assignment Environmental health promotion 30% Demonstration and role play 70% Supportive courses Apprenticeship Common courses Health facility attachment (English, mathematics, IT and entrepreneurship) Community attachment

Global Evidence of Community Health Workers Deployment But duration of training for HEWs intended to HEWs are deployed in the health post, a com- work in the pastoralist community is only six munity level health facility that serves a popu- months due to the problem of finding trainees lation of about 5000 people. The health post is that meet the criteria laid out in the HEP gui- the lowest level health facility. Five such health delines and using a slightly changed (lighter) posts together with a health center constitute a curriculum.By the end of 2008, 30,190 HEWs had primary health care unit of the Ethiopian health been trained in 32 TVETS distributed throughout care delivery system. There were 9914 health the country, 18 in Oromia, 3 in Amhara, 7 in posts constructed in the country in 2007. Two SNPPR, and one each in Gambella, Benishangul HEWs are deployed in each health post and Gumuz, Somali and Afar regions. are supported by village community health workers (VCHWs) in each kebele. The number of Till recently the training of HEWs focused prima- VCHWs in a kebele usually ranges between 10 rily on agrarian and pastoralist HEP. However in and 25. As a result HEWs to population ratio is 2009 training package for urban HEP has been usually 1:2500. Health posts are built either by launched and urban HEWs are expected to be the health system or the community and will deployed after graduation of the first round usually have at least two rooms. trainees. The HEWs are trained at the certificate level. They are able to upgrade to higher levels On-going Training of CHWs of health professional status through training and growth in the career path prepared by the In HEP the HEWs are expected to attend a se- MoH and the government. The Urban HEWs ries of integrated refresher training (IRT) to im- are registered nurses who are trained for three prove their skill and sustain their motivation and months on urban HEP packages. Figure 3 shows contribution. The district health office identifies the annual build up of HEWs since the begin- gaps in knowledge and skills of HEWs through ning of the Program: regular supervision visits.

Figure 3: Cumulative number of HEWs Trained and Deployed (2004 – 2008)

35000 30000 30786 25000 24751 20000 15000 17653

10000 9900

No. of HEWs Trained of HEWs No. 5000 2737 0 2004 2005 2006 2007 2008 Year

Data source: Abaseko, 2009

329 Training of Trainers Trainers of HEWs are based at Technical and years, there has not been many comprehensive Vocational Training Schools (TVETS). These TVETS evaluations of the national HEP/HEWs program are under the Ministry of Education (MOE) and of Ethiopia. The only comprehensive evalua- are distributed throughout the country, in diffe- tion was carried out by CNHDE and The Earth rent regional states. However, the trainers, who Institute of Columbia University in 2007 and the are environmental health workers and nurses by findings were released in 2009. This evaluation profession, are recruited by the MOH and then was done after about one and a half years of im- transferred to MOE institutions and trained for plementation and the findings may not reflect three months before assuming their new role the performance of the program when it is fully of training HEWs. Their instructors were drawn implemented and fairly resourced. Some of the from the health sector. challenges identified in the report are being addressed already. The CHNDE evaluation study Equipment and supplies which had a before and after design, looked into three aspects of the HEP: effect of the program The basic equipment and supplies available to on health and related aspects of the households, the HEW are shown in Box 8 (Center for National HEWs’ performance in provision of the health Health Development in Ethiopia, 2008c). service packages and the performance of HPs in terms of facilities and productivity. Reports Supervision of the study released in three volumes corresponding to three aspects of the program. The The importance of supervision has received repeated cross-sectional study compared the more emphasis recently as a reaction to gaps baseline study information that was collected identified from early assessment of imple- in 2005 with the findings of the follow-up study mentation of the program. In response to the conducted between November 1-December 30, problem government launched a strong super- 2007 from the HEP communities. Table 40 shows visory system. The supervisors are either nurses some of the findings of the evaluation.85-87 or environmental health professionals who are trained for two months on supervisory skills to support the HEP. So far about 3200 HEW su- Incentives pervisors have been trained. The supervision is Like many developing countries Ethiopia has linked with integrated refresher training (IRT) to experimented with volunteer CHWs after the address the skill and knowledge gaps identified PHC declaration of Alma Ata. One of the lessons during supervisory visits. There is one supervisor from the past was that incentive is a crucial for ten HEWs and five health posts. A Checklist is factor in sustaining community based health used in the supervisory visit and HEWs are pro- services provided by volunteers. Therefore, in vided supportive supervision. The supervisors the national HEP, Ethiopia has tried to address are health center-based and are accountable to this problem by introducing paid HEWs who are the District Health Management Office (DHMO). no more volunteers but civil servants paid from The DHMOs are in turn supported by Regional the treasury of state governments. The monthly Health Bureaus (RHB), which are also visited salary has slight variation from region to region every 3 months by the FMOH. ranging between Birr 530 (about USD 45) and 760 (about USD 63) with majority getting Birr Performance Evaluation 670 (about USD 56). This is a fairly reasonable stipend by Ethiopian standards. However, Primarily due to its short life of just about five according to a 2007 evaluation by The Center

Global Evidence of Community Health Workers for National Health Development in Ethiopia and community based organizations such as (CNHDE) and The Earth Institute at Columbia schools, women and youth associations and University, about half of the HEWs do not feel religious institutions. As part of this effort HEWs that the level of payment is adequate and/or carry out community mobilization, community- commensurate with the workload and training based organization mobilization and provide duration that they undergo (Center for National services at 3-4 outreach sites. Health Development in Ethiopia, 2008b).85 Referral System Community Involvement The HEW screens patients who need treatment Communities are involved in selecting the beyond first aid and refers them on to the HEW who will work in their area. They are also health centre or the nearest available health involved in supporting the work of the HEW in facility. She also helps to follow up patients in communication of health information to the the community on long-term treatment such as community using traditional and indigenous HIV/AIDS and TB patients and links them to the community associations which in the Ethiopian health facility. situation are called “idir”, “mahber” and “ekub”,

Box 8: Basic Equipment and Supplies Available at the Health Post for Use by the HEW Service area Furniture and equipment ANC and delivery Adult weighing scale, ANC kit, Blood pressure apparatus, Foetoscope Delivery kit, Delivery table, Neonatal resuscitation mask & bag Child care Baby weighing scale, Measuring tap (1.5mt, Measuring board Graduated measuring jar Spoons Immunization Refrigerator , Vaccine carriers (ice bags) , Ice box First aid care Gowns, Examination bed, Stretcher, Stethoscope, Thermometer Others Spatula, Torch light HEALTH POST ESSENTIAL MEDICINES Service areas Essential medicines Antimalarial Drugs Coartem(ACT), Chloroquine, Both ant malarial drugs Diarrheal control ORS Contraceptive methods Oral contraceptives, Depo-provera injection, At least one method Both contraceptive methods Micronutrient Supplementation Iron Tablet , Folic Acid, Vitamin A, Capsule 100,000 IU Vitamin A, Capsule 200,000 IU Others Analgesics -Aspirin/Paracetamol, Ergometrine-500mg, TTC eye ointment Baby Lotion (Bottle HEALTH POST SUPPLIES General supplies AD Syringes and needles, Mixing Syringes , Syringes and needles, Gloves Gauze, BCG OPV, DPT, Measles, TT, Alcohol, Savlon, Iodine , GV, Disinfectants , Cord Ties , RDT for Malaria , Condoms

331 Professional Advancement and career path for HEWs HEWs are also entitled to upgrading programs as, bachelors, masters and PhD degrees subject that would raise their level of education from to their fulfilling university entry requirements. certificate to diploma level as registered nurses. The method of upgrading is designed in a dis- Documentation and tance course mode with a period of hands-on training. Guidelines are being developed to Information Management allow them to continue their professional career Basic records are kept by the HEW on cases seen even into higher degrees of qualification such or referred and items dispensed or used.

Table 40: Summary of Selected Performance Indicators from Evaluation Reports Program coverage Coverage is about 100% Preventive and promotive Vaccination promotion coverage: BCG coverage is 57.1%, and measles service delivery 39.5% Contraceptive usage: CPR is 24.8% Support system for CHWs Recruitment: 80% that meets program selection criteria Training: 100% and their performance received introductory training Knowledge: 38% of HEWs had comprehensive knowledge on ANC. Skills and knowledge gaps exist especially related to pregnancy, delivery and care of the newborn, Supplies and equipment: 22.6% of health posts had at least 60% of the minimum set of medical equipment, only 7.5% had 80% of minimum medical equipment, 81% had vaccine carriers, 30.2% of health posts were equipped to carry out static immunization services, 67% of posts had first aid kits. Salaries: HEWs get regular payment from the district Supervision and LHS: 50% reported supervisor meeting in last 30 days Support from health care delivery system: % facilities that lacked important medicines and supplies on the day of survey (other drug availability or stock out information) 36% of health posts lacked Coartem, 41% lacked ORS; 45% of health posts reported not having had stock out of Coartem for the 3 months preceding the survey CHW services and the poor As HEP services involve all households in the community and are free of charge the poor will have equal access to the services through the home visits, one-on-one conversation with mothers and husbands, community packages and health post based services in the community. But the poor may not comply with the referral of the HEWs. IIndicators of population served compared with national figures? 1.2 millions In Central Plateau and half of the Artibonite region. CHW impact on health Any information on how CHWs impact on health areas served compared to those not served? Improved knowledge and use in HEP areas compared to non-HEP areas in improved sanitation (75.6% of 36.3%), proper human waste disposal (57.6% of 34%), hand washing facilities present (55.7% of 39.9%). There was less improvement in CPR (24.8% of 21.7%). CHW costs – The program has reliable funding for salary of HEWs. But supplies, current and future supervision and training seemed to face some challenges.

Global Evidence of Community Health Workers 3 2 2 3 3 Current Current Level/ Evidence 3 (best practice) community from Recruited If when possible. not possible, the community is consulted and agrees during the process selection. on recruitment community, Health system, the role/ and CHW design expectations and policies in place that support CHW Role and expectations role. CHW and clear to are for Process community. and discussion of update role/expectations in place CHW and community for Initial training is provided within the six all CHWs to months that is based on for CHW. defined expectations Some training is conducted in the community or with community participation. with is consistent Training health facility guidelines for community and health care in training. facility is involved On-going training is provided CHW on new skills, update to and initial training, reinforce he/she is practicing ensure is Training skills learned. tracked and opportunities in a consistent offered are all and fair manner to (not only some) CHWs All necessary supplies; no substantial stock-out periods. - - - CHW is not recruited from com from CHW is not recruited munity but the community is on the final selection.consulted defines (policies Health system but without exist) the CHW role community input. Role is clear CHW and communityto but little discussion of specific expectations. General agree between CHW, ment on role and community. health system, to Initial training is provided year within the first all CHWs does Training of recruitment. not include participation community from or health center. referral On-going training is provided Some super basis. on a regular up with coaching. visors follow have CHWs Functional Note: updated) been trained (or within the last 18 months. on ordered Supplies are basis although a regular Stock delivery can be irregular. out of supplies essential for defined CHW tasks occur at of x per year/mo a rate 2 - - 1 from CHW is not recruited community but the commu nity (reluctantly) accepts the identified CHW after selection. of CHW exists role No formal (no policies in place) General to expectations given are CHW (initial training) but CHW and not specific. are community do not always on role/expectations. agree Minimal initial training is etc). (1 workshop, provided works attend Some CHWs topics. hops on specific ad hoc visits Occasional, supervisorsby provide some coaching. Inconsistent supply and supportrestocking to formal No defined CHW tasks. re-ordering. for process Table 41 - CHW Program Functionality Assessment Tool (CHW-PFA)-Ethiopia Tool Assessment Functionality 41 - CHW Program Table 0 community CHW not from and in the recruitment. no role plays upon Role is not clear or agreed community between CHW, health system. and formal No initial training is provided. No ongoing training is provided No equipment and supplies provided. are Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Recruitment a where and from How community health worker and selected, is identified, a community. to assigned CHW Role design Alignment, and clarity from of role and CHW, community, perspectives. system health Training Initial to provided Training role for prepare CHW to in MCH services delivery he/she has the and ensure necessary skills provide to and quality care. safe Training On-going On-going training to CHW on new skills,update initial training, reinforce he/she is and ensure practicing skills learned. and Supplies Equipment equipment Required deliver and supplies to expected services. 1 2 3 4 5

333 3 2 2 2 Current Current Level/ Evidence - 3 (best practice) Regular supervision visit every 1-3 months that includes reports,reviewing monitoring Data is of data collected. solving problem used for Supervisorand coaching. makes visits community, skills provides home visits, Supervisor CHW. coaching to is trained in supervision and has supervision tools. evaluation least once/year At that includes individual performance (local eva luation) and evaluation of or monitoring coverage data (national /program evaluation) Community is feedback asked provide to on CHW performance. for clear rewards are There good performance, and community a role plays rewards. in providing and/or non-financial Financial partly are incentives based on good performance. Incentives balanced and in line with are expectations placed on CHW. Examples of non-financial that engage incentives workers might include (advancement, recognition, certification process) an activeCommunity plays in all supportrole for areas such as development CHW, feedback, providing of role, providing solving problems, establish helps to incentives, CHW as leader in community. - Regular supervision visit at least every months that three reports,includes reviewing monitoring of data collected and occasionally provide supportproblem-solving to Supervisors trained not are CHW. in supportive supervision but facility are based health workers. evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage data (national /program evaluation). Community is not on feedback asked provide to There performance. CHW’s good for some rewards are performance, such as small etc. recognition, gifts, incentive Some financial or non-financial provided. are incentives Examples of non-financial incen include occasional formal tives additional training, recognition, and other small incentives. significant Community plays in supportingrole the CHW groups, mother’s through CHW is widely networks, etc. for and appreciated recognized serviceproviding community. to 2 - 1 Supervision visits conducted times between two and three collect to reports/per year meetings at group data (or facility turn to in monitoring No individual perforforms). workmance supporton offered coaching) (problem-solving, evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage no rewards are There data. good performance. for provided incentives No formal but community recognition a reward is considered Community is sometimes education) (campaigns, involved with the CHW and some people in the community recognize the CHW as a resource. 0 No supervision or regular evaluation occurs outside of by CHWs occasional visits to nurses or supervisors when or less). possible (1x/year evaluation of No regular performance CHW. by No financial or non-financial provided incentives with Community is not involved ongoing support CHW to Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Supervision Supervision conducted carry basis to on a regular tasks out administrative individual provide and to performance support data- (feedback, coaching, driven problem-solving). Evaluation Performance fairly to Evaluation assess work during a set period of time. Incentives salary Financial= and bonuses Non-financial= training, certification,recognition, etc. medicines, uniforms, Involvement Community Role that community in supportingplays CHW. 6 7 8 9

Global Evidence of Community Health Workers 2 2 3 Current Current Level/ Evidence - - - 3 (best practice) CHW knows when to signs, client (danger refer etc) additional treatment, CHW and community know facility is and referral where plan for a logistics have (transport,emergencies with a funds) Client is referred slip of paper and information to CHW with a back flows and/ form referral returned or monthly monitoring. is (promotion) Advancement who performto CHWs offered an and who express well in advancement if the interest opportunity exists (advance for ment might mean path to mal sector or change in role) opportunities are Training to learnto CHW new offered skills and advance their role to of them. CHW is made aware to is intended Advancement good performancereward or and is based on achievement, is fair evaluation. Retirement encouraged and incentives encourage to provided are at a set age. retirement document their CHWs and group visits consistently facilitymonitoring visits to who CHWs by attended are bring monitoring forms. Supervisors quality monitor of documents and provide CHWs/ help when needed. communities work with supervisor facility or referral use data in problem-sol to ving at the community. - - CHW knows when to refer CHW knows refer when to additional signs, client (danger CHW and etc) treatment, community know referral where facility is and usually have transportthe means to client with a slip of Client is referred tracked paper and informally by CHW (checking in with family, up visit) but information follow to CHW. back does not flow is (promotion) Advancement to CHWs sometimes offered for been in program who’ve Limited specific length of time. training opportunities offe are learn CHW to new skills to red Advancement advance role. to good reward to is intended performance or achievement, although evaluation is not (advancement might consistent sector or formal mean path to reti No path to change in role). CHWs is made clear to rement document their CHWs and group visits consistently facilitymonitoring visits to are who bring CHWs by attended Supervisorsmonitoring forms. qualitymonitor of documents help when needed. and provide do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 2 - - - 1 client CHW knows refer when to additional treat signs, (danger CHW and communityment, etc) facility know referral where referral no formal is but have is not Referral process/logistics tracked community by or CHW is (promotion) Advancement to CHWs sometimes offered been in program who’ve specific length of time. for No other opportunities discussed with CHW. are to is not related Advancement performance or achievement. document their Some CHWs monitoring visits and group by facilityattended visits to are who bring monitoring CHWs do CHWs/communities forms. ef no and analyzed data see not fort use data in problem-sol to ving at the community is made. 0 in place: CHW system No referral might know to when and where plan client, but - no logistics refer the communityin place by for - information emergency referral is not tracked or documented advancement No professional is offered. documentation for No process management is followed or info Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional

335 Table 42- Community Health Worker Functionality Matrix – MCH Interventions MCH INTERVENTIONS YES COMMENTS 1 ANTENATAL CARE A Iron folate supplements Comprehensive knowledge levels on ANC Counsel x found to be low Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Maternal nutrition Counsel x Provide commodity or intervention/Assess and treat x Refer for commodity, intervention, or treatment x C Counsel on birth preparedness/complication readiness x (includes counseling to use skilled birth attendant) o D Tetanus toxoid Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x E Deworm Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x 2 CHILDBIRTH and IMMEDIATE NEWBORN CARE A Prevent Infection/Clean Delivery x (Hand washing, clean blade +/or clean delivery kit) o

B Provide Essential Newborn Care a. Immediate warming and drying x b. Clean cord care x c. Early initiation of breastfeeding x C Recognize, initially stabilize (when possible) and refer Skills levels were found in evaluation to be low for maternal and newborn complications x in these areas that deal with pregnancy, deli- a. newborn asphyxia x very, and care of the newborn. b. sepsis, x c. hypertensive disorder x d. hemorrhage e. prolonged labor and post-abortion x complications D Prevent PPH: AMTSL or use of uterotonic alone Plans are underway to introduce Misoprostol in absence of full AMTSL competency (e.g. oral o Misoprostol) E Provide special care for Low Birth Weight newborns (Kangaroo Care) o

3 POST-PARTUM and NEWBORN CARE A Provide counseling on evidence-based maternal newborn health and nutrition behaviors x a. clean cord care; x b. exclusive BF through 6 months; x c. thermal protection; hygiene;

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS d. danger sign recognition; x e. maternal nutrition, etc. x B Assess for maternal newborn danger signs and provide appropriate referral. x C Provide Treatment for severe newborn infection (when They only provide first aid then refer community-based treatment supported by national o guidelines.) 4 EARLY CHILDHOOD A Infant and young child feeding, IYCF: x Provide counseling for immediate BF after birth; exclusive BF < 6 months; age-appropriate complementary foods B Promote growth monitoring, weighing infants and x recording progress C Provide community based management of acute mal- o They provide advice on nutritional nutrition (CMAM) using Ready to Use Therapeutic Foods practices and nutritious foods. (community-based recuperation of children with acute moderate to severe malnutrition without complications) D Community-based treatment of pneumonia x Counsel re recognition of danger signs, seeking care/ o antibiotics x Assess and treat with antibiotics o Refer for antibiotics Refer after treating with initial antibiotics G Community-based prevention and treatment of diarrhea Counsel on hygiene x Counsel on point-of-use water treatment o Provide point-of-use water treatment o Refer point-of-use water treatment o Counsel on ORS o Provide ORS x Refer for ORS x Counsel on Zinc o Provide Zinc o Refer for Zinc H Vitamin A supplements (twice annually children 6-59 months) x Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment I Effectively assess and recognize severe illness in chil- x dren (danger signs) with appropriate referral. j Counsel on immunizations x Mapping/tracking for immunization coverage x Provide Immunizations: -DTP x -polio and or measles x

337 MCH INTERVENTIONS YES COMMENTS - +/- HIB o - Hep B o -Pneumovax o -Rotavirus o Refer for immunizations x 5 FAMILY PLANNING/HEALTHY TIMING AND SPACING OF PREGNANCY A Counsel on HTSP/contraceptives x Provide contraceptives: x - condoms x - Lactation Amenorrheic Method (LAM) x - oral contraceptives x - depo x Refer for contraceptives: x - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - long-acting and permanent methods x Provide FP counseling +/ - administer contra- x ceptives (e.g.;Oral Contraceptives) 6 MALARIA (Optional - Dependent Upon Country) A Insecticide-treated mosquito nets to pregnant women and children Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Intermittent preventive malaria treatment (IPTp) Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x C Community-based treatment of malaria (testing with Rapid Diagnostic Test or presumptive treatment per antimalarial per national guidelines.) Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x 7 PMTCT (Optional - Dependent Upon Country) A Healthy timing and spacing of pregnancy Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Antibody testing to pregnant women and mothers x Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment C Prophylactic ARVs/HAART to pregnant women mothers x Counsel o

Global Evidence of Community Health Workers INTERVENTIONS YES COMMENTS Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment E Prophylactic ARVs/HAART to infants Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o F Early infant diagnosis Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o G Pregnant HIV-infected women tracking Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x H HIV-exposed infant tracking Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o

339 Summary and Conclusions Ethiopia is implementing a nation-wide health of a total of 34 on the MNCH matrix. There are extension program which is dependent on the clear national policies and guidelines for su- health extension workers for implementation. pervision, referral and linkage with the formal The country has prioritized the development of health care delivery system, which carries out the HEP as a strategy to increase access to es- regular supervision. The career pathway and sential health services for her people. The HEW opportunities for personal growth of the HEW is at the centre of this effort. This is being imple- are built into the program. mented with a unified strategy, curriculum and uniform training and supervision guidelines. The 7. Uganda Village HEW are considered an extension of the formal health system and receive a regular pay. There Health Teams are also clear structures for their supervision George W. Pariyo, Elizeus Rutebemberwa, Saul and linkage with the health department. They Kamukama (Dept of Health Policy, Planning and have the opportunity to upgrade their skills and Management, Makerere University School of advance in their careers. The program is well Public Health) established and a first evaluation has shown Socio-economic and positive results in terms of increased access to basic care services and improving coverage of political context key interventions. The HEW works as part and as Uganda is located in East Africa land locked an extension of the health care delivery system with Kenya to the east, Sudan in the north, the and are considered civil servants. The program Democratic Republic of Congo to the west, and is well accepted by all stakeholders and enjoys Rwanda and Tanzania to the south. It covers an strong government leadership and funding area of 241,139 square kilometers of which 18% through established budgetary mechanisms. An is covered by open water and swamps. Uganda assessment of the context shows that the HEP/ gained independence from Britain in 1962 and HEW program is reasonably well established has had military dictatorships for many years. The with a score on the total program functionality current government took over after a protracted matrix of 27 (Min 24, Max 36). However, there guerilla war from 1981 to 1986. According to the is still much scope for improvement particu- UNDP report of 2007/2008, Uganda has a per larly with regard to the scope of MNCH services capita of 1454 US $ and this gives the country being offered. The program would score 17 out a rank of 154th out of 177 countries whose data

Box 9: The structure of the Uganda National Health system Health unit Physical structure Location Population Health Centre I None Village 1,000 Health Centre II Outpatient services only Parish 5,000 Health Centre III Outpatient services, maternity, Sub-county 20,000 General Ward and laboratory Health Centre IV Outpatients, Wards, Theatre, County 100,000 Laboratory and blood transfusion General Hospital Hospital, laboratory and X- ray District 100,000 – 1,000,000 Regional Referral Hospital Specialists services Region (3 – 5 districts) 1,000,000 – 2,000,000 National Referral Hospital Advanced Tertiary Care National Over 20,000,000

Source: Adapted from Government of Uganda, Health Sector Strategic Plan, 2000/01 – 2004/05

Global Evidence of Community Health Workers Uganda Village Health Teams was used. The same report quotes the physician and CHWs Program to population ratio of 8:100,000. 88 The need to meet the Poverty Eradication Action Plan (PEAP) targets and the Millennium The total population of the country was esti- Development Goals (MDGs) necessitated the mated at 29.6 million by 2008. With an annual harmonization and universalisation of efforts population growth rate of 3.24%, the country towards community empowerment and mobi- is expected to have about 39 million people lization for health (CEMH). Because of this, the by 2015. The median age is 15.6 years accor- National Health Policy of 1999 and the Health ding to the 2002 national census. The infant Sector Strategic Plan (HSSP) 1 (2000/2005) and mortality rate stands at 76/1000 live births and HSSP II (2005/2010) included the CEMH as a child mortality rate at 137/1000 according to one of the elements of the Uganda National the 2006/07 Uganda Demographic and Health Minimum Health Care Package (UNMHCP). It Survey of 2006/07. The maternal mortality ratio was, however, the Home Based Management per 100,000 live births is 435, total fertility rate of Fevers (HBMF) program, rolled out after the 6.7, percentage of stunted children under five Abuja Declaration 2000 that demonstrated the 38% and life expectancy 50.4 years.89 practicality and massive benefits of a sustained universal community empowerment and mo- The Uganda health care system bilization intervention in Uganda. When this was added to successes of more focal commu- Uganda operates a decentralized health system nity efforts, such as Guinea worm Eradication where the health sector structure follows the Program, CB-DOTS, Ivermectin distribution, it administrative structure as indicated in the ta- became clear that an all embracing integrated ble below. community empowerment and mobilization strategy, the village health team (VHT) strategy The national head quarters has the function of could indeed be practicable and synergistically setting policies and guidelines for programim- more beneficial.92, 93 The VHT strategy rolled plementation and service delivery, capacity out started in 2003.94, 95 building, monitoring, evaluation and support supervision, resource mobilization and coordi- This program was selected for review as it is nation while the planning and implementation the main officially recognized nationwide CHW of the health sector is at the district level. The program that Uganda is developing/ imple- community health workers (CHWs) function at menting. It is the only CHW program that is well 90 village level under the virtual health centre I. structured, and with clear curriculum and training materials agreed on by all the partners. All The private health care providers comprise other programmes are rather ad hoc in nature about 80% of the outpatient health care pro- and not nation-wide. The government is consi- vision. Approximately a quarter of the health dering the use of only VHT members in every facilities are owned by the Private-Not-For-Profit community based health intervention.96, 97 which are mainly faith based and are located in the hard to reach areas. The majority of outpatient care is offered by private providers and Recruitment Process 37% of the total health expenditure was out-of- The selection of CHWs follows a face to face pocket household payments according to the sensitization session where the community WHO statistical information system 2005.91 members are first educated about the program and the need to have volunteers. The session fa-

341 cilitator who might be a technical person from quality attributes remain the same and there is the District Health Team or the nearest Health an added value of better service delivery since Centre (II or III) explains the kind of people they the drug distributors are serving a smaller area would prefer on the program. and fewer people to whom they have a kinship attachment 100, 101. For the VHT, selection is done by a popular vote after sensitization and consensus building of all This approach has proved to be more effective stakeholders in the village and from all house- than the classic-community directed treatment holds and below is the criteria: with ivermectin in terms of treatment coverage, decision on treatment location and mobilization Maturity (above 18 years of age) for CDTI activities. A resident of the village Ability to read and write at least in a local To ensure sustainability and to avoid parallel language programs, development partners rarely create new structures of community health workers. A good community mobilizer and Partners like NGOs build on the existing resour- communicator ce persons given that their activities are short A dependable and trust-worthy person lived.

Someone interested in health and Community health workers are usually taken as development volunteers within the community they hail from. Willingness to work for the community They are not salaried or transferred from one (showing the spirit of voluntarism) place to another. They are not given a written contract spelling out the terms of service and Preference is given to people already serving as payment. They may, however, be rejected by the 94, 97 CHWs especially if they have served well community when the community members do not use their services and through their leaders In the case of community medicine distributors cause to have another one appointed as a repla- (previously called community drug distribu- cement for the one who falls out of favour with tors), the Health Assistant from a Health Centre the community. If they do not fulfill their obliga- III would organize a meeting of village mem- tions to the supervisors at the health facilities, bers through the Local Council (LC) I Chairman. the latter can also have them replaced. They can Together with a member of the District Health migrate to other places but they would cease to Team, a sensitization about the program would function as CHWs unless they are again selected be conducted and the community members to be CHWs by their new host communities. briefed on the selection criteria for the community medicine distributor (CMD) 98, 99. The CHW Role In the case of Ivermectic distribution, the The roles of Community Health Workers are Kinship-enhanced community directed treat- explained well in the guidelines. For the VHT ment with Ivermectin is being used in districts strategy which is an all inclusive approach, the of Uganda where there is Onchocerchiasis. In selection process tries to mix different portfolios this model, the community is divided around like the community medicine distributors, some kinships and these kinships select the distribu- extension workers (for the hygiene and sani- tors of ivermectin from amongst themselves. The tation), peer educators (for health education),

Global Evidence of Community Health Workers some traditional birth attendant and some to fill in the registers. Technical issues include member of the water source committees etc. the diagnosis and treatment (handling and ad- Out of the nine VHT members, efforts are made ministration of drugs). to include different categories of community health workers. There are guidelines explaining The District Health Team then takes it upon itself the roles of community volunteers including to train the trainers. The trainers are usually invi- those who may not fall under health. For exam- ted from Health Centres (levels III and II). Because ple the Ministry of Water and Environment of understaffing at health centre IIs, trainers are through the Directorate of Water Development usually drawn from the Health Centre III. The du- has guidelines specifying the selection and the ration of the training depends on the resources roles of water source committee members. available (including the capacity of the training agency) and context. The roles can range from community mobilization and sensitization for activities like im- In the case of the VHT strategy where all the munization, pregnancy monitoring to ensure other categories of community health workers compliance with safe motherhood for traditio- are being integrated, the training manual is so nal birth attendants, drug distribution, referring comprehensive that it tackles almost all com- patients, filling the registers (Community Based munity health aspects and the initial training is – HMIS), organizing health education events, supposed to last 10 working days. The others are participating in outreaches etc. In the VHT, al- needs based sessions which are conducted du- though the members are drawn from different ring the quarterly meetings at the health facility portfolios, the training is done in such a way or as these members collect the supplies. The that every member acquires skills to handle all contents of the VHT training manual, divided these roles at the end of the training. into modules are as below:96 Initial Training of CHWs MODULE1: THE VILLAGE HEALTH TEAM (VHTS) CONCEPT The training of community health workers is Topic 1 The Village Health Teams (VHTs) conducted in a cascading manner whereby the Topic 2 Key actors in the VHTs implementation district leadership is first sensitized about the and sustainability program or strategy to be used. This is done by national level facilitators who might be from the MODULE 2: COMMUNICATION Ministry of Health or any other development Topic 1 Communication partner like the NGOs. Topic 2 Interpersonal Communication (IPC) Topic 3 Counseling Because of resource constraints, the Ministry of Topic 4 Adult–learning and facilitation skills Health and the districts have been unable to roll Topic 5 Provision of basic health messages out the VHT strategy and this has called for sup- (Health Education) port from the Development Partners. There are training guidelines for the VHT strategy which MODULE 3: COMMUNITY MOBILIZATION were developed by the Ministry of Health and AND EMPOWERMENT these guidelines have management and tech- Topic 1 Community mobilization and nical issues that the VHT members have to be empowerment trained on. Management issues include; plan- Topic 2 Community situation analysis ning, coordination, data management like how Topic 3 Community participation and

343 involvement Topic 3 Home visits Topic 4 Participatory planning Topic 5 Resource mobilization and management Topic 6 Community–based health information On-going Training of CHWs management system Continuous training of CHWs is largely through needs based sessions which are conducted du- MODULE 4: CHILD GROWTH AND ring the quarterly meetings at the health facility DEVELOPMENT or as these members collect the supplies. Topic 1 Home Based Management of Fevers Topic 2 Immunization Training of Trainers Topic 3 Control of diarrhea Topic 4 Food and nutrition The trainers are mixed in such a way that both Topic 5 Breast feeding the management and technical aspects in the training manual are handled. Development par- MODULE 5: CONTROL OF COMMUNICABLE tners rely on the district health personnel from DISEASES the Health Centers II, III, or the District Health Topic 1 Sexually transmitted diseases (STDs) Team for the technical personnel to handle the Topic 2 HIV/AIDS technical aspects. Where there is need, different Topic 3 Malaria trainers who may not necessarily be health Topic 4 Tuberculosis (TB) workers come in to handle the management aspects. Where Development Partners are invol- MODULE 6: SEXUAL AND REPRODUCTIVE ved, these may be the project staff or consul- HEALTH tants. The sensitization about the strategy is Topic 1 Family planning (Child spacing) done at the district, Sub County and Parish level Topic 2 Pre-conception and antenatal care and it is usually from these Health Centres (II and Topic 3 Care given after delivery III) that trainers are identified. They then attend Topic 4 Adolescent sexual and reproductive the training at the Sub County level to come health back and train the selected VHT members. Topic 5 Gender-based violence Equipment and supplies MODULE 7: ENVIRONMENTAL HEALTH Topic 1 Sanitation Community Health Workers are provided with Topic 2 Water different equipments and supplies depending Topic 3 Personal hygiene on the program and the availability of resour- Topic 4 Domestic hygiene ces. In districts where development partners are Topic 5 School hygiene actively participating, the facilitation can stretch Topic 6 Food hygiene up to provision of bicycles, umbrellas, T-Shirts, Gum-boots, sometimes allowances etc. MODULE 8: COMMON NON-COMMUNICABLE DISEASES These are, however, not affordable for commu- Topic 1 Mental health nity health workers who are purely facilitated by the government and this creates competition MODULE 9: MONITORING for these community health workers. Topic 1 Monitoring Topic 2 Record keeping Under the Public Private Partnerships for health

Global Evidence of Community Health Workers policy, the Project Steering Committee is sup- conduct a spot check. The other way in which posed to allow those development partners faults are found is when the registers have some who are coming in to fill gaps in the use of shortcomings. In cases of failure, a replacement VHTs. is sought. Cases of community health workers “If you have a project that facilitates community charging fees for the services, delayed referrals, health workers and leaves out others, those left out discrimination, extra have all been rectified plus the community will refuse to own the project though this joint supervision. and they will always say that those are AMREF VHTs” (KI, AMREF). The support supervision is built within the community and the health system. The community With the old system of each program having passes some form of bye-laws that can be based its community health workers, there has been on how to handle beneficiaries who do not attempts to adopt cost effective models like comply for like the case of latrine construction; the home based care of TASO was initially very there is a fine which the culprit pays to the local expensive until they adopted the drug distribu- council. The health worker provides support tion points where patients go for drug refills and supervision on the weaknesses identified in the the use of a community nurse to offer home reports, complaints from the community and based care to the bed ridden clients. Some of questions or challenges presented by the com- the drugs distributed at home include Coartem, munity health workers themselves. It is usually Amoxycillin and Paracetamol. during the quarterly meetings, escorted referral, on outreaches or when collecting supplies that Supervision community health workers and the health workers interface. The CHW supervisors main functions are to: Provide support and guidance “The requirement for quarterly meetings helps to rejuvenate the competences of these community Monitor patients in case of adverse reactions to health workers. This could be based on the way drugs data is recorded in registers or the experience sha- Provide the necessary supplies ring in a meeting of community health workers” (KI, UNACOH). Monitor the performance of the program Tracking the medicines and other supplies re- In the case of Ivermectin distributors, there are leased to these VHTs supervisors at community level to supervise the kinship distributors, 2 supervisors at parish Supervision of community health workers is level (one community member and a Chairman done in both a supportive and fault finding LC II or the Parish Chief). In addition, the Health way. In the sensitization meetings with the Assistant at the HC III supervises the activities of village members, there is some form of yard all the above persons. stick establishment which can be used to hold these community health workers responsible Performance Evaluation and accountable. The beneficiaries report their complaints to the local council leadership or the The Ugandan VHT program is still new and no nearest health facility. Also the nearest health evaluation has been done as yet. However, there facility which is supposed to supervise the ac- have been isolated evaluations of various NGO tivities of these community health workers can programs that involve CHWs. UNICEF conducted

345 an assessment of Home Based Management of referred by the CHW” (KI, MoH) Fevers using the CORPs (Community Owned 102, 103 Resource Persons). Professional Advancement Some community health workers accumulate Incentives experience and are sometimes used to train The Ugandan CHWs officially do not receive a others. There were no cases of retirement repor- stipend and mechanisms to support them are ted except those who get opportunities outside left at the discretion of the communities they the community and they are replaced. Attrition serve as well as NGOs operating in their areas. is high among the youth because they are likely Some projects provide CHWs with T-shirts, to get married or leave the village in search of gum-boots, rain jackets, bicycles, transport allo- jobs. At the moment there is no formal certifica- wances and lunch allowance. tion program for CHWs. Community Involvement Documentation and Community involvement happens through Information Management the community selecting their CHWs and also The records do vary according to the program. monitoring their performance in relation to ex- In the updated VHT strategy which will com- pectations from the community. As mentioned mence in January 2010, these data tools have before, the community can cause their CHW to been harmonized to be used by any community be replaced if they are dissatisfied with his/her health worker. performance. The community gets linked to the activities of the health facility through the CHW We have even adopted new registers and we do interacting with the local health facility staff who not want for example the Community Medicine have the responsibility to supervise the CHWs. Distributors having different registers from other VHT members we want them to have a harmo- Referral System nized register. We now need a VHT register that is standardized for all these community health wor- The CHWs are not considered a part of the kers. (KI, UNICEF). formal health system. In areas where they are active, they are known to the health staff operating there, and they freely refer. CHWs are Records are kept by CHWs mainly involved in the prevention of diseases CHWs are expected to maintain basic health through health promotion. They are involved records on curative activities e.g., how many in curative services only when they have been cases of malaria or pneumonia seen in the provided with basic medicines which they can month, how many doses of treatments given administer to patients in the community. For out, any treatment complications, any referrals. the bed ridden patients, a referral is made to the These records are reviewed by their supervisors appropriate service provider. In the case of HIV/ when they come to visit. In addition, CHWs AIDS for example, the referral system involves provide monthly returns to the health facility as calling a health worker to come to the patient accountability for the drugs dispensed, on basis and provide home based care. of which new drugs and supplies are provided. The same records are used by health workers “For the mothers, when you are taking the child to monitor patients. For the HIV/AIDS service for treatment at a health centre, you feel confident delivery, adherence to ART and cases of drug because you are not going to suffer with the health misuse are monitored through such records. workers who do not know you once you have been

Global Evidence of Community Health Workers 3 1 1 3 2 Current Current Level/ Evidence 3 (best practice) Recruited from community from Recruited If when possible. not possible, the community is consulted and agrees during the process selection. on recruitment community, Health system, the role/ and CHW design expectations and policies in place that support CHW Role and expectations role. CHW and clear to are for Process community. and discussion of update role/expectations in place CHW and community for Initial training is provided within the six all CHWs to months that is based on for CHW. defined expectations Some training is conducted in the community or with community participation. with is consistent Training health facility guidelines for community and health care in training. facility is involved On-going training is provided CHW on new skills, update to and initial training, reinforce he/she is practicing ensure is Training skills learned. tracked and opportunities in a consistent offered are all and fair manner to (not only some) CHWs All necessary supplies; no substantial stock-out periods. - - - CHW is not recruited from com from CHW is not recruited munity but the community is on the final selection.consulted defines (policies Health system but without exist) the CHW role community input. Role is clear CHW and communityto but little discussion of specific expectations. General agree between CHW, ment on role and community. health system, to Initial training is provided year within the first all CHWs does Training of recruitment. not include participation community from or health center. referral On-going training is provided Some super basis. on a regular up with coaching. visors follow have CHWs Functional Note: updated) been trained (or within the last 18 months. on ordered Supplies are basis although a regular Stock delivery can be irregular. out of supplies essential for defined CHW tasks occur at of x per year/mo a rate 2 - - 1 from CHW is not recruited community but the commu nity (reluctantly) accepts the identified CHW after selection. of CHW exists role No formal (no policies in place) General to expectations given are CHW (initial training) but CHW and not specific. are community do not always on role/expectations. agree Minimal initial training is etc). (1 workshop, provided works attend Some CHWs topics. hops on specific ad hoc visits Occasional, supervisorsby provide some coaching. Inconsistent supply and supportrestocking to formal No defined CHW tasks. re-ordering. for process Table 43 - CHW Program Functionality Assessment Tool (CHW-PFA) – Uganda (CHW-PFA) Tool Assessment Functionality 43 - CHW Program Table 0 community CHW not from and in the recruitment. no role plays upon Role is not clear or agreed community between CHW, health system. and formal No initial training is provided. No ongoing training is provided No equipment and supplies provided. are Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Recruitment a where and from How community health worker and selected, is identified, a community. to assigned CHW Role design Alignment, and clarity from of role and CHW, community, perspectives. system health Training Initial to provided Training role for prepare CHW to in MCH services delivery he/she has the and ensure necessary skills provide to and quality care. safe Training On-going On-going training to CHW on new skills,update initial training, reinforce he/she is and ensure practicing skills learned. and Supplies Equipment equipment Required deliver and supplies to expected services. 1 2 3 4 5

347 2 2 2 1 Current Current Level/ Evidence - 3 (best practice) Regular supervision visit every 1-3 months that includes reports,reviewing monitoring Data is of data collected. solving problem used for Supervisorand coaching. makes visits community, skills provides home visits, Supervisor CHW. coaching to is trained in supervision and has supervision tools. evaluation least once/year At that includes individual performance (local eva luation) and evaluation of or monitoring coverage data (national /program evaluation) Community is feedback asked provide to on CHW performance. for clear rewards are There good performance, and community a role plays rewards. in providing and/or non-financial Financial partly are incentives based on good performance. Incentives balanced and in line with are expectations placed on CHW. Examples of non-financial that engage incentives workers might include (advancement, recognition, certification process) an activeCommunity plays in all supportrole for areas such as development CHW, feedback, providing of role, providing solving problems, establish helps to incentives, CHW as leader in community. - Regular supervision visit at least every months that three reports,includes reviewing monitoring of data collected and occasionally provide supportproblem-solving to Supervisors trained not are CHW. in supportive supervision but facility are based health workers. evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage data (national /program evaluation). Community is not on feedback asked provide to There performance. CHW’s good for some rewards are performance, such as small etc. recognition, gifts, incentive Some financial or non-financial provided. are incentives Examples of non-financial incen include occasional formal tives additional training, recognition, and other small incentives. significant Community plays in supportingrole the CHW groups, mother’s through CHW is widely networks, etc. for and appreciated recognized serviceproviding community. to 2 - 1 Supervision visits conducted times between two and three collect to reports/per year meetings at group data (or facility turn to in monitoring No individual perforforms). workmance supporton offered coaching) (problem-solving, evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage no rewards are There data. good performance. for provided incentives No formal but community recognition a reward is considered Community is sometimes education) (campaigns, involved with the CHW and some people in the community recognize the CHW as a resource. 0 No supervision or regular evaluation occurs outside of by CHWs occasional visits to nurses or supervisors when or less). possible (1x/year evaluation of No regular performance CHW. by No financial or non-financial provided incentives with Community is not involved ongoing support CHW to Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Supervision Supervision conducted carry basis to on a regular tasks out administrative individual provide and to performance support data- (feedback, coaching, driven problem-solving). Evaluation Performance fairly to Evaluation assess work during a set period of time. Incentives salary Financial= and bonuses Non-financial= training, certification,recognition, etc. medicines, uniforms, Involvement Community Role that community in supportingplays CHW. 6 7 8 9

Global Evidence of Community Health Workers 1 0 2 Current Current Level/ Evidence - - - 3 (best practice) CHW knows when to signs, client (danger refer etc) additional treatment, CHW and community know facility is and referral where plan for a logistics have (transport,emergencies with a funds) Client is referred slip of paper and information to CHW with a back flows and/ form referral returned or monthly monitoring. is (promotion) Advancement who performto CHWs offered an and who express well in advancement if the interest opportunity exists (advance for ment might mean path to mal sector or change in role) opportunities are Training to learnto CHW new offered skills and advance their role to of them. CHW is made aware to is intended Advancement good performancereward or and is based on achievement, is fair evaluation. Retirement encouraged and incentives encourage to provided are at a set age. retirement document their CHWs and group visits consistently facilitymonitoring visits to who CHWs by attended are bring monitoring forms. Supervisors quality monitor of documents and provide CHWs/ help when needed. communities work with supervisor facility or referral use data in problem-sol to ving at the community. - - CHW knows when to refer CHW knows refer when to additional signs, client (danger CHW and etc) treatment, community know referral where facility is and usually have transportthe means to client with a slip of Client is referred tracked paper and informally by CHW (checking in with family, up visit) but information follow to CHW. back does not flow is (promotion) Advancement to CHWs sometimes offered for been in program who’ve Limited specific length of time. training opportunities offe are learn CHW to new skills to red Advancement advance role. to good reward to is intended performance or achievement, although evaluation is not (advancement might consistent sector or formal mean path to reti No path to change in role). CHWs is made clear to rement document their CHWs and group visits consistently facilitymonitoring visits to are who bring CHWs by attended Supervisorsmonitoring forms. qualitymonitor of documents help when needed. and provide do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 2 - - - 1 client CHW knows refer when to additional treat signs, (danger CHW and communityment, etc) facility know referral where referral no formal is but have is not Referral process/logistics tracked community by or CHW is (promotion) Advancement to CHWs sometimes offered been in program who’ve specific length of time. for No other opportunities discussed with CHW. are to is not related Advancement performance or achievement. document their Some CHWs monitoring visits and group by facilityattended visits to are who bring monitoring CHWs do CHWs/communities forms. ef no and analyzed data see not fort use data in problem-sol to ving at the community is made. 0 in place: CHW system No referral might know to when and where plan client, but - no logistics refer the communityin place by for - information emergency referral is not tracked or documented advancement No professional is offered. documentation for No process management is followed or info Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional

349 Table 44 - Community Health Worker Functionality Matrix MCH INTERVENTIONS YES COMMENTS 1 ANTENATAL CARE A Iron folate supplements Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o B Maternal nutrition Counsel x Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment o C Counsel on birth preparedness/complication readiness (includes counseling to use skilled birth attendant) D Tetanus toxoid Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o E Deworm Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o 2 CHILDBIRTH and IMMEDIATE NEWBORN CARE A Prevent Infection/Clean Delivery (Hand washing, clean blade +/or clean delivery kit)

B Provide Essential Newborn Care a. Immediate warming and drying x b. Clean cord care x c. Early initiation of breastfeeding x C Recognize, initially stabilize (when possible) and refer for maternal and newborn complications x a. newborn asphyxia x b. sepsis, o c. hypertensive disorder x d. hemorrhage e. prolonged labor and post-abortion x complications D Prevent PPH: AMTSL or use of uterotonic alone in absence of full AMTSL competency (e.g. oral o Misoprostol) E Provide special care for Low Birth Weight newborns (Kangaroo Care) x

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS d. danger sign recognition; x e. maternal nutrition, etc. B Assess for maternal newborn danger signs and provide appropriate referral. x C Provide Treatment for severe newborn infection (when community-based treatment supported by national o guidelines.) 4 EARLY CHILDHOOD A Infant and young child feeding, IYCF: x Provide counseling for immediate BF after birth; exclusive BF < 6 months; age-appropriate complementary foods B Promote growth monitoring, weighing infants and x recording progress C Provide community based management of acute mal- o nutrition (CMAM) using Ready to Use Therapeutic Foods (community-based recuperation of children with acute moderate to severe malnutrition without complications) D Community-based treatment of pneumonia o Counsel re recognition of danger signs, seeking care/ o antibiotics o Assess and treat with antibiotics o Refer for antibiotics Refer after treating with initial antibiotics G Community-based prevention and treatment of diarrhea x Counsel on hygiene o Counsel on point-of-use water treatment o Provide point-of-use water treatment x Refer point-of-use water treatment o Counsel on ORS o Provide ORS Refer for ORS o Counsel on Zinc o Provide Zinc o Refer for Zinc H Vitamin A supplements (twice annually children 6-59 months) o Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment I Effectively assess and recognize severe illness in chil- x dren (danger signs) with appropriate referral. j Counsel on immunizations x Mapping/tracking for immunization coverage o Provide Immunizations: -DTP o -polio and or measles o

351 MCH INTERVENTIONS YES COMMENTS - +/- HIB o - Hep B o -Pneumovax o -Rotavirus o Refer for immunizations o 5 FAMILY PLANNING/HEALTHY TIMING AND SPACING OF PREGNANCY A Counsel on HTSP/contraceptives o Provide contraceptives: o - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - depo o Refer for contraceptives: o - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - long-acting and permanent methods o Provide FP counseling +/ - administer contra- o ceptives (e.g.;Oral Contraceptives) 6 MALARIA (Optional - Dependent Upon Country) A Insecticide-treated mosquito nets to pregnant women and children Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Intermittent preventive malaria treatment (IPTp) Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o C Community-based treatment of malaria (testing with Rapid Diagnostic Test or presumptive treatment per antimalarial per national guidelines.) Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o 7 PMTCT (Optional - Dependent Upon Country) A Healthy timing and spacing of pregnancy Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o B Antibody testing to pregnant women and mothers o Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment C Prophylactic ARVs/HAART to pregnant women mothers o Counsel o

Global Evidence of Community Health Workers INTERVENTIONS YES COMMENTS Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment E Prophylactic ARVs/HAART to infants Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o F Early infant diagnosis Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o G Pregnant HIV-infected women tracking Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o H HIV-exposed infant tracking Counsel o Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o

353 Summary and Conclusions The Ugandan CHW program is being imple- a poor country with many problems but the mented as part of the wider Village Health Team social indicators are improving. For instance, (VHT) strategy. Although the idea was initiated under 5 mortality fell from 235 per 1,000 live way back in 2003, implementation has been births in 1990/92 to 138 per 1,000 live births in slow, mainly due to lack of resources. Hence, the 2008. Economic and social reforms have been program is still in its infancy. The total program undertaken and the economy registered an functionality score was 20 (Min 24, Max 36) and impressive 8% growth rate between 1996 and the score on the MNCH matrix was only 8 out 2008, accompanied by falling poverty rates of a total score of 34. There has been slower and a 76% increase in net enrolment in primary than expected progress. However, most sta- school.104 keholders have now bought into the idea and nationwide implementation is being rolled out. However, life expectancy at birth is estimated at An assessment of the context shows that the re- 42 years and total adult literacy is estimated at cruitment and initial training of the community 44%. Only 42% of the total population has access health workers is highly functional. The clarity of to improved drinking water sources, while only role, supervision, performance evaluation and 19% of the rural population was using improved community involvement, documentation, in- sanitation facilities by 2006. By 2007, only 15% formation and management are functional but of children under five with fever were estimated gaps still remain. Ongoing training, supply of to be accessing anti malarial drugs. There is an equipment and supplies, provision of incentives estimated HIV prevalence rate of 12.5% in the and integration in a referral system are not ade- population age-group 15-49 years.105 quately done. Worse still, there is no professional advancement offered. Health Systems Overview 8. Mozambique Agentes The health sector in Mozambique is led by the Ministry of Health, “Ministério de Saúde” (MISAU). Polivalentes Elementares Health facilities include hospitals, health centres Program and health posts. The health services are organized at 3 levels; national, provincial and district Socio-economic and level. political context Mozambique has 3 main Central hospitals in With a population of about 20 million, each region located in Maputo (which is also the Mozambique has over the years registered an final referral hospital for the whole country) for impressive recovery from civil and political un- the Southern region, Beira for the Central region rest. It gained independence from Portugal in and Nampula for the Northern region. 1975 and endured a civil war between FRELIMO and RENAMO. A new constitution was appro- The lowest level of care is provided by Health ved in 1990 and civil war ended in 1992. Since Posts (1 per about 28,000 people). Other health then, the country has held regular multi-party facilities include: elections and experienced peaceful change of leadership. Multiparty politics has been esta- Health Centres (1 per about 35,000 people) blished and the country is stable. Rural Hospitals (1 per about 700,000 people) At GNI per capita of $340, Mozambique is still Provincial or General Hospitals (1 for every 1,500,000 people).

Global Evidence of Community Health Workers greater emphasis on policy and strategy deve- The main challenges that Mozambique faces lopment and lowering the transaction costs of with regards to health are: foreign assistance. Low access to health care. Between 30-50% of the population have access to basic preventive A total of 26 partners participate in the Health and curative health services; i.e., those living SWAP structure to enhance strategic dialogue within 10kms of a health facility, among partners and between the Ministry of Health and partners on sector policies, priorities High level of Communicable Diseases (e.g., and performance in the context of Absolute about 13% of adults are living with HIV/AIDS; Poverty Reduction Plan of Action (PARPA) and annually there are about 18,000 cases of Malaria delivery of the sector strategic plan (PESS). Up to per 100,000), 30% of external funding is channelled through a 106 Lack of health staff and low health worker den- Common Fund Mechanism (Prosaude). sities (0.027 physicians per 1,000; 0.322 nurses/ midwives per 1,000; 0.029 environmental and Mozambique Agentes public health workers per 1,000) Polivalentes Elementares General lack of material and financial resources Program (only $9 per capita in 2001, $12 pc in 2003). Mozambican total health expenditure as per- Mozambique gained independence from centage of GDP was estimated at 4.7% (2003). Portugal in 1975. Immediately after this, Per capita total expenditure on health is about Mozambique adopted the primary health care $12 p.c. ($7 from government). Close to 40% approach as strategy to provide health care to of household expenditure on health is out of the population. In 1978 the Ministry of health pocket. The share of national budget allocated started the Community Health Workers Program to health is at about 11%, still shy of the 15% here known as Agentes Polivalentes Elementares committed at Abuja. (APE). The objective of this program was to rapidly expand health care to the rural areas which The major causes of death among children un- had been underserved during the colonial der 5 years include; neonatal causes (29%), HIV/ period. Between 1978 and 1988 a total of 1,500 AIDS (13%), diarrheal diseases (17%), malaria APEs were trained under this program. As a result (19%), and pneumonia (21%). of civil war between 1977 and 1992, the training process and supervision were done under a lot With the successful peace process and ensuing of constraints. In 1983 the program started to stability with regular elections, a large number decline. In 1989 the Ministry of Health officially of international development partners came declared that the program was being interrup- to provide support to Mozambique, especially ted. From then up to date the Ministry of Health in the health sector. In 2007, foreign aid contri- has not been able to implement it in a structured buted to 70% of the health sector’s budget and manner. Despite the fact that the Ministry did this was expected to increase to 73% in 2008. not train new APEs during this period, it continued providing medicine for the group. In seve- Mozambique adopted a “Sector Wide Approach” ral provinces NGOs had carried out the training (SWAp) to the health sector in 2000 with the aim for new APEs. However, most of these workers of improving the performance of the sector, have disappeared from the system, calling into strengthening government leadership, putting question sustainability of the program.

355 Now, the Ministry of Health is undertaking a plan to restore functionality of the APE program The candidate must have the ability to read using a new model.107 The rest of this document and write Portuguese and have basic notions of focuses on the proposed new approach. arithmetic Should be between 18 to 35 years, This program was selected for review as it is the main officially recognized nationwide CHW past experience in community development, programthat Mozambique is developing/ im- willing to carry out the services from her home plementing. It is the only CHW program that is Able to relate well both with the community to well structured, and with clear curriculum and be served and with the health care system. training materials agreed on by all the partners. All other programmes are rather ad hoc in na- The final selection of the APEs will be done ture and not nation-wide. The APE program is after the candidates undertake a reading and part of Mozambique’s strategy to contribute to 108, 109 writing test. The proposal is that all the APEs will objectives of MDG 4 and 5. have a contract with the local Government and will receive a stipend in line with the country’s Recruitment Process (new minimum wage (equivalent to about 50 USD). proposed model) Guidelines and instruments to be used for supervision are under development. The new APEs will be selected from the same community where they will work. Preference The contract will be signed on an annual basis. will be given to female candidates. The selec- In case of lack of satisfactory performance of tion process will be managed by the District their duties the contract will be terminated if at- Health Directorate in conjunction with the tempts to correct the situation are unsuccessful. community where the health professionals in The community will be involved in this process. the area will play a facilitative role in the selec- 110, 111 tion process. As a measure to divert the APEs from the current tendency to mainly focus on providing curative services, the new approach The APE’s Role recommends that most of the training should The prime role of the APE is to carry out health happen outside the health institutions. Also, it promotion and preventive activities for the is recommended in this model that the training Population within the catchment area. Each APE process must be carried out in the community is expected to serve a population of 500 up to where the APE will develop his/her activities. 2,000 inhabitants. The APEs establish the linkage The candidate interested in becoming an APE between the national health care delivery sys- must demonstrate his/her willingness to work tem and the community, and will be responsible in his/her community. The information will be for mobilizing the community to participate in disseminated through the health facilities and health services and health activities.112 community radios. Selection of CHW is based on the following criterion: The APE’s routine activities are to:110-112 Preference for females (at least 60% should be Describe and Map the health area under his/her women), responsibility permanent resident of the area (for which she Register all family members in the catchment is recruited), areas during their visits to households, and

Global Evidence of Community Health Workers maintain up to date information (this is to be Disseminate health education messages on started within the towns) individuals and community hygiene and sanitation as well as information regarding preventive To develop community awareness on the impor- measures against spread of AIDS tance of the individual and community hygiene Submit monthly progress reports to in charge To disseminate messages on the importance of health center containing information regarding protecting water sources all activities carried out by him/her Visit with regularity the households under his/ To use rationally the medicine contained in the her responsibility kit under his/her control. Keep in close liaison with influential women of her area including lady teachers, traditional Initial Training of APEs birth attendants The training of APEs will be conducted in 4 Motivate and counsel clients for adoption and blocks for a total of 18 working weeks using pro- continuation of family planning methods gram training manuals and curriculum, which To promote the deliveries within the health is then followed by continual training at the facilities health facility along with refreshers. After each Participate in outreach activities from health block of lectures the trainees will be involved facilities, promoting growth monitoring, asses- in practical activities in the field. After the first sing common risk factors causing malnutrition block, the task consists of learning how to design and nutritional counseling the catchment area and how to identify, along with the community leaders, the main health Promote nutritional education with emphasis problems in a given health catchment area. on breast-feeding and weaning practices, ma- After the second block, the task is to identify in ternal nutrition and macronutrient malnutrition the catchment area other community health Coordinate with EPI for immunization of mo- workers and develop with them 3 sessions of thers against tetanus and children against health education. The third practical activities vaccine preventable diseases and participate in consist of identifying health workers working various campaigns for immunization against EPI in preventive activities and developing 3 ses- target diseases sions of health education. After the last block, the trainee has the opportunity to work within Get involved in surveillance activities the Health Facility to learn how to deal with the Carry out prevention and treatment of com- short list of diseases for which he/she has been mon ailments e.g. malaria, diarrhea diseases, trained. 110, 111 acute respiratory infections, intestinal parasites, scabies, snake bites, injuries and other minor Initial training (Block 1: 80 hours training) diseases using essential drugs and refer cases to The first block of basic training will take a total nearest centers as per given guidelines of 80 hours. In this period, the newly recruited APEs are trained to understand: Get involved in DOTS and malaria control programs Identify and refer to the health facilities the suspected cases of AIDS, Tuberculosis and other conditions.

357 The role and the APE’s responsibility within the Community How to use the material provided for community health education The relation between the community, APE and the health System How to register the activities developed in the community and to fill the existing forms and to The role of the leaders within the community prepare the activity reports on the health issues The importance of washing hands and personal How the health system is organized including hygiene for disease prevention the different levels of care The importance of health sanitation in disease How the primary health care team is composed prevention including the exact role of the community The importance of water conservation to pre- health worker within this group vent common diseases The basic principles of communication for change The basic mechanism of transmission of: ma- The basic principles of professional ethics laria, diarrheal diseases, STIs, Tuberculosis and other respiratory infections. The concepts of health and disease The basic principles for prevention of malaria The notion of health determinants within a gi- transmission and other infectious diseases ven community Block 3: (120 hours training) How to do a community health status assess- The second block follows the field practical acti- ment based on a guideline vities. In this block, it is expected that at the end the trainee will be able to: Block 2: Health promotion activities (120 hours of training) Manage non complicated malaria cases with The objectives of this block are to provide the first line drugs trainee with the understanding on: Manage non complicated cases of diarrhea Why the mothers have to follow antenatal and using oral re-hydration salts postnatal care in health facilities Identify cholera cases in the community and The potential risk of lack of antenatal care and refer them to health facilities home delivery Manage non-complicated cases of Acute The main methods for HIV prevention Respiratory Infections in children under five years old The importance of vaccination of children and women Provide first aid observing bio-safety best practices The importance of exclusive breastfeeding Identify suspected Tuberculosis cases, Leprosy How to best use the locally available nutrients cases, AIDS and other transmitted infection ca- The importance of family planning for child ses and refer them to the health facilities. survival Correctly use the protocols for patient referral The importance of monitoring child growth and and transference development

Global Evidence of Community Health Workers Block 4 (40 hours) Thermometer Clinical This block is dedicated for practical activities in Scissors the community, to revise what has been covered and to do evaluation of the training. CHW Kit Bags containing weighing scale etc. On-going Training of CHWs Salter Scale with Trouser From time to time the health authorities will organize a refreshment training based on the Supervision training needs identified during the supervision process. There is as yet no pool of supervisors trained. These supervisors are expected to be drawn Training of Trainers from existing health facilities. These facilities are There is a national pool of about 20 CHW trai- in turn routinely supervised by the health teams ners who are expected to train other trainers at from the district and provincial levels. The health provincial and district levels. Training guidelines workers at the health units will be responsible are being developed. A training of trainers will to supervise the APEs close to their facilities. be carried out and these trainers will in turn be responsible to train and supervise local health The supervisors are public servants on a month- facility staff that will be in day to day contact ly salary. However, during the supervision visits with the APEs. they receive a per diem allowance. The health facilities are responsible to provide the means Equipment and supplies of transportation. Usually they use the vehicle The CHWs are basically provided with essential available at the health unit. medicines and supplies (in Kit C) including the following: Performance Evaluation Paracetamol Tabs 500mg An evaluation of previous CHW activities is re- Coartem ported to have been conducted by the Swiss co-operation. The evaluation noted that the trai- Mebendazole Tabs 100mg ning was unstructured, ad hoc, involved mainly Oral rehydration solution NGOs, was often localized in small areas and varied in duration and quality. 110, 111 Specific data Cotrimoxazole Syp. on program coverage, service delivery, support Ferrous Fumerate 150mg + Folic Acid 0.5mg systems, impact on health and costs were not Cotton Bandages 4” x 3m available. Benzyl Benzoate Lotion In 2007, a national meeting on community Paracetamol Syp 120mg/ml involvement was convened and made the following observations: 110, 111 Antiseptic Lotion Community involvement is still not well un- List of Non-Drug Items: derstood by health sector staff at all levels, who Cotton Wool (250 Gram) are not ready to develop community outreach activities; Sticking Plaster 1” x 5m Most of the community outreach initiatives in Pencil Torch with Two Cells the provinces are carried out by NGOs;

359 There is no clear guidance regarding implemen- immunization, growth monitoring, follow-up of tation of community outreach activities; chronic diseases treatment (Tuberculosis and The charges for consultations and sale of drugs Leprosy). by community health workers are not any different from those of private practice Very often within the community there are other kinds of health activists and volunteers. The training for community health workers and The APE has the role to coordinate and in some paramedics does not follow uniform criteria des- cases supervise these groups. These agents and pite being carried out by the Provincial Health activists are being supported by among others Directorate in partnership with NGOs; and NGOs, the Red Cross, women groups and others. There are inequalities in the payment of incenti- It is proposed that all these will come under the ves to community health workers. overall supervision and co-ordination of the APE who will also act to link them up to the national This national meeting also noted that data that health care system. are sent are often unreliable and that HIV/AIDS “counselors” are starting to exert pressure to be- Referral System come integrated into the NHS. 110, 111 The APEs are recognized by the health facilities. The APE can refer all patients with complicated Incentives conditions to the nearest health facility. In some During training the APE will receive a small areas the APE has a station where he/she does amount of money for basic needs. This amount see patients. In that place usually he/she works is not yet established. As soon as they start to together with the TBA to assist the deliveries work, they will have a contract with the local happening at the community level. government and they will receive the equivalent of the minimum wage in the country Professional Advancement (about USD 50). All medicines will be free under The APE is still not considered as part of the for- the new model. mal human resources for health. He/she doesn’t fit within the human resources for health career Community Involvement pathways. Because of this, even within the new One of the roles of the APE is to establish the model, APEs are not considered part of the pu- linkage between the health system and the blic system and even though they have access to community. In this role, the APE is in charge of a retirement plan. In other to favor their growth mobilizing the community to be involved in within the system, all APEs are encouraged to several activities oriented to promoting better continue with studies to upgrade their level. health. The community usually participates in When the APE achieves the recommended sanitation activities e.g., to build community level to start formal training as a health worker water and sanitation facilities. 110, 111 he/she will have priority for selection. This is the only way for an APE to become part of the for- When the health team organizes outreach ac- mal system and enter a career pathway. tivities, it is a primary responsibility of the APE to mobilize the community to participate. The It is planned that those who are trained according outreach package in Mozambique includes: to the new CHW profile and curriculum will be reco- Antenatal care, postnatal care, family planning, gnized by the Ministry of Health and all partners.

Global Evidence of Community Health Workers Documentation and Information Management Basic records that will be kept by the APE will include numbers and types of patients seen, medicines given out, and health activities carried out. It is on the basis of submission of these reports that the APE will receive a new Kit C.

361 3 1 2 3 2 Current Current Level/ Evidence 3 (best practice) Recruited from community from Recruited If when possible. not possible, the community is consulted and agrees during the process selection. on recruitment community, Health system, the role/ and CHW design expectations and policies in place that support CHW Role and expectations role. CHW and clear to are for Process community. and discussion of update role/expectations in place CHW and community for Initial training is provided within the six all CHWs to months that is based on for CHW. defined expectations Some training is conducted in the community or with community participation. with is consistent Training health facility guidelines for community and health care in training. facility is involved On-going training is provided CHW on new skills, update to and initial training, reinforce he/she is practicing ensure is Training skills learned. tracked and opportunities in a consistent offered are all and fair manner to (not only some) CHWs All necessary supplies; no substantial stock-out periods. - - - CHW is not recruited from com from CHW is not recruited munity but the community is on the final selection.consulted defines (policies Health system but without exist) the CHW role community input. Role is clear CHW and communityto but little discussion of specific expectations. General agree between CHW, ment on role and community. health system, to Initial training is provided year within the first all CHWs does Training of recruitment. not include participation community from or health center. referral On-going training is provided Some super basis. on a regular up with coaching. visors follow have CHWs Functional Note: updated) been trained (or within the last 18 months. on ordered Supplies are basis although a regular Stock delivery can be irregular. out of supplies essential for defined CHW tasks occur at of x per year/mo a rate 2 - - 1 from CHW is not recruited community but the commu nity (reluctantly) accepts the identified CHW after selection. of CHW exists role No formal (no policies in place) General to expectations given are CHW (initial training) but CHW and not specific. are community do not always on role/expectations. agree Minimal initial training is etc). (1 workshop, provided works attend Some CHWs topics. hops on specific ad hoc visits Occasional, supervisorsby provide some coaching. Inconsistent supply and supportrestocking to formal No defined CHW tasks. re-ordering. for process Table 45 - CHW Program Functionality Assessment Tool (CHW-PFA) – Mozambique (CHW-PFA) Tool Assessment Functionality 45 - CHW Program Table 0 community CHW not from and in the recruitment. no role plays upon Role is not clear or agreed community between CHW, health system. and formal No initial training is provided. No ongoing training is provided No equipment and supplies provided. are Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Recruitment a where and from How community health worker and selected, is identified, a community. to assigned CHW Role design Alignment, and clarity from of role and CHW, community, perspectives. system health Training Initial to provided Training role for prepare CHW to in MCH services delivery he/she has the and ensure necessary skills provide to and quality care. safe Training On-going On-going training to CHW on new skills,update initial training, reinforce he/she is and ensure practicing skills learned. and Supplies Equipment equipment Required deliver and supplies to expected services. 1 2 3 4 5

Global Evidence of Community Health Workers 2 1 2 0 Current Current Level/ Evidence - 3 (best practice) All necessary supplies; no substantial stock-out periods. Regular supervision visit every 1-3 months that includes reports,reviewing monitoring Data is of data collected. solving problem used for Supervisorand coaching. makes visits community, skills provides home visits, Supervisor CHW. coaching to is trained in supervision and has supervision tools. evaluation least once/year At that includes individual performance (local eva luation) and evaluation of or monitoring coverage data (national /program evaluation) Community is feedback asked provide to on CHW performance. for clear rewards are There good performance, and community a role plays rewards. in providing and/or non-financial Financial partly are incentives based on good performance. Incentives balanced and in line with are expectations placed on CHW. Examples of non-financial that engage incentives workers might include (advancement, recognition, certification process) an activeCommunity plays in all supportrole for areas such as development CHW, feedback, providing of role, providing solving problems, establish helps to incentives, CHW as leader in community. - Regular supervision visit at least every months that three reports,includes reviewing monitoring of data collected and occasionally provide supportproblem-solving to Supervisors trained not are CHW. in supportive supervision but facility are based health workers. evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage data (national /program evaluation). Community is not on feedback asked provide to There performance. CHW’s good for some rewards are performance, such as small etc. recognition, gifts, incentive Some financial or non-financial provided. are incentives Examples of non-financial incen include occasional formal tives additional training, recognition, and other small incentives. significant Community plays in supportingrole the CHW groups, mother’s through CHW is widely networks, etc. for and appreciated recognized serviceproviding community. to 2 - 1 Supervision visits conducted times between two and three collect to reports/per year meetings at group data (or facility turn to in monitoring No individual perforforms). workmance supporton offered coaching) (problem-solving, evaluation that is not Once/year based individual performance and includes only evaluation or monitoring of coverage no rewards are There data. good performance. for provided incentives No formal but community recognition a reward is considered Community is sometimes education) (campaigns, involved with the CHW and some people in the community recognize the CHW as a resource. 0 No supervision or regular evaluation occurs outside of by CHWs occasional visits to nurses or supervisors when or less). possible (1x/year evaluation of No regular performance CHW. by No financial or non-financial provided incentives with Community is not involved ongoing support CHW to Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional Component Component Definition Supervision Supervision conducted carry basis to on a regular tasks out administrative individual provide and to performance support data- (feedback, coaching, driven problem-solving). Evaluation Performance fairly to Evaluation assess work during a set period of time. Incentives salary Financial= and bonuses Non-financial= training, certification,recognition, etc. medicines, uniforms, Involvement Community Role that community in supportingplays CHW. 6 7 8 9

363 1 2 0 Current Current Level/ Evidence - - - 3 (best practice) CHW knows when to signs, client (danger refer etc) additional treatment, CHW and community know facility is and referral where plan for a logistics have (transport,emergencies with a funds) Client is referred slip of paper and information to CHW with a back flows and/ form referral returned or monthly monitoring. is (promotion) Advancement who performto CHWs offered an and who express well in advancement if the interest opportunity exists (advance for ment might mean path to mal sector or change in role) opportunities are Training to learnto CHW new offered skills and advance their role to of them. CHW is made aware to is intended Advancement good performancereward or and is based on achievement, is fair evaluation. Retirement encouraged and incentives encourage to provided are at a set age. retirement document their CHWs and group visits consistently facilitymonitoring visits to who CHWs by attended are bring monitoring forms. Supervisors quality monitor of documents and provide CHWs/ help when needed. communities work with supervisor facility or referral use data in problem-sol to ving at the community. - - CHW knows when to refer CHW knows refer when to additional signs, client (danger CHW and etc) treatment, community know referral where facility is and usually have transportthe means to client with a slip of Client is referred tracked paper and informally by CHW (checking in with family, up visit) but information follow to CHW. back does not flow is (promotion) Advancement to CHWs sometimes offered for been in program who’ve Limited specific length of time. training opportunities offe are learn CHW to new skills to red Advancement advance role. to good reward to is intended performance or achievement, although evaluation is not (advancement might consistent sector or formal mean path to reti No path to change in role). CHWs is made clear to rement document their CHWs and group visits consistently facilitymonitoring visits to are who bring CHWs by attended Supervisorsmonitoring forms. qualitymonitor of documents help when needed. and provide do not see CHWs/communities and no effortto data analyzed use data in problem-solving at the community is made. 2 - - - 1 client CHW knows refer when to additional treat signs, (danger CHW and communityment, etc) facility know referral where referral no formal is but have is not Referral process/logistics tracked community by or CHW is (promotion) Advancement to CHWs sometimes offered been in program who’ve specific length of time. for No other opportunities discussed with CHW. are to is not related Advancement performance or achievement. document their Some CHWs monitoring visits and group by facilityattended visits to are who bring monitoring CHWs do CHWs/communities forms. ef no and analyzed data see not fort use data in problem-sol to ving at the community is made. 0 in place: CHW system No referral might know to when and where plan client, but - no logistics refer the communityin place by for - information emergency referral is not tracked or documented advancement No professional is offered. documentation for No process management is followed or info Level of Functionality: 0= non-functional; 1=partlyLevel functional; 2= functional; 3 = highly functional

Global Evidence of Community Health Workers 365 Table 46 - Community Health Worker Functionality Matrix MCH INTERVENTIONS YES COMMENTS 1 ANTENATAL CARE A Iron folate supplements Counsel o Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x B Maternal nutrition Counsel x Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment x C Counsel on birth preparedness/complication readiness x (includes counseling to use skilled birth attendant) D Tetanus toxoid Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x E Deworm Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x 2 CHILDBIRTH and IMMEDIATE NEWBORN CARE A Prevent Infection/Clean Delivery o Kit provided only for TBAs (Hand washing, clean blade +/or clean delivery kit) o

B Provide Essential Newborn Care x They do not provide but promote these a. Immediate warming and drying practices especially as part of the Integrated x b. Clean cord care Maternal and Newborn and Child Health. c. Early initiation of breastfeeding x C Recognize, initially stabilize (when possible) and refer for maternal and newborn complications o a. newborn asphyxia x b. sepsis, x c. hypertensive disorder o d. hemorrhage e. prolonged labor and post-abortion x complications x D Prevent PPH: AMTSL or use of uterotonic alone in absence of full AMTSL competency (e.g. oral o Misoprostol) E Provide special care for Low Birth Weight newborns (Kangaroo Care) x

Global Evidence of Community Health Workers MCH INTERVENTIONS YES COMMENTS d. danger sign recognition; x e. maternal nutrition, etc. x B Assess for maternal newborn danger signs and provide x appropriate referral. C Provide Treatment for severe newborn infection (when o They refer when infection recognised community-based treatment supported by national guidelines.) 4 EARLY CHILDHOOD A Infant and young child feeding, IYCF: x Provide counseling for immediate BF after birth; exclusive BF < 6 months; age-appropriate complementary foods B Promote growth monitoring, weighing infants and x They recognize and refer recording progress C Provide community based management of acute mal- o They recognize and refer to health nutrition (CMAM) using Ready to Use Therapeutic Foods facility (community-based recuperation of children with acute moderate to severe malnutrition without complications) D Community-based treatment of pneumonia o Started in some provinces to provide Counsel re recognition of danger signs, seeking care/ o treatment using cotrimoxazole antibiotics o Assess and treat with antibiotics o Refer for antibiotics Refer after treating with initial antibiotics There are plans to introduce zinc G Community-based prevention and treatment of diarrhea o supplementation Counsel on hygiene o Counsel on point-of-use water treatment o Provide point-of-use water treatment o Refer point-of-use water treatment x Counsel on ORS x Provide ORS o Refer for ORS o Counsel on Zinc o Provide Zinc Refer for Zinc H Vitamin A supplements (twice annually children 6-59 months) x Counsel o Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment I Effectively assess and recognize severe illness in chil- x dren (danger signs) with appropriate referral. j Counsel on immunizations x Mapping/tracking for immunization coverage o APEs participate to help the health Provide Immunizations: worker in carrying out these activities but not by themselves -DTP o -polio and or measles o

367 MCH INTERVENTIONS YES COMMENTS - +/- HIB o - Hep B o -Pneumovax o -Rotavirus o Refer for immunizations o 5 FAMILY PLANNING/HEALTHY TIMING AND SPACING OF PREGNANCY A Counsel on HTSP/contraceptives x Provide contraceptives: o Oral contraceptives being provided - condoms x in some areas - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - depo o Refer for contraceptives: x - condoms o - Lactation Amenorrheic Method (LAM) o - oral contraceptives o - long-acting and permanent methods x Provide FP counseling +/ - administer contra- x ceptives (e.g.;Oral Contraceptives) 6 MALARIA (Optional - Dependent Upon Country) A Insecticide-treated mosquito nets to pregnant women and children Government provides ITNs within Counsel x health facilities Treatment for malaria Provide commodity or intervention/ Assess and treat x provided as part of home management of malaria Refer for commodity, intervention, or treatment x B Intermittent preventive malaria treatment (IPTp) Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment x C Community-based treatment of malaria (testing with Rapid Diagnostic Tests (RDTs) are Rapid Diagnostic Test or presumptive treatment per being introduced in some areas. antimalarial per national guidelines.) Counsel x Provide commodity or intervention/ Assess and treat x Refer for commodity, intervention, or treatment x 7 PMTCT (Optional - Dependent Upon Country) A Healthy timing and spacing of pregnancy Counsel x Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment o B Antibody testing to pregnant women and mothers x Discussion are going on to introduce Counsel o community level testing for HIV Provide commodity or intervention/ Assess and treat o Refer for commodity, intervention, or treatment C Prophylactic ARVs/HAART to pregnant women mothers x Counsel o

Global Evidence of Community Health Workers INTERVENTIONS YES COMMENTS Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment E Prophylactic ARVs/HAART to infants x Counsel o Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment F Early infant diagnosis x Counsel o Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment G Pregnant HIV-infected women tracking x Counsel o Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment H HIV-exposed infant tracking x Counsel o Provide commodity or intervention/Assess and treat o Refer for commodity, intervention, or treatment

369 Summary / Conclusions Mozambique has chosen to develop and implement a preferred unified program of community health workers, Agentes Polivalentes Elementares (APE), as a means to increase access to basic health services to its people. Although CHW training is said to have started way back in 1978, the APE program is still considered to be under development and national plans, strategies, curricula and guidelines have only recently been put in place. Implementation is still in its early stages. This is further seen in the fact that the APE only scores 19 (Min 24, Max 36) on the CHW program functionality score. It is also clear that they are only offering a narrow scope of MNCH activities. The APE score on the MNCH functionality matrix was only 10 out of possible total of 34.

The APEs are expected to come from the communities which they will serve and communities are to be fully involved in their selection and monitoring their activities. An assessment of the context shows that while plans for their training as well as content seems to be clear and guidelines developed and in place, the link they will have with the formal health care delivery structures, their supervision, and career development are not yet well articulated. The APE are expected to work as part and as an extension of the health care delivery system and will receive a monthly remuneration close to the minimum wage, effectively making them civil servants. The program design was informed by wide scale reviews and consultation with the majority of the health stakeholders and thus has wide buy in. How effective the APE program will be in reaching the people with the impressive essential package of services that is being planned remains to be seen.

Global Evidence of Community Health Workers > 92,957 in 2005-06 78,000 in 2008 1,200,000 in 1996 1240,000 in 2009 > 1,600 in 2009 30,190 trained up to have 7,000 as of 2009 <1,000 trained as of 2009 New/newly New/newly functional CHWs Number of CHW’s in Program Number of CHW’s Baseline < 20,000 in 1994-95 1,080 in 1990 500,000 in 1970 5,000 in 1994 < 30 in the village in 1985 of Cange - - - Total Program Program Total Functionality (Min: 24/ Score Max: 36) 13 18 10 4 12 17 8 10 Total Program Program Total Functionality (Min: 24/ Score Max: 36) 28 25 20 34 31 29 20 19 Table 47: Scoring Chart for Functional CHWs. Chart 47: Scoring Functional for Table Region/ Department National Level NGO organization the to coverage given whole Bangladesh National Level National Level Mountainous Central of Haiti and half Plateau of the Artibonite region Artibonite) (Lower Country-wide implementation country-wide Proposed implementation country-wide Proposed implementation CHW Program Workers Lady Health – Pakistan Program Bangladesh Rural Committee Advancement Volunteer Health Village Thailand Program Saúde da Família Programa Comunitários da Saúde) (Agentes CHW Program Zanmi Lazante’s Health Extension Program Health Village Uganda CHW Program Team Polivalentes Agentes CHW Program Elementares Country Pakistan Bangladesh Thailand Brazil Haiti Ethiopia Uganda Mozambique

371 Summary of Country Case Studies We summarized a typology of CHW programs effectively strengthened. They have shown a based on the country case studies performed, positive impact on utilization of health services taking into consideration the context and and on infant mortality in the influence area of the diversity of training program (including the running NGOs. duration and content of training, supervision activities, and tasks assigned to CHWs), while Long duration training programs with preventive acknowledging the existing limitations in the and basic curative tasks for CHWs, with a relatively available information and in the methods used weak supervision system, and within a weak health (Functionality assessment tool, desk review and system: Ethiopia Health Extension Program interviews with key informants during country (HEP) and Mozambique Agentes Polivalentes visits). Elementares (APE) Program. In Ethiopia, initial training lasts one year and includes diverse Typology of CHW programs aspects such as community documentation, family health care, disease prevention and based on training, supervision, control, environmental health promotion, sup- task assignment characteristics, portive courses and common courses (English, and on strength and profile of mathematics, IT and entrepreneurship). Practical health system lessons are based on models training, group assignment, demonstration and role play, and Short to intermediate duration training programs, there are also apprenticeship activities related with preventive and basic curative tasks for CHWs, to health facility attachment and community with relatively strong supervision activities, and attachment. As for on-going training, the CHWs within a weak health system: Haiti. Initial training are expected to attend integrated refresher trai- lasts 3 months for health agents, 2 weeks for ning courses to improve their skill and sustain accompagnateurs, and 1 month for traditional their motivation and contribution, and the dis- birth attendants, and on-going training is per- trict health office identifies gaps in knowledge formed during one year on a monthly basis. and skills of CHWs through regular supervision Content of training privileges promotional and visits. Supervision activities are receiving further preventive activities, with inclusion of theoreti- attention, although they need still substantial cal and practical lessons, and through the use improvement. In Mozambique, initial training of a problem-based learning methodology. lasts 18 weeks, and on-going refreshment trai- Specific training content varies depending on ning activities are organized from time to time the type of CHW. The supervisory system is by health authorities, based on the training well organized and involves all levels of hierar- needs identified during the supervision process. chy of each institution, starting from the head Content of training is basically the same to that of the Commune to public health nurses, HIV in Ethiopia, with emphasis on promotive, pre- program nurses/ social workers to senior health ventive and basic curative messages to be lear- agents/accompagnateurs to the rest of each ned through theoretical and practical lessons. group. These CHW programs are implemented Supervision is not well structured and planned. by NGOs in the context of a weak health sys- These programs are implemented in Ethiopia tem, and they have a weak link with the health and Mozambique within weak health systems, system, being restricted therefore to the NGO and their link with the health system is incipient. geographical influence area. Scaling-up of this For Ethiopia, there is an external evaluation kind of programs is unlikely to happen across which is suggesting an association between the country, unless the public health system is the program implementation and increased uti-

Global357 Evidence of Community Health Workers lization and coverage. Whereas, in Mozambique Lady Health Workers (LHW) Program. This is there is no evidence that they have an impact implemented by the central government wi- on coverage and utilization of health services, thin a mixed public and private health system. let alone on health outcomes. Initial training lasts 15 months. As for on-going training, all LHWs attend their respective health Short duration training programs with preventive facility/ training center for one day each month and basic curative tasks for CHWs, with a relatively to get refresher training on an identified topic. strong supervision system, and within a weak Training courses are divided into integrated health system: Uganda Village Health Teams. training and task based training. Primary health This program is relatively new and is being im- care topics receive emphasis during the first plemented by the public sector with important period and field work is privileged during the support from donors. CHWs are not considered second period. Major promotive, preventive part of the health system and therefore there is and basic care topics are included during the no formal link with it. Initial training lasts 10 days. whole training program. There is a well structu- Continuous training of CHWs is largely through red supervision system. The program link to the needs based sessions which are conducted wider health system is quite strong, as revealed during the quarterly meetings at the health fa- by a formal referral system and a continued cility or as these members collect the supplies. political and budgetary support by the public Content of training courses include aspects sector. This LHW program is being implemented of community mobilization and sensitization within a relatively weak health system. There is for activities like immunization, pregnancy quite convincing evidence that this type of monitoring to ensure compliance with safe CHW program has an impact on health outco- motherhood for traditional birth attendants, mes, although several health system limitations drug distribution, referring patients, filling the should be addressed to guarantee an effective registers, organizing health education events, scaling up. and participating in outreach activities, as well as diagnosis and management of prevalent Short duration training programs, with mostly maternal, neonatal and childhood problems. promotional, preventive and basic curative tasks Supervision activities are well structured and are for CHWs and with a relatively strong supervision aimed to happen as both supportive and fault system, within a relatively strong health system: finding ways. No evaluation studies have been BRAC in Bangladesh, run by the private sector. performed yet. Although the Uganda Village Context: This program has been implemented Health teams program receives continued within a context of relatively strong health support from the government, there are several systems. There is evidence showing that im- drawbacks needing improvement, which inclu- plementation of BRAC is related to increased de deficient on-going training, irregular supply coverage and utilization of health services in of provision equipment and supplies, and ina- Bangladesh. It has been replicated in other dequate provision of incentives and integration countries such as Afghanistan. A high drop-out in a referral system, as well as lack of clear plans rate is the main limitation of the BRAC program. for professional advancement. However, the referral system needs to be further strengthened and the formal evaluation of the Long duration training programs, with promotio- CHWs should also be done on a regular basis to nal, preventive and basic curative tasks for CHWs, further improve their performance. with a relatively strong supervision system, and within a relatively weak health system: Pakistan’s

373 Short duration training programs, with mostly larly performed by health professionals. They promotional, preventive and basic curative tasks are expected instead to timely and adequately for CHWs and with a relatively weak supervision identify families and individuals at risk and refer system, within a relatively strong health system: them to the family health team. Supervision ac- The Village Health Volunteers Program (VHV) tivities are regularly performed. Periodically, the in Thailand, run by the public health sector. instructor/supervisor (a nurse) brings together Context: this program has been implemented the CHWs, to evaluate their work and to reorient within a context of relatively strong health their activities. Alternatively, a nurse-supervisor systems. CHWs activities are strongly linked to visits each agent under her charge at least once the wider health system, although supervision a month to review problem cases and collect activities in Thailand are rather limited. There is services data. In addition, one of the nine staff convincing evidence about the impact of the members of the agent program at the central VHV worker program on health indicators such office meets with each municipal supervisor as malaria control, management of TB and HIV/ every 2 to 4 months. The FHP is being imple- AIDs and other infectious diseases like avian mented within a relatively strong and unified H5N1. In addition, the decentralization of health health system. CHWs activities are strongly care system in Thailand has proved the inherent linked to the wider health system. Specifically, sustainability of the CHW program which conti- CHWs are a key part of Family Health Teams, and nues to show improvement in the health sce- all their activities are integrated to such family nario of the country by consistently decreasing teams. There is compelling evidence about the burden of diseases prevalent in the country. the positive impact of the FHP on health cove- However, the referral system needs to be further rage, utilization and various health outcomes. strengthened and the formal evaluation of the Challenges to be overcome include develo- CHWs should also be done on a regular basis to pment of effective recruitment and retention further improve their performance. strategies, balance between CHWs personal expectations and managerial objectives aiming Long duration training programs, with mostly pro- at reducing leakage of human health resources, motional and preventive tasks, and very restricted need to change training from a narrow “medica- and basic curative tasks for CHWs, with a strong lized” vertical approach to further emphasis on supportive supervision, and within a relatively social determinants of health, and a continued strong health system, such as the Family Health resistance of professional corporations to the Program (FHP) in Brazil. Initial training lasts 3 FHP innovative approach. months, and on-going education is provided during local monthly and quarterly meetings. Synthesis of country This training is oriented toward local concerns of the agents or clinical family health team. case studies Standardized training is provided whenever Evidence shows that human force drives health new practices are instituted, such as care for system performances. Throughout history, pe- acute respiratory infections or procedures for riods of acceleration in health have been spar- reporting causes of deaths. The content of ked by popular mobilization of workers in so- training privileges understanding of social and ciety.113 Higher worker density and better work environmental determinants of health, as well quality improve population based health and as promotive and preventive aspects. Curative population survival. In this section we took an topics are restricted to vary basic aspects, as in-detail ride of eight different CHW programs CHWs are not expected to replace tasks regu- across the world.114

Global Evidence of Community Health Workers A lot of similarities were found across these ought to be extensive, thorough and complete programs with very few differences which were which should always be appraised by the exam rather existed to meet the country specific or viva, so that it assures their competency in targets and goals. According to the paramount working in the community. The period of initial functionality of CHWs program, CHW must be training varied in these programs, and ranged from the community and it even becomes the from 10 days in Uganda to 18 months in Pakistan, best if CHWs are chosen by the community. All while none of the program has outlined any re- these programs that we reviewed followed the fresher courses. CHWs are usually given updates best practice criteria and recruited CHWs from in monthly supervisory meetings. The basic role the community. In Brazil, Haiti, Ethiopia, Uganda of CHWs in primary health care services is same and Mozambique, community is involved in throughout these programs but it varied a lot their final selection; whereas in Pakistan and in more specified and focused delivery of inter- Thailand, they are chosen by community leaders; ventions related to MNCH, Malaria, TB and AIDS and in BRAC Bangladesh, they are nominated control and other non communicable diseases. by village health organization. Apart from these Overall, the role of CHWs in services delivery for characteristics, CHWs in all these programs are MNCH, nutrition, malaria, tuberculosis is pro- also scrutinized on their age limits, sex, marital found and showed improved maternal and status, occupational status etc. taking into child health and reproductive health indicators considerations their culture and social values. in their catchment areas, but interventions initiatives for the control and treatment of HIV/ The literature also shows that merely being AIDS are in infancy in many of these programs a person from community is not enough to particularly in Asia. Programs from Latin America ensure that they can create an impact on the and Africa have given special attention to the health and social wellbeing of community, prevention, control and treatment of HIV/AIDS, education has its own imperative effects. The and several pieces of evidence showed consis- educated person gives responsible direction to tent results of benefits under supervised inter- the community and at the same time has his/ ventions. All in all, their roles in relation to MDGs her own social standing and respect in commu- were promotive, preventive, therapeutic and in nity, which makes his/her role easy in imparting few cases rehabilitative. knowledge and bringing up healthy modifica- tions in attitudes and practices. In Thailand, Haiti, For a competent program, investment in pro- Uganda and Mozambique, CHWs are selected if vision of proper supervision, equipment and they are able to read and write, while the educa- supplies, and linkages with health system in tional criteria was updated from read and write also required to compliment their training. to 8 years of schooling in Brazil after 2004. CHWs Supervision has proven to be effective in - im in Pakistan and Ethiopia are only given a privi- proving the impact of CHWs driven interven- lege to become a worker if they have 8 years or tions. Pakistan, Bangladesh and Ethiopia have above school education. trained and deployed assigned supervisors for CHWs who also work and support them in Training is the most crucial element in the im- community, but there are programs in Haiti and plementation of the program. This is the phase Mozambique which are utilizing the services where the much touted transfer of knowledge of health care staff like doctors and nurses for from professionals to community representati- supervising CHWs. They are all fully equipped ves takes place.114 Though universal guidelines with necessary equipment and essential sup- for the extent of training are not laid down but it plies but major shortages in the stock has been

375 recorded and reported in almost all of these program must score at least level 2 in each of programs because of intermittent deficiency in the 12 components in order to be considered the overall funding and lack of proper logistic minimally functional, as we can observe coun- management in the program. The services from tries had scored less than 2 in different compo- CHWS with proper skills and handful supplies nents showing their limitation in those areas. can be further enhanced if they work hand to In the bullets below we have identified some hand with formal health system. The role of common limitations across these countries. CHWs in the community would be incomplete if they work in isolation, without creating a link Most of the programs have shortages or lack with health care system. Key functional areas for of medical equipment for patient examination, CHW activity include creation of effective linka- and drugs/ supplies useful for promotive, pre- ges between communities and the health care ventive and curative health services. Irregularity system, where they can refer cases. Across all in the supply of vaccines, drugs, and necessary these countries that we reviewed had created a equipment has been reported and their availa- link with health system. bility and sustainability of resources is a major concern. The main programmatic advantage to cash incentives is lower attrition rate among CHWs. Lack of opportunities for upgrading and training One of the most critical problems for CHW pro- and refresher courses on relevant areas such as grams is the high rate of attrition which leads to delivery services, counseling for HIV/AIDS etc. In a lack of continuity in the relationship between some countries assessments showed that the a CHW and community, and increased costs in CHWs had lower competence in interventions selecting and training CHWs. Indeed, the very related to some curative services including ma- effectiveness of CHW work usually depends laria control and acute respiratory infection. on retention. CHWs in Pakistan, Brazil, Haiti, Ethiopia, and Mozambique are paid workers Lack of promotion, and professional but drop-outs among them are still their main advancement concern. On the other hand, BRAC has allowed their CHWs to earn meager amount from the The curriculum and the modules for CHWs trai- sales of drugs and are given performance based ning needs to be revised according to country incentives for referring patients for complica- specific MDGS goals and targets. Also the tions during pregnancy and bringing women to curriculum had more time for theory beyond health care center for delivery. Apart from mo- the needed skill they would implement in the netary rewards, in countries where these CHWs future, but with less time for acquiring practical are volunteers, they are given non-monetary skills due to little time for hands-on practice. rewards in terms of career advancement, and recognition and rewards for their services. Countries had also reported deficiencies in the practical training of CHWs particularly on skilled Countries under review from South Asia, Sub delivery and key clinical skills due to limited fa- Saharan Africa, and Latin America have surely cilities for large numbers of trainees. reached impressive health and social gains from their CHWs programs. However, these achie- Within countries time use of CHWs and working vements are not exempt of challenges and schedule are not harmonized and varied from difficulties. As discussed earlier, according to one place to the other place. program functionality assessment criteria, CHW

Global Evidence of Community Health Workers There are no clear guidelines for working rela- Creating practical linkages with the health cen- tionship between CHWs and the other com- ters and hospital services and ensuring effective munity based heath workers (if any) trained and regular support from the higher levels of previously, such as the community mobilizers the system is also a challenge. and TBAs. The necessary working and living conditions In some countries, CHWs are expelled on migra- for CHWs are not created in most of the cases ting from deployed area. In order to overcome which is compounded by poor communication such issues, guidelines needs to be set on the and transportation system and long distances outset regarding their transfers, leave of ab- from health centers. sence, and career structure. The resources needed to support the training, Documentation and reporting are not instituted supplies and equipment, to pay the salary and properly. to conduct regular supportive supervision requires sufficient funds. By the time the targets Referral system and linkage with the health are achieved they will make nearly half of the system is weak. The CHWs do not have good workforce and the financial implications of relationship with health workers working in achieving these would be huge. higher level health institutions. Moreover, communities’ attitude towards the CHWs is not to the desired level due to their failure to assist in some curative and some preventive health services. The continued demand for curative care services with weakened referral system may compromise community’s confidence in CHWs. The other challenge is the limited capacity of health systems to support the CHW program.

Table 48: Summary of CHW Program Functionality Assessment Across Selected Countries CHW-PFA Pakistan Bangladesh Thailand Brazil Haiti Ethiopia Uganda Mozambique Recruitment 3 3 3 3 3 3 3 3 CHW Role 3 2 3 2 3 3 2 2 Initial Training 3 2 3 3 3 3 3 3 Ongoing Training 2 3 2 3 2 2 1 1 Equipment and Supplies 2 3 2 3 2 2 1 2 Supervision 3 3 0 3 3 3 2 2 Performance Evaluation 3 2 0 3 2 2 2 1 Incentives 2 2 2 3 3 2 1 0 Community Involvement 2 3 3 3 2 2 2 2 Referral System 1 1 1 3 3 2 1 1 Professional Advancement 2 0 1 2 2 2 0 2 Documentation, Information System 2 1 0 3 3 3 2 0 Aggregated Total Score 28 25 20 34 31 29 20 19

377 Table 49: Summary of CHW Program Functionality Assessment Across Selected Countries CHW Program Training duration Tasks Supervision Health system Pakistan Long Promotional, preventive and basic curative Strong Weak BRAC Short Promotional, preventive and basic curative Strong Strong Thailand Short Promotional, preventive and basic curative Weak Strong Brazil Long Promotional, preventive and basic curative Strong Strong Haiti Short to intermediate Preventive and basic curative Strong Weak Ethiopia Long Preventive and basic curative Weak Weak Uganda Short Preventive and basic curative Strong Weak Mozambique Long Preventive and basic curative Weak Weak Training Duration: - Long: more than 4 months - short & intermediate: between 1 month to 4 months - short: Less than 1 month Supervision: - strong: where system has trained their own program supervisors and supervision is well structured - weak: where system has not trained their own program supervisors OR supervision is not well structured OR where supervisors were trained but supervision was provided to less than 50% of the workers Health System: - weak: linked to a weak health system - strong: linked to a wider and strong health system

Global Evidence of Community Health Workers 379 Referral Referral system (linkage with health system) linkages between local TBA teachers, and health system linkages with local health centers - - - Career Career pathway & deve lopment on completion of minimum education for supervisor promo they as ted supervisors on completion of minimum education FPO for promoted as FPO - - -Pregnancy -Pregnancy identifica Tk.30 tion -Brining mothers for deli Tk.100 very -Providing Tk.100 ENC Tk.100 -Refer - ensuring birth wt Tk.30 Perfor- mance incentives (if any) 3 per Rs. cycle of pills 0.5 and Rs. per condom volunteer volunteer part time employment Volunteer/ Volunteer/ salaried (US$) / reimbursed salaried Rs. time 3090 Full employment - Monitoring super vision & evaluation Lady health supervisors 1LHS : 25 LHW evaluation 4 partythird (external) evaluations has been conducted Shasthyo kormi 1LHS : 25-30 LHW evaluation regular internal evaluation Pathways & role & role Pathways to in relation MDG Promotive, preventive, Therapeutic, Rehabilitation Promotive, and Preventive therapeutic Promotive, and Preventive therapeutic - Key com petencies (MNCH/ TB/ HIV/ Nutrition / Malaria) MNCH, nutrition, Malaria, AIDS TB, (preventive part) MNCH, nutrition, Malaria, AIDS TB, (preventive part) CHW Contextual Factors CHW Contextual Deployment Deployment (Public NGO, sector, private) public sector NGO Certifi- cation process (exam, course completion course completion course completion - - - -

Table 50: Summary of CHW Contextual factors across eight selected 50: Summaryfactorseight countries across of CHW Contextual Table Training Training content, & duration (initial role & ongoing) Initial: 4 weeks Ongoing: once per month Role key MNCH= coordinate ANC, IP and PNC; FP servicesdeliver &immunization Nutrition= GM, nutritional counse BF promotion ling, TB= Malaria, control prevention, PHC= and treatment sanitation etc. water, for and treatment common ailments Initial: 18 months Ongoing: once per month Role key MNCH= coordi ANC, IP and PNC; nate FP servicesdeliver and injectable)(oral & immunization Nutrition= growth monitoring, nutritional counse of promotion ling, anemia control, BF, defi iron treat TB= ciency Malaria, control prevention, AIDS= and treatment PHC= raise awareness sanitation water, Educational Educational criteria for entry? of 8 years schooling of years few schooling -

Recruitment (open merit, community recommen dations, others ) Recommen- by dations local counselor Applicant be must -20-50 years of age - from community -female -permanent final resident selection by local counselor and EDO-H Recommen- dations by local village organization Applicant must be -25-45 years of age -female -married and with no children less than 2 of age years -acceptable to community

Country Pakistan Bangladesh

Global Evidence of Community Health Workers Referral Referral system (linkage with health system) linkages with health facility linkages with local health centers - - Career Career pathway & deve lopment on completion of further education they are as hired public health officers - - Perfor- mance incentives (if any) volunteer volunteer health free facility salaried USD 112/month Volunteer/ Volunteer/ salaried (US$) / reimbursed - - Monitoring super vision & evaluation no direct supervisor Health center staff super vises them no formal evaluation system local health nurses center frequent external evaluation Pathways & role & role Pathways to in relation MDG Promotive, preventive, Therapeutic, Rehabilitation Promotive, and Preventive therapeutic Promotive, and Preventive therapeutic - Key com petencies (MNCH/ TB/ HIV/ Nutrition / Malaria) MNCH, nutrition, Malaria, AIDS TB, MNCH, nutrition, Malaria, AIDS TB, (preventive part) Deployment Deployment (Public NGO, sector, private) public sector public sector Certifi- cation process (exam, course completion course completion course completion - - - - - key Role key key Role key Training Training content, & duration (initial role & ongoing) Initial: 8 weeks Ongoing: once per month MNCH= coordinate ANC, IP and PNC; FP servicesdeliver and immunization Nutrition= growth monitoring, nutritional coun promotion seling, TB= of BF Malaria, control prevention, PHC= and treatment sanitation etc. water, for and treatment common ailments, dental hygiene NCDs= screening of hypertension, and diabetes vision problems Initial: + 15 7 days on-the-jobdays Ongoing: once per month MNCH= coordinate ANC, IP and PNC; de FP servicesliver & im munization Nutrition= monitoring, growth nutritional counseling, pro of BF, promotion TB= motion of Malaria, control prevention, PHC= and treatment sanitation etc. water, for and treatment common ailments, NCDs= hygiene dental of hyper screening and diabetes tension, vision problems Educational Educational criteria for entry? and write read and write read or minimum of 8 years education - -

Recruitment (open merit, community recommen dations, others ) selected by leaders village Applicant be must own -have occupation earnto - not govern ment official living in the community Recommen- dations by community must Applicant be -minimum 18 of age years of -resident the same community

Country Thailand Brazil

381 Referral Referral system (linkage with health system) linkages with local health centers linkages with local health centers - - upgrade upgrade them as nurses Career Career pathway & deve lopment - - Perfor- mance incentives (if any) salaried USD 50-130 salaried USD 40-63 Volunteer/ Volunteer/ salaried (US$) / reimbursed - Monitoring super vision & evaluation doctors of health centers village CHWs External evaluation has been conducted Pathways & role & role Pathways to in relation MDG Promotive, preventive, Therapeutic, Rehabilitation Promotive, and Preventive therapeutic Promotive, and Preventive therapeutic - Key com petencies (MNCH/ TB/ HIV/ Nutrition / Malaria) MNCH, nutrition, Malaria, AIDS TB, (preventive part) MNCH, nutrition, Malaria, AIDS TB, (preventive part) Deployment Deployment (Public NGO, sector, private) public sector public sector Certifi- cation process (exam, course completion course completion course completion - - - - Training Training content, & duration (initial role & ongoing) Initial: 6-12 months Ongoing: frequent Role key MNCH= coordinate ANC, IP and PNC; FP servicesdeliver and immunization Nutrition= growth monitoring, nutritional coun promotion seling, TB, of BF Malaria, AIDS (PMTCT)= control prevention, PHC= and treatment sanitation etc. water, for and treatment common ailments, dental hygiene Initial: 7 days Ongoing: once per month k ey Role MNCH= coordi ANC, IP and PNC; nate FP servicesdeliver and immunization Nutrition= growth nutritio monitoring, pro nal counseling, motion of BF Malaria, AIDS (PMTCT)=TB, control prevention, PHC= and treatment sanitation etc. water, for and treatment common ailments, dental hygiene Educational Educational criteria for entry? literate of 10 years schooling - -

Recruitment (open merit, community recommen dations, others ) chosen by community must Applicant be - minimum 18 age of years the com -from where munity they will work -patients TB and with also HIV are encouraged to be a worker of involvement community in their selection must Applicant be -18 years or above willing -female and serve live to community

Country Haiti Ethiopia

Global Evidence of Community Health Workers Referral Referral system (linkage with health system) linkages with local health centers linkages with local health centers - - Career Career pathway & deve lopment they train others - - Perfor- mance incentives (if any) volunteer Salaried USD 50 still under consideration Volunteer/ Volunteer/ salaried (US$) / reimbursed - - Monitoring super vision & evaluation CHW supervisors still no formal evaluation has been conducted health workers health from su centers pervise them no formal supervision mechanism ENC: Essential Newborn Care ENC: Essential Newborn Care

Pathways & role & role Pathways to in relation MDG Promotive, preventive, Therapeutic, Rehabilitation Promotive, and Preventive therapeutic Promotive, and Preventive therapeutic - Key com petencies (MNCH/ TB/ HIV/ Nutrition / Malaria) MNCH, nutrition, Malaria, AIDS TB, (preventive part) MNCH, nutrition, Malaria, AIDS TB, (preventive part) Deployment Deployment (Public NGO, sector, private) public sector public sector TB: Tuberculosis TB: PMTCT: Prevention of Mother to child Transfer Transfer of Mother child to Prevention PMTCT: Certifi- cation process (exam, course completion course completion course completion -

- -

Training Training content, & duration (initial role & ongoing) Initial: 18 weeks Ongoing: need based Role key MNCH= coordinate ANC, IP and PNC; FP servicesdeliver and immunization Nutrition= growth monitoring, nutritional coun promotion seling, TB, of BF Malaria, AIDS (PMTCT)= control prevention, PHC= and treatment sanitation etc. water, for and treatment common ailments Initial: 10 days Ongoing: need based Role key MNCH= coordi ANC, IP and PNC; nate FP servicesdeliver and immunization Nutrition= growth nutritional monitoring, promo counseling, tion of BF Malaria, AIDS (PMTCT)=TB, control prevention, PHC= and treatment sanitation etc. water, for and treatment common ailments PNC: Postnatal Care Care PNC: Postnatal IntrapartumIP:

Educational Educational criteria for entry? and write read and write read - -

Recruitment (open merit, community recommen dations, others ) of involvement community in their selection must Applicant be years -18 above or live to -willing serve and in community ANC: Antenatal Care Care ANC: Antenatal Planning Family FP: involvement of involvement community in their selection Applicant bemust -18-35 years of age -preferably -perma female nent resident of community

Country Uganda Mozambique

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