Case Studies of Large-Scale Community Health Worker Programs: Examples from Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe January 2017 Prepared by: Henry Perry Rose Zulliger Kerry Scott Dena Javadi Jessica Gergen Katharine Shelley Lauren Crigler Iain Aitken Said Habib Arwal Novia Afdhila Yekoyesew Worku Jon Rohde Zayna Chowdhury Rachel Strodel Table of Contents Introduction ............................................................................................................................... 1 The Community-Based Health Care System of Afghanistan ...................................................................... 2 Summary ...................................................................................................................................................... 2 What is the historical context of Afghanistan’s Community Health Worker Program? ............................ 3 Key health needs ......................................................................................................................................... 3 Health system structure .............................................................................................................................. 4 Scope of work of the CHWs ......................................................................................................................... 4 Community roles .......................................................................................................................................... 5 CHW selection process and criteria ............................................................................................................ 5 Training of CHWs .......................................................................................................................................... 5 Support and supervision ............................................................................................................................. 6 Linkages with the formal health system ..................................................................................................... 6 Compensation and motivation .................................................................................................................... 6 Monitoring and data use ............................................................................................................................. 7 Demonstrated impact of the CBHC Program ............................................................................................. 7 Financing of CBHC and its development .................................................................................................... 7 Program scale-up ......................................................................................................................................... 8 Impact and continuing challenges .............................................................................................................. 8 The BRAC Shasthya Shebika Community Health Worker in Bangladesh .................................................. 9 Summary ...................................................................................................................................................... 9 What is the historical context of BRAC’s Shasthya Shebika Program? ................................................. 10 What are Bangladesh’s health needs?.................................................................................................... 10 What is the existing health infrastructure? ............................................................................................. 10 What type of program has been implemented? ..................................................................................... 11 What about the community’s role? .......................................................................................................... 12 How does BRAC select, train, and retain Shasthya Shebikas? .............................................................. 12 How does BRAC supervise its Shasthya Shebikas? ............................................................................... 12 How is the program financed? ................................................................................................................. 12 What are the program’s demonstrated impact and continuing challenges? ........................................ 13 References ................................................................................................................................................ 13 The Government Family Welfare Assistant and Health Assistant programs in Bangladesh....................14 Summary ................................................................................................................................................... 14 What is the historical context of Bangladesh’s government CHW programs? ...................................... 15 What are Bangladesh’s health needs?.................................................................................................... 15 What is the existing health infrastructure? ............................................................................................. 15 What type of program has been implemented? ..................................................................................... 15 What about the community’s role? .......................................................................................................... 16 Case Studies of Large-Scale Community Health Worker Programs: Examples from Afghanistan, iii Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe How does the government select, train, and retain its CHWs? .............................................................. 16 How does the government supervise its CHWs? .................................................................................... 16 How is the program financed? ................................................................................................................. 16 What are the program’s demonstrated impact and continuing challenges? ........................................ 17 References ................................................................................................................................................ 17 The Community Health Agent Program of Brazil ......................................................................................18 Summary ................................................................................................................................................... 18 What is the historical context of Brazil’s Community Health Worker Program? ................................... 19 What are Brazil’s health needs? .............................................................................................................. 20 What is the existing health infrastructure? ............................................................................................. 20 What type of program has been implemented? ..................................................................................... 21 What about the community’s role? .......................................................................................................... 21 How does Brazil select, train, and retain Community Health Agents? .................................................. 22 How does Brazil supervise its Community Health Agents? .................................................................... 22 How is the Programa Saúde da Família financed? ................................................................................ 23 What are the program’s demonstrated impact and continuing challenges? ........................................ 23 References ................................................................................................................................................ 24 Ethiopia’s Health Extension Program ......................................................................................................26 Summary ................................................................................................................................................... 26 What is the historical context of Ethiopia’s Community Health Worker Program? ............................... 27 What are Ethiopia’s health needs? .......................................................................................................... 27 What is the existing health infrastructure? ............................................................................................. 28 What type of program has been implemented? ..................................................................................... 28 What about the community’s role? .......................................................................................................... 29 How does Ethiopia select, train, and retain Health Extension Workers and Health Development Army Volunteers? ...................................................................................................................................... 29 How does Ethiopia supervise its Health Extension Workers? ................................................................ 30 How is the Health Extension Program financed? ...................................................................................