Health for the People: National Community Health Worker Programs from Afghanistan to Zimbabwe Henry B. Perry, Editor www.mcsprogram.org Cover photo: A Village Health Team member in Uganda takes a blood sample from a child to perform a rapid diagnostic test for malaria during a home visit. Photo credit: Henry Bugembe The Maternal and Child Survival Program (MCSP) is a global, $560 million, 5-year cooperative agreement funded by the United States Agency for International Development (USAID) to introduce and support scale- up of high-impact health interventions among USAID’s 25 maternal and child health priority countries, as well as other countries. MCSP is focused on ensuring that all women, newborns and children most in need have equitable access to quality health care services to save lives. MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health systems strengthening, water/sanitation/hygiene, malaria, prevention of mother-to-child transmission of HIV, and pediatric HIV care and treatment. This publication is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA- A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government. April 2020 Table of Contents Foreword ......................................................................................................................................... v Preface .......................................................................................................................................... vii Authors ........................................................................................................................................... ix Introduction and Historical Perspectives ...................................................................................... 1 The Community-Based Health Care System of Afghanistan .................................................... 23 The Government Family Welfare Assistants, Health Assistants, and Community Health Care .............................................................................................................. 43 Providers in Bangladesh ............................................................................................................. 43 The BRAC Shasthya Shebika and Shasthya Kormi Community Health Workers in Bangladesh ............................................................................... 51 The Community Health Agent Program of Brazil ....................................................................... 61 Ethiopia’s Health Extension Program ........................................................................................ 75 Ghana’s Community Health Officers and Community Health Volunteers ............................... 87 The Guatemala Community Health Worker Program ............................................................. 103 India’s Auxiliary Nurse-Midwife, Anganwadi Worker, and Accredited Social Health Activist Programs ............................................................................ 113 India’s National Village Health Guides Scheme ...................................................................... 135 Indonesia’s Community Health Workers (Kaders) .................................................................. 149 Iran’s Community Health Worker Program ............................................................................. 165 Kenya’s Community Health Volunteer Program ...................................................................... 177 Liberia’s National Community Health Worker Programs ........................................................ 189 Madagascar’s Community Health Worker Programs .............................................................. 207 Malawi’s Community Health Worker Program ........................................................................ 227 Mozambique’s Agentes Polivalentes Elementares ................................................................ 247 Myanmar’s Community-Based Health Workers ..................................................................... 257 Nepal’s Community Health Worker System ........................................................................... 273 Niger’s Program of Agents de Santé Communautaire and Relais Volunteers ..................... 285 Nigeria’s Paths to Primary Health Care ................................................................................... 295 Pakistan’s Lady Health Worker Program ................................................................................. 315 Rwanda’s Community Health Worker Program ...................................................................... 329 Sierra Leone’s Community Health Workers ............................................................................ 345 Ward-Based Primary Health Care Outreach Teams in South Africa ...................................... 363 Tanzania’s Community-Based Health Program ...................................................................... 381 Village Health Volunteers in Thailand ...................................................................................... 395 Uganda’s Village Health Teams Program ................................................................................ 405 Health for the People: National Community Health Worker Programs from Afghanistan to Zimbabwe iii Zambia’s Community Health Assistant Program ................................................................... 415 Zimbabwe’s Village Health Worker Program .......................................................................... 429 Observations, Trends, and the Way Forward ......................................................................... 443 iv Health for the People: National Community Health Worker Programs from Afghanistan to Zimbabwe Foreword For many decades governments and their partners—at national and global levels—have been trying to extend health care services and interventions to better reach the whole population, particularly those segments of the population poorly served by existing health services. Clearly, prevalent health issues and available resources vary across settings but there have been common challenges: • How to efficiently make key life-saving interventions available to the whole population (e.g., immunizations, insecticide-treated mosquito nets, micronutrient supplementation)? • How to overcome the challenges of distance and geographic barriers to extend services to segments of the population that cannot easily reach more well-equipped and staffed health centers? • How to bridge cultural gaps that may exist between educated health professionals—many originally hailing from urban settings—and local people? In many settings over the years it has been evident that our current systems and approaches have not been fully up to the challenge and that there is a need for some kind of community-level provider to bridge that gap at community level. Through the 1960s and 1970s, the largest-scale program efforts in global health focused mostly on specific illnesses—malaria, smallpox, TB—and it was common to employ locally-recruited outreach workers who were quickly trained and deployed for program-specific community-level work. There were few large-scale examples of integrated community health worker programs (China’s barefoot doctor program, described in the introductory chapter, being a notable exception). In various regions of the world there were, however, small-scale, NGO-run programs (e.g., Jamkhed and SEARCH/ Gadchiroli in India) that were clearly having impact and exemplified what seemed to be key principles that could orient larger-scale efforts. A vital insight was that community-level workers in effective programs needed to be: (1) accepted and respected by the community, and (2) well-connected to and supported by the primary health care system (including being provided with a reliable supply of needed commodities). The 1978 Declaration of Alma-Ata marked a global-level recognition of the potential for Community Health Workers (CHW) to serve as a foundation for primary health care (PHC). Inspired by this vision, beginning in the early 1980s, many countries established national CHW programs. But over the following years it was increasingly evident that important lessons from earlier program experiences were not consistently being acknowledged and applied. Instead many saw CHWs as a panacea, a way of delivering PHC on the cheap. As a result, many CHW programs were inadequately supported and experienced high attrition. By the late 1980s, the pendulum had swung away from such programs. Two seminal books cast a sharp critical eye, drawing lessons from large-scale CHW programs implemented over the preceding decade: Community Health Workers in National Programmes edited by Gill Walt (1990) and The Community Health Worker: Effective Programmes for Developing Countries, edited by Stephen Frankel (1992). Both drew attention to critical systems support needed if CHW programs were to be effective as a part of robust PHC services, operating at scale. In the decades since then, there have been further cycles of waxing and waning of enthusiasm for CHW programs. Again, today, it is recognized that CHWs have potential to play an important role in PHC