CHWs: are national programmes in crisis?

Community health workers (CHWs) have become the distinguishingfeature of many primary health care schemes. CHW programmesexpanded during the 1970s and early 1980s as long-term evidencefor the effectiveness of small-scale programmes grew. However,there is a growing suggestion of a decline in support for CHWs.Criticisms have grown, evaluations of existing programmes havepointed to difficulties in implementation and a number of reviewshave highlighted weaknesses in key areas. Training of CHWs hasbeen suspended in some countries, and fewer than originallyplanned are being trained in others. In this paper it is arguedthat although the financial recession has affected support forCHW programmes, there are other reasons why they are now underpressure. On the whole they have been implemented as ‘vertical’programmes, against a background of unrealistic expectationsand minimal professional interest. Structural political andeconomic factors have been neglected. Lessons have not beendrawn from the experience of community workers in other sectorssuch as agriculture and community development. The paper analysesall these issues within a health policy perspective concludingthat, unless adjustments are made, CHW programmes will drifttowards demise, not because CHWs themselves cannot deliver,but because the support that makes them effective is, in general,absent.     

Community health workers in national programmes: the case of the family welfare educators of Botswana

Community health worker programmes have become a prominent feature of many primary health care schemes in developing countries. This paper, which is based on a larger collaborative study undertaken in 3 countries, focuses on the experiences with such workers in Botswana, and concludes that many of the key issues that were highlighted in the Botswana study are similar to those in other countries. These can be summarized under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulty of maintaining quality of care. The future success of these workers will depend on their being integrated more systematically into local services, with concomitant strengthening of management support and supervision.     

Health promotion in the occupational setting: what are the prospects in the Italian situation?

Over the past decades advances in sciences and medicine have improved living and health conditions and lengthened life expectancy. These benefits are associated with an increase in prevalence of chronic degenerative diseases. With their multi-factorial aetiology these diseases are influenced by life styles and personal habits and require prolonged medical care and high social costs. Now days health is no longer considered as the absence of disease but a state of mental, physical and social well-being. The World Health Organization has defined health promotion as "the process of enabling people to increase control over and to improve health". Since the 70s in the USA many health promotion programmes have been proposed, especially by large corporations, in order to ensure a more efficient, productive and motivated work-force, to reduce health insurance costs and to provide a better company image. Workplaces,--particularly when the working population is relatively stable--are excellent areas for health promotion programmes because workers can be monitored over a long period of time. The most successful programmes are aimed at modifying behaviour in risk patterns (smoking, alcohol abuse, eating disorders, etc.) through information, active participation, screening, follow-up, personalized programmes, changes in the working environment, physical exercise programmes. These health promotion programmes are extremely hard to develop for Italian workers. Most firms are small or very small and much still remains to be done to eliminate well-known occupational risk factors. The current flexibility of modern work patterns could constitute a further obstacle.     

The female community health volunteer programme in Nepal: Decision makers’ perceptions of volunteerism,payment and other incentives

The Female Community Health Volunteer (FCHV) Programme in Nepal has existed since the late 1980s and includes almost 50,000 volunteers. Although volunteer programmes are widely thought to be characterised by high attrition levels, the FCHV Programme loses fewer than 5% of its volunteers annually. The degree to which decision makers understand community health worker motivations and match these with appropriate incentives is likely to influence programme sustainability. The purpose of this study was to explore the views of stakeholders who have participated in the design and implementation of the Female Community Health Volunteer regarding Volunteer motivation and appropriate incentives, and to compare these views with the views and expectations of Volunteers. Semi-structured interviews were carried out in 2009 with 19 purposively selected non-Volunteer stakeholders, including policy makers and programme managers. Results were compared with data from previous studies of Female Community Health Volunteers and from interviews with four Volunteers and two Volunteer activists. Stakeholders saw Volunteers as motivated primarily by social respect, religious and moral duty. The freedom to deliver services at their leisure was seen as central to the volunteer concept. While stakeholders also saw the need for extrinsic incentives such as micro-credit, regular wages were regarded not only as financially unfeasible, but as a potential threat to the Volunteers’ social respect, and thereby to their motivation. These views were reflected in interviews with and previous studies of Female Community Health Volunteers, and appear to be influenced by a tradition of volunteering as moral behaviour, a lack of respect for paid government workers, and the Programme’s community embeddedness. Our study suggests that it may not be useful to promote a generic range of incentives, such as wages, to improve community health worker programme sustainability. Instead, programmes should ensure that the context-specific expectations of community health workers, programme managers, and policy makers are in alignment if low attrition and high performance are to be achieved.     

Community views on health sector reform and their participation in health priority setting: case of Lushoto and Muheza districts, Tanzania

BACKGROUND: Community participation (CP) is a key concept under 'primary health care' programmes and 'Health Sector Reform' (HSR) in many countries. However, international literature with current empirical evidence on CP in health priority setting and HSR in Tanzania is scanty. OBJECTIVES: To explore and describe community views on HSR and their participation in setting health priorities. METHODS: A multistage sampling of wards and villages was done, involving group discussions with members of households, Village Development Committees (VDCs) and Ward Development Committees (WDCs). RESULTS: Respondents at village and ward levels in both districts related HSR with a cost sharing system at public health facilities. Views on the advantages or disadvantages of HSR were mixed, most of the residents pointing out that user charges burden the poor, there is a shortage of drugs at peripheral health facilities, the performance of government health service staff and village health workers does not satisfy community needs, health insurance is promoted more than people actually benefit, VDC and WDC poorly function as compared to local community-participatory priority-setting structures. CONCLUSION: HSR may not meet the desired health needs unless more efforts are made to enhance the performance of the existing HSR structures and community knowledge and enhance trust and participation in the health sector programmes at all levels.     

Mawas Diri a tool to stimulate community participation

The term ‘community participation’ is popular developmentrhetoric yet it tends to remain a topic of discussion aroundconference tables rather than a reality in most communitiesof the developing world. Political will may be guaranteed butthe tools which can facilitate the process of translating communityparticipation into reality are scarce. To help fill this gapan Indonesian non-governmental organization, Yayasan IndonesiaSejahtera, developed a problem-solving tool called Mawas Diri.The tool is employed by representatives of the target groupand uses indicators directly related to their situation. Itis used by village health workers (VHWs) or others who havebeen trained in its use, to evaluate the healthiness of homesand the neighbourhood in general. With this tool, VHWs have succeeded in collecting reliable datawhich are used for village planning activities and monitoringthe progress of programmes. It has also proved to be an effectivemotivational tool for stimulating people to initiate a widevariety of activities aimed at creating a healthier environmentand life-style. More fundamentally, this problem-solving toolhas reversed the usual procedure of ‘outsiders’determining a community's problems and providing programmesfor their solution. With Mawas Diri the community members aremore aware of the nature and extent of their problems and canthen determine which of these they can solve using their ownresources, and which require government or other outside participation. Experiences with Mawas Diri in Indonesia have illustrated thatvillage communities can play a significant role in planning,implementing and monitoring programmes leading to healthierlives.     

Sickness Absence from Work and Influenza Immunization

The worth of influenza immunization for employees in U.K. industryhas been debated for more than a decade. In this study no evidencecould be found of a protective effect for sickness absence patterns.Other evidence is also cited that suggests routine influcnzalimmunization programmes for healthy adults of working age areno longer justilied. *Requests for reprints should be addressed to: Dr Robin Philipp, Department of Epidemiology and Community Medicine, University of Bristol, Bristol BS8 2PR.     

Health education services in developing countries: the case of Zimbabwe

Little research has been done on the organization of healthservices in developing countries. This study uses a checklistapproach to assess Zimbabwe's health service and combines itwith an historical analysis. The data include interviews withkey staff members of the Department of Community Medicine andobservations by one of the authors during work as a districtdoctor. Policy formulation, organization and management, andresources have developed to a medium level. However, supportof peripheral health workers has been weak. Services on theground, almost exclusively carried out by non-specialists, areunsatisfactory. Improvements in health status have mainly beendue to the success of service delivery programmes such as immunization.Diseases which require behaviour changes have not improved or,as in the case of AIDS, even worsened. Health education serviceshave evolved from a ‘village educator’ to a ‘diplomaeducator’ stage. In order to facilitate the use of moreeffective and participatory methods, a speedy upgrading of theservice to a ‘specialist stage’ is needed togetherwith a further training and re-orientation of health workersat district level.     

Epidemiology training: a necessity for primary health care.

In spite of planned development and expansion of health services, especially in rural areas in India, mortality due to preventable conditions has remained unacceptably high. Important reasons for failure of the health system to detect the problems early are centrally planned programmes based on inadequate data and time-bound numerical targets for achievement. This promotes a tendency for passive implementation which destroys initiative and incentive for conceptualisation of problems and strategies. For health programmes to be far more successful, the entire health team needs to be given training in epidemiology appropriate to the level of each category, so that programme planning based on epidemiologically determined local needs can be done at district level by the District Health Organisation. Participation of health workers and the community will then be more active and relevant to the needs of the community.     

Intersections of girl child marriage and family planning beliefs and use: qualitative findings from Ethiopia and India

Child marriage and subsequent early first birth is a considerable social, economic and health concern, and a pervasive practice in sub-Saharan Africa and South Asia. This study explores barriers and facilitators to family planning among women and girls, and their marital decision-makers subsequent to receipt of child marriage prevention programmes in Ethiopia and India. In-depth interviews with 128 women and girls who were married as minors or who cancelled or postponed marriage as minors and their marital decision-makers were analysed using content analysis. Respondents identified social norms, including child marriage and pressure to have children, and lack of information as barriers to family planning. Benefits included delayed first birth and increased birth spacing, improved maternal and child health and girls’ educational attainment. Respondents associated family planning use with delayed pregnancy and increased educational attainment, particularly in Ethiopia. Child marriage prevention programmes were identified as important sources of family planning information. Ethiopia’s school-based programme strengthened access to health workers and contraception more so than India’s community-based programme. Findings highlight young wives’ vulnerability with regard to reproductive control, and support the need for multi-sector approaches across communities, schools and community health workers to improve family planning among young wives.     

Community health workers and integrated primary health care teams in the 21st century

Community health workers are an integral part of many healthcare systems. Their roles vary and include both the socially oriented tasks of natural helpers and specific constrained tasks of health extenders. As natural helpers, community health workers play an important role in connecting public and primary care to the communities that they serve. As primary health care becomes more patient-centered and community-oriented, the natural helper roles that include trust, rapport, understanding, and the ability to communicate with the community take on an increased significance. Community health workers are effective and make the health care system more efficient. In some states, the community health worker has become a more formal member of the integrated primary health care team, and it is in this role that she or he provides structured linkages between the community, the patient, and the health care system. The effective community health workers are strongly embedded in the communities that they serve; they have clear supervision within the health care system; they have clearly defined roles in the health care system; and they are well trained and have a defined system of advancing their education and roles within the health care system.     

Childcare Practices among Construction Workers in Chira Chas,Jharkhand

This study aims at examining the childcare practices and issues experienced by the low-income construction workers in India. It is concerned with understanding varied aspects relating to problems that construction workers, as parents, face while bringing up their children in one of the small construction companies of eastern India, in the state of Jharkhand. Qualitative methods have been used in order to collect the data based upon phenomenological principles. Ethnography and photo-elicitation were used as a primary method of data collection. Apart from this, in-depth interviews were also conducted with the workers of the construction company. Discussion with the participants led to the emergence of four themes: children left alone; playing at risky site areas; poor health of children; and children working along with parents. The research findings indicate that infants are taken by their parents to their place of work whereas children between five and 10 years had to be left alone at home. It was also found that acute poverty was a major cause leading to the consumption of inadequate and low nutritional food, leading to poor health of the children. Based on the study findings, there is an imperative that societal forerunners and philanthropists continue to use research findings to understand the childcare practices amongst the low-income workers and draft strategies accordingly, to improve the situation.     

Urban poverty: delivering babies in the slum

Government of India statistics indicate that about 3 million of New Delhi's 11 million people live in slums, while another 3 million people, most fleeing rural poverty, are expected to migrate to the capital by 2000. ASHA Community Health and Development Society is a nongovernmental organization currently working in 23 of India's slums, serving a population of about 150,000 people. The group has pioneered the use of community-based networks in New Delhi to improve health in the poorest communities. While ASHA has a small, full-time staff, most of the daily health care work is conducted by slum volunteers. Ekta Vihar is a slum community of 1800 residents. Community members' primary source of health care are Vimla Rana and Sobha, two illiterate women who reside in the community and are part of a team of community health workers trained by ASHA. Rana and Sobha deliver almost all of the babies born annually in the slum and care for community members when they become ill.     

Adding value and equity to primary healthcare through partnership working to establish a viable community health workers’ programme in Namibia

Community health worker (CHW?) programmes have been criticized on two fronts: either as being inappropriate for effectively improving healthcare in impoverished societies, or as being fraught with relationship problems between partners. This paper uses an example from Namibia to suggest that both these criticisms can be overcome: the first by clarifying the objectives of a CHW programme, the second by careful planning. It is concluded that CHW programmes do have a legitimate and important role to play in the delivery of primary healthcare in developing countries. In particular, at a small incremental cost, they can reduce inequalities in access to and utilization of formal healthcare services by deprived communities.     

Designing financial-incentive programmes for return of medical service in underserved areas: seven management functions

In many countries worldwide, health worker shortages are one of the main constraints in achieving population health goals. Financial-incentive programmes for return of service, whereby participants receive payments in return for a commitment to practise for a period of time in a medically underserved area, can alleviate local and regional health worker shortages through a number of mechanisms. First, they can redirect the flow of those health workers who would have been educated without financial incentives from well-served to underserved areas. Second, they can add health workers to the pool of workers who would have been educated without financial incentives and place them in underserved areas. Third, financial-incentive programmes may improve the retention in underserved areas of those health workers who participate in a programme, but who would have worked in an underserved area without any financial incentives. Fourth, the programmes may increase the retention of all health workers in underserved areas by reducing the strength of some of the reasons why health workers leave such areas, including social isolation, lack of contact with colleagues, lack of support from medical specialists and heavy workload.     

So many, yet few: Human resources for health in India

ABSTRACT: BACKGROUND: In many developing countries, such as India, information on human resources in the health sector is incomplete and unreliable. This prevents effective workforce planning and management. This paper aims to address this deficit by producing a more complete picture of India's health workforce. METHODS: Both the Census of India and nationally representative household surveys collect data on selfreported occupations. A representative sample drawn from the 2001 census was used to estimate key workforce indicators. Nationally representative household survey data and official estimates were used to compare and supplement census results. RESULTS: India faces a substantial overall deficit of health workers; the density of doctors, nurses and midwifes is a quarter of the 2.3/1000 population World Health Organization benchmark. Importantly, a substantial portion of the doctors (37%), particularly in rural areas (62%) appears to be unqualified. The workforce is composed of at least as many doctors as nurses making for an inefficient skill-mix. Women comprise only one-third of the workforce. Most workers are located in urban areas and in the private sector. States with poorer health and service use outcomes have a lower health worker density. CONCLUSIONS: Among the important human resources challenges that India faces is increasing the presence of qualified health workers in underserved areas and a more efficient skill mix. An important first step is to ensure the availability of reliable and comprehensive workforce information through live workforce registers.     

Lay food and health worker involvement in community nutrition and dietetics in England: definitions from the field

Background  Community-based food initiatives have developed in recent years with the aim of engaging previously 'hard to reach' groups. Lay workers engaged in community nutrition activities are promoted as a cost-effective mechanism for reaching underserved groups. The primary objective of the study was to explore perceptions and definitions of lay helping within the context of National Health Service (NHS) community nutrition and dietetic services to identify existing terms and definitions and propose an overarching term.
Methods  Interpretive qualitative inquiry; semi-structured interviews with lay food and health worker (LFHW) and NHS professionals employed by community-based programmes, serving 'hard-to-reach' neighbourhoods, across England.
Results  In total, 29 professionals and 53 LFHWs were interviewed across 15 of the 18 projects identified. Across all the projects, there was a preference for the use of one of two terms, either Community Food Worker or Community Nutrition Assistant, in reference to lay workers. There was no consensus in terms of a unifying term or definition for this new role.
Conclusions  Current variation in the terms and definitions used for this role is problematic and is hindering development and effective utilization of lay helping within the broad remit of community food and health and dietetics. The umbrella term 'Lay Food and Health Worker' is proposed based upon definitions and interpretations from the field.     

Effective scale-up: avoiding the same old traps

Despite progress in developing more effective training methodologies, training initiatives for health workers continue to experience common pitfalls that have beset the overall success and cost-effectiveness of these programs for decades. These include lack of country-level coordination of health training, inequitable access to training, interrupted services, and failure to reinforce skills and knowledge training by addressing other performance factors. These pitfalls are now seen as aggravating the current crisis in human resources for health and impeding the effective scale-up of training and the potential impact of promising strategies such as task shifting to address health worker shortages. Drawing on IntraHealth International's lessons learned in designing reproductive health and HIV/AIDS training and performance improvement programmes, this commentary discusses promising practices for strengthening human resources for health through more efficient and effective training and learning programmes that avoid the same old traps. These promising practices include the following:     

Growth charts: help or hindrance?

The use of growth charts is being promoted world-wide, particularlyby UNICEF, as one of the essential ingredients of any primaryhealth care programme. Though they are being adopted in manycountries, their effectiveness has been evaluated in very few. In this analysis of the effectiveness of the use of growth chartsin Papua New Guinea it is hypothesized that growth charts areused to fulfil four purposes: (a) to assist health workers todiagnose children who are suffering from, or are in danger ofsuffering from, malnutrition; (b) to select those children thatare seriously malnourished and may need referral; (c) to evaluatethe impact of nutrition programmes; and (d) to assist healthworkers to educate mothers about child growth and nutrition.A review of research in Papua New Guinea reveals that growthcharts, as they are being used at present, do not fulfil anyof these purposes. As such, it is questioned whether, consideringthe resources that are necessary to carry Out growth monitoringwith growth charts, it is sensible to continue promoting theiruse.     

Indian approaches to retaining skilled health workers in rural areas

Problem

The lack of skilled service providers in rural areas of India has emerged as the most important constraint in achieving universal health care. India has about 1.4 million medical practitioners, 74% of whom live in urban areas where they serve only 28% of the population, while the rural population remains largely underserved.

Approach

The National Rural Health Mission, launched by the Government of India in 2005, promoted various state and national initiatives to address this issue. Under India’s federal constitution, the states are responsible for implementing the health system with financial support from the national government.

Local setting

The availability of doctors and nurses is limited by a lack of training colleges in states with the greatest need as well as the reluctance of professionals from urban areas to work in rural areas. Before 2005, the most common strategy was compulsory rural service bonds and mandatory rural service for preferential admission into post-graduate programmes.

Relevant changes

Initiatives under the National Rural Health Mission include an increase in sanctioned posts for public health facilities, incentives, workforce management policies, locality-specific recruitment and the creation of a new service cadre specifically for public sector employment. As a result, the National Rural Health Mission has added more than 82 343 skilled health workers to the public health workforce.

Lessons learnt

The problem of uneven distribution of skilled health workers can be solved. Educational strategies and community health worker programmes have shown promising results. Most of these strategies are too recent for outcome evaluation, although this would help optimize and develop an ideal mix of strategies for different contexts.