Skip to 0 minutes and 8 seconds Hi. I’m Dr Tanya Caulfield. In the next few minutes, we’re going to look at three community-based health programs as examples of how community health workers have been recruited to improve community health outcomes. The first program is the Health Extension Worker program in Ethiopia. Prior to the 1990s, Ethiopia’s health system was characterised by weak infrastructure, insufficient health resourcing and financing, and minimal community participation. The Health Extension Worker program aimed to improve rural primary health services through a community-based approach that focused on prevention, healthy living, and basic curative care. The program consists of 17 health interventions
Skip to 0 minutes and 51 seconds from four principal components: family health, disease prevention and control, personal and environmental hygiene, and health education. More than 34 000 Health Extension Workers have been recruited nationwide based on national criteria. Workers need to be a resident in the village they work, speak the local language, be a tenth grade graduate, and be willing to return to and serve that village. Most workers selected are adult women. The workers receive one year pre-training service provided through a train the trainer approach. The responsibilities of the workers include health promotion, disease prevention, and treatment of uncomplicated and non-severe illnesses such as malaria, pneumonia, diarrhoea, and malnutrition. After completing the training, Health Extension Workers are employed by local governments and receive a salary and benefits.
Skip to 1 minute and 44 seconds Since the implementation of the program in 2004, evaluations have shown that the program has contributed to improving community access to health services in remote villages. Two thirds of the rural population have greater access to toilet facilities and health service coverage in rural communities has increased. The second example of a community health worker program is the Accredited Social Health Activist or ASHA program in India. The program was introduced in 2005. Women are recruited from villages and are based in their communities to create awareness on health and its social determinants. The women receive 23 days of training with a further 12 days of refresher training annually.
Skip to 2 minutes and 28 seconds Although volunteers, ASHAs receive performance- and service-based compensation for tasks such as facilitating institutional delivery through referrals and escorting women to facilities, immunisation, and construction of toilets in villages. The ASHA program guidelines, developed by the Ministry of Health and Family Welfare, envisage three roles for ASHAs. First, ASHAs are to play a central role in achieving national health and population policy goals through the impact of their work in villages. Also, ASHAs should function as a link worker between rural and marginalised populations and health services. Thirdly, ASHAs are to serve as health activists to generate awareness on health and its social determinants. They also mobilise the community towards local health planning and increased utilisation and accountability of health services.
Skip to 3 minutes and 19 seconds Program evaluations have shown mixed results. The work of ASHAs has contributed to increasing institutional deliveries. However, their influence on increasing immunisation levels has been limited. Also, the care ASHAs provide to communities has been mixed due to factors such as the lack of drugs, skills, and support. The third example is the Lady Health Worker Programme in Pakistan. The program was established in 1994 and aimed to reach rural and urban slums, covering primary health care services such as health promotion, preventative and curative services, to improve patient provider interactions, and to facilitate timely access to care.
Skip to 4 minutes and 0 seconds Women were recruited and deployed throughout all five provinces and were attached to the local health facility in their area, but primarily undertook community-based work from their homes. The Lady Health Workers were selected based on national criteria, which included having a minimum of eight years’ education. Given the limited number of women with this education level, this requirement has been difficult to fulfil in some areas. Women must also be aged between 18 and 50 and be recommended by the community they serve. Preference is also given to married women with children and to those willing to work from their homes. Once recruited, the women receive three months’ classroom training and then return to their communities to undertake a one-year on-the-job training.
Skip to 4 minutes and 44 seconds Annually, they receive 15 days refresher training. However, this varies across the provinces. The role of the Lady Health Workers focuses on newborn care, participation in large-scale health campaigns, community management of TB, and providing health education to communities on HIV and AIDS. The health workers are responsible for approximately 27 households and conduct consultations from their home. They receive a salary, which is often the only source of family income, and should not work in other paid activities, although some health workers do. Evaluations have highlighted that the program has contributed to increasing the percentage of fully-vaccinated children. The populations served have better immunisation coverage than those not served. And there were increased levels of exclusive breastfeeding in program areas.
Skip to 5 minutes and 33 seconds The Health Extension Worker program in Ethiopia has led to substantial increase in health service coverage. The increase has been influenced by the ownership and leadership by the government and local communities. This has meant that communities have been involved in all stages of the program. For example, communities have been in charge of providing material and labour support for health post construction and maintenance and have facilitated the duties of the Health Extension Workers. The workers also have a presence on village councils. The district administration secures budget for the program, which includes the workers’ salaries, and facilitates the planning and monitoring of the work performed by the workers.
Skip to 6 minutes and 14 seconds Health Extension Workers have been provided with ongoing refresher training to strengthen their capacity due to gaps identified in their knowledge, skills, and confidence. Also, supervisors have been trained and deployed to support the field work of Health Extension Workers. There have been several challenges identified which have limited program effectiveness. These include the lack of provision of health kits and an increasing number of tasks allocated to Health Extension Workers, which has compromised their ability to complete their work. There has also been a shortage of drugs, medical supplies, and equipment. And there is no career trajectory for Health Extension Workers, resulting in higher levels of staff turnover.
Skip to 6 minutes and 55 seconds The ASHA program in India has been effective in increasing institutional deliveries, one of the main objectives of the program. However, there have been several challenges. For example, the training period is very short and the manuals used have been knowledge-based rather than skills-based and considered irrelevant to an ASHA’s day-to-day activities. Their work has also been limited by supply side factors, including the lack of drugs and support. There have been concerns about ASHAs’ lack of clarity on the role and tasks in communities. And ASHAs are poorly remunerated and incentivised for the work they do. This results in ASHAs only focusing on tasks they receive remuneration for.
Skip to 7 minutes and 37 seconds Despite national guidelines on ASHA supervision, support structures are weak and are unable to provide the required level of supervision and feedback to ASHAs. Finally, restrictive gender norms limit the capacity of ASHAs to engage with communities. Traditionally, women do not participate in community decision making processes, thus limiting their ability to negotiate with communities in prioritising maternal health in community development agendas. Lastly, evaluations of the Lady Health Worker program in Pakistan have shown significant improvements in health indicators, particularly those related to immunisation coverage. Evaluation suggests that effectiveness has been the result of regular monthly supervision meetings between Lady Health Workers and their supervisors. The supervision is highly organised and tiered with program district coordinators monitoring the Lady Health Supervisors.
Skip to 8 minutes and 32 seconds Lady Health Workers also receive regular refresher training, which has increased their performance and ability to take on additional tasks. Importantly, they are highly accepted by communities. This is due to the community role on Lady Health Worker and supervisor selection committees and community involvement in program decision making, planning, and monitoring and evaluation. Lady Health Workers also receive a salary, which is an important incentive for their work. However, there have been some ongoing challenges for the program. The main challenge is underfunding, which has resulted in reduced spending in areas such as providing regular supplies and irregular salary payments to Lady Health Workers.
Skip to 9 minutes and 14 seconds The inadequate supply of drugs, replacement supplies for Lady Health Worker kits, and contraceptives have been ongoing challenges for the program. In addition, Lady Health Workers are reluctant to participate in health campaigns due to their vulnerability to violence in areas where the Taliban is present. And there are gender-related challenges in terms of the workers’ inability to communicate effectively with men on topics such as family planning.
Challenges and opportunities of implementing community health worker programs
This video demonstrates the importance of country context in community health programs, and how programs adapt to contextual differences.
Select one of the programs discussed in the video:
- Health extension workers in Ethiopia;
- Accredited Social Health Activists (ASHAs) in India; or
- Lady health workers in Pakistan,
Identify at least one way in which the program has adapted to challenges in the local context. Share your thoughts and ideas with others by posting your response in the comments section below.
You may choose to look up more information on the programs in the ‘see also’ section below to help formulate your response.
© Nossal Institute for Global Health at the University of Melbourne