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Community Health Worker Discussion

Question 1: (Pakistan)

Rather than training more CHWs, would it not be more cost effective to recruit, retrain or reorient those who already exist as health workers in the community like traditional birth attendants (TBAs), traditional healers (THs), shopkeepers, etc.?

Great question. I think it all depends on local context and situation. At BRAC in Bangladesh there are a few CHWs who also work as TBAs (both traditional as well as family) and this hasn't created much of a problem for them to function as CHWs as well. In some societies, TBAs are considered 'low status' and this may affect their ability to function as a successful CHW. The shopkeepers may not have much time available to devote for the job of a CHW. Similarly, a TH may not wish to leave her/his traditional practice (some of which may be 'harmful').  To cut the response short, again, I think it largely depends on the context.  But in any case the critical issue is how these CHWs (including TBA/TH/shopkeeper- turned CHW) are linked to an existing and functional health system.

As we had indicated earlier, the concept of ‘Community Health Worker’ varies from country to country and the use these cadres are put to. If we are to follow the statement from a WHO Study Group that suggest that ‘Community Health Worker’s should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers’… then your observation about cost effectiveness in using the existing types comes into focus. However, most countries especially in sub-Saharan Africa are training new midlevel health workers and placing them in the Communities as ‘Community Health Workers’. This is a shift from the ‘traditional’ definition of a CHW. In Ghana, that is what we have been trying to do, since our experience with the types you described who are also not part of the formal system has not been sustainable and as such, not cost effective in delivering primary health care (PHC).  

Question 2: (Pakistan)

Over the last 20 years working in Pakistan and East Africa, I have learned that the CHWs program certainly fails if it is not consistently backed by formal health system. However, the major difficulty of formally trained health providers (particularly doctors) not accepting CHWs continues to be a challenge. I am aware of numerous examples when CHWs brought in a sick child who was given some simple treatment, and were insulted by doctors for not doing a good job.  As a result, the CHWs felt humiliation and stopped referring anyone to that health facility. Have you also faced similar problem and how have you been able to resolve this conflict?

Another great question. This problem is raised quite often and we do face this from time to time. This is particularly true when the services provided by doctors (or paraprofessionals) are less than the demand. In a recent program, we are trying to address the issue of maternal newborn and child health through an intensive community-based intervention. For reducing mortality (of mother and newborn) some cases require specialized facilities such as emergency obstetric care (EmOC). We are trying to link the community-based activities (with CHWs as the nucleus) with facilities where available. There are instances where the cases referred by CHWs are given less importance. To address this, we are trying to motivate the EmOC staff to be more sympathetic to the referred cases. Also, as a pilot we are posting one of our colleagues at these facilities to liaise and do the motivation work. We are mindful of the risk attached that the facility staff may treat the patients referred by us more carefully than others just because of our presence there.

For the success of a CHW program such as above, the support and sympathy of doctors is very important. In this the role of the organizing NGO is very important. They must prepare their doctors to work with CHWs as members of the system. There are instances, where the doctors tend to use CHWs as 'bureaucratic servants' to deliver government services. In such a situation the CHW program is destined to fail.

Indeed, these experiences abound, especially in our settings where the ‘traditional’ community health workers are seen as not ‘professionals’ and not part of the health systems. Hence the non-acceptance of their contributions to service provision by the professional cadres. Clearly, these are some of the difficulties that shaping the decisions of most countries, like Ghana, to deploy midlevel cadres of the health system to stay in communities as community health officers. However, there has been a massive drive in Ghana to create awareness that the ‘Community level’ is an integral part of the health system and the types of cadres that work there especially to the professional groups. It is hoped that this will be able to influence the ‘attitudes’ the various levels of health workers to each other.    

Question 3: (USA)

What type of health system is necessary to ensure the delivery of community-based services? What is in place in Africa and what needs to be developed or improved?

Most of the CHW programs emerged out of frustrations with the top-down healthcare programs in existence prior to Alma ata of 1978. The Health-for-All movement created new hopes for implementation of its principles of equity, intersectoral collaboration, community involvement and the use of appropriate technology. But due to the global economic recession of the 1980s accompanied by 'reforms' in many countries particularly in Sub-Saharan Africa resulted in collapse or near collapse of health systems in many countries. Some countries have been able to come out of it quite well I think. But the real expert to comment on this is Frank and I leave it to him to jump in!

It is increasingly obvious that the delivery of community-based services should be in the context of a strengthened Health System of countries that includes the functioning of National and Sub-national levels. In Ghana, even though we have focused on strengthening district health systems as a way of ensuring the delivery of community-based services, we have tried to strengthen the Regional and National Levels to provide that crucial support systems. The district health systems concept in Ghana is depicted below with the Community-based Health Planning and Services (CHPS)

Health System Levels in Ghana 

The health systems in most African countries are weak and fragmented and as not well-delineated as above and the challenge for these countries in Africa is to reorganize how services are delivered recognizing the importance of the community level. But we should also be conscious of the fact that community-based services do not provide a panacea for the ills of the health systems as a whole.

Question 4: (USA)

Can the concept of Community Health Workers be inclusive of training community representatives to serve as mid-level cadres in the Allied Health Services areas of Physical Therapy associates, Speech and Hearing associates and Hospice services associates? Has the above option been explored for addressing human resources capacity building?

If I understand the question correctly, the Physical Therapy associates, Speech and Hearing associates and Hospice services associates may be considered as 'paraprofessionals' who are proxy's for doctors or similarly trained professionals. In situations where doctors and similarly trained professionals are difficult to train (for lack of resources, proper institutions, and availability of individuals to be trained), short and crash programs have been undertaken to meet the shortage as a short to medium-term option. For example, para-obstetricians have been trained in Mozambique and paramedics have been trained in Bangladesh to do tubectomy.  Such paraprofessionals are to be found in many countries, who have been trained both at the government as well as private (and NGO) levels. Such paraprofessionals are different from CHWs as they are likely to be more educated and take up jobs in areas not necessarily their own villages.

This is a tough one! Our experience has been to avoid creating sub-specialties at this level and rather move towards a multipurpose health worker equipped with enough knowledge to deal with primary symptoms within the context of PHC! We have had some proposals for community mental officer and community dental officers etc. However, our efforts have been to get generalist ‘community health officers’ to cover the basic needs of the populations and refer when necessary.

Question 5: (USA)

Can you elaborate on the use of incentives for community health workers?
Should they be paid- or are tee-shirts and other material incentives enough?

There are examples where CHWs are paid an honorarium (as in Pakistan) by the government or NGOs and others where CHWs are not paid employees. In the latter, however, the success (in terms of their continuing) depends on how the programs have been able to build incentives, particularly financial.  Since most of the CHWs are poor, they do need incentives for continuing on their work as volunteerism has a limit. The BRAC program in Bangladesh has built-in financial incentives.  These include:

1. As they are part of the micro finance program, they are eligible to receive loans for health as well as other income generating activities.
2. They are allowed to sell essential drugs and other health products such as sanitary napkins, iodized salt, soap, safe delivery kits, seeds, etc. with a mark-up.
3. They are given an honorarium for completing treatment of TB patients with DOTS.

The issue of incentives for community health workers has been frequently discussed and again depends on the specific country and program context. In the ‘traditional’ definition of CHW, the assumption is that they are ‘volunteers’ and needed to be provided with some level of incentives to keep them interested. And a variety of methods have been adopted such as in-kind gifts and ‘honorariums’ etc by the programs and projects they work for. Communities are also prevailed upon to provide incentives such as farms or ‘special Sunday church collections’ to the CHWs. Clearly, our experience is that, if these are not formalized, then it is not sustained. Our experience with the Community-based Health Planning and Services (CHPS) is that the Community Health Officers are part of the formal Health System and are paid. Efforts are also made to provide them with additional incentives to stay within the Communities. The ‘Volunteers’ who assist them are the responsibility of the Community Health Committees, which provides them with a variety of incentive schemes like ‘farms’ and regular community work on the volunteers’ farms. These ‘volunteers’ are also rewarded by the programs with Tee-shirts, bicycles and occasional cash incentives. It seems to be working so far….

Question 6: (Philippines)

Given the characteristics and functions of a Community Health Worker, what then are the possible roles that they could take on in the healthcare delivery system (health educator, social mobilizer, etc.)? By coming up with a typology of a community health worker, do you think such types of health workers would have a role to play in middle-income countries whose disease burden is mainly that of non-communicable diseases?

CHWs have been found to work very well in preventive, promotive and curative care of simple but common illnesses in low income societies. They can also help their colleagues in the formal health system to do their work better through social mobilization. For example, the CHWs in some Bangladesh programs help government health workers by bringing in children for immunizations and ante-natal care services. Being part of the community they are also ideally suited to monitor the activities of the government health system staff. In this, however, it is important that they are adequately empowered to do so. The question of using CHWs for non-communicable diseases is interesting.  My own knowledge of such experiences is quite limited. However, let’s take the example of US where non-communicable diseases form the major burden, with cardiovascular disease, cancer, diabetes and injuries are the major causes of death. If we look at this disease burden with a public health lens, then the causes are tobacco, poor diet, lack of exercise, alcohol and other addictions and gun injuries. If this is the case, then CHWs can certainly play a role there as well.

From the earlier discussions, Mushtaque and I outlined the functions of the typical community health worker in our countries. The basic function I believe we identified was the provision of information to the households about their health and facilitate the individuals in the households and communities to make the ‘correct’ decisions about their health within the premise that individuals and households are the primary producers of health and the decisions they make depends on the information available to them. So the primary responsibility of the Community Health Worker in the Ghanaian CHPS initiative is Health education, Community Mobilizer for Health action and delivery of basic primary health service.

I believe, in using the same principles, that this type of community health worker can be value in middle-income countries in providing health education from house to house on non-communicable diseases and also serving as focal points for community mobilize for health action.

Question 7: (Ethiopia)

Is it possible to have a generic model of community-based health service delivery that can be applicable to most countries?

A generic model may be difficult to identify but efforts may be made to ensure certain principles (Alma Ata): equity, intersectoral collaboration, community participation and use of appropriate technologies.

Yes. It is possible to have a generic model of community-based health service delivery that can be applicable to most countries – once the basic functions are agreed on and their positions within the formal health systems are clarified. Community Health Workers are within a defined District Health System and for most sub-Saharan African District Health Systems, there are three service delivery levels – the Community Level, where community health workers and volunteers perform, - the sub-district level, where the Health Centres and most mid-level health workers are stationed (to provide backstopping for the CHW’s) and – the District Level, where the District Hospital and District Health Managers are and serves as the referral centre for the sub-district structures.

Question 8: (Ethiopia)

How could the community health workers be linked to the conventional health system?

Ideally the CHWs should be the lowest level link for the health system.  They should be the link with the community for which the system works. The health system (HS) needs to understand the contributions and acknowledge what CHWs can do to making the HS’s work effective. The CHWs should also be seen (and ensured) as the monitor of HS activities on behalf of the community (‘the community voice’). On the other hand, the HS should also ensure the training of CHWs, both basic and continuing and provide supportive supervision for their work.

We have already discussed the various scenarios of linkage of CHW’s to the formal health systems and articulated that in the experience of Ghana, the CHPS Initiative ensures that the CHW’s are part of the formal health system (designated as Community Health Officers, CHO) and are paid by the formal system. In other experiences, the CHW’s are outside the formal system and had issues about supervision and sustainability

Question 9: (Ethiopia)

What is the similarity and/or difference of community health workers from volunteers?

In most cases, they are synonymous, and have been used interchangeably.

In the context that we operate now in Ghana, the Community Health Officer is a paid staff deployed to live and deliver services in a defined location consisting of communities providing house to house services or close-to-client services. They are assisted by volunteers, who are not ‘trained’ health workers and not part of the formal health system, but are selected by each Community Health Committees (CHC’s). It is the responsibility of the CHC’s to provide the volunteers with incentives etc. and replace them when necessary. The CHO’s assign tasks to the volunteers that might include arranging immunization sites, distribution of condoms, and distribution of packages of home-based treatments.

Question 10: (Ghana)

Who should motivate (i.e. financial) the community health worker (CHW) – the community or the sector ministry and why? 

There are compelling reasons on both sides. Again, I think it will depend on the context in which the CHW program is launched. In Pakistan, for example, the government provides financial support to the Lady Health Workers program. On the other hand, the BRAC program in Bangladesh is entirely a voluntary program with no salary provided by the sponsoring organization.

The issue of incentives for community health workers has been frequently discussed and again depends on the specific country and program context. In the ‘traditional’ definition of CHW, the assumption is that they are ‘volunteers’ and needed to be provided with some level of incentives to keep them interested. And a variety of methods have been adopted such as in-kind gifts and ‘honorariums’ etc by the programs and projects they work for. Communities are also prevailed upon to provide incentives such as farms or ‘special Sunday church collections’ to the CHWs. Clearly, our experience is that, if these are not formalized, then it is not sustained. Our experience with the Community-based Health Planning and Services (CHPS) is that the Community Health Officers are part of the formal Health System and are paid. Efforts are also made to provide them with additional incentives to stay within the Communities. The ‘Volunteers’ who assist them are the responsibility of the Community Health Committees, which provides them with a variety of incentive schemes like ‘farms’ and regular community work on the volunteers’ farms. These ‘volunteers’ are also rewarded by the programs with Tee-shirts, bicycles and occasional cash incentives. It seems to be working so far….

Question 11: (Ghana)

Community based health financing (CBHF) schemes are springing up in developing countries: how can resources from such schemes be harnessed for the activities of the CHW?

Such schemes can beneficially be used to support CHW activities. For example, microinsurance schemes, now being experimented in many countries, can generate some financial benefit for CHWs. While calculating premiums for such schemes, the financial incentive may be included in the package, and CHWs can be the first level of service provision.

Community based health financing (CBHF) schemes in developing countries are means of bridging the financial barriers to access health care in the communities and community health workers – whether ‘traditional’ of part of the formal health system – have a key role to play in ensuring that services are available to members of the schemes

Question 12: (Ghana)

What are some of the best (or emerging) practices of community participation that enhances the activities of the CHW?

Facilitation community participation in health is a major rationale for undertaking CHW activities. The WHO study group which idealized it had suggested ‘ CHWs should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of the organization’. Some programs have been able to ensure these principles; others have done it with some compromises.

Experiences abound under the Ghana CHPS Initiative where community mobilization and participation are key to the success of each zone. There are experiences like ‘Community Decision Systems’ in some of the CHPS zones in Ghana where members of Communities in a zone come together either on monthly or quarterly basis to discuss health and developmental issues (facilitated by the CHO in charge of the zone), develop action plan to tackle the root causes of the problems they identified to be amenable under their control and execute these plans. They then review the effects of their actions at the next CDS Meeting ……. Clearly, there are lots of the best (or emerging) practices of community participation enhancing the activities of the ‘CHWs’ out there that can be shared!

Question 13: (India)

The Outreach workers at the village levels seem to be hired on almost voluntary basis. Or example the Accredited Social health Activitist ( ASHA) is very poorly paid. What would motivate them to work, what would motivate the communities and public to take their promotive work seriously? How do we promote integrative approach with HIV, Rural evelopment, information management etc?

As we have stated earlier, the experience of Community Health Workers vary from country to country, and the session is to draw experiences on what works and what fails. The ASHA experience, I believe is one that can be evaluated to see what works, what fails and provide appropriate remedies. It will be useful for someone who is conversant with the ASHA Program to respond to these interesting questions.

As I said earlier in response to another question, incentive, particularly financial is a very important and critical issue in CHW deployment and their effective involvement. In most cases where the CHWs have been trained, the CHWs are selected from amonst the poor and marginalized groups. They are found to be keen in working for their community but they also have opportunity costs. They are poor and they need to earn for their own and family's subsistence. Any time they devote to this should be compensated and it is for the organisers of CHW programs to help identify ways of providing those compensation. In Bangladesh, the CHWs are also members of microfinance groups which entitles them to receive loans for any income generating activities (not necessarily only on health). They also sell essential drugs and other health products (sanitary napkins, soap, contraceptives, iodized salt, vegetable seeds, etc.) with a mark-up. In addition, they also receive incentives for participating in any other health programs such as identifying and treating TB through DOTS, etc. (See: Chowdhury, S., Islam, M.N., Islam, M.A. & Vaughan, J.P. (1997). Control of tuberculosis by community health workers in Bangladesh. Lancet 350: 169-172).

For sustaining their interest in the health work and to create public trust in them, it is also important that the CHWs are linked to a functioning health system. This is important for their continuing education, capacity building and creating credibility in the community they serve. The health system should provide supportive supervision to the work of CHW. Effective linkages with other sectors such as agriculture and rural development may also help them position themselves along with others in the fight against poverty, exploitation and the like. Being part of the community with regular contacts through the health work, they can also be wonderful and reliable source of information for the state or NGOs.

Question 14: (USA)

How can a health system sustain community health workers?  Can they be volunteers and be sustainable?  Do they have to be paid?  If they are paid by their government, what is the evidence about their cost-effectiveness?  If they are to generate remuneration from the sale of a limited set of drugs or other products, is there a tendency to overprescribe?  What kind of attrition rates should be expected for (1) volunteers, (2) those paid by government, and (3) those selling drugs and other products?

One of the key experiences that the Navrongo  Community Health and Family Planning  Project (CHFP) and earlier deployment of Village Health workers, in Ghana, generally point to the fact that ‘community health worker’ concept is not ‘sustainable’ if the ‘CHW’s’ are seen to be ‘outside’ the health system.  This has also driven countries like Ghana (and other sub-Saharan African countries) to consider training midlevel cadres such as Community Health Nurses and deploy them into communities as Community Health Workers that are supported and supervised within the Health System to provide House to House Primary Health Care Services. Outside the Health System and without any remunerations, the attrition of the volunteer ‘community health workers’ is high and practically unsustainable.  In Ghana, with CHPS, the attrition rate of the CHO’s is currently at a minimum; however, there is no guarantee that the CHO’s will also not start migrating.  As far as I am aware, nobody in Ghana has yet conducted any comparative cost effectiveness study   on the deployment of Government paid CHO’s compared to volunteer community health workers, but I guess that should be in the pipeline soon.  We also observed that, if the CHW’s are outside the health system, it is difficult to supervise them and they in turn start activities beyond their mandates and become ‘village’ doctors overcharging and over prescribing!

I would also like to draw attention to a Review Article published in the Lancet by Andy Haines et el entititled 'Achieving child survival goals: potential contributions of community health workers' which amongst other things try to describe the impact and cost-effectiveness of community health workers in some settings.

Question 15: From Khaleda Islam, HSAN Member (Sri Lanka)

At the moment we are training Community Health Volunteers (CHVs) from camps of Internally Displaced Peoples (IDPs)to support the IDPs in getting proper health care from existing health facilities and to create awareness with basic health messages. But because of less number of staff and short duration of it has become difficult to monitor the activities of CHVs. Please share your experience:

Response from Tarry Asoka, HSAN member

An effective support system for Community Health Volunteers (CHVs) involves more than just monitoring and supervision. It involves follow-up support and encouragement that requires plenty of understanding and patience. It should also be regarded as a two-way feedback mechanism.

An ideal support system for CHVs should be made up of 4 different sources.
1. The health worker's community - especially where an effective Community Health Committee is functional.
2. Other health workers in nearby communities, especially those who have been working longer and have more experience.
3. Instructors or Advisers from the Health program itself
4. Hospitals, Clinics and Agencies to which special problems can be referred to

Although instructors or adviser from the training program may appear to be the best persons to provide health workers with follow-up support, the particular situation at hand should be evaluated to see which of the sources outlined above would best meet the requirements. In most instances multiple sources may be used to re-enforce this supportive framework.

It has been found in many programs in Nigeria that the frequency with which support persons visit CHVs depend less on the need than the limitation of time and distance. When advisers manage to visit their CHVs less frequently, support from community health committees and neighboring CHVs become more important. In the case of village or community health committees, programs often have to provide additional organizational help to these committees so that they in-turn provide effective support to CHVs without taking charge.

Record keeping has been found to be a helpful monitoring tool. CHVs can use them to evaluate their work and get suggestions from advisers. But the record forms should be few and kept very simple.

Finally, we have also noted that how often a health worker will need visits from his adviser depends on the support he gets from his community as well as the type of training he has had. Those that have received training that help to develop self-confidence, problem-solving skills, initiative and the ability to use books effectively tend to work more independently and require less supervision. Whereas training programs that emphasize obedience, memorizing facts and filling out forms tend to create health workers who need a lot of supervision.

Therefore a strategy for sustaining CHVs training programs should recognize the main elements of an effective support system and build them into the training programs by assisting trainees to develop the capacity to make these linkages themselves.

Comments from Khaleda Islam

Thanks a lot for sharing your experiences. I will be reviewing all the points thoroughly and will try to incorporate ideas which are suitable for our situation. Regarding the 4 points:

1. The health workers community- here the community is IDPs living in camp where there is no community health committee
2. Other health workers in nearby community - we are trying to utilize the local NGO health workers
3. Instructors or Advisors from the health program itself - 2 groups are working, one our project staff, who are insignificant in number and number 2, the Public Health Staff of Sri Lankan government, we are trying to make the best use of both the groups
4. Hospitals, clinics and Agencies where the special problems are referred- The CHV with whom we are dealing are themselves vulnerable (IDPs) and rarely reach upto that level, mostly they are limiting themselves upto referral not accompaning them and on the other hand the hospital staff are overstressed with sudden increase in workload.

Your observation is very correct, right at the moment we are trying to develop their confidence, so that they themselves come forward to take the responsibility of health care of their community

Comments from Khaleda Islam

This is a continuation of the previous scenario, I have posted...

In our training of CHV from the IDP camps, in addition to basic health messages, we are conducting sessions on gender issues.  During follow up and monitoring in the camps we found change in behavior related to health issues like more use of health care by the IDP women now, but there is no obvious outcome related to gender issues.  Please share your experiences how to make the training on gender issues more effective (we don't have much support!)

Comments from Tarry Asoka

Gender issues could be very sensitive culturally and socially too. CHVs, especially the young and single and from the same community may find it very difficult to address gender issues. It may seem ridiculous or even insulting to older ones.
In our experience when such cases occur, it is often very useful for the young CHVs to explain the situation to some of the respected older women or men in the community. Rather then trying to undertake gender related activities on their own, the CHVs asks these older persons for their advice and gets them to help in organizing and running these programs. That way the young health worker does not lead the activities but stays at the background, sharing the information and ideas that she has learned during the training.

For this approach to be successful, it is best if CHVs get used to doing this during their training. Students should be encouraged to invite local women, opinion leaders and other experienced persons to take part in classes and in actual gender related activities conducted during the training course.

Comments from Hannah Faal, Senior Eye Care Programme Consultant, Sight Savers International- West Africa

Health Democracy and the Community Basket Approach
 
The current way of using health workers does focus on health services provision and it addresses the management of diseases either as common diseases or as diseases of public health significance. The emphasis is on delivery of something ranging from vaccines to bed nets to tablets-- public health campaigns or the treatment of malaria, diarrhea etc.

There is a much bigger need in the community. It has to do with keeping people in health i.e. health democracy, health by the people for the people.  People are provided enough information, knowledge and skills in their own language and on their own terms to make the right decisions and take responsibility for their own health.

Is there a person in the community who knows fully the health profile of the people of the community, who knows who has missed antenatal clinics and perhaps the reasons why, is not taking anti hypertensive, in fact did not buy the prescribed drugs, is not complying or adhering to treatment? Is there someone who will visit each family and screen in a very simple non threatening way for the diseases before they become obvious to the sufferer?  Is there someone who has the time to go and sit with each family to explain to their understanding the contributory and risk factors to health and disease they may have and the simple role that the family can play to maintain health? Is there someone who will answer all the fears and questions and barriers which keep the people from taking up services which are provided or simply make them aware of what is available?
Most poor communities develop survival and fantastic coping skills. The state of ill health is stoically coped with until it is very advanced and by implication very expensive to treat and with a worse prognosis. Is there someone who will work with the persons to ensure an early intervention?

Question 16:
Is there any study which has designed training and uses of a community responsive worker, tested and provided the evidence for the effectiveness, the quality of life issues, the savings made by the health service by having a health savvy community?

In our attempt to get rid of diseases within time bound programs, the community is now being approached by various global and national programs each with its own worker. The community's ownership is defined by the fact that the community is to select a person to do the last bit of work, e.g. pass a health message, give a tablet, and write a name. Each program has a different level of incentive; the community may have several of such persons selected.

Question 17:
Is it possible to have a basket funding approach in which ALL the community targeted program put all their community targeted resources into one basket, sit down with the communities, agree on who and how on  the resources. This will help to remove the divisive results of the richer program getting the best response and thus the best results; potentially damaging to a community in the long run.

Question 18:
Is it possible for the health system to recognize that the last and most important link in health delivery is the person who can go into homes, deal with families and enable the family to take responsibility for its own health?

The poorer the community the more this needed. In the developed world, the health visitor, the district midwife, the abundant information material everywhere and now on the net is addressing this need. The patient can access the information easily and is really responsible for their own health status. In the developing world, the health systems mention the cost of having such community persons. It is more expensive not to have them than to have them. They are about health, social work, development, wealth.

I would appreciate the discussants view on who the community health worker can be and how the community can be in the driving seat, respected and partnered by the health system.

FN Response:

Hello Hannah, I could not agree with you more…… Our experience in Ghana is that the overriding factor for community service delivery should be the empowerment individuals and households to take issues health into their own hands. This is based on our firm believe that the primary producers of health.
We therefore define CHPS as A STRATEGY for the health care delivery system to provide cost-effective health services to individuals and households in Communities through the engagement of the communities in the Planning and Delivery of the services. Key elements of the strategy could be described as:

Communities (as Social Capital)
Households and Individuals (as Target)
Plan with them (community participation)
Serve delivery with them (client focused)

Emerging evidence from our implementation of the initiative points to the fact that: The majority of people living in communities do not want sophisticated clinics and hospitals. What they need is someone who is nearby and knowledgeable to tell them:

1. What is wrong
2. What action to take
3. Where to go to become healthy

The ancient and powerful mechanisms of community organization, chieftaincy lineage, social networks, women societies, communication systems and other institutions and stakeholders are mobilized by CHPS for developing primary health care operations.
I will encourage you to review the findings of the Navrongo Health Research Center's Community Health and Family Planning Project (CHFP) and its subsequent roll out into a national program – the Community-based Health Planning and Services (CHPS) initiative in Ghana. You can visit the website – www.ghana-chps.org for further information on some of the issues you raised and how these are being addressed within the concept of CHPS.

Question 19: (US)

I'm concerned that community health workers are being overburden with excessive donor reporting requirements, taking away from their principal role of serving the health care needs of their communities. What improvements or innovations to health services delivery could be made to reduce the amount of time required for information and data gathering and reporting so that health workers can better serve the public health care needs?

You are right, but the community health workers are not only being overburdened by the ‘donor’ but also by the local health authorities. Where they have been rolled out, Community Health Workers are being increasingly seen ‘polyvalent’ workers and being assigned additional tasks with their various reporting systems. They are becoming the proverbial ‘beast of burden’ to deliver all health interventions and report on them. We are seeing, increasingly, burnt out community health workers and plans are being made to resolve this. A key strategy within our CHPS initiative is to pair the CHO’s and assign specific tasks. Another strategy is to introduce Personal Digital Assistants or PDA’s for data collection at the community level thereby reducing the time spent on manual reporting of data collected. We are in the process of piloting these in a few communities and should be able to share the results very soon.

Question 20: (US)

How important is it to have standardized training and credentialing programs in countries for community health workers?  Can this serve to increase employment opportunities and greater use of CHWs?

As we had indicated earlier on in our answers, the concept and notion of Community Health Workers vary widely from country to country and a variety of experiences exist. Indeed, experience has shown that standardized training and credentialing programs for CHW had increased their acceptability and recognition in the health systems that they work in. In Ghana, the process of clarifying, standardizing and credentialing has led to the realization that the numbers of these cadres needed to service the ‘system’ was about 6 times the number available. This has led to the effort to train and absorb over six to ten thousand more of these cadres - clearly an increased opportunity for employment and greater use of CHWs. Ethiopia decided to train over 30,000 Health Extension Workers and deploy them into the communities after identifying the need for the community level service provision and standardizing the cadre that are needed to work in the program.    

Question 21: (UK)

I am preparing an article on Community Health Workers for the Encyclopedia of Public Health published by Elsevier and aimed to be the most comprehensive reference source of current knowledge in the field.

I would be really grateful if you could send me websites that might be useful to include in this article or references to any key articles that might be included in the further readings section.

Nyonator, Frank K, J Koku Awoonor-Williams, James F. Phillips, Tanya C. Jones, Robert A. Miller. 2005.  "The Ghana Community-based Health Planning and Services Initiative for scaling up service delivery innovation. Health Policy and Planning 20 (1): 25-34.

Nyonator, Frank K, Tanya C. Jones, Robert A. Miller, James F. Phillips, J Koku Awoonor-Williams. 2005.  "Guiding the Ghana Community-based Health Planning and Services Approach to scaling up with  Qualitative Systems Appraisal. International Quarterly of Community Health Education (CHE). Vol23, No.3 2004-2005.

You could add the following websites to your references:
http://www.ghana-chps.org
http://www.ghanahealthservice.org
http://www.expandnet.net

Question 22: (US)

Would standardized training and credentialing programs assist in expanding employment opportunities for CHWs and increase their utilization?

As we had indicated earlier on in our answers, the concept and notion of Community Health Workers vary widely from country to country and a variety of experiences exist. Indeed, experience has shown that standardized training and credentialing programs for CHW had increased their acceptability and recognition in the health systems that they work in. In Ghana, the process of clarifying, standardizing and credentialing has led to the realization that the numbers of these cadres needed to service the ‘system’ was about 6 times the number available. This has led to the effort to train and absorb over six to ten thousand more of these cadres - clearly an increased opportunity for employment and greater use of CHWs. Ethiopia decided to train over 30,000 Health Extension Workers and deploy them into the communities after identifying the need for the community level service provision and standardizing the cadre that are needed to work in the program.

Question 23: (Ethiopia)

What is the role of community health workers in improving safe delivery service for laboring mothers in a country with 94% of mothers are giving birth at home?

Ghana, as in many Commonwealth countries, has more than half of the births (53%) occurring at home. It is also evident that a child born in an urban area is two and a half times more likely to have been delivered at a health facility than a rural born child. A variety of reasons has been assigned to this, including the unavailability of health professionals as well as the facilities to deliver in the rural areas. In an effort to bridge the gap and provide health delivery services as close to the family, the Community based health planning and services (CHPS) initiatives trains’ frontline health workers (CHO) in core competencies in midwifery or professional midwives to better understand and respond to the needs of pregnant mothers, who prefer mostly to deliver at home close to their families. As stated in earlier responses the community health officers provide house to house service delivery in communities they are stationed. Clearly, this is the advantage in using health professionals as community health workers.

Question 24: (Nigeria)

What should be the minimum academic qualification of a Community Health Worker? What quality control measures are in place to monitor the skills and activities of CHW? Background: Two CHWs recently administered BCG to two HIV exposed infants against mothers' objection with one of the mothers disclosing her HIV status. One of the children has died.

The minimum qualification will depend on the context and the work that expected of the CHWs. In the rural Bangladesh context, most of the CHWs are illiterate but they are capable of doing a host of things as I indicated in a previous response. In the urban areas where we have started working more recently, the CHWs are more literate. Obviously, if they are literate there are certain additional advantages such as that they can keep records themselves (in rural areas, they needed to keep a minimum of records; they also utilize their children or literate relatives to record when needed) , but do run more risks of dropping out due to availability of other opportunities.

The CHWs need to be functionally connected to a functioning health system for them to maximize their potentials as CHWs. The health system and the community the CHWs serve should monitor and supervise their activities.