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TheThe
PepsiCo
PepsiCo
Foundation
Foundation
Meeting
March 31, 2008
The Role of Community Health Workers
The Key to Progress in Delivering Care to the Poorest of the Poor
Eric Swedberg
Child Health & Nutrition Advisor
Page 1
Discussion Outline
•
Why Community Health Workers (CHWs)?
•
Roles
•
Operational Considerations
•
Results in Selected Countries: Mali, India, Ethiopia
•
Costs
•
Progress-to-Date and Future Plans
•
Ethiopia Video of CHW
Page 2
Rationale
• Shortage of health-care professionals throughout the
developing world
Some countries have 1 doctor for every 50,000 people
compared to US ratio of 1/391
• Inability of health care delivery systems to meet needs
Worldwide 200 million children under age 5 do not get basic
health care when they need it
• Inaccessibility within rural communities
Reaching the nearest health facility requires a journey on
foot of several hours or even a day
Page 3
Low Access: Nicaragua
1. Blurred photo due to a tropical downpour.
2. 24 mile trip to clinic for baby’s (in plastic) pneumonia.
3. Better off than her neighbors, she’s on “cusp of inaccessibility.”
Page 4
Community Health Workers
Characteristics
• Volunteer health workers who live in communities with
the parents and children who need help most
• Community members carefully selected, trained, and
equipped to be health workers
• Serve as first line of defense against the most common
killers of children
Page 5
Diverse CHW Roles
• Preventive Health Education
– Health education to their neighbors
– Referral to health facilities for illness
• Reproductive Health
– Trained birth attendants to ensure safe childbirth and proper newborn care
– Family planning counseling and contraceptives
Page 6
Diverse CHW Roles…Cont’d
• Child Health
– Immunization, growth monitoring and promotion
– Individual and group counseling on exclusive breastfeeding and complementary
feeding practice
– Referring severe acute malnutrition to facilities
• Treatment Provision—Save the Children is expanding
the CHW role to include
– Management of child illness: diarrhea, pneumonia, malaria, newborn sepsis
– Treatment for severe acute malnutrition
Page 7
Key Operational Considerations
Page 8
Critical CHW Program Components
• Establish the roles and responsibilities
• Establish criteria and methods of recruitment
• Carry out competency-based training
• Provide tools to enhance performance, e.g. job aids
Take action to maintain performance
• Measure performance after training
• Identify problem areas and provide feedback
Page 9
Performance of CHWs
• One of the foremost concerns of CHW programs
• Critical success factors (driving higher quality
services)
– Increased supervision
– Less population to cover
– More experience
• SC approach
– Build MOH capacity
– Engage local village leadership
– Increase coverage e.g.. 2 CHWs per village, regular refresher trainings
Page 10
Retention
• Significant challenge: Starts with close attention to the
operational components—particularly selection
• Monetary and In-kind / other incentives
– Profit from medicine sales
– Assistance with farming
– Basic equipment such as bicycles
– Refresher training
• SC approach
– Health impact valued by communities
– Local recognition (badges, certificates, t-shirts, caps)
Page 11
Drug Supply
Essential part of CHW effectiveness
• Restock—through closest Ministry of Health
facilities or purchase separately
• Financing—by national government/outside
donors or community cost-recovery
Page 12
Community Case Management
• Equip and train Community Health Workers
– Treat and sometimes refer common, serious, community-acquired childhood infections (pneumonia,
malaria, diarrhea, newborn sepsis)
– Manage small drug boxes
• Train Families
– Recognize and promptly seek treatment for childhood danger signs
– Complete the treatment or accept referral
• Equip and train Ministry of Health partners at clinics
– Support, supply, supervise CHWs
Page 13
Results
Page 14
Mali
Page 15
5 Districts with a total
population of nearly 1 million
Health Zones of Sikasso Region, Mali
79 health zones
with 478 drug kits
in Sikasso Region
Health center
Village drug kits
5 to 15 km from
health center
Page 16
The Village Drug Kit System
• Two Community Health Workers
– Main CHW
– Assistant to CHW in case CHW is away
• CHWs selected by community and trained by MOH
and Save the Children
• Print materials in each kit
– Counseling materials
– Notebooks to record sales and track stock
– Notebook for births and deaths
– Notebook to record behavior change activities
– Register of referrals to health center
Page 17
Products in the Drug Kits
• Oral rehydration salts and zinc
• Paracetamol pills and syrup
• Aureomycin ointment 1%
• Contraceptives: Pills & Condoms
• Insecticide for treating mosquito nets and long lasting
mosquito nets
• Chloroquine tablets and syrup
Withdrawn according to government policy in June 2007 and
replaced with new malaria treatment
Page 18
CHW and Village Oversight Committee
Page 19
Drug Kits and Health Center
Referral of ARI and severe cases,
restocking, monthly meetings
Formation/refresher training and
supervision for CHWs
Page 20
Results in Mali:
Malaria Treated = Lives Saved
Health
Districts
Bougouni
Kolondièba
Yanfolila
Sélingué
Yorosso
Total
Page 21
Episodes Of Fever Treated
Drug Kits
Health
Number
Centers
Treated
57%
43%
15,854
72%
28%
6,511
71%
47%
49%
55%
Period: July 2006 – June 2007
29%
53%
51%
45%
3,977
3,680
30,778
60,800
Results in India:
Saving Newborn Lives
• Funded by Gates Foundation
• CHWs…
– Delivered key messages

Clean delivery, immediate breastfeeding, skin-to-skin
care, etc.

Home visits: 2 antenatal,
postnatal day 0/1, 3
– Trained community volunteers
• Results: 50% reduction in NMR
(after only 1 year’s implementation)
Page 22
Results in Ethiopia:
Pneumonia Case Management
90
80
%
Clinic-based
treatment of
pneumonia and
malaria.
70
60
Community Case
Management (CCM) of
pneumonia and malaria.
*
50
40
30
20
10
17%
58%
84%
1997
2001
2006
0
* = 200,000 untreated cases of childhood pneumonia,
malaria, and diarrhea every year
Page 23
Costs
• One CHW can assist 50 -100 children.
• It only costs about $100 to train a CHW each year and
$25 to equip her.
• It costs about $1000 to train a medical professional who
will supervise 10 CHWs.
• One community health worker can save one to 3
children’s lives in high mortality settings every year.
Page 24