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"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.

By: 
Rachel Strodel

Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.

Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time. 


Summary
Background

Niger’s current CHW program originates from a village health worker program founded in the mid 1960’s, which primarily served the rural Maradi region1. Health initiatives in the early 21st century began the development of a two-tiered CHW program (comprised of both paid workers and volunteers) and the construction of health posts out of which Niger’s CHWs operate, of which there are now roughly 2,000.2, 3 This case study examines the roles of both paid Agents de Santé Communautaire (ASCs) and Relais volunteers.

Implementation

Niger’s first ASCs were dispatched in 1999.2 As of 2009, there were currently 2,308 paid health workers operating 1,938 community health posts as well as an estimated 4,000 Relais volunteers (for a total of 6,308 CHWs) for Niger’s population of 17.8 million people, or 1 CHW for 2,822 people.3 Health posts are constructed near communities far from local health centers or hospitals, and ASCs typically work full-time to provide primary health care, including preventive services, at these posts. Relais volunteers also support health posts and work closely to promote health at the community level.2

Training

Beginning in 1999, ASCs received 6 months of training prior to their deployment.2 From 2008- 13, Relais volunteers and ASCs received additional training in key family practices (such as breastfeeding, bednet use, and handwashing) through the Catalytic Initiative/Integrated Health Systems Strengthening Program (CI/IHSS).2 From 2008-13, ASCs also received a 6-day additional training in Integrated Community Case Management of Childhood Illness (iCCM).2, 3

Roles/responsibilities

ASCs are responsible for providing basic primary health care interventions including iCCM (treating fever, diarrhea, and pneumonia); providing immunizations; providing vitamin A supplements and bednets; offering nutrition support/child health promotion; and screening for acute malnutrition.2 ASCs are expected to staff health posts while Relais volunteers are expected to work primarily in communities, where they completing home visits, demonstrating key family practices, developing community awareness, and encouraging parents of sick children to seek out care.2

Incentives

ASC workers are paid a stipend of US$100 per month.4Relais workers are unpaid volunteers.2

Supervision

Health posts—and the ASCs that staff them—are rarely supervised.5

Impact

Niger has made remarkable ground in reducing the mortality rate of children younger than 5 years of age, which has decreased from 226 deaths per 1,000 live births in 1998 to 128 deaths per 1,000 live births in 2009. This decline in mortality is largely attributable to an expansion in the coverage of child survival interventions and an approximately 50% decline in wasting.

Niger’s ASCs and Relais volunteers have made important contributions to these achievements. The introduction of CHWs has also made it possible to increase percentage of the Niger population living within 5km of a health center or post rose from 48% to 80%.

What is the historical context of Niger’s Community Health Worker Program?

Niger’s CHW program was born out of a participatory rural extension service founded in 1963 to promote community development. In 1965, the Ministry of Health set forth a framework for training local health workers and traditional birth attendants in villages, which involved short, week-long courses in basic health services such as nutrition education and emergency care.1

The Niger government began building health posts following a call for increased access to health care in the president’s Declaration for Rural Development in 2000.3 By 2009, the health worker program had scaled up to 1938 operating health posts staffed by 2,308 paid health workers. Health posts have continued to function as sites for the implementation of health initiatives such as education on key family practices (KFPs) from 2008 to 2013 and the integration of zinc as a treatment for diarrhea between 2007 and 2009.3

What are Niger’s health needs?

Among both adults and children, malaria, respiratory disease, and diarrhea remain the leading causes of death.6 Malaria remains the cause of half of the deaths in children younger than 5 years of age, and chronic malnutrition affects about 44% of children, according to a 2012 multiple-indicator health and demographics survey.7 The maternal mortality ratio in 2005 was the second highest in Africa,6 and the lifetime risk of maternal death in 2013 was 1 in 20.8 As Niger is ranked among the poorest nations in the world, family financial burdens continue to be a significant barrier to health care access, although free health care for children and pregnant women since 2006 has increased affordability for these populations.3

What is the existing health infrastructure?

In Niger there are currently three levels of health care institutions. At the most local level, health posts—or Cases de Santé—provide basic primary health care and preventive care services. These posts are staffed by ASCs and supported by local community members.9 There are currently 2,502 health posts in Niger.7 Health centers (Centres de Santé Intégrés) exist at the next tier of care, and are operated by nurses who provide both outpatient and inpatient services to treat non-severe health conditions for multiple communities. Nurses and health workers otherwise refer patients to district or regional hospitals, which serve at the highest tier of care.9 As of 2014, there were 876 integrated health centers and 42 district/regional hospitals.7

The Niger Government also introduced free health services for children and pregnant women in 2006, greatly reducing the financial burden of seeking care.3

What type of program has been implemented?

The CHW current program in Niger is a two-tiered system comprised of full-time CHWs (called Agents de Santé Communautaire) and Relais volunteers.2 The Niger government funds ASCs to occupy approximately 2,000 health posts located in remote regions of Niger,2 where they are supported by one or more Relais volunteers and provide numerous basic primary health care services and interventions, including: treatment for non-severe cases of malaria, diarrhea, pneumonia (and referral for severe or complicated cases of each condition); antenatal care, distribution of vitamin A and bednets, family planning services; screening and referrals for acute malnutrition; promotion of key family practices (KFPs); as well as preventive care and education.2, 3

Information about the number of ASCs is difficult to ascertain. Health post construction began in the year 2000, where ASCs function. Whether or not there were ACSs prior to this is not clear, nor the number of ASCs in 2000. By 2007, 1,700 health posts had been constructed and 431 health workers had been trained in Integrated Management of Childhood Illness (IMCI), but it is not reported how many of these were ACSs.3 By 2009, a total of 2,308 CHWs (presumably ASCs) had been trained in IMCI, and there were 1,938 functioning health posts staffed by ASCs.3 However, according to another report,2 there were 1,535 ASCs functioning in 2014 but 2,560 ASCs had received six days of training in integrated community case management (iCCM) between 2008 and 2013.

The number of Relais volunteers is also difficult to determine. One report2 indicates that according to a 2013 census of health posts in Niger, there were almost two Relais for every ACS. Thus, we estimate that the total number of CHWs in Niger is 2,560 ACSs and 4,000 Relais (a total of 6,560 CHWs) in a population of 17.8 million, or 1 CHW per 2,822 population.

What about the community’s role?

Relais volunteers serve as a high-touch connection point between a health post and the community it serves. They often complete home visits (or help ASCs perform them), and help engage the community by facilitating outreach initiatives.2 Community members also have the opportunity to serve on community-based management committees (called COGES), which supervise health centers and their cost-recovery initiatives.5

How does the government select, train, and retain its CHWs?

Both ASCs and Relais volunteers are selected from the communities that they will serve. ASCs have at least a primary-school education, while respected community elders, both male and female, are often selected to be Relais volunteers.2 ASCs are predominantly male (in 2013, reportedly  about 75%) and receive 6 months of training prior to deployment as full-time health workers. ASCs and Relais volunteers also receive additional training, for example, in KFPs and iCCM.2

How does the government supervise Its CHWs?

There is very little government supervision of health posts, ASCs, or Relais.5

How is the program financed?

The Niger government finances the ASCs and health posts, paying ASCs a monthly stipend of US$100; however, development partners provided funding for iCCM training.4

What are the program’s demonstrated impact and continuing challenges?

Niger has made remarkable ground in reducing the mortality rate of children younger than 5 years of age, which has decreased from 226 deaths per 1,000 live births in 1998 to 128 deaths per 1,000 live births in 2009.3 This decline in mortality—as well as improvements in the scope of child survival interventions and an approximately 50% decline in wasting—may be attributable to the variety of development initiatives implemented through Niger’s ASCs and Relais volunteers. The development of health posts and the CHW infrastructure in Niger has increased health coverage geographically, too: from 1998-2009, the percentage of the Niger population living within 5km of a health center or post rose from 48% to 80%.3

On the Human Development Index, Niger ranked last out of 186 countries in 2012.7 Poverty, equipment and commodity shortages, lack of supervision, poor physical infrastructure, unavailability of health workers, and poor health post functioning are present barriers to the current CHW program and other parts of the health system in Niger.7

References

1. Lehmann U, Sanders D. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organization; 2007. Available at: http://www.who.int/hrh/documents/community_health_workers.pdf (accessed 1 August 2015).
2. Leon N, Sanders D, Van Damme W, et al. The role of 'hidden' community volunteers in community-based health service delivery platforms: examples from sub-Saharan Africa. Global health action 2015; 8: 27214.
3. Amouzou A, Habi O, Bensaid K, Niger Countdown Case Study Working G. Reduction in child mortality in Niger: a Countdown to 2015 country case study. Lancet 2012; 380(9848): 1169-78.
4. Bennett S, George A, Rodriguez D, et al. Policy challenges facing integrated community case management in Sub-Saharan Africa. Trop Med Int Health 2014.
5. Ridde V, Diarra A. A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa). BMC Health Serv Res 2009; 9: 89.
6. WHO. Niger: Health Profile. 2013. Available at:

http://www.who.int/gho/countries/ner.pdf?ua=1  (accessed 1 August 2015).

7. WHO. WHO Country Cooperation Strategy Brief: Niger. 2014. Available at: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ner_en.pdf... (accessed 3 October 2016).

8. UNICEF, WHO. Countdown to 2015. Fulfilling the Health Agenda for Women and Children: the 2014 Report. 2014. Available at: http://www.countdown2015mnch.org/documents/2014Report/Countdown_to_2015- Fulfilling%20the%20Health_Agenda_for_Women_and_Children-The_2014_Report- Conference_Draft.pdf (accessed 1 July 2015).
9. Page AL, Hustache S, Luquero FJ, Djibo A, Manzo ML, Grais RF. Health care seeking behavior for diarrhea in children under 5 in rural Niger: results of a cross-sectional survey. BMC Public Health 2011; 11: 389.


0This case study was written by Rachel Strodel, an undergraduate student at Yale University.


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