"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
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.
The VHW program began in the 1980s as part of Zimbabwe’s transition toward PHC. VHWs focus on disease prevention and provide community care at the primary level in rural and peri-urban wards, where they serve as a key link from the community to the formal health system.
VHWs collaborate with other community-based workers, such as traditional healers, trained traditional birth attendants (tTBAs), and community-based distributors of FP.
The Ministry of Health and Child Welfare (MOHCW) conducts an initial 8-week VHW training. This consists of a period of classroom training followed by a period of practical training.
Refresher trainings are conducted as needed and when funds are available.
VHWs have a broad range of roles and responsibilities from prevention and health promotion to treating common conditions (including diarrhea and malaria) and identifying and referring complicated cases to higher levels of the health system.
VHWs receive a quarterly allowance of $42, though remuneration is often irregular. They are also provided with a bicycle and a medical supply kit.
VHWs are directly supervised by the nurse-in-charge at the health center within their ward. In addition, they are broadly supported by the ward health team at the community level.1
There is no information available about the impact of this program.
What is the historical context of Zimbabwe’s Village Health Worker Program?
Following Zimbabwe’s independence from Britain in 1980, Zimbabwe’s health sector adopted a strong focus on PHC.2 Zimbabwe moved from a “curative, urban-based and minority-focused health care system to one which emphasized health promotion and prevention and provided some acceptable level of health care to the majority rural population.”3 As part of the shift toward PHC, the National Village Health Worker Program was formally launched in 1981 with a goal of training 15,000 village-based basic health workers and extending health care coverage to people who would otherwise have no access.2 This program was influenced by a VHW program introduced in 1980 by the Bondolfi Mission in Masvingo, a southern province of Zimbabwe, where over the course of six months, 293 VHWs were selected and trained.2
From 1982 to 1987, the government trained 900–1,000 VHWs annually, so that by 1987 there were 7,000 VHWs.4 The selection of VHWs was supposed to be driven by the community in consultation with the District Council. In contrast to the Bondolfi VHWs, the national VHW cadre received more formal training and less compensation, and they had to cover a comparatively larger catchment area. Bondolfi VHWs were selected by village committee and remained accountable to the community, whereas the government VHWs were selected by the local government structure, through which they were remunerated (David Sanders, personal communication). Bondolfi VHWs did not receive remuneration, and some were recruited into the government program while others resigned over time (David Sanders, personal communication). The VHWs were not considered to be extensions of the formal government health service, but rather were envisioned to be stewards of the community’s commitment to health promotion.4 In 1984, the VHWs were transferred to the Ministry of Women’s Affairs, Cooperatives and Community Development and renamed “Village Community Workers”.1 The Village Community Workers took on a broader set of development activities and, as a result, had little time for health and health promotion activities.1
Over the course of a decade, the share of the health budget dedicated to preventive services rose from 6.7% in 1980 to 14.4% in 1989.2 Unfortunately, economic deterioration in the mid-1990s led to a rapid decline in the health system and health status of Zimbabweans, including a collapse of the VHW program.5
A 1999 Review Commission of the Health Sector called for the reintroduction of VHWs into the MOHCW; in 2000, the VHW program was reinstated under the Nursing Directorate of MOHCW.1 Since 2009, efforts have been under way to revitalize the VHW program, partially through support from the Global Fund to Fight AIDS, Tuberculosis and Malaria and various partner organizations. VHWs are expected to be key players in efforts to reach the MDGs, and they are also now viewed as an essential element of the health system decentralization process.1 The remainder of this case study describes the current status of the VHW program in Zimbabwe.
What are Zimbabwe’s health needs?
There has been a dramatic deterioration in Zimbabwe’s key health indicators since the early 1990s. Life expectancy fell from 62 years in 1990 to 44 years in 2008,5 and has since partially recovered to 54 years.6 The MMR rose from 284 per 100,000 live births in 1994 to 960 in 2010.7 While the prevalence of HIV has dropped in the last decade from 26% in 2000 to 15% in 2012, there are an estimated 1.2 million Zimbabwean adults living with HIV/AIDS, which places a huge burden on the health system.8 TB prevalence is 547 per 100,000 population, more than double the average of 243 per 100,000 for Southern Africa, where Zimbabwe is located.6 The nutritional status of children is also a key health challenge as indicated by the most recent DHS data: among children under five, 32% were stunted, 3% were wasted, and 10% were underweight.7
What is the existing health infrastructure?
The health system is divided into four levels of care, including primary, secondary, tertiary, and quaternary.5 The primary level includes VHWs and the rural health centers or clinics that offer basic maternity, preventive, and curative services. For community members, these facilities are the first point of contact with the formal health system.5,9 The secondary level includes facilities that receive patients on referral from primary-level facilities, but also provide primary care services to patients within the immediate area surrounding the facility. Tertiary-level facilities include the seven provincial hospitals in Zimbabwe, which have specialist staff on hand to deal with referrals from secondary-level facilities. The most advanced level of care is the quaternary level, which includes six central hospitals that have equipment, staff, and pharmaceuticals for dealing with patients requiring highly specialized care.5
What type of program has been implemented?
The MOHCW outlines several key objectives in its document outlining a strategic direction for the VHW program, including the following:
To equip communities with knowledge and skills to take responsibility for their own health
To increase the capacity of communities to prevent and control diseases within communities
To enable communities to manage and take actions on health activities within communities
To empower communities to value their own health and to take actions that promote positive behavior change for adopting healthy lifestyles1
VHWs provide a link from the community to the formal health system. VHWs have a broad scope of work (Table 2), but they primarily focus on prevention. They provide some curative care, including first aid and treatment of common conditions with drugs (including malaria and diarrhea).5 VHWs collaborate with other community-based workers such as traditional healers, traditional birth assistants, and community-based distributors of FP.1 VHWs are provided with various drugs and medical supplies to carry out their multiple roles (Table 2).
What about the community’s role?
According to government documents describing the program, local leaders, including qualified health care workers, teachers, traditional and religious leaders, women leaders, and youth leaders, support the VHWs in a variety of ways, including (1) mobilizing the community around health issues; (2) supporting planning, implementation, and monitoring of VHW activities; (3) mobilizing resources to support VHW activities; and (4) advising the VHWs.1 In addition, the community plays an essential role in the selection of VHWs as described below.
How does Zimbabwe select, train, and retain its Village Health Workers?
The VHW selection process starts when a clinic or hospital communicates with the community that it needs voluntary workers. The clinic development committee and the political leaders then take the lead in choosing suitable candidates to become VHWs. Persons selected as candidates usually have a proven commitment to the community such as previous volunteer work at their local clinic (CHAI, personal communication). Relying on community input for selection is essential because the community members must have trust and confidence in the VHWs.1 The community’s participation in the selection process differentiates VHWs from auxiliary health workers in that the VHWs answer to the community, while the auxiliary workers answer to the formal health system.4 The VHW selection criteria include the following:1
- Aged 25 years or older
- Mature, married resident of the village
- Able to read and write
- Possessing strong communication skills
- Respected in the community
- Interested in health and development issues
- Willing to work at the community level and on a volunteer basis
- Able to maintain confidentiality of health information
The MOHCW conducts an initial VHW training that lasts 8 weeks. The classroom training is organized into two sessions that are separated by a period of practical training. Refresher trainings are conducted as needed and when funds are available, but new skills and knowledge sharing are generally just taught on the job (CHAI, personal communication). Topics covered in the VHW training include PHC; roles and responsibilities of VHWs in the community; reporting responsibilities of VHWs; the community as the client; communicable and non-communicable diseases; communication, advocacy, social mobilization, and community mobilization; environmental health, water supplies, sanitation, and cholera; malaria; personal hygiene, hand washing, zoonotic conditions; IMCI; nutrition and infant feeding; HIV/AIDS, TB, PMTCT of HIV, voluntary HIV counseling and testing; treatment of minor ailments; first aid and wound care; mental health (stress, burnout, child abuse, hazardous substances); community-based rehabilitation; emergency preparedness and response; collaboration and coordination; contents of the VHW kit; health promotion and education; teaching methods; communication network and technology system; M&E and data management; and dental health promotion and hygiene.1
How does Zimbabwe supervise its Village Health Workers?
At the national level, the MOHCW’s Director for Nursing Services oversees the VHW program. Responsibilities are further delegated to the Provincial Nursing Officers, District Nursing Officer, and finally to clinic staff (CHAI, personal communication). VHWs are directly supervised by the Nurse-in-Charge at the rural health center within their ward. VHWs are also supported by the ward health team at the community level.1 VHWs are expected to attend monthly meetings at the rural health center.1
How is the Community Health Assistant Program financed?
The MOHCW provides funding to a small proportion of VHWs through support obtained from the Global Fund to Fight AIDs, Tuberculosis and Malaria. This funding provides for three weeks of VHW refresher trainings. As of 2010, development partners were supporting VHWs in 24 of Zimbabwe’s 60 rural districts. These partners include UNICEF, the WHO, the United
Nations Development Program, the Central Emergency Relief Fund of the United Nations, and various NGOs including Merlin, World Vision International, Save the Children, and the Zimbabwe Vitamin A for Mothers and Babies Project.1
The VHW role is not supposed to be one of “professionalized” full-time work. Rather, VHWs should work part-time while remaining engaged in normal day-to-day family and village activities.4 When the VHW program began, it was envisioned that the communities would take over the responsibility of providing compensation to VHWs after one to two years, thereby making the program more community owned and community driven.4 However, this has not been the case, and compensation has generally come from the government or partners. During 2010, VHWs received a quarterly allowance of $42 from the MOHCW. Some VHWs also received a bicycle provided through the Global Fund.1
What are the program’s demonstrated impact and continuing challenges?
Several evaluations of the VHW program were carried out in the early 1980s,4 but data on the impact of the present-day VHW program are not available. Data on routine community activities are maintained by VHWs in a domiciliary visit register. Information from this register is periodically shared with the supervising health facility. Some community-based data are included in the national health information system.1
The current number of VHWs is not documented. The goal of the VHW program is to achieve national coverage with 15,000 VHWs.10 However, only an estimated 19% of villages have currently active VHWs, and a 2009 household survey revealed that fewer than half of the respondents had access to a VHW in their ward.9 The program faces many challenges. VHW training programs have been closed down in many districts. Remuneration is inadequate and irregular. And shortages of the drug supply are common.9
- Zimbabwe MOHCW. The Village Health Worker Strategic Direction. Harare, Zimbabwe; 2010.
- Sanders D. The potential and limits of health sector reform in Zimbabwe. In: Rohde J, Chatterjee M, Morley D, eds. Reaching Health for All. New Delhi, India: Oxford University Press; 1993:239-65.
- Woelk G. Primary health care in Zimbabwe: Can it survive? Soc Sci Med 1994; 39(8): 1027– 1035.
- Sanders D. The State and democratization in PHC: community participation and the village health worker programme in Zimbabwe. In: Frankel S, ed. The Community Health Worker: Effective Programmes for Developing Countries. New York, NY: Oxford University Press; 1992:178-219.
- Osika J, Altman D, Ekbladh L, et al. Zimbabwe Health System Assessment 2010. Bethesda, MD: Health Systems 20/20 Project, Abt Associates Inc.; 2011. Available at: http://www.healthsystems2020.org/content/resource/detail/2812/.
- WHO. Zimbabwe: Health Profile. 2012. Available at: http://www.who.int/gho/countries/zwe.pdf?ua=1.
- Zimbabwe National Statistics Agency, ICF International. Zimbabwe Demographic and Health Survey 2010-11. Calverton, MD: ICF International; 2012. Available at: http://www.measuredhs.com/pubs/pdf/FR254/FR254.pdf.
- UNAIDS. Zimbabwe HIV and AIDS Estimates. 2012. Available at: http://www.unaids.org/en/regionscountries/countries/zimbabwe/.
- Zimbabwe MOHCW. The Zimbabwe Health Sector Investment Case (2010-2012): Accelerating Progress towards the Millennium Development Goals. Harare, Zimbabwe; 2010. Available at: http://www.unicef.org/esaro/Health_Investment_Case_Report1.pdf.
- Mushavi A. Zimbabwe’s efforts to scale up and integrate community support with medical services to end vertical transmission. In: Symposium on Closing the Gap: Ending Vertical Transmission through Community Action. 2012. Available at: http://www.ccaba.org/wp- content/uploads/Mushavi-Angela-Zimbabwe%E2%80%99s-Efforts-to-Scale-Up-and- Integrate-Community-Support-With-Medical-Services-to-End-Vertical-Transmission.pdf
Katharine Shelley, a student at the Johns Hopkins Bloomberg School of Public Health, wrote this case study. We are grateful to David Sanders for his comments on an earlier draft of this.