Chapter 2: Lessons Learned from Viewing the History of Large-scale CHW Programs

By: Donna Bjerregaard, Initiatives Inc. and Henry Perry, JHU

The CHW Reference Guide was produced under the Maternal and Child Health Integrated Program, the United States Agency for International Development Bureau for Global Health’s flagship maternal, neonatal and child health project.

Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers helps us reflect on what we have learned about large-scale CHW programs and how to recruit, train, supervise, and incentivize CHWs. What can we learn about financing, roles and responsibilities, community involvement, and linkages with the health sector?

As we search for ways to develop large-scale CHW programs, it would be wise to look back at the roots of these programs. The first was in the 1920s in Ding Xian, China. Dr. John B. Grant (Rockefeller Foundation) and Jimmy Yen, a Chinese community development specialist, trained illiterate farmers to record births and deaths, vaccinate against diseases, give health talks, and explain how to keep wells clean. These trained farmers become known as Barefoot Doctors; by 1972 there were one million Barefoot Doctors serving 800 million people in rural China.

Faced with the need to address the health of rural populations in the 1960s, the Barefoot Doctor model was adapted in other countries, including Honduras, India, Indonesia, Tanzania, and Venezuela. It led to a new approach to health services, based on the principles of social justice, equity, community participation, prevention, collaboration, and decentralization. This movement also led to the health team concept that included community-based workers to strengthen health and welfare in communities.

In 1978, influenced by the work of the Christian Medical Commission, the World Health Organization and UNICEF sponsored an international conference on primary health care which led to the Alma-Ata Declaration of Health for All.  It also defined CHWs as important providers of primary health care. In the 1970s and 1980s, national CHW programs were developed in Indonesia, India, Nepal, Zimbabwe, Tanzania, Malawi, Mozambique, Nicaragua and Honduras as well as other Latin American countries.   In the same period, smaller CHW programs were started by non-governmental organizations in low-income countries. But the national programs were beset by lack of political will and as inadequate training, supervision, remuneration, incentives, support for logistics, acceptance by formal health care providers, and financial support for program operations. Many governments reduced or discontinued their large CHW programs in the 80s and early 90s in favor of vertical programs that had strong donor and technical support.

Evolution

The effective functioning of large-scale CHW programs offers one of the most important opportunities for improving the health of impoverished populations in low-income countries. Research findings on the effect of community-based programs in improving child health have led to a resurgence of interest in CHW programs around the world.

In the 1980s and 90s, there was a loss of momentum of the primary health care movement envisioned at Alma-Ata.  A global recession and a push to reduce public sector financing led to loss of support for health initiatives in general.   Successful examples of CHW programs emerged in the mid-1980s. In 1987, Brazil’s national health care program started and gradually achieved universal coverage of health services. In the country’s 8^th National Health Conference, the principle that health is “a citizen’s right and the state’s duty” was established. Brazil has one of the largest CHW networks in the world: 222,280 CHWs providing home visits and services to 110 million people.

In the 1990s, more examples of large-scale programs appeared. In 1997 Bangladesh had 30,000 female CHWs providing home-based family planning services. Bangladesh’s family planning program is now regarded as one of the most successful programs in a developing country not undergoing rapid socioeconomic development. Malawi’s CHW Program began in the

1950s providing immunizations by salaried Health Surveillance Assistants (HSA).  In 2008, Global Fund assistance enabled the government to double its HSA workforce to 10,000.

The evidence regarding the effectiveness of CHW interventions in maternal and child health has gradually emerged, leading to stronger investments in CHW programs to enable countries to accelerate progress in achieving the Millennium Development Goals (MDGs), particularly MDGs 4 and 5 for reducing child and maternal mortality. Interest has also grown in decentralization as a way to reach the poorer segments of the population with services for every household. In 2004, Ethiopia started its Health Extension Worker program, which has enabled it to reach the MDG for child health by training 38,000 CHWs in five years and reaching every household with basic services. 

The lessons learned from the past help us to see what is important today as we move toward expanding and strengthening large-scale CHW programs. Ensuring financial sustainability and quality improvements through monitoring and periodic evaluations will be essential if programs are to achieve long-term viability and maximum impact on health. 

 

 

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