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Community health workers for universal health-care ...

Bull World health Organ 2013;91:847 852 | doi: & practice847 Community health workers for universal health -care coverage: from fragmentation to synergyKate Tulenko,a Sigrun M gedal,b Muhammad Mahmood Afzal,c Diana Frymus,d Adetokunbo Oshin,e Muhammad Pate,e Estelle Quain,d Arletty Pinel,f Shona Wyndg & Sanjay ZodpeyhFrom Alma-Ata to universal health coverageFrom the early years of primary health care, Community -based health workers and volunteers (henceforth referred to as com-munity health workers [CHWs]) have played a key role in sat-isfying the need and demand for essential health services. The Alma-Ata Declaration states that primary health care relies, at local and referral levels, on health workers , including physi-cians, nurses, midwives, auxiliaries and Community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team a

Bull World Health Organ. 2013;91:847–852 | doi: http://dx.doi.org/10.2471/BLT.13.118745. 849. Policy & practice Kate Tulenko et al. Synergy for scaling up CHW ...

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1 Bull World health Organ 2013;91:847 852 | doi: & practice847 Community health workers for universal health -care coverage: from fragmentation to synergyKate Tulenko,a Sigrun M gedal,b Muhammad Mahmood Afzal,c Diana Frymus,d Adetokunbo Oshin,e Muhammad Pate,e Estelle Quain,d Arletty Pinel,f Shona Wyndg & Sanjay ZodpeyhFrom Alma-Ata to universal health coverageFrom the early years of primary health care, Community -based health workers and volunteers (henceforth referred to as com-munity health workers [CHWs]) have played a key role in sat-isfying the need and demand for essential health services. The Alma-Ata Declaration states that primary health care relies, at local and referral levels, on health workers , including physi-cians, nurses, midwives, auxiliaries and Community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the Community .

2 1 The values and principles set down at Alma-Ata continue to be relevant today, even though the primary- health -care movement has encountered difficulties in many countries and at many levels when seeking to put them into practice. With the growing momentum for making universal health cover-age (UHC) a core strategy for shaping the post-2015 global health agenda, known barriers to coverage and access must be This also applies to factors that undermine the role of CHWs in the health path-finding pilots for Community -based primary health care and CHW models took place in nongovernmental settings in the beginning of the 1970s.

3 The Christian Medical Commission of the World Council of Churches, in proactive engagement with the World health Organization (WHO),3 was instrumental in making the case for this paradigm shift in health care by joining efforts with lead projects in Gua-temala, India, Indonesia and elsewhere, among them the Comprehensive Rural health Programme in Jamkhed, India, established in 1970,4 which continues today. After the Com-mission s pioneering work, hundreds of other faith-based groups and nongovernmental organizations (NGOs) have continued to refine Community -based health -care models and CHW Alma-Ata, the eagerness of public health authorities to produce national blueprints for the rapid scale-up of pri-mary health care did, however, generally miss out on creating ample space for Community participation.

4 The comprehen-siveness and continuity of care so basic to the model were soon replaced by selective interventions for focused results, including selected maternal and child health interventions and family planning. Well-intended, top down national planning and external support created wave after wave of CHWs in the making and reshaping, under different names and with different roles. Many countries and many communities can recall a history of training, deployment and failure of several repeating initiatives, such as that in the United Republic of Tanzania in the Caught between the formal health system and the Community and often in a grey zone between public, nongovernmental and private health systems, CHWs were for a long time seen as a stopgap measure and did not Abstract To achieve universal health coverage, health systems will have to reach into every Community , including the poorest and hardest to access.

5 Since Alma-Ata, inconsistent support of Community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs current drive towards universal health coverage (UHC) presents an opportunity to enhance people s access to health services and their trust, demand and use of such services through CHWs.

6 For their potential to be fully realized, however, CHWs will need to be better integrated into national health -care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability.

7 In moving towards UHC, much can be gained by investing in building CHWs skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to CapacityPlus, IntraHealth, 1776 I St, NW, Washington, DC 20006, United States of America (USA).b Norwegian Knowledge Center for the health Services, Oslo, Global health Workforce Alliance, Geneva, United States Agency for International Development, Washington, Federal Ministry of health , Abuja, Genos Global, Panama City, Joint United Nations Programme on HIV/AIDS, Geneva, Public health Foundation of India, New Delhi, to Kate Tulenko (e-mail: 10 March 2013 Revised version received: 24 May 2013 Accepted: 1 July 2013 )Bull World health Organ 2013.

8 91:847 852 | doi: & practiceSynergy for scaling up CHW programmesKate Tulenko et the adequate support needed for the epidemic of HIV infec-tion set in, Community -based care models found new expressions. The need to act grew organically out of the affected communities in the early days of the epidemic. People living with HIV infection had no choice but to help one another. What evolved was a system rooted in the local context and born out of friendship and a shared experience: mothers supported mothers, gay men supported gay men and grandmoth-ers helped grandmothers. When the early antiretrovirals became available, projects and programmes funded by governments, donors and NGOs spotted the opportunity to utilize existing com-munity HIV support networks and be-gan funding training and development for CHW programmes specific to the needs of HIV programmes, yet largely without being part of the local health services and clinics.

9 What started out as Community -based responses began to evolve into multiple, stand-alone CHW programmes focused on HIV care with varying degrees of formality, sustain-ability, success, support and use of CHWs for childhood development and maternal, neonatal and child health care has a long history, as illustrated in India. The Accredited Social health Activists (ASHA) model for the follow-up of women during pregnancy, delivery and the postnatal period has been relatively successful in overcoming barriers to service delivery and increasing institutional The ASHA programme has attained roughly 70% coverage of both mothers and neonates in participating health workers in Pakistan, behvarz in the Islamic Republic of Iran, agentes communit rios de sa de in Bra-zil, BRAC Community health workers in Bangladesh, village health volunteers in Thailand.

10 And health extension workers in Ethiopia all represent different suc-cessful CHW Zambia agreed on a national CHW strategy in 2010 and implemented a Community health assistant programme in 2012. In August 2011 Nigeria held its very first national meeting on human resources for health , which brought together various partners and representatives of all levels of gov-ernment. Similar national meetings have taken place in Kenya in 2011 and in 2013 the United Republic of Tanzania. These programmes and processes have, in dif-ferent ways, brought in the voices of the CHWs and their communities and seek to optimize the potential contribution of skilled and supported CHWs to primary health care (Box 1).


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