Governing Large-Scale Community Health Worker Programs

Simon Lewin and Uta Lehmann

23 September 2013

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Key Points Improving how community health worker (CHW) programs, and health systems more broadly, are governed is increasingly recognized as important in achieving universal access to health care and other health-related goals. Governing comprises the processes and structures through which individuals and groups exercise rights, resolve differences, and express interests. The process of governing involves ongoing interactions among actors, such as health care decision-makers, community representatives, and agencies, and structures, with regard to the laws, resources, and beliefs within which these actors operate. Because CHW programs are located between the formal health system and communities and involve a wide range of stakeholders at local, national, and international levels, their governance is complex and relational. In addition, CHW programs frequently fall outside of the governance structures of the formal health system or are poorly integrated with it—making governing these programs more challenging. In the past, poor governance has undermined the planning and management of programs and the delivery of services. This chapter discusses the following key questions that decision-makers need to consider in relation to governing CHW programs:

• How, and where within political structures, are policies made for CHW programs?

• Who, and at what levels of government, implements decisions regarding CHW programs?

• What laws and regulations are needed to support the program?

• How should the program be adapted across different settings or groups within the country or region?

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INTRODUCTION In this chapter, we consider and discuss a number of relevant questions regarding the governance of community health worker (CHW) programs. This chapter is intended to be read alongside Chapter 12 on community participation in CHW programs.

WHAT IS MEANT BY “GOVERNING” IN THE CONTEXT OF HEALTH SYSTEMS? Governing in the context of health systems can be seen as being concerned with “political, economic, and administrative authority in the management of health systems.”1 Governing comprises “the complex mechanisms, processes, and institutions through which citizens and groups articulate their interests, mediate their differences, and exercise their legal rights and obligations.”2 As this definition suggests, governing involves ongoing interactions and relationships between actors, such as health care decision-makers, community representatives, associations, and agencies, and structures, including the laws, policies, resources, and beliefs within which these actors work.3 Governing is therefore a process rather than a static set of policies and structures. Consequently, this process is closely linked to context and may change over time as societies, health systems, and CHW programs change and evolve. Moreover, governing in the context of health systems may often overlap with management, which is sometimes seen to be more concerned with running or implementing programs.4 Governing health services can also be conceptualized in terms of inputs, processes, and outputs.5 Governance inputs include how and by whom the institutions governing the health system are constructed and managed. This includes “participation,” or the stakeholders involved in defining and designing health policies; and “consensus orientation,” or the extent to which government officials collaborate with or involve other stakeholders in setting goals and formulating policies for health. The processes of governance concern how administrative procedures and rules governing the health sector are implemented. This includes transparency, accountability, monitoring, and control of corruption. Finally, governance outputs can be seen as the benefits that should result from the implementation of governance rules and processes within a health system. Different political systems may emphasize different governance outputs, but these may include measures of how well the health system responds to population needs, equity of access to health services, and efficient use of health resources.

WHY IS GOVERNING AN IMPORTANT ISSUE FOR CHW PROGRAMS? Decisions on the type of structures established for governing CHW programs, who will be involved in governing (i.e., the actors), and how these will relate to the wider health and political systems are political. These decisions are important, as they will affect a range of other processes in these programs, including day-to-day accountability, and will ultimately impact performance and sustainability. Some of important decision parameters include:

• Extent to which the CHW program is part of the formal health system

• Extent to which CHWs are formally recognized as a cadre within the health system

• Extent of decentralization of authority for governing CHW programs and for their management

• Scale of the program

• Roles that key stakeholders, including communities and/or service users, have in governing the programs

• How, and by whom, resources are obtained and administered

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Also important is the extent to which CHWs are organized, for example, through a union or health provider organization. Different decisions on these parameters, in response to specific contexts and needs, may result in different models for governing CHW programs. For example, in relation to the health system:

• Some programs are not part of the formal facility-based health system, but have structures that provide good links to this system (e.g., the Accredited Social Health Activists [ASHA] CHW program in India and the Building Resources Across Communities (BRAC) CHW program in Bangladesh.

• Some programs are integrated with the formal health system and are well-supported within it (e.g., the Family Health Teams in Brazil, the Health Extension Worker [HEW] program in Ethiopia, and the CHW program in Venezuela).

• Some programs are centrally driven with national guidance, but implemented through separate structures (e.g., CHW programs in South Africa, which are currently largely implemented through NGOs, but within parameters established at the national level).

These varied models for governing CHW programs have implications, in turn, for how programs are financed and funded; how and by whom CHWs are selected and trained; how CHWs are supported and supervised; how CHWs are paid; and how communities are involved; among many other issues. We discuss the implications of these differing configurations in more detail below. Improving how CHW programs, and health systems more broadly, are governed is increasingly recognized as important in achieving universal access to health care and other health-related goals. The concept of “good governance” is now used widely and can be understood as the interactions between relevant stakeholders and processes that enable monitoring, transparency, and accountability and that lead to public value and the common good.6 Improving on how CHW and other health system programs are governed requires a range of enabling factors. For example, clear goals and priorities for the CHW program; appropriate structures for implementing, coordinating, and integrating the program; standards regarding the selection and training of CHWs; data on how well these programs are performing; mechanisms for motivating CHWs and their supervisors; and meaningful involvement of, and accountability to, the range of stakeholders linked to these programs, including local communities and recipients of CHW care. Governing CHW programs, therefore, requires financial and other resources, and how these resources are managed will, in turn, impact the extent to which good governance can be achieved.7, 4 Table 1 provides a summary of governance principles within health care. Table 1: Health systems governance principles2

GOVERNANCE PRINCIPLE

EXPLANATION

Strategic vision Leaders have a broad and long-term perspective on health and human development, along with a sense of strategic directions for such development. There is also an understanding of the historical, cultural, and social complexities on which that perspective is grounded.

Participation and consensus orientation

All men and women should have a voice in decision-making for health, either directly or through legitimate intermediate institutions that represent their interests. Such broad participation is built on freedom of association and speech, as well as capacities to participate constructively. Good governance of the health system mediates differing interests to reach a broad consensus on what is in the best interests of the group and, where possible, on health policies and procedures.

Rule of law Legal frameworks pertaining to health should be fair and enforced impartially, particularly the laws on human rights related to health.

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GOVERNANCE PRINCIPLE EXPLANATION

Transparency Transparency is built on the free flow of information for all health matters. Processes, institutions, and information should be directly accessible to those concerned with them, and enough information is provided to understand and monitor health matters.

Responsiveness Institutions and processes should try to serve all stakeholders to ensure that the policies and programs are responsive to the health and non-health needs of its users.

Equity and inclusiveness

All men and women should have opportunities to improve or maintain their health and well-being.

Effectiveness and efficiency

Processes and institutions should produce results that meet population needs and influence health outcomes while making the best use of resources.

Accountability Decision-makers in government, the private sector, and civil society organizations involved in health are accountable to the public, as well as to institutional stakeholders. This accountability differs depending on the organization and whether the decision is internal or external to an organization.

Intelligence and information

Intelligence and information are essential for a good understanding of health system, without which it is not possible to provide evidence for informed decisions that influences the behavior of different interest groups that support, or at least do not conflict with, the strategic vision for health.

Ethics The commonly accepted principles of health care ethics include respect for autonomy, nonmaleficence (a principle of bioethics that asserts an obligation not to inflict harm intentionally), beneficence (actions to benefit others), and justice. Health care ethics, which includes ethics in health research, is important to safeguard the interest and the rights of the patients.

WHAT KEY QUESTIONS DO DECISION-MAKERS NEED TO CONSIDER REGARDING GOVERNING CHW PROGRAMS? Because CHW programs, to varying degrees, are located between the formal health system and communities, and can involve a wide range of stakeholders at local, national, and international levels, their governance is often complex and relational. CHW programs frequently fall outside of the governance structures of the formal health system or are poorly integrated with it, making governing these programs more challenging. In addition to the previously discussed topics, this chapter outlines key questions that decision-makers need to consider for governing CHW programs, and illustrates the options for governing with examples and case studies from programs in the field. These key questions are:

• How and, where within political structures, are policies made for CHW programs?

• Who, and at what levels of government, implements decisions regarding CHW programs?

• What laws and regulations are needed to support the program? How should the program be adapted across different settings or groups within the country or region? Table 2 summarizes the sub-questions for each of the main questions above. Tables 3 and 4 provide a cross-country comparison of issues in the governing of the overall CHW programs and policies that affect individual CHWs. These are based on case studies of Brazil, Ethiopia, India, Pakistan, and South Africa. We refer to examples from these tables in the main text. These tables also include additional material that complements and illustrates the issues raised in the main body of the chapter.

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How, and Where within Political Structures, Are Policies Made for CHW Programs? CHW programs experience a number of challenges in relation to policy processes. For example:

• Policies to govern these programs may be lacking if the program is seen to be peripheral to, or outside of, the formal health system or if it has developed out of programs initiated by nongovernmental organizations (NGOs), community-based organizations (CBOs), or civil society organizations (CSOs).

• Existing policies may not be “fit for purpose”; for instance, CHW program functioning may be hampered if a national Ministry of Health (MOH) department decentralizes primary health care (PHC) management to the regional or district level, but does not put in place policies that allow managers at those levels to manage and disburse funds to the CHW program itself and its staff.

• It may be difficult to ensure program consistency, for example, in terms of tasks and responsibilities, across a region or country where there are multiple players involved, including local and international NGOs and agencies and government health services. A national CHW policy framework may be needed to achieve this consistency.

It is therefore important to consider how and where policies for CHW programs are made, and the implications of this for developing and running the program. These policy decisions (such as whether to develop a volunteer-based or fully remunerated CHW program) need to be distinguished from implementation decisions (such as the timetable for continuing education of CHWs within a particular district or province). Key issues to consider for CHW programs include the following:

• Where are policy decisions made?

• Who are the stakeholders involved in defining and designing these policies (participation), and to what extent is this done in a collaborative manner (consensus orientation)?

• Are there important historical legacies that may shape CHW policymaking?

• How might wider health and political systems goals in a particular context influence how CHW programs are governed?

Where Policy Decisions Are Made Authority to make policy and operational decisions regarding CHW programs is located at different levels of government within different countries, depending on the country’s constitutional or legislative arrangements or historical policy legacies (see below). In some countries, such authority may be located with the national ministry or department of health. In other countries, regional or provincial departments of health or legislatures may have authority to develop health policies, or such authority may have been delegated by the legislature or the MOH to an independent body, such as a CHW Commission. Each of these scenarios has different benefits and drawbacks, as follows:

• When policy authority is located at the national level, it may be easier to achieve consistency of approach for CHW programs across a country. However, policymaking may be very removed from the day-to-day running of CHW programs and may therefore not be very responsive to challenges as they are experienced.

• When policy authority is delegated to an independent body, it may facilitate more rapid and responsive policy development since these decision-makers have a clear focus on the CHW program. However, policies made by this body may not be well-aligned with other policies developed by the MOH or other government ministries.

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Those wishing to develop or change policies governing CHW programs need to consider2:

• Where are laws and regulations relevant to health initiated?

• Do laws need to be initiated by cabinet or parliament? Can other stakeholders initiate laws or regulations through other mechanisms?

• Who can initiate such laws and regulations? Do laws need to be initiated by a government minister or a ministerial permanent secretary?

In addition, consideration needs to be given to what provisions there are locally for accountability and support. For example, what recourses citizens have if they feel that they not being treated respectfully, or if CHWs are not carrying out their duties adequately? This is addressed in more detail in Chapter 12. Box 1: Governance within the Brazilian Family Health Program, where policy decisions are made8

In Brazil, the new constitution adopted in 1988 reinforced the role of state (provincial) and municipal governments in implementing public policies, while the central government had the role of issuing the main guidelines for implementing public policies. Later legal provisions shifted more responsibility for the management and organization of health services over to municipal governments, while at the same time, emphasized the technical and financial role of the central government and the states. Municipalities have the authority to decide whether to implement the Family Health Program. Once a decision to implement is made, the local government determines the organization of the program in their municipality, for example, specifying the number of family health teams they want to establish and selecting the areas to which these teams will be assigned. The positive effects on the program resulting from such a process of implementation appear to be more local ownership of the implementation and improved local management of the program. On the other hand, the process could lead to unprepared and uncommitted local management, as well as heterogeneity of implementation.

Box 2: Governance of programs supported by the National Rural Health Missions in India8

The three tiers of governance (i.e., government, state, and panchayats) in India pose challengesfor a range of government programs, including for carrying out certain functions of the National Rural Health Mission (an initiative of the Ministry of Health and Family Welfare to strengthen rural health services). An evaluation from 2009 reported that transfers of funds to lower levels of governance were being held up at the state levels. The evaluation proposed direct disbursement of funds from the central government to the panchayats as a solution to this problem. However, it was noted that this change may be difficult, given that health is defined as a state responsibility in the constitution of India. The evaluation suggests that individual states would like to gain more autonomy from the center. However, states are reluctant to devolve the necessary powers to govern CHW programs to the panchayat level, where primary health centers and sub-centers are located. Similar tensions were reported between the central government and the states in relation to program financing.

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Who, and at What Levels of Government, Implements Decisions Regarding CHW Programs? Stakeholders Involved in Defining and Designing these Policies and to What Extent Is this Done in a Collaborative Manner A range of stakeholders may have roles in defining and designing CHW policies. The extent to which there is wide participation in this process may depend on the orientation of the political system within a particular context, the formal and informal power stakeholders are able to exert, and the attitudes of those driving a particular policy process. Which stakeholders are involved in CHW policymaking, and how these stakeholders are involved, have important benefits and drawbacks for programs:

• When it is not clear who has final responsibility for policymaking, decisions may not be made or may be much delayed.

• When policy decision-making is dispersed across a range of stakeholders, important inconsistencies may develop across program policies. For example, CHWs may have authority to deliver antibiotics for neonatal sepsis in one region of a country but not in another; or may be compensated differently among regions, as is the case for example with India’s ASHA Program.

• Involving a wide range of relevant stakeholders in CHW program policymaking may help to build consensus, consistency, and buy-in regarding these policies. This, in turn, may facilitate implementation of CHW policies. However, it may be difficult to achieve such consensus, and decision-making may, as a result, be very prolonged, or may fail to keep pace with changes encountered by the programs on the ground.

Questions that need to be considered in relation to stakeholder involvement include1:

• Who are the key stakeholders for policies related to community health services? In addition to the national Ministry or Department of Health, this may often include other ministries or departments, such as Finance, Education and Training, Employment, Public Works, etc.; provincial or regional ministries or departments of health; CSOs; professional organizations, such as doctors’ or nurses’ unions; regulatory authorities, such as bodies that register health care professionals; private sector organizations, such as private clinics; national and international NGOs, who may employ or manage CHWs or other elements of the health system; CHWs themselves; communities where CHWs are working; and donors, including bilateral and multi-lateral organizations and private foundations.

• To what extent are these key stakeholders consulted and involved in policymaking for community health services? To what extent is there a consensus orientation, in which state authorities cooperate with other stakeholders in policy development? There may be a trade-off between involving a very wide range of stakeholders and involving a narrower group of stakeholders. The former may maximize input and buy-in to the policy but may result in no one stakeholder having overall responsibility for policy development, leading to delays and indecision. The latter approach may make the policy process more manageable, but may reduce buy-in or may result in policies that are not aligned with related policies in other governments departments or sectors.

• How are inputs solicited from stakeholders?

1 Adapted in part from 2

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There are a range of ways in which this may be done, including convening a national or regional policy dialogue,9-11 requesting written inputs, and holding public consultations. Important challenges include:

• Having a leader or champion who has motivation, the necessary experience with CHW programs, and the credibility with stakeholders to take forward a consultation process. The leader also needs to have the authority to adapt the policy based on the inputs received.

• Having resources for and commitment to a consultation process.

• Having skills to synthesize inputs received in ways that advance the policy process.

• How are the varied objectives, motivations, and views of different stakeholders reconciled within the policy process? Stakeholders may have very different views in relation to a particular policy question, based on their constituencies. For example, an international donor may lobby for a “vertical” CHW program for a particular health problem, such as providing treatment support for people living with HIV/AIDS. However, the national department of health may favor a more integrated model, in which CHWs are part of the PHC team in each primary care facility, as more useful and appropriate in the setting. At the same time, the nurses’ professional association may be concerned to limit the range of tasks that CHWs are permitted by policy to undertake because they want to protect their profession’s scope of practice. Those leading and managing the policy process need to decide if the views of stakeholders will be made available publicly, the extent to which consensus is desirable or possible, and what mechanisms will be used to address the different views and objectives of different stakeholders. Mechanisms that may be used include involving key stakeholders in drafting a policy and facilitating dialogue on a draft policy.

Important Historical Legacies that May Shape CHW-Related Policymaking In addition to being constrained by existing laws and regulations, policymaking for CHW programs may also be shaped by historical legacies. These legacies may include previous and current policies, experiences, and practices. For example, a CHW program may have been established with the specific purpose of improving equity of access to health care for historically marginalized groups, such as populations living in geographically remote areas of the country. The Brazilian Family Health Program, for instance, has its antecedents in a regional program, established to respond to a severe drought (see Table 3, row 3). The model developed in this setting has shaped the program across the country. Programs may also be shaped by specific health system legacies: for instance, CHW policies may need to take into account an existing nurse auxiliary cadre or a program based on salaried CHWs, or may need to absorb an existing network of community health volunteers. Efforts to establish a national CHW policy framework in South Africa, for example, were influenced by the absence of a national CHW program and the presence of a large number of small-to-medium-sized programs, largely managed by NGOs, in which CHWs had different scopes of practice and levels of training (see Table 3, rows 2 and 3). Historical legacies are important as they may determine stakeholders’ views of and reactions to policies. These legacies may also constrain what is possible; for instance, it may be difficult to make substantial changes to CHWs’ existing scopes of practices, such as introducing curative tasks to a program focusing on health promotion, or to the types of recipients targeted, for example, from women and children to everyone in the household or from rural to urban households.

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Questions that need to be considered here include:

• Are there important health system legacies, in relation to governance, financial, or delivery arrangements2, that may shape CHW-related policymaking?

• It may be very challenging to establish community-led systems for governing CHW programs in a health system in which governance and financial management are highly centralized and in which there is little experience with more decentralized forms of governing. Similarly, it may be difficult to put in place policies to expand the roles of CHWs if these roles are likely to be seen to overlap with those of another cadre.

• Are there important political system legacies, in relation to institutions, interests, or ideas3 that may shape CHW-related policymaking? Issues to be considered here include whether there is a constitutional mandate to decentralize the management of programs to district level; whether important funders of a CHW program, such as the Ministry of Finance or international donors, will support a policy change; and whether there is a body of research that may provide support for shifting the way in which a health service is delivered.

• To what extent are these historical legacies in alignment with the planned policy? What scope is there for re-shaping the policy or bypassing these legacies? Decision makers involved in governing CHW programs need to consider how these historical legacies may impact a planned policy. A number of tools are available, such as a SWOT (strengths, weaknesses, opportunities, and threats) analysis, which may be useful in approaching this assessment in a systematic way.12-14

Wider Health and Political System Goals May Influence How CHW Programs Are Governed How CHW programs are governed may be influenced by the particular goals or benefits (sometimes called governance outputs) that have been prioritized within a specific health or political system. CHW and other health policies may be assessed by decision-makers in relation to the extent to which they help to achieve these goals or outputs. Such goals may include improved equity, improved responsiveness to population needs, greater efficiency in the delivery of services, more decentralized services, increased employment, or greater involvement of the private sector in the delivery of services. There are a number of ways in which wider health and political system goals may influence how CHW programs are governed. Firstly, it may be difficult to develop CHW program policies and governance processes where these do not align with wider goals. For instance, developing structures to allow CHWs to work more closely with private sector providers, such as drug dispensers, may not be feasible if such arrangements are not seen as legitimate or important within the wider health system. Similarly, the governance of CHW programs may be neglected if there is a shift in goals in the political system toward increasing the number of providers with

2 Governance arrangements are concerned with political, economic, and administrative authority in the management of health systems, as noted above. Financial arrangements include funding and incentive systems, while delivery arrangements include human resources for health, as well as service delivery. 3 Drawing on political science theory, the term “institutions” is used here to refer to both the formal and informal structures and processes of policymaking (constitutional rules, structures through which decision are made, and features of the policy process, such as the level of transparency). The term “interests” concerns the stakeholders who shape a policy and their views on whether the policy will have benefits or drawbacks for them or others. The term “ideas” refers to the values and knowledge held by stakeholders, including those in government and civil society, and comprises information from both research and experience. 12–14

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higher levels of training, such as nurses and doctors. In contrast, ways of governing CHW programs that align closely with political system goals, such as the decentralization of services, may be easier to develop and implement. Secondly, health and political system goals may drive the development, or indeed the demise, of a CHW program. In many settings, programs have been developed or scaled up to help achieve the goal of improved equity in access to health services. In Ethiopia, the HEW program aims to improve access to care for rural populations particularly (see Table 3, row 3). In South Africa, efforts by the first democratic government to improve equity and quality in PHC prioritized nurses as the lead cadre and viewed CHWs as giving second-rate care. Consequently, funding and support for CHW programs declined and many programs ceased to function15 (see Table 3, row 3). Questions that need to be considered in relation to health and political system goals include:

• What goals are emphasized currently within the health and political system in a particular context?

• To what extent will CHW-related policies help to achieve these goals, and how can this be demonstrated within the policy process?

• What changes need to be made to proposed CHW policies to better align them with relevant governance goals?

• Where CHW-related policies diverge from prioritized governance goals, how can this be justified and advocated for within the policy process?

• Are there role players with political influence who can advocate for CHW programs? There are a number of ways, both formal and informal, in which these questions may be considered. Those governing CHW programs can reflect on the goals of the program, and those of the wider health and political system, and the extent to which CHW policies will help to achieve these wider goals. Wider consultations, such as deliberative dialogue processes,10 may be useful in identifying current and future health and political system goals, in considering how CHW policies align with these, and in assessing how the governing of CHW programs may need to shift in order to support important health and political system goals. A number of policy analysis tools are available that may be useful in this process.16-19 Additional Factors to Consider Regarding Who Implements Decisions and at What Levels of Government After a policy decision has been made, the next key challenge is transforming this policy into practical actions. Policy implementation is challenging in most settings for a range of reasons, including the complexity of the health system. The process of implementing policy decisions may involve multiple levels of government, as well as other stakeholders, and the coordination and management of complex processes. Such complex processes may include: 1) limited financial resources or difficulties in disbursing resources to the levels where they are needed, 2) deficits of other resources, including human resources for health care delivery and management, 3) competing priorities within and beyond the health system, and 4) challenging physical environments, such as very remote communities. The implementation of decisions regarding CHW programs may, therefore, take place in an unsystematic way or be slowed by a range of obstacles. Careful and systematic planning is needed to ensure that CHW program policies are implemented as intended.

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Questions that can be considered by policymakers when planning the implementation of policies for CHW programs include: 4

• What factors might affect the successful implementation of the policy? In what ways can potential barriers be overcome or minimized and facilitators harnessed?

• Is there a clear implementation plan for the policy that includes the objectives to be achieved, adequate resources, and a timeframe, and that addresses important barriers and facilitators? There are additional issues to be considered here:

• What is the extent of decentralization for the implementation of CHW policies? Which stakeholder(s) will lead and which level(s) of government and other agencies need to be involved?

• What strategies should be considered in planning implementation of the policy in order to facilitate the necessary changes among health care recipients, health care professionals, organizations, and the health system?

• How will implementation of this policy affect the day-to-day running of ongoing CHW (and other) programs?

• To what extent will communities and CSOs be involved, and how will this be operationalized? (See Box 3 below and Chapter 12 on relationships with communities.)

• How will implementation ensure that key governance goals, such as equity, participation, and accountability, are maximized?

• How will implementation of policies be monitored and evaluated to ensure that their objectives are met? (Also see Chapter 4 on planning for CHW programs.)

Box 3. Community involvement in CHW program implementation in Zimbabwe8

Studies analysing the implementation of the Village Health Worker (VHW) program in Zimbabwe provide in-depth analysis of why such local citizen bodies may have failed to stimulate meaningful community involvement. These studies suggest that the government, while attempting to redirect resources to the village level, developed an increasingly large bureaucracy that reinforced centralization of power, and local citizen bodies became extensions of the central government structures. People’s representation was supposed to be mediated through village and district committees. However, these structures were regarded by communities as remote and as a part of civil service structures that were accountable to the government, and not to poor people within communities. Effective popular mobilization in the planning and development of the VHW program was seen to have declined inversely in relation to the bureaucratization of the program.

WHAT LAWS AND REGULATIONS ARE NEEDED TO SUPPORT THE PROGRAM? The governing and implementation of CHW programs may be shaped or constrained by existing laws or regulations5 in relation to, for instance, the organization of health services, human resources, drugs, technologies, and financing. As noted above, these “policy legacies”20 may include regulations regarding the kinds of health care providers who can prescribe and dispense

4 Adapted from 2,13 5 A law can be defined as “a rule of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority” (From: www.merriam-webster.com/dictionary/law Accessed 26 June 2013). A regulation can be described as “A law on some point of detail, supported by an enabling statute, and issued not by a legislative body but by an executive branch of government” (From: www.duhaime.org/LegalDictionary/R/Regulation.aspx , accessed 26 June 2013).

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different types of medications. These legacies may also include laws regarding the disbursement of funds from health departments to community structures that may be responsible for supporting CHWs. Further, CHW programs may experience challenges if laws and regulations that are needed to enable effective program functioning are not put in place in a timely manner or if existing laws and regulations are not amended as needed. For example, regulations in Brazil regarding the need to advertise civil service posts nationally were changed to help ensure that CHWs employed by the Family Health Program came from the community in which they were to work.21 In South Africa, it has been argued the functioning of CHW programs was hampered by poor regulation that limited the rights of CHWs and contributed to low pay levels.22 Appropriate legal and regulatory frameworks are, therefore, needed for large-scale programs to function effectively.23 These need to address issues related to CHWs, such as selection and remuneration, as well as issues related to the wider health system, such as governance structures for PHC. As such, those developing and scaling up CHW programs need to consider which existing laws and regulations need to be taken into account and whether changes to them are needed to ensure the effective governing of the program and its implementation as intended. Questions that should be considered in relation to laws and regulations:

• Which laws and regulations are relevant to the governing and scale-up of CHW programs?

• How are these laws and regulations translated into rules and procedures that may affect program implementation in the field, and who has responsibility for this?

• Will any changes be required to these laws and regulations to allow the program to be scaled-up as intended? Will any new laws and regulations be needed?

• Where laws or regulations need to be promulgated or amended, which government bodies would be responsible for leading this process? Which other bodies would need to be involved in this process? Are there key laws or regulations that may act as critical barriers or bottlenecks to policy implementation and that should be priorities for promulgation or amendment?

• What is the likely timeframe for these legislative or regulatory processes?

• Can scale-up be implemented in parallel to changes in laws and regulations?

HOW SHOULD THE PROGRAM BE ADAPTED ACROSS DIFFERENT SETTINGS OR GROUPS WITHIN THE COUNTRY OR REGION? For CHW programs operating at scale, there may be tension between, on one hand, adopting a fairly standard approach to the governing of programs and to their implementation and, on the other hand, trying to ensure that the program is tailored to the needs of different settings or groups. The former approach may allow for more rapid scale up and may require fewer resources. The latter approach, while more resource intensive and more difficult to implement, may help to ensure that the program is seen as useful by local communities and health services, may be more sustainable,24, 25 and may have a greater impact in the medium to long term. There are a number of reasons why programs may need to be adaptable. Firstly, different population groups within a country may have very different health and therefore program needs. Secondly, programs may need to be adapted for particular local contexts, such as remote areas with poor physical access where operational challenges differ dramatically from more densely populated urban areas. Thirdly, CHW programs may need to be adapted to local or regional health system arrangements, such the availability of other health care providers in the

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area, the presence of private drug sellers or other sources of drugs, or the extent of private sector health care provision. Questions that need to be considered:

• Is the program targeted toward specific groups or settings in the country or region?

• Are there important differences across groups or settings in the country or region that may affect the roll-out of the program and that may require its adaptation?

• If the program is to be adapted:

• What are the specific needs of these groups or settings; what barriers do these groups experience in accessing the program; and what challenges might be encountered in adapting the program to their needs or setting?

• Which are the core elements of the program that should be retained across settings or groups and which elements can be adapted to address specific needs?

• To what extent does adaptability need to be built into the program policy?

• Which entities will have responsibility for adapting the program in response to local needs?

• Will the adapted program need to be piloted before it is scaled up?

ADDITIONAL CONSIDERATIONS Other issues that may be important to consider in relation to governing CHW programs at scale include the requirements that scale-up of the program might impose on the health system (including managers, health care providers, and users) and on other sectors. Factors affecting the sustainability of the program, and ways in which national, regional, and international stakeholders can be mobilized to support a national CHW program. These issues are discussed further in the chapters on relations with the health system (Chapter 11), on financing (Chapter 12), and on planning (Chapter 3).

CONCLUSIONS Governing CHW programs can be complex because of the location of these programs between the formal health system and communities, and the involvement of a wide range of stakeholders at local, national, and international levels. CHW programs frequently fall outside of the governance structures of the formal health system or are poorly integrated with it. The most appropriate and acceptable model(s) for governing CHW programs depends on the community, on local health systems, and on the political context of the program. Policymakers and other stakeholders in each setting need to consider what systems are currently in place and what might work in their context, and develop a locally tailored governance approach. Where community or local participation is well-established, models of community governance and accountability may be appropriate and useful for CHW programs. Where local participation in governance is not well-established (e.g., because governance of the health and political systems are highly centralized) or is weak, stakeholders need to explore other mechanisms for accountability. It is challenging to include a very local participatory structure for governing a CHW program within a large-scale program, and there are few sustained examples of this. For large-scale programs, formal local governance structures, such as elected local government councils, may

4–14 Draft December 2013

need to be relied on. Stakeholders need to consider how to organize CHW program governance in such contexts. Ultimately, local participation in governing CHW programs is difficult to achieve at scale without substantial resources, adequate planning, and sustained attention to maintaining these local structures. Stakeholders must consider what resources are needed and how these can be made available. Table 2: Governing CHW programs – key questions and sub-questions

KEY QUESTIONS SUB-QUESTIONS

How, and where within political structures, are policies made for CHW programs?

Where are policy decisions made? Where are laws and regulations relevant to health initiated? Do laws need to be

initiated by cabinet or parliament? Can other stakeholders initiate laws or regulations through other mechanisms?

Who can initiate such laws and regulations? Do laws need to be initiated by a government minister or a ministerial permanent secretary?

Who are the stakeholders involved in defining and designing these policies (participation), and to what extent is this done in a collaborative manner (consensus orientation)? Who are the key stakeholders for policies related to community health services? To what extent are these key stakeholders consulted and involved in policy

making for community health services? To what extent is there a consensus orientation in which government authorities cooperate with other stakeholders in policy development?

How are inputs solicited from stakeholders? How are the varied objectives, motivations and views of different stakeholders

reconciled within the policy process? Are there important historical legacies that may shape CHW-related policy making? Are there important health system legacies in relation to governance, finance or

service delivery that may shape CHW-related policy making? Are there important political system legacies in relation to institutions, interests

or ideas that may shape CHW-related policy making? To what extent are these historical legacies in alignment with the planned policy?

What scope is there for re-shaping the policy or bypassing these legacies?

How might wider health and political systems goals in a particular context influence how CHW programs are governed? What goals are emphasized currently within the health and political system in a

particular context? To what extent will CHW-related policies help to achieve these goals, and how

can this be demonstrated within the policy process? What changes need to be made to proposed CHW policies to better align them

with relevant governance goals? Where CHW-related policies diverge from prioritized governance goals, how can

this be justified and advocated for within the policy process? Are there role players with political influence who can advocate for CHW

programs?

Draft December 2013 4–15

KEY QUESTIONS SUB-QUESTIONS

Who implements decisions regarding CHW programs, and at what levels of government?

What factors might affect the successful implementation of the policy? In what ways can potential barriers be overcome or minimized and facilitators harnessed?

Is there a clear plan for implementation of policy decisions that includes the objectives to be achieved, adequate resources, and a timeframe, and that addresses important barriers and facilitators?

How will implementation ensure that key governance goals, such as equity, participation and accountability, are maximized?

How will implementation of policies be monitored and evaluated to ensure that their objectives are met?

What laws and regulations are needed to support the program?

Which laws and regulations are relevant to the governing and scale up of CHW programs?

How are these laws and regulations translated into rules and procedures that may affect program implementation in the field, and who has responsibility for this?

Will any changes be required to these laws and regulations to allow the program to be scaled up as intended? Will any new laws and regulations be needed?

Where laws or regulations need to be promulgated or amended, which government bodies would be responsible for leading this process? Which other bodies would need to be involved in this process? Are there key laws or regulations that may act as critical barriers or bottlenecks to policy implementation and that should therefore be priorities for promulgation or amendment?

What is the likely timeframe for these legislative or regulatory processes? Can scale-up be implemented in parallel to changes in laws and regulations?

How should the program be adapted across different settings or groups within the country or region?

Is the program targeted toward specific groups or settings in the country or region?

Are there important differences across groups or settings in the country or region that may affect roll out of the program and that may require its adaptation?

How will the program be adapted, if this is needed?

4–16

Dr

aft D

ecem

ber 2

013

Tabl

e 3:

Cro

ss-c

ount

ry c

ompa

rison

of C

HW p

rogr

am g

over

nanc

e6

K

EY

GO

VER

NAN

CE

CO

NS

IDER

ATIO

NS

REL

EVA

NC

E A

ND

IM

PO

RTA

NC

E O

F TH

E IS

SU

E

CO

UN

TRY

BR

AZI

L FA

MIL

Y H

EALT

H

PR

OG

RA

M

PA

KIS

TAN

LA

DY

HEA

LTH

W

OR

KER

P

RO

GR

AM

IND

IA

AS

HA

PR

OG

RA

M

SO

UTH

AFR

ICA

WA

RD

-BA

SED

P

RIM

AR

Y H

EALT

H

CA

RE

(PH

C)

OU

TREA

CH

TEA

MS

ETH

IOP

IA

HEA

LTH

EXT

ENS

ION

P

RO

GR

AM

Ince

ptio

n ye

ar

(as

a na

tiona

l pro

gram

) 1

99

4

19

94

2

00

5

20

11

2

00

3

Cad

res

Is th

ere

one

or a

re

ther

e se

vera

l ca

dres

?

His

toric

al

expe

rienc

es, b

oth

nega

tive

and

posi

tive,

may

sh

ape

view

s an

d re

spon

ses.

D

iver

sity

and

un

clea

r bo

unda

ries

can

lead

to c

onfli

ct

amon

g ca

dres

an

d/or

gap

s in

pr

ovis

ion

Com

mun

ity

Hea

lth A

gent

(C

HA)

Lady

Hea

lth

Wor

ker

(LH

W)

Accr

edite

d S

ocia

l H

ealth

Act

ivis

t (A

SH

A)

Com

mun

ity H

ealth

W

orke

r H

ealth

Ext

ensi

on

Wor

kers

(HEW

s)

Hea

lth D

evel

opm

ent

Arm

y (H

DA,

form

erly

ca

lled

Com

mun

ity

Hea

lth P

rom

oter

s, o

r C

HPs

) Va

rious

oth

er C

HW

ca

dres

incl

udin

g C

omm

unity

-Bas

ed

Rep

rodu

ctiv

e H

ealth

Ag

ents

(CB

RH

As)

and

HIV

lay

coun

selo

rs

Siz

e of

the

pr

ogra

m

Is th

is a

nat

iona

l or

sm

all-s

cale

lo

cal p

rogr

am?

Siz

e an

d sc

ope

of

prog

ram

impa

cts

on th

e co

mpl

exity

of

gov

erni

ng th

e pr

ogra

m

23

6,0

00

wor

king

in

33

,00

0 fa

mily

he

alth

car

e te

ams

10

0,0

00

8

20

,00

0 A

SH

As

have

bee

n se

lect

ed (a

cros

s 3

1 S

tate

s an

d U

nion

Ter

ritor

ies)

Prio

r to

pro

ject

in

itiat

ion

ther

e w

ere

arou

nd

72

,00

0 C

HW

s,

atta

ched

to

vario

us N

GO

s an

d pr

ogra

ms

>3

4,0

00

HEW

s;

>1

00

,00

0 C

HPs

in

15

,00

0 k

ebel

es

(com

mun

ities

)

6 T

he in

form

atio

n in

this

tabl

e is

dra

wn

from

the

case

stu

dies

in th

e Ap

pend

ix a

t the

end

of t

his

guid

e.

4–17

Dr

aft D

ecem

ber 2

013

K

EY

GO

VER

NAN

CE

CO

NS

IDER

ATIO

NS

REL

EVA

NC

E A

ND

IM

PO

RTA

NC

E O

F TH

E IS

SU

E

CO

UN

TRY

BR

AZI

L FA

MIL

Y H

EALT

H

PR

OG

RA

M

PA

KIS

TAN

LA

DY

HEA

LTH

W

OR

KER

P

RO

GR

AM

IND

IA

AS

HA

PR

OG

RA

M

SO

UTH

AFR

ICA

WA

RD

-BA

SED

P

RIM

AR

Y H

EALT

H

CA

RE

(PH

C)

OU

TREA

CH

TEA

MS

ETH

IOP

IA

HEA

LTH

EXT

ENS

ION

P

RO

GR

AM

Ince

ptio

n ye

ar

(as

a na

tiona

l pro

gram

) 1

99

4

19

94

2

00

5

20

11

2

00

3

His

tori

cal

lega

cies

Ar

e th

ere

impo

rtan

t hea

lth

syst

em le

gaci

es in

re

latio

n to

how

pr

ogra

ms

are

gove

rned

, and

in

term

s of

key

pl

ayer

s an

d sp

ecifi

c in

stitu

tions

, fin

anci

al o

r de

liver

y ar

rang

emen

ts th

at

may

sha

pe C

HW

po

licy-

mak

ing?

To

wha

t ext

ent a

re

thes

e hi

stor

ical

le

gaci

es in

al

ignm

ent w

ith th

e pl

anne

d po

licy?

W

hat s

cope

is

ther

e fo

r bu

ildin

g on

or

re-s

hapi

ng

the

polic

y or

by

pass

ing

thes

e le

gaci

es?

His

toric

al le

gaci

es

may

def

ine,

co

nstr

ain

or

faci

litat

e C

HW

po

licie

s. P

olic

y m

ay b

e sh

aped

by

prev

ious

ex

perie

nce

or

exis

ting

prac

tices

. Le

gaci

es w

ill

dete

rmin

e w

hat

acto

rs th

ink

of

polic

y an

d ho

w

they

will

ena

ct

and

reac

t to

it

The

prog

ram

has

its

ant

eced

ents

in

a r

egio

nal

prog

ram

in C

eará

S

tate

, whe

re it

em

erge

d fr

om a

n em

erge

ncy

resp

onse

to a

se

vere

dra

ught

. 26

In 1

99

3 P

akis

tan

esta

blis

hed

the

Prim

e M

inis

ter’

s Pr

ogra

m fo

r Fa

mily

Pl

anni

ng a

nd

Prim

ary

Hea

lth

Car

e th

at

empl

oyed

CH

Ws

to

prov

ide

prim

ary

heal

th c

are

serv

ices

in th

eir

com

mun

ities

. The

pr

ogra

m

subs

eque

ntly

onl

y em

ploy

ed fe

mal

e C

HW

s an

d th

e La

dy H

ealth

W

orke

r (L

HW

) pr

ogra

m w

as

deve

lope

d in

1

99

4.

ASH

As a

re th

e m

ost r

ecen

t in

carn

atio

n of

co

mm

unity

hea

lth

wor

kers

(CH

Ws)

in

a lo

ng h

isto

ry o

f na

tiona

l and

sta

te-

leve

l CH

W

prog

ram

s in

Indi

a.

In m

any

stat

es, t

he

ASH

A pr

ogra

m

built

upo

n pr

e-ex

istin

g C

HW

pr

ogra

ms.

Th

e C

hhat

tisga

rh

Mita

nin

CH

W

prog

ram

, lau

nche

d in

20

03

as

a pr

ecur

sor

to th

e AS

HA

prog

ram

, ha

s re

tain

ed th

e na

me

“Mita

nin”

for

thei

r he

alth

w

orke

rs b

ut h

as

othe

rwis

e be

en

enco

mpa

ssed

by

the

ASH

A pr

ogra

m.

Sou

th A

fric

a ha

s ne

ver

had

a la

rge-

scal

e, n

atio

nal

com

mun

ity h

ealth

w

orke

r pr

ogra

m,

but h

as h

ad

num

erou

s sm

alle

r an

d la

rger

CH

W

proj

ects

sin

ce th

e 1

98

0s.

In th

e 1

99

0s

and

early

2

00

0s

thes

e C

HW

s of

ten

wor

ked

as

volu

ntee

rs a

nd

sing

le-p

urpo

se

wor

kers

, with

in

secu

re fu

ndin

g.

The

pres

ent

emer

ging

nat

iona

l pr

ogra

m b

uild

s on

th

is “

stoc

k” o

f C

HW

s an

d th

eir

expe

rienc

e.

In th

e 1

99

7/8

fisc

al

year

the

Ethi

opia

n Fe

dera

l Min

istr

y of

H

ealth

laun

ched

the

Nat

iona

l Hea

lth

Sec

tor

Dev

elop

men

t Pr

ogra

m (H

SD

P).

This

pro

gram

shi

fted

th

e he

alth

sys

tem

’s

focu

s fr

om

pred

omin

antly

cu

rativ

e to

mor

e pr

even

tive

and

prom

otiv

e ca

re a

nd

prio

ritiz

ed th

e ne

eds

of th

e ru

ral

inha

bita

nts

who

co

nstit

ute

83

% o

f th

e Et

hiop

ian

popu

latio

n. T

he

“Acc

eler

ated

Ex

pans

ion

of

Prim

ary

Hea

lth C

are

Cov

erag

e” a

nd th

e H

ealth

Ext

ensi

on

Prog

ram

(HEP

) was

la

unch

ed in

20

03

.

4–18

Dr

aft D

ecem

ber 2

013

K

EY

GO

VER

NAN

CE

CO

NS

IDER

ATIO

NS

REL

EVA

NC

E A

ND

IM

PO

RTA

NC

E O

F TH

E IS

SU

E

CO

UN

TRY

BR

AZI

L FA

MIL

Y H

EALT

H

PR

OG

RA

M

PA

KIS

TAN

LA

DY

HEA

LTH

W

OR

KER

P

RO

GR

AM

IND

IA

AS

HA

PR

OG

RA

M

SO

UTH

AFR

ICA

WA

RD

-BA

SED

P

RIM

AR

Y H

EALT

H

CA

RE

(PH

C)

OU

TREA

CH

TEA

MS

ETH

IOP

IA

HEA

LTH

EXT

ENS

ION

P

RO

GR

AM

Ince

ptio

n ye

ar

(as

a na

tiona

l pro

gram

) 1

99

4

19

94

2

00

5

20

11

2

00

3

Hea

lth s

yste

m

stru

ctur

e H

ow d

oes

CH

W

polic

y fit

into

wid

er

heal

th g

over

nanc

e st

ruct

ures

?

CH

W p

rogr

ams

in

man

y se

ttin

gs

rem

ain

perip

hera

l to

the

rest

of t

he

heal

th s

yste

m.

This

und

erm

ines

th

eir

legi

timac

y,

ham

pers

al

ignm

ent o

f ta

sks

and

resp

onsi

bilit

ies,

an

d m

ay c

ut th

em

off f

rom

m

ains

trea

m

fund

ing

sour

ces.

Ther

e ar

e th

ree

leve

ls o

f hea

lth

care

pro

vide

d in

B

razi

l with

str

ong

emph

asis

on

basi

c (p

rimar

y) h

ealth

ca

re. T

his

care

is

the

entr

y po

int t

o m

ore

adva

nced

ca

re, b

ut a

lso

has

prom

otiv

e an

d pr

even

tive

com

pone

nts.

Fa

mily

Hea

lth C

are

Team

s ar

e th

e m

ain

serv

ice

prov

ider

s an

d ar

e co

mpr

ised

of o

ne

doct

or, o

ne n

urse

, on

e au

xilia

ry

(ass

ista

nt) n

urse

, an

d a

min

imum

of

four

com

mun

ity

heal

th w

orke

rs.

Ther

e ar

e th

ree

tiers

of

gov

erna

nce

in th

e Pa

kist

ani p

ublic

he

alth

sys

tem

: fe

dera

l, pr

ovin

cial

an

d di

stric

t. R

espo

nsib

ility

for

heal

th s

ervi

ces

rest

s w

ith p

rovi

nces

, w

ith th

e ex

cept

ion

of a

nat

iona

l M

inis

try

of

Reg

ulat

ion.

Th

e di

stric

t lev

el is

re

spon

sibl

e fo

r al

loca

tion

and

supe

rvis

ion

of

LHW

s. A

ll tie

rs o

f go

vern

men

t are

in

volv

ed in

the

LHW

pr

ogra

m, a

nd L

HW

s ar

e in

tegr

al to

se

rvic

e de

liver

y of

m

ost c

omm

unity

he

alth

initi

ativ

es in

th

e co

untr

y.

The

rura

l pub

lic

heal

th s

yste

m is

de

sign

ed fr

om th

e vi

llage

to th

e st

ate

leve

l. In

add

ition

to

an A

SH

A w

orke

r,

each

vill

age

shou

ld

have

an

Anga

nwad

i W

orke

r (A

WW

). A

mul

tipur

pose

w

orke

r (M

PW) a

nd

an a

uxili

ary

nurs

e m

idw

ife (A

NM

) are

em

ploy

ed to

co

nduc

t out

reac

h to

vi

llage

s on

a

mon

thly

bas

is. T

he

MPW

wor

ks o

ut o

f th

e su

b-ce

nter

, a

clin

ic th

at s

erve

s se

vera

l vill

ages

. The

AN

M is

bas

ed in

the

prim

ary

heal

th

cent

er (P

HC

), a

larg

er c

linic

that

is

to b

e op

en 2

4/7

an

d in

clud

es a

do

ctor

. Ref

erra

ls

can

be m

ade

from

th

ere

to th

e co

mm

unity

hea

lth

cent

er (C

HC

) and

di

stric

t hos

pita

l.

Sou

th A

fric

a in

trod

uced

a d

istr

ict

heal

th s

yste

m

shor

tly a

fter

its

first

de

moc

ratic

ele

ctio

n in

19

94

. The

mos

t re

cent

hea

lth s

ecto

r re

form

s, a

imin

g at

re

vita

lizin

g PH

C,

have

intr

oduc

ed

com

mun

ity h

ealth

se

rvic

es c

onsi

stin

g of

clin

ics,

sch

ool

heal

th te

ams,

sp

ecia

list t

eam

s,

and

PHC

out

reac

h te

ams

at

com

mun

ity a

nd

hous

ehol

d le

vels

. Fi

rst-

leve

l hos

pita

l ca

re is

ren

dere

d th

roug

h di

stric

t ho

spita

ls, a

nd

refe

rral

s ta

ke p

lace

fr

om th

ese

to

seco

ndar

y an

d te

rtia

ry h

ospi

tals

.

The

Ethi

opia

n he

alth

sy

stem

is

dece

ntra

lized

and

ha

s be

en r

eorg

aniz

ed

into

thre

e tie

rs: (

1)

prim

ary

heal

thca

re

units

com

pris

ed o

f a

heal

th c

ente

r an

d fiv

e sa

telli

te h

ealth

pos

ts

alon

g w

ith

dist

rict/

wor

eda

hosp

itals

; (2

) zo

nal/

gene

ral

hosp

itals

; and

(3)

spec

ializ

ed/r

efer

ral

hosp

itals

.

4–19

Dr

aft D

ecem

ber 2

013

K

EY

GO

VER

NAN

CE

CO

NS

IDER

ATIO

NS

REL

EVA

NC

E A

ND

IM

PO

RTA

NC

E O

F TH

E IS

SU

E

CO

UN

TRY

BR

AZI

L FA

MIL

Y H

EALT

H

PR

OG

RA

M

PA

KIS

TAN

LA

DY

HEA

LTH

W

OR

KER

P

RO

GR

AM

IND

IA

AS

HA

PR

OG

RA

M

SO

UTH

AFR

ICA

WA

RD

-BA

SED

P

RIM

AR

Y H

EALT

H

CA

RE

(PH

C)

OU

TREA

CH

TEA

MS

ETH

IOP

IA

HEA

LTH

EXT

ENS

ION

P

RO

GR

AM

Ince

ptio

n ye

ar

(as

a na

tiona

l pro

gram

) 1

99

4

19

94

2

00

5

20

11

2

00

3

Str

uctu

re o

f th

e pr

ogra

m

How

is th

e pr

ogra

m

inte

grat

ed/a

ligne

d w

ith th

e fo

rmal

he

alth

sys

tem

?

Sig

nals

how

the

prog

ram

is

loca

ted

in th

e go

vern

ance

st

ruct

ures

of

heal

th s

yste

m.

CH

As o

pera

te a

s m

embe

rs o

f the

fa

mily

hea

lth

care

team

s (E

quip

o de

Saú

de

Fam

iliar

) tha

t are

m

anag

ed b

y m

unic

ipal

ities

. Th

ese

team

s ar

e ba

sed

with

in th

e Fa

mily

Hea

lth

Prog

ram

clin

ics

and

prov

ide

serv

ices

to 6

00

-1

,00

0 fa

mili

es o

r a

max

imum

of

4,5

00

peo

ple.

LHW

s ar

e at

tach

ed

to a

loca

l hea

lth

faci

lity,

but

they

ar

e pr

imar

ily

com

mun

ity-b

ased

, w

orki

ng fr

om th

eir

hom

es. T

he h

omes

of

LH

Ws

are

nam

ed H

ealth

H

ouse

s, a

nd

emer

genc

y tr

eatm

ent a

nd c

are

are

prov

ided

from

th

ese

hous

es.

ASH

As a

re b

ased

in

thei

r vi

llage

s bu

t re

fer

peop

le to

th

eir

loca

l CH

C a

nd

PHC

. Vill

age

Hea

lth

and

San

itatio

n C

omm

ittee

s (V

HS

Cs)

, co

mpo

sed

of

villa

ge r

esid

ents

in

clud

ing

the

ASH

A, a

lso

prov

ide

supp

ort f

or th

e AS

HA’

s ac

tiviti

es

(see

: Loc

al

Gov

erna

nce)

. Al

thou

gh s

ervi

ce

deliv

ery

varie

s by

st

ate,

in g

ener

al,

ASH

As a

re

expe

cted

to a

tten

d w

eekl

y m

eetin

gs a

t th

eir

loca

l PH

C a

nd

mak

e ho

me

visi

ts

in th

e co

mm

unity

as

nee

ded.

The

y w

ork

appr

oxim

atel

y 2

ho

urs

a da

y, fo

ur

days

per

wee

k.

The

new

sys

tem

fo

r th

e fir

st ti

me

sees

CH

W a

s pa

rt

of th

e sy

stem

of

serv

ice

deliv

ery.

S

imila

r to

the

Bra

zilia

n m

odel

, PH

C o

utre

ach

team

s co

nsis

t of 5

-6

CH

Ws

supe

rvis

ed b

y a

nurs

e. T

hey

rend

er

serv

ices

in

hous

ehol

ds a

nd

com

mun

ities

, and

re

fer

patie

nts

to

clin

ics

as n

eede

d.

The

aim

of t

he H

EP

is to

“pr

ovid

e eq

uita

ble

acce

ss to

pr

omot

ive,

pr

even

tive

and

sele

ct c

urat

ive

heal

th in

terv

entio

ns

thro

ugh

30

,00

0

gove

rnm

ent-s

alar

ied

Hea

lth E

xten

sion

W

orke

rs (H

EWs)

, tw

o pe

r ke

bele

(n

eigh

borh

ood)

, lo

cate

d at

a h

ealth

po

st. T

he H

EWs,

yo

ung

loca

l wom

en

with

gra

de 1

0

educ

atio

n, a

re

recr

uite

d by

Keb

ele

and

Wor

eda

Cou

ncils

and

giv

en

one

year

of t

rain

ing

prio

r to

em

ploy

men

t w

ith th

e W

ored

a H

ealth

Off

ice.

4–20

Dr

aft D

ecem

ber 2

013

K

EY

GO

VER

NAN

CE

CO

NS

IDER

ATIO

NS

REL

EVA

NC

E A

ND

IM

PO

RTA

NC

E O

F TH

E IS

SU

E

CO

UN

TRY

BR

AZI

L FA

MIL

Y H

EALT

H

PR

OG

RA

M

PA

KIS

TAN

LA

DY

HEA

LTH

W

OR

KER

P

RO

GR

AM

IND

IA

AS

HA

PR

OG

RA

M

SO

UTH

AFR

ICA

WA

RD

-BA

SED

P

RIM

AR

Y H

EALT

H

CA

RE

(PH

C)

OU

TREA

CH

TEA

MS

ETH

IOP

IA

HEA

LTH

EXT

ENS

ION

P

RO

GR

AM

Ince

ptio

n ye

ar

(as

a na

tiona

l pro

gram

) 1

99

4

19

94

2

00

5

20

11

2

00

3

Empl

oym

ent

stat

us o

f CH

Ws

Are

CHW

s em

ploy

ees

of th

e st

ate

and/

or

appo

inte

d by

co

mm

uniti

es?

Sign

als

who

CH

Ws

are

acco

unta

ble

to,

and

how

firm

ly

embe

dded

they

ar

e in

stru

ctur

es

of th

e he

alth

sy

stem

.

Sta

te e

mpl

oyee

sS

tate

em

ploy

ees

Con

side

red

volu

ntee

rs b

ut

rece

ive

a go

vern

men

t st

ipen

d.

Empl

oyed

by

NG

Os

who

in tu

rn h

ave

serv

ice

cont

ract

s w

ith s

tate

hea

lth

serv

ices

at d

istr

ict

leve

l.

Sta

te e

mpl

oyee

s

Pro

gram

fin

anci

ng

How

are

CH

W

prog

ram

s fin

ance

d?

How

CH

W

prog

ram

s ar

e fin

ance

d re

flect

s bo

th n

atio

nal a

nd

loca

l prio

ritie

s an

d is

als

o a

key

gove

rnan

ce

mec

hani

sm.

The

Fam

ily

Hea

lth P

rogr

am

is c

o-fu

nded

by

stat

es a

nd

mun

icip

aliti

es,

but r

egul

ated

by

the

natio

nal

gove

rnm

ent.

The

CH

W p

rogr

am is

an

inte

gral

par

t of

Fam

ily H

ealth

Pr

ogra

m a

nd

thus

fund

ed a

s pa

rt o

f it.

The

Paki

stan

i go

vern

men

t is

the

larg

est f

unde

r of

LH

W s

ervi

ces,

al

thou

gh th

e pr

ogra

m h

as b

een

unde

rfun

ded

sinc

e its

ince

ptio

n. T

he

vast

maj

ority

(a

roun

d 7

0%

) of

the

cost

s ar

e co

mpr

ised

of L

HW

st

ipen

ds, d

rugs

an

d co

ntra

cept

ives

. 4%

of

ove

rall

cost

s ar

e fo

r tr

aini

ng.

In 2

00

6, t

he

MoH

FW s

tipul

ated

th

at th

e pr

ogra

m

wou

ld c

ost

US

$1

85

per

AS

HA.

Th

is in

clud

ed th

e co

sts

of s

elec

tion,

so

cial

mob

iliza

tion,

tr

aini

ng, d

rug

kits

, id

entit

y ca

rds

and

supp

ort f

or A

SH

As

thro

ugh

the

PHC

s an

d su

perv

isor

s. It

di

d no

t inc

lude

the

ASH

As’ s

tipen

ds,

whi

ch w

ere

to

com

e fr

om th

e bu

dget

s of

oth

er

MoH

FW in

itiat

ives

.

In th

e pa

st,

prog

ram

s w

ere

larg

ely

fund

ed

from

ext

erna

l gr

ants

. The

new

pr

ogra

m w

ill

incr

easi

ngly

be

fund

ed th

roug

h th

e he

alth

bud

get.

Fina

nced

by

a m

ix o

f na

tiona

l and

sub

-na

tiona

l gov

ernm

ent

entit

ies,

bila

tera

l an

d m

ultil

ater

al

dono

rs, n

on-

gove

rnm

enta

l or

gani

zatio

ns,

priv

ate

cont

ribut

ions

, alo

ng

with

use

r fe

e re

venu

es.

At th

e lo

cal l

evel

, fin

anci

ng a

nd

plan

ning

are

de

cent

raliz

ed a

nd

the

wor

edas

rec

eive

bl

ock

gran

ts to

co

ver

HEP

ex

pens

es.

4–21

Dr

aft D

ecem

ber 2

013

K

EY

GO

VER

NAN

CE

CO

NS

IDER

ATIO

NS

REL

EVA

NC

E A

ND

IM

PO

RTA

NC

E O

F TH

E IS

SU

E

CO

UN

TRY

BR

AZI

L FA

MIL

Y H

EALT

H

PR

OG

RA

M

PA

KIS

TAN

LA

DY

HEA

LTH

W

OR

KER

P

RO

GR

AM

IND

IA

AS

HA

PR

OG

RA

M

SO

UTH

AFR

ICA

WA

RD

-BA

SED

P

RIM

AR

Y H

EALT

H

CA

RE

(PH

C)

OU

TREA

CH

TEA

MS

ETH

IOP

IA

HEA

LTH

EXT

ENS

ION

P

RO

GR

AM

Ince

ptio

n ye

ar

(as

a na

tiona

l pro

gram

) 1

99

4

19

94

2

00

5

20

11

2

00

3

Pro

gram

sca

le-

up

Will

the

prog

ram

be

take

n to

sca

le

and,

if s

o, h

ow w

ill

this

occ

ur?

CHW

pro

gram

s ge

nera

lly a

im to

im

prov

e ac

cess

to

and

qual

ity o

f he

alth

car

e fo

r re

mot

e an

d po

or

com

mun

ities

.

In 1

99

0 th

ere

wer

e 7

8,8

05

C

HAs

and

ther

e ar

e no

w o

ver

23

6,0

00

CH

As

that

pro

vide

se

rvic

es to

98

m

illio

n pe

ople

w

ithin

85

% o

f B

razi

l’s

mun

icip

aliti

es.

A 2

00

0 e

valu

atio

n es

timat

ed th

at

15

0,0

00

LH

Ws

wer

e ne

eded

to

obta

in o

ptim

al

cove

rage

in th

e co

untr

y. S

ince

then

th

ere

has

been

a

cons

iste

nt s

cale

-up

, to

90

,07

4 in

2

00

8. T

his

incr

ease

d LH

W

cove

rage

in m

ore

rura

l and

poo

rer

area

s, b

ut th

e pr

ogra

m s

till d

oes

not r

each

the

mos

t di

sadv

anta

ged

area

s...

Initi

ally

(20

05

-2

00

8) t

he A

SHA

prog

ram

was

a

com

pone

nt o

f the

N

atio

nal R

ural

H

ealth

Mis

sion

on

ly in

18

“H

igh

Focu

s S

tate

s” a

nd

in th

e tr

ibal

di

stric

ts o

f oth

er

stat

es. I

n 2

00

9 th

e pr

ogra

m w

as

exte

nded

to c

over

th

e en

tire

coun

try.

Th

e ta

rget

num

ber

of A

SH

As is

8

88

,65

0; 9

4%

ha

ve n

ow b

een

sele

cted

.

The

inte

ntio

n is

to

roll

the

prog

ram

ou

t nat

iona

lly.

Num

erou

s pi

lot

site

s ar

e op

erat

iona

l at t

his

stag

e an

d ar

e be

ing

care

fully

m

onito

red

and

eval

uate

d.

Ther

e ha

ve b

een

four

HS

DPs

sin

ce it

s in

cept

ion

in 1

99

7.

Rol

lout

has

occ

urre

d in

a s

tep-

wis

e m

anne

r, in

whi

ch

the

spee

d w

as

influ

ence

d by

av

aila

ble

reso

urce

s fo

r he

alth

pos

ts a

nd

pres

ence

of e

ligib

le

wom

en to

bec

ome

HEW

s.

4–22

Dr

aft D

ecem

ber 2

013

K

EY

GO

VER

NAN

CE

CO

NS

IDER

ATIO

NS

REL

EVA

NC

E A

ND

IM

PO

RTA

NC

E O

F TH

E IS

SU

E

CO

UN

TRY

BR

AZI

L FA

MIL

Y H

EALT

H

PR

OG

RA

M

PA

KIS

TAN

LA

DY

HEA

LTH

W

OR

KER

P

RO

GR

AM

IND

IA

AS

HA

PR

OG

RA

M

SO

UTH

AFR

ICA

WA

RD

-BA

SED

P

RIM

AR

Y H

EALT

H

CA

RE

(PH

C)

OU

TREA

CH

TEA

MS

ETH

IOP

IA

HEA

LTH

EXT

ENS

ION

P

RO

GR

AM

Ince

ptio

n ye

ar

(as

a na

tiona

l pro

gram

) 1

99

4

19

94

2

00

5

20

11

2

00

3

Loca

l (c

omm

unity

) go

vern

ance

How

are

co

mm

uniti

es

invo

lved

in

deci

sion

-mak

ing

abou

t CH

W

activ

ities

at l

ocal

le

vel?

Are

they

in

volv

ed in

se

lect

ion?

Can

th

ey h

old

CHW

s to

ac

coun

t? C

an th

ey

influ

ence

de

cisi

on-m

akin

g ab

out f

undi

ng,

supp

ort,

etc.

?

Com

mun

ity

acce

ptan

ce a

nd

ther

efor

e co

mm

unity

pa

rtici

patio

n is

co

nsid

ered

ce

ntra

l to

any

CHW

pro

gram

, bu

t mec

hani

sms

of c

omm

unity

pa

rtici

patio

n in

go

vern

ing

prog

ram

s ar

e of

ten

poor

ly

deve

lope

d an

d dy

sfun

ctio

nal.

Com

mun

ity

gove

rnan

ce

func

tions

thro

ugh

natio

nal,

stat

e an

d m

unic

ipal

he

alth

cou

ncils

, ov

er 5

,50

0

mun

icip

al

coun

cils

pa

rtic

ipat

ing.

C

ounc

ils a

re

com

pris

ed o

f 5

0%

use

rs, 2

5%

he

alth

wor

kers

an

d 2

5%

hea

lth

man

ager

s an

d se

rvic

e pr

ovid

ers.

H

ealth

co

nfer

ence

s ar

e al

so h

eld

ever

y fo

ur y

ears

to

prop

ose

dire

ctiv

es fo

r he

alth

pol

icie

s.

The

sele

ctio

n co

mm

ittee

for

LHW

s in

clud

es a

pe

rson

nom

inat

ed

by th

e lo

cal

com

mun

ity, a

nd

pote

ntia

l LH

Ws

are

iden

tifie

d th

roug

h lo

cal c

omm

unity

st

ruct

ures

wer

e po

ssib

le. P

rogr

am

plan

ning

, im

plem

enta

tion

and

mon

itorin

g an

d ev

alua

tion

also

sho

uld

incl

ude

com

mun

ity

part

icip

atio

n.

How

ever

, the

ex

tent

to w

hich

th

is o

ccur

s va

ries.

ASH

As a

reto

be

sele

cted

by

and

acco

unta

ble

to th

e lo

cal v

illag

e le

vel

gove

rnm

ent,

calle

d th

e G

ram

Pa

ncha

yat,

thro

ugh

a pa

rtic

ipat

ory

proc

ess

invo

lvin

g th

e w

hole

vill

age.

Af

ter

sele

ctio

n,

ASH

As a

re to

wor

k cl

osel

y w

ith th

e Vi

llage

Hea

lth a

nd

San

itatio

n C

omm

ittee

(VH

SC

). Th

is c

omm

ittee

is

com

pris

ed o

f key

st

akeh

olde

rs in

the

villa

ge.

All h

ealth

dis

tric

ts

have

dis

tric

t he

alth

cou

ncils

w

ho h

ave

repr

esen

tatio

n fr

om c

ivil

soci

ety.

Im

plem

enta

tion

is

at a

n ea

rly s

tage

an

d un

even

th

roug

hout

the

coun

try.

Fu

rthe

rmor

e,

com

mun

ity h

ealth

co

mm

ittee

s ar

e su

ppos

ed to

ov

erse

e th

e fu

nctio

ning

of

serv

ice

deliv

ery

in

com

mun

ities

and

fa

cilit

ies.

Ther

e ar

e ac

tive

heal

th c

omm

ittee

s in

volv

ed in

the

sele

ctio

n an

d ov

ersi

ght o

f HEW

s an

d th

ey a

re

invo

lved

in th

ese

activ

ities

with

CH

Ps

in s

ome

geog

raph

ical

are

as.

Addi

tiona

lly, t

he

kebe

le c

ounc

il is

su

ppos

ed to

be

invo

lved

in e

very

st

ep o

f the

HEP

from

pr

ogra

m p

lann

ing

thro

ugh

to

eval

uatio

n.

4–23

Dr

aft D

ecem

ber 2

013

K

EY

GO

VER

NAN

CE

CO

NS

IDER

ATIO

NS

REL

EVA

NC

E A

ND

IM

PO

RTA

NC

E O

F TH

E IS

SU

E

CO

UN

TRY

BR

AZI

L FA

MIL

Y H

EALT

H

PR

OG

RA

M

PA

KIS

TAN

LA

DY

HEA

LTH

W

OR

KER

P

RO

GR

AM

IND

IA

AS

HA

PR

OG

RA

M

SO

UTH

AFR

ICA

WA

RD

-BA

SED

P

RIM

AR

Y H

EALT

H

CA

RE

(PH

C)

OU

TREA

CH

TEA

MS

ETH

IOP

IA

HEA

LTH

EXT

ENS

ION

P

RO

GR

AM

Ince

ptio

n ye

ar

(as

a na

tiona

l pro

gram

) 1

99

4

19

94

2

00

5

20

11

2

00

3

Rel

atio

nshi

p w

ith

the

form

al

heal

th s

ervi

ces

Wha

t are

line

s of

re

port

ing

and

acco

unta

bilit

y?

Wha

t is

the

leve

l of

inte

grat

ion?

In m

any

CH

W

prog

ram

s, li

nks

with

the

form

al

heal

th s

ervi

ces

are

tent

ativ

e an

d no

t wel

l tho

ught

th

roug

h.

Prof

essi

onal

s at

th

e fir

st fo

rmal

le

vel o

f ser

vice

de

liver

y (h

ealth

ce

nter

s, e

tc.)

ofte

n re

sist

en

gage

men

t with

an

d su

ppor

t for

C

HW

s.

CH

As a

re

man

aged

by

loca

l nu

rses

who

sp

end

half

thei

r tim

e w

orki

ng in

th

e lo

cal c

linic

. Th

us, C

HAs

are

cl

osel

y in

tegr

ated

in

to fo

rmal

hea

lth

serv

ices

. The

y al

so h

ave

stro

ng

refe

rral

sys

tem

s in

whi

ch th

ey

repo

rt a

ny il

l pe

rson

with

in

thei

r ca

tchm

ent

area

to a

nur

se.

All L

HW

s ar

e at

tach

ed to

a F

irst

Leve

l Hea

lth

Faci

lity

in th

e fo

rm

of e

ither

a r

ural

he

alth

cen

ter

or a

ba

sic

heal

th u

nit.

LHW

s ge

nera

lly

rece

ive

thei

r su

pplie

s fr

om

thes

e fa

cilit

ies,

al

thou

gh th

ere

are

chal

leng

es w

ith

insu

ffic

ient

sta

ff

and

stoc

k ou

ts a

t lo

cal c

linic

s.

Alth

ough

AS

HAs

ar

e su

ppos

ed to

be

rep

rese

ntat

ives

of

and

ac

coun

tabl

e to

the

peop

le, t

hey

rece

ive

thei

r pa

ymen

ts th

roug

h th

e AN

M a

t the

PH

C a

nd a

re o

ften

tr

eate

d as

ex

tens

ions

of t

he

heal

th s

yste

m.

CH

Ws

are

man

aged

by

nurs

es a

nd

stru

ctur

ally

link

ed

to th

e fo

rmal

he

alth

ser

vice

s.

Prio

r pr

actic

es a

nd

expe

rienc

es w

ere

very

mix

ed a

nd

depe

nden

t on

links

bet

wee

n N

GO

s an

d he

alth

se

rvic

es. T

hey

wer

e of

ten

depe

nden

t on

pers

onal

re

latio

nshi

ps a

s w

ell.

HEW

s ar

e fu

ll m

embe

rs o

f the

fo

rmal

hea

lth

wor

kfor

ce. T

hey

staf

f hea

lth p

osts

an

d ar

e re

spon

sibl

e fo

r C

HPs

and

mod

el

fam

ilies

. Man

y H

EWs

wor

k in

har

d-to

-rea

ch a

nd

isol

ated

are

as,

whe

re s

uper

visi

on,

supp

lies

and

refe

rral

s re

mai

n a

chal

leng

e.

4–24

Dr

aft D

ecem

ber 2

013

Tabl

e 4.

Gov

erna

nce

stru

ctur

es a

nd m

echa

nism

s in

rela

tion

to th

e de

finiti

on, s

elec

tion,

trai

ning

, sup

port

and

rem

uner

atio

n of

indi

vidu

al C

HWs7

GO

VER

NA

NC

E IS

SU

E B

RA

ZIL

PA

KIS

TAN

IND

IA

SO

UTH

AFR

ICA

ETH

IOP

IA

CH

W C

rite

ria

CH

As a

re a

dults

who

wor

k in

th

e co

mm

unity

whe

re th

ey

are

from

/ pe

rman

ently

re

side

. The

onl

y ot

her

sele

ctio

n cr

iterio

n is

co

mpl

etio

n of

prim

ary

scho

ol.

LHW

s ar

e fe

mal

es w

ho

have

a m

inim

um o

f eig

ht

year

s of

edu

catio

n. T

hey

also

mus

t be

betw

een

18

an

d 4

5-5

0 y

ears

old

, re

side

in a

nd b

e ac

cept

able

to/

reco

mm

ende

d by

thei

r co

mm

unity

, and

pre

fera

bly

be m

arrie

d w

ith c

hild

ren.

ASH

As a

re to

hav

e cl

ass

eigh

t edu

catio

n or

hig

her

and

pref

erab

ly b

e be

twee

n th

e ag

es o

f 25

and

45

. AS

HAs

are

to b

e “d

augh

ter-

in-la

w”

of th

e vi

llage

, i.e

., m

arrie

d w

omen

(or

wid

owed

or

div

orce

d) s

o th

at th

ey a

re

likel

y to

live

in th

e vi

llage

for

the

fore

seea

ble

futu

re.

Crit

eria

for

sele

ctio

n va

ry, b

ut in

mos

t ca

ses,

cad

res

who

w

ere

activ

e th

roug

h N

GO

s pr

ior

to th

e in

trod

uctio

n of

a

natio

nal p

rogr

am a

re

bein

g dr

awn

on to

co

ntin

ue r

ende

ring

serv

ices

.

HEW

s ar

e ad

ult f

emal

es

who

hav

e co

mpl

eted

1

0th

gra

de. H

EWs

are

supp

osed

to w

ork

in o

r cl

ose

to th

eir

nativ

e co

mm

unity

/ pe

rman

ent

resi

denc

e.

Sel

ectio

n P

roce

ss

CH

As a

re h

ired

by th

eir

mun

icip

aliti

es b

ased

on

thei

r de

mon

stra

ted

abili

ties

whi

le

addr

essi

ng s

imul

ated

co

mm

unity

pro

blem

s du

ring

the

sele

ctio

n pr

oces

s.

LHW

are

sel

ecte

d us

ing

a cl

early

del

inea

ted

proc

ess.

LH

W p

osts

are

adv

ertis

ed

and

appl

ican

ts a

re th

en

inte

rvie

wed

and

sel

ecte

d ba

sed

on p

re-s

et c

riter

ia

by a

sel

ectio

n co

mm

ittee

.

Loca

l gov

erna

nce

stru

ctur

es

and

the

wid

er c

omm

unity

sh

ould

be

invo

lved

in A

SH

A se

lect

ion.

How

ever

, the

se

sele

ctio

n pr

oces

ses

are

not

alw

ays

adhe

red

to.

Sel

ectio

n pr

oces

ses

vary

wid

ely,

de

pend

ing

on th

e N

GO

s w

ho c

ontr

act

with

the

CH

Ws.

Ther

e ar

e ac

tive

heal

th

com

mitt

ees

that

are

in

volv

ed in

the

sele

ctio

n of

HEW

s fr

om th

e lo

cal

com

mun

ity.

CH

Ps a

re n

omin

ated

and

el

ecte

d by

the

com

mun

ity o

r se

lect

ed

by H

EWs

and

appr

oved

by

the

com

mun

ity.

Sco

pe o

f Wor

k O

ne o

f the

goa

ls o

f the

Fa

mily

Hea

lth P

rogr

am is

to

prom

ote

com

mun

ity

enga

gem

ent a

nd to

ana

lyze

th

e co

mm

unity

’s n

eeds

. Th

us, C

HAs

are

exp

ecte

d to

se

rve

as th

e lin

k be

twee

n th

e Fa

mily

Hea

lth C

are

Team

s an

d th

e su

rrou

ndin

g co

mm

unity

.

Fam

ily H

ealth

Car

e Te

ams

prov

ide

com

preh

ensi

ve c

are

thro

ugh

prom

otiv

e,

prev

entiv

e, re

cupe

rativ

e, a

nd

reha

bilit

ativ

e se

rvic

es.

Cent

ral s

ervi

ces

prov

ided

by

CHAs

incl

ude

the

prom

otio

n of

bre

astfe

edin

g, th

e

LHW

s ar

e ex

pect

ed to

link

th

e co

mm

unity

to fo

rmal

he

alth

ser

vice

s an

d to

be

mem

bers

of t

he

com

mun

ity w

here

they

w

ork.

The

y al

so p

rovi

de a

ra

nge

of c

omm

unity

de

velo

pmen

t ser

vice

s an

d pa

rtic

ipat

e in

com

mun

ity

mee

tings

.

The

LHW

pro

gram

has

ev

olve

d ov

er ti

me.

LH

Ws’

sc

ope

of s

ervi

ces

has

grow

n fr

om a

n in

itial

focu

s on

mos

tly m

ater

nal a

nd

child

hea

lth; i

t now

als

o in

clud

es p

artic

ipat

ion

in

larg

e he

alth

cam

paig

ns,

The

gove

rnm

ent o

f Ind

ia

desc

ribes

the

ASH

A’s

role

as

havi

ng th

ree

key

com

pone

nts.

Firs

t, AS

HAs

ar

e to

pla

y an

impo

rtan

t rol

e in

ach

ievi

ng n

atio

nal h

ealth

an

d po

pula

tion

polic

y go

als.

S

econ

d, th

ey a

re to

act

link

ru

ral p

eopl

e w

ith th

e he

alth

sy

stem

. Thi

rd, t

hey

are

to

serv

e as

soc

ial c

hang

e ag

ents

who

will

cre

ate

awar

enes

s on

hea

lth a

nd it

s so

cial

det

erm

inan

ts a

nd

mob

ilize

the

com

mun

ity

tow

ards

loca

l hea

lth

plan

ning

and

incr

ease

d ut

iliza

tion

and

acco

unta

bilit

y

A PH

C o

utre

ach

team

w

ill in

itial

ly b

e re

spon

sibl

e fo

r:

Id

entif

ying

and

ca

ptur

ing

deta

ils

of p

eopl

e w

ho

live

in th

e ho

useh

olds

in

the

catc

hmen

t ar

ea a

nd

asse

ssin

g th

ose

who

are

mos

t at

risk;

Prov

idin

g he

alth

pr

omot

ion

and

prev

entio

n;

Te

stin

g fo

r H

IV

and

scre

enin

g fo

r

HEW

s ar

e fu

ll-tim

e em

ploy

ees

who

are

su

ppos

ed to

spl

it th

eir

time

betw

een

heal

th

post

s an

d th

e co

mm

unity

. HEW

s sh

ould

spe

nd a

t lea

st

80

% o

f the

ir tim

e in

th

ese

com

mun

ity-b

ased

ac

tiviti

es, a

lthou

gh

cons

ider

able

ane

cdot

al

evid

ence

sug

gest

s th

is is

no

t the

cas

e.

HEW

s’ m

ain

role

is in

he

alth

pro

mot

ion,

di

seas

e pr

even

tion,

and

tr

eatm

ent o

f un

com

plic

ated

and

non

-

7 T

he in

form

atio

n in

this

tabl

e is

dra

wn

from

the

case

stu

dies

dev

elop

ed fo

r th

is s

erie

s of

cha

pter

s (s

ee A

ppen

dix

1).

4–25

Dr

aft D

ecem

ber 2

013

GO

VER

NA

NC

E IS

SU

E B

RA

ZIL

PA

KIS

TAN

IND

IA

SO

UTH

AFR

ICA

ETH

IOP

IA

prov

isio

n of

pre

nata

l, ne

onat

al a

nd c

hild

car

e, th

e pr

ovis

ion

of im

mun

izat

ions

, an

d th

e cl

inic

al m

anag

emen

t of

infe

ctio

us d

isea

ses,

in

clud

ing

scre

enin

g fo

r and

pr

ovid

ing

treat

men

t for

H

IV/A

IDs

and

tube

rcul

osis

. C

HAs

reg

iste

r th

e ho

useh

olds

in th

e ar

eas

whe

re th

ey w

ork

and

are

also

are

exp

ecte

d to

em

pow

er th

eir

com

mun

ities

an

d lin

k th

em to

the

form

al

heal

th s

yste

m.

new

born

car

e, c

omm

unity

m

anag

emen

t of

tube

rcul

osis

and

hea

lth

educ

atio

n on

HIV

/AID

S.

of th

e ex

istin

g he

alth

se

rvic

es.

Anga

nwad

i Wor

kers

(AW

Ws)

pr

ovid

e ba

sic

child

hea

lth

info

rmat

ion,

med

icin

e an

d nu

triti

onal

sup

plem

enta

tion

to c

hild

ren

youn

ger

than

6

year

s of

age

, pre

gnan

t and

la

ctat

ing

wom

en, a

nd

adol

esce

nt g

irls.

TB;

C

heck

ing

imm

uniz

atio

n st

atus

of

child

ren;

Faci

litat

ing

use

of

ante

nata

l car

e ea

rly in

pr

egna

ncy

and

use

of

cont

race

ptio

n;

and

R

espo

ndin

g to

th

e lo

cal b

urde

n of

dis

ease

.

seve

re c

ases

of m

alar

ia,

pneu

mon

ia, d

iarr

hea,

m

alnu

triti

on a

nd

mea

sles

in th

e co

mm

unity

. HEW

s pr

ovid

e a

rang

e of

se

rvic

es in

clud

ing:

pr

even

tion/

heal

th

prom

otio

n/he

alth

ed

ucat

ion

role

; sup

port

ro

le fo

r ou

trea

ch w

ork

by

heal

th s

ervi

ces;

co

mm

unity

-bas

ed

dist

ribut

ion

role

that

do

es n

ot in

volv

e cl

inic

al

judg

men

t; cl

inic

al c

ase-

man

agem

ent r

ole

that

in

volv

es e

xerc

isin

g cl

inic

al ju

dgm

ent;

ongo

ing

care

or

supp

ort

role

to a

ssis

t peo

ple

with

a

chro

nic

illne

ss (e

.g.,

HIV

/AID

S);

and

part

icip

atio

n or

sup

port

ro

le in

cam

paig

n-ty

pe

activ

ities

. The

y al

so

prov

ide

imm

uniz

atio

ns,

inje

ctab

le

cont

race

ptiv

es, b

asic

fir

st a

id, a

s w

ell a

s di

agno

sis

and

trea

tmen

t of

mal

aria

, dia

rrhe

a an

d in

test

inal

par

asite

s.

Trai

ning

Th

e na

tiona

l Min

istr

y of

H

ealth

–w

ith M

inis

try

of

Educ

atio

n ap

prov

al –

is

resp

onsi

ble

for

the

trai

ning

of

CH

As in

Bra

zil a

nd tr

ains

th

em in

reg

iona

l hea

lth

scho

ols.

CH

As r

ecei

ve e

ight

w

eeks

of t

rain

ing

from

loca

l nu

rses

, fol

low

ed b

y fo

ur

LHW

s ar

e tr

aine

d fo

r th

ree

mon

ths

on P

HC

in

clas

sroo

ms

and

then

hav

e on

e ye

ar o

f on-

the-

job

trai

ning

. Thi

s sh

ould

in

clud

e on

e w

eek

of

trai

ning

per

a m

onth

for

a pe

riod

of 1

2 m

onth

s an

d 1

5 d

ays

of r

efre

sher

ASH

As a

re to

rec

eive

23

da

ys o

f tra

inin

g ov

er th

eir

first

yea

r, b

ased

on

five

trai

ning

man

uals

. The

y ar

e th

en to

rec

eive

12

add

ition

al

days

of t

rain

ing

each

yea

r th

erea

fter

. Tw

o ad

ditio

nal

trai

ning

mod

ules

hav

e ju

st

been

add

ed to

the

trai

ning

The

trai

ning

exi

stin

g C

HW

s ha

ve r

ecei

ved

varie

s w

idel

y, a

nd h

as

been

pro

vide

d by

a

wid

e ra

nge

of N

GO

s an

d tr

aini

ng

prov

ider

s. T

he M

OH

is

now

aim

ing

to

stan

dard

ize

trai

ning

,

HEW

s ha

ve m

ore

than

on

e ye

ar o

f pre

-ser

vice

tr

aini

ng c

ondu

cted

by

trai

ners

that

wer

e ca

paci

tate

d us

ing

a tr

ain-

the-

trai

ner

appr

oach

. HEW

trai

ning

is

a c

olla

bora

tion

of th

e M

inis

try

of H

ealth

and

4–26

Dr

aft D

ecem

ber 2

013

GO

VER

NA

NC

E IS

SU

E B

RA

ZIL

PA

KIS

TAN

IND

IA

SO

UTH

AFR

ICA

ETH

IOP

IA

wee

ks o

f sup

ervi

sed

field

w

ork.

Thi

s in

clud

es tr

aini

ng

on h

ome

visi

ts, h

ow to

co

nduc

t a fa

mily

cen

sus,

and

th

en o

n sp

ecifi

c pr

iorit

y he

alth

car

e in

terv

entio

ns.

CH

As r

ecei

ve m

onth

ly a

nd

quar

terly

ong

oing

edu

catio

n tr

aini

ng d

urin

g m

eetin

gs.

CH

As a

re a

lso

trai

ned

by

nurs

es a

nd s

tate

hea

lth

secr

etar

iat s

taff

in th

eir

loca

l cl

inic

s; th

ese

trai

ners

un

derg

o an

80

-hou

r tr

aini

ng

mod

ule.

trai

ning

eac

h ye

ar,

alth

ough

ther

e is

su

bsta

ntia

l var

iatio

n in

tr

aini

ng p

atte

rns

acro

ss

prov

ince

s. T

he F

eder

al

Proj

ect I

mpl

emen

tatio

n U

nit i

s re

spon

sibl

e fo

r ap

prov

al o

f all

LHW

tr

aini

ng a

nd, w

ith th

e M

inis

try

of H

ealth

, de

velo

ps tr

aini

ng

curr

icul

um, o

rgan

izes

and

co

ordi

nate

s tr

aini

ng, a

nd

trai

ns m

aste

r tr

aine

rs

whi

le P

rovi

ncia

l and

D

istr

ict P

roje

ct

Impl

emen

tatio

n U

nits

are

re

spon

sibl

e fo

r th

e lo

cal

trai

ning

s.

regi

men

. AS

HA

trai

ning

has

in

som

e st

ates

bee

n ou

tsou

rced

to N

GO

s, a

nd in

ot

her

stat

es is

bei

ng

cond

ucte

d by

hea

lth

prof

essi

onal

s w

ithin

the

publ

ic s

yste

m. T

rain

ing

gene

rally

take

s pl

ace

in a

ca

scad

ing

man

ner,

by

whi

ch

stat

e te

ams

are

trai

ned

and

then

pas

s on

thei

r tr

aini

ng

know

ledg

e to

dis

tric

t tra

inin

g te

ams.

The

se d

istr

ict t

eam

s th

en p

ass

on th

eir

trai

ning

to

bloc

k-le

vel A

SH

A tr

aine

rs.

ASH

As a

re th

en to

be

trai

ned

at th

e bl

ock

or s

ub-b

lock

le

vel.

alth

ough

this

pro

cess

is

stil

l aw

aitin

g fin

aliz

atio

n.

the

Min

istr

y of

Edu

catio

n an

d oc

curs

at 4

0

Tech

nica

l and

Voc

atio

nal

Educ

atio

n Tr

aini

ng

Sch

ools

.

CH

Ps h

ave

a br

ief i

nitia

l tr

aini

ng th

at is

co

nduc

ted

by th

e H

EWs

that

is le

ss th

an 3

wee

ks

in le

ngth

.

Wom

en fr

om m

odel

fa

mili

es a

re g

iven

96

ho

urs

of tr

aini

ng o

n pr

even

tion

of

com

mun

icab

le d

isea

ses,

fa

mily

hea

lth,

envi

ronm

enta

l and

ho

useh

old

sani

tatio

n,

and

heal

th e

duca

tion.

Feed

back

and

S

uper

visi

on

CH

As a

re s

uper

vise

d by

nu

rses

and

phy

sici

ans

from

th

e lo

cal h

ealth

cen

ters

. S

uper

viso

ry n

urse

s sp

end

50

% o

f the

ir tim

e in

thes

e su

perv

isor

y ro

les

and

the

rest

of t

he ti

me

staf

fing

the

loca

l hea

lth c

ente

r, a

fact

or

that

has

bee

n id

entif

ied

as a

cr

itica

l com

pone

nt to

the

prog

ram

’s s

ucce

ss.

Sup

ervi

sion

is h

ighl

yor

gani

zed

and

tiere

d in

the

Paki

stan

i LH

W p

rogr

am.

LHW

s ar

e ea

ch a

ttac

hed

to

a pu

blic

hea

lth c

linic

and

ar

e su

perv

ised

on

a m

onth

ly b

asis

by

a LH

W

supe

rvis

or (L

HS

). Th

ere

are

two

laye

rs o

f sup

ervi

sion

ab

ove

the

LHS.

LH

Ws

shou

ld h

ave

com

mun

ity-

base

d su

perv

isio

n at

leas

t on

ce a

mon

th in

whi

ch

supe

rvis

ors

mee

t with

cl

ient

s an

d w

ith th

e LH

Ws

in th

e co

mm

unity

whe

re

the

LHW

wor

ks, r

evie

w th

e LH

W’s

wor

k, a

nd jo

intly

m

ake

a w

ork

plan

for

the

next

mon

th.

Acco

rdin

g to

nat

iona

l gu

idel

ines

, the

re is

to b

e on

e AS

HA

Faci

litat

or fo

r ev

ery

20

AS

HAs

. The

Fac

ilita

tor

is to

he

lp w

ith th

e se

lect

ion

of th

e AS

HA,

run

mon

thly

AS

HA

mee

tings

, est

ablis

h a

syst

em

to r

espo

nd to

AS

HA

grie

vanc

es, a

ccom

pany

AS

HAs

on

hom

e vi

sits

, m

aint

ain

reco

rds

of A

SH

A ac

tiviti

es, a

tten

d Vi

llage

H

ealth

and

Nut

ritio

n D

ays

with

the

ASH

As, a

nd a

tten

d m

onth

ly B

lock

PH

C

mee

tings

. The

AS

HA

faci

litat

or is

sup

ervi

sed

at

the

Blo

ck le

vel b

y th

e B

lock

C

omm

unity

Mob

ilise

r, w

ho is

in

turn

sup

ervi

sed

by th

e D

istr

ict M

obili

zatio

n /

Coo

rdin

atio

n U

nit,

whi

ch

liais

es w

ith th

e st

ate-

leve

l

Feed

back

and

su

perv

isio

n is

pr

esen

tly p

rovi

ded

thro

ugh

NG

Os

but w

ill

in fu

ture

be

prov

ided

th

roug

h th

e nu

rse

supe

rvis

or a

ttac

hed

to e

very

out

reac

h te

am.

HEW

sup

ervi

sion

ap

pear

s to

var

y ac

ross

th

e hi

stor

y of

the

prog

ram

and

ge

ogra

phic

al c

onte

xts.

In

20

05

HEW

s ha

d re

lativ

ely

high

leve

ls o

f su

perv

isio

n w

ith a

n av

erag

e of

thre

e su

perv

isor

y vi

sits

ove

r th

e co

urse

of n

ine

mon

ths.

The

re a

re

supp

osed

to b

e m

ultip

le

leve

ls o

f HEW

su

perv

isio

n, in

clud

ing

the

wor

eda

supe

rvis

ory

team

that

is c

ompr

ised

of

a h

ealth

off

icer

, pub

lic

heal

th n

urse

, en

viro

nmen

tal/

hyg

iene

ex

pert

, and

a h

ealth

ed

ucat

ion

expe

rt.

4–27

Dr

aft D

ecem

ber 2

013

GO

VER

NA

NC

E IS

SU

E B

RA

ZIL

PA

KIS

TAN

IND

IA

SO

UTH

AFR

ICA

ETH

IOP

IA

ASH

A re

sour

ce c

ente

r.

HEW

s su

perv

ise

othe

r ca

dres

suc

h as

CH

Ps,

trad

ition

al b

irth

atte

ndan

ts, a

nd

Com

mun

ity-b

ased

R

epro

duct

ive

Hea

lth

Agen

ts.

Com

pens

atio

n/

ince

ntiv

es

CH

As a

re s

alar

ied,

full-

time

wor

kers

, but

ther

e is

a la

rge

varia

tion

thro

ugho

ut th

e co

untr

y in

thei

r sa

lary

. CH

As

are

supp

osed

to e

arn

at

leas

t the

nat

iona

l min

imum

w

age

of ~

US

$1

12

eac

h m

onth

.

LHW

s re

ceiv

e a

sala

ry o

f ab

out $

34

3 p

er y

ear

and

are

not s

uppo

sed

to

enga

ge in

any

oth

er p

aid

activ

ity, a

lthou

gh s

ome

do.

The

LHW

stip

end

is o

ften

th

e on

ly s

ourc

e of

fam

ily

inco

me

and

is a

crit

ical

fa

mily

sup

port

.

Alth

ough

AS

HAs

are

co

nsid

ered

vol

unte

ers,

they

re

ceiv

e ou

tcom

e-ba

sed

rem

uner

atio

n fo

r fa

cilit

atin

g in

stitu

tiona

l del

iver

ies,

im

mun

izat

ion,

fam

ily

plan

ning

(sur

gica

l st

erili

zatio

n) a

nd to

ilet

cons

truc

tion.

Mor

e re

cent

ly,

an in

cent

ive

of U

S$

4.6

0

(Rs.

25

0) h

as b

een

esta

blis

hed

for

prov

idin

g ho

me-

bas

ed n

ewbo

rn c

are.

Fa

cilit

atin

g in

stitu

tiona

l de

liver

ies

is th

e m

ost

com

mon

act

ivity

for

whi

ch

ASH

As r

ecei

ve p

aym

ents

. AS

HAs

are

als

o co

mpe

nsat

ed fo

r tr

aini

ng

days

, att

endi

ng m

eetin

gs,

and

addi

tiona

l hea

lth-r

elat

ed

activ

ities

. The

am

ount

s va

ry

from

sta

te to

sta

te.

In m

ost p

rovi

nces

in

Sou

th A

fric

a, N

GO

s re

ceiv

e fu

ndin

g fr

om

the

MO

H to

con

trac

t w

ith a

nd p

ay C

HW

s.

Mor

e re

cent

ly, a

t le

ast o

ne p

rovi

nce

has

deci

ded

to

cont

ract

with

CH

Ws

dire

ctly

and

put

them

on

to th

e go

vern

men

t pa

yrol

l. S

alar

ies

are

appr

oxim

atel

y at

the

natio

nal m

inim

um

wag

e.

HEW

sar

e re

gula

r em

ploy

ees

with

a r

egul

ar

sala

ry a

nd b

enef

its. A

ra

nge

of n

on-fi

nanc

ial

ince

ntiv

es h

ave

been

ef

fect

ive

with

CH

Ps,

incl

udin

g fo

rmal

re

cogn

ition

, ong

oing

m

ento

rshi

p, c

ertif

icat

ion,

an

d co

mm

unity

ce

lebr

atio

ns.

Car

eer

oppo

rtun

ities

N

o st

ruct

ured

opp

ortu

nitie

s fo

r ca

reer

adv

ance

men

t for

C

HAs

exi

sts.

The

LHW

Pro

gram

off

ers

prof

essi

onal

adv

ance

men

t op

port

uniti

es fo

r LH

Ws.

LH

Ws

can

rece

ive

addi

tiona

l tra

inin

g to

ser

ve

as a

LH

S, w

hich

is a

n in

cent

ive

for

good

pe

rfor

man

ce.

Car

eer

adva

ncem

ent w

ithin

th

e pr

ogra

m fo

r AS

HAs

is

limite

d.

The

issu

e of

car

eer

deve

lopm

ent i

s no

t ad

dres

sed

in th

e ne

w

polic

y, b

ut in

sev

eral

pr

ovin

ces

pilo

ts a

re

unde

rway

to p

rovi

de

care

er p

aths

into

pr

ofes

sion

s su

ch a

s nu

rsin

g an

d so

cial

w

ork.

HEW

s w

ho e

nrol

l in

addi

tiona

l tra

inin

g ca

n qu

alify

as

regi

ster

ed

nurs

es.

4–28 Draft December 2013

Acknowledgments Our thanks to Lauren Crigler, Steve Hodgins, Claire Glenton, Henry Perry, and Sharon Tsui for their thoughtful comments on earlier versions of this chapter.

Draft December 2013 4–29

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