Development of Policy Conference Nay Pi Taw 15 th February

Development of Policy Conference Nay Pi Taw 15 th February

To outline some Country Examples of the Role of Community Volunteers in Health from the region To indicate success factors in improvements to child health and impacts on child mortality To highlight main policy priorities

Lay Health Workers (LHW) Community Health Workers (CHW) Volunteer Health Workers (VHW) Village Health Volunteer (VHV) Health Activists Country or Language Specific Terminology Lady Health Visitor in Pakistan Barangay Health Worker in the Philippines

Volunteers provide primary health care services, including diagnosis and management of basic diseases (respiratory diseases, diarrhoea, and uncomplicated malaria) as well as performing health education, assist in vaccination campaigns and insecticide treatment of bednets, and reporting of morbidity and mortality data to health or district health offices. VHVs are selected by the village committee in consultation with villagers, the Community Health and the District Health Office. Selection is based on pre-determined criteria. Each village is required to have two volunteers. But there is often only one person who has the literacy skill to be a VHV in rural areas. Malar J. 2010 Dec 1;9:347. An assessment of early diagnosis and treatment of malaria by village health volunteers in the Lao PDR. Phommanivong V

A Communal Health Station is built in each community with populations of around six thousand people on average providing basic PHC services (assistant physician, nurses and midwives for population of 6000) Community Health Workers village, hamlet or cooperative level Main functions social mobilization and health education Monthly allowance for VHWs, based on a performance related incentive scheme with assessment and classification on a performance scale A key policy issue that should be given due attention is how to make the VHWs stay in their jobs after training. GAVI HSS Vietnam case Study Sept 2009 www.gaviallance.org

Organized into teams in the village known as a Village Health Support Group (2 members per group) They are linked to a Health Center Management Committee chaired by local authority with community and health representation Functions Health Education, Social Mobilization and in some limited cases service delivery (community based distribution of family Planning, malaria diagnoses and treatment, diarrheal disease management, community based IMCI and referral) Common features of VHV system in Cambodia quite often local authority, incentive payments, capacity building and monthly meetings at Health centre, usually program specific and focus on education and mobilization.

CRITERIA FOR SELECTION: ASHA must primarily be a woman resident of the village, literate with formal education (Level 8) SELECTION PROCESS: ASHA will be selected by various community groups and health sector staff CAPACITY BUILDING: Capacity building of ASHA is being seen as a continuous process ROLES AND FUNCTIONS: first level care, mobilization, health educator, counselor, planner focus on the deprived PAYMENT: The ASHAs will receive performancebased incentives

Perform health education and promotion Diagnose, treat and provide health education on diarrhea, dysentery, fever, common cold, worm infection, gastric ulcer, allergic reaction, scabies and ringworm infection Identify pregnant women Encourage pregnant women to utilize services in government facilities Visits women at 42 days of delivery Give special care to Low Birth Weight (LBW) babies Organize income generating activities Prepare and submit monthly progress report Works on DOTS program

Pakistan s Lady Health Workers (LHW) 90,000 nationwide, with coverage of 1 CHW per 1000 (70% nationwide coverage) The prime role of LHWs is to provide PHC services (prevention and curative), to organize community by developing women groups and health committees in her area Selection process according to set criteria Long duration training programs Incentive based remuneration Promotional, preventive and basic curative task for CHWs Supported by a strong supervision system functioning within a weak health system Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals WHO/Global Health Workforce Alliance

A focus on prevention and mobilization Targeted or project based medical interventions (TB, Malaria, Family Planning, Pneumonia) Community level selection with identified criteria for selection Management Support in the form of Training and Supervision Performance Based Payments or Incentives

There is a wide range of services offered by the CHWs to the community, ranging from provision of safe delivery, counseling on breast-feeding, management of uncomplicated childhood illnesses, from preventive health education on malaria, TB, HIV/AIDs, STDs and NCDs to their treatment and rehabilitation of people suffering from common mental health problems. The services offered by CHWs have helped in the decline of maternal and child mortality rates and have also assisted in decreasing the burden and costs of TB and malaria. However, the coverage by such programs is slow and the overall progress towards achieving the MDG targets is very slow. Results confirm that CHWs provide a critical link between their communities and the health and social services system. Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals WHO/Global Health Workforce Alliance

A total of 30 studies were reviewed related to the role of CHWs in dealing with childhood illnesses. The CHWs involved in the childhood illnesses related intervention made a great contribution towards the achievement of Goal 4 of the MDGs by promoting exclusive breastfeeding and preventive care through immunization and hygiene. Their role in identifying and treating pneumonia is also a great contribution towards bringing down the figures of under-5 child mortality rate Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals WHO/Global Health Workforce Alliance

Eighty-two studies met the inclusion criteria. The majority were conducted in high income countries (n = 55) Analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation uptake; promoting initiation of breastfeeding, any breastfeeding and exclusive breastfeeding ; and improving pulmonary TB cure rates when compared to usual care. Conclusion: LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, Odgaard-Jensen J, Johansen M, Aja GN, Zwarenstein M, Scheel IB. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004015. DOI: 10.1002/14651858.CD004015.pub3.

Randomized Control Trials and Systematic Reviews published in the Lancet and other leading public health journals demonstrate the impact of CHW and community interventions on reductions in neo natal mortality One study in India demonstrated that if the NNM is > 50, then impressive declines can be achieved (through home visits and care in the first two days of life) One study in Nepal demonstrated sharp declines in NNM associated with participatory women's group activities at village level (promoting ANC, PNC, institutional deliveries) In Pakistan, improved stillbirth and neonatal mortality rates observed indicate that CHWS can be effective in implementing a community and outreach package that leads to improved home care practices by families, increased care-seeking behaviour and greater utilization of skilled care providers.

An assessment of early diagnosis and treatment (EDAT) of malaria by village health volunteers in the Lao PDR. EDAT with malaria rapid diagnostic test (MRDT) and artemisinin combination therapy (ACT) was prospectively assessed among 36 randomized village health volunteers (VHVs) and 720 patients in six malaria-endemic provinces of Laos MRDT and ACT are useful and efficient and can be used by VHVs. VHVs' global EDAT performance is enhanced through training and monitoring. Persistent gaps in knowledge, care of patients and wrong treatment have to be addressed Malar J. 2010 Dec 1;9:347. An assessment of early diagnosis and treatment of malaria by village health volunteers in the Lao PDR. Phommanivong V

Pilot study investigated the feasibility of delivering a package of community-based interventions for improving peri-natal care using lady health workers (LHWs) and traditional birth attendants (Dais) in rural Pakistan. The intervention was implemented in four of eight village clusters (315 villages, total population 138,600), while four served as a comparison group The improved stillbirth and neonatal mortality rates observed indicate that community health workers (i.e. LHWs and Dais) can be effective in implementing a community and outreach package that leads to improved home care practices by families, increased care-seeking behaviour and greater utilization of skilled care providers. Bull World Health Organ. 2008 Jun;86(6)Implementing community-based perinatal care: results from a pilot study in rural Pakistan.Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens S, Martines J.

The reduction in child mortality is achievable by ensuring: Full coverage of immunization programs Exclusive breastfeeding for 6 months, scaling up of vitamin A and nutritional supplements Prevention and effective treatment of diarrhea, pneumonia, malaria and other infectious diseases Promotion of hand washing and using safe and clean drinking water.

CHW programs should be based in communities and respond to community needs They should be trained, as required, on the promotive, preventive, curative and rehabilitative aspects of care related to maternal, newborn and child health, malaria, tuberculosis, HIV/AIDs as well as other communicable and non-communicable diseases. CHWs should be explicitly included within the HRH strategic planning at country and local level. The CHW programs should regulate a clear selection/ deployment procedure The programs should have established referral protocols with community-based health and social service agencies. The programs should have regular and continuous supervision and monitoring systems Global Experience of Community Health Workers for Delivery of Health Related Millennium Development Goals WHO/Global Health Workforce Alliance

Community choice of volunteers, Clear volunteer expectations of role and function Ongoing, participatory training in teams Supportive supervision and regular meetings. Brenner JL, Kabakyenga J, Kyomuhangi T, Wotton KA, Pim C, et al. (2011) Can Volunteer Community Health Workers Decrease Child Morbidity and Mortality in Southwestern Uganda? An Impact Evaluation. PLoS ONE 6(12): e27997. doi:10.1371/journal.pone.0027997

CHW schemes contribute to child mortality declines, but this is founded on strong systems of managerial support Managerial Support :Required particularly for training, supervision, monitoring and essential equipment supply Links to Health System must be clearly defined in terms of referral and complementarities of role and function (include in HR system or planning) Investment Plan is required in training, supervision and equipment supply to sustain the program CHW Policy should document: Role and Function (scope of work) Criteria for Selection Selection process Contents of Training package Supportive Supervision Mechanism Incentive and professional advancement system Links to the Health System and Local Community Structures System of monitoring of process and impacts (including research)