CHW Reference Guide - Governance
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Transcript of CHW Reference Guide - Governance
Governing Large-Scale Community Health Worker Programs
Simon Lewin and Uta Lehmann
23 September 2013
Draft December 2013 4–1
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
Draft December 2013 4–3
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.
Draft December 2013 4–5
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.
Draft December 2013 4–7
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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