Global Change

Global Experience of Community Health Workers for
Delivery of Health Related Millennium Development Goals:

A Systematic Review, Country Case Studies, and Recommendations for
Integration into National Health Systems
Global Experience of Community Health Workers for Delivery of
Health Related Millennium Development Goals:
A Systematic Review, Country Case Studies, and Recommendations
for Integration into National Health Systems
Zulfiqar A. Bhutta, Zohra S. Lassi, George Pariyo* and Luis Huicho**

Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan
*Makerere University School of Public Health, Kampala, Uganda
**Universidad Peruana Cayetano Heredia, Universidad Nacional Mayor de San Marcos
and Instituto de Salud del Niño, Lima, Peru
Corresponding author:
Zulfiqar A. Bhutta
Division of Maternal and Child Health
The Aga Khan University
P.O. Box 3500 Stadium Road,
Karachi-74800, Pakistan
E-mail: zulfiqar.bhutta@aku.edu Graphic Design: www.creapixel.ch
1
Global Evidence of Community Health Workers
CONTENTS
Acknowledgements 4
List of Acronyms 5
Executive Summary 6
Core Report 12
Background 12
Methods 14
Main Findings from Global Systematic Review
and Country Case Studies 20
Discussion and Way forward 22
References: 41
Annex I: 44
Global Systematic Review 44
References 191
Annex II: 215
Country Case Studies 215
References 366
3
Acknowledgements
The authors would like to thank the Global
Health Workforce Alliance for entrusting them They would further like to thank Dr Maimoona
with this important piece of research. Azhar Salim, Research Officer, Division of
Maternal and Child health, Aga Khan University,
The authors would also like to thank numerous Pakistan, who accompanied the research and
persons from diverse public and private orga- writing process. Moreover, they extended their
nizations for their hospitality and support in sincere appreciation for the medical students
providing contacts, information, sharing docu- (Salimah Valliani; Salima Bhimani; Arif Valliani)
ments and insights into the functioning of the for their assistance in literature screening and
country-specific CHW Programs, and those we retrieval.
interviewed in person, by telephone or through
electronic communication: Dr Zahid Larik,
Dr Iqbal Lehri, Dr Rashid Jooma, Dr Zareef Khan,
Dr Majeed Memon, Dr Assad Hafeez, Ministry
of Health Pakistan; Prof Anwar Islam, Dr Koasar
Afsana, and Dr Taskeen Chowdhury from BRAC,
Bangladesh; Dr Tahmeed Ahmad ICDDRB;
Dr Felix Rigoli, Dr J Paranaguá de Santana and
Augusto Campos from PAHO Brazil; Prof Maria
Fátima de Sousa from Universidade de Brasília
and Núcleo de Estudos em Saúde Pública; Ena
Galvao & Christian Morales fromWHO/PAHO Haiti;
Dr Lambert Wesler from Zanmi Lazante, Haiti;
Dr Wesler, Jude Jean, two public health nurses in
LasCahobas and Boucan Carre; Gregory Jerome
from Haiti; Dr Keseteberhan Admasu Berhane;
Abaseko Hussein Mohammed, Woldemariam
Hirpa, and Dr Tizita Hailu, from Ethiopian Federal
Ministry of Health; Dr Fatoumata Nafo-Traoré,
Dr Gebrekidan Mesfin, Dr Sofonias Getachew,
and Martha Teshome from WHO country of-
fice for Ethiopia; Dr Flavia Mpanga from UNICEF
Uganda; Dr Benjamin Sensasi from WHO
Uganda; Jessica Anguyo from AMREF Uganda;
Richard Okwi from MoH Uganda; John Mukisa
from UNACOH Uganda; Tom Lakwo from MoH
Uganda; Nantume Sophie Mawejje from TASO
Uganda; Sengendo from Uganda Community
Based Health Care Association (UHBHCA);
Dr Leonardo Chavane from MOH Mozambique;
Dr Benzerroug from WHO Mozambique; Dr
Antoine Bureau from WHO country office
Mozambique.

List of Acronyms
AIDS Acquired Immunodeficiency Syndrome
ARI Acute Respiratory Infections
ART Anti Retroviral Treatment
BLDS British Library for Development Studies
BRAC Bangladesh Rural Advancement Committee
CHW Community Health Worker
CHW-PFA Community Health Worker- Program Functionality Assessment
CM Community Mobilizer
DOTS Directly Observed Treatment Support
EmOC Emergency Obstetric Care
GDP Gross Domestic Product
GNI Gross National Income
HAART Highly Active Anti Retroviral Treatment
HIV Human Immunodeficiency Virus
IMCI Integrated Management of Childhood Illnesses
IPT Intermittent Presumptive Treatment
KAP Knowledge, Attitude, and Practices
KMC Kangaroo Mother Care
LBW Low Birth Weight
LHWP Lady Health Workers Program
MDG Millennium Development Goal
MoH Ministry of Health
MNCH Maternal, Newborn and Child Health
NCD Non-Communicable Disease
NGO Non-Government Organization
NS Non Significant
ORS Oral Rehydration Salts or Oral Rehydration Solution
ORT Oral Rehydration Therapy
PACS Programa de Agentes Comunitários de Saúde
PC Peer Counselor
PMTCT Prevention of Mother to Child Transfer
RCT Randomized Controlled Trial
STI Sexually Transmitted Infections
TBA Traditional Birth Attendant
TB Tuberculosis
TT Tetanus Toxoid
UNFPA United Nations Fund for Population Agency
WHA World Health Assembly
WHO World Health Organization
5
Executive Summary Methodology
Human resources for health crisis is one of the For the systematic review, a comprehensive
factors underlying the poor performance of search of studies was performed in several data
health systems to deliver effective, evidence-based sources, without language restrictions, focusing
interventions for priority health problems, on studies performed in developing countries.
and this crisis is more critical in developing Eligible studies included randomized, quasi-ran-
countries. Participation of community health domized and before/after trials which had relied
workers (CHWs) in the provision of primary upon CHWs in community settings. In addition,
health care has been experienced all over other less rigorous study designs like observa-
the world for several decades, and there is an tional (cohort and case-control) and descriptive
amount of evidence showing that they can studies were also reviewed to understand the
add significantly to the efforts of improving the context within which they were implemented,
health of the population, particularly in those the typology of health care providers, the types
settings with the highest shortage of motivated of intervention delivered and reported results.
and capable health professionals. Studies were included if (a) they detailed the
role of CHWs and (b) if the outcomes consider-
With the overall aim of identifying CHWs programs ed are those related to reaching the health and
with positive impact on Millennium nutrition MDGs like child mortality, maternal
Development Goals (MDGs) related to health mortality, combating HIV/AIDS, TB, malaria,
or otherwise, a global systematic review was among other target health problems. The main
undertaken of such interventions, as well as comparison was between CHW interventions
eight in-depth country case studies in Sub- compared to no intervention or routine care; or
Saharan Africa (Ethiopia Mozambique and one form of CHW intervention compared with
Uganda), South East Asia (Bangladesh, Pakistan another form.
and Thailand) and Latin America (Brazil and
Haiti). The focus was on key aspects of these For country case studies, a review of published
programs, encompassing typology of CHWs, and unpublished reports was conducted on
selection, training, supervision, standards for specific country experiences with CHWs, and
evaluation and certification, deployment pat- also a direct contact with key personnel over-
terns, in-service training, performance, and seeing the program was made through electro-
impact assessment. For impact indicators, the nic correspondence and country visits. The pri-
focus was on those related to maternal and mary level of evidence on impact derived from
child health, HIV/AIDS, TB and malaria, as well country specific assessment of CHW programs
as on those related to mental health and non- and from objective evaluation data (where
communicable diseases. In addition, building available). The evidence was also triangulated
on the systematic review and the country case from the global systematic review to the speci-
studies, draft recommendations was develop for fic programs and types of CHWs in the selected
recruitment, training and supervision criteria for countries. In addition to that, stakeholders fami-
CHWs programs to address the health MDGs, for liar with program management and evolution
further regional and global consultation among were also contacted for specific inputs. In this
stakeholders, and for their eventual adaptation process, information was assembled related
in varied contexts. to: program descriptions, job descriptions, or
official descriptions of the role of the CHWs
and the process followed to identify and recruit
them; records identifying numbers of trained
CHWs, dates of recent trainings, and documents

describing training content and process as well These country case studies demonstrate the
as the supervision or monitoring process; and re- participation of the respective governments
cords of current numbers of CHWs. Following the and the NGOs in financing and implementa-
assembly of information from multiple sources, tion of their policies for the CHW programs.
a USAID supported CHW Program Functionality Results confirm that CHWs provide a critical
Assessment Tool (CHW-PFA) was utilized to assess link between their communities and the health
the functionality of the CHW programs across and social services system. Communities across
these countries. The CHW-PFA proposes twelve all the countries that we studied recognized
programmatic components for a CHW program the value of CHWs as a member of the health
to be effective. delivery team and therefore have supported
the utilization and skill development of CHWs.
Key Findings These case studies further speak out the achie-
vements of their CHW programs in relation to
The review of CHWs across the globe provided us their modeling and level of commitment from
an interesting and diverse picture of the current their human resource. The region lagging far
scenario in outreach services of health care wor- behind the MDG targets is Africa especially the
kers. There is a wide range of services offered by the sub-Saharan Africa. Various factors have been
CHWs to the community, ranging from provision identified to be responsible. These include
of safe delivery, counseling on breast-feeding, ma- inadequate human resource especially work
nagement of uncomplicated childhood illnesses, force who are dying with HIV/AIDS and poor
from preventive health education on malaria, TB, remuneration for their work leading to high
HIV/AIDs, STDs and NCDs to their treatment and drop outs, lack of supervision, and equipment
rehabilitation of people suffering from common and drug supplies needed to provide essential
mental health problems. The services offered by maternal, child and reproductive health services
CHWs have helped in the decline of maternal and and those required to control and treat poten-
child mortality rates and have also assisted in de- tially preventable infectious diseases. Based on
creasing the burden and costs of TB and malaria. the review and the gaps identified in the exis-
However, the coverage by such programs and ting CHW programs and the services rendered,
the overall progress towards achieving the MDG various recommendations are made regarding
targets is very slow. The growing consensus re- their recruitment criteria, training content, certi-
garding this current pace of progress, especially in fication process, ongoing and refresher training,
the low-income countries, is that it relates to fra- supervision, incentives and professional advan-
gile health and economic systems. Country case cement. Although it is recognized that varying
studies identified a wide range of CHW programs contexts are important, attention to specific
with different mix of CHW typology. For example, criteria and issues could potentially improve
Uganda Village Health Teams program has short the working of CHWs and help scaling up key
duration of training with preventive and basic interventions in relation to MDG targets. These
curative tasks for CHWs, with a relatively strong are detailed in the main Report and the sum-
supervision system, and within a weak health mary messages below represent major points
system, while, on the other hand, Pakistan’s Lady for consideration.
Health Workers (LHW) Program has long duration
training programs, with promotional, preventive
and basic curative tasks for CHWs, with a relatively
Limitations of the study
strong supervision system, and within a relatively The review identified a number of limitations.
weak health system Firstly, most of the reviewed studies when im-
7
plemented, neglected to document the com- cultural diversity of the population served, and
plete description and characteristics of CHWs promote shared decision making among the
deployed, especially the level and amount of program’s governing body, staff, and commu-
supervision provided to those workers, which nity health workers.
could have helped us in identifying the im-
portance of this factor and its association with Given the broad role that many CHWs play in
other outcomes. Additional information on the primary care, a program must assure that a core
initial level of education of CHWs, provision of set of skills and information related to MDGs be
refresher training, mode of training: balance provided to most CHWs. Therefore, the curricu-
of practical/ theoretical sessions would have lum should incorporate scientific knowledge
provided greater assistance in understanding about preventive and basic medical care, yet
the threshold effect, if any, of these factors on relate these ideas to local issues and cultural
CHW performance in community settings. traditions. They should be trained, as required,
Importantly, community ownership and super- on the promotive, preventive, curative and re-
vision of CHWs is a key characteristic which is habilitative aspects of care related to maternal,
insufficiently described and analyzed in availa- newborn and child health, malaria, tuberculosis,
ble literature. HIV/AIDs as well as other communicable and
non-communicable diseases. Other training
Secondly, studies related to the role of CHWs in content and training duration may be added
HIV/AIDS prevention and care, mental health pertinent to the specific intervention that the
and food security and nutrition were scarce. CHW is expected to work on as detailed in main
report.
Thirdly, few evaluation studies/reports were at
scale and none had followed an a-priori experi- The CHW programs should regulate a clear
mental design or impact assessment process. selection/ deployment procedure that reassure
appointing those who certify the course com-
Strategic Messages pletion and pass the writing or verbal exam at
the end of training.
The programs should be coherently inserted
in the wider health system, and CHWs should The CHW programs should support provision
be explicitly included within the HRH strategic of requisite and appropriate core supplies and
planning at country and local level. equipment to enable appropriate functionality
of such workers.
Community preparedness and engagement is
a vital element that is relatively rarely practiced. The programs should have established referral
From the outset, program should develop vil- protocols with community-based health and
lage health committees in the community that social service agencies.
can also contribute in participatory selection
processes of CHWs. The programs should have regular and conti-
nuous supervision and monitoring systems
CHW programs should be based in and respond in place and supervision should be taught to
to community needs. In practical terms, such be undertaken in a participatory manner that
programs should continually assess community ensure two-way flow of information. Moreover,
health needs and demographics, hire staff from both external and internal evaluations need
the community who reflects the linguistic and to be carried out on regular basis to improve
8
the services and analyze the need of various providers in the fields of health education,
logistics, supplies and training according to the promotion and management of specific health
requirements. Ideally, programs should evaluate problems.
their own performance on annual basis, while a
third party evaluation could be recommended Given the global burden, specific studies on the
in every 4-5 years, which would generate a neu- potential role of CHWs in HIV/AIDS prevention
tral and free from bias findings. and care, as there is very limited empirical infor-
mation on this.
CHW programs should also provide opportunities
for career mobility and professional develop- Further systematic reviews are also requi-
ment. These should include opportunities for red on factors affecting the sustainabi-
continuing education, professional lity of CHW interventions when scaled up;
Global Evidence of Community Health Workers the effectiveness of different approaches
Page 10 of 388 to ensure program sustainability; and the
recognition, and career advancement. This cost-effectiveness of CHW interventions for
can be through specific programmatic oppor- different health issues.
tunities or access to educational and training
scholarships. Additional analysis is required on the volume
of work and type of activities and hence the
The outline of the country plan of action to number of CHWs required for such tasks. An
develop and improve CHW program(s) should example of this type of analysis is provided by a
be finalized by a working group of relevant study in Bangladesh which assessed how many
multiple stakeholders, including identification additional health workers would be needed to
of resources needed, indicators and targets, and implement IMCI protocols. However, further
monitoring tools, and formally authorized by studies are needed to determine the CHW
the Ministry of Health workforce needed and their functional needs
for MDG specific interventions.
Finally, sustained resources should be available
to support the program and workers therein. Recommendations on how
GHWA can utilize
Knowledge gaps requiring the Report/Findings
further study
The findings from this report should be dissemi-
There is a remarkable dearth of information on nated to policymakers at country level, to health
the cost-effectiveness of CHW programs. care delivery organizations, and to organizations
in charge of developing HRH programs. As an
Studies are needed to assess whether the CHW initial step, an international consultation on
programs promote equity and access. CHW study and a global review would facilitate
this exchange.
Studies are required to assess the effectiveness
of paid workers versus voluntary workers. That consultation should involve interactive
debates that draw attention to key aspects of
Studies are needed to evaluate quality of care the community component and planning pro-
and effectiveness of health care provided by cess, help clarify issues and address practical
CHWs as compared to professional health care
9
questions related to operationalization of these interventions, potential role of CHWs in HIV/
findings. AIDS prevention and care, functional needs of
CHWS for MDG specific interventions etc.
GHWA should organize theme-focused work-
shops with existing CHW programs, to facilitate GHWA should also take responsibility for
more interaction and generate quality output publishing country specific CHW program eva-
and in the long run, facilitate follow-up visits luations and reports, and as much as possible,
in these countries to provide technical support utilizing innovative, quasi-experimental designs
and guidance for CHW programs, including to assess impact of such programs.
operational research.
GHWA should also facilitate in undertaking

studies related to cost-effectiveness of CHW
10
Action Plan
Gathered existing information
Already done
Performed situation analysis

(Collect additional information if needed)
GHWA Specific Country specific
Review Results (Global Consultation)

Further actions required
Set country priorities
Update CHW programs

based on recommended criteria
Define indicators with targets

and integrated monitoring tools
Develop a strategic plan within

national HRHCHW plan
11
Core Repor t
Background
The year 2000 marked an important event or health technologists. According to a report
when 189 countries signed the UN Millennium by World Health Organization (WHO) 2006, 57
Declaration which translated into the eight countries, from Africa and Asia are facing shorta-
Millennium Development Goals (MDGs). Three ges of health care workforce, and an estimated
out of those eight are directly related to health, 4,250,000 workers are needed to fill in the gap.15
namely: Although several countries in Latin America have
experienced sustained economic growth within
1 Reducing child mortality by two-thirds from the last few years, much social inequality and
base levels of 1990; health inequities remain in the region, between
and within countries. This is reflected in an ine-
2 Reducing maternal mortality by three quarters
quitable distribution of health workers, with 15
from base levels of 1990; and
countries in the region having less than 20 to
3 Combating HIV/AIDS, malaria and other 25 health workers for every 10,000 inhabitants,
diseases. considered the minimum density for making
a difference in health indicators. Shortage of
However, progress on achieving these targets health personnel contributes to weaker health
is far from the expectations, especially for the systems and the overall burden of disease in
low-income developing countries. Despite these countries parallels the maldistribution of
considerable evidence from recent reviews health workforce crises countries.16
of interventions that can impact on maternal,
newborn and child health and survival, a major It is for reasons of achieving a wide range of the
issue is the availability of trained health workforce population with cadres other than traditional
to scale up these interventions in population health workers, that many countries have explo-
settings.1-11 It is well recognized that critical red alternative strategies. An important strategy
shortage of physicians and indeed misdistribu- towards attaining the health related MDGs is
tion underlies poor access to skilled care and investing in cadres of CHWs, and this has been
commodities by populations in need.12 This adopted by many African and Asian countries.17
recognition parallels the awareness that a range CHWs are community based workers that help
of community health workers (CHWs), both individuals and groups in their own commu-
skilled and semi skilled, can play a major role in nities to access health and social services, and
community mobilization and deliver a range of educate community members about various
commodities. health issues.18, 19 WHO has elaborated the
definition of CHWs as “(they) should be members
Given the limited resources available for scaling of the communities where they work, should be
up interventions to reach the MDG goals, two selected by the communities, should be answera-
major barriers have been identified. One, the ble to the communities for their activities, should
critical need for health systems strengthening be supported by the health system but not neces-
has been underscored13 and key shortages of sarily a part of its organization, and have shorter
health care workers identified, which ought training than professional workers”. 20
to be addressed by innovative strategies such
as development of alternative cadres and task During the 1980s, CHWs were considered a cor-
shifting.14 Health care workers are personnel nerstone for primary health care, as envisioned
whose activities are aimed to improve health, by the Alma Ata Declaration, but its importance
and traditional trained health care workers declined in the 1990s with a changing focus on
include cadres of doctors, nurses, midwives alternative vertical programs and service delivery

models. It is now evident that this change in di- program.27 These factors can be alleviated by
rection was misplaced and given the increasing certified training and supportive supervision,
interest in integrated primary care and the reco- along with other incentives (financial and non-
gnition of the enormous mismatch between di- financial) to keep CHWs satisfied and motivated
sease prevalence and optimal care,21 there has to perform their duties well. Furthermore, efforts
been a rekindling of interest in the importance geared to standardize training and certification
of CHWs. This interest is related to potential re- for CHW programs, could further provide a
allocation of interventions and specified tasks career pathway and enable them to effectively
from more specialized to less specialized health contribute to their communities. A recent study
care workers (also called “task shifting”).22 by Kash et al.27 have concluded that certified
CHWs are potentially an important health task
While CHWs may not replace the need for force towards improving access to health care
sophisticated and quality health care delivery and social services and improve utility of resour-
through highly skilled health care workers, they ces to the underserved.
could play an important role in increasing ac-
cess to health care and services, and in turn, A large number of countries, many in the high
improved health outcomes, as an effective link burden countries of South Asia and sub-Saha-
between the community and the formal health ran Africa, are off target for reaching the MDGs
system, and as a critical component in the set for the year 2015. One of the mechanisms to
efforts for a wider approach that takes into ac- effectively reduce this gap is by improving the
count social and environmental determinants of mechanisms and channels for delivering the
health. Successful examples are evident by the interventions with a potential to improve the
efforts of the Bangladesh Rural Advancement health and nutrition status of the mothers and
Committee (BRAC), Bangladesh for setting up a children. The important role of formally trained
CHW program based on cumulative experience health professionals like doctors and nurses in
and learning.23 Brazil is another example where primary care and community settings is well-
CHWs provide coverage to over 80 million recognized. There is a shortage of such staff in
people.24, 25 Ethiopia is currently training about many countries which has emerged as a major
30,000 workers with emphasis on maternal and limitation in the delivery of useful maternal and
child health, HIV and malaria. Similar programs child interventions. With appropriate training,
are also being considered in other developing some of these tasks can be successfully perfor-
countries like India, Ghana and South Africa. In med by CHWs and other cadres of workers like
Pakistan, a huge public sector program for trai- traditional birth attendants, and lay health wor-
ning and deploying Lady Health Workers (LHWs) kers. Engaging CHWs could provide improved
has been in place since 1994 and has been ex- access to the basic essential health services and
panded to cover over 70% of the rural popula- commodities, and could also influence commu-
tion with a work force exceeding 90,000.26 nity demand creation. The role of CHWs, if any,
in facilitating delivery of various interventions in
For CHW programs to effectively perform, it is community and primary care setting is to im-
vital to lay due emphasis on training and su- prove MDG outcomes in a subject of increasing
pervision. Prior experiences have documented public health interest but has not been syste-
that low interest/use by the government, in- matically analyzed.
consistent remuneration, inadequate staff and
supplies and lack of community involvement We undertook this review to evaluate the impact
are key factors to negatively impact the CHW of global experience of CHWs in delivering the
13
Methods
health related MDGs and components thereof. Global Systematic Review
This was accomplished through a systematic Criteria for considering studies for this systema-
review of available literature and in-depth case tic review.
studies of large CHW programs in both the pu- The types of health care providers included
blic and private (NGO) sector in eight countries CHWs (paid or voluntary) encompassing village
representing various parts of the developing health workers, lady health workers/visitors,
world. birth attendants, etc. We restricted our review
to CHWs undertaking activities related to achie-
ving the health and nutrition activities and whe-
Objectives rever possible, targeting disorders/conditions of
direct relevance to related MDGs. It was reco-
The specific objectives of the systematic review gnized that many CHWs in developed countries
included had significantly higher levels of education, trai-
ning, experience and support as compared to
Assessment of the evidence base of the impact comparable cadres in developing countries. To
and effectiveness of global experience of CHWs ensure comparability of experience from various
in delivering care related to health and nutrition settings, we set an a priori criterion that CHWs
MDGs. Special focus was paid on the should have received training in some manner
o Typology of CHWs in relation to the interventions and targets, but
o Training practices excluded those with formal professional or para-
o Supervisory practices professional grooming, certification or a degree
o Standards for evaluation and certification from tertiary learning centre.
o Deployment patterns
o In-service training Our first level of evidence derived from ex-
perimental designs and evaluations of CHWs
Undertaking case studies to evaluate the ty- in various settings. We thus identified and
pology, impact, and performance assessment reviewed randomized, quasi-randomized and
of the practices of CHWs deployed at scale before/after trials which had relied upon CHWs
in 8 countries across the world, two being in in community settings. In addition, other less ri-
Latin America (Brazil and Haiti), three in Africa gorous study designs like observational (cohort
(Ethiopia, Uganda and Mozambique), and and case-control) and descriptive studies were
three in South Asia (Pakistan, Bangladesh and also reviewed to understand the context within
Thailand). which they were implemented, the typology of
health care providers, the types of intervention
Based on the above, the development of an delivered and reported results. Studies were
analytical summary and draft recommendations included if (a) they detailed the role of CHWs
for recruitment, training and supervision criteria and (b) if the outcomes considered are those
for CHW programs to address the health MDGs related to reaching the health and nutrition
for regional and global consultation among MDGs like child mortality, maternal mortality,
stakeholders. combating HIV/AIDS etc. The main comparison
was between CHW interventions compared to
Prepare the framework for finalization of recom- no intervention or routine care; or one form
mendations for consideration and adaptation of CHW intervention compared with another
by stakeholders form. Box 1 is a list of alternative names used for
outreach workers globally.
14
Box 1: Alternative Names for Outreach Worker
Bangladesh Shasthyo Sebika
Bangladesh, India, Greece & Gambia Village Health Workers
Peru Agente Comunitario de Salud
Pakistan Lady Heath Workers
India Saksham Sahaya
Brazil Community Health Agents
Brazil Agente comunitário de saúde
Brazil Visitadora
Burkina Faso Women Group Leaders
Burma Maternal Health Worker
Bangladesh Community Nutrition Worker
India Anganwadi Workers
India Maternal & Child Health Promotion Workers
India Community-based Workers
Nepal Female Community Health Volunteer
Ethiopia Village Malaria Worker
Nepal and China Maternal Child Health Workers
Ecuador, Colombia, Nicaragua Voluntary Malaria Workers
United States & Mexico Promotoras de Salud
Madagascar, Ghana, & Bolivia Nutrition Volunteers
Community Egypt Raedat
Health Worker Haiti Accompagnateurs
(CHWs) India Community Health Volunteer
Iran Behvarz
India Village Health Guide
Senegal Nutrition Worker
Latin America Colaborador Voluntario
Uganda Community Drug Distributor
Kenya Village Health Helper
Indonesia Kader Posyandu
Ethiopia Mother Coordinator
Mali Village Drug-Kit Manager
South Africa Lay Health Worker
Uganda Community Reproductive Health Worker
United States Lay Health Visitor
England Mental Health Workers
England Postnatal Support Worker
United States Community Volunteer
United States Community Health Advocates
Unites States Community Health Aide
Guatemala Village Health Promoters
Guatemala Rural Health Worker
Nicaragua Brigadistas
Bangladesh Community-based Skilled Birth Attendant
Traditional Pakistan Dai
Birth Malaysia Bidan Kampong
Attendant Bangladesh Skilled Birth Attendants
(TBAs) Guatemala Traditional Midwives
Egypt Dayas
Pakistan Community Volunteers
Community Nepal & India Facilitator
Mobilizer Bangladesh Female Peer Facilitator
(CMs) India Change Agents
India Doot
Brazil Peer Educators
Peer Counselor Brazil Lay Counselor
(PCs) England Volunteer Counselor
United States Volunteer Peer Counselor
England Peer Support Worker
15
Methods for literature search, information sour-
ces, abstraction and synthesis
worker*» OR «primary health care» OR «Task
All the evidence available, relevant to the role
Shifting» OR «community based interventions»
of CHWs in achieving the health and nutrition
OR «Female village health worker*» OR «village
related MDG targets around the world, was
health worker*» OR «birth attendant*» OR «tra-
systematically analyzed. The following sources
ditional birth attendant*»]. Language restric-
of information were used to search literature for
tions were not applied and our search strategy
review:
included relevant Library of Congress Subject
1 All available electronic references libraries of in- Headings, and MeSH terms.
dexed medical journals and analytical reviews
Studies in languages other than English were
2 Electronic reference libraries of non-indexed included after relevant translation. The abstracts
medical Journals (and the full sources where abstracts not availa-
3 Non-indexed journals not available in electronic ble) were screened by two authors to identify
libraries studies adhering to our objectives. Any argu-
ment on selecting studies between these two
4 Pertinent books, monographs, and theses authors was resolved by a third reviewer. After
5 Project documents and reports retrieval of the full texts of all the studies that
meet the inclusion/exclusion criteria, each study
The following principal sources of electronic was double data abstracted into a standardized
reference libraries were searched to access form. The key variables elicited were study
the available data on CHWs studies: Cochrane setting, location, study design, participants, in-
Reference Libraries, Medline, PubMed, Popline, tervention delivered, outcome effects and type
World Bank’s JOLIS search engine, British Library of outreach workers involved. Since the objec-
for Development Studies BLDS at IDS as well as tive of this systematic review is to assess the
the IDEAS database of unpublished working effectiveness of CHWs in delivering care related
papers, Capacity Project website, HRH Global to health and nutritional MDGs, special focus
Resource Center, Google and Google Scholar. has been laid in extracting information related
Detailed examination of cross-references and to CHWs, their educational requirement for se-
bibliographies of available data and publications lection as outreach worker, training content and
to identify additional sources of information modalities (didactic, practicum, experiential etc),
were also performed. In particular, this search training duration, certification, refreshers / on-
was also extended to review the gray literature going training, key competencies, specific role
in non-indexed and non-electronic sources. The and tasks assigned, supervision and monitoring,
bibliographies of books with sections pertai- incentives (if any), population coverage, impact
ning to CHWs were also searched manually to of CHW programs/ evaluation. All final studies
identify relevant reports and publications. were entered into the Endnote XI database.
The following search strategy was modified Country Case Studies

for the various databases and search engines.
Two interrelated approaches were used to gather
[«Community Health Aides» [Mesh] OR «Primary
information on the CHWs program from each of
Health Care» [Mesh] OR «community health
the selected country. First, we conducted a re-
worker*» OR «lady health worker*» OR «village
view of published and unpublished reports on
health volunteer*» OR «village health guide*»
the countries experiences with CHWs. Second,
OR «lay health worker*» OR «mid level health
we made a direct contact with key personnel,
16
overseeing the program, through electronic 4 On-going Training: On-going training is provided
correspondence and country visits. to update CHW on new skills, reinforce initial
training, and ensure he/she is practicing skills
Our primary level of evidence derived from eva- learned.
luation reports of CHWs in selected countries.
We thus identified and reviewed all published 5 Equipment and Supplies: The requisite equipment
and supplies are available when needed to deliver
or unpublished reports which considered CHWs
the expected services.
in the community settings. We also included
evidence, pertinent to CHWs from selected ei- 6 Supervision: Supervision is conducted on a re-
ght countries, identified from global systematic gular basis to carry out administrative tasks and
review. We also contacted stakeholders, who to provide individual performance support (fee-
are familiar with how the program is managed dback, coaching, data-driven problem-solving).
or supported and the regions within which it
functions, to get a deep insight about program 7 Performance Evaluation: Evaluation to fairly as-
functionality through country visits and/or email sess work during a set period of time.
correspondence. In this process we congrega- 8 Incentives: A balanced incentive package that
ted information related to: program descrip- includes financial incentives, such as salary and
tions, job descriptions, or official descriptions of bonuses and non-financial incentives, such as
the role of the CHW and the process followed training, recognition, certification, uniforms,
to identify and recruit the CHW; records identi- medicines, etc. that is appropriate to the work
fying numbers of trained CHWs, dates of recent expectations.
trainings, and documents describing training
content and process; documents that describe 9 Community Involvement: The role that commu-
the supervision or monitoring process; records nity plays in supporting a CHW.
of current numbers of CHWs etc. 10 Referral System: A process for determining when
referral is needed, a logistics plan in place for
After assembling information from multiple transport and funds when required, a process
sources, USAID’s CHW Program Functionality to track and documented referrals.
Assessment Tool (CHW-PFA)28 was utilized to
assess the functionality of the CHW programs 11 Professional Advancement: The possibility for
across these countries. The CHW PFA proposes growth, advancement, promotion and retire-
twelve programmatic components for a CHW ment for a CHW.
program to be effective. These components are:28
12 Documentation, Information Management:
1 Recruitment: How and from where a community How CHWs document visits, how data flows to
health worker is identified, selected, and assigned the health system and back to the community,
to a community. and how it is used for service improvement.
2 The CHW Role: The alignment, design and clarity
of role from community, CHW, and health system Functionality Rating:
perspectives. For each of the 12 components listed above,
3 Initial Training: Training is provided to the CHW to four levels of functionality are described that
prepare for the role in MCH services delivery and range from non-functional (Level 0) to highly
ensure he/she has the necessary skills to provide functional as defined by suggested best prac-
safe and quality care. tices (Level 3). These levels describe situations
17
commonly seen in CHW programs and provide presented some national or NGO driven CHW
enough detail for assessor to identify where that programs in the form of “CHW Snapshots” ap-
program fall within that range. Level 3, the hi- pearing randomly in annex I. We also undertook
ghest level, provides an accepted best practice case studies in eight representative countries
for each component. Because each of these from Latin America, Africa and Asia, with high
components is equally necessary for a program burden of diseases, to understand the typology,
to succeed a CHW program must be rated at least experience, training needs, program roll out and
level 2 in each of the 12 components in order to assessments of CHWs to-date.
be considered minimally functional. Moreover,
a set of widely accepted programmatic and cli- Based on our findings from global systematic re-
nical elements were also considered to evaluate view and country case studies, we constructed a
their role in MCH. A ‘functional’ CHW providing typology of CHWs, taking into consideration the
MCH services must deliver at least one of the expert opinion and the context and diversity of
key MCH classified by antenatal, childbirth, early training programs, while ackowldeging the exis-
post-partum and early childhood periods in the ting limitations in the avilable information and
MCH care-continuum. in the methods used (Functionality assessment
tool, desk review and key informants interviews
Scoring of MCH Intervention: during country visits).
MCH roles Interventions are grouped by cate-

gories which includes antenatal care, birth and
newborn care, postpartum and newborn care,
family planning, PMTCT, etc. One complete in-
tervention requires a check mark in the column
titled YES – indicating full implementation of the
intervention at that program level. The scores
from CHW program functionality assessment
matrix and MCH intervention matrix are sum-
med up separately and reported in the score
card.
Data Analysis
For global systematic review, the studies were
categorized based on interventions relevant
to health and nutrition related MDGs and then
analyzed by the type of outreach workers and
study design employed in order to explore the
impact and effectiveness of global experience
of CHWs in delivering healthcare. This helped us
in outlining the typology, training and supervi-
sion needs, tasks and feasibility of developing
and deploying CHWs as a way towards the
achievement of the MDG targets. We have also
18
Structure of Report
Global Systematic Recommendations

Review (published & CHW Typology
Analysis = key
unpublished papers - Educational level
Findings and Gaps
& reports) - Recruitment
- Training Country specific
- Monitoring & Supervision
- Incentives
- Evaluation
Country Case Study -
- Deployment
CHW programs (country
- Documentation &
visits + CHW-PFA +Key
Experts Opinion Information System
informant’s interviews)
Input Process Output
19
Main Findings from Global Systematic Review and
Country Case Studies
Global Systematic Review Summary

CHWs were employed to deliver a wide range They promoted antenatal, intrapartum and
of interventions that were arranged into groups, postnatal care, initiation of early and exclusive
each containing studies that used broadly simi- breastfeeding, promoted use of colostrums and
lar methods to influence a single health care growth monitoring of children.
outcome. Their role in preventive medicine can be as-
sessed from the emphasis that they lay in their
1 Nutritional interventions
communities regarding appropriate nutrition
2 Maternal Health interventions and to remain healthy. They also emphasized
on usage of condoms and change in sexual
3 Birth and Newborn Care Preparedness
behavior, in HIV prevalent communities. In fact,
Interventions
some were trained in the social marketing of
4 Promotion of breastfeeding condoms.
Besides advocating preventive strategies they
5 Neonatal Health Interventions
also offered treatment for uncomplicated ma-
6 Childhood Illnesses and Immunization laria, pneumonia and treatment compliance
Interventions was ascertained in case of TB and anti-retroviral
therapy of HIV as DOTS.
7 Primary Health Care Interventions
8 Malaria Control Interventions
9 Tuberculosis Control interventions
10 HIV/AIDS Prevention and control Interventions
11 Mental Health Interventions
12 Interventions related to Non-Communicable
Diseases (NCDs)
13 Knowledge, attitude & practices of community
health workers

1 Typology of CHW programs system, within a relatively strong health system:
Short to intermediate duration training pro- The Village Health Volunteers Program (VHV)
grams, with preventive and basic curative tasks in Thailand
for CHWs, with relatively strong supervision ac- 7 Long duration training programs, with mostly
tivities, and within a weak health system: Haiti promotional and preventive tasks, and very res-
Zanmi Lazante’s Community Health Program tricted and basic curative tasks for CHWs, with a
2 Long duration training programs with preven- strong supportive supervision, and within a re-
tive and basic curative tasks for CHWs, with a latively strong health system, such as the Family
relatively weak supervision system, and within a Health Program (FHP) in Brazil.
weak health system: Ethiopia Health Extension
Program (HEP) & Mozambique Agentes
Polivalentes Elementares (APE) Program.
3 Short duration training programs with preven-
tive and basic curative tasks for CHWs, with a
relatively strong supervision system, and within
a weak health system: Uganda Village Health
Teams.
4 Long duration training programs, with pro-
motional, preventive and basic curative tasks
for CHWs, with a relatively strong supervision
system, and within a relatively weak health
system: Pakistan’s Lady Health Workers (LHW)
Program.
5 Short duration training programs, with mostly
promotional, preventive and basic curative tasks
for CHWs and with a relatively strong supervision
system, within a relatively strong health system:
BRAC in Bangladesh
6 Short duration training programs, with mostly
for CHWs and with a relatively weak supervision
21
Discussion and
Way forward behind the MDG targets is Africa especially
the sub-Saharan Africa.29 Various factors have
The intentions underlying this global review been identified to be responsible. These include
was to assess the role of CHWs in the interven- inadequate human resource especially work
tions related to the MDGS and to bring forth the force who are dying with HIV/AIDS, lack of su-
image of how various countries in the world pervision, and equipment and drug supplies
are running their CHW programs through our needed to provide essential maternal, child and
country case studies. reproductive health services and those required
to control and treat potentially preventable in-
The review of CHWs across the globe provided fectious diseases.
us a vivid picture of the current scenario in
outreach services of health care workers. There There has been long and unresolved debate
is a wide range of services that are offered by about what functions one CHW can effectively
the CHWs to the community from safe delive- carry out, coupled with concerns about how
ries, counseling on breastfeeding to the mana- many tasks a CHW can realistically perform. An
gement of uncomplicated childhood illnesses, in-depth analysis of the CHWs contributions
from preventive health education on malaria, TB, and their outcomes in various interventions has
HIV/AIDs, STDs and NCDs to their treatment and led us to identify various gaps in the effective
rehabilitation of people suffering from common working of these health workers. The PHC wor-
mental health problems. The services offered by kers provided basic health care and appropriate
them have helped in the decline of maternal referrals where needed. They increased health
and child mortality rates and have decreased awareness and promoted preventive health
the incidence of TB and malaria. However the behaviors. Their services however, were found
overall progress towards achieving the MDG to be fully utilized where the area of their de-
targets is very slow. The growing consensus re- ployment was in the rural vicinity. Roles and
garding this current pace of progress, especially responsibilities that CHW were fulfilling in rela-
in the low income countries is due to the fragile tion to MDGS, as evident from global literature
health and information systems. and national programs, were maternal and child
health care, TB care, malaria control, HIV/AIDS
Our country case studies, on the other hand, care, with very less reports can be found about
demonstrate the participation of the respective the use of CHWs in food security and nutrition.
governments and the NGOs in financing and
implementation of their policies for the CHW The role of nutrition workers, in small scale pro-
programs. Results from these country case jects, was mainly related to counseling and ad-
studies confirm that CHWs provide a critical vocacy in community. While, on the other hand,
link between their communities and the health in large CHW programs, they were involved in
and social services system. Communities across iron/folate supplementations, counseling on
all the countries that we studied recognized maternal nutrition, promotion of growth moni-
the value of CHWs as a member of the health toring and weighing of newborns, provision of
delivery team and therefore have supported community based management of acute mal-
the utilization and skill development of CHWs. nutrition using ready to use therapeutic foods.
These case studies further speak out the achie- Studies under our review also identified low
vements of their CHW programs in relation to education in CHWs as a main factor that hin-
their modeling and level of commitment from dered them in carrying out the advocacy skills
their human resource. The region lagging far properly. On the other hand, there were studies

that highlighted the importance of CHW super- monitoring but at instances unavailability of
vision and refresher training. Some programs physical weigh balance did not allow them to
experienced challenges in which supervisors fulfill their job. Apart from inadequate supply
were not involved which later diminished when of drugs and equipment, lack on ongoing and
program involved supervisors. Keeping in view, refresher training was another major barrier in
the current transition in dietary pattern, we proper functionality of CHW when adequate
found a complete absence of CHW’s role in life time was not allocated for practical aspect du-
style modification, physical activity and dietary ring their initial training. Studies in which CHWs
changes particularly from large scale CHW pro- performed their services under the supervision
grams, while, it was only found in small scale and attended monthly meetings were able to
programs from developed countries. bring about positive impact and their standing
in the community increased with updated
Almost all of the CHWs driven interventional knowledge.
studies showed a significant impact on redu-
cing maternal, perinatal and neonatal mortality We, on the other hand, also assessed CHW pro-
and improvement in perinatal and postpartum grams against MNCH interventions list prescri-
service utilization indicators. In most of these bed by USAID, which showed that none of the
studies they were trained and deployed as program delivered all the interventions sugges-
maternal and child health care providers and ted. CHWs in these programs mainly complied
reproductive health workers. They promoted on delivering antenatal care, postpartum care,
the concept of antenatal, intrapartum and pos- immediate newborn care and immunization
tnatal care, exclusive breastfeeding, maternal services in community with special emphasis
and child nutrition, immunizations and family on counseling and referring cases to the health
planning. The newborn care providers amongst facilities. But very few programs focused on re-
these CHWs were trained to teach kangaroo cognizing and referring maternal and newborn
mother care for LBW babies and monitor growth complications, prevention of post partum he-
for children under-five years of age. Apart from morrhage, providing kangaroo mother care for
delivering general health related promotional low birth infants, community based treatment
interventions, these health workers were also of pneumonia, other referral services for severe
involved in the preventive and therapeutic illness among children. Looking at the variety of
maternal, newborn and childhood illnesses tasks under MNCH domain, CHWs are facing job
interventions. They managed uncomplicated stresses which are leading to high attrition rates.
common childhood illnesses and identified LHWs (Pakistan) in one study reported that low
those requiring referral to higher health facility. socio-economic status and long travelling dis-
However, the major barriers that came in the way tances for work, inconsistent medical supplies,
of their services included traditional beliefs and inadequate stipends, lack of career structure
practices. Their major efforts had to be directed and not being equipped to communicate ef-
towards behavioral change of the community fectively with families were the main factors for
to convince them for the provision of adequate job dissatisfaction and attrition.30 In addition,
nutrition to the pregnant women, to avoid pre- BRAC Shasthyo Shebika identified factors res-
lacteal feed in newborn and give colostrums ponsible for their dropouts as low income and
and exclusive breastfeed for at least 4-6 months. small profit gains from selling medication and
Inadequate supplies of equipment and drugs contraceptive methods.31
were another barrier in the way of their tasks
accomplishment. They were trained for growth
23
Globally, the incidence of malaria has been de- cus of CHW training programs in most parts of
clining but especially in the sub-Saharan region the world despite of it being a part of MDGs. The
malaria, which is preventable and controllable, role of CHWs pertaining to HIV was restricted to
still continues to take millions of lives. The role creating awareness and providing ART using
of malaria workers in the literature reviewed DOTS. From global systematic review, hardly 17
was to promote use of insecticide treated nets studies were found which described the role of
and provide treatment for uncomplicated mala- CHWs related to HIV/AIDS out of which just 1
ria. While, from country case studies, their main study revealed that the concept of PMTCT was
role was found in counseling and referral for conveyed to the CHWs and both the mother
insecticide bed nets, IPTp treatment, and rapid and the HIV exposed newborn were treated
diagnostic test. Only two programs, Ethiopia with single dose of medicine. And a single study
Health Extension Program and BRAC Bangladesh reported the CHWs’ rehabilitative role towards
have trained their CHWs for rapid diagnostic HIV/AIDS patients in the form of psychosocial
tests and treatment. The CHWs working in this support. Whereas, none of the program from
domain often faced shortage in supply of new our country case studies delivered all the inter-
malaria drugs and insecticide treated bed-nets ventions (as per USAID PMTCT interventions) re-
preventing them from offering services in their lated to assessment and treatment of HIV/ AIDS
true capacity. Since in many studies, CHWs were in mothers and newborns. Only two programs
local farmers or drug distributors from the com- (Brazil and Haiti) among all, included training
munity, they were, in principle, always accessi- for PMTCT interventions which was restricted
ble to the villagers, who had been motivated to counseling and referral. These observations
through health education to consult the CHW reveal that the CHWs in general were not gi-
for any fever episodes. Key problems in these in- ven a comprehensive training on the issue of
terventions revolved around the limited scope HIV-prevention, treatment and rehabilitation.
of the CHWs’ practice and their ambiguous role CHWs were not armed with the supportive and
within the health care system. More specifically, rehabilitative strategies that would help them
Delacotte et al. observed that CHWs wanted ease the life of HIV patients who are generally
to be more than symbolically remunerated for living with the social stigma related to the di-
their services; they were eager to receive further sease. Owing to its socioeconomic impact and
training so as to expand their scope of practice, the multi-system diseases introduced by HIV/
and they wanted to become a formal part of the AIDS in a person like multi-drug resistant TB and
health structure. other infections, the issue of HIV/AIDS deserves
special attention in terms of preventive, thera-
In combating HIV as a goal set in MDGs, there peutic and rehabilitation strategies.
has been a decline in the incidence of newly
affected HIV positive people. The number of Another intervention area that seems ne-
deaths from HIV has also decreased with the glected and where the CHWs can create a
expansion of ART services. The HIV epidemic difference is that of mental health. The current
has drastically increased the demand for health living standards with global economic crisis and
services, yet a growing number of health wor- unemployment rates have led to a number of
kers in high prevalence regions are themselves mental health problems in the society the most
dying or unable to work as a result of HIV/AIDS. common being anxiety and depression. These
The role of CHWs in reducing the incidence of problems tend to further deteriorate the health
HIV however has not been very significant partly and socioeconomic situation and may even lead
because HIV was not found to be the major fo- to loss of life in the form of crimes and suicide,
24
Education
if left unattended. Despite of these facts, the Setting up stringent post-primary or secondary
sphere of mental health illnesses has not been education criteria as a pre-requisite for beco-
given its due importance. We recommend that ming a health worker does not sound practical
this intervention be galvanized into the preven- when it comes to meeting the health care needs
tive and rehabilitative strategy of primary health of less privileged communities far removed
care as well as every MDG related intervention. from health care facilities. However, keeping
criteria of primary education and incorporating
On the whole, factors limiting the range and adult education comprising of basic arithmetic,
quality of CHWs impacts are identified as below reading and writing should be considered into
and are further described in the recommenda- the training curriculum of the CHWs to ensure
tion section. proper documentation, referrals and records
keeping of the supplies. Moreover, CHWs who
Shortage of basic drugs and irregular supply of are involved in case management should be
vaccines and commodities (e.g. condoms) strictly scrutinize for their education level. In an
ideal situation for giving a fair chance, candidate
Inadequate and irregular supervision
with at least primary level education should be
Lack of equipment and non-functional equipment given a preference.
Insufficient initial and continuing education
Recruitment criteria
Low status and remuneration of CHWs
All the studies and CHW programs, that we
Inadequate linkages with health system. reviewed, emphasized that CHWs should be
chosen from the communities they will serve
Based on our review and the gaps identified in and that communities should have a say in the
the existing CHW programs and the services selection of their CHWs. As far as the selection of
rendered by them in terms of MDGs, we are able the CHW is concerned, we would recommend
to make the following recommendations regar- that they should be directly chosen by the hou-
ding their recruitment criteria, training content, seholds that they will work with. Neither health
certification process, ongoing and refresher trai- or other officials, nor even community leaders
ning, supervision, incentives and professional should make this choice alone. CHWs should be
advancement (Table 1). There is a wide range of accountable to the local neighbourhood com-
different CHWs, performing an even wide range munity that they volunteer to serve, for which
of tasks. A typology is therefore not easy. One they will be trained and supported by the health
simple distinction, however, is that between ge- bureaucracy. We also reviewed from BRAC
neralist and specialist CHWs like MNCH workers, example that villages initiated village health
nutrition workers, TB and HIV/AIDS workers etc. committees which also help and are respon-
We also recognize the importance of varying sible for selecting CHW candidates. However,
contexts, therefore our recommendations are most studies reported that CHWs were chosen
based on core as well as for different types of or selected “by the communities themselves”.
interventions carried out by CHWs, which is Community preparedness and engagement is
definitely not suggesting having different types a vital element that is relatively rarely practiced.
of CHWs. Attention to the following criteria and From the outset, program should develop vil-
issues could potentially improve the working of lage health committees in the community that
CHWs and help scaling up key interventions. can also contribute in participatory selection
processes of CHWs.
25
Table 1: Recommendations - CHW Core Typology
CHW Contextual Factors
competencies
Recruitment Educa- Training content, duration Certification Monitoring Volunteer/ General or Career Referral
Key
tional & role (initial & ongoing) process supervision salaried Performance pathway & system
criteria & evaluation based incentives development
Community primary Initial: 6 months Exam after Supervisors volunteers * allow to sale Should be offered linkages
Involvement in level On-the-job: 6 months initial training 1 supervisor: medication for to advance their between
identification schooling Ongoing: once per month 20-25 CHWs OR minor ailments career as supervi- TBAs and
of potential Refresher: every 6 months sor on completion health
community health didactic,interactive sessions Salaried allow to sale contra- of minimum system
workers Core training: on passing exam keeping in ceptives methods education level
- ability to access resources and completion Evaluation: view that and experience
- Advertisement in - coordination of services of initial training annual internal they are poor Free health coverage required to reach
local newspaper or - crises management they should be evaluation for themselves and the next level.
radio channel - knowledge of medical services awarded with title Full time for their family
for interested - leadership external employment (if possible)
cadidates to join - organizational skills evaluation in
- interpersonal communication skills
Community Health Worker
every 5 year
Applicant must be - confidentiality on completion of
-18-40years of age key Role : on-job training
- from the local - visits households they should be
community - growth monitoring of children awarded with
-permanent resident - routine immunization of children and a certificate
pregnant women
Test: on literacy - promote exclusive breastfeeding
and numeracy - promotion of oral rehydration for diarrheal
diseases
Interview: to judge - prevention of STD/AIDS, premature
on motivation pregnancy
and willingness - identification of pregnant women &
promotion of importance of prenatal
final selection by care at the health facility
community and - periodic household visits for prenatal
local health follow-up, identifying risk signs and
center symptoms, orientating on feeding and
mother preparation for delivery, and
promoting breastfeeding
- monitoring of newborns & mothers
after delivery
- educational activities on family planning
methods
- educational activities on family &
community dietary habits
- educational activities on oral & dental
hygiene, with emphasis onpediatric group
- educational activities for water , sanitation
and personal hygiene
-educational activities for promotion of
mental health
*Volunteers (community members who volunteer few hours a week) Salaried (full time CHWs)
26
Although, the countries scored highest (PFA- female, married and children with not less than
3) in program functionality assessment on 5 years of age, as they have lower tendency
following best practice for recruitment of their for migration. Moreover, they have their own
CHWs, but difference were found on the nature experience of dealing with issues related to
and selection checklist. It is recommended that pregnancy and motherhood and taking care of
CHWs should be recruited for training on the their own children when they were sick. During
basis of standard and transparent criteria for interview, they should particularly be assessed
selection. An advertisement in the most acces- for their own acceptance and attitude towards
sible local newspaper or local radio channel family planning.
should be possibly made for walk-in interviews
of interested candidates. Since being a perma- TB and HIV/AIDS Workers:
nent resident of that locality is the most impor- For TB and HIV workers, preference should be gi-
tant criteria for selection, therefore, evidences ven to those who are former drug user, or those
confirming their residency must be strictly and who themselves suffered from tuberculosis and
stringently examined during their first assess- HIV/AIDS and have completed their treatment
ment, followed by cross confirmation of their regimens. Preference can also be given to those
educational certificate and work experience who have taken care of a family member suffe-
(if any). The assessment may include a test for ring from tuberculosis or HIV/AIDS. This would
literacy and numeracy as well as interviews to specifically work in areas with high burden of
assess aptitude, competence and motivation. TB and HIV /AIDS diseases like Africa, and where
Candidates should be thoroughly gauged for a large number of outreach workers are dying
their interest for voluntary work (depending from same condition. Their experience and
on local national program), and serving their courage for the fight against disease can give a
own community even in situation of no mone- motivational light to others.
tary rewards. It is also recommended that some
process for community buy-in and ownership Training content
of this screening and selection process be ins-
While a large number of articles discussed or
tituted, free from political interference, so that
at least mentioned the training of CHWs, not
the most suitable candidates are identified and
surprisingly length, depth, organization of, res-
there is local accountability.
ponsibility for and approaches to training vary
dramatically across programs. Training courses
In summary, while the selection of CHWs from
varied from several hours to several days to
local communities is common practice, parti-
even several months. Training is in many cases
cipatory selection processes remain an ideal
conducted by members of the formal health
that is relatively rarely practised, particularly in
services, either doctors or nurses, or, in the case
large-scale programs. The final selection should
of NGO-driven programs, by the NGOs them-
be proposed by community (or village health
selves. CHWs across all the country profiles and
committee) with the consensus of community
global review, were delivering promotional,
leaders and district health officer. Other recruit-
preventive and therapeutic interventions with
ment criteria may be added pertinent to the
very few studies identified with their role in
specific intervention that the CHW is expected
rehabilitative services especially with chronic
to work on as mentioned below.
diseases and HIV/ AIDS. Majority of the studies
under our review found positive impact of their
MNCH workers:
interventions on health and nutrition outco-
Workers for MDGs 4 and 5 should preferably be
27
Recommendations – Typology of Nutritional Health CHW
competencies
Key
criteria & evaluation incentives development
Community primary Initial: 1-2 weeks Exam after Supervisors volunteers * identification Should be offered linkages
Involvement in level On-the-job: 2 weeks initial training 1 supervisor: of severally to advance their between
identification schooling key Role : 20-25 CHWs OR malnourished child career as supervi- TBAs and
of potential Promotive, preventive and sor on completion health
community health therapeutic interventions: Salaried monitoring growth of minimum system
workers - promotion of exclusive breastfeeding on passing exam keeping in of a child for a year education level
for first 6 months and completion Evaluation: view that and experience
- Advertisement in - appropriate complimentary of initial training annual internal they are poor required to reach
local newspaper or feeding for next 6-24 months they should be evaluation the next level.
radio channel - iron and folic acid supplementation awarded with title Full time
for interested for children external employment
cadidates to join - improved hygiene and sanitation evaluation in
- improved dietary intake for pregnant every 5 year
Applicant must be and lactating women on completion of
-18-40years of age - micronutrient supplementation for on-job training
- from the local prevention of anemia and Vitamin A they should be
Nutrition Worker
community deficiency for mothers and children awarded with

-permanent resident - ORT for diarrhea a certificate
- timely treatment for infectious and
Test: on literacy parasitic disease
and numeracy - treatment and monitoring of severely
malnourished children
Interview: to judge - treatment for clinical sings of
on motivation vitamin A deficiency
and willingness
final selection by
community and
local health
center
28
mes. Studies particularly attempted to evaluate CHWs rather than using training packages deve-
the sensitivity, specificity and predictive values loped for facility-based workers. As suggested,
reported better diagnosis and case manage- CHWs should at least be educated up to primary
ment by CHWs, confirming the thoroughness school; therefore, course should be developed
and appropriateness in the training modality in simpler language, and incorporate more illus-
and training content. Looking at the diversity trations and more interactive components for
of interventions they deliver in community, less-educated CHWs. These days CHW’s role has
they should be classroom trained for at least 6 been enhanced for therapeutic interventions,
months with an additional 6 months of hands- in which they diagnose and treat infectious di-
on-training which gives practical flavour to their seases in children specifically acute respiratory
theoretical lessons. infections. They are mostly given algorithms for
proper identification and management, which
Approaches to training have changed over the are better for literate workers but are less un-
years. While in the past it was too theoretical and derstood by illiterate workers who mostly rely
too classroom-based, while in today, competen- on memory. In such case, keeping in view the
ce-based approaches are usually used. However, educational level of CHWs, visual or pictorial cue
it is recommended that didactic training be cards should be utilized.
given with ample interactive sessions including
small group discussions, role plays and field Furthermore, continuing or refresher training is
activities. This type of learning is usually more as important as initial training. A number of stu-
effective especially where the CHWs are either dies have found that if regular refresher training
illiterate or less educated. Also the simulations is not available, acquired skills and knowledge
as in role plays would help CHWs tackle real life are quickly lost and that, on the other hand,
situations more efficiently. In this approach, the good continuing training may be more impor-
skills and competencies required of the CHW are tant than who is selected. Curtale et al. suggest
defined and usually expanded into steps and that “three additional training days provided
standardized procedures required for a specific regularly to the CHV every year, will result in
skill. improved quality of service with consequent
increased utilization”.32
The ideal location of training, where CHWs will
have sufficient opportunity to practise, varies Given the broad role that many CHWs will play
by CHW program. Some programs recommend in primary care, it is recommended that a core
that the training take place in the community set of skills and information related to MDGs be
rather than in health facilities to provide hands- provided to most CHWs. These include informa-
on experience in the work environment of the tion on major causes of MNC ill health and mor-
CHW. In other contexts, training may take place tality, TB, HIV/ AIDS, its prevention, treatment
in the facilities because there are more cases of and rehabilitation. Other training content and
sick children presenting within the training pe- training duration may be added pertinent to
riod, thus providing more opportunities for the the specific intervention that the CHW is expec-
trainer to demonstrate skills in a real-life situation ted to work on as mentioned in CHW core and
and for CHWs to practise newly learned skills. MDGs specific typology.
Because CHWs work within the constraints of
the community and usually have limited formal
education, programs often develop or adapt
training materials and activities specifically for
29
Recommendations – Typology of Maternal and Newborn Health CHW
competencies
Key
Community primary Initial: 4 weeks Exam after Supervisors volunteers * - Pregnancy Should be offered linkages
Involvement in level On-the-job: 1-2 months initial training 1 supervisor: identification to advance their between
identification schooling key Role : 20-25 CHWs OR career as supervi- TBAs and
of potential Promotive, preventive and - Brining mothers sor on completion health
community health therapeutic interventions: Salaried for delivery of minimum system
workers Maternal and Newborn: on passing exam keeping in - Providing ENC education level
- adequate diet and completion Evaluation: view that and experience
- Advertisement in - iron/folate supplementation of initial training annual internal they are poor - Referral of maternal required to reach
local newspaper or - Tetanus Toxoid immunization
Maternal and Newborn Health CHW
they should be evaluation and newbor the next level.

radio channel - malaria prevention and Intermittent awarded with title Full time complication
for interested preventive treatment external employment
cadidates to join - healthy timing and spacing of delivery evaluation in - ensuring birth wt
- deworming every 5 year
Applicant must be - facilitate access to maternal health on completion of
-18-40years of age services for ANC and PNC on-job training
- from the local - skilled birth attendance they should be
community - prevention of mother to child transfer awarded with
-permanent resident - HIV/STI screening a certificate
-Married preferably - birth and newborn care preparedness
- children with not - temperature control in newborn
less than 2 years (thermoregulation)
of age - recognizing sick newborns and danger
signs requiring referrals
Test: on literacy - cord care (cleaning & avoiding the use of
and numeracy traditional materials)
- home care of low-birth-weight infants
Interview: to judge - treatment of neonatal pneumonia with
on motivation oral antibiotics,
and willingness
final selection by
community and
local health
center
30
Recommendations – Typology of Child Health CHW
Key
competencies
Community primary Initial: 4 weeks Exam after Supervisors volunteers * - identification of Should be offered linkages
Involvement in level On-the-job: 1-2 months initial training 1 supervisor: sick newborn to advance their between
identification schooling key Role : 20-25 CHWs OR – completion of career as supervi- TBAs and
of potential Promotive, preventive and essential sor on completion health
community health therapeutic interventions: Salaried immunization of minimum system
workers Children: on passing exam keeping in education level
- appropriate breastfeeding and completion Evaluation: view that and experience
- Advertisement in - essential newborn care of initial training annual internal they are poor required to reach

local newspaper or - hand washing they should be evaluation the next level.
radio channel - appropriate complimentary feeding awarded with title Full time
for interested (6-24 months) adequate iron external employment
cadidates to join - vitamin A supplementation evaluation in
- oral rehydration every 5 year
Applicant must be - zinc therapy on completion of
-18-40years of age - full immunization for age on-job training
- from the local - malaria prevention strategies they should be
community - deworming awarded with
-permanent resident - growth monitoring a certificate
-Married preferably - prevention and treatment of childhood
- children with not illnesses
less than 2 years
of age
Test: on literacy
and numeracy
Interview: to judge
Child Health CHW

on motivation
and willingness
final selection by
community and
local health
center
31
Deployment
CHWs should always be posted in the areas that with supervisory skills. Clear strategies and pro-
they belong to so to assure maximal local enga- cedures for supervision and the activities with
gement and ownership. However, it is recogni- which supervisors will be charged should be
zed that given health worker needs, there may well defined. The skills need to be taught so that
be exceptions. In that event, CHWs should be health personnel, CHWs and community health
provided with safe and secure housing as well committee members know what is expected of
as local transport as needed. This is particularly them as supervisors. Supervisors should be sup-
relevant for CHWs rendering services in the far portive and available to offer help where needed
flung areas especially those with geographical instead of merely policing whether CHWs are on
constraints as in mountainous or desert areas so duty or are carrying out the required quantities
that the CHWs can perform outreach functions. of work. Supervision should be taught to be un-
dertaken in a participatory manner. Top-down
Supervision mechanistic supervision emphasizes the social
It is widely acknowledged and emphasized in distance between supervisor and supervisee
the literature that the success of CHW programs and leads to communication breakdowns and
hinges on regular and reliable support and su- ultimately to program damage. The guidelines
pervision. It is equally acknowledged, however, for supervision should include a list of supervi-
that supervision is often among the weakest links sory activities. The most important element of
in CHW programs. Among studies we reviewed, supervision is ensuring the two-way flow of in-
we found that small-scale projects were often formation. It is also vital that the supervisor acts
successful because they manage to establish as a role model so that their behavior can be co-
effective support and supervisory mechanisms pied. It is also recognized that experienced and
for CHWs, often including a significant amount competent CHWs may be allowed further trai-
of supervision and oversight by the community ning and opportunities for skills development
itself. National programs, on the other hand, to rise to a level of supervisors. In an ideal and
are rarely able to achieve this consistently. realistic situation, one supervisor should head
Evaluations have documented the weakness of 20 to 25 CHWs which allows strong supervisory
supervision and support in national programs, system as evident from lady health worker pro-
which are often irregular or nonexistent. In the gram (Pakistan) and BRAC (Bangladesh).
worst cases, CHWs do not even know who their
supervisors are or what they can expect from Equipment and Supplies
them. In few CHW programs, we found that Issues such as the reliable provision of transport,
supervisors were formal health staff from the drug supplies and equipment have been identi-
health services, who, however, may not unders- fied as another weak link in CHW effectiveness.
tand the CHWs or their own role properly and The result is not only that they cannot do their
furthermore may resent the additional task. The job properly, but also that their standing in
CHW programs without supervision system communities is undermined. Failure to meet
have shown gaps in program functionality in the expectations of these populations (with
terms of inadequate documentation and linka- regard to supplies), destroys their image and
ges with overall health system. credibility. If CHWs are used in programs that
have drug treatment at their core, such as TB
We would therefore recommend that supervi- DOTS or HAART, the situation becomes more
sors should be the members of community, who critical but most programs include the need for
again should be selected according to the set supply of drugs and/or equipment, including
criteria. They should be trained and equipped transport. Ideally, supplies and equipment
32
Recommendations – Typology of Malaria Control CHW
Key
competencies
Community primary Initial: 1 weeks Exam after Supervisors volunteers * - identification of Should be offered linkages
Involvement in level On-the-job: 2-3 weeks initial training 1 supervisor: suspected case to advance their between
identification schooling key Role : 20-25 CHWs OR career as supervi- TBAs and
of potential Promotive, preventive and - sales of insecticide sor on completion health
community health therapeutic interventions: Salaried treated bed nets of minimum system
workers - prompt treatment with effective drugs for on passing exam keeping in education level
all people especially children suspected t and completion Evaluation: view that and experience
- Advertisement in have malaria of initial training annual internal they are poor required to reach

local newspaper or - increased access to low cost insecticide they should be evaluation the next level.
radio channel treated bed nets, especially for children awarded with title Full time
for interested and women external employment
cadidates to join - protection for pregnant women evaluation in
(e.g. regular prophylaxis/ intermittent every 5 year
Applicant must be preventive treatment). on completion of
-18-40years of age - Community-based treatment of malaria on-job training
- from the local (testing with Rapid Diagnostic Test or they should be
community presumptive treatment for malaria per awarded with
-permanent resident national guidelines.) a certificate
Test: on literacy
and numeracy
Interview: to judge
on motivation
and willingness
final selection by
community and
Malaria control CHW

local health
center
33
should be organized through district or regio- and almost no examples exist of sustained com-
nal dispensaries, and collected and delivered by munity financing of CHWs. Even NGOs tend to
CHWs. In cases where villages are very remote find ways of financially rewarding their CHWs.
to the central health centre, village dispensaries Moreover, control on attrition can be achieved
can be established to cater for the drug needs with regular and performance based financial
of the populations. Equipment and supplies incentives and hiring CHWs as full time em-
may be added pertinent to the specific inter- ployees rather than part time volunteers. They
vention that the CHW is expected to work on as should also be given a wage if they work as full
mentioned below. time, and those working as part time should be
given small incentives for their work. We would
Nutrition workers: make a strong recommendation for ensuring the
Weighing scale, growth monitoring chart, Iron/ CHWs be paid adequate wages commensurate
Folate, ORS, Anti-helminthics, pictorial material with their work load and timings. Performance
for teaching incentives could be the other pay back option,
which can also motivate them to work with full
MNCH workers: determination. Moreover, relatively small things,
Iron/ folate, TT vaccine, anti-helminthics, family such as an identification badge, can provide a
planning methods, ORS, growth monitoring sense of pride in their work and increased status
charts, weighing scale, antibiotics for case in their communities. In cases where possible,
management, insecticide treated bed nets etc, free health coverage for themselves and for
pictorial material for teaching their family should be provided. In the end, we
would recommend that CHWs should be given
Malaria workers:
multiple incentives over time to keep them
insecticide treated bed nets, malaria drugs, and
motivated. We have also proposed some basic
rapid diagnostic test materials, pictorial material
MDGS specific performance based incentives
for teaching
for CHWs.
TB and HIV/AIDS Workers: BCG vaccines, TB
drugs, ART drugs for HIV /AIDS, condoms, picto- Nutrition workers:
rial material for teaching identification of severally malnourished child,
monitoring growth of a child over the period of
Incentives 1 year.
Keeping in mind the dearth of health workers
MNCH workers:
and the rising need of CHWs to meet the health
pregnancy identification, bringing mothers for
care demands, it is imperative to prevent dro-
institutional deliveries, providing essential new-
pouts from training programs. Much of the
born care, referral of a complicated pregnancy
literature tends to imply that volunteers are the
case, ensuring taking birth weight, identifica-
ideal to which most CHW schemes aspire, and
tion of sick newborn, completion of essential
assumes that there is a sufficient pool of wil-
immunization.
lingness to conduct voluntary social service in
rural areas and informal settlements. However, Malaria workers:
the reality is different, probably in acknowled- identification of suspected case.
gement of the fact that as a rule CHWs are poor
TB and HIV/AIDS Workers:
people, living in poor communities, who require
completion of DOTS therapy for a cure of TB,
income. Evidence shows that most programs
identification of symptomatic case, identifica-
pay their CHWs either a salary or an honorarium
34
Evaluation
tion of HIV positive pregnant women, leading It is necessary to keep up with the changing
monthly support group meeting with HIV/ AIDS demands of the health care needs of com-
patients. munity in terms of both supplies and services.
Moreover, the effect of the additional workload
Professional advancement on the trained CHWs also need to be monitored,
Professional advancement is another way out for to ensure that the they are not being overbur-
controlling attrition among CHWs and ensuring dened and that there is no detrimental effect on
continued interest and enthusiasm. In addition the provision and supervision of services to the
to potential rise to the level of supervisors men- community. As such both external and internal
tioned above, other opportunities for career evaluations need to be carried out on regular
development and additional training must be basis to improve the services and analyze the
provided. Some countries are actively explo- need of various logistics, supplies and training
ring distance education and support programs according to the requirements. We would re-
for CHWs. Career enhancement opportunities commend that programs should evaluate their
should be offered on completion of minimum own performance on annual basis, while a third
education level and experience required to party evaluation could be recommended in
reach the next level and may be used as an in- every 4-5 years, which would generate a neutral
centive for career development. and free from bias findings. We would make a
special plea for publishing such evaluations and
Documentation, Information System and as much as possible, utilizing innovative, quasi-
Referral System experimental designs to assess impact of such
The attitudes and interactions of health per- programs.
sonnel in the formal health services with CHWs
have an immediate impact on critical aspects of Self-Protection of CHWs
CHW program management, such as selection, While delivering health care to the community
continuing training and supervision. In many these CHWs are themselves at risk of contac-
programs, health care personnel who come into ting infectious diseases. They are especially at
most contact with CHWs are not involved in the the risk of air borne and blood borne diseases
planning, implementation, monitoring and eva- while treating TB patients and while conducting
luation of such programs. It is hardly surprising, deliveries and must therefore receive available
therefore, that they lend little support to these preventive vaccines such as Hepatitis B, H1N1
initiatives. Furthermore, many health personnel vaccine etc. We also strongly recommend that
lack the background and orientation to provide they should be armed with appropriate tools
a supportive environment for CHW programs. and training to safe practices and prevention
A proper linkage is required to be created with strategies against common communicable di-
health system right from the planning of intro- seases such as TB, hepatitis and HIV.
ducing the CHW program in some vicinity to
the implementation of actual program. CHWs Up till now we recommended some general and
should be properly linked in to how they would MDGs specific CHW typology, their entry and
be referring a case to the health centre and how training criteria, certification and deployment
the documentation would take place to prevent pathways, core functions etc., which might not
duplication in case report. work in all scenarios. Therefore, we finish by ma-
king recommendations based on the evidence
of what works and what not in different settings,
building on the constructed typology, on the
35
Recommendations – Typology of TB DOTS CHW
competencies
Key
Community primary Initial: 4 weeks Exam after Supervisors volunteers * - completion of Should be offered linkages
Involvement in level Ongoing: once per month initial training 1 supervisor: DOTS therapy to advance their between
identification schooling key Role : 20-25 CHWs OR for cure of TB career as supervi- TBAs and
of potential Promotive, preventive, therapeutic sor on completion health
community health and rehabilitative interventions: Salaried - identification of of minimum system
workers Tuberculosis: on passing exam keeping in symptomatic case education level
- BCG immunization for children and completion Evaluation: view that and experience
- Advertisement in - DOTS for infectious case to prevent of initial training annual internal they are poor required to reach
local newspaper or transmission and emergence of drug they should be evaluation the next level.
radio channel resistance strains -early identification for awarded with title Full time
for interested symptomatic case -DOTS to cure TB external employment
cadidates to join evaluation in
every 5 year
Applicant must be on completion of
-18-40years of age on-job training
- from the local they should be
community awarded with
TB DOTS CHW
-permanent resident a certificate

Preferably people
who have comple-
ted TB treatment
Test: on literacy
and numeracy
Interview: to judge
on motivation
and willingness
final selection by
community and
local health
center
36
Recommendations – Typology of HIV/AIDS Care CHW
Key
competencies
Community primary Initial: 4 weeks Exam after Supervisors volunteers * - identification of HIV Should be offered linkages
Involvement in level Ongoing: once per month initial training 1 supervisor: positive pregnant to advance their between
identification schooling key Role : 20-25 CHWs OR women career as supervi- TBAs and
of potential Promotive, preventive and sor on completion health
community health therapeutic interventions: Salaried - leading monthly of minimum system
workers on passing exam keeping in support group education level
HIV /AIDS: and completion Evaluation: view that meeting with and experience
- Advertisement in - condom promotion and other safe sex of initial training annual internal they are poor HIV/AIDs patients required to reach

local newspaper or health promotion they should be evaluation the next level.
radio channel - Provide information and education on TB awarded with title Full time
for interested and HIV to increase community awareness external employment
cadidates to join of both infections and their evaluation in
inter-relationship, every 5 year
Applicant must be - Intensify tuberculosis case finding in on completion of
-18-40years of age areas of high HIV prevalence, on-job training
- from the local - Building HIV support groups in the they should be
community community for social and psychological awarded with
-permanent resident rehabilitation. a certificate
Preferably people
have AIDs or those PMTCT:
who have taken - Healthy timing and spacing of pregnancy
care of any family - antibody testing to pregnant women
member with AIDS and mothers
- prophylactic ARVs/HAART
Test: on literacy - prophylactic ARVs/HAART to infants
and numeracy - early infant diagnosis
- Cotrimoxazole preventive therapy (CPT)
Interview: to judge
HIV/AIDS Care CHW

on motivation
and willingness
final selection by
community and
local health
center
37
global review of evidence, and on the country Short to intermediate duration training pro-
case studies. grams, with preventive and basic curative tasks
for CHWs, with relatively strong supervision acti-
Long duration training programs with a content vities, and implemented by NGOs within a weak
mostly promotional and preventive, and also health system, have shown to have impact on
aimed at understanding social and environmen- infant mortality in the area of influence of invol-
tal determinants of health, strongly supervised, ved NGOs (Haiti). Their impact when implemen-
with CHWs playing basically a role of empower- ted at scale is not known.
ment of the community and health promotional
and preventive activities improve health of the
population and should be replicated in other Limitations
settings. This type of program seems to work on
The review identified a number of limitations.
the condition that CHWs activities are organized
Firstly, most of the reviewed studies when im-
as part of a wider health team and on the condi-
plemented, neglected to document the com-
tion that programs are effectively linked to the
plete description and characteristics of CHWs
public health system that is able to provide effi-
deployed, especially the level and amount of
cient stewardship and financing, and that consi-
supervision provided to those workers, which
ders health as a basic human right that should
could have helped us in identifying the im-
be available to all citizens, free at the point of
portance of this factor and its association with
use. There is no evidence on whether this mo-
other outcomes. Additional information on the
del could be equally effective when delivered
initial level of education of CHWs, provision of
by private providers. Several years of schooling
refresher training, mode of training (balance
as a selection and recruitment criterion seems
of practical/ theoretical sessions) would have
unpractical, and alternatively, basic schooling
provided greater assistance in understanding
or literacy as a minimum requirement should
the threshold effect, if any, of these factors on
be attempted, while taking care of monitoring
CHW performance in community settings.
and evaluating the effect of such modification
Importantly, community ownership and super-
on the overall performance and impact of the
vision of CHWs is a key characteristic which is
program. Also, where the need of alternative
insufficiently described and analyzed in availa-
health providers is more pressing, task shifting
ble literature. Secondly, studies related to the
with CHWs assuming basic curative tasks should
role of CHWs in HIV/AIDS prevention and care,
be implemented and evaluated.
mental health and food security and nutrition
were scarce. Lastly, there were few evaluation
Short duration training programs, with mostly
studies/reports at scale and none had followed
an a-priori experimental design or impact asses-
for CHWs and with a relatively strong supervi-
sment process.
sion system such as BRAC in Bangladesh and
VHV in Thailand are associated with increased
coverage and utilization of health services and
with certain improved health outcomes, and
should be implemented in other settings. Such
programs have been implemented in contexts
with relatively strong health systems and have
been effectively linked to the health system.
38 Global Evidence of Community Health Workers

CHW Program Specific Recommendations
The programs should be coherently inserted The CHW programs should support provision
in the wider health system, and CHWs should of requisite and appropriate core supplies and
be explicitly included within the HRH strategic equipment to enable appropriate functionality
planning at country and local level. of such workers.
Community preparedness and engagement is The programs should have established referral
a vital element that is relatively rarely practiced. protocols with community-based health and
From the outset, program should develop vil- social service agencies.
lage health committees in the community that
The programs should have regular and conti-
can also contribute in participatory selection
nuous supervision and monitoring systems
processes of CHWs.
in place and supervision should be taught to
CHW programs should be based in and respond be undertaken in a participatory manner that
to community needs. In practical terms, such ensure two-way flow of information. Moreover,
programs should continually assess community both external and internal evaluations need
health needs and demographics, hire staff from to be carried out on regular basis to improve
the community who reflects the linguistic and the services and analyze the need of various
cultural diversity of the population served, and logistics, supplies and training according to the
promote shared decision making among the requirements. Ideally, programs should evaluate
program’s governing body, staff, and commu- their own performance on annual basis, while a
nity health workers. third party evaluation could be recommended
in every 4-5 years, which would generate a neu-
Given the broad role that many CHWs play in
tral and free from bias findings.
primary care, a program must assure that a core
set of skills and information related to MDGs be CHW programs should also provide opportuni-
provided to most CHWs. Therefore, the curricu- ties for career mobility and professional develo-
lum should incorporate scientific knowledge pment. These should include opportunities for
about preventive and basic medical care, yet continuing education, professional recognition,
relate these ideas to local issues and cultural and career advancement. This can be through
traditions. They should be trained, as required, specific programmatic opportunities or access
on the promotive, preventive, curative and re- to educational and training scholarships.
habilitative aspects of care related to maternal,
The outline of the country plan of action to
newborn and child health, malaria, tuberculosis,
develop and improve CHW program(s) should
HIV/AIDs as well as other communicable and
be finalized by a working group of relevant
non-communicable diseases. Other training
multiple stakeholders, including identification
content and training duration may be added
of resources needed, indicators and targets, and
pertinent to the specific intervention that the
monitoring tools, and formally authorized by
CHW is expected to work on as detailed in main
the Ministry of Health
report.
Finally, sustained resources should be available
The CHW programs should regulate a clear
to support the program and workers therein.
selection/ deployment procedure that reassure
appointing those who certify the course com-
pletion and pass the writing or verbal exam at
the end of training.
39
Conclusion and Areas
for Further Study the CHW programs promote equity and access;
and to evaluate the effectiveness of paid workers
The UN Secretary General Ban Ki-moon said: versus voluntary workers. Moreover, studies are
“Time is short. We must seize this historic mo- needed to evaluate the effectiveness of CHWs as
ment to act responsibly and decisively for the compared to professional health care providers
common good”. He used these words to stron- in delivering interventions in the fields of health
gly urge the governments to work constructi- education, promotion and the management of
vely for a high level meeting in September 2010 disease.
to review their country’s progress towards the
MDGs. With just six years left to meet the MDG Given the global burden, specific studies on the
2015 deadline a gigantic responsibility rests on potential role of CHWs in HIV/AIDS prevention
the shoulders of governments to upscale health and care are particularly required, as there is very
and nutrition interventions and provide adequa- limited empirical information on this. Further
te funding and support to their health systems systematic reviews are also required on: factors
to fulfill the pact they signed way back in 2000 affecting the sustainability of CHW interventions
as the UN Millennium Declaration. Induction of when scaled up; the effectiveness of different
more workforces into the programs as CHWs approaches to ensure program sustainability;
and supervisors with ascertained commitment the cost-effectiveness of CHW interventions for
can greatly help us achieve MDG targets. It is different health issues; and factors that deter-
expected that increased emphasis on the issue mine the effectiveness of CHW interventions in
of HIV in the training module of a CHW, field different settings. An additional analysis is requi-
experience before deployment, better super- red on the volume of work and type of activities
vision, switching them from volunteers to full and hence to determine the number of CHWs
time paid health care workers and regular eva- required for such tasks. An example of this type
luation can lead to a stronger outreach system of analysis is provided by a study in Bangladesh
of healthcare delivery and could eventually help which assessed how many additional health
meet the MDG targets. workers would be needed to implement IMCI
protocols.33 However, further studies are nee-
We constructed a core and MDGs specific CHW ded to determine the CHW workforce needed
typology from the evidences and gaps identi- and their functional needs for MDG specific
fied from global systematic review and country interventions.
case studies. The next step which is required is
to explore the impact of deploying CHW with
suggested typology on achieving MDGs.
During the course of undertaking this review, we

found dearth of data on the cost effectiveness
of CHW programs. Although it was not the aim
of this review, but economic studies should ac-
company trials to establish the cost effectiveness
of different CHW interventions, because CHWs
are more accessible and acceptable to clients
in their communities, and they are expected to
improve the overall coverage of services as well
as equity. Studies are needed to assess whether

References:
1 Jones G SR, Black RE, Bhutta ZA, Morris SS. 9 Graham WJ, Cairns J, Bhattacharya S, Bullough
Bellagio, Child Survival Study Group. How many CHW, Quayyum Z, K R. «Maternal and perinatal
child deaths can we prevent this year? Lancet. conditions.» 2006. Disease Control Priorities in
2003; 362:65-71. Developing Countries. 2nd Ed. New York: Oxford
University Press; 2006.
2 Darmstadt GL BZ, Cousens S, Adam T, Walker N,
de Bernis L, Lancet Neonatal Survival Steering 10 Haws RA, Thomas AL, Bhutta ZA, Darmstadt GL.
Team. Evidence-based, cost-effective interven- Impact of packaged interventions on neonatal
tions: how many newborn babies can we save? health: a review of the evidence Health Policy
Lancet. 2005; 365:977-988. and Planning. 2007;22:193-215.
3 Campbell OM, Graham WJ, Lancet Maternal 11 Bhutta ZA, Darmstadt GL, Lawn R, Goldenberg R.
Survival Series Steering Group. Strategies for A global review of interventions to address still-
reducing maternal mortality: getting on with births. BMC Pregnancy and Child Birth. 2009.
what works. Lancet. 2006; 368:1284-1299.
12 Bhutta ZA, Soofi SB. Community based newborn
4 Engle PL, Black MM, Berham JR, et al, International care: are we there yet? Lancet. 2008; 372:1124-
Child Development Steering Group. Strategies 1126.
to avoid the loss of developmental potential
in more than 200 million children in the deve- 13 Travis P, Bennett S, Haines A, et al. Overcoming
loping world Lancet. 2007; 369:229-242. health-systems constraints to achieve the
Millennium Development Goals. Lancet. 2004;
5 Bhutta ZA, Ahmed T, Black RE, et al, Maternal and 364(9437):900-906.
child Undernutrition Study Group. What works?
Interventions for maternal and child undernutri- 14 World Health Organization. The global shortage
tion and Survival. Lancet. 2008;371:417-440. of health workers and its impact. WHO Fact
sheet 302. 2006.
6 Kerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong
P, Starrs A, Lawn JE RH, Wilczynska-Ketende K, 15 Fraser B. Human resources for health in the
Hill K. Continuum of care for maternal, newborn Americas. Lancet. 2007; 369(9557):179-180.
and child health: from slogan to service delivery.
Lancet. 2007; 370:1358-1369. 16 Haines A, Sanders D, Lehmann U, et al. Achieving
child survival goals: potential contribution of
7 Bhutta ZA, Ali S, Cousens S, et al. Interventions to community health workers. Lancet. 2007; 369:
address maternal, newborn and child survival: 2121-2131.
what difference can integrated primary health
care strategies make? Lancet. 2008; 372:972- 17 Earp JA, Falx VL. What lay health advisors do:
989. an evaluation of advisors activities. Cancer
Practioners 1999; 7(1):16-21.
8 Adam T, Lim SS, Mehta S, et al. Cost effectiveness
analysis of strategies for maternal and neonatal 18 Rosenthal EL. A summary of national commu-
health in developing countries. British Medical nity health advisor study. Baltimore, MD: Annie
Journal. 2005; 331: 1107. E Casey Foundation; 1998.
41
19 World Health Organization. Strengthening the 27 Kash BA, May ML, Tai-Seale M. Community health
performance of community health workers in worker training and certification programs
primary health care: a report from a WHO study in the United States: findings from a national
group. Geneva: World Health Organization; survey. Health Policy and Management. 2007;
1989. 80(1):32-42.
20 Kurowski C, Wyss K, Abdulla S, Mills A. Scaling 28 Crigler L, Hill K. Rapid assessment of community
up priority health interventions in Tanzania: the health worker programs in USAID priority MCH
human resource challenge. Health Policy and countries USAID Health Care Improvement
Planning. 2007; 22(3):113-127. Project 2009.
21 World Health Organization. Taking stock: health 29 Achieving the Millennium Development Goals
worker shortages and the response to AIDS. in Africa 2008.
Geneva: World Health Organization; 2006.
30 Khan Z, Iqbal Z, Rahman A. Job stress among
22 Standing H, Chowdhury AM. Producing effective community health workers: a multi-method
knowledge agents in a pluristic environment: study from Pakistan International Journal of
what future for community health workers? Mental Health System 2008; 2(15).
Social Science and Medicine. 2008; 66(10):2096-
2107. 31 Khan SH, Chowdhury AMR, Karim F, Barua MK.
Training and retraining Shasthyo Shebika:
23 Macinko J, Guanais FC, Souza MdFMd. Evaluation reasons for turnover of community health wor-
of the impact of the family health program on kers in Bangladesh. The Health Care Supervisor
infant mortality in Brazil, 1990-2002. Journal 1998; 17(1):37-47.
of Epidemiological Community health. 2006;
60(1):13-19. 32 Curtale F, Siwakoti B, Lagrosa C, LaRaja M, Guerra
R. Improving skills and utilization of community
24 World Health Organization. Community Health health volunteers in Nepal. Social Science and
Workers: what do we know about them? The sta- Medicine. 1995; 40(8):1117-1125.
te of evidence on programmes, activities, costs
and impact of health outcomes of using health 33 Khan MM, Ahmed S, Saha KK. Implementing IMCI
workers. Geneva: World Health Organization; in a developing country: estimating the need for
2007. additional health workers in Bangladesh; 2000.
25 Rocha R SR. Evaluating the Impact of Community-

Based Health Interventions: Evidence from
Brazil’s Family Health Program. Discussion Paper
Series. IZA DP No. 4119. Discussion Paper No.
4119. Bonn, April 2009.
26 Oxford Policy Management. Lady Health Worker

Programme: External Evaluation of the National
Programme for Family Planning and Primary
Health Care 1999-2002: Final Report: Oxford
Policy Management March 2002.

040
Global Evidence of Community Health Workers 43
Annex 1:
Global Systematic
Review
For global systematic review, the studies were out of which 315 papers (276 original studies)
categorized based on interventions relevant passed the eligibility criteria for inclusion.
to health and nutrition related MDGs and then Among these 315 papers, 231 papers described
analyzed by the type of outreach workers and the role of CHWs in delivering interventions, 39
study design employed in order to explore the studies trained TBAs and evaluated the impact
impact and effectiveness of global experience of their training, and nineteen studies utilized
of CHWs in delivering healthcare. This helped us peer counselors, while 7 described the role of
in outlining the typology, training and supervi- community mobilizers. As far as study designs
sion needs, tasks and feasibility of developing are concerned, 31 of the selected studies were
and deploying CHWs as a way towards the clustered RCTs, 45 were RCTs, 42 were Quasi
achievement of the MDG targets. We have also RCTs, 34 were prospective before-after interven-
presented some national or NGO driven CHW tion studies and 147 were descriptive studies.
programs in the form of “CHW Snapshots” ap- Box 2 presents the included studies according
pearing randomly in this report. to country and continent where it was actually
conducted. During our search we also identified
six ongoing studies which matched our eligibi-
Description of included studies lity criteria and are described in table 2.
The defined search strategy identified 136,996
studies from multiple search engines (Figure 1).
1060 studies were retrieved for full text review,
Box 2: Included studies by continent and country

Asia n Africa n Europe n America n Australia n
Bangladesh 29 Burkina Faso 6 Netherlands 1 Bolivia 4 Australia 1

Burma 3 Cameroon 2 Turkey 1 Brazil 10 New Zealand 2
China 2 Egypt 1 England 3 Canada 2
India 34 Ethiopia 6 Colombia 2
Iran 2 Gambia 7 Ecuador 2
Indonesia 2 Ghana 5 Guatemala 6
Iraq 1 Guinea 1 Haiti 5
Korea 1 Madagascar 1 Latin America 1
Laos 1 Mali 2 Mexico 2
Malaysia 1 Malawi 3 New England 3
Nepal 11 Mozambique 1 Nicaragua 1
Pakistan 19 Nigeria 5 Peru 4
Palestine 1 Kenya 8 United States 54
Philippines 2 Rwanda 1
Thailand 8 Senegal 1
Vietnam 1 Sierra Leon 1
South Africa 7
Swaziland 1
Tanzania 7
Uganda 10
Zaire 1
Zambia 2
Zimbabwe 1

Figure 1: Search Flow diagram
Search Strategy Identified 136,995 studies
PubMed = 67166
Popline = 27938
Google Scholar = 18400
Science Direct = 19238
Cochrane Trial Register = 4253
Gray literature
Capacity Project = 312 Excluded 136099 papers
HRH Global Resource Center = 162 from first screen
World Bank JOLIS = 78
BLDS = 22
IDEAS = 49
1060 were retrieved for full text review

745 Excluded: 40 review
papers and 705 did not
meet the inclusion criteria
315 Papers (276 original papers) included for review
8 ongoing studies
(not included in analysis)
By type of outreach worker By design By Target MDGs
CHWs 230 cRCT / RCT 76 MDG 1: Nutrition 10
TBAs 39 Quasi RCT 42 MDG 4: Child Health 87
Community mobilizers 7 Pre/post 34 MDG 5: Maternal Health 73
Peer counselors 19 Descriptive 147 MDG 6: Malaria/TB/HIV/NCD

/Mental health / NCDs 94
45
46
Table 2: Ongoing Trials/ Studies
Study / Study Outreach Participants Interventions Outcomes Trial Anticipated
country design worker registration end date
Experimental arm Control arm
number
Ronald 1 cRCT CHWs General population A: Experimental Peer Health Workers Patients in communities Virologic suppression NCT00675389 Dec 2010
Uganda with HIV positive status Intervention: Peer health workers without peer educators. at 6 months
are themselves PLWHA on ART who Virologic failure at
have demonstrated good ART adhe- all time intervals
rence for at least 6 months. The peers from ART initiation
are responsible for ~15-20 patients and Adherence measured
are expected to visit the patients in by pill counts
their homes once every two weeks.
Experimental Peer Health Workers and
Mobile Phone Intervention: In addition
to the peer health worker intervention,
this arm adds a mobile phone
Chakaya & cRCT CHWs 15 Years and older In the intervention group, the hou- In line with routine care, incidence of TB , inci- NCT00850915 Dec 2011
Klinkenberg 2 population sehold contacts of enrolled TB/HIV eligible index cases dence of adverse events,
Kenya co-infected patient are visited at home are requested to send incidence of TB-related
by community health workers. their contacts to the symptoms in household
They are offered isoniazid at 300mg (5 clinic for evaluation contacts proportion of
mg per Kg for children) once daily for 6 household contacts star-
months, regardless of their HIV-status. ting IPT, discontinuing IPT,
adhering to IPT treatment
Osrin cRCT CHWs Women who give birth Facilitator will convene commu- The control group does Neonatal mortality rate. ISRCTN96256793 01/01/2010
et al.2008 3 or any woman who gives nity groups to explore maternal not receive an interven- Antenatal, delivery and
India birth in the study area is and neonatal health issues. Groups tion. Control areas benefit postnatal care uptake.
potentially a participant. will meet once or twice monthly from the health service
The age range would and move through action research provision activities of the
be 12 to 49 years. cycles. The role of the facilitator is City Initiative for Newborn
to activate & strengthen groups, Health: improved mater-
support them in identifying problems, nal and newborn care at
help to plan possible solutions and health posts, maternity
implementation & monitoring of homes, general hospitals
solution strategies in the community. and tertiary hospitals.
Rahman 4 cRCT CHWs Married, consenting wo- The intervention arm will receive seven The control arm The duration of exclusive ISRCTN45752079 01/06/2010
Pakistan men, aged 17 – 40 years. sessions of this maternal focused will receive a similar breastfeeding and its rate
Pregnant; in their 3rd approach to promote breastfeeding number of visits of routine at 6 months Psychological
trimester of pregnancy through Lady Health Workers. counseling for breastfee- distress at 3 and 6 months
ding through different
Lady Health Workers.
Costello 5 cRCT CHWs Women of repro- CHWs will be convening monthly The control group Neonatal mortality rates, ISRCTN87820538 01/01/2010
Nepal ductive age, infants women’s groups in which they will does not receive stillbirth rates, maternal
under a year of age. identify, prioritize the problems an intervention. mortality ratios, Sepsis
and then develop and implement management
strategies and evaluate their success.
CHWs will be trained to care for
vulnerable newborn infants.

Study / Study Outreach Participants Interventions Outcomes Trial Anticipated
country design worker registration end date
Experimental arm Control arm
number
Gill 6 cRCT TBAs TBA trained in Training traditional birth attendants Active Comparator TBAs Neonatal, perinatal NCT00518856 completed
Lufwanyama, safe delivery a modified version of the neonatal continuing with current & sepsis related
Zambia resuscitation protocol (NRP) and by standard of practice mortality cost effec-
improving their ability to identify sepsis tiveness, successful
and initiate antibiotics in the field. delivery of nevirapine
prophylaxis to HIV
exposed deliveries
Costello 7 cRCT CMs TBAs women of 15-49 Implemented a participatory learning Control group was not maternal mortality, neo- ISRCTN54792066 completed
Kenya years of age and action cycle in which they identify provided with partici- natal mortality, stillbirths,
& prioritize problems, then formulate patory learning groups perinatal mortality, other
strategies and implemented & monitored service delivery and
and finally evaluated the process + group newborn care outcomes

was again divided into two according
to the trained TBAs for asphyxia or not
Barnett 8,9 cRCT CMs TBAs women of 15-49 IImplemented a participatory learning Health committees in maternal mortality, neo- ISRCTN21817853 completed
Jharkhand years of age cycle, through developing women’s control clusters were for- natal mortality, stillbirths,
& Orissa, groups where they identify & prioritize med to give Community perinatal mortality, other
India maternal and newborn health problems a voice in the design service delivery and
in their community, implemented the and management of newborn care outcomes
strategies, and evaluated the results local health services.
47
Results
According to WHO, CHWs should be members Maternal, Neonatal and Child health
of the communities where they work, should interventions
be selected by the communities, should be o Maternal health interventions
answerable to the communities for their activi- o Breastfeeding promotion interventions
ties, should be supported by the health system o Birth and Newborn Care Preparedness (BNCP)
but not necessarily a part of its organization interventions
and have shorter training than professional o Neonatal health interventions
workers.10 o Childhood illnesses and immunization
interventions
CHWs were first formally introduced in 1970s
and 80s after Alma Ata declaration for the ini- Other Primary health care promotion
tiation and provision of primary health care ser- interventions
vices at grass root levels to entire population.11
However, they gained their popularity due to the Malaria control interventions
shortage of human resources for health care.11
They not only support in the promotional and Tuberculosis control interventions
prevention activities but also take part in the
management and treatment of illnesses.11, 12 HIV/ AIDS prevention and control interventions
CHW programs have been said to be able to Mental Health interventions

provide three major benefits: health benefits
including improvement in health indicators, Other non communicable diseases prevention
utilization of health services and changes in interventions
behaviours directly related to health; non-
health benefits to individuals including infor- Nutritional Interventions
mational benefits, cultural appropriateness and
the promotion of autonomy; and non-health Background
social benefits which can include community The first seven Millennium Development Goals
empowerment sustainability and economic are directly or indirectly linked with the activities
benefits. While now being acknowledged as a of the health and nutrition. There are many sy-
potential important tool in improving health, nergies among these goals and related activities,
CHW programs are often held back by unrealistic and nutrition underlies achievement for most
expectations, poor initial planning, problems of of the health MDGs, so working for all MDGs at
sustainability and the difficulties of maintaining the same time, such as education, water and
quality.13 sanitation, and gender is likely to be the most
effective way of achieving progress in health
Studies according to MDGs and nutrition goals. Every year, it is estimated
that under nutrition contributes to the deaths
In this global systematic review, we grouped and of about 5.6 million children under the age of
analyzed selected studies according to health five.14 One out of every four children under
related MDGs. Studies are clustered according five or 146 million children in the developing
to the following categories: world is underweight for his or her age, and at
increased risk of an early death. When nutrition
Nutritional interventions falls short, damage is done to individuals and
to society. When pregnant women are not ade-

quately nourished, their babies are born at low (Table 3A and Table 3B). Those recruited were
weights, putting their survival at risk. When girls mostly locals from the community.15-19 They
are undernourished, their future ability to bear were trained using didactic mode of trai-
healthy children is threatened. Under-nutrition ning16-19 and the training content varied from
and micronutrient deficiencies can lead to de- health education on nutritional requirements
velopmental delays throughout childhood and of mother and child16, 18, 19 to the counseling
adolescence, making individuals less produc- related to nutritional consumption with limited
tive as adults. Prevention and control of under financial resources.17
nutrition is possible through simple community
based interventions lead by community wor- In Hossain et al., children were weighed and their
kers. We therefore included studies that initiated care giver was counseled on health, family plan-
community based nutrition interventions by ning, breast feeding, caring practices, personal
community workers and monitored their results hygiene and the use of iodized salt.16 Children
in creating an impact on improving nutritional who did not gain weight in three consecutive
health of community. months were enrolled in a supplementary fee-
ding program and provided standard packets
Community Based Evidence of food.16 However the intervention did not
show any impact on evaluation by pre/post
A total of nine studies were reviewed to as- intervention questionnaire as compared to in-
sess the impact of nutrition related interven- terventions where only counseling on nutrition
tions involving the CHWs in the community was provided.17, 18, 20 The CHWs in the Staten et
CHW Snapshot 1
Village Health Workers Program Bhutan
Program overview
Bhutan initiated its Community health workers program in 1979 with the name of village health workers program. Their
basic idea was to build a link between community and health service utilization. Through this program the concept of
primary health care was disseminated and includes improvement in basic hygiene and sanitations prevention of vaccine
preventable diseases and other preventive and promotive aspects of health.
Operational aspects and considerations

Village health workers were selected if they were found confident, Village Health Workers, Bhutan
trusted and popular in the community, living permanently in the Training 12 days training
community and had a good personal hygiene and health care and Supervision BHU staff
community participation. Their role in the community is to provide Incentive voluntary and only receive
health education towards better health care, including family plan- financial benefit during training
ning, provide simple first aid treatment for emergencies and minor
illnesses, notification of the outbreak of any epidemics in the community, recognizing danger signs and symptoms of
serious and chronic patients, playing an important role in out-reach clinics and expanded program of immunization and
referral to the nearest health centre. They are also expected to participate in any development activities in the community,
for example electricity and water programs.
Coverage and eﬀectiveness

Village health workers have been recognized as a positive force in the community at all levels, including the National
Assembly. There is a great demand for VHW training from those communities which do not have VHWs, either, because
no-one was trained before or, to replace the drop-outs. However, as the program is totally dependent on donors, even
maintaining the network of close to 1,300 VHWs is becoming a challenge.

Conclusion
al. organized bi-monthly walks and encouraged Overall the role of CHWs involved in nutritional
the participants to find walking partners and intervention was promotive in nature and had
support each other in health improving goals15 a preventive baseline strategy. They promoted
and also encouraged each other to increase health education with positive impact on ma-
their fruit and vegetable intake.15 The CHWs ternal and child health, thus contributing to the
who participated in the Tandon et al. conducted achievement of MDG goal 4 and 5 targets. We
nutrition program for the preschool children, found that simple promotive interventions lead
pregnant women and lactating mothers.18 The to create an impact on the nutritional status
effectiveness of this intervention were evalua- of children, pregnant women and society as a
ted by the outcomes of counseling which did whole.
not create an impact on the nutritional status of
children as evident by 0.1% decrease in severe
malnutrition cases over the period of 8 years.18
Health education on topics like hygiene, proper
positioning of infant while feeding and adequate
nutrition was the domain of CHWs in Zuvekas et
al.21 The CHWs in Winchagoon et al. monitored
growth of children and managed diarrhea using
oral rehydration solution.19
In an intervention by Winch et al., the CHWs pro-

vided dispersible zinc tablets in 14-tablet blister
packs for children under five years of age.22
The Macharia et al., cross-sectional study on the
other hand provided region specific data on the
nutrition status in the world.23 Only the CHWs
in Tandon et al., were paid honorarium18, which
did not seem to have impact on their working
as compared to other studies where the health
workers were just volunteers.15, 17, 20
Other contextual factors related to CHWs were

poorly reported in the included studies. The
educational levels of these CHWs, their actual
recruitment process and duration of training,
refresher and supervision provided were mostly
missing in these studies.
Thus we cannot comment on the effect of these

factors on overall performance of CHWs and
their impact on nutritional outcomes.

CHW Snapshot 2
BRAC – Bangladesh Nationwide Shastho Shebika Program
Program overview
The BRAC was formed in 1972 and has been supporting CHW program since 1977. The BRAC program has trained commu-
nity health workers who are known as 56 Shastho Shebika and is responsible for treating the essential 10 diseases: anemia,
cold, diarrhea, dysentery, fever, goiter, intestinal worms, ringworm, scabies and stomatitis. They sell medications for these
ailments for a nominal fee. Each CHW is responsible for approximately 300 households and visits about 15 households each
day. In addition to treating the 10 diseases and referring patients, the Shastho Shebika work in many different programs
(treatment of tuberculosis cases through directly observed therapy, control of diarrheal disease, immunization, family plan-
ning and prevention of arsenic poisoning), encourage people to seek care at BRAC and government clinics, and assist at
satellite clinics that focus on antenatal care and immunization.24
Operational aspects and considerations Shastho Sebika, Bangladesh

The 56 Shastho Shebika are women chosen by the community and Education Few years of schooling
are members of the BRAC-sponsored village organizations. Shastho Training 18 days basic and 3 days
Shebika are volunteers, they support themselves through the sale TB management training
of commodities provided by BRAC, such as oral contraceptives, Refresher One day each month
birth kits, iodized salt, condoms, essential medications, sanitary Supervision Shastho Kormi
napkins and vegetable seeds. The Shastho Shebika use a system
Incentive Sales of medication
of verbal referral.25

BRAC have achieved extensive coverage and have been associated with marked improvements in women and children’s
health. Oral rehydration therapy was first used clinically for diarrheal illness in Bangladesh, and BRAC was the first orga-
nization to implement a community-based program promoting oral rehydration therapy on a wide scale. Reductions in
neonatal, post-neonatal and infant mortality were observed in study districts after the introduction of the oral therapy
extension program.

52
Table 3A: Nutrition Interventions – Description of Studies
Study / Study Outreach Interventions Years of Participants Outcomes
country design worker Experimental arm Control arm study
Hossain et RCT CHWs Three intervention groups: (1) provider No intervention was 24 months women over age 50 All three intervention groups showed an increase
al.200516 counseling, (2) provider counseling and delivered to control arm in self-reported weekly minutes of moderate-
Arizona, USA health education, or (3) provider counse- to-vigorous physical activity, with no significant
ling, health education, and CHW support. differences between the groups. Significantly
more women who received the comprehensive
intervention of provider counseling, health edu-
cation, and CHW support progressed to eating
five fruits and vegetables per day, compared with
participants who received only provider counseling
or provider counseling plus health education.
Staten et Quasi CHWs Child was weighed, & the carer received Children in control areas 60 months Children of 6-59 Severe low WAZ (<-3 z-scores) 11.4% in intervention
al.200415 RCT counseling on health, family planning, receive routine care * months of age areas compare to 12.1% in control (NS) Moderate low
Rural breastfeeding, caring practices, personal WAZ (> 3 z-scores and ,<-2 z-scores) 35.2% in inter-
Bangladesh hygiene & the use of iodized salt. All or vention areas compare to 36.3% in control (NS) Severe
who failed to gain the required weight low HAZ (<-3 z-scores) 11.6% in intervention areas
in three consecutive monthly weighing compare to 12.4% in control (NS) Moderate low HAZ
was enrolled in a supplementary (> 3 z-scores and ,<-2 z-scores) 27.5% in intervention
feeding program. They were given the areas compare to 27.6% in control (NS) Severe low
food (rice, pulses, molasses and oil) WHZ (<-3 z-scores) 1.0% % in intervention areas com-
was given in standard packets. pare to 1.1% in control (NS) Moderate low WHZ (> 3
z-scores and ,<-2 z-scores) 13.4% 14.3% in control (NS)
Tandon Quasi CHWs nutrition and education services at ICDS service was not 96 months children under A study of the nutritional status (by weight-for-
198918 RCT the village level through Anganwadi initiated in control areas 6 years of age age estimations) of the children in the non-ICDS
India centers, each of which was run by populations showed a drop in severe malnutrition
a local part-time female worker from 19.1% to 8.4% between 1976 and 1985.
The status of malnutrition in 1985 in the ICDS
populations after 3-5 years and 8 years of
implementation decreased from 6.4% to 6.3%
Chowdhury & Quasi CHWs CHWs visited each house on monthly bass No intervention was pro- 24 months pregnant women, group had the greatest reduction in low birth
Mahmud20 RCT and provide education and conducted vided in Non BRAC areas adolescent girls, weights, i.e. 36% between 1992 and 1994
Mymensingh, monthly nutrition and health education children compared to women from other BRAC areas
Bangladesh meetings and managed growth
monitoring sessions by children ages less
than 2 yrs and educated mothers and
identified malnourishment. Pregnant
women received monthly antenatal care,
education and nutrition assessment.
Winch et Compa- CHWs Dispersible zinc tablets in 14-tablet blister packs were provided 5 months children under 27% of children presented with diarrhea symptoms
al.200822 rative cross through community health centers and drug kits managed by CHWs. 5 years of age to CHWs and 14% to community health centers
Bougouni, sectional Village meetings and individual counseling provided by CHWs. similar percent of (29%) children with diarrhea and
Mali survey fever symptoms presented to CHWs and community
health center 17% and 29% of children with diarrhea
and ARI presented to CHWs and community health
centers respectively 27% and 29% of children
with diarrhea, fever and ARI presented to CHWs
and Community health centers respectively.

Winchagoon Cross CHWs Nutritional improvement has been implemented as an integral part in the year women and children Weekly iron supplementation of school children
2002 19 sectional of primary health care and community development extending 2000 was piloted in 2000, and is now being extended.
Thailand survey beyond government services to include community participation. Other strategies utilized to address iron deficiency
Utilization of village health volunteers has been a crucial feature of include food fortification, dietary improvement
the program. Universal iron supplementation has been the major and complementary public health measures
strategy for pregnant women, using village health volunteers
to encourage continuation of the antenatal care schedule and
encouraging a preventive approach by health service providers.
Iron tablets (60 mg dose) were dispensed along with multivitamin
mineral tablets monthly or bimonthly, according to ANC schedules
Macharia et Compa- CHWs provide region specific data on the nutrition situation in the 2 months Children between The prevalence of stunting in the project area (46.5%)
al.200523, 26 rative World Vision Project area and establish whether there is any 6 – 59 months was slightly higher than among the non-project area
Kenya cross- significant difference from the non-operational area (42.1%). There was no significant difference in preva-

sectional lence of stunting, wasting and underweight between
surveys the world vision project area and non project area.
Zuvekas et Cross CHWs Regional Medical Center at Lubec, Maine uses CHWs to 24 months children adolescents 12 presentations were given on nutrition at area
al.199821 sectional promote the health of the community. The CHW pro- and elderly schools; 11 call-in shows on health education topics
Lubec, USA gram focuses on providing services to the community’s were aired on the local public access channel;
most needy: children, adolescents, and the elderly.
53
54
Table 3B: Characteristics of outreach workers
Study Education Recruitment Training Duration Certification Refreshers Role key compe- Supervision Incentive coverage Evaluation
Criteria Content / Ongoing tencies (if any) mode
training
Staten et >50 yr old Provided information, support Provided coun-
al.200415 bilingual, & organized bimonthly walks seling, health
introduce where they encouraged education, and
CHWs (F) women, who participants to find walking social support
could pro- partners, build friendships, for behavior
vide outreach, and support each other in change.
translation their health improvement
services goals. Also encouraged to
increase their fruit & vegetable
consumption incrementally
Hossain et Workers from Didactic Home visits made, child Nutrition Questionnaires
al.200516 community They were trained weighed and care giver coun- counseling for assessing
under Bangladesh seled on health, family plan- the effec-
CHWs Integrated ning, breast feeding, caring tiveness of
Nutrition Project practices, personal hygiene counseling
and the use of iodized salt
Kilaru et Locally Didactic Training Collected monthly filled Nutrition
al.200517 trained Trained by nutritionist questionnaire on feeding counseling
counselors & pediatrician, related and child care behavior, and
CHWs to appropriate feeding study infants were weighed
of an infant. Also at this time, using the SECA
trained to be mindful solar scales, developed for
of constraints in terms UNICE Conveyed messages
of available household related to: developmen-
food, limited financial tally appropriate local foods
resources, decision & preparation of these
making capacity foods; feeding frequency;
and privilege within
Complementary feeding
the family structure
followed by breastfeeding;
while counseling the
community members avoidance of feeding bottles.
Tandon Community Didactic Training Conducted nutrition program Nutrition and Honorarium Effectiveness
198918 workers Counseling and health for preschool children (under education paid assessed by
education related 6 years old), pregnant women, services the outcomes
CHWs (F) to consumption of and lactating mothers. of counseling
fruits & vegetables
every day.
Chowdhury Monthly visits to household ANC, health
& for monitoring, nutrition education,
Mahmud20 assessment and and nutrition
health education assessment.
CHWs

training
Winchagoon Selected Didactic trained Activities included growth Maternal and
2002 19 from the on essential health monitoring, diarrhea child health
community knowledge and management using oral care activities
CHWs assigned specific rehydration therapy (ORT),
preventive and pro- identifying pregnant women
motive tasks with a and encouraging them to
focus on maternal attend antenatal care services
and child health
and nutrition.
Zuvekas Health education on topics as Primary health
et basic as proper hygiene, how care services
al.199821 to correctly hold and feed an

infant and proper nutrition
CHWs
55
Maternal Health Interventions
Background and outreach workers are reported in Table 4A
The inclusion of maternal health in the millen- and Table 4B. The types of CHWs involved in the
nium development goals in itself reflects the interventions studied, related to maternal health
gravity of the issue. The targets set are reduction are the community health workers (CHWs), the
in the maternal mortality ratio by three-quarters community mobilizers (CMs) and the traditional
between the years 1990-2015, and universal ac- birth attendants (TBAs). In 16 studies CHWs alone
cess to reproductive health services by the year or in combination with TBAs and CMs delivered
2015. Several indicators that are set to monitor the interventional packages related to maternal
the progress towards meeting the MDGs are health, while in 6 studies only TBAs delivered
maternal mortality ratio, proportion of births maternal health interventions in community.
attended by a skilled birth attendant, coverage Out of 42 included studies in this section, only
of emergency obstetric care, proportion of de- seven were conducted in high income country
sire for family planning, adolescent fertility rate, (USA).
contraceptive prevalence rate and HIV prevalen-
ce amongst 15-24 year old pregnant women.27 Almost all of the CHWs driven interventional
studies showed a significant impact on redu-
According to the joint report of WHO, UNICEF, cing maternal, perinatal and neonatal mortality
UNFPA and the World Bank in the year 2005 on and improvement in perinatal and postpartum
maternal mortality estimates, the sub-Saharan service utilization indicators In most of these
Africa and the south Asia account for the 86% studies they were trained and deployed as ma-
of the maternal mortality rate in the world.28 ternal and child health care providers and repro-
The efforts made to reduce the maternal morta- ductive health workers. A review of the litera-
lity ratio were focused at providing skilled birth ture from various parts of the world shows that
attendant, who would have midwifery skills.27 introduction of skilled birth attendant reduced
These skills include conducting normal delive- direct obstetric mortality.32-37 The utilization of
ries, recognizing danger signs if any, provide antenatal care was found to be availed by 90%
initial management and appropriate referral to of the pregnant women in a survey conducted
the health care facility.27 In the areas where the by Navaneetham and Dharmalingam in India.38
maternal mortality burden is high, intrapartum
period is not the only domain that needs to be Most of workers were selected from the commu-
taken care of. The role of antenatal and post- nity.32, 39, 40 While some of them were required
natal care, family planning, and safe abortion to have a few years of schooling for recruitment
cannot be undermined in the improvement of as CHWs40-43 or TBAs39, the CHWs participa-
the maternal health scenario and reduction in ting in the intervention presented by Teela et
maternal mortality rate.29 al, were required to have 4 months of medical
training prior to their recruitment, but since the
study was descriptive qualitative we could not
Community-Based Evidence analyze it against studies where extensive medi-
Total of 44 studies were identified that delive- cal training was not required. However, we com-
red interventions related to maternal health pared studies in which CHWs were educated
improvements. There were 12 quasi RCTs, 5 (studies which failed to mentioned education
prospective before and after intervention stu- were assumed that educational level was not
dies, 3 comparative cross sectional studies and their condition for recruitment) and found that
rest were descriptive cross sectional qualitative all these studies showed a positive results on
or quantitative studies. Characteristics of studies uptake of family planning methods concluding

that educated workers usually have positive modalities like theoretical lectures with field
attitude towards family planning methods and training,34, 39, 45, 47, 60, 61 only theoretical lec-
in turns results in positive impact towards using tures, 41 or didactic training sessions alone.32,
family planning. 44 37, 40, 43, 46, 48, 51, 54, 56-58, 62 In Begum et al the
training also included field visits for two days
CHWs were provided training based on various per week.33 In the intervention by Douthwaite
topics like clean and safe deliveries,32, 33, 36, the CHWs were trained for 3 months initially
39, 45-55 family planning,32, 34, 40, 41, 43, 48, 56, and then took 12 months of in-service training
57 immunization,48, 58 recognition of obstetric in primary health care while the study focused
complications and referral.51-53, 57 In some of their role in family planning services and their
the interventions the CHWs were trained to impact on uptake of family planning methods.43
offer Emergency Obstetric Care (EmOC).34, 59 Refresher training was also offered59 and in one
In an intervention by Xu et al. the CHWs were of the interventions related to maternal health
trained to manage high risk pregnancies.35 The the skilled birth attendant took three months of
duration of training varied between 6 hours 54 advanced course on management of complica-
to 6 months.41, 47 The training content was de- tions in mother and newborn.47 These skilled
livered to the participants using various training birth attendants were in Bangladesh and were
CHW Snapshot 3
Community Health Agents Program, Brazil
Program overview
In 1988 the Brazilian government launched the Unified Health System (Sistema Unico de Saúde), with the declared aim to
provide universal health services to Brazilians, which was evolved from primary health care initiative (community health
agents’ program) in the northeastern state of Ceará. The basic initial focus was on universal coverage but later on during
1990s program expanded its horizon into the Family Health Program (Programa Saúde da Família) that encompassed inte-
grated components like promotional and preventive activities and curative and health care, using a family health team of
workers assigned to a specified geographic area. The standard team comprises of one physician, one nurse, nurse aides’ and
4-6 community health workers. Community health agents are responsible for home visits, in which they collect demogra-
phic, epidemiological and socioeconomic information of each assigned family, promote healthy practices, and link families
to health services. Their activities ensure the implementation of a community component in IMCI.30

Community Health Agents, Brazil
These CHWs are selected from the community where program is
Education Primary School
implemented and are selected by the program. Ninety Five percent
(95%) of these workers are women and are supervised by a nurse Training 8 weeks residential course + 4
who also works full-time in the basic health unit, as part of the family weeks field work
health team. The program uses a team approach for referrals of sick Refresher Monthly & quarterly
children. A unique operational aspect of the program is that CHWs Supervision Nurse
are paid health professionals. The state government is paying the Incentive voluntary and only receive
salaries of CHWs on agreement of municipal government to also provides a salary for a nurse supervisor.30, 31

Program gained its coverage drastically; when the program was initiated there were approximately 35 participating mu-
nicipalities with 1500 CHWs. In 1998, 150 municipalities joined hands and 8000 CHWs were deployed in communities. The
initiative was expanded in 1994 to the family health program, a team approach to primary health, and adopted at a national
level. In 2001, there were 13,000 family health program teams covering 3,000 municipalities, with an estimated coverage of
more than 25 million people. Currently there are more than 30,000 family health teams and more than 240,000 CHWs across
the country, covering about half of the Brazilian population. Program activities include expanded vaccination coverage,
promotion of breastfeeding, increased use of oral rehydration salts, management of pneumonia and growth monitoring.
The extended coverage of the Program has been associated with declines in the infant mortality rate.31

certified by the Bangladesh Nursing Council at injections using single-use, auto disposable
the end of their training.47 Most of them were syringes.40
deployed in the rural areas.33, 39, 46, 53, 60, 61
CHWs were supervised during these interven-
Several competencies were developed in these tions by the government teams 34, 45, or by mid-
CHWs during the interventional training. Some wives, community health nurse and doctors,51,
developed counseling skills to increase utiliza- 60 or by the female paramedic supervisors.33, 47
tion of the prenatal and postnatal services.36, In Shaheen et al. proper monitoring and super-
55, 63 In an intervention by McCormic et al. the vision could not be done due to deterioration
CHWs were specifically trained to encourage of political conditions in Palestine.62 In Pakistan
the use of prenatal services by people in lower the CHWs were supervised by the Lady Health
income communities.64 Immunization of pre- Supervisors43 and in the intervention by Yadav
gnant women with tetanus toxoid was also et al. in Malaysia, the supervision was done by
done in a few interventions.32, 34, 48 the nurses.55
Most of these health workers were working as
The role of the CHWs as such was well-oriented volunteer and a few were paid meager salaries
with the indicators set to achieve the MDG Goal as incentives43, 48, 53 while just the transport
5 targets. They were promoting the utilization cost was covered in Yadav et al. intervention.55
of antenatal and postnatal care.55, 61 In the
intervention of Shaheen et al. the CHWs also Salaried TBAs in Bailey et al. 199453 did not crea-
spread awareness on breast and cervical cancer ted an impact of increasing the usage of health
prevention by teaching breast self-examination care services in women, while Swaminathan
and doing pap smears.62 et al. 198648 did find an impact on increasing
health care service utilization among women
Which relates to the sexual health component when their TBAs were given a monthly stipend.
of the MDG Goal 5. In this regard, they encou- Thus it shows that providing wages or salaries
raged preventive behavior towards HIV,56 the to these outreach workers did not have any im-
details of which shall be discussed in the sec- pact on improving the maternal health.
tion on HIV. The CHWs also recognized anemia
in pregnant women and managed it with iron Evaluation of the CHWs, trained in the inter-
and folate supplementation.32, 66 They also ventions was done in a few studies. The impact
counseled mothers regarding their nutritional of their training was assessed by prospective
needs.48, 55 In case of parasitic infections they surveys by interviewing people from covered
provided curative care for deworming the pa- households.40, 41 In the Williams and Yumkela
tient34 and also provided chemoprophylaxis for intervention, the impact of CHWs was evaluated
malaria.45 They made referrals, after providing by the WHO and the UNICEF.51
initial management, in case any complications
arise.39, 45-47, 60 Our disaggregated analysis on quasi-randomi-
zed study designs revealed that there were two
In an intervention by Douthwaite et al. the CHWs studies in which CHWs were linked with TBAs
called Lady Health Workers were exclusively and integrated with health system (Greenwood
evaluated for providing family planning servi- et al. 199045; Foord 199560) and delivered inter-
ces.43 In another intervention by Stanback et ventions. Greenwood 199045 found a significant
al. the CHWs not only emphasized on the need impact on decreasing neonatal deaths, and
of family planning but also provided DPMA increasing institutional deliveries possibly with

the reason that TBAs trained for 10 weeks were followed criteria for selection. They should be
directly supervised by CHWs and training team, linked with local TBAs and health system and
while in Foord 1995,60 they were supervised by must be trained to play an intermediary role in
health care providers like doctors midwives etc. connecting these two extreme levels of health
working in health centers which might required care provision structures.
to be tighten up by linking them with CHWs
working in that area.
Conclusion
The maternal health concerns all over the world
can only be addressed with effective training,
monitoring and supervision of the CHWs who
reach out to the communities at the grass
root level. The important finding from analysis
signifies that CHWs education (at least 6 yrs
of schooling and above) must be stringently
CHW Snapshot 4
Rural Primary Health Care in Iran
Program overview
In 1970s, based on the experience of Azerbaijan province, where a research project around delivering primary health care in
the province had been conducted, a network for the delivery of primary health care was developed for the whole country.
At the beginning the whole focus was on the rural areas but steadily it spread into the urban areas as well. The most basic
unit of service delivery is the health house which covers an average of 1200 to 1600 people. This is staffed by a community
health worker known as a behvarz. Usually there will be two behvarz in each health house, with one being male and one
being female. Every health house covers one main village and one or more satellite villages. The health house is responsible
for: maternal and child health care, family planning, case finding, and follow up of infectious diseases (TB and Malaria), men-
tal health problems and, more recently, other chronic illnesses such as Diabetes and Hypertension, limited symptomatic
treatment, environmental health, and occupational health 65.

The community health workers (behvarz) are selected by the com- Behvarz, Iran
munity and trained at the Behvarz Training Centre which exists in Education Secondary School
each district. Their health team comprised of physician, among Training 2 years training
whom one physician works as an administration and another super- Supervision Physician
vises Behvarz and see the patients referred by them in their health
houses.

60
Table 4A: Maternal health interventions – Characteristics of included studies
Ronsmans Quasi CHWs MCH-FP areas (referrals for sick Comparison area did 72 months Women of 3% reduction in direct obstetric
1997 32, 67 RCT cases, safe delivery kit, iron & folate for not have MCH-FP ser- reproductive age mortality per year (CI: 1-5%)
Matlab, mothers, family planning, management vices and was provided
Bangladesh of obstetric complication etc) with routine services*
Alisjahbana Quasi CHWs TBAs Government of Gambia implemented Non- PHC areas have 36 months Pregnant women No impact of intervention on maternal mortality
199546 RCT OHC service and trained TBAs regarding routine delivery service 33% reduction in neonatal deaths 56% reduction in
Gambia, clean deliveries at home, referrals for outlets like health fa- late neonatal deaths No impact of intervention on
Africa delivery and promotion of antenatal cilities and hospitals still births Increased in institutional deliveries by 56%
and post care among mothers
Alisjahbana Quasi TBAs Trained TBAs for enhanced complication Routine services 15 months Pregnant women ANC in intervention arm 89.6% and in control
199546 RCT referrals, teaching mothers for danger provided by govern- arm 76.1% Complication during pregnancy and
Rural signs. Improved accessibility to health ment health care during postpartum period in intervention arm
West-Java, care services and trained hospital facilities and hospitals 66% and in control arm 62% Institutional deliveries
Indonesia doctors and nurses for appropriate care 12% in intervention arm & 0.4% in control arm
management, distributed home based Complication during delivery in intervention
maternal and neonatal action records arm 17% and in control arm 20% PMR in inter-
vention and control arms were same i.e. 0.4%
Bhuiyan Quasi TBAs Trained Skilled Birth Attendants (SBAs) SBAs were not - Pregnant women Deliveries by SBAs in intervention arm were
200539 RCT who delivered ANC, PNC, newborn trained and commu- 52% while in control area was 32%
Rural resuscitation and counsel mothers nity was provided
Bangladesh for newborn care management with routine care*
Foord Quasi TBAs Trained TBAs, registered pregnant Services were provided 24 months Pregnant women No impact of intervention observed on maternal
199560, 69 RCT CHWs women, treated anemia and by government mortality No impact of intervention observed
Rural infection, identified and referred health centre for reducing stillbirths No impact of intervention
Gambia all potential obstetric problems observed for reducing perinatal deaths
Zeighami Quasi CHWs CHWs were providing services In control areas, 14 months Married women 28% of married women were using contra-
et RCT regarding family planning services were not of 15-44 years ceptives compared to 15% of married women
al.197741 provided by CHWs in the same age group in control group
Iran
Shaheen et Quasi CHWs Basic service delivery model includes IControl group was - Low parity women Second home visit by the CHW was associated with
al.200370 RCT home visits by a CHW to recently receiving routine care in postpartum a substantial increase in the likelihood of visiting the
West Bank delivered women 2-3 days after delivery. period MCH clinic on day 40 (49.1% of intervention group
& Gaza, During the second home visit the CHW mothers versus 35.6% of control group mothers,
Palestine reminded the women about their day p<0.05). The second visit was also associated with
40 clinic visit for postpartum care and increased support provided by the husband to
highlighted the importance and benefits visit the clinic on day 40 (51.0% of intervention
of contraception, and breast and cervical group husbands versus 29.0% of control group
cancer awareness and prevention. husbands, p<0.05), as well as increased likelihood
of husband-wife communication about timing
of next pregnancy (86.0% of intervention group
couples discussed timing of next pregnancy
versus 77.0% of control group couples, p<0.05).

Stanback et Quasi CHWs Trained CHWs to provide DMPA Routine services 12 months Women of Ninety-five percent of community-worker clients
al.200740 RCT injections using single-use autodisable from governmental reproductive age were “satisfied” or “highly satisfied” with services, and
Nakas syringes. These workers were active health centers 85% reported receiving information on side-effects.
providers of pills and condoms
Zhang Quasi CHWs trained CHWs and they provided no interventions 48 months mothers with Mean number of obstetric visits in intervention
200461 RCT prenatal maternal care services was provided to children under group was 6.6 as compare to 5.6 in control arm (P <
Rural areas to mothers at grass root levels control group 3 years of age 0.05) number of times women in intervention arm
of China was told to visit doctors was higher in intervention
arm as compare to control (P <0.05) 94% of women
in intervention arm was told by contraceptive
methods as compare to 79% in control arm (P<0.05)
Cesar et Quasi CHWs trained CHWs visited women and routine care by 18 months pregnant mothers Pregnant women visited by community health

al.2008 66 RCT provided prenatal care which included health care facilities agents began prenatal visits earlier than other
Rio Grande, lab tests, clinical exams, breastfeeding in their area groups, had more prenatal visits, lab tests, and
Brazil counseling and iron supplementation clinical exams, and received more counseling
on breastfeeding and iron supplementation.
Bailey et Quasi TBAs TBAs were trained to increase in TBAs’ TBAs in control areas 36 months pregnant mothers The incidence of postpartum complications
al.1994 42, 53 RCT detection of obstetric complications were not trained - decreased after the intervention, controlling for in-
Rural and referral for them or women tervention community. On the other hand, after the
Guatemala must recognize danger signs and intervention TBAs were less likely to recognize most
go to a hospital on their own. maternal complications, and referral rates did not
increase significantly. The likelihood of using health
care services increased six-fold among women who
were not attended by TBAs, and no increase was
observed among those who were attended by TBAs.
Moore et Quasi CHWs Group 1-women were visited at home Control group-wo- 4 months pregnant mothers percentage postpartum appointment in group 1 was
al.197471 RCT and given information on child care & men who were not 79%, in group 2 it was 84% and in control it was 76%
New Orleans, self care, as well as encouragement to visited at home.
USA keep the postpartum appointment.
Group 2-womenwere visited at home
but only for encouraging them to attend
the clinic for postpartum examination.
Ahmed pre/post TBAs Trained Skilled birth attendants who counseled; provided essential 12 months pregnant mothers delivered over 65,000 babies referred
& Jakaria obstetric skills in antenatal care, childbirth and post-partum care for 21,000 women needing medical care
200947 the woman and her newborn; - identified complications requiring
Bangladesh referral; motivated women, their households and neighbors on
need for skilled attendance and care for pregnant women
Begum pre/post TBAs TBAs were trained for the management of childbirth 24 months pregnant mothers Maternal deaths reduced from 4.8 / 1000 to
198733 1.5/ 1000 live births after training Stillbirths
Rural Districts declined from 76.9 / 1000 births to 46.2/ 1000
(Bongra, births after training Average number of ANC
Tongi & increased from 1.3 to 2.9 after training Average
Dhaka) PNC visits increased from 1 to 2 after training
Bangladesh
61
62
Mc Pherson pre/post CHWs Health messages, management of PPH with Misoprostol, 24 months Pregnant women 53% decline in NMR (P=0.004). Improvement in
et al.200734 Iron-folate for women, TT doses, Postnatal home visits birth attended by skilled birth attendants, institu-
Rural Nepal tional deliveries. 52% of women in Banke district
were prevented from PPH, While 11% in Jhapa
Emond et pre/post CHWs The interventions included the establishment of antenatal clinics 30 months pregnant women During 1995 there were 4 maternal deaths from 1
al. 200256 at the district’s health centers, the opening of the maternity 195 pregnancies (maternal mortality of 335/100
Felipe facilities at the polyclinic for low-risk deliveries, the introduction 000), during 1998 (post-intervention), there were
Camarão, of a family planning clinic and a breast-feeding clinic, support no maternal deaths. In 1993 no deliveries took
Brazil from pediatricians for under-5 (well-baby) clinics, children’s place at the polyclinic, but in 1998 there were
outpatient services and children’s emergency care, and the 946 deliveries at the clinic without any serious
introduction of health agents recruited from the local community. complications. The method of delivery, the
incidence of prematurity, and the incidence of low
birth weight did not change significantly Infant
mortality rate decreased from 60/1 000 live births
to 37/1 000 live births. Over 95% of both samples
initiated breast-feeding, but a higher proportion
of the post-intervention sample reported breast-
feeding for longer than 6 months (41% vs. 32%, P =
0.0005). No differences were apparent in the use of
under-5 clinics, but immunization rates improved.
Xu 199535 Quasi CHWs Changes were introduced into the organization of 36 months pregnant mothers Maternal mortality in intervention areas reduced
Beijing, RCT maternal care for obstetric emergencies, staff training from 151/ 10 000 live births to 37 per 10 000 live
China and health education of families and community births, while maternal mortality in control areas
decreased from 99/ 10 000 to 93 / 10 000 live births
Benara & Compa- TBAs trained TBAs and evaluated their performances 12 months pregnant mothers Distribution of contraceptive methods was higher
Chaturvedi rative cross with those who were not been trained among trained TBAs compare to untrained TBAs.
1990 72 sectional Registration of women for antenatal checkups was
Bassi Trained vs. 39% among trained TBAs group compared to 6%
Bhanpurkalan untrained in untrained TBAs group. PNC among trained TBAs
& Sirsi, India TBAs group was 13% compare to 8% in untrained group.
Douthwaite Compa CHWs CHWs evaluation was performed to determine the effect of the 6 months Reproductive age Women served by Lady Health Workers are
et al.200543 rative cross Program on the uptake of modern reversible contraceptive methods group population significantly more likely to use a modern reversible
Burma sectional method than women in communities not served
study by the Program (OR = 1.50, 95% CI: 1.04–2.16,
LHWP vs. p =0.031), even after controlling for various
non LHWP household and individual characteristics.
Smith et survey TBAs TBAs were trained and data were then regressed to - Reproductive age odds of intrapartum referral due to TBAs training
al.2000 57 identify the factors associated with training and maternal group population were 1.95 (95% CI: 0.92-4.16) odds of postpartum
Ghana outcomes. And evaluated to assess the impact of the use referral due to TBAs training was 1.04 (95% CI: 0.34-
of improved techniques in ante, intra and post partum care 312) effect of TBAs training also shown decreased
on maternal and perinatal morbidity and mortality in retention of placenta by 65% (95 CI: 4-875)

Diakite et cross CHWs By offering an intervention mix that included maternal and newborn 24 months mothers Injectable methods for family planning increased
al.200958 sectional care, nutrition and micronutrients, HIV/AIDS, and immunization. & pregnant women from 347 in 2006-07 to 4632 2007-08 Oral
Guinea contraceptives increased from 6540 in 2006-07
to 35027 in 2007-08 IUD increased from 90 to
228 in a year’s time Condom usability increased
from 38107 to 70348 in a year’s time.
Padmanaban Descriptive CHWs CHWs were trained to deliver babies and encourage 168 months pregnant mothers Improved maternal health services leading to
et al.200936 reported and counsel during perinatal and post natal period reduction in maternal mortality from 380 in
Tamil Nadu, National 1993 to 90 in 2007. increased rate of institutional
India Surveys deliveries from 20% in 1971 to 97.7% in 2007 PNC
given by Tamil Nadu within two days of birth, is
87.2%, and 91.3% receive PNC within 42 days

Bisika Cross- TBAs TBAs were trained and then qualitatively data from community - pregnant mothers 22.7% of deliveries were attended to by TBAs, 50.
200875 sectional people i.e. from women of reproductive health was conducted and 2% of deliveries were attended by a nurse or trained
Malawi Qualitative midwife, 5.4% by a doctor, and 2.4% by no-one
survey
Purdin et Prospec- CHWs IRC established EmOC centers, trained community members 48 months Pregnant women The MMR among Afghan refugees in the area
al.200937 tive Cross on safe motherhood, linked primary health care with education and children improved from 291 per 100 000 live births in
Hangu, sectional on danger signs of pregnancy and the importance of skilled 2000 to 102 per 100 000 live births in 2004. The
Pakistan surveys attendance, and improved the health information system proportion of refugee births attended by skilled
staff increased from 5% in 1996 to 67% in 2007.
Complete prenatal care coverage increased from
49% in 2000 to 90% in 2006, and postnatal coverage
more than trebled from 27% in 2000 to 85% in 2006
Gabrsch et Cross CHWs The new culturally sensitive model involves features such as 24 months Pregnant women The proportion of births delivered in the health
al.200950 sectional a rope and bench for vertical delivery position, inclusion of facility increased from 6% in 1999 to 83% in 2007
Ayacucho, family and traditional birth attendants in the delivery process with high satisfaction levels.
Peru
Williams & Cross TBAs 3 years training program was conducted and evalua- - Pregnant women Referrals to hospital was 57% Attempted deli-
Yumkela sectional tion of TBAs after their training was performed very and if found difficult referred to hospital 3%
1986 51 Complication during delivery & referral of Prolong la-
Sierra Leon bor case to hospital 17%. Immunization referral 32%
Mushi Cross CHWs CHWs were tested and assessed a community-based 24 months Pregnant women Some improvement in the overall knowledge
200776 sectional safe motherhood intervention, their main role was of maternal health from a score of 44% to 52%.
Mtwara, survey to promote delivery with a skilled attendant Changes were observed with regards to causes of
Tanzania pregnancy complications (29% to 47%) and HIV/
AIDS as the threat to safe motherhood (76% to
90%). There was a significant increase in the early
antenatal care booking (18.7% in 2004 to 37.7% in
2006) and the utilization of a skilled attendant at
delivery (33.3% to 49.8%). Referral advice by SMPs
from home to the first line facilities (referral rate
52.9%) was well received with a compliance of (66%)
63
64
McCormic et Cross CHWs community health works were trained and sent in community for - Women registered Of the 599 women enrolling for prenatal care
al.198964 sectional encouraging use of prenatal services in low-income communities for prenatal care during the intake period for the study, only 52
Harlem, USA survey at clinics had had an outreach contact before the start of
prenatal care despite extensive field activity.
Zuvekas et Cross CHWs Brownsville Community Health Center’s CHW program, Muno A 10 months pregnant women From January 1997 – October 1997 promotorus
al.199821 sectional Muno (Hand-in-Hand), uses promotorus (health promoters) from in Brownsville conducted 18-20 presentations
Brownsville, this Texas/Mexico border community to conduct home visits to per month From January 1997 – October 1997
USA identify pregnant women and help them gain access to prenatal promotorus in Brownsville and Matamoros each
care; educate the community on a comprehensive array of health made approximately 400-500 home visits per month
conditions; and refer clients to services available in the community.
Zuvekas et Cross CHWs Logan Heights Family Health Center located in San - youth and Changes in attitudes with respect to adolescent
al.199821 sectional Diego, California, has two CHW programs that focus on adolescents sexuality. Changes in attitudes toward
San Diego, the protection of sexually active youth through parental contraception by adolescents. Improved com-
USA organization and education and peer counseling. munication between adults and adolescents
and between agencies. Changes in the availability
and accessibility of contraception.
Zuvekas et Cross CHWs Syracuse Community Health Center’s Comprehensive Medicaid - high risk pregnant Contacted 2,669 patients who have visited
al.199821 sectional Case Management program provides case-management services to women with infants the emergency room for acute care services
Onondaga, high-risk pregnant women and women with infants. Its AmeriCorps rate for follow-up prenatal appointments of 73
USA Community Health Corps members: work on projects related to pa- percent in 1996 up from 70 percent in 1995
tient services; educate patients about the importance of preventive
primary care and how to use a managed care system; and collecti-
vely work on community health education and awareness projects.
Zuvekas et Cross CHWs West Alabama Health Services in Alabama operates the Home - Pregnant women Sixty-three percent (269) of pregnant women
al.199821 sectional Visitor program which provides community-based home visits by using prenatal care did so in their first trimester.
West CHWs that: 1) provide support to pregnant women through the Thirty percent (128) sought prenatal care in their
Alabama, perinatal period; 2) ensure that appropriate care provided for new- second trimester and only seven percent (32) began
USA borns; 3) teach the mother appropriate parenting skills; 4) ensure receiving prenatal care in their third trimester.
communication between the home and health provider; and 5) as-
sist the provider by evaluating the home situation of at-risk patients.
Zuvekas et Cross CHWs Logan Heights Family Health Center located in San Diego, has two - youth and Changes in attitudes with respect to adolescent
al.199821 sectional CHW programs that focus on the protection of sexually active youth adolescents sexuality and contraception by adolescents.
San Diego, through parental organization and education and peer counseling. Improved communication between adults and
USA adolescents and between agencies. Changes in
the availability and accessibility of contraception.
Hussein & Cross TBAS trained and untrained traditional birth attendants (TBAs) in - pregnant women Trained TBAs were more knowledgeable on danger
Mpembeni sectional identifying women with danger signs for developing complications signs during pregnancy and childbirth and were
2005 52 survey during pregnancy and childbirth as well as their referral practices more likely to refer women with complications to
Mkuranga, a health facility, compared to untrained TBAs.
Tanzania

Bhiromrut cross CHWs intensification of maternal and child health/family planning 42 months Pregnant women Fertility rate declines to 2.1 live births per
1990 77 sectional CMs TBAs information and services through mobile motivation women which is below replacement level.
Narativas, outreach teams and creation of a village level service Contraceptive rate increased from 15% to 71%
Thailand delivery system through CHWs and TBAs
Bailey & Cross TBAs To evaluate the impact of the TBA training. 36 months Pregnant women 81% of the time complication was detected
Coombs sectional and out of which 43% were referred
199678 survey
Verapaz,
Guatemala
Foster et Cross TBAs Evaluation of training TBAs 72 months TBAs Formal evaluation of this training is unde-
al.200454 sectional rway but results are not yet available.
Guatemala

Navaneetham Cross CHWs Mode of maternal health care utilization was surveyed in India 12 months Married women 90% of all women received antenatal care Around
& sectional 70% of all women received > 4 ANC visits
Dharmalingam Around 50% of all deliveries took place at
200238 institutional level 70% of all deliveries were
Southern undertaken by skilled birth attendant
India
Yadav 198755 Cross TBAs TBAs attended deliveries and advised mothers on antenatal 70 months Pregnant women Deliveries from skilled birth attendant increased
Kerian, sectional and postnatal issues and also provided nursing care to from 23% to 40% and from TBAs decreased from
Malaysia babies and new mothers some basic steps on baby care 47% t o 19%
Wollast et Cross TBAs TBAs trained to registered all pregnant women, indentify high risk 24 months Pregnant women MMR of 452 / 100 000 deliveries (27 deaths)
al.199379 sectional pregnancies, provide referrals and evacuate to the health facilities observed. Obstructed labor was the main cause
Burkina Faso with all the necessary equipment related to pregnancy and delivery of maternal death.
Ahluwalia et Descriptive CHWs Qualitative data from group interviews and program data from 18 months general population Project activities increased community participation
al. 2003 80 CBRHP were used to assess progress in development and use of in maternal health. An increase was seen in
Northwestern community level transport systems and support for the village knowledge of danger signs, birth planning,
Tanzania health workers (VHWs) timely referrals, and transport of pregnant
women to hospitals, as well as in support
and retention of VHWs. More women with
obstetrical problems are using the community-
based transport system to get to hospitals.
Goodburn et compara- TBAs trained TBAs were compared with untrained TBAs and postpartum 18 months TBAs Trained TBAs were significantly more likely to
al. 200081 tive cross infections were then compared among the two groups practice hygienic delivery, and then untrained.
Bangladesh sectional (45% vs. 19%, P <0.0001). No significant diffe-
survey rence in the rates of postpartum infections.
65
66
Table 4B: Description & Characteristics of Outreach workers
training
Ronsmans Didactic These Immunized women with Maternal health Evaluation on
199732, 67 CHWs were trained TT and provide contra- mortality rate
on delivering ceptives on door steps. after 3 years
CHWs (F) services during twi- of implemen-
ce-monthly home tation of this
visits. Immunized program
women with
TT and provide
contraceptives
on door steps.
Green- Selected by Theory and 10 weeks Conducted hygienic delive- Maternal health Governments
wood villages practicum ries and advised on antenatal training team
et al. Deliver women at and postnatal care also
199068 home and given gave chemoprophylaxis of
antenatal and malaria for pregnant women
postnatal care and
CHWs (F) advised them for
referrals to health
facility and trained
to give chemopro-
phylaxis of malaria
TBAs (F) Illiterate Selected by 10 weeks
villages
Alisjahbana Didactic Training of Reported identified pre- Maternal health
199546 TBAs in detection gnancy and the births she
of pregnancy attended to the interviewers,
TBAs (F) complications and ideally within 24 hrs
taking appropriate
action (referral)
Bhuiyan Selected from Theory and prac- Maternal and
200539 community ticum Training of Delivered antenatal neonatal care.
TBAs in detection and postnatal care and Resuscitation
of pregnancy counseled mothers for
TBAs (F) newborn care management
complications &
providing referral
Foord Theory and Registration of pregnant Safe and Supervision
199560, 69 practicum women in antenatal hygienic home from mid-
Trained to provide programs, treatment of deliveries wife, CHNs
CHWs (F) antenatal care, treat anemia and infections and doctors
anemia, infections
and identification
of emergency
&complicated cases
and their referral to
tertiary care centre

training
PRACTICUM They Early identification of midwives,
TBAs (F) were required to pregnant women CHNs and
accompany mid- doctors
wives during the
village visits; their
task was to assists
in home deliveries.
Zeighami 6 years of positive Theoretical trai- 6 months Curative services for Provision of Interviewed
et al.1977 education attitude to- ning on preventive, common colds, ear and eye vaccination, people from
41 wards family curative and family infections, Kept a record card health covered
CHWs planning planning benefits, of those interviewed and education and households
(M & F) preventive services noted estimate of duration contraceptive
like immunization of contraceptive use. education
well baby visits etc,
Shaheen Didactic training Explained to women the Maternal health Proper
et al.2003 On how to provide importance of conducting a monitoring and

70 counseling and day 40 visit to the clinic, family supervision
CHWs (F) services that are planning methods, maternal could not be
tailored to the care, breast feeding, breast done due to
needs of low parity self-exam and newborn deteriorating
women. Trained to during 1st home visit and political
do pap smears and ensured visit to health care conditions.
breast examination. facility by day 40 after delivery.
Stanback Few years of From Didactic training They provided DPMA Prospective
et al.2007 schooling community where they injections to their com- surveys
40 were trained to munities, emphasized on
CHWs provide DMPA the importance of family
(M & F) injections to their planning methods
communities using
single-use auto
disable syringes.
Zhang Theoretical and 2 weeks
200461 practical training
CHWs on prenatal and
postpartum
services
Cesar et Trained on
al.200866 emphasizing the
CHWs importance of
prenatal visits,
breastfeeding
counseling, and
iron folate
supplementation
Bailey et Can read Oral exami- Educational and pro- Salaried
al.199442, nation to motional activities
53 certify them
CHWs as workers
67
68
training
Moore et Make postpartum visits to Maternal health
al.197471 educate and encourage
them to return to a healthy
CHWs pre-pregnant state and
to have a healthy baby
Ahmed Willingness to theoretical and 6 months skilled birth After Visited women and Counseling female
& Jakaria stay and serve practical knowledge attendants spending 9 indentified pregnancies in skills, Essential paramedics
200947 the com- for counseling by the months as the community. During their obstetrical Supervisors
munity with essential obstetric skills Bangladesh community- home visits they also identi- skills and receive
midwifery in antenatal care, child- Nursing based SBA fied complicated pregnan- neonatal care
TBAs (F) services birth and post-partum Council they undergo cies and referred women
care for the woman 3 months in case of complication
and her newborn, advance
-identifying complica- course on
tions requiring referral, mngtt of
motivate women, complica-
their households tions, I in
and neighbors on mother and
need for skilled newborn
attendance and care
for pregnant women
Begum no formal TBAs, selected Class lectures, 3 months Used aseptic technique, Maternal and Assistant 1 TBA per 2298
198733 education through demonstrations, training advised mothers on nutrition neonatal health supervisor & population
interviews and field visits were and importance of colos- paramedic
TBAs (F) organized for two trums, counseled for longer
days in each week duration of breast feeding
Mc Pherson Theory and Community-level antenatal Maternal and monitored

et al.200734 practicum Health contact. Strengthening child health by Ministry
education & inter- existing services like basic of Health &
CHWs (F) ventions including emergency obstetric care Population,
iron and folate (BEOC), management of Family Health
supplementation, complications and EPI. Division and
deworming and District Health
TT, recognition of
danger signs, SBA
attendance, emer-
gency obstetrical
care and essential
newborn care.

training
Emond et Didactic Health Made visits with the Maternal and
al. 2002 56 Education on an- message of breastfeeding, child health
tenatal care, breast causes & mngtt of diarrheal services
CHWs feeding, causes & respiratory diseases, and
and management prevention of HIV. Promote
of diarrheal and visit to antenatal clinics, well
respiratory diseases, baby Clinics and for immu-
encouraging nization and, and advised
health seeking hypertensive adults to go for
behavior for infant monitoring and treatment
and in elderly, and
prevention of HIV
Xu 1995 35 Educated women Their role was to encourage

about maternal for antenatal examination,
CHWs health issues management of high risk
pregnancies, & streamlined
information system
Cordon & They were trained
Fonseca- to for behavior
Becker change communi-
200482 cation to make sure
women and their
CMs families aware of
improved services
Swaminat Didactic and 1month Register every pregnant wo- Female health Rs. 3oo per
han et practical man, provide antenatal, natal workers month and
al.198648 and postnatal care, provide and health Rs. 2 for each
TBAs (F) TT immunization, PHC servi- assistants delivery
ces, family planning services,
provide maternity kits.
Douth- 8 years of Didactic for 3 15 months Uptake of contraceptive PHC services Lady health 1: 1000 Oxford Policy
waite et schooling months and methods supervisors population Management
al.200543 12 months of evaluation
CHWs (F) in-service training
Teela et 4 months Refreshers

al.2009 of medical were given
59, 73, 74 training
CHWs (F) previously
Smith et Didactic Trained 2 weeks Identification of pre-
al.200057 on care during gnancies, recognition of
CHWs ante partum, complication, referrals,
intrapartum and family planning, , growth
postpartum period monitoring &immunization
69
70
training
Diakite et Didactic training 3 day training Workers maintained
al.200958 for family planning information system and
CHWs information register pregnant women
and counsel and provide
family planning methods
Purdin et Didactic Safe raising awareness Maternal health
al.200937 motherhood regarding PHC, including
CHWs reproductive health
(M & F)
Williams & Panel of Didactic Trained 3 weeks Identify pregnancies, provi- Maternal and Nurse/ WHO and
Yumkela nurses and for clean and safe training ded safe and clean delivery child health midwives from UNICEF
198651 midwives practices for delivery and recognized compli- workers health facility
TBAs (F) recruited and recognition of cation and danger sings
them complication
during delivery
Foster et Didactic They were 6 hours of Monthly mee-
al.200454 trained to iden- training tings where
TBAs tify risk factors, good they shared
hygiene and transfer experiences
Complicated cases.
Yadav Practical training Identified pregnancies, Nurses Transport cost
198755 They were taught on provided ANC and PNC
TBAs simple hygienic
procedures,
cleanliness and basic
nutrition education
Wollast et from Theoretical and 1 month 2 week re- identify high risk pregnancies pregnancy supervised
al.199379 community practical trained training fresher course and evacuate to the health and child birth by ministry of
TBAs to deliver facility during complication procedure social affairs
babies, learnt
asepsis and
simple obstetrical
manipulations and
also provided with
clean delivery kit,

Birth and Newborn Care
Preparedness Interventions
Background studies and 1 comparative cross sectional study.
Several of these studies used CHWs and /or TBAs
Ninety-eight percent of the four million annual
to provide care at community level and few of
neonatal deaths occur yearly in middle and
these studies utilized community mobilizers for
low income countries, and two-thirds or more
delivering these interventions in conjunction
of these deaths occur in the first week of life.83
with TBAs and CHWs. Substantial improvement
Despite large reductions in mortality for children
was observed in reducing perinatal and neona-
under 5 years of age, neonatal mortality remains
tal mortality and increasing service utilization
largely unaltered, and now contributes to over
services like institutional deliveries, deliveries by
one-third of total mortality of children under
skilled birth attendants. However, Manandhar et
five.83, 84 The precise contribution of various
al.87 reported substantial impacts of interven-
causes of neonatal deaths is difficult to ascer-
tions in reducing maternal mortality.
tain since the vast majority of births and deaths
occur in homes, and are thus poorly reported
The CHWs and the TBAs recruited in these inter-
and categorized.85
ventions were from the local community88-98.
Their training ranged from 3 days to 6 weeks,
In an effort to improve outcomes for both mo-
while in Bhutta et al. 200892 & Bhutta et al. 200997,
thers and their newborn infants, the “Mother-
CHWs were already trained by government and
Baby Package” was introduced by the WHO in
were given additional 6 days of training on birth
1994.86 The “Mother-Baby Package” consists of
and newborn care preparedness. The training
a set of interventions considered essential to
imparted to them for interventions were mostly
maternal and newborn health. These include
didactic in nature.88-92, 95-98, 101-104 The trai-
interventions such as antenatal registration
ning content included birth and newborn care
and care, iron/folate supplementation, tetanus
preparedness messages, provision of essential
toxoid immunization, prevention and manage-
newborn care, clinical assessment of the neona-
ment of STIs and HIV in endemic areas, treat-
tes, promotion of exclusive breastfeeding and
ment of underlying medical conditions such as
referral to hospital of newborns with danger si-
malaria and hookworm infestation, nutritional
gns95, 96 and management of the sick neonates
advice, ensuring clean delivery, presence of a
with an IMCI adopted algorithm.91 They were
trained birth attendant at delivery, recognition
trained to provide home-treatment of serious
and management of maternal and neonatal
infection with oral chloroquine.95 In an inter-
complications, neonatal resuscitation, early and
vention by Bhutta et al. 2009, the CHWs were
exclusive breast-feeding; and prevention and
trained to provide bag and mask resuscitation in
management of neonatal hypothermia and in-
case of birth asphyxia.97 The TBAs in this study
fections including ophthalmia neonatorum and
were also trained to recognize low birth weight
cord infections.
babies, provide them care and refer to the CHWs
for further management.97 In another study, the
Community-based evidence: CHWs were trained for appropriate immuniza-
We identified 22 studies that were undertaken tion of the infant and in the use of oral rehydra-
in community settings and included a compre- tion solution in case of diarrhea.101
hensive birth and newborn care preparedness
plan rather than solitary interventions (Table 5A In an intervention by Bhutta et al. 2008, empha-
and Table 5B). Among these studies there were sis was laid on adequate maternal nutrition, iron
10 RCTs, 4 quasi RCTs, 6 prospective pre/post and folate use and rest during pregnancy and
promotion of early breast feeding and colos-

CHW Snapshot 5
CARE Community Initiatives for Child Survival, Siaya, Kenya
Program overview
In 1995, CARE Kenya implemented the Community Initiatives for Child Survival in Siaya after the completion of original
project which was ended in 1999. In 2003, second phase of wide-ranging intervention package aimed at improving child
and maternal health in the Siaya district.99 Community health workers in this district were trained to treat children with
multiple diseases by using simplified IMCI guidelines. Promotion of family planning, immunization and AIDS prevention are
also included in the education package. The CHWs are assigned to 10 households in their community. The supply of drugs in
this program is based on the Bamako Initiative. Community-based pharmacies are established and serve as resupply points
for the CHWs’ drug kits. The CHWs sell the drugs to community members and use monies from sales to buy more drugs to
restock their kits in a revolving fund scheme.99

Community Health Workers, Kenya
The CHWs are selected by the community and trained to use the
guidelines to classify and treat malaria, pneumonia and diarrhea/ Training 3 weeks initial training
dehydration concurrently, and use flow sheets to assist in the ap- Refresher One week
plication of these algorithms.100 CHWs provide verbal referral, and Supervision Field staff
referred cases are taken to the front of the line to receive treatment Incentive None
at facilities.

Every two years, CDC in the United States evaluates the performance of CHWs. The recent evaluation demonstrated that
85% of the cases that the CHWs treat are classified as malaria, acute lower respiratory infection or diarrhea. CHWs adequa-
tely treated 90.5 per cent of malaria cases, but they had difficulty in classifying and treating sick children with pneumonia.
Four years after the implementation of the project, a reduction 49% in the child mortality rate was noted.
trums administration.92 They were also trained supervised studies did not show greater impact
to provide treatment of neonatal pneumonia on the outcomes.
with oral trimethoprim-sulphamethoxazole.92
This intervention showed significant reduction The CHWs involved in the interventions re-
in still births, NMR and MMR.92 It also showed viewed promoted the utilization of antenatal,
improvement in institutional deliveries and ini- postpartum and neonatal care with recognition
tiation of early and exclusive breast feeding.92 of danger signs in the neonates of the commu-
nity.91, 92, 94, 96, 97, 103, 104 They also provided
Refresher training sessions were held related to treatment of infections with oral Chloroquine e
management of maternal and newborn com- 95 and with oral trimethoprim-sulphamethoxa-
plications in most of the interventions reviewed zole in case of neonatal pneumonia.92 In case
in this regard and showed a greater impact in of diarrhea they provided the neonate oral
the outcomes of those interventions91, 93, 94, rehydration solution101 and would also offer
96, 97 as compared to those without refresher immunization services.92 Their role therefore
training.101 Some of the interventions were can be perceived to be in compliance with the
supervised by the regional supervisors.95-97 In achievement of the MDG targets in reducing un-
the Bolam et al. CHWs were supervised by its der- 5 mortality. Besides this they also provided
principal investigators.101 However as compa- emergency obstetric care to the mother in case
red to the studies without any supervision, the of any obstetric complication and promptly re-

Conclusion
ferred where needed.91, 94 The CHWs in Bhutta The percentage neonatal mortality contributes
et al.2009 intervention resuscitated case of birth to the under-5 mortality ratio demands active
asphyxia using bag and mask resuscitation, while participation from the health care teams and
the TBAs in the same intervention were trained the community to bring a decline in these
to offer mouth-to-mouth resuscitation.97 The preventable deaths. The interventions reviewed
Barnes-Boyd et al. intervention worked at the have shown that the financial incentives did not
improvement of psychological well being of the affect the working of the CHWs, and as such the
mothers, social support and the overall impact outcomes of those interventions. However, the
on the baby.90 additional training which demands active invol-
vement from the CHWs, did seem to reinforce
A few of the CHWs involved were paid sti- the positive outcomes of the intervention.92
pends92, 96, 98 or transport cost.97 However this
did not affect the outcome as compared to the
studies where the CHWs were all volunteers.91,
94, 95
73
74
Table 5A: Birth and Newborn Care Preparedness – Characteristics of Included Studies
Jhokio et RCT TBAs Trained all TBAs for improved services TBAs were not trained 14 months Pregnant women No impact of intervention on mortality of
al.200594 CHWs for enhanced referrals, antenatal care and did not receive mothers 30% reduction in PMR (CI: 18 – 41%)
Larkana, and postpartum visits, and provided delivery kits. Routine care 31% reduction in still births (CI: 17 – 43%) 29%
Pakistan them with delivery kits. TBAs were was delivered by LHWs reduction in NMR (CI: 17-38%) 39% reduction
also linked with Lady Health Workers in hemorrhage related complication during
(LHWs) in the community pregnancy (CI: 21- 53%) 50 % increased in referrals
in emergency obstetric care (19 – 91%)
Baqui et cRCT CHWs CMs Home care arm received interventions Comparison arm 30 months All married women 44% reduction in NMR (CI: 7 – 53%)
al.2008 for birth and newborn care prepared- received the usual of reproductive age improved breastfeeding initiation
105-107 ness, iron/folic acid supplementation, health services provided
Rural , enhanced referrals & community care by the government,
Bangladesh arm were mobilized through group and non-government
meetings with pregnant women and organizations and pri-
community leaders. Refresher training vate providers. Refresher
was provided to government health training for government
workers in both the intervention groups workers was provided.
Bari et cRCT CHWs TBAs Counsel women on birth and newborn Routine care* 12 months Married women of Health care seeking from qualified provider OR
al.2008 95 care preparedness, made postnatal visits reproductive age 2.98 (CI: 2-4.44) Referral to Project facility OR2.9 (CI:
Rural for enhanced referrals for sick newborns. 1.91-4.41) Health care seeking from unqualified
Bangladesh providers decreased to 69% (CI: 53-79%)
Bhutta et cRCT CHWs LHWs in the interventional arm were LHW training program 24 months Married women of No impact of intervention on maternal mortality 29%
al.200892 TBAs CMs given additional training after their continued as usual, reproductive age, reduction in Still births (CI: 11- 43%) 31% reduction
Hala, usual training & they were linked with with regular refresher older women and in NMR (CI: 13 – 45%) 28% reduction in PMR (CI:
Pakistan Dais (who were given training for sessions, but no attempt adolescent girls 15-39%) Improvement in institutional deliveries,
newborn resuscitation & immediate was made to link LHWs initiation of early and exclusive breastfeeding
newborn care), promotion of nutritional with the Dais. Special
counseling, BNCP, enhanced antennal training in basic and
and postnatal visits + training in basic intermediate newborn
and intermediate newborn care was care was offered to all
offered to all public-sector staff public-sector staff
Darmstadt cRCT CHWs Provision of essential newborn Control arm received 16 months Stakeholders, No improvement of intervention observed in
et care, birth preparedness, enhanced the usual services of community leaders, reduction in maternal mortality in intervention
al.2008108, referrals plus thermoregulation governmental and pregnant women, and control groups. 50% reduction in NMR (CI:
109 along with all other intervention non-governmental their immediate 31-64%) among these 41% decline occurred in early
Uttar organizations in the area family members, neonatal period (CI: 16 – 59%) and 68% decline
Pradesh, neighbors and occurred in late neonatal period (CI: 15-88%) 47%
India relatives reduction in PMR (CI: 27 – 62%) 45% reduction in
still births (CI: 5-55%) 59% reduction in complication
due to prolonged labor (CI: 51 – 67%) & 50%
decline in eclampsia related complication (CI: 4-74%)
Improvement in initiation of early breastfeeding

Bhutta et cRCT CHWs LHWs = Along with the basic training Trained LHWs on 36 months Pregnant women No impact of intervention on maternal mortality
al.200997 TBAs (for control group) they received community mobiliza- and whole 20% reduction in still births (CI: 10-29%) 16% reduc-
Naushero additional training on recognition tion through building community tion in perinatal mortality (CI: 9-23%) 12% reduction
Feroze, of high risk pregnancies and referral, support groups, promo- in neonatal mortality (CI: 1-22%) No impact on
Pakistan management of Birth Asphyxia, serious tion and use of clean early neonatal mortality No impact observed in
bacterial infections, LBW infants. delivery kits, recognition late neonatal mortality 24% increase in receiving at
TBAs = along with the basic training of neonatal illness and least one ANC observed (CI: 5-48%) 22% increase in
(for control group) they received referral for care and TBAs birth attendance by skilled attendant (CI: 4-44%)
additional training on promotion of LHW were linked with LHWs
attendance at births and resuscitation
(mouth to mouth) of newborn
Manandhar cRCT CMs Organize village women groups in inter- Routine care + 24 months Women of 78% reduction in MMR (CI: 10-95%) 30% reduction in
et al.200487, vention areas where they hold monthly improvements in reproductive age NMR (CI: 6-47%) Positive behavior change in institu-

110-112 meetings to participatory design and equipment and training tional deliveries, birth attendance, clean delivery kit)
Makwanpur, implementation of monthly meeting to provided at all levels of
NepalBrazil address obstetric and perinatal problems the healthcare system
Manan et cRCT CHWs Trained CHWs who made two antenatal No CHWs trained 24 months Pregnant women Absence of an early CHW visit (OR: 11.3, 95% CI: 6.7,
al.2005113 and three postpartum home visits to or deployed - 18.9) and feeding of pre-lacteal (OR: 2.8, 95% CI: 1.3,
Sylhet, promote and support practices for 5.9) were significantly associated with having a fee-
Bangladesh birth and newborn care preparedness ding problem at a late first-week visit. On adjusted
(BNCP) and newborn care including analysis, absence of an early CHW visit (OR: 11.4, 95%
support for breastfeeding CI: 6.7, 19.3) and feeding of prelacteal (OR: 2.5, 95%
CI: 1.1, 5.7) continued to have significant association
with feeding problem persisting at late visit.
Bolam et RCT CHWs Group A: health education immediately Control group did not 18 months women admitted to Mothers in groups A and B (received health
al.1998101 after birth and three months later receive these health Prasuti Griha hospital education at birth) were slightly more likely
Khatmando, Group B: at birth only education teaching for delivery residing to use contraception at six months after birth
Nepal Group C: at three months only The and counseling in study areas compared with mothers in groups C and D (no
topics covered were infant feeding, health education at birth) (odds ratio 1.62, 95%
treatment of diarrhea, recognition of confidence interval 1.06 to 2.5). There were no other
acute respiratory infection in young significant differences between groups with regards
infants, the importance of immu- to infant feeding, infant care, or immunization.
nization, and the importance of
contraception after the puerperium.
Baqui et al. Quasi RCT CHWs CMs Trained CHWs and CMs who deli- Received standard 24 months Pregnant women No impact of intervention observed in differences
200893, 114. vered antenatal intervention, birth government health of mortality Improvement observed in institu-
Uttar Pradesh, preparedness, disposable delivery kit, and Integrated Child tional deliveries or conducted by skilled birth
India newborn care, postnatal intervention Development Services attendant, initiation of early breast feeding
Syed 2006115. Quasi RCT CHWs Increased coverage of CHWs , Available rou- 20 months Pregnant mothers Improvement observed in initia-
Rural trained health care providers and tine care was utilized and family members tion of early breastfeeding
Bangladesh TBA, use of clean delivery kit, in control area
antenatal and postnatal visits
75
76
Turan & Say Quasi RCT CHWs The antenatal education consisted of Routine care was 18 months First time expectant behaviors related to infant health (breastfeeding
2003102 eight daytime 2-hour. Session topics provided in control areas mothers and infant check-up) and contraception appeared
Istanbul, included health during pregnancy, to be influenced by participation in the program
Turkey pregnancy nutrition, preparing for
childbirth, childbirth, motherhood
and communication, infant feeding,
infant care and health, women’s health
and contraception after the birth.
Barnes-Boyd quasi RCT CHWs community health workers were trained comparison group did 60 months African American IMR in experimental arm was 3/1000 and in
et al.200190 on advocacy, maternal and health not had any advocate families comparison arm was 5/1000 live births PNMR
Chicago, issues and community internship was for their counseling among experimental arm was 2/ 1000 and in
USA at the end was employed there was comparison arm was 5/ 1000 live births no impact
one group which received advocacy was observed in health problems in 2 arms
from trained advocate and immunization rates in experimental arm was 77%
while in comparison arm it was 63% (P<0.001)
O’Rourke et pre/post CHWs TBAs Impact of women group diagnosing, designing, imple- 36 months pregnant women 63% reduction in PMR (CI: 27-56%) 25%
al.199889, menting, and evaluating community-based solution increase in breastfeeding rates (25.3%
116 to maternal and perinatal health problems pre to 50.3% post intervention)
Inquivisi,
Bolivia
McPherson pre/post CHWs CMs Birth preparedness plan, keychain containing information 24 months pregnant women Essential newborn care preparedness increased
et on antenatal, care of mother and newborn, danger sings from 20-30%. No improvement in early initiation of
al.2006103 breastfeeding (P 0.06) No improvement in skilled
Siraha, birth attendants at birth (0.55) Odds of breastfeeding
Nepal when exposed to messages was 4.2 (P<0.001)
Moran et pre/post CHWs MNH program of JPIEGO focused on birth preparedness, 36 months pregnant women Planning for delivery from skilled birth
al.2006104 recognition of danger sings given birth within attendant increased to 26% (P<0.001)
Rural 12 months
Burkina
Faso
Hadi & pre/post CHWs TBAs trained TBAs were trained for promotion of ANC and PNC 24 months pregnant women TT immunization of 4 + shots in intervention areas
Ahmed services, awareness of complications, early and exclusive were 31.2% compare to 17.8% in control areas. TT
200588 breastfeeding, promoting institutional delivery, nutrition coverage in intervention areas were 93% &75%
Rural supplement and education, care for LBW neonates and in control areas PNC visits in intervention areas
Bangladesh refer severe children to hospitals Safe home deliveries, was 53% and 9% in control areas LBW among
knowledge of signs of sick neonates, manage compli- intervention areas was 27% while in control areas
cations at home, promote antenatal care, referral of the 32% PMR in intervention areas was 63/1000 live
sick newborns to clinics, nutrition supplementation. births and in control areas it was 84/1000 population
NMR in intervention areas was 49/1000 live births
and in control areas it was 34/1000 population
SBR in intervention areas was 42/1000 live births
and in control areas it was 38/1000 population

Cordon & pre/post CHWs CHWs encouraged families and communities to develop 24 months Pregnant women Almost a third of women (29%) and men (31%)
Fonseca- emergency plans (Eps) to help make timely decisions to seek in the follow-up were exposed to some aspect
Becker 200482 qualified medical care in the event of an obstetrical or neonatal of the program’s activities and messages. 66%
Guatemala emergency. The plans detailed maternal danger signs and the of exposed women recognized that severe
necessary preparations for childbirth both at the family level bleeding is dangerous, compared to 31% in the
(knowing where to go, how much money needs to be on hand, baseline and 51% of exposed men recognized
and who will take care of the house and the other children) the danger of severe bleeding, compared to
22% in the baseline. Exposed women (93%) in
the follow-up were significantly more likely to
believe that a woman should receive prenatal
care from a skilled provider than non-exposed
women (72%), and women in the baseline (66%)
Fullerton et pre/post CHWs Mothers & their home birth attendants were taught to recognize 48 months Pregnant women The percentage of increase in acceptance of

al.2005117 & take action to resolve selected maternal &neonatal life- tetanus Toxoid immunization (From 37% to
Uttar Pradesh, threatening problems. Community mobilization efforts were 76%) and the ingestion of iron supplements
India designed to reduce delays in transport to emergency obstetric (from 1% to 36%) Maternal deaths de-
care referral units and to increase use of family planning creased from 1.5% to 0.4% (P=0.053)
maternal bleeding and newborn sepsis was enhanced
Julnes et compara- CHWs The Resource Mothers Program (RMP) supports disadvantaged - teen mothers When compared with a traditional clinic-based
al.1994 98 tive cross teens through the use of para-professional home visitors who are and her family multi-disciplinary program (MDP) using health
Richmond, sectional similar to the teens in race and socio-economic status. In addition professionals, the Resource Mothers Program
Newport survey to recruiting teens into the program and encouraging early pre- reached a higher percentage of high-risk ado-
News, and natal care, the Resource Mothers Program provides teen mothers lescents (e.g., 75.5% RMP vs. 45.6% MDP clients
Norfolk, USA and their families with practical help and increases community aged 17 years old or under), promoted a higher
awareness regarding infant mortality and adolescent pregnancy. level of prenatal care (e.g., 53.1% RMP vs. 32.6%
MDP clients beginning prenatal care before the
fourth month of pregnancy), and resulted in
pregnancy outcomes that favored the MDP but
were comparable (e.g., 89.8% RMP vs. 93.5% MDP
client babies were over 2500 grams at birth).
Walraven et Compa- TBAs In this study perinatal mortality was observed among During1990 Pregnant women Occurred in home births 76% perinatal deaths.
al. 1995 118 rative women delivered at home vs. those delivered Risk ratio for perinatal deaths among home births
Kwimba, Cross via trained skilled birth attendant. was 3.29 (95% CI: 1.28-9.22) as compared
Tanzania sectional to those delivered via skilled birth attendants
Study at dispensaries and clinics
Trained
vs. UTBA
Darmstadt qualitative TBAs Traditional birth attendants (Dayas) conducted most deliveries. - pregnant women Suboptimal practices included lack of disinfection
2008 96 Advice was rare, except for breastfeeding of delivery instruments, unhygienic cord care,
Cairo, Egypt lack of weighing of newborns, and lack of
administration of eye prophylaxis or vitamin K.
77
77
Table 5B: Characteristics of Outreach Workers in Birth and Newborn Care Preparedness activities
training
RJhokio et TBAs from Didactic and 3 days 1 days Register all pregnant Antepartum, Unpaid 1 TBA per Follow up
al.200594 community Practicum They training refresher 3-4 women and inform LHW. intrapartum 1000-5000 done by LHW
were trained on ante times during They were asked to visit and post- population who asked
TBAs (F) partum, intrapartum, the study each woman & pregnancy partum care,
and postpartum care; to check for dangerous signs Emergency
how to conduct a & to encourage women Obstetrical
clean delivery; use of with such signs to seek Care; Neonatal
the disposable delivery emergency obstetrical care. care
kit; when to refer wo-
men for emergency
obstetrical care; and
care of the newborn.
Baqui Recruited Hands-on supervised 6 weeks Refresher ANC visits to promote BNCP, Perinatal care 1 CHW
et al. from training The training training iron& folic acid supple- Emergency per 4000
2008105- community included skills develop- sessions for mentation postnatal home Obstetrical care population
107 ment for BCC, provision management visits to assess newborns on Management
of essential newborn of maternal the first, third, and seventh of childhood
CHWs (F) and newborn
care, clinical assess- days of birth, & referred or illnesses
ment of neonates, & complications treated sick neonates.
management of sick
neonates with an IMCI
adopted algorithm
CMs (M Recruited Didactic Management disseminated of birth 1 CM per
& F) from They held group of maternal and newborn-care 18000
community meetings for the and newborn preparedness messages population
dissemination of complications
BNCP messages.
Bari et These Resided in the Didactic. The CHWs 1 month (a) Behavior change com- Maternal and The Field 1 CHW Data
al.200695 CHWs had population were trained to munication, (b) identification child health Supervisors per 4000 presented
a minimum they would carry out bi-monthly and referral of sick newborns population from the
CHWs (F) of 10th serve pregnancy surveillance in the community, and (c) project MIS
and made home-visits strengthening of neonatal
grade in the third and the care in health facilities.
education eighth month of
pregnancy to counsel
families on (BNCP).
After delivery, the
CHWs made ho-
me-visits to pro-
mote evidence-based
domiciliary newborn
care and to identify and
refer sick newborns,
home-treatment of
serious infection with
oral co-trimoxazole.

training
Trained TBAs to Regional
TBAs (F) promote referral program
to hospital for supervisor
newborns with
danger signs.
Bhutta et At least 8 Women from Didactic. Standard Standard conducted community Essential Approxi- 1 CHW External eva-
al.200892 years of local commu- curriculum included: 18 months education group sessions maternal and mately per 1000 luation done
CHWs (F) schooling nities, with at Promotion of ANC; training from They should liaise closely with newborn care, US$ 30 per population and found
least 8 years iron and folate use in government Dais and medical staff at basic contracep- month plus
of formal pregnancy, Immediate and 6 days health units or rural health tive advise and local travel
education newborn care; Cord extra training centers to monitor growth immunization costs.
and 6 months care; Promotion of for this study and to provide antenatal services
of training exclusive breastfeeding. care, contraceptive advice
to deliver Additional curriculum: and immunization services.

healthcare in Promotion of adequate
the home maternal nutrition and
rest; Early breastfeeding
& colostrum admi-
nistration; thermore-
gulation; Home care
of low-birth-weight
infants; Treatment of
neonatal pneumonia
with oral trimethoprim-
sulphamethoxa-
zole; Recognizing sick
newborns and danger
signs requiring; Training
in group counseling
& communication
strategies
TBAs Theory and 3 days Encouraged health Basic Cost of
(Female) practicum Trained maternal and newborn resuscitation transport
in basic newborn education, recognition of and immediate & meals
care for Dais, newborn danger sings newborn care.
which included
basic resuscitation
and immediate
newborn care.
CMs Theory and Supported LHWs in
(Female) practicum Trained conducting 3-monthly
in basic newborn group education sessions
care for Dais, & helped to establish an
which included emergency transport
basic resuscitation fund for mothers
and immediate and newborns.
newborn care.
78
79
training
Darmstadt 12 years Recruited Theory and practicum 7 days Regional Essential newborn care, Maternal and supervised $30-40/ two door-to-
et al. or more of from the local A combination of training program Thermal care, breast feeding , child health by a regional month door inquiries
2008108, education community classroom-based and supervisors counseling, danger sign reco- program super-
109 proficient in apprentice ship-based had daily gnition, behavior change ma- visor who were
communi- field training on nagement and trust building responsible for
cation &reaso- knowledge, attitudes, 6–7 Saksham
CHWs (F) ning skills, and practices related Sahayaks
to essential newborn (CHWs)
care within the
community, behavior
change management,
and trust-building
Bhutta et 8 years of Local CHWs Didactic and 5 days monthly re- Attendance at birth Maternal Lady health Transport Surveys.
al.200997 education trained by practicum fresher group Routine postnatal visit for and neonatal worker cost
CHWs (F) LHW national Recognition of high sessions the mother and newborn health and supervisors
program risk pregnancies, within 48 hours after birth resuscitation trained CHWs
working in referral. Recognition of
commu- domiciliary manage-
nity were ment of birth asphyxia
recruited by bag and mask
resuscitation. & bac-
terial infections as per
protocol preventive
care of LBW infants
Local TBAs Theory and 3 days monthly re- Promotion of antenatal care Maternal evaluation
TBAs (F) from com- practicum they fresher group sessions led by LHWs. To deli- and neonatal of the
munity were were trained on sessions were ver perinatal care, & conduct health and
recruited promotion of LHW arranged delivery in the presence of resuscitation
attendance of births; in which LHW & to recognize LBW
newborn resuscitation problems infant & sick newborn, provide
(mouth to mouth); encountered care and refer LHWs for further
standardized maternal were management and referral.
post-partum care discussed
and resolved
Manan- Nominated Didactic They were Organize monthly meetings 1 supervisor 1 CHW
dhar et al. by leaders, ad- given brief training in to address obstetric and for every 3 per 7000
200487, vertisement, perinatal health issues perinatal problems facilitator population
110-112 after which all
potential can-
CMs (F) didates were
interviewed

training
Manan et CHWs Didactic and 21 days Refresher Early post partum visits Breast feeding A female 1 CHW
al.2005113 recruited from practicum Training on training was between days 1 to 3, 4 to guidance, trainer per 4000
CHWs (F) community essential newborn care, organized on 5 and 6 to 7 of birth. To counseling, observed population
which included an 8-h areas needing ensure best practices with motivation, ne- each trainee
module on breast- improvement regard to breast feeding gotiation and CHW while
feeding counseling & in assessing demonstration assessing
support, followed by a & supporting a new
6-h practical session on breastfeeding breastfee-
observation & assess- mothers. ding mother,
ment of breastfeeding using a
and a 4-h practical structured
session on counseling. checklist.
Topics covered

included importance
& basic features of
breastfeeding. Training
methods included
lectures, hands-on
demonstration &
practical exercises with
real-life postpartum
breastfeeding mothers
& video-guided lessons.
Bolam et fluent in the Didactic. Trained for Conducted first education Maternal and monitored
al.1998101 two local promotion of exclusive session before discharge newborn weekly
CHWs languages, breast feeding, appro- from the hospital and health during the
Nepali and priate immunization second education session trial by two
Newari of infant, knowledge was conducted in the principal
of oral rehydration mothers’ home three investigators
solution in case of months after delivery
diarrhea, infant signs
suggesting pneumonia
and uptake of postnatal
family planning.
Baqui et Recruited Hands-on supervised 6 weeks Refresher ANC visits to promote Mother & 1 CHW
al. 2008 from Training included training birth and newborn-care newborn care per 4000
93, 114. community skills development for sessions for preparedness, iron &folic population
CHWs (F) behavior-change com- management acid supplementation
munication, provision of maternal postnatal home visits to
of essential newborn and newborn assess newborns on the
care, clinical assess- complications first, third, and seventh
ment of neonates, and days of birth, &referred
management of sick or treated sick neonates.
neonates with an IMCI
adopted algorithm
80
81
Study Education Recruit- Training Duration Certification Refreshers Role key compe- Supervision Incentive coverage Evaluation
ment Content / Ongoing tencies (if any) mode
Criteria training
CMs Recruited Didactic They held Management disseminated of birth Mother & supervised 1 CM per
(M & F) from group meetings for of maternal and newborn-care newborn care by a regional 18000
community the dissemination of and newborn preparedness messages program super- population
BNCP messages. complications visor who were
responsible for
6–7 Saksham
Sahayaks
(CHWs)
Barnes- Literate Residents of Didactic Training and 6 months Maternal To develop a supportive rela- Community Hourly mini-
Boyd et the serving field experience Trained Child Health tionship with the mother and health mum wage
al.200190 commu- in the concepts of Advocates to model problem-solving education payment
CHWs nity, reliability, community health, skills. This helped to improve with special without
literacy, and health prevention mothers’ psychological well- emphasis on benefits
history of practices and promo- being and their perceived maternal-child
volunteering tion, social problems level of social support. health issues.
service that impact infant
health and maternal-
child health issues
O’Rourke selected they were trained to Create awareness on the Health evaluated
et from increase knowledge of issues of reproduction and education and by obstetric
al.199889, community reproduction, contra- family planning, danger counseling behavior
116 ceptive use, danger signs and self-care and to before and
CHWs (F) signs of complications, encourage women to receive after the
and self-care, (b) delivery care from TBAs intervention
improve immediate
newborn care, and (c)
increase the percentage
of women who receive
delivery care from trai-
ned birth attendants
TBAs local TBAs TBAs were trained Conducted safe deliveries home deliveries
(F) for management
of childbirth
Mc they were trained to 2 days +3 increasing knowledge Inter-personal Maternal and
Pherson et increase knowledge of additional of community members counseling newborn
al.2006103 reproduction, contracep- days and practice of beneficial skills with health
CHWs (F) tive use, danger signs household behaviors and by individuals and
of complications, and increasing the use of maternal groups towards
self-care, (b) improve and newborn health services desired
immediate newborn care, behavior for
and (c) increase the per- maternal and
centage of women who neonatal care
receive delivery care from by use of BPP.
trained birth attendants

Study Education Recruit- Training Duration Certification Refreshers Role key compe- Supervision Incentive coverage Evaluation
ment Content / Ongoing tencies (if any) mode
Criteria training
CMs Trained on counseling Two days CHWs visited
(Female) techniques for them once
small groups and every 3-4
individuals and the months.
use of BPP tools.
Moran et hands-on problem- Provided one-on-one Counseling and

al.2006104 solving approach counseling with pregnant intrapersonal
CHWs (F) Knowledge of birth women and their families communica-
preparedness package, on key messages focused tion skills
complication readiness on birth-preparedness and
and recognition complication readi-ness

of danger signs and recognition of danger
signs using a flip-chart
Hadi & local TBAs TBAs were trained by identification of Pregnant Communication health
Ahmed were Physicians and mid- women, antenatal interview skills for desired providers
2005 88 selected wives, and they were before two weeks of the behavior and (community
TBAs (F) trained for behavior delivery, interview at 48 neonatal care midwives)
change communication hours after delivery & supervised
and essential newborn follow-up interviews after TBAs
care management 4 weeks of delivery.
Julnes et women Didactic Training To provides teen mothers and Maternal and Paid
al.199498 from the Trained to assist their families with practical newborn
CHWs (F) community adolescent parents and help and increases communi- health
to serve as their families with the ty awareness regarding infant
resource non-medical dimen- mortality and adolescent
sions of pregnancy pregnancy. Also acts as a
mothers for
and child care. liaison between the teens and
pregnant the relevant public agencies.
teens
Darmstadt Trained to provide 1 day training Register pregnant women, re- Nurses
200896 antenatal, intrapartum cognized danger sings, intra-
CHWs (F) and early postnatal partum & immediate neonatal
care including resuscitation,
thermal control and skin care.
82
Promotion of Breastfeeding
Background
Each year about 10.8 million children die be- ten were conducted in high income countries,
cause of preventable causes and almost all from 124,125,126,127,128,129 seven in middle income
poor countries.119 Most of these deaths can be countries130,131,132 and five from lower income
reduced through universal coverage of simple countries. 133,134,135,136,137 Interventions in
interventions like breastfeeding and estimates Quinn et al. 2005133 were delivered in three
predict that improved breast-feeding practices study sites (countries) Madagascar, Bolivia and
could save the lives of 1.5 million children per Ghana. Studies included 10 RCTs, 3 Quasi RCTs,
year.120 The World Health Organization and 3 pre/post studies, and 1 comparative cross
UNICEF recommend exclusive breastfeeding sectional study (Table 6A & Table 6B) in which
for first six months of life and appropriate com- breastfeeding was either promoted by peer
plementary foods after six months along with counselors or volunteers from community.
breastfeeding until two years and beyond.121,
122 However, exclusive breastfeeding and ap- In some studies breastfeeding was initiated
propriate complementary feeding are far from during the antenatal period usually during
optimum. In developing countries rate of ex- hospital visits by pregnant women. During pos-
cusive breastfeeding ranges between 30-50%, tnatal period most interventions were delivered
while equally unsatisfactory rate for complimen- during home visits by CHWs but occasionally
tary feedings has been observed.123 Low rates were delivered by telephone. This was the main
of breastfeeding brings along a high burden mode of delivery in Dennis et al.126 and Graffy
of childhood illness like recurrent diarrhea, ARI, et al.138 In some cases breastfeeding counseling
and other infections resulting to poor nutritional was done during both antenatal and postnatal
status of children. Several studies done in deve- period.134,135
loped countries have consistently shown that
duration of breastfeeding has been associated Workers were usually peers or volunteers se-
with reduced risks of childhood/adolescent lected from community, although this was
obesity and some chronic diseases in adulthood. not clear in two studies.125,129 Peer counselors
The major challenge is now how to improve the were usually women from community and had
breastfeeding practice to ensure universal cove- previous experience of breastfeeding their own
rage. Studies done in developing countries have children and were more extensively trained then
shown that effective breastfeeding counseling CHWs. Our disaggregated analysis on results re-
can improve the rate of exclusive breastfeeding vealed no difference in the impact of outcomes
substantially. An important aspect of communi- and both of these workers managed to create a
ty-based breastfeeding promotion is the home positive result in increasing early and exclusive
based peer counseling, which involves training breastfeeding rates.
lay health workers to contact and advice peers
from the same community. The peer counse- Training of the CHWs varied in terms of inten-
ling intervention further improves its rate. We sity and content and was delivered by range of
therefore have separately analyzed the effect different agencies and individuals. For example
of promotion of breastfeeding counseling by in one study training was by board of-certi-
CHWs on breastfeeding rates, a subset indicator fied lactation consultants127 in one study by
of MDG. National Childbirth-accredited counselors.138
and in two studies by specialists in lactation
Community-based evidence management.130, 132 Among these studies,
CHWs trained in Chapman et al.127 Agrasada et
Twenty two studies were identified, of which al.130 and Morrow et al.132 found improvements

in exclusive breastfeeding rates as compared to contact was made only during the third trimes-
Graffy et al.138 Duration of training varied from ter.126, 130, 131, 134, 138, 140
2.5 hours of orientation to approximately 280 In Morrow et al.132 breastfeeding education
hours in two studies.125, 140 Some studies inclu- based on six visits was compared with three
ded a substantial practice period for the workers visits counseling, and significant results were
for 6 months in non-study neighborhood prior found in 6 visits breastfeeding education, with
to the actual trial.132 the reason that women obtained information at
each phase of their breastfeeding, and with time
Most studies (n = 14) were intended to pro- became comfortable with their peer volunteers
mote health and/or offer psychosocial support and started sharing with them all the problems
for breastfeeding through the provision of related to breastfeeding and started following
counseling, education and support to mothers. their guidance effectively. In another study,
Most of the interventions involved face-to-face breastfeeding counselor was compared with
contact with women in their homes to promote counselors trained for general care; it was found
breastfeeding. However, two studies delivered that rates of excusive breastfeeding among wo-
support mainly by telephone namely Dennis men counseled by breastfeed counselors were
et al.126 and Graffy et al.138 and several studies higher as compare to general care counselor.
used a combination of both the approaches as
in MacArthur et al.125 Discussions generally fo- In a few studies CHWs were paid and were gi-
cused on ways to overcome potential obstacles ven a monthly wage ranging from USD 12 per
to breastfeeding as well as on the importance hour127 to USD 100-120 /month,131 but this sa-
and benefits of breastfeeding. In some studies, lary did not show an added benefit in increasing
LHWs initiated contact before the third trimester initial and exclusive breastfeeding rates.127, 130,
of pregnancy125, 127, 132 while in other studies 131, 134
CHW Snapshot 6
CARE Peru Enlace and Redes Program
Program overview
CARE Peru, in close collaboration with both the ministry of health and community health promoter associations and
committees (APROMSA and COPROMSA), has supported community health workers program through the child survival
projects Enlace (1996–2000) and Redes (2000–2004). Within this program, the CHWs are responsible for case management
of diarrhea and acute respiratory infection and refer cases needing care at higher facilities. The CHWs are also responsible for
mapping out the population, but they identify and track households with young children and pregnant women 139.

The comunitarios de salud, both men and women, are selected by Community Health Workers, Peru
the communities in which they serve. Each health centre under
the ministry of health is responsible for training its corresponding Refresher Regular meetings
community health workers. Supervision and support are provided Supervision Promoter association
by facility-based ministry of health personnel, as well as promoter
associations. Through both active and passive detection, CHWs locate and refer cases to the nearest health facility.

During the Enlace program, more than 70 per cent of individuals in need of facility-based care were referred from com-
munities with referral slips, and approximately 50 per cent of these referred cases were counter-referred to the CHW for
follow-up. Over the five years of this project, the follow-up visits (counter-referrals) of CHWs increased from 40 per cent of
sick children monitored at baseline to 81% monitored during the final evaluation.

averted through proper and timely initiation
Conclusion and continuation of breastfeeding. CHWs show
Improved breastfeeding rates plays a major promising benefits in breastfeeding rates as
role for achieving health and nutrition rela- compared to usual care. Their contextual factors
ted to MDGS goals. Breast feed is the first and in increasing the rates of breastfeeding by mo-
most important food in newborns life can help thers only had an impact when they were pro-
them protect against major infections through fessionally trained by accredited body. However,
strengthening defense mechanism. Many the additional training and mode of training
preventable deaths among neonates can be demands active involvement of CHWs with
community though direct visitation to women
did seem to reinforce the positive outcomes of
the intervention.

87
Table 6A: Promotion of Breastfeeding – Characteristics of Included studies
Haider et cRCT PCs PCs were trained and visited mothers at No PCs were recruited - Pregnant women Proportion of infants breastfed at the end
al.2000134 10 times during antenatal and postnatal for control group. aged 16–35 years, of 5 months was > 70% in the intervention
Dhaka, period. They mothers and key family with no more than areas compare to <10% in control areas.
Bangladesh members about importance of exclusive 3 living children
breastfeeding, early breastfeeding,
discouraging prelacteal and post
lacteal foods and proper positioning
of breastfeeding, further they advised
mothers of healthy nutrition diet.
Leite et al. RCT PCs Mothers in intervention arm were taught The control group - mothers who The intervention increased exclusive breastfeeding
2005 131 on correct positioning of breastfeeding, received no specific had given birth (24.7% vs. 19.4%; p = 0.044), delayed the introduction
Fortaleza, early and exclusive breastfeeding intervention. They were of formula and increased the time infants substituted
Brazil instructed to seek out breastfeeding to bottle milk (bottle milk 33.4% in the
their local health service control group and 20.1% in the intervention group; p
facility in case of any = 0.00002). When comparing the frequency of artifi-
health problems. cial breastfeeding versus all other forms of breast-
feeding (exclusive+ predominant + partial), the
intervention increased breastfeeding rates in 39%
(RR = 0.61; CI 95%: 0.50–0.75); 15% of children were
free from artificial feeding (absolute risk reduction)
Dennis et RCT PCs Women allocated to the peer support Women allocated to 15 months In-hospital, More mothers in the peer support group than in the
al.2002126 group had access to all of the conventio- the control group had primiparous, breast- control group continued to breast-feed at 3 months
Toronto, nal support services that control group access to the conven- feeding women of post partum (81.1% v. 66.9%, p = and did so exclusi-
Canada was availing, in addition to being paired tional In hospital & 16 yrs of age, had vely (56.8% v. 40.3%, p = 0.01) Breast-feeding relative
with a peer volunteer, and they were community postpartum a singleton birth at risk were 1.10 (95% confidence interval [CI] 1.01–2.72)
given support and education related to support services such 37 wks gestation at 4 weeks, 1.13 (95% CI 1.00–1.28) at 8 weeks and
breastfeeding through these counselors as those provided by or later &resided in 1.21 (95% CI 1.04–1.41) at 12 weeks post partum
hospital-based nursing the local region
and medical staff
Bhandari et cRCT CHWs TBA, CHWs and nutrition workers in the Routine services 50 months mothers of infants At 3 months, exclusive breastfeeding rates were 79%
al.2003135, intervention communities to counsel were provided at (381) in the intervention and 48% (197) in the control
141 mothers for exclusive breastfeeding at the control sites. communities (odds ratio 4·02, 95% CI 3·01–5·38,
Haryana, multiple opportunities. Worker assessed p<0·0001). The 7-day diarrhea prevalence was lower
India and provided information on the benefits in the intervention than in the control communities
of exclusive breastfeeding. At age 3 at 3 months (0·64, 0·44–0·95, p=0·028) and 6 months
and 6 months, mothers & infants were (0·85, 0·72–0·99, p=0·04). The mean weights and
visited at home by a member of the lengths, and the proportion with weight-for-height or
study team to ascertain exposure to height-for-age Z scores of 2 or less, at age 3 months
different counseling sources, the details of and 6 months did not differ much between groups.
counseling received, and any instances of
disease in the infant in the past 3 months.

Morrow et RCT PCs six visits intervention group In the Control-group mothers 21 months Included were At 3 months post partum, exclusive breastfeeding
al.1999132, six-visit group, mothers were visited with lactation problems mothers residing in was practiced by 67% of six-visit, 50% of three-visit,
142 in mid and late pregnancy, in the first were referred to their study area whose and 12% of control mothers (intervention Groups vs.
San Pedro week and weeks 2, 4, and 8 post partum own physicians. No youngest child was controls, p<0·001; six-visit vs. three – visit, p=0·02).
Martir, three visits intervention group mothers other sources of < 5 years of age Duration of breastfeeding was significantly (p=0·02)
Mexico were visited in late pregnancy, in the breastfeeding coun- longer in intervention groups than in controls,
first week, & week 2 postpartum. seling were available and fewer intervention than control infants had
in the community an episode of diarrhea (12% v s 26%, p=0·03).
Chapman et RCT PCs Exclusive breastfeeding peer Women assigned to 18 months Expectant mothers, At 3 months, 97% in the Control Group and 73%
al.2004127, counseling Support offering 3 the control group (CG) less than 32 weeks in the Peer counseling group had not exclusively
143, 144 prenatal home visits, daily perinatal only received conven- gestation and consi- breastfed (relative risk [RR] =1.33; 95% CI, 1.14-1.56)
New visits, 9 postpartum home visits, and tional breastfeeding dering breastfeeding during the previous 24 hours. The likelihood of

England telephone counseling as needed. education prena- nonexclusive breastfeeding throughout the first
tally from the Women’s 3 months was significantly higher for the Control
Ambulatory Health Group than the Peer Counseling Group (99% vs.
Services clinic staff 79%; RR=1.24; 95% CI, 1.09-1.41) The likelihood
of having 1 or more diarrheal episode in infants
was cut in half in the Peer Counseling Group
(18% vs. 38%; RR=2.15; 95% CI, 1.16-3.97).
Agrasada et RCT PCs Two intervention groups receiving control group of 19 months mothers with > At 6 mo, 44% of the breastfeeding counseled
al.2005145 home based counseling visits, one by mothers who did not 18 years, vagi- mothers, 7% childcare-counseled mothers
Manila, counselors trained in breastfeeding receive counseling nally delivered a LBW and none of the mothers in the control
Philippines counseling, the other by counselors singleton & intended group were exclusively breastfeeding
trained in general childcare to breastfeed
Graffy et RCT PCs Counselors visited women once No support provided 40 months Women considering Offering support in breast feeding did not signifi-
al.2004138 before birth and offering postnatal to control group breast feeding. cantly increase the prevalence of any breast feeding
London & support by telephone or further home to six weeks (65% (218/336) in the intervention
south Essex, visits if requested. At the antenatal group and 63% (213/336) in the control group;
England visit the counselors gave the women relative risk 1.02, 95% confidence interval 0.84 to
a contact card and two leaflets. 1.24). Survival analysis up to four months confirmed
that neither duration of breast feeding nor time to
introduction of formula feeds differed significantly
between control and intervention groups.
MacArthur et cRCT PCs An antenatal peer support worker ser- Women in the control 5 months All pregnant IThe groups did not differ for initiation of breast
al.2009125. vice planned to comprise a minimum clusters received women feeding: 69.0% (747/1083) in the intervention
Birmingham, of two contacts with women to provide standard antenatal care, group and 68.1% (896/1315) in the control
England advice, information, and support from which included usual groups; cluster adjusted odds ratio 1.11
approximately 24 weeks’ gestation information and ad- (95% confidence interval 0.87 to 1.43).
within the antenatal clinic or at home vice from midwives on
breast feeding, without
input from community
peer support workers.
88
89
Frank et RCT PCs The first intervention, research Routine counseling 16 months delivered women Women who received the research discharge
al.1987129 breast-feeding counseling, consisted by hospital staff pack, compared with those who received the
Boston, USA of an individualized 20- to 40-mi- commercial pack, were more likely to prolong
nute postpartum counseling session exclusive breast-feeding (P = .004, one-tailed), to
in the hospital by a trained counselor, be partially breast-feeding at 4 months postpartum
followed by eight scheduled telephone (P = .04, one tailed), and to delay the daily use
calls from the counselor when the
infant was 5, 7, 14, 21, 28 days of age
and 6, 8, and 12 weeks of age.
control group did not 7-10 days African-American Trends toward a positive impact of the breastfeeding
receive interventions WIC participants promotion activities were evident but weak,
and largely gone by 7-10 days postpartum.
Anderson RCT PCs Women assigned to the peer counseling Control group did not 3 months 18 yrs or older, At hospital discharge, 24% in the CG compared with
et al. 2005 group were offered 3 prenatal home receive interventions gestation age 9% in the PC had not initiated breastfeeding, with
144 visits, 9 postpartum home visits, and of 32 weeks or 56% and 41%, respectively, nonexclusively breastfee-
USA daily in-hospital visits during postpartum younger, healthy ding. At 3 months, 97% in the CG and 73% in the PC
hospitalization, from the assigned peer and absence of any had not exclusively breastfed (relative risk [RR] =1.33;
counselor (in addition to the routine medical condition 95% CI, 1.14-1.56) during the previous 24 hours. The
breastfeeding support received by the (diabetes, hyperten- likelihood of nonexclusive breastfeeding throughout
control group). During the prenatal sion, HIV/AIDS or the first 3 months was significantly higher for the CG
visits, the woman was provided with an using illegal drugs) than the PC (99% vs. 79%; RR=1.24; 95% CI, 1.09-1.41).
opportunity to watch a breastfeeding Mothers in the CG were less likely than their PC
video. The family was also encouraged to counterparts to remain in at 3 months (33% vs. 52%;
participate in the education, especially RR=0.64; 95% CI, 0.43-0.95). The likelihood of having
the person expected to support the 1 or more diarrheal episode in infants was cut in half
woman after delivery. The mothers could in the PC (18% vs. 38%; RR=2.15; 95% CI, 1.16-3.97).
contact the mothers by phone if they
had any urgent breastfeeding problems
between visits. The assigned peer
counselor also visited the mother-infant
pair at least once a day starting within 24
hours after delivery and continued for as
long as the dyad remained hospitalized
Mclnnes et Quasi RCT PCs Intervention comprised peer Women in control area 24 months Pregnant women At delivery, the proportion initiated breastfeeding
al.2000128 counseling of pregnant women, was given teaching were 23% of the intervention subjects and
Glasgow, support of breastfeeding mothers and at health center 20% of the control. At 6 weeks of postnatal
USA local awareness raising activities period the proportion in intervention areas
was 10% and in control area it was 8%
Schafer et Quasi RCT PCs volunteers taught a series of in-home, no significant 24 months Pregnant women Eighty-two percent of intervention compared
al.1998124 one-to-one lessons about healthy diet breastfeeding with 31 percent of control group women initiated
Iowa, USA and breastfeeding, and maintained promotion programs breastfeeding. Mean duration of breastfeeding
informal contact to answer for intervention and control group women was
5.7 and 2.5 weeks, respectively. At 4 weeks,
56 percent of intervention and 10 percent of
control group women were still breastfeeding.

Davies- Quasi RCT CHWs The training of health workers on breast- In control arm, - Pregnant women The results show that the training was the most
Adetugbo feeding and lactation management is to no training was powerful predictor. CHW recommendations
et enable them make correct breastfeeding provided to CHWs on breastfeeding (OR 60.25, p-0.000), and of
al.1997137 recommendations to mothers. ‘perfect’ breastfeeding knowledge (OR=1.92.49,
Osun, p=0.000). Younger CHWs (in the age bracket
Nigeria 20 to 29 years) were significantly more likely to
make correct recommendations on exclusive
breastfeeding (OR=3.02, p=0.0304).
Quinn et pre/post CHWs Trained CHWs who disseminated 36 months pregnant infants breastfed within one hour of birth increased
al.2005133 messages through a combination of women, from 34% pre intervention to 78% post intervention
Madagascar interpersonal communication strategies grandmother infants exclusively breastfed in 24 hours increased
(health worker to mother, community and other from 46% pre intervention to 68% post intervention
worker to mother, mother to mother), decision
Quinn et pre/post CHWs group activities and community 24 months makers such infants breastfed within one hour of birth increased

al.2005133 mobilization, and mass media (Radio, as grand from 56% pre intervention to 74% post intervention
Bolivia television, and print). Women were fathers and infants exclusively breastfed in 24 hours increased
reached through small- and large-group husbands from 54% pre intervention to 65% post intervention
activities, one-on-one counseling in
homes and they promoted breastfeeding
Quinn et pre/post CHWs via songs performed by women’s groups 24 months infants breastfed within one hour of birth increased
al.2005133 &musical troupes, and community from 32% pre intervention to 40% post intervention
Ghana mobilization events such as local theater, infants exclusively breastfed in 24 hours increased
health fairs, and festivals celebrating from 68% pre intervention to 79% post intervention
breastfeeding & child health days.
Coutinho et compara- CHWs The main objective was to compare the hospital-based 5 months mothers delivered The hospital-training intervention achieved a high
al. 2005 147 tive cross intervention (BFHI training of maternity staff ) with a combined a baby rate (70%) of exclusive breastfeeding in the hospitals,
Brazil sectional hospital-based and community-based intervention (BFHI training but this rate was not sustained at home and at 10
and postnatal home visits). The primary outcome measure days of age only 30% of infants were exclusively
was rates of exclusive breastfeeding from birth to 6 months. breastfed The patterns of exclusive breastfeeding in
the two trial groups for days 10–180 differed signi-
ficantly (p_0·0001), with a mean aggregated preva-
lence of 45% among the group assigned home visits
compared with 13% for the group assigned none.
Haider et al. Cross CHWs mothers were individually counseled by CHWS 2 weeks of partially breast 25% failed to breastfed their child.
1997 148 sectional to breastfeed their infants aged 1-12 weeks who follow up fed infants
Dhaka, survey have been admitted with acute diarrhea
Bangladesh
Nakhunda et Qualitative PCs After training CHWs returned to their communities - pregnant women They identified common breastfeeding problems
al.2006136 survey and started supporting breastfeeding peers as “insufficient breast milk”, sore nipples, breast
Iganga, engorgement, mastitis and poor positioning at the
Uganda breast. They further observed that most of these
problems were eased by correct positioning of the
baby at the breast. The peer counselors were easily
accepted by their communities. The mothers were
happy to have someone within their community
helping them with their breastfeeding problems.
90
91
training
Haider At least Women with Didactic demons- 10 days (4 h They mothers &key family Counseling Their perfor- (£16 1 PC for 12-
et al. 4 years breastfeeding trations and role daily) Worked members about importance skills for encou- mance was [US$22.50] 25 mothers
2000134 schooling, experience, play WHO/UNICEF Part-time of exclusive breastfeeding, ragement of monitored at per
willingness breastfeeding early breastfeeding, discou- breast feeding. least thrice over month).
to help other counseling course and raging prelacteal and post Prenatal and the total study
PC (F) mothers King’s book were used lacteal foods and proper postpartum period by two
breastfeed, as guides. Were taught positioning of breastfeeding, counseling breastfeeding
by demonstrations and further they advised mothers supervisors.
role play and included. of healthy nutrition diet.
Leite et personal theory-practice trai- 20 hours periodic They visited mothers on the Counseling on Supervision US$4 for
al.2005131 experience in ning All members of training 5th day from birth, 15th, breast feeding were provided each home
PCs (F) breastfeeding this group were trained 30th, 60th, 90th and 120th visit, about
is associated on a course adapted US$100–120
with the from Breastfeeding per month
Milk Bank at training course
the Federal
University
of Ceará´
Dennis postseconda- previous Didactic and 2.5hours the activity Contact the new mother Counseled mo- Effectiveness
et al. ry education breast- Interactive orienta- logs within 48 hours after thers benefits of counse-
2002126 feeding tion session was to distributed hospital discharge and as and proper ling assessed
PCs experience develop the peer during the frequently thereafter as the method of using a
of at least volunteers’ telephone orientation mother deemed necessary breast feeding 5-point
6 months’, support and referral session were Likert scale
a positive skills; incorporated reviewed
breast-fee- various topics such in relation
ding attitude as breast-feeding to the peer
benefits, general volunteer
breast-feeding interactions.
information
Bhandari health and Didactic and 3 days Used various materials Growth Growth
et al.2003 nutrition hands-on training for communication were monitoring and monitoring
135, 141 workers in counseling indi- posters for doctors’ clinics, breastfeeding techniques n
PCs viduals or groups of flip books for workers, a counseling reading were
mothers information card with feeding recom- supervised
on the benefits of mendations, a counseling before sending
exclusive breastfee- guide on solving common workers for
ding and feed on breastfeeding difficulties, field work
demand based on and a mother-and-child card
an adaptation of the handed out at Antenatal cli-
IMCI Training Manual nics or at the first home visit.
On Breastfeeding
Counseling,

training
Morrow high-school aged 25–30 Didactic and Home visits to pregnant Breast feeding supervised An exit
et al. years and practicum training women focused on the counseling by staff of interview at
1999132, they did not consisted of 1 week benefits of exclusive breast- La Leche 6 months
142 necessarily of classes, 2 months feeding, especially during League of post partum
have previous in lactation clinics and illness; positioning of the Mexico and
PCs personal with mother-to-mother infant and “latching on” the physi-
breastfeeding support groups, and cian study
experience. 1 day of observation coordinator
and demonstration
by visiting experts
Chapman high-school community Didactic classroom 30 hours biweekly 1 prenatal home visit, daily Prenatal, Supervised $12 per
et al.2004 women who training. Topics case review perinatal visits, 3 postpartum
perinatal and by experien- hour &
127, 143, have breast- covered were meetings home visits, and telephone postpartum ced peer receive
144 fed a child for breast anatomy and with program contact as needed. counseling counselor health care

a minimum physiology, manage- director for exclusive for 3 to 6 on working
PCs of 6 months ment of breastfeeding, breast feeding months 20 hr/wk
counseling techniques, and telephone
and related cultural counseling
and social factors as needed.
Agrasada formal previous posi- Interactive Didactic 40 hours The breastfeeding counselors Counseling A certified transport
et al. education tive personal informed mothers of the on exclusive lactation cost paid
2005145 breastfeeding benefits of exclusively breast feeding counselor during
PCs experience breastfeeding infants up to and child care training &
6 mo, & assisted mothers home visit
in preventing & managing
breastfeeding problems.
Graffy themselves Didactic Training On Accredited Gave the women a contact Breastfeeding
et al. have breast counseling techniques counselors for card and two leaflets counseling
2004138 fed their child for promoting the National during antenatal visit and
PCs breast feeding. Childbirth Trust. offered postnatal support
by telephone or further
home visits if requested.
Mac Didactic Training 8 weeks Kept a log of activities of Worked directly Evaluated
Arthur based on the Unicef women who had reached with the an- by positive
et al. baby friendly breast- 24-28 weeks gestation, then tenatal clinics outcome
2009125 feeding management at around 36weeks. Also and counseled
PCs course, and addressed followed up women who for early breast
cultural beliefs and initiated breast feeding to feeding.
barriers appropriate to give postnatal support.
the local population.
Frank et Offered individualized
al.1987129 20- to 40-minute postpartum
PCs counseling session in
the hospital by a trained
counselor, followed by
eight scheduled telephone
calls from the counselor
92
93
training
Mclnnes mothers who Didactic training and Counseling of pregnant Breastfeeding Postnatal
et al.2000 had at least skills to enable them women, support of breast- counseling question-
128 1 child under to promote breast feeding mothers and local naires were
5yrs of age, feeding and to support awareness-raising activities. used to
had breastfed breast feeding mothers assess the
PC s(F) a baby for at impact of
least 3months counseling.
Schafer et Breastfeeding Didactic training 9 hrs taught a series of Encouraged

al.1998124 experience Topics included gene- in-home, one-to-one breast feeding
of at least ral nutrition, advanta- lessons about healthy by counseling
PC s(F) 3 months ges of breastfeeding, diet and breastfeeding, mothers
basic management of
breastfeeding, listening
and communication
skills, and goal setting.
Davies- Health Didactic Training Focused group discussions Encouraged Evaluated

Adetugbo workers Breast feeding Course with lactating mothers breast feeding after 4
et al.1997 manual modified for and grandmothers by counseling months of
137 a non-Hospltal based mothers
CHWs primary care selling,
Quinn et staff from Short-term Disseminated messages counseling in

al.2005133 government practical training through a combination breastfeeding
Madagascar offices heavy on counseling/ of interpersonal
CHWs and NGOs negotiation and Communication strategies
along with communication skills (group activities and com-
community- for health and frontline munity mobilization, and
Quinn et based community workers mass media (Radio, televi-
al.2005133 volunteers aimed at training sion, and print). Included
Bolivia large numbers to fathers & grandmothers
CHWs counteract attrition as secondary audiences
to promote behaviors
supporting mothers to
Quinn et optimally breastfeed
al.2005133
Bolivia
CHWs

training
Nakhunda 24–35 years Interactive, Didactic 18 hrs The peer Recruited pregnant mothers BREASTFEEDING Each peer Once every
et al.2006 old, and and Practicum training counselors for follow-up and at each visit COUNSLING counselor would two weeks,
136 must have was run by two and they would offer information AND be visited by a a supervisor
breastfed a lactation consultants. supervisors about breastfeeding. For mo- MANAGEMENT supervisor every observed each
child who Breastfeeding Answer held monthly thers planning to breastfeed, OF two weeks and peer counselor
PC s(F) was less than meetings
Book by Mohrbacher the peer counselor offered BREASTFEEDING a monthly mee-
five years old. and Stock was used where to help the mother with PROBELEMS ting held for all.
Also had to as reference material. reports and breastfeeding after the birth.
be literate challenges by
in Lusoga, peer coun-
the local selors were
language, and discussed
acceptable and possible
to the solutions

community. agreed.
94
Neonatal Health Interventions
Background
The likelihood of death of a child under five years ted in rural areas of South Asian countries
of age, born in a developing country is over 13 (Pakistan,155 India156-160 and Bangladesh161)
times that of a child born in an industrialized (Table 7A & Table 7B). The interventions re-
country.149 The Sub-Saharan Africa accounts for viewed on community health workers’ role in
about half of the under five child mortality in neonatal health have shown positive outcomes
the developing world.150 There has been some where the trained CHWs were used to outreach
decline in the under five mortality but that is far the sick children of the community.155, 158, 162,
below the MDG target for Goal 4 i.e., to reduce 163 The types of outreach workers involved in
the under five mortality rate by two-thirds.150 these activities were the CHWs, TBAs, and CMs.
The educational level of the CHWs was gene-
According to Walsh et al., pregnancy-related rally poorly described. The TBAs involved in the
illnesses and complications during pregnancy Saleem et al. were all literate155 while those
and delivery are associated with a significant in Bang et al. were illiterate.157 The CHWs in
impact on the fetus, resulting in poor pre- other interventions reviewed had a few years of
gnancy outcomes leading to greater health schooling.158, 159, 163
risks for the infant.151 These health risks include
childhood illnesses, disability or even death.151
In developing countries, almost two-thirds of The training modalities used were mostly didac-
births occur at home and only half are attended tic159-161, 163 and sometimes in combination
by a trained birth attendant.152 Of the 136 mil- with practicum.155, 157, 158 The training in Bang
lion babies born every year, approximately 3.2 et al. was hands-on, workshop based training.165
million are stillbirths and four million are neo- The training content focused on management
natal deaths, 98% of which are in developing of birth, birth asphyxia, hypothermia, manage-
countries. The first week of life is a particularly ment of LBW babies, recognition of danger signs
vulnerable period, with 60 to 70% of neonatal in neonates and breast feeding problems.155,
157-159, 163 The CMs trained in the Dongre et al.
deaths occurring within the first seven days
after birth.153, 154 intervention were trained to identify newborn
danger health signs and promptly refer as per
The reduction in child mortality is achievable the country specific adaptation of IMCI to ensure
by ensuring full coverage of immunization household-to-hospital continuum of care.160
programs, exclusive breastfeeding for 6 months,
scaling up of vitamin A and nutritional supple- In Sloan et al. BRAC CHWs (government trai-
ments, prevention and effective treatment of ned nutrition workers) delivered interventions
diarrhea, pneumonia, malaria and other infec- related to nutritional counseling and taught
tious diseases, hand washing and using safe and Kangaroo-Mother-Care to mothers. These CHWs
clean drinking water.150 These tasks are do-able were provided frequent refreshers and supervi-
with the appropriate and active engagement of sion but despite of providing close monitoring
the CHWs.150 and supervision and frequent refreshers, inter-
vention did not create an impact on reducing
neonatal deaths and infant mortality.161
Community Based Evidence
We identified eight studies including 2 RCTs, 3 We identified 6 studies in which CHWs delivered
quasi- RCTs, and 3 before/after trials that descri- preventive and therapeutic interventions for im-
bed interventions to improve neonatal health proving neonatal health. Among these Bang et
outcomes. All of these studies were conduc- al.1994 and Bang et al.1999 particularly trained

CHWs to identify and treat neonatal infection seen in health care seeking and uptake of im-
and provided referrals where necessary. Both munization services in newborns. CHWs in these
of these studies found substantial reduction studies were extensively trained to create a link
of up to 24% in neonatal deaths and declined between TBAs and local health center. In Daga
pneumonia specific neonatal deaths by over et al. CHWs were also given a remuneration of
40%. In these projects CHWs along with TBAs Rs 50 per month.159
were trained to make visits and identify sick
neonates who require treatment with antibio- Neonatal resuscitation was another major in-
tics.158, 162 In Bang et al.1993, illiterate TBAs tervention which was utilized to manage birth
were trained to count respiratory rate through asphyxia for the improvement and reduction
“Breath counter” and sand timer to identify ta- of neonatal deaths. In Bang et al. the TBAs were
chypnoea.157 Workers involved in the treatment trained to manage birth asphyxia via mouth-
and management of neonatal infections were to-mouth, tube – mask or bag-mask resuscita-
closely supervised by a physician158 and by tion.163 Since TBAs involved in these interven-
field supervisors157 and therefore managed to tion were illiterate, therefore they were given
avert neonatal mortality and more particularly extensive 3 days hands on training to manage
pneumonia specific neonatal mortality. those babies who failed to cry or breathe at birth
and undertook drills every 2 months to refresh
Dongre et al. and Daga et al. trained CHWs to their practice.163 Extensive training along with
assess and refer sick newborns and they created incentive of $1 per case showed up an impact
referral mechanism with health systems.159, 160 of reducing neonatal mortality by 70%.163
In these studies significant improvement was
CHW Snapshot 7
Female Community Health Volunteers Nepal
Program overview
The Female Community Health Volunteer (FCHV) Program in Nepal was started in 1988 by the Ministry of Health and
Population in order to improve community participation. In the mid-1990s a “population based” strategy was adopted in
28 districts whereby additional FCHVs were recruited leading to a current total of nearly 50,000 FCHVs in Nepal and 97% of
them are in are in the rural areas 164. FCHVs play an important role in contributing to a variety of key public health programs,
including family planning, maternal care, child health, vitamin A supplementation and immunization coverage.
Operational aspects and considerations Female Community Health volunteers, Nepal

The CHWs are chosen from community; they work for community
Training 5 days
and refer sick cases to the nearest health facility.
Refresher 2 days after 2-3 months
The program is currently operates in 17 of 75 districts in the country. As of 2001, there were more than 9,000 community
health workers trained in pneumonia case management. Many partners help maintain the program, and it is estimated that
a much larger proportion of pneumonia cases are treated in program areas (43–44). The Nepal Demography and Health
Survey (NDHS 2006) indicates that about 10% of children with ARI in CB-IMCI districts go to FCHVs compared with 19% of
children who go to government rural facilities. Only 13% of treatment FCHVs failed to treat any children over six months due
to lack of medicines. Evidence from districts that have all treatment FCHVs is that 88% of FCHVs treat successfully if trained.
The 2006 NDHS survey found that 90% and 84% coverage for vitamin A and deworming, respectively.

Conclusion
The evidence based review of the interventions MDGs related intervention. However, their per-
described above shows that the extensively trai- formance can be enhanced through vigorous
ned CHWs were able to manage preventive and training, supervision and pay for performance
therapeutic care in compliance with the MDG incentives. But at the same time, we need to
4 targets.150 The TBAs were equally competent create a system where these TBAs should be
in managing neonatal infections and birth coupled with literate health workers who can
asphyxia through antibiotics and resuscitation liaise on with the health system for maintaining
respectively.155, 159 Despite the fact that they proper referral feedback mechanism for achie-
are illiterate and were a part of informal health ving better outcomes as evident in included
system, we cannot ignore their role in delivering studies.

99
Table 7A: Neonatal health– Characteristics of Included Studies
Saleem et cRCT TBAs TBAs identified pregnant women. The saline wipes were used 7 months pregnant women skin infection among experimental arm
al.2007155 chlorhexidine vaginal wipe was used by instead of chlorhexidine was 16% while in control arm was 22%
Karachi, TBAs & applied on entire cervix, vagina & neonatal deaths in experimental arm was
Pakistan external genitals, the neonate was also 0% while in control arm it was 2%
wiped after delivery within 6 hrs of birth
Sloan et al. cRCT CHWs The government started Integrated Women in controlled - all late (>7 months) NMR = OR adj = 1.060, 95% CI: 0.761–1.477
2008 161 Nutrition Program (BINP), which arm were served with gestation and IMR = OR adj =1.039, 95% CI: 0.770–1.40
Sylhet & later became the National Nutrition community nutrition recently postpartum
Dhaka, Program (NNP), provided advice & workers who were not women and
Bangladesh supplementation to pregnant women. trained for CKMC their families
In this study BINP’s community nutrition
workers were trained to teach CKMC to
participants In the intervention group
villages. They were taught to breastfeed
promptly, exclusively, and on demand.
Bang 1999 Quasi RCT CHWs Train paramedics, village HCW, and TBA In control areas these 35 months Pregnant women 24% reduction in NMR (CI: 5-38%) 94%
165-168. in administration of antibiotics and tasks were done by the reduction in CMR due to pneumonia
Gadchiroli, counseling in mother and newborn care government health ser-
India vices & the Integrated
Child Development
Service (ICDS) workers
Bang Quasi RCT CHWs TBAs Assessed the impact of TBA training on TBAs in control areas 84 months Pregnant women 70% reduction in NMR (CI: 59-81%)
2005156 neonatal resuscitation and home based were not additio- 56% decline in PMR (CI: 46-68%) 49%
Gadchiroli, care education on neonatal mortality nally trained as TBAs reduction in still births (CI: 31-66%)
India in intervention arm,
but they did receive
usual training from
government sources
Bang et Quasi RCT CHWs TBAs TBAs and CHWs were trained to services were provided 42 months neonates pneumonia specific mortality reduced to 44%
al.1993 162 diagnose pneumonia and treat by government while total neonatal mortality reduced to 20%
Gadchiroli, neonates with antibiotics health facilities
India
Dongre et pre/post CMs Educate women about newborn danger sings birth 36 months pregnant women Significant improvements seen in health care seeking
al.2009160 preparedness, health care seeking, and conduction from private health care providers for sick newborns
Rural of monthly village based meeting
Wardha,
India
Daga et pre/post CHWs TBAs TBAs were trained for providing warmth, resuscitation, and 36 months pregnant women ANC registration increased from 467 in 1987 to
al.1993 159 identification and referral of a baby with foot length less than 6.5 and newborns 630 in 1989. improvement in immunization and
Rural India cm. CHWs were also trained to make a link between TBAs and beneficiaries in immunization was also reported
health system. and they visited each newborn on birth for the
assessment and referral in case found to need hospitalization

Waldemar pre/post TBAs TBAs were trained on essential newborn care, initiation of breathing 24 months newborns RR before and after intervention for essential
et al. 2010 and resuscitation, thermoregulation, early and exclusive breastfee- newborn care intervention group did not change
362 ding, kangaroo care, recognition and management of complication. much and was 0.99, 95% CI: 0.81-1.22, where as
Argentina, in neonatal resuscitation group it was 0.87, 95%
Congo DR, CI: 0.65-1.16. Stillbirths in essential newborn
Guatemala, resuscitation group was 0.69, 95% CI: 0.54-0.88
India, &in neonatal resuscitation group was 1.05; 95%CI:
Pakistan 0.82-1.33 Perinatal deaths in essential newborn
and care group was 0.85, 95%CI: 0.70-1.02 & in neonatal
Zambia resuscitation group was 0.94, 95%CI:0.76-1.17

100
101
Table 7B: Characteristics and description of outreach workers
Study Education Recruitment Training Duration Certification Ongoing Role key compe- Supervision Incentive coverage Evaluation
Criteria Content training tencies (if any) mode
Saleem Literate Skilled TBAs Didactic and Conducted safe &hygienic de- Postpartum By study Small
et who had practicum training livery using the kits provided Infection supervisor stipend
al.2007 conducted to conduct safe and and used chlorhexidine as control in
155 at least five clean delivery and vaginal wipe was, the neonate mother and
deliveries use of chlorhexidine was also wiped after delivery neonate
per month as vaginal wipes and within 6 hours of birth
TBAs
for use in neonates.
Bang Village Those who Theoretical and Made home visits, took Management A physician was
1999 women with were willing practicum Trained the history, examined mother of birth entrusted with
165-168. 5–10 years to work were CHWs to take histories and child, weighed the asphyxia, LBW field supervi-
of school chosen as of pregnant women, child each week, and infants and sion fortnightly
education village health observe the process of managed minor illnesses and breast feed
CHWs workers. labor, examine neonates, pneumonia in the neonates. counseling
and record findings. Managed birth asphyxia, Diagnosed
Workers were given color premature birth or low birth and treated
photographs of various weight, hypothermia, and neonatal sepsis
neonatal signs for visual breast-feeding problems.
reference. The female
workers were also trained
in case management of
pneumonia in children,
including neonates.
Sloan community Didactic monthly CKMC To teach community- Breastfeeding BRAC $7.50 a
et al. nutrition Trained to teach CKMC refresher trai- based kangaroo mother counseling supervisors month
2008161 workers to the pregnant or ning sessions care to all expectant and +KMC
postpartum women postpartum women in
CHWs and were trained on the intervention villages
nutritional counseling
Bang 5 to 10 years VHWs were Hands-on Workshop 3 days drills practiced Provided home-based Measurement Trained field CHW was Evaluation
2005 156 of schooling resident based They were on dummy neonatal care in newborns of indicators supervisors given done in the
CHWs women of trained in how to dolls every with birth asphyxia or and the ma- $1.00 per next workshop
the village manage a baby at 2 months weak or no cry at birth nagement of case 2 months later
birth and how to birth asphyxia.
manage those who
did not cry or breathe
at birth by following
an algorithm.
Bang Illiterate Local birth Didactic and Conducted safe hygienic de- Diagnosis of Trained field Field
et al. attendants practicum trained livery and offered newborn pneumonia supervisors supervisors
1993162 in safe and hygienic care. Completed case record later visited
TBAs (f) delivery and better including clinical signs and homes and
care of the neonates; symptoms, Side effects of Verified the
treatment follow up, and records.
outcome of treatment in
every case diagnosed.

Study Education Recruitment Training Duration Certification Ongoing Role key compe- Supervision Incentive coverage Evaluation
Criteria Content training tencies (if any) mode
Dongre village based Didactic Community mobilization, Behavior supervised 1 CHW Evaluated by a
et al. CLICS doot CMs were trained health education efforts, change by village per 1000 pretested and
2009160 were selected by ‘Community Led recognition of danger communica- coordination population predesigned
CMs from village Initiatives for Child signs and prompt referral tion(health committees questionnaire
Survival CLICS program care seeking using Lot after 3years
on identification of behavior), Quality by paying
newborn danger signs and health Assurance home visits
and prompt referral education Sampling
under household and (LQAS)
community IMNCI technique
(country specific
adaptation of IMCI) to
ensure household-to-
hospital continuum
of care (HHCC).

Daga et few years of chosen by Didactic 3 months house hold visit on day newborn Rs. 50 per performa nce
al.1993159 schooling community trained on of delivery, assessment of assessment months was observed
CHWs (F) assessment and newborn, referral to hospital and referral after 1 yr
referrals of sick after their
newborn to hospital deployment
and create a link
between TBAS and
Health system
102
Childhood Illnesses and
Immunization Interventions
Background in high income countries,170-174 and remaining
Approximately 29,000 children under the age all were from lower or middle income countries.
of 5 years die each day, 21 every second. More (Table 8A and 8B).
than 70% of 11 million child deaths occur
mainly from preventable diseases like mala- The CHWs involved in these interventions were
ria, diarrhea, neonatal infections, pneumonia, mostly local residents 175-180 while some were
preterm delivery or lack of oxygen at birth.169 from the neighborhood.171, 172, 181 Some of the
Some of the deaths occur from measles, teta- CHWs had a few years of schooling,177, 178while
nus, HIV/ AIDS, while malnutrition and lack of the ones involved in Fisher et al. intervention
safe water and sanitation contribute to half of had high school education.172 All of these stu-
all these children’s deaths. These deaths oc- dies with literate CHWs found significant results
cur mainly in developing countries while sub on study outcomes.
Saharan Africa has the higher rates. The global
effort for averting these deaths, countries joint The training modality used to train these CHWs
their hands and signed a pledge to ensure a was mostly didactic 171, 172, 177-179, 181-186 while
two-third reduction in child mortality by 2015 Arifeen et al. and Ali et al. used didactic and
and the effort and goals are listed under the practical approach to train their CHWs.175, 176
MDGs. Research and experience have shown
that six million of the almost 11 million children The training content included identification
who die each year could be saved by low-tech, and management of a wide range of childhood
evidence-based, cost-effective measures such illnesses like acute upper respiratory tract infec-
as vaccines, antibiotics, micronutrient supple- tions,174, 176, 181, 183, 184 pneumonia,157, 177, 186
mentation, insecticide-treated bed nets and diarrhea,175, 188 asthma172 and uptake of immu-
improved family care and breastfeeding prac- nization services.170, 171, 173, 180, 182, 183, 189 The
tices.169 Training of health workers in countries intervention by Kelly et al. dealt with common
with IMCI implementation have been shown to childhood illnesses,100 while the one by Cesar
have positive effects. Furthermore, they have et al. trained CHWs in treatment of scabies,
also shown promising results in promoting the infection by helminthes and in use of anti-py-
uptake of immunization in children. retic agents.178 The CHWs in the Alderman et al.
intervention were trained in deworming treat-
In this section we have reviewed all the evidence ment and micronutrient supplementation.189
of CHWs driven intervention for improving child
health and illnesses through identification and A total of 3 randomized control trials were ex-
management of diseases and promoting the clusively based on delivering education related
uptake of childhood immunization. We have to promotion of immunization against common
separately reported evidence based results of illnesses among children. The Pence et al. trial
studies pertinent to malaria in malaria control showed positive outcomes of immunization
section. services by reduction in the rates of infant, early
and late child mortality.182 The CHWs involved
in this study visited households to talk about
Community Based Evidence hygiene and child immunization and made
community aware of their availability for treat-
A total of 30 studies were reviewed related to ments and referrals.182 The CHWs in the Barnes
the role of CHWs in dealing with childhood ill- et al. were involved in immunization outreach,
nesses. Among these 5 studies were conducted tracking and follow-up in the community.170

The Rodewald et al. on the other hand, was de- feeding. Their outcomes showed increase in the
signed to reduce missed immunizations and the practice of exclusive breast feeding and 70%
role of CHWs here was to prompt parents for the correct treatment of all illnesses among children
immunization of their children.171 The CHWs in by the CHWs.175
some other studies as well played their part in
the promotion of immunization.173, 180, 183 The CHWs working in most of the interventions
were volunteers and only those working in
The CHWs involved in the treatment of acute Cesar et al., Chopra et al. and Perry et al. were
respiratory infections could recognize and dif- paid a meager financial incentive which did not
ferentiate between no pneumonia, pneumonia seem to have an impact on the working of the
and severe pneumonia and could also provide volunteers as compared to the studies where
its management.157, 175, 177, 186, 188 The Fisher CHWs were unpaid.178, 180, 190
et al. intervention focused on counseling and
management of asthma, use of asthma control- Of all the interventions only a few were su-
ling and relieving medications as well as beha- pervised. Supervision was done by project
vior modification for better outcomes of treat- physicians,175 or by a nurse and psychologist
ment.172 The CHWs in the Arifeen et al. adhered as in Fisher et al.172 or by health care staff like
to the IMCI case management strategies for the nurses.179, 183, 186 However, supervision also
treatment of pneumonia.175 This intervention did not seem to effect the outcomes of these
also laid special emphasis on malnutrition of studies as compared to those where the CHWs
children and counseled mothers for breast were not supervised.
CHW Snapshot 8
Village Drug Kits, Bougouni, Mali
Program overview
A village drug kit in southern Mali was implemented by the Malian government in 1990 in which gerent de caisse phar-
maceutique, or village drug-kit manager were trained who used to manage a kit containing eye ointment, paracetamol,
oral rehydration salts, alcohol, bandages, Chloroquine tablets and Chloroquine syrup. Ant malarial treatment is given pre-
sumptively. In limited areas, zinc treatment for diarrhea is also distributed and sulfadoxine-pyrimethamine is provided as
intermittent presumptive treatment for pregnant women.

Village drug-kit managers are selected by the villages they serve, ge- Village drug-kit managers, Mali
nerally by a committee of village leaders. In community they counsel
and manage the drug kit. The CHWs are provided with visual aids Education Usually illiterate
to help them explain to caregivers how to administer Chloroquine Training 35 days literacy classes and one
to children in various age groups, and describing the symptoms, week malaria treatment classes
such as convulsions and difficulty breathing that require immediate Refresher One each month
referral to a health facility. Training Village committees

An evaluation of this CHW initiative found that the drug kits were successful in increasing the availability of Chloroquine
at the village level.187 In household interviews, parents reported that 42% of children in the intervention group were
referred to the community health centre by the drug-kit manager, versus 11% in the comparison group (OR = 7.12, 95% CI:
2.62–19.38).187 This intervention is now implemented in all the village drug-kit programs established by Save the Children
in collaboration with the local health services.

Conclusion
The CHWs involved in the childhood illnesses
related intervention made a great contribu-
tion 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 mor-
tality rate.

107
Table 8A: Childhood illnesses and immunization – characteristics of Included Studies
Arifeen et cRCT CHWs CHWs were trained to provide com- CHWs were not deployed 60 months children between 2 Children ill and taken to health provider was 24% in
al.2009 munity case management of non- and they were receiving months to 5 years intervention areas and 5% in control areas Correct
175, 191 severe pneumonia and diarrhea routine care * management of all illness among children was
Matlab, and referrals for severe cases 70% in intervention areas and 4% in control areas
Bangladesh Exclusive breastfeeding in children younger than
6 months in intervention was 76% and in control
areas was 65% Breast milk and complementary
feeding among children aged 6-9 months was
68% in intervention areas and 57% in control areas
Wasting in intervention areas were 13% while in
control areas was 14% Stunting in intervention
areas was 50% while in control was 57%
Fisher et RCT CHWs Coaches reinforced basic asthma No intervention for 24 months children of 2-8 Within 3 months of randomization to the
al.2009 172 education and encouraged key mana- control group years of age asthma coach group, 89.6% of parents had at least
St. Louis, gement behaviors through home visits 1 substantive contact with the coach, with an
USA and phone calls tailored to parent’s average of 21.1 contacts per parent The proportion
readiness to adopt management of children are hospitalized was 35 of 96 (36.5%) in
practices and emphasizing a nondirec- the Asthma coach group and 55 of 93 (59.1%) in the
tive supportive style (cooperative and usual care group (P=.01), controlling for parental
accepting of feelings and choices). education and child age, sex, and hospitalization
in the year prior to the index hospitalization.
Pence et cRCT CHWs The intervention implements both A comparison area 60 months Children less than Reductions were observed in infant (6
al.2005 182 approaches and establishes close receives services 5 years of age percent), early child (20 percent), and
Kassena- links between the MOH nurse and the according to standard late child (41 percent) mortality
Nankana, community leaders and volunteers. MOH guidelines.
Ghana They visit households to talk about
hygiene, child immunization, and other
health issues, and to make the com-
munity aware that they are available
for basic treatments and referrals.
Barnes et RCT CHWs Immunization outreach, tracking, and Control children were 7 months Children less Significantly more intervention children were
al.1999 170 follow-up were provided by commu- notified of immuniza- than 2 years, with up-to-date with their vaccination series than controls
New York, nity volunteers throughout follow-up tion status at enrollment no-shows for a (75% vs. 54%; P = .03). Children in the control group
USA but received no booked appoint- were 2.8 times more likely to be late for a vaccine
further contact until the ment, & overdue than intervention children (odds ratio = 2.8; P = .02).
conclusion of follow-up for a vaccine In addition, an immunization delay of longer than
30 days at enrollment was a significant predictor of
final immunization delay (odds ratio = 2.6; P=.02)
Rodewald RCT CHWs In the first intervention, tracking with no intervention was 18 months ages 0 to 12 months Complete immunization coverage levels
et outreach (tracking/outreach). The given to this group were: control, 74%; prompting-only, 76%;
al.1999171 second intervention was a program tracking/outreach-only 95%; and combined
New York, to reduce missed immunization tracking/ outreach with prompting, 95%.
USA opportunities (prompting) in the
primary care offices. In the third
intervention tracking with outreach
and prompting were provided

Black et al. RCT CHWs All children received services in a No interventions 12 months children The impact of intervention status on cognitive
2003 192 multidisciplinary growth and nutrition development varied as a function of children’s ages
Baltimore, clinic. A community based agency at recruitment, with younger children showing
USA provided the home intervention. beneficial effects of home intervention. There were
Families in the HI group were schedu- no changes in motor development associated
led to receive weekly home Visits for 1 with intervention status. During the study period,
year by lay home visitors, supervised children gained skills in interactive competence
by a community health nurse. The during feeding, and their parents became more
intervention provided maternal sup- controlling during Feeding, but differences
port and promoted parenting, child were not associated with intervention status.
development, use of informal and for-
mal resources, and parent advocacy.
Brugha & RCT CHWs CHWs visited homes and referred No interventions 6 months children under five Immunization coverage rose from 60 to 85%.

Kevany children to clinics. They also targeted Which was 20% higher than control (P <0.005).
1996 193 those children who failed to
Urban complete immunization schedules.
Ghana
Rowe et al. RCT CHWs CHWs were analyzed for correct No interventions 2 months The mean percentage of assessment, classification
2007194 identification and treatment and treatment procedures performed correctly
Urban of children for each child was 79.8% (range 13.3—100%). Of
Ghana the 187 children who required at least one
treatment or referral to a health facility, only
38.8% were Prescribed all treatments (including
referral) recommended by the guidelines.
Ali et Quasi RCT CHWs Trained CHWs to identify both No training to CHWs 60 months Children > 5 years ALRI death rate among intervention areas
al.2001176 active and passive ARI cases from was 6.42/ 1000 children per yr and in control
Matlab, households, and provide re- areas were 11.82/ 1000 children per year
Bangladesh ferrals to severe cases
Bang et Quasi RCT CHWs TBAs Extensive health education was Routine treatment was 24 months children below pneumonia specific mortality rate in the intervention
al.1993 157 provided in the intervention area on provided by govern- 5 years of age area was 40% less in the neonates and about 80%
Gadchiroli, when to suspect pneumonia in a child ment health facilities less in the second month and rest of infancy
India and where to seek immediate care. compared with the control area.
Curtale et Quasi RCT CHWs TBAs The intervention, which included not covered by any 24 months children below the study revealed that children (12-23 months
al.1995183 preventive and curative activities, intervention 5 years of age of age) in the index group had higher coverage
Nepal was carried out through the in BCG, DPT, OPV, measles and in the percentage
existing Primary Health Care of fully immunized (84% vs. 66%, P = 0.0001)
(PHC) structure, utilizing CHVs 94% said they would give it to their children
with diarrhea, if available, vs. 76% in the control
group (P =0.0001). In the index group 37% of the
children reporting ARI symptoms, according to
the mothers, were given co-trimoxazole by CHVs
compared to < 1% in the reference group. Just
22% in the index group and even less, 3%, in the
reference group had GMCs at the time of the survey,
though the difference was significant (P = 0.001).
108
109
Khan et Quasi RCT CHWs CHWs were trained to administer Children in control areas 24 months Children under ALRI specific mortality in infants in intervention
al.1990 177 sulphamethaxaole for suspected were treated by health 5 years was 10/1000 and in control was 15/1000 All
Abbottabad, pneumonia or acute otitis media center, dispensaries or cause specific infant mortality in intervention
Pakistan before referring to health center private practitioners and control areas was 53/1000 and 55/1000 ALRI
specific child mortality among intervention group
was 4/1000 and in control area was 7/1000 All
cause specific child mortality among intervention
group was 21/1000 and 28/1000 in control areas
Congsuviva- Quasi RCT CHWs CHWs were trained to detect serious ARI Control group was 4 months Children under Probability of getting one infection in the interven-
twong et al and given initial care by sponging and to given routine care 5 years of age tion group was 0.884 (95% CI: 0.4 – 1.95) P=0.76
1996184 advice referral of cases to health center
Pattani,
Thailand
Stewart et Quasi RCT CHWs Immunization counseling by CHWs Routine services by 24 months General population Immunization rates among children under 5 in
al.1970173 governmental facilities intervention areas reached to 160/1000 while it was
Okla, USA 40/ 1000 in control area Immunization among
population of 5-14 years reached up to 323/1000 in
intervention areas while it was 36/1000 in control
area Population over 15 years age had an immu-
nization rate reached up to 37/1000 while it was
9/1000 in control areas
Mtango & Quasi RCT CHWs CHWs visited each home every 6-8 Routine services 24 months children under under 5 motality reduced from 32/ 1000 chil-
Neuvians weeks and gave health education from governmental 5 years dren to 29/1000 children in intervention area
1986 181 on recognition and prevention of health centers and from 40/ 1000 to 35/ 1000 in control area
Bagamoyo, ARI, treated them with antibiotic and Pneumonia specific mortality reduced from 12
Tanzania referring them to a higher level to 10 /1000 children / year in intervention areas
and from 14 to 12 / 1000 in control areas.
Black et al. RCT CHWs All children received services in a multi- No intervention was 12 months Children with mean Children’s weight for age, weight for height, and
1995 195 disciplinary growth and nutrition clinic. delivered to control arm age 12.7 months height for age improved significantly during the
USA The intervention provided maternal 12-month study period, regardless of intervention
support and promoted parenting, child status. Children in the Home group had better
development, use of informal and receptive language over time and more child-
formal resources, and parent advocacy. oriented home environments than children in the
clinic-only group. The impact of intervention status
on cognitive development varied as a function of
children’s ages at recruitment, with younger Children
showing beneficial effects of home intervention.
There were no changes in motor development
associated with intervention status. During the study
period, children gained skills in interactive compe-
tence during feeding, and their parents became
more controlling during feeding, but differences
were not associated with intervention status.

César et pre/post CHWs CHWs made weekly visits and distributed medicine like analgesics, 108 months children under In 1988, the infant mortality rate was 83 per 1,000
al.1998 178 antipyretics, ointments, and drugs against helminthes and scabies. 5 years When this project was implemented; the IMR had
Itapirapua been reduced to 65 per 1,000, or seven deaths per
Paulista, year. During the first year of intervention, only two
Brazil children died. The following year, one child died and
in the third year, two deaths occurred. This indicates
that the IMR was reduced by 4.2 times in three years.
Chaudhary pre/post CHWs The Anganwadi workers (AWWS) and the supervisory staff 12 months Children under The performance on correct treatment of cases by
et were given 5 days IMCI training using WHO package. The 5 years of age AWWs weeks were trained 4 – 6 weeks prior to follow
al.2005185 supervisors gave follow up visits to AWWs using standardized up was better than group followed up one year after
Haryana, follow up forms adapted from WHO material. 2nd batch of the completion of training (81.8% and 47.9% respec-
India AWWs was followed up 4-8 weeks after training in IMCI. tively). At the same time, the performance on correct
treatment showed significant improvement during

the second follow up (47.9% and 83.8% respectively).
Alderman pre/post CHWs Organized communities, which in turn mobilized community 24 months Children under The odds ratio of being underweight for children in
et health and nutrition workers to provide growth monitoring 3 years of age program villages after introduction of the
al.2008189 services and counseling to all mothers of young children intervention was 0.83 (95% CI 0.69, 1.00), after
Senegal in selected communities, encourage pregnant women and controlling for regional trends and village and
caregivers to seek preventive health care such as antenatal household characteristics.
and postnatal care and coordinate with health personnel
for delivery of essential health services, such as vaccination,
deworming and micronutrient supplementation
Ghebreyesus multiple CHWs CHWs were trained and sent to field they were in close 36 months children under on average 60, 000 patients per month were treated
et al. surveys contact with health facilities staff. 5 years children under 5 years decreased from 30/1000 to
1999179 18/1000
Tigray,
Ethiopia
Anand et al cross CHWs Workers were given training in the management of diarrhea 24 months children under ORS advice was adequate. Oral antibiotic use
2004 188 sectional and ARI. Children requiring referral were sent to Ballabgarh 5 years among dysentery was satisfactory (75 per cent).
Haryana, The overall prevalence of severe malnutrition as
India diagnosed by health workers was quite high. This
may be due to the use of mid-arm circumference
as a criterion for severe malnutrition. Vitamin A
use was quite low. This was due to poor supply of
vitamin A during the study period. The workers
gave dietary advice more often; however, its
effectiveness was not assessed during this study.
Measles was adequately managed in most cases.
Fagbule compara- CHWs CHWs took histories, and performed physical evaluation. - children less than Most commonly prescribed medication by
& Kalu tive cross They also performed symptomatic diagnosis and treatment 5 years of age CHWs was paracetamol, Chloroquine, and
1995196 sectional of ARI. antibiotics. Many of the workers did not attended
Rural survey continuing education program, and supervision
Nigeria in the previous 2 years was also irregular.
110
111
Cauffman et Cross CHWs Community health aides were recruited and trained to teach - mothers 90% of all mothers were instructed on treatment
al.1970174 sectional mothers how to care for their children when they had an of upper respiratory infections, while 45%
Los Angeles, survey upper respiratory infection (URI) complied with the treatment regimens
USA
Chopra & compara- CHWs CHWs were trained and they delivered intervention related 6 months Children aged 92% immunization coverage observed in intervention
Wilkinson tive cross to immunization level 3-59 months areas compared to 73% in control areas (P <0.001)
1997 180 sectional
Rural South
Africa
Kelly et Prospective CHWs Community health worker (CHW) used an algorithm 48 months CHWs One hundred, 108, and 114 CHWs participated
al.2001100 cross for managing common childhood illnesses. CHWs were in the evaluations in 1998, 1999, and 2001,
Siaya, sectional observed managing sick outpatient and inpatient children respectively. The proportions of children treated
Kenya survey at a hospital, and their management was compared with “adequately” (with an antibiotic, anti malarial,
that of an expert clinician who used the algorithm oral rehydration solution, or referral, depending
on the child’s disease classifications) were 57.8%,
35.5%, and 38.9%, respectively, for children
with a severe classification and 27.7%, 77.3%,
and 74.3%, respectively, for children with a
moderate (but not severe) classification. CHWs
adequately treated 90.5% of malaria cases (the
most commonly encountered classification).
Perry et cross CHWs Study compares the under-five mortality in the Hospital 48 months under 5 years of Under-five mortality was 58% less in the
al.2006 sectional Albert Schweitzer (HAS) Primary Health Care Service age children HAS service area, and mortality for children
190, 197 Area with that for Haiti in general. HAS provides an 12–59 months of age was 76% less
Haiti integrated system of community-based primary health
care services, hospital care and community development
Huicho et cross CHWs the clinical performance of health workers with longer - children under The proportions of children correctly managed by
al. 2008198 sectional duration of preservice training (those with >4 years of 5 years of age health workers with longer duration of preservice
Bangladesh, post-secondary education in Brazil or >3 years in the other training in Brazil were 57·8% (n=43) versus 83·7%
Brazil, three countries) and shorter duration (all other health workers (n=61) for those with shorter duration of training
Uganda and providing clinical care). We calculated quality of care with (p=0·008), and 23·1% (n=47) versus 32·6% (n=134)
Tanzania indicators of assessment, classification, and management (p=0·03) in Uganda. In Tanzania, those with longer
of sick children according to IMCI guidelines. Every child duration of training did better than did those
was examined twice, by the IMCI-trained health worker with shorter duration in integrated assessment
being assessed and by a gold-standard supervisor. of sick children (mean index of integrated asses-
sment 0·94 [SD 0·15] vs. 0·88 [0·13]; p=0·004). In
Bangladesh, both categories of health worker did
much the same in all clinical tasks. We recorded
no significant difference in clinical performance in
all the other clinical tasks in the four countries.

Lindblade cross CHWs Finger-prick blood samples were taken from all consenting parti- 3 months children aged 2 The prevalence of anaemia (Hb < 11 g/dl) in these
et al. sectional cipants. Haemoglobin (Hob) levels from the HCS were compared months to 2 years groups was 87%, 79%, 74% and 52%, respectively.
2006199 with results from a HemoCueTM portable haemoglobinometer and a sample of The prevalence of severe anaemia (Hb < 7 g/dl) was
western pregnant women 24%, 11%, 10% and 2%, respectively. The sensitivity
Kenya of the HCS for anaemia ranged from 60% to 79%
and specificity from 59% to 94%. The sensitivity
of the HCS for severe anaemia ranged from 24%
to 63% and the specificity from 97% to 100%
Edward cross CHWs The community-based child survival programme ensured 45 months children under The child survival programme implemented in
et al. sectional equitable and universal coverage of all households with 5 years of age Chokwe district of Gaza province, Mozambique,
2007 200 children under 5 years of age by organizing 173 ‘care groups’, achieved high coverage for bed net use (80%),
Gaza, each consisting of 10—15 volunteers who were trained through oral rehydration therapy for children with diarrhea

Mozambique culturally appropriate methods of instruction (drama, song, role (94%) and prompt care-seeking from trained
play, etc.). Each volunteer was assigned to ten of her neighbou- providers for children with danger signs. Evidence
ring households and conducted monthly home visits to provide from this system indicated a 66% reduction in
health education for the caretaker and to register vital events. infant mortality and a 62% reduction in under-five
mortality. The mortality survey showed reductions
of 49% and 42% in infant and under-five mor-
tality, respectively. The leading causes of death
identified by verbal autopsies were malaria (30%),
neonatal causes (17%) and pneumonia (21.3%).
Dawson et Program CHWs Female community health volunteers were selected as 20 years children under Community-based management of pneumonia
al.2008186 description the national cadre to manage childhood pneumonia at 5 years doubled the total number of cases treated compared
Nepal community level using oral antibiotics. A technical working with districts with facility-based treatment only. Over
group composed of government officials, local experts half of the cases were treated by the female com-
and donor partners embarked on a process to develop a munity health volunteers. The program was phased
strategy to pilot the approach and expand it nationally. in over 14 years and now 69% of Nepal’s under-five
population has access to pneumonia treatment.
112
113
Table 8B: Description & Characteristics of Outreach workers in Childhood illnesses and immunization
training
Arifeen Recruited Didactic and 10 days Extensive mo- -managing Adaptation to IMCI case IMCI field supervi- 1 CHW Survey was
et al. from the Practicum deployed training nitoring and children management strategies and management sors respon- per 2200 repeated
2009175, population with supplies of in case supervision in both use of structured referral form. sible for 5-9 population after 2 years
191 essential commoditie manage- first-level and VHWs + regular of imple-
Special emphasis ment and referral-level visits by project mentation
CHWs 5 days in Facilities
on pneumonia physicians of program
(female) counseling
and malnutrition
Fisher et High school Recruited Didactic Trained and 3 months Asthma counseling, Asthma Nurse and Hospitalization
al.2009172 from neigh- contents covered administration of asthma management psychologist data was used
bourhood the asthma disease controlling medications and to evaluate the
CHWs (F) process, asthma action asthma reliever medications effectiveness
plans, communication and asthma monitoring
techniques, social
support, and behavior
change strategies
Pence et Didactic trained 90 days

al.2005182 for counseling, training
CHWs (M) education, follow
up and diagnosis
Rodewald College Recruited They were trained

et al.1999 education from neigh- to identify children,
171 bourhood prompt their parents
CHWs (F)
Ali et Recruited Didactic and Detection and management Case

al.2001 176 from the Practicum trained of ARI [Collected data Management
CHWs (F) community on diagnosing an ARI on spatial distribution of strategies for
as no pneumonia, health practitioners] pneumonia
pneumonia, and
severe pneumonia
Bang et Illiterate From the Trained to treat
al.1993157 neighborhood pneumonia, fur-
TBAs (F) thermore they were
also trained safe and
hygienic delibery
Khan et 10 years Recruited Didactic they were Their role in to deliver Children and
al.1990177 from village trained to delivering immunization, antenatal maternal
CHWs (F) health education care, maternal nutrition, health services
and management health education and
of common illness malaria control
related to maternal
and child health

training
Congsu- Didactic WHO 2 days Identified cases with ARI detection
vivatwong receommended training ARI, management with and treatment
et al curriculum was antibiotics and referrals in
1996184 developed. They were case of serious illness
CHWs trained to detect ARI
Mtango & from didactic training trai- visit each household, identify
Neuvians neighborhood ned to provide health children under 5 years of age
1986181 education to mothers from household, educate
CHWs (F) about symptoms of ARI mother about the sings and
and treatment of pneu- symptoms of childhood
monia with antibiotics infection and treatment of
pneumonia among children

Black et from the didactic training There was an The home-visiting program Lay home
al. 1995 community children’s health and eight-session was developed as a visitors
195 nutrition, infant and training negotiated partnership supervised
toddler development, program between families and by a
activities to promote interventionists. Home community
children’s develop- visitors began by asking health nurse.
ment, parent child families about their strengths,
interaction, behavior needs, and priorities, and
management, then worked with them to
relationship building, develop an individualized
family relationships family service plan with
(including violence), specific goals and objectives
child & family advo-
cacy, problem-solving
strategies, &com-
munity resources
and services.
César et 3-10 yrs of Local Didactic Trained on CHWs made weekly visits Childhood $140/month This quality
al.1998178 formal residents how to diagnose and and distributed medicine illness control
Itapirapua school treat diarrhea and like analgesics, antipyretics, recognition consisted at
Paulista, education infectious respira- ointments, and drugs against and treatment least of five yrs
Brazil tory diseases , infant helminthes and scabies.
immunizations and Followed approximately
CHWs
health seeking from 410 children per week
(M & F) health services for
serious illnesses
Choudhary Accepted Didactic They were 3-4 hours Visit households, Supervisory 1 CHW
et by the trained to provide each day provide health and staff at ICDS per 1000
al.2005185 community basic health care, nu- for 5 days nutrition counseling 1 supervisor population
CHWs (F) trition and preventive responsible
and curative services for 20-25
workers
114
115
training
Alderman Didactic trained to They provided counseling,
et al.2008 promote exclu- screen and monitored
189 sive breastfeeding, children and delivered
CHWs (F) adequate and effective community mo-
timely complimen- bilization programs
tary feeding, hygiene
behaviors, micronu-
trient intervention,
treatment for malaria
Ghebre- Read and Selected by Didactic Diagnosis Every month Malaria Nurse
yesus write community and treatment they had control incharge
et al. of malaria a meeting
1999179 where they
shared
CHWs (F) reports
Anand et al Given training on 3 days Refresher
2004 188 management of training were given
CHWs diarrhea and ARI
(M & F)
Chopra & Accepted They were given 4 months CHW $ 10/day 1 CHWs
Wilkinson by the training on promo- facilitators per 100
1997180 community tional, preventive and homesteads
CHWs (F) curative services
Perry et Trained to provide They provided peer to peer Monitors Paid 1 CHW per
al.2006190, immunization, family health education, assist were 400-500
197 planning, expand with clinic activities and recruited to population
CHWs (F) prenatal care and safe provide referral to higher supervise
delivery practices, level of care and promote these CHWs
promote the preven- community involvement in
tion and treatment of planning, implementation
childhood diarrhea and evaluation of services
Dawson et Identified by Didactic training Their main task was Treatment of Health
al.2008186 technical wor- Management of to promote healthy pneumonia care staff
CHWs (F) king group childhood pneumo- behaviors and provide
nia and treatment services in their villages
with oral antibiotics

Primary Health Care Interventions
Background
Community participation and utilization of and nutrition of mother and children.203 They
CHWs are essential components of the primary were also trained to provide chemoprophylaxis
health care model. CHW can undertake various of malaria and purpose and preparation of oral
tasks, including case management of childhood rehydration solution.203 They were evaluated by
illnesses (e.g. pneumonia, malaria, and neonatal their research team who reported their degree
sepsis) and delivery of preventive interventions of success.203 The CHWs involved in Omer et
such as immunization, promotion of healthy al. were trained in primary health care services,
behavior, and mobilization of communities. family planning methods and provision of sup-
In this section we have basically pooled up all plies, nutritional counseling, treatment of com-
those studies that have implemented primary mon ailments like diarrhea, malaria, ARI, TB and
health care interventions related to maternal, intestinal parasites.204 They were also trained to
newborn and child health and nutrition related provide DOTS and disseminate awareness regar-
interventions. ding preventive measures against HIV.204 These
CHWs received a monthly stipend of Rs 3600
Evidence from Community per month, which seemed to have a moderate
impact in the outcomes of this intervention as
Based Health worker projects compared to the studies where the CHWs were
We found 12 studies related to the role of CHWs all volunteers.204
in the overall primary health care interventions
(Table 9A & Table 9B). The CHWs recruited in A study conducted by Sauerborn et al. assessed
these interventions were mostly literate201-203 the service utilization of health care workers
however those mentioned in the oxford policy as compared to other health facilities.206 The
management and Omer et al. had 8 years of for- outcomes of the study showed that 69% of
mal school education.204, 205 The CHWs involved the population approached CHW for primary
in Wayland et al. also had age criteria for selec- health care.206 The CHWs involved in Bukhari
tion and were supposed to be at least 18 years & Gupta were village health guides who were
old for participation in the intervention.203 trained to deliver primary health care facilities in
the community.207 The role of CHWs in Couper
The training modality used to impart knowledge et al. encompassed maternal and child health
to the CHWs involved in promotion of primary care, family planning, case finding, and follow
health care was mostly didactic201-203 while up of infectious diseases like TB and malaria and
practicum was an added modality in the Omer mental health problems.65 They were also trai-
et al. and Oxford Policy Management report.204, ned to provide limited symptomatic treatment
205 The training content was pertinent to basic of diabetes and hypertension and addressed
health care. In Hill et al. the CHWs were trained the issues of environmental and occupational
to promote community participation in health health.65 In Zuvekas et al. the CHWs provided
education, water and sanitation.201 The CHWs community health care to the fellow farm wor-
involved in Edpuganti et al. were trained to kers, increased awareness of preventive health
provide health education related to diarrhea, behaviors and promoted early enrollment of
purpose and preparation of oral rehydration pregnant women for prenatal care.21
solution, infant nutrition, usage of birth control
and growth monitoring of children.202 The Kauffman & Myers trained the CHWs in the
fundamentals of primary health care including
The Wayland et al. trained CHWs in the preven- health promotion and disease prevention.206
tion of rabies and counseling on breastfeeding The CHWs in Reis et al. promoted use of ORT and

Conclusion
vitamin A supplements to prevent dehydration The CHWs involved in primary health care played
and blindness due to insufficient consumption their role in health promotion and preventive
of vitamin A.208 health education. They also provide treatment
for minor ailments and injuries as a therapeutic
intervention. In the studies reviewed financial
incentive was paid only in one intervention
which seemed to have a moderate impact on
its outcome as compared to those where the
CHWs were working as volunteers.
CHW Snapshot 9
China Bare Foot Doctors
Program overview
In 1968, China introduced the program of bare foot doctors as a national policy under the guidance of Red Flag.63 The
program was aimed at providing services, including immunization, delivery for pregnant women, and improvement of sa-
nitation. They not only prescribed antibiotics and western medicine but also performed simple surgical operations. Training
of barefoot doctors varied and their recruitment depended on a candidate’s political attitude and local relationship rather
than educational background.
Program constraint and limitation

In 1980, after the collapse of reform in the health care system, from Bare Foot Doctors, China
cooperative medical system to a payment-based system of medical
care in rural areas. In that era bare foot doctors lost their institutional Education secondary school
and financial support and in 1985 their title got canceled by the mi- Training 3-6 months
nistry if health and some of them became village doctors.

119
Table 9A: Other Primary Health Care intervention – characteristics of included studies
Hill et Quasi RCT CHWs TBAs Each of them was responsible for intervention areas 180 months general population Following the establishment of the PHC system
al.2000 201 the supplies, supervision and the were compared with in 1983, infant mortality dropped from 134/1000
Farafenni, continuing education of the village areas where PHC were in 1982–83 to 69/1000 in 1992–94 in the PHC
Gambia health workers (VHWs) and trained not developed villages & from 155/1000 to 91/1000 in the non-PHC
birth attendants (TBAs) in about 5 villages over the same period. Between 1982 & 83
PHC villages. They provide EPI and &1992–94, the death rates for children aged 1–4
maternal and child health services fell from 42/1000 to 28/1000 in the PHC villages &
from 45/1000 to 38/1000 in the non-PHC villages.
In 1994, when supervision of the PHC system
has weakened, infant mortality rates in the PHC
villages have risen to 89/1000 in 1994–96.
Edpuganti pre/post CHWs Health agents were trained to perform their task in field, they 2 months general population Community had lack of knowledge in the
1995 202 were trained to visit household under their coverage and provide causes of diarrhea, purpose of ORT, sources
Pacatuba, them health education related to diarrhea, purpose of ORT, infant of infant nutrition, usage of birth control
Brazil nutrition, usage of birth control and they also weighed children. and purpose of weighing children.
Wayland cross CHWs Brazil implemented a nationwide CHW program in 1991. 1 months mothers and 12% of population received prenatal care, 9%
2002 203 sectional The goal of this program, called PACS (Programa de Agentes children under receive breastfeeding counseling, 13% on immu-
Rural Brazil Retro- Comunitárias de Saúde), is to improve PHC coverage for five population nization, 18% on diarrhea and ORS preparation,
spective children under five and pregnant women in low-income 9% on nutrition and 5% on respiratory infections
households. During these visits the CHW should measure
the nutritional status of pregnant women and children
under the age of two in each household. When the CHW
encounters a malnourished child or pregnant woman
she registers them for the and educate family members
on various health topics during their monthly visits
Bukhari & cross CHWs village health guides were trained to deliver primary health 4 months general malaria promotion activities were undertaken
Gupta 207 sectional care facilities in the community population 0.006% time health education sessions were given
India study 5% times treatment of minor ailments were 47%
time family planning promotion activities were
performed 17% times and immunization 4% time
Couper Cross CHWs Every health house covers one main village and one or General No outcome reported
200465 sectional more satellite villages. The health house is responsible for population
Iran maternal and child health care, family planning, case finding,
and follow up of infectious diseases (TB and malaria), mental
health problems and, more recently, other chronic illnesses
such as Diabetes and Hypertension, limited symptomatic
treatment, environmental health, and occupational health.
Omer Cross CHWs Over the last decade the GOP and several NGOs have focused 12 months general Women in exposed group were 61% likely to stop her
2002204 sectional attention on improvement in the health sector. One initiative population routine work during pregnancy, 60% gave colostrum,
Pakistan to improve accessibility to primary health care for women and 60% more likely to feed her newborn breast milk after
children is the National program for LHW, in which LHWs were birth, twice more likely to introduce liquid other than
recruited and provide services for family planning and PHC breast milk to child before the age of four moths,
compare to women who were not exposed to LHWs

OPM Cross CHWs Evaluation of National lady health workers program 36 months General population Coverage is about 70%, Vaccination promotion cove-
Evaluation sectional rage: 67% of children under five, Contraceptive usage:
205, 209 20% of all users of modern contraceptives, 50% of all
Pakistan LHW seen and referred emergency case in previous
three months. Indicators of population served by
LHWs were slightly better off than National figures
Zuvekas et Cross CHWs Northwest Michigan Health Service’s Camp Health Aide - general migrant CHAs had 1710 encounters with 168’5 users
al.199821 sectional Program uses migrant farm workers as health-resource persons population CHAs made 687 referrals for migrants for services
Michigan, in the migrant camps to provide community health care at the health center, dentist, social service
USA among fellow farm workers and promote early enrollment agency, etc. CHAs performed 3 11 liaison encounters
of women intoprenatal care; improve the health of migrant between the migrants and the health center
CHWs families; and increase awareness of preventive be- staff and various agencies. CHAs administered
haviors and general health for the migrant population. basic first aid on 402 occasions to migrants.

Rowe et al. Cross CHWs TBAs A representative household survey was carried out in order - General population Villagers consulted their CHW only m 8.8% of
2007194 sectional to study the utilization of CHW in relation to other sources of mild diseases, in 69% the family contacted CHWs
Burkina health care for primary care. In the case of serious diseases,
Faso which the CHW was supposed to identify and
refer, the villagers by passed the CHW m 96 5%
Reis et cross CHWs CHWs promoted use of ORT and vitamin A supplements to 12 months General population 76% of all children were weighed 34% of all mothers
al.1991 208 sectional prevent dehydration secondary to diarrhea and blindness were advised of growth, 40% on immunization,
Indonesia study sue to insufficient consumption of vitamin A. 36% in family planning and 48% in diarrheas
management. 81% were distributed vitamin A.
Kauffman cross CHWs CHWs were trained in health promotion and disease 2 weeks general population Majority of villagers did not know about CHWs
& Myers sectional prevention and fundamentals of PHC and only few had used their services.
1997210 Qualitative
Thailand
Colombo et Compa- CHWs Initially, families were divided into two groups, one 23 months Pre school Findings suggest that special intervention
al. 1979 211 rative with and one without outreach workers. Outreach children from programs, using indigenous and nonprofessional
Portland, cross- workers (neighborhood health coordinators) were poverty families. outreach workers, can increase preventive
USA sectional trained in prevention and health education. They were service utilization by poverty groups.
surveys then assigned to specific subgroups of the poverty
population to teach the importance of preventive ser-
vices and to motivate persons to use these services.
120
121
training
Hill et Didactic They They were Community
al.2000201 were trained to trained in health nurses
Farafenni, provide community close liaison
Gambia participation in health with nurses
education, water and TBAs
and sanitation
Edpuganti Health agents Didactic health 2 months Visit and provide health Childhood local supervi- community
1995202 from the education related to education related to illnesses sors and the members were
community diarrhea, purpose of diarrhea, purpose of ORT, officials at the interviewed
CHWs ORT, breast feeding, in- infant nutrition, usage of State Secretary
fant nutrition, usage of birth control and they of Health
birth control and they also weighed children.
also weighed children.
Wayland Literate From local Didactic Trained in written exam Teaching people how to health Researchers
2002203 neighborhood basic healthcare. make oral rehydration education and evaluated to
Rural Brazil Attended continuing solution (ORS), immunizing prophylaxis report degree
CHWs education workshops children, providing malaria of malaria of success
on specific topics (e.g. prophylaxis, etc.
rabies prevention,
breastfeeding) They are
required to work eight
hours a day, Monday
to Friday. Had to pass
Omer 8 years of Recruited didactic and practical 18 months monthly provision of treatment They are PHC Lady health Rs. 3600 / 1 CHW OPM
2002204 school from the they are trained on meeting with of common ailments, service provider supervisor month per 1000 evaluation
CHWs (F) community primary health care ser- supervisor participate in immunization population
vices, family planning where they campaigns, provision of
methods and provision share their nutritional and family
of supplies, nutritional experiences planning counseling,
counseling, treatment antenatal care and post
of common ailments natal care of women, growth
like malaria, diarrhea monitoring of children
disease, ARI, tuberculo-
sis, intestinal parasites
etc. and involve in
DOTS treatment,
disseminate preventive
measures against HIV

training
OPM 8 years of From local didactic and practical 18 months monthly provision of treatment of They are PHC Lady health Rs. 3600 / 1 CHW OPM
Evaluation school neighborhood they are trained meeting with common ailments, participate service provider supervisor month per 1000 evaluation
205 on primary health supervisor in immunization campaigns, population
CHWs 8F9 care services, family where they provision of nutritional and
planning methods and share their family planning counseling,
provision of supplies, experiences antenatal care and post
nutritional counseling, natal care of women, growth
treatment of common monitoring of children
ailments like malaria,
diarrhea disease,
ARI, tuberculosis,
intestinal parasites
etc. and involve in
DOTS treatment,

disseminate preventive
measures against HIV
Colombo from Outreach workers 6 months The role of coordinators

et al. 1979 neighborhood (neighborhood health was to provide information
211 coordinators) were and to educate selected
trained in prevention persons regarding the chosen
and health education preventive services. They were
expected to encourage and
motivate people to obtain the
services within the Kaiser-
Permanente program.
122
Malaria Control Intervention
Background
Malaria currently kills up to 3 million people cruited in the Delacollete et al. and Deressa et al.
per year worldwide and a child somewhere in were literate,218, 228 while those in the Rubesh
the world every 30 seconds, most of them chil- II et al. 1990 intervention were both literate
dren in sub-Saharan Africa.212 The disease also and illiterate.230 The training modality used to
contributes significantly to anaemia among train these CHWs included didactic approach in
children which is a major cause of poor growth 12 studies215-222, 224-226, 228, 229, 231 as well as
and development. Malaria during pregnancy is didactic along with practicum in 3 studies.214,
also associated with severe anaemia and other 226, 232 The training provided to the CHWs in the
illness in the mother and contributes to low Kroeger et al. was workshop based.223
birth weight among newborn infants which is
one of the leading risk factors for infant morta- Refresher training was provided in few of the
lity and poor growth and development. Yet the interventions. The Kouyate et al. provided just
disease is absolutely treatable and highly pre- one refresher course during the study period,
ventable. Therefore, the international commu- 214 while in Delacollette et al. there used to be
nity has vowed malaria part of its MDGs to make a monthly meeting with the project coordina-
appropriate investments and interventions to tor.218 The refresher training in Pagoni et al. was
bring this disease under control. Malaria is truly Conducted by the core group of mothers220 and
a disease of poverty, which is badly affecting by the malaria treatment study team in Mayxay
the poor who live in malaria-prone rural areas et al. intervention.232 In some studies refresher
in poorly-constructed dwellings that offer few training was provided from time to time after
barriers against mosquitoes. Despite malaria’s the volunteers had spent some years working
shocking role in illness, lives, and economic in the community.226, 227 The refresher training
costs,213 measured are not taken as vigorously had an impact on the outcomes of interventions
as it should be. Malaria’s preventable and trea- as compared to the studies which did not have
table cycle of illnesses can be altered through refresher or on-going training. This is evident
simple measures by community volunteers. We from high number of self reported Chloroquine
therefore reviewed all the interventions applied treatment and more referrals in Kouyate et al.
to control and prevent malaria through simple and from decrease in malarial cases in interven-
community based interventions by CHWs. tion arm in Delacollette et al. and Pagoni et al.
Community Based Evidence The peer counselors (PC) in the Kidane &
Morrow 2000 helped neighbor group mothers
There are total of 29 studies identified that recognize and treat symptoms and also to re-
delivered intervention related to malaria pre- cognize the adverse effects of treatment if they
vention and control in community (Table 10A & might occur 215. These PCs were supervised
Table 10B). Among these identified these, seven by the CHWs from the community 215. The
were RCTs, five were quasi RCTs, eight were proper monitoring and supervision of PCs and
pre/post design while three were comparative educating neighbor group mothers resulted in
cross sectional studies. Studies targeted general reducing under five mortality by 40% (P <0.003).
population, children under 5 years of age and The CHWs in most of the interventions were
pregnant women for malarial treatment. trained to provide treatment of uncomplicated
malaria with Chloroquine. 214, 219-222, 224, 226-
The CHWs in a total of 21 studies identified un- 228, 231 However additional training on how to
der the domain of malaria were mostly residents take thick film and refer to health centre if fever
of the community.214-229 The health workers re- not treated in 3 days.218 They were supervised

by the nurse in-charge of health centre.218 The The CHWs involved in this intervention were
CHWs in Sievers et al. intervention were also unpaid but provided free medical services at
trained in laboratory monitoring and checking government hospitals.226 Their role was to
hemoglobin of all the children with malaria.221 spread health education related to malaria pre-
Those involved in Mayxay et al. were also invol- vention, to make blood smears, offer presump-
ved in the Laboratory diagnosis of malaria.232 tive treatment and maintain patient record.226
The CHWs involved in Das et al. distributed Since the nature of study was a cross sectional
Chloroquine, free of charge to all fever cases225 survey so we could not report the effectiveness
while in the Mbonye et al. the CHWs dealt with through comparison, but it does show that they
the chemoprophylaxis of malaria in the pre- collected blood smears of 15% and 30% of the
gnant women.216 population in Thailand and Latin America res-
pectively. They identified 9% and 47% of all the
The intervention carried out by Okanurak & cases of malaria in Thailand and Latin America
Ruebush II was conducted in two parts of the respectively.226
world, namely Thailand and Latin America.226
CHW Snapshot 10
Anganwadi Workers (Village Health Guides) – India
Program overview
The CHW scheme in India was introduced in 1977 with the aim of providing health services at the doorsteps. The titles of
community health worker has been changed over time from community health workers in 1977 to village health guides
(Anganwadi workers) in 1981.233, 234 In 2002 the village health guides scheme was completely sponsored by family welfare
program.

village health guides are the people from community and their main Anganwadi Workers, India
goal is to provide curative, preventive and promotive health care at
Education minimal schooling
door steps and to involve rural people in the provision, monitoring
Training 3 months
and control of basic health services, and to create resource person
trusted by the local population who could provide link between Supervision community
primary health center and the local community. They devote and Incentive Rs. 50 per month
work for at least 3 hours per day.233, 235 and basic medicines of Rs. 50
Constraints in Sustainability
village health guides program is functional since last 25 years and the program comes under the state government and
they are getting financial support from central government, but none of these are willing to take an ownership for the its
sustainability. The program has encountered number of difficulties, among which is the initiation of perceiving themselves
as village medical practioners.

Similarly the intervention by Kroeger et al. was HOMAPAK which resulted in 10% improvement
conducted in three countries namely Ecuador, in the community effectiveness of malarial treat-
Colombia and Nicaragua.223 The CHWs involved ment. In these studies mothers were supervised
in this intervention were trained to diagnose by community workers for proper identification
and treat uncomplicated malaria.223 After ini- and treatment of children at their homes.
tial training, the refresher training workshops
were conducted once a month by the research Conclusion
team.223 This intervention seemed to have a
positive impact on the outcomes as compared The interventions related to the malaria preven-
to the studies which did not have frequent tion have shown positive outcomes especially
and regular refresher workshops as evident by in studies with regular supervision. The role of
increased knowledge of malaria in intervention CHWs in outreaching the community to reduce
group by 33-61% as compared to the control. the incidence of malaria has been very effective
through their awareness campaigns, laboratory
The CHWs involved in Kolaczinski et al. inter- diagnosis and treatment that they provided for
vention provided their services in the internally uncomplicated malaria.
displaced persons (IDP) camp using color coded
HOMOPAK according to age of the child.229
In Nsungwa-Sabiiti et al. CHWs actually trained

mothers and provided them with 3 days pre
packaged Chloroquine and other medicines as
CHW Snapshot 11
Community Health Workers – Sri Lanka
Program overview
In Sri Lanka the concept of community health workers started back in 1915 after involving teachers and village leaders
work voluntarily. The initiation was introduced by Rockefeller Foundation who campaigned of hookworm infection control.
Service organization such as family planning association started to train volunteers in 1970s from 60 in 1973 to 40, 000 in
1987. From 1976 onwards, the Health Education Bureau developed its volunteer program and trained 100,000 volunteers.

Volunteers were supposed to be from community and they were the Community Health Workers, Sri Lanka
educated males and females from rural areas. Their primary task was
Education educated
to provide health communication message and liaise on with com-
Training 3 months training
munity and health care providers. Each volunteer is responsible for
10 households. Their training differed from areas to areas.236 There Supervision none
were no material incentive for either health staff or volunteers and
the means of the cost of the program is very low.

CHW Snapshot 12
Thailand Buddhist Monks (Village Health Volunteers)
Program overview
The Malaria Division of the Thai Ministry of Public Health started the Village Voluntary Malaria Collaborator program in
1961. The volunteers used to provide presumptive treatment with sulfadoxine-pyrimethamine226, 227 but such treatment
was phased out at the end of 2001. Volunteers are also trained to provide education about malaria prevention methods,
chemical and biological vector control practices, writing of reports, and community motivation techniques.

Malaria volunteers are selected using a variety of methods. They Village Health volunteers, Thailand
are chosen from an established group in the community, identified
Education Compulsory education
by a malaria field officer in collaboration with the village leader,
Training 1-2 days
or selected by community leaders at a community meeting. The
majority of volunteers are males over 30 years old and farm as their Refresher periodic
main occupation.226, 227 Training takes place over one to two days, Supervision Program officer
with periodic refresher training. Topics covered during the training Incentive Free care at government
include: general information about malaria, such as basic epidemio- facilities and certificate
logy, prevention, and signs and symptoms; vector control, including of recognition
spraying and biological control; management of malaria, including blood slide collection and preparation, and presumptive
treatment; completion of patient records; and sensitization of the community.237

In 1990, there were approximately 40,000 malaria volunteers in Thailand. The volunteers took 15% of all the smears used
for epidemiological surveillance. Case detection by volunteers was, however, less efficient than in clinics, with only 9% of
the volunteers’ smears positive, in comparison with 54% of smears positive at the malaria clinic and 26 per cent positive
through other passive detection.
126
127
Table 10A: Other Primary Health Care intervention – characteristics of included studies
Kouyaté et RCT CHWs Three types of workers: health workers Control arm received 24 months children aged Self-reported CQ treatment of fever episodes
al.2008214 (nurses); women group leaders; and the routine care * 6–59 months at home as well as referrals to health centers
Farafenni, main care takers (usually the mothers) increased over the study period. Compared to
Gambia were trained. Thereafter, the women baseline findings, the prevalence of anemia
group leaders trained mothers on correct (29% vs. 16%, p < 0.0001) and malaria para-
malaria management. Thus, CQ and meters such as prevalence of P. falciparum
paracetamol were pre-packed in plastic parasitaemia, fever and palpable spleens was
bags in four age-specific doses each lower at follow-up but there were no differences
with a specific color and containing between the intervention and control group
pictorial guidelines according to
national malaria treatment guidelines
Kidane & cRCT CHWs mother were trained to teach nei- In control areas mother 24 months children under Under-5 mortality was reduced by 40%
Morrow ghbor-group mothers to recognize were not trained. 5 years in the intervention localities (95% CI from
2000215 symptoms in their under-5 children 29·2–50·6%; paired t test, p<0·003)
Tigray, that might be a result of malaria, to give
Ethiopia the appropriate course of Chloroquine
for their age, to share Chloroquine
properly, and to recognize possible
adverse reactions from the drug.
Winch et cRCT CHWs Improve the skills of the village drug CHWs of control group 3 months children under The intervention was associated with significant
al.2003187 kit managers to counsel parents also received their 5 years of age increases in knowledge of danger signs requiring
Bougouni, on correct home administration of standard training but referral, reported quality of Counseling by the CHW,
Mali Chloroquine (CQ), and (ii) increase they were not given and correct administration of CQ in the home.
the referral of sick children to additional training on Parents reported that 42.1% of children in the
community health centers. counsel & referral intervention group were referred to the CHC by
the CHW compared with 11.2% in the comparison
group (odds ratio = 7.12, 95 % CI 2.62-19.38).
Mouou- cRCT CHWs deltamethrin treated bed no interventions 12 months children of ages For the months of April, June and August
Somo et al. nets given to household 0-15 years (rainy season),deltamethrin impregnated
1995 238 bednets did not reduce malaria prevalence
South West significantly, but the overall malaria prevalence
Cameroon for all months of the study was significantly
reduced (chi 2 MH = 9.17, P = 0.002).
Koreger et cRCT CHWs deltamethrin treated bed no interventions 12 months general population The protective efficacy varied between 0% and
al. 1995239 nets given to household 70% when looking only at the postintervention
eucador differences between intervention and control
groups. The average protection was 40.8%
Koreger et when considering a four-month incidence of
al. 1995239 clinical malaria attacks and 28.3% when consi-
Colombia dering a two-week malaria incidence.

Snow et cRCT CHWs permethrin treatment nets were not treated 4 months General population The incidence of febrile episodes with associated
al. 1987 of existed bed nets malaria parasitaemias throughout the rainy season
240 Rural, and the prevalence of splenomegaly and parasitae-
Gambia mia at the end of the rainy season were determined
in 233 children aged 1–9 years who slept under bed
nets and in 163 children who did not. Bed nets were
used correctly by the children in the study cohort,
but direct observations showed that a significant
number of children left their nets for a period during
the night. There was no significant difference in the
incidence of clinical attacks of malaria or in any other
malariometric measurement between the 2 groups.
Rowald et cRCTl CHWs trained CHWS to conduct no treatment in 6 months 10% in the intervention arm compared to

al. 1996 241 massm meetings with vil- control areas 22.4% in control arm developed malaria.
Baghicha lage elders and issue bednets
& Kagan, and treatment with insecticide
Pakistan
Mbonye et Quasi RCT CHWs Train community resource people ITTp was provided 21 months Pregnant women The prevalence of malaria episodes decreased
al.2008216 to distribute IPTp. In Uganda, through health center from 906 (49.5%) of 1830 to 160 (17.6%) of 909 (P
Mukono, IPTp consists of two therapeutic < 0.001) with the new delivery system and from
Uganda doses of SP (three tablets of 500 mg 161 (39.1%) of 412 to 13 (13.1%) of 99 (P < 0.001)
sulfadoxine + 25 mg pyrimethamine) with health units. There was a lower proportion
of low birth weight 6.0% with the new delivery
system versus 8.3% with health units (P < 0.03)
Nsungwa- Quasi RCT CHWs Volunteers educated mothers and Children in control area 18 months Under 5 children 13.5% improvement in the accumulated pro-
Sabiiti et provided a 3-day course of pre-pac- was given routine care portion of patients Anti malarial drug efficacy
al.2007217, kaged Chloroquine plus sulfadoxine/ resulted in a 10.4% improvement in the community
242, 243 pyrimethamine tablets (HOMAPAK) effectiveness of malaria treatment
West
Ugandan,
Uganda
Delacollette Quasi RCT CHWs In control areas CHWs provided In control arm, no 24 months General population Episodes of malaria cases decreased significantly
et treatment of malaria and also specific malaria control and more cases were treated at home (+16%)
al.1996218 provided referrals to patient effort was undertaken and by CHWs (+16%). Malaria cses in intervention
Katana, arm decreased to
Zaire
Menon et Quasi RCT CHWs community health workers treated workers were not trained 48 months children 3-59 49% reduction in children mortality and 73%
al.1990231, all children with fever during rainy for malaria treatment months of age reduction in attacks of clinical malaria
244 seasons with Chloroquine in control group
Farafenni,
Gambia
128
129
Onwujekwe Quasi RCT CHWs The CHWs were trained to treat Routine care was 6 months Adult population ex- The use of community health workers (CHWs)
et al.2006219 only uncomplicated cases of fever provided cept pregnant ladies increased from 0% to 26.1% (p < 0.05), while
Enugu State, and to refer all other cases to the self-treatment in the homes decreased from 9.4%
Nigeria health centre or general hospital to 0% (p < 0.05) after the implementation of
the CHW strategy. Use of patent medicine
dealers also decreased from 44.8% to 17.9% (p
< 0.05) after CHW strategy was implemented.
Pagoni et pre/post CHWs Training a core group of mothers in every village and supplying 12 months Children under All malaria cases decreased from 4712 in 1990 to
al. 1997220, community health workers with essential anti malarial drugs specially 7 years of age 2612 in 1995. Proportion of malaria in 1990 was 5.6%
245 packed in age-specific bags containing a full course of treatment. (95% CI: 4.9 – 6.2) to 6.09% in 1995 (95%CI: 5.2 – 7.0)
Sourou, They used a simple algorithm for diagnosis of uncomplicated malaria.
Burkina
Faso
Sievers et pre/post CHWs The record review examined a total of 551 pediatric admis- 12 months Children under The percentage of suspected malaria admissions
al.2008221 sions to identify 1) laboratory-confirmed malaria, defined by 5 years of age that were laboratory- confirmed was greater during
Kayonza, thick smear examination, 2) suspected malaria, defined as the pre-intervention period (80.4%) relative to the
Rwanda fever and symptoms consistent with malaria in the absence post-intervention period (48.1%, prevalence ratio
of an alternate cause, and 3) all-cause admissions [PR]: 1.67; 95% CI: 1.39 – 2.02; chi-squared p-value <
0.0001). Among children admitted with laboratory-
confirmed malaria, the risk of high parasitaemia was
higher during the pre-intervention period relative to
the post intervention period (age-adjusted PR: 1.62;
95% CI: 1.11 – 2.38; chi-squared p-value = 0.004) Risk
of severe anemia was more than twofold greater
during the pre-intervention period (age adjusted PR:
2.47; 95% CI: 0.84 – 7.24; chi-squared p-value = 0.08)
Spencer et pre/post CHWs CHWS were provided Chloroquine Phosphate 27 months Neonates, infants Neonatal mortality increased from 37 /1000
al.1987222 to provide treatment for malaria and children live births to 49/ 1000 live births. Slight decline
Seradidi, observed in post neonatal mortality i.e. from 73
Kenya to 67 /1000 live births. Early childhood mortality
reduced from 25 to 18 per 1000 children
Koreger et pre/post CHWs There were two phases of the intervention: (I) the training of 24 months General population The knowledge of malaria etiology and symptoms
al. 1996 233 village health workers, and (2) community workshops. In interven- was 33-61 % better in the intervention group
Eucador tion communities the topics were related mainly to malaria and than in the control group. Knowledge of the
in the control communities to other common health problems. recommended doses of Chloroquine increased
Koreger et pre/post CHWs There were two phases of the intervention: (I) the training of 24 months significantly (34% in Ecuador, 93% in Colombia but
al. 1996223 village health workers, and (2) home visits and community not in Nicaragua) and correct use of Chloroquine
meetings organized by the village health workers In intervention in the treatment of malaria episodes also
Colombia
communities the topics were related mainly to malaria and in improved (26% in Ecuador, 85% in Colombia)
the control communities to other common health problems.
Kroeger et pre/post CHWs There were two phases of the intervention: (I) the training of 12 months
al.1996223 village health workers, and (2) home visits and community
Nicaragua meetings organized by the village health workers. In intervention
communities the topics were related mainly to malaria and in
the control communities to other common health problems.

Thang et Pre/post CHWs National Malaria Control Program (NMCP) was launched using 33 months General population Malaria prevalence significantly decreased from
al.2009 224 community-based monitoring of malaria cases.. The national 13.6% (281/2,068) in December 2004 to 4.0%
Vietnam insecticide-treated bed net (ITN) campaign, supported by (80/2,019) in December 2006. Malaria incidence
an intensive media campaign on the importance of malaria decreased by more than 50%, from 25.7/1,000
and ITN use, and the widespread use of artemisin derivati- population at risk in the second half of 2004
ves for treatment, were at the basis of such a success to 12.3/1,000 in the second half of 2006.
Das et Compa- CHWs Volunteers from villages were selected for distribution of 24 months General population Mean annual incidence of 331.8 cases per 1,000
al.2008 225 rative Chloroquine and the selection was made either by villagers population during the three-year study period. The
Orrisa, cross or head of the village. The services of the volunteers were average morbid days due to fever (AFD) was reduced
India sectional absolutely free and voluntary in nature. Chloroquine to 1.6 ± 0.1 from 5.9 ± 2.1 in the experimental villages
was provided free of charge to all fever cases. while it remained at 5.0 ± 1.0 in the check villages.
Mayxay et compara- CHWs Thick and thin stained blood smears were prepared by 10 months general population After 1 h training 64 village health volunteers
al.2004232 tive cross the VHVs from the same finger-prick for later microscopic (VHVs) from rural Laos, with no previous laboratory

Rural Laos sectional examination. Patients with positive rapid tests at VHVs’ houses experience, performed two malaria rapid diagnostic
study were treated with oral Chloroquine (25 mg/kg over 3 days; tests (ParacheckPfTM and OptiMALTM) accurately.
Lao national guidelines), or were referred to the district clinic,
where they were treated with either oral Chloroquine (above)
or sulphadoxine-pyrimethamine single dose (25/1.25 mg/
kg) or oral artesunate (4 mg/kg once a day for 3 days) plus
mefloquine (15 mg/kg on day 1, 10 mg/kg on day 2).
Lindsay et compara- CHWs TBAs Malaria control program was implemented in PHC areas - general population Number of mosquitoes collected in PHC and
al.1993246, tive cross where insecticide impregnated nets and targeted non-PHC villages were not statistically different.
247 Soma, sectional chemoprophylaxis was used. The mosquitoes were found in the appre-
Gambia PHC with ciable numbers in 4 months of the year
nonPHC (Geometric mean = 32.5, 95% CI: 18.2-57.3)
Okanurak retrospec- CHWs CHWs responsibility was to take patient information, Over more General population CHWs collected 15% population blood smears
& Ruebush tive cross blood smears, and administer presumptive treatment than 30 8.8% of all malarial infection were detected
II 2001237 sectional with Pyrimethamine-sulfadoxine to residents with suspected years
Thailand malarial illnesses or to those with high risk behaviors.
Okanurak retrospec- CHWs volunteer collaborator network was built in which CHWs over more children 3-59 49% reduction in children mortality and 73%
& Ruebush tive cross were trained and they to take patient information, blood than 40 months of age reduction in attacks of clinical malaria
II 2001237 sectional smears, and administer presumptive treatment of malaria years
Latin
America
Deressa et cross CHWs and training on health education, diagnosis of suspected 2 months general population The case fatality rate and proportionate mor-
al.2005228 sectional malaria cases and treatment by Sulfadoxine-Pyrimethamine (SP), tality ratio for malaria were 20.8% and 90.9%
Oromia, survey referral of severe cases, source reduction of mosquito breeding in August, respectively, in the Hospital.
Ethiopia sites, registration and reporting of treated cases, consumed
anti malarial, registration of deaths and assessment of the
overall status of the epidemic in their particular areas
Kolaczinski cross CHWs Distribute pre-packaged Chloroquine plus Sulfadoxine 1 months Children under 95.0% (CI: 93.3% – 98.4%) of their children had
et al.2006229 sectional Pyrimethamine (HOMAPAK®) free of charge 5 years of age received the correct dose for their age and
Gulu, to caretakers of febrile children. 52.3% of caretakers had retained the blister pack.
Uganda Assuming correct self-reporting, the overall
adherence was 96.3% (CI: 93.9% – 98.7%).
130
131
Okanurak & Cross CHWs CHWs were trained for malaria collaborator program 48 months general population 10% of all malaria cases were detected by
Sornmani sectional volunteers in 1987 which remain static over the
1992 227 years and was around 9% in the year 1990
Thailand
Rubesh II et pre/post CHWs 28 CHWs were trained to detect malaria and treat the case 24 months general population illiterate counters treated an average of 10
al. 1990230 patients per months while literate treated 12 per
Guatemala month,. illiterate treated 36% of the population
while literate treated 30% of the population

training
Kouyaté et permanent Didactic and 5 days one refresher The main roles were: malaria supervision They 1 CHW per
al.2008214 residency in Practicum Health course over the Training of health staff, diagnosis and by their local earned 15 mothers
CHWs the sub- Education and malaria study period women group leaders and treatment health workers money
village, age management. mothers; Sensitization of after selling
30–50 years communities; Drug supply out drugs
to women group leaders,
revolving fund Supervision
of health workers and
women group leaders

Kidane & Mother Didactic Trained to Kept track of and Record, in Supervised
Morrow coordinators teach neighbor group monthly format of all births by CHWs
2000215 mothers to recognize and deaths, and of drug
symptoms in their supply. To help neighbor
under-5 children that group mothers recognize and
might be a result of treat symptoms of malaria
malaria, to give the and also to recognize
appropriate course of
treatment for their age, its adverse effects if they may

PCs
to share Chloroquine occur. Would make appro-
properly, and to priate referrals where needed.
recognize possible
adverse reactions
from the drug.
From collected the monthly Supervised

CHWs community reports on births, deaths, by team from
migration in and out of the the TCBMCP
community, and referrals,
and checked whether drugs
were short and reported any
problems. Supervised mother
coordinators and acted as
executive for social affairs
of the local community.
132
133
training
Mbonye et Community Didactic Training 1 week Distributed IPTp, gave iron Chemoprop-
OPM
al.2008216 resource Module included and folic acid supplementa- hylaxis of
evaluation
CHWs people. dangers of malaria in tion, deworming, and infor- malaria in
pregnancy; malaria mation on proper nutrition. pregnant
prevention in pre- women.
gnancy; the benefits of
SP and its side-effects;
taking blood samples
for parasite count and
hemoglobin analysis;
taking the baby’s
weight; and estimating
gestational age
Nsungwa- Didactic training 3 days provided anti-malarial in two Provided district

Sabiiti et on recognition of age-specific, colour-coded treatment health team
al.2007217, illness symptoms, formulations, a red pack of Malaria on a monthly
242, 243 advising mothers on for infants aged 2—23 and offered basis.
CHWs the use of HOMAPAK months and a green pack it under
and health facilities, for those aged 2—5 years. directly
and on keeping observed
treatment registers. therapy
Dela- Literate Local villa- Didactic in-service trai- 2 weeks Monthly Quickly provided Chloroquine Supervised Received
collette gers/ farmers ning at health centre meeting phosphate treatment for by nurse In only symbo-
et al.1996 in the use of simple with project isolated episodes of fever charge of HC lic monetary
218 treatment algorithm coordinator (presumed malaria). Take reward.
CHWs for fever and early of the project thick film and refer to HC
recognition and ma- if not cured in 3days
nagement of malaria
Onwu- selected Didactic Training 1 month Kept record of patient clinical Treatment of Paid commis- Post interven-
jekwe et community trained to treat only data, cost of drug and drug uncomplica- sion on drugs tion survey to
al.2006 219 members uncomplicated cases supplies, provided treatment ted malaria evaluate the
CHWs of fever and to refer by home visit if patient unable effectiveness
all other cases to the to reach them. Referred cases of CHWs
health centre or general with persistent fever to the
hospital within town. health centre or hospital that
was nearest to the sick person.
Pagoni Workers Didactic Training Use Refresher held the supply of drugs Treatment of Supervised allowed to Assessed
et al. from the of a simple algorithm training by and were instructed to sell uncomplica- by the nurse keep O.6 using a
1997220, community for diagnosis of the core treatments to the mothers ted malaria from the US cents for survey was
245 uncomplicated malaria. group of upon request, provided the and record dispensary each bag performed
mothers child did not need Referral. keeping of one year after
CHWs the imple-
Compiled monthly returns, drug supply
indicating the number of mentation
bags sold for each age group.

training
Sievers et Community Didactic Training Managed children with Management
al.2008221 workers trained to distribute uncomplicated malaria of uncompli-
CHWs anti-malarial within each and referred those with cated malaria
village to children of five severe illness and dehydra-
years of age or less with tion to hospitals. Laboratory
fever and symptoms monitoring, including
consistent with checking admission
uncomplicated malaria. hemoglobin for all children
All therapeutic regimens with suspected malaria.
were in accordance
with Rwanda Ministry
of Health guidelines

Spencer et Volunteer Didactic training Provided Chloroquine census and
al.1987222 village health Trained to treat phosphate for the registration of
CHWs helpers uncomplicated malaria treatment of malaria, vital events
with Chloroquine
Menon et Didactic they were Visit households, identify chil-
al.1990231, trained how to treat dren with febrile illness and
244 febrile illness with treat Chloroquine medication
CHWs (F) Chloroquine
Kroeger et Local Health Didactic and works- Weekend Provided workshop based Malaria Supervised by The research
al.1996223 promoters hop based training training training to the community diagnosis and the research team observers
Ecuador on community based workshops related to malaria. treatment team and the workshops
CHWs malaria control. were held health staff &evaluated the
once a month of ministry problems and
Kroeger et Malaria by I or 2 PMade home visits and orga- of health. achievements
al.1996223 volunteers members of nized community meetings of health
Colombia the research promoters.
CHWs team
Kroeger et Volunteer
al.1996223 malaria
Nicaragua workers
CHWs
Thang et Village health Didactic Training Updated census file with Malaria
al.2009224 workers trained to use rapid births, deaths and migrations diagnosis and
CHWs diagnostic tests, to records and reported monthly treatment
take blood slides to the malaria provincial
and administer the station where the electronic
treatment to malaria census file was managed. Also
patients according involved in health promotion
to the test results and malaria control activities.
134
135
training
Das et Volunteers Didactic Training on 1 week provided Chloroquine Distributed
Unpaid Impact was
al.2008225 selected by diagnosis based on the to those patients who Chloroquine,
evaluated
CHWs villagers or symptoms of malaria approach them for treat- free of charge
head of the and on Chloroquine based on
ment and to fill up a ‘fever to all fever
village and administration as the changes
treatment sheet’ and the cases.
some malaria prescribed in the observed in
number of Chloroquine ta-
workers also National Anti-Malaria fever days,
blets given. Volunteers with
included. Program through group incidence, para-
no educational background
discussion sessions site incidence
were supplied with pre-
and demonstrations and parasite
packed tablets in colored
prevalence.
disposable plastic pouches
for different age classes.
Mayxay et Chosen Practicum training 1hr follow-up Prepared thick and thin Laboratory Monitor at
al.2004232 on their included training and re- stained blood smears for later diagnosis Phalanxes
CHWs willingness to in blood collection, teaching by microscopic examination. of malaria District Clinic.
participate. performance & inter- the malaria If a patient returned with
pretation of rapid tests treatment symptoms, they would
and making malaria study team repeat the test and to
smears, was held in retreat or refer, according
the Lao language to the patient’s condition.
Okanurak Selection Didactic and 1-2 days Certificate Refresh Spread awareness on malaria dia- Supervised by Unpaid. Evaluated on
& made by the Practicum Includes from Malaria course malaria prevention, made gnosis and malaria field Provided the basis of
Ruebush malaria field general information on Division & organized blood smears, offered treatment officer on a free medical performance.
II 2001237 officer and malaria transmission, from Ministry from time to presumptive treatment and weekly basis. services at
the village symptoms, prevention, of Public time after the maintained patient record government
Thailand headman. how to prepare Health in volunteers hospitals
CHWs
thick blood smears, the 2nd year have been and centres.
Okanurak administer presump- of service. working for
& tive treatment and some years.
Ruebush II complete the patient
report forms. Also
2001237
trained in motivational
Latin techniques for
America antimalarial activities
CHWs in the community.
Deressa literate Community Didactic training on 3days diagnosis and treatment of Provision Supervision
et al.2005 –capable of malaria workers health education, uncomplicated malaria cases of malaria carried out
228 reading and selected from diagnosis of suspected with SP; referral of severely treatment of by Pas
CHWs writing Epidemic- malaria cases and ill patients; community mo- malaria under
affected treatment by Sulfadoxine- bilization on environmental supervision
peasant asso- Pyrimethamine (SP), mngtt & health education
ciations (Pas). referral of severe on malaria transmission,
cases, source reduction prevention, control &the
of mosquito breeding importance of early diagnosis
sites, registration and & treatment, & weekly repor-
reporting of treated cases, ting of their performances.
consumed antimalarial,
registration of deaths and
assessment of the overall
status of the epidemic

training
Kolaczinski Community Didactic training On provided the correct dose of skills to Monthly Unpaid Evaluations
et al.2006 drug provision of color- coded color coded HOMAPAK®, and manage Record carried out
229 distributors HOMAPAK according recorded the age of the child malaria illness screened by
CHWs to age of the child to in IDP camps surveyor
his/her care giver and
maintenance of record
Okanurak & established didactic training 1-2 days refresher were they were trained to malaria basic performance
Sornmani community covered 6 subjects. training provided after provide health education control and remuneration evaluation
1992227 groups, and This subjects included working for to the community, they treatment and (per diem).
CHWs then that general information some time were also trained to increase management Reward pin
community about malaria, malaria community awareness on

decided control, how to prepare how to prevent malaria and
a think blood slide, where to get treatment
drug distribution and
report writing and mo-
tivation of community
Rubesh illiterate from commu- at volunteer home they 1 week made visits at community detection and supervision people in
II et al. and nity through were trained how to orientation household and they were as- treatment by evaluators community
1990230 literate community fill report, and how to & 2 days ked to inform the family to re- of malaria every 8 weeks were aksed
poll administer three days training port malaria to these workers to report
presumptive treatment differences
of malaria and were in literate &
given a booklet for illiterate
dosage schedule
136
Tuberculosis Control
interventions
Background
Tuberculosis (TB) is known to afflict mankind with pulmonary TB (both clinically diagnosed
since ancient times. With the arrival of che- and sputum/ culture AFB positive TB patients)
motherapy and establishment of short course in 11 studies,251-261 children and adults in 2
treatment regimen in 1970s and 1980s, it was studies.262, 263 In several studies CHWs were
believed that TB would surely be conquered peers or people who have recently comple-
soon. Steady declines in case notifications were ted TB treatment;256, 262 while in others they
observed in most of the developed countries in were CHWs or volunteers from community. In
early 80s,248 while no such declines were seen Clarke et al. consumers themselves selected the
in most developing countries. Before it could CHWs.264
have eradicated completely a reversal of the
declining trend started with the emergence of Educational level of CHWs was not mentioned
HIV/ AIDs disease. Consequently, TB was decla- in any of the study, while 3 studies mentioned
red a global emergency by the World Health that their CHWs were illiterate members from
Assembly (WHA) in 1991 and a frame work for the community.258, 259, 260 In every study
TB control was developed in the form of DOTS CHWs were the members from local residence.
(the internationally recommended strategy for They all received didactic training except in
TB control).249 The principle target of MDGs Phomorphub et al. in which CHWs were given
for TB control adopted in the year 2000 is to practicum training in addition to classroom
ensure that the incidence rate of TB is declining teaching.265 When the number screened by
by 2015. The supplementary targets are to halve CHWs in Phomorphub et al. was compared with
the prevalence of TB and TB mortality rates by those diagnosed by health center or hospital
2015 as compared to 1990. The ultimate goal is staff, their performance was better than health
to eliminate TB by 2050, when the annual inci- center but poor than hospital staff.265
dence should be less than one case per million
population. Content of training varied between studies.
In Shargie et al. CHWs distributed leaflets and
To control TB, the DOT strategy was introduced discussed symptoms of TB at community ga-
in late 1990s.250 In this section we will be fo- thering, plus they also screened population at
cusing on the intervention delivered by CHWs monthly diagnostic outreach clinics.251 While
in their community to achieve a part of MDG in some other studies CHWs or family members
goal-6. trained as promoter delivered and monitored
TB DOTS therapy.252, 253, 256, 259-262, 264
Community-based evidence
In Clarke et al. and Walley et al.253 the direct
Twenty three studies were included in this observations therapy strategy by CHWs was
group that delivered interventions related to compared with family members. Both of these
management of tuberculosis in the community. studies showed that cured rates were higher
Studies included seven RCTs, 1 quasi-RCT, 1 pre/ among CHWs arm as compare to family mem-
post design, and other cross sectional or com- ber arm.
parative cross sectional studies (Table 11A &
Table 11B). all of these studies were from lower Training of these workers varied from 2 days as
or middle income countries except one which in Niazi & Al Delamimi intervention257 to 30 days
was from high income country i.e. USA.21 in Chowdhury et al.258 Studies that utilized BRAC
CHWs were provided with close monitoring and
The participating consumers included adults supervision258-260 while only Chowdhury et al.

Conclusion
reported that their CHWs were provided with The interventions related to the tuberculosis
refresher training once a month.258 prevention have shown positive outcomes
especially in studies with regular supervision of
Workers from BRAC areas were given small CHWs in TB DOTS program. The role of CHWs
remuneration of 125 Taka,260 sales of drugs258 in outreaching the community to the cure
and transport cost.256 Disaggregated analysis rates of tuberculosis has been very effective
showed that all these studies where CHWs were through their awareness campaigns, laboratory
given remuneration for work had significant screening and treatment that they provided for
tuberculosis cure rates. eradicating tuberculosis.
CHW Snapshot 13
Community Health Workers – Burkina Faso
Program overview
A pilot program in Burkina Faso sponsored by the National Centre for Malaria Control (Centre National de Lutte contre le
Paludisme) relies on community health workers who supply anti malarial drugs at the community level. The CHWs sell the
pre-packaged Chloroquine regimens to mothers under a cost-recovery mechanism, in accordance with Bamako Initiative
principles. The CHWs are given the first stock of drug packages and are expected to sell the drugs at a pre-approved price.

Nurses from the health centers train core groups of mothers, village leaders and CHWs in symptom classification and correct
dosage schedules. The core mothers and leaders are then responsible for sharing the messages with other members of the
community. The CHWs and community leaders are responsible for providing advice about treatment and referral, acting as
intermediaries between the health system and the community. Posters depicting the correct dosage of anti malarial by age
are placed in the villages and are given to core mothers, village leaders and CHWs. Health centre nurses are responsible for
supervision of the CHWs through monthly visits and reviewing the sales of packages. Referral is indicated for those patients
with convulsions or other neurological complications and for those who are febrile 48 hours after treatment.220, 245
In a study evaluating this program, it was found that 59% of those children treated with pre-packaged tablets received the
treatment over the recommended three days. The correct dosage packet for age was received by 52% of the children, with
31% under-dosed (given a packet for younger child) and 17% over-dosed (with packet for older child).
CHW Snapshot 14
Philippines- Barangay Health Workers
Program overview
The Barangay health workers or government trained health volunteers have been operating in rural villages in the Philippines
since 1981. Being a vital part of the health system these CHWs were operating in all parts of the country. Functioning within
the capacity of primary health care workers they epitomize health care as acceptable, affordable and accessible.266

These workers were recruited and selected and then adequately oriented to tackle malaria in community. They are female
residents of community. And receive training from health center personnel to promote and give initial care for common
ailments.
these workers are expected to deliver comprehensive care directed to common ailments prevailing in rural communities
and nutritional activities like weighing children under six, maternal and child health services, family planning and immuni-
zation. With more than a dozen of task need to be performed by these workers their roles has been questioned.

139
Table 11A: Tuberculosis Control Interventions – Characteristics of Included Studies
Shargie et RCT CHWs Health workers held monthly diagnostic In control communities, 12 months General population 159 and 221 cases of smear-positive TB were
al.2006251 outreach clinics at which they obtained cases were detected detected in the intervention and control groups,
Lemo & sputum samples for sputum micros- through passive case- respectively. Case-notification rates in all age
Hadiya, copy from symptomatic TB suspects. In finding among sympto- groups were 124.6/105 and 98.1/105 person-years,
Ethiopia addition, trained community promoters matic suspects reporting respectively (P = 0.12). The corresponding rates
distributed leaflets and discussed to health facilities in adults older than 14 years were 207/105 and
symptoms of TB during house visits and 158/105 person-years, respectively (P = 0.09). The
at popular gatherings. Symptomatic proportion of patients with >3 months’ symptom
individuals were encouraged to visit the duration was 41% in the intervention group
outreach team or a nearby health facility. compared with 63% in the control group (P<0.001).
Pre-treatment symptom duration in the intervention
group fell by 55–60% compared with 3–20% in
the control group. In the intervention and control
groups, 81% and 75%, respectively of patients
successfully completed treatment (P = 0.12).
Newell et cRCT CHWs In intervention arm Community DOTS in control arm, family 12 months all new > 15 years Community DOTS and family-member DOTS achie-
al.2006252 strategy was used in which drug taking member DOTS was used of age patients ved success rates of 85% and 89%, respectively (odds
Hills supervised daily by a female com- as a strategy in which with sputum ratio of success for community DOTS relative to fa-
districts munity health volunteer or a village drug taking supervised smear-positive mily-member DOTS, 0·67 [95% CI 0·41–1·10]; p=0·09).
of Nepal health worker with drugs provided daily by a household Estimated case-finding rates were 63% with the com-
to the supervisor every month. member selected by munity strategy and 44% with family-member DOTS.
the patient, with drugs
provided to the patient’s
supervisor every week.
Walley et RCT CHWs DOTS with direct observation self-administered 28 months adults with new Within the strengthened tuberculosis services, the
al.2001253, of treatment by health workers treatment sputum-positive health-worker DOTS, family-member DOTS, and
267 DOTS with direct observation of tuberculosis self administered treatment strategies gave very
Rawalpindi, treatment by family members similar outcomes, with cure rates of 64%, 55%, and
Pakistan 62%, respectively, and cure or treatment-completed
rates of 67%, 62%, and 65%, respectively.
Clarke et cRCT CHWs TB patients were issued with at Patients in control arm 12 months new smear-positive The successful treatment completion rate in adult
al.2005 264 most 1 month’s anti tuberculosis received TB DOTS from adult TB patients TB patients was 18.7% higher (P= 0.042, 95%CI
Western treatment. And patients were chose health facility where 0.9–36.4) in the intervention group than in the
Cape, South to receive DOT from the LHW they were issued with control group. Case finding for adult TB cases
Africa sufficient drugs for 1–4 was 8% higher (P = 0.2671) in the intervention
weeks, depending on group compared to the control group.
the distance they live.
Dudley et RCT CHWs In intervention arm, attendance of In control arm, self su- 16 months adult (> 15 years) All groups achieved similar outcomes (LHW vs.
al. 2003270 patients with TB was expected 5 days pervised patients visited with TB, who clinic nurse: risk difference 17.2%, 95% confidence
Cape Town, per week for the first 8 weeks for new the clinic once a week, started a course of interval [CI] 0.1–34.5; LHW vs. self Supervision 15%,
South Africa patients (12 weeks for re-treatment or sent a family member TB treatment (new 95%CI _3.7–33.6). New patients benefit from LHW
patients), followed by 3 days per to collect their drugs and retreatment) supervision (LHW vs. clinic nurse: risk difference
week for the continuation phase 24.2%, 95%CI 6–42.5, LHW vs. self supervision
39.1%, 95%CI 17.8–60.3) as do female patients
(LHW vs. clinic nurse 48.3%, 95%CI 22.8–73.8,
LHW vs. self supervision 32.6%, 95%CI 6.4–58.7)

Wright et RCT CHWs Community health worker super- Family member/carer 26 months Adults or children There was no significant difference in the cure
al.2004262 vision. Community health workers supervision. A family diagnosed with and completion rate between direct observation
Lubombo, acted as treatment supporters with member or carer was smear +ve or of treatment by CHWs and family members [2%
Swaziland the patient visiting every day for nominated by the –ve pulmo- difference (95% CI 3% to 7%), exact P ¼ 0.52]. A
direct observation of treatment patient to become the nary tuberculosis; before-and-after comparison of outcomes demons-
treatment supporter extrapulmonary trated that the cure and treatment completion rate
tuberculosis or re- improved from a baseline of 27–67% following
lapse of previously implementation of community-based DOTS.
treated tuberculosis
Kamohan- RCTl CHWs In the intervention group, TB patients In the control group, 14 months all tuberculosis ca- Cure and treatment-completion rates were
tanakul et were given the choice of selecting patients received drugs ses presenting with significantly higher in the DOT cohort (76% and
al.1999256 either health centre staff, community for 1 month of treatment sputum smears 84%) than in the control group (67% and 76%).
Thailand health volunteers or family members after diagnosis and after positive for acid-fast

as supervisors (health centre staff each follow up visit. No bacilli (AFB)
visited the patients’ homes: twice per treatment supervision
month during the initial 2 months was offered between
of treatment, and once per month follow-up visits.
during the remaining 4 months.
Chaisson et RCT CHWs Patients were assigned to receive Patients were assigned 16 months at least 18 years Adherence to isoniazid preventive therapy by
al. 2001 268 directly observed isoniazid pre- to receive daily self- old, used injection injection drug users is best with supervised care.
Baltimore, ventive therapy twice weekly with administered isoniazid drugs, had a Peer counseling improves adherence over routine
USA peer counseling and education. with routine care. positive tuberculin care, as measured by electronic monitoring of
skin test pill caps, and patients receiving peer counseling
more accurately reported their adherence.
Datiko & RCT CHWs We trained HEWs in the intervention no intervention 17 months patients with TB Two hundred and thirty smear-positive patients were
Lindtjorn kebeles on how to identify suspects, identified from the intervention and 88 patients from
2009 269 collect sputum, and provide the control kebeles. The mean case detection rate
Southern directly observed treatment. The was higher in the intervention than in the control
Ethiopia HEWs in the intervention kebeles kebeles (122.2% vs 69.4%, p,0.001). In addition, more
advised people with productive females patients were identified in the intervention
cough of 2 weeks or more duration kebeles (149.0 vs 91.6, p,0.001). The mean treatment
to attend the health posts. success rate was higher in the intervention than in
the control kebeles (89.3% vs 83.1%, p = 0.012) and
more for females patients (89.8% vs 81.3%, p = 0.05)
Niazi & Quasi RCT CHWs The intervention group were control group attended 10 months newly TB Cure rates for patients treated at home were
Al-Delaimi visited TB patients daily at the local health centre diagnosed significantly better than controls (83.7% versus 68.6%),
2003257 home for the 2-month initial for treatment patients so too was compliance (100.0% versus 14.0%). Smear
Baghdad, phase by trained members of conversion rates were significantly better in inter-
Iraq the Iraqi Women’s Federation vention cases compared with controls at all stages.
Menon et quasi- RCT CHWs TB control program via CHW No interventions 12 months Tuberculosis Data were collected for 2873 adult TB patients. For
al.1990231, was delivered in an area to control arm patients smear-positive TB patients, treatment cure rates
244 were higher in the intervention area (Guguletu)
Farafenni, than in the control area (Nyanga) (58% vs. 50%, P
Gambia = 0.0378) and for retreatment cases (47% vs. 35%,
P = 0.0791), treatment success rates were similar.
140
141
Chowdhury pre/post CHWs The community health workers distributed information about 84 months General population In the phase-two analysis, 3497 (90%) of 3886 cases
et al. 1997258 tuberculosis to the community, especially through village organiza- identified had accepted 12-month treatment. In
Rural tion meetings and posters. They also detected cases of pulmonary phase three, all of 1741 identified cases accepted
Bangladesh tuberculosis, & followed up individuals with chronic cough of 4 weeks’ the 8-month regimen. 2833 (81·0%) and 1496
duration or longer and collect two early-morning sputum samples. (85·9%) in phases two and three, respectively,
were cured; 336 (9·6%) and 133 (7·6%) died.
Adatu et al. pre/post CHWs As part of routine tuberculosis control programme operations, to 24 months Tuberculosis Following the implementation of CB-DOTS, treatment
2003271 measure the effectiveness and acceptability of community-based patients success among new smear-positive pulmonary TB
Kiboga, tuberculosis (TB) care using the directly observed treatment, cases increased from 56% to 74% (RR 1.3, 95%CI
Uganda short-course (DOTS) strategy for TB control. The implementation of 1.2–1.5, P < 0.001) and treatment interruption
the DOTS strategy with active participation of local communities in decreased from 23% to 1% (RR 16.5, 95%CI 6.1–44.7,
providing the option of treatment supervision in the community P < 0.001). There was no significant difference
is known in Uganda as community-based DOTS (CB-DOTS). in the proportion of deaths before and after the
implementation of CB-DOTS (15% vs. 14% for new
smear-positive pulmonary, and 38% vs. 29% for new
smear-negative and extra-pulmonary TB cases)
Islam et cross CHWs Since 1993, a national TB program has been implemented 12 months general adult In the BRAC area, each cured patient cost the
al.2002 260 sectional based on the WHO recommended DOTS strategy Both BRAC population health system US$ 52, while successfully treated
Rural study and national TB programs use the same treatment regimens (5), patients cost the system US$ 48 each. However,
Bangladesh (BRAC but BRAC mainly relies on the use of community health workers the total overall cost per patient cured was higher,
areas with (CHWs) to deliver directly observed therapy (DOT) while the at US$ 64 (Table 4). In the government area, the
Government government provides DOT mostly through health complexes equivalent figures were US$ 77, US$ 70, and US$
areas) 96, respectively. Treatment completion rate in
sputum-negative patients was 62.5% in the BRAC
area and 87.5% in the government area. The
overall treatment success rate was 83.3% in the
BRAC area and 82.7% in the government area.
Chowdhury compara- CHWs For the first decade of operation, the BRAC program relied on Between General TB Consistent cure rates of around 85% are testi-
1999259 tive cross a 12-month treatment regimen, but from 1995 an 8-month 1997 compa- population mony to the effectiveness of the BRAC program
Rural sectional short-course regimen was introduced. The CHW identifies red success and the DOTS approach the cure rates in 1992
Bangladesh study 12 people with chronic cough and sends samples of sputa to &failure was 81% while it increased to 90% in 1997
months a local BRAC laboratory for microscopy. The acid-fast-bacilli- rates of 1992
regimen positive cases are brought to treatment immediately. The CHW with 1997
vs. 8 provides the drugs, received free from the government.
months
Ravichan- cross CHWs BRAC trained their CHWs who then go into the - TB patients their detection rate is 30% and cure rate is about 95%
daran sectional grass root level and provide treatment to TB
2003261 survey patients through WHO DOTS strategy
Rural
Bangladesh

Drobac et Retros- CHWs CHWs performed drug sensitivity testing of the child’s 48 months Children under Forty-five percent of the children had malnutrition
al.2006263 pective tuberculosis isolate or suspected on the basis of the 15 years of age or anemia at the time of diagnosis, 29% had severe
Lima, Peru case series presence of clinical symptoms for a child with a household radiographic findings (defined as bilateral or cavitary
contact with documented multidrug-resistant Tuberculosis, disease), and 13% had extra pulmonary disease.
was performed and initiated a supervised individualized Forty-five percent of the children were hospitalized
treatment regimen for multidrug-resistant tuberculosis initially because of the severity of illness. Adverse
events were observed for 42% of the children, but no
events required suspension of therapy for _5 days.
Ninety-five percent of the children (36 of 38 children)
achieved cures or probable cures, 1 child (2.5%)
died, and 1 child (2.5%) defaulted from therapy
Mitnick et Retro- CHWs results of community based therapy for multidrug-re- 84 months TB population Among the 66 patients who completed four or
al.2003272, spective sistant tuberculosis in a poor section of Lima, Peru more months of therapy, 83 percent (55) were

273 cross probably cured at the completion of treatment. Five
Lima, Peru sectional of these 66 patients (8 percent) died while receiving
therapy. The predictors of the time to treatment
failure or death were a low hematocrit (hazard
ratio, 4.09; 95 percent confidence interval, 1.35 to
12.36) and a low body-mass index (hazard ratio,
3.23; 95 percent confidence interval, 0.90 to 11.53)
Phomorphub Cross CHWs this study compared the proportions of tuberculosis (TB) cases 48 months population with TB 55 (8%) were diagnosed of TB, including 44 (6%)
et al.2008265 sectional detected under a project launched in lower part of southern smear-positive cases. The proportions of smear-
Southern Thailand 1) by screener type [village health volunteer (VHV), positive cases among those screened by VHV, health
Thailand health center staff, and hospital staff ]; and 2) by region center and hospital staff were 6.7%, 3.4% and 12.9%;
respectively. The corresponding proportions for TB
cases were 8.4%, 5.1%, and 12.9%. The proportions
of smear-positive cases were 2.5%, 21.7%, and 14.6%
for those from the Region A, B and C, respectively.
Khan et al. cross CHWs The role of CHWs continues to grow as their responsibilities - CHWs The role of CHWs continues to grow as
2002274 sectional extend beyond care of the infected and affected and their responsibilities extend beyond care of
Rawalpindi, prevention education in the communities studied. the infected and affected and prevention
Gujranwala, education in the communities studied.
Sahiwal,
Pakistan
Floyd et al. cross CHWs To assess the cost and cost-effectiveness of new treatment stra- 2 months Tuberculosis For new smear-positive pulmonary patients, two stra-
2003275 sectional tegies for new pulmonary tuberculosis patients, introduced in patients tegies were compared: 1) the strategy used until the
Lilonwe, 1997. For new smear-positive pulmonary patients, two strategies end of October 1997, involving 2 months of hospita-
Malawi were compared: 1) the strategy used until the end of October lisation at the beginning of treatment, and 2) a new
1997, involving 2 months of hospitalization at the beginning decentralised strategy introduced in November 1997,
of treatment, and 2) a new decentralized strategy introduced in which patients were given the choice of in- or out-
in November 1997, in which patients were given the choice of patient care during the first 2 months of treatment.
in- or out-patient care during the first 2 months of treatment.
142
143
Zuvekas et Cross CHWs Alameda County Health Care for the Homeless Program operates an 12 months general homeless Read PPD results for 1740 persons (78%)
al.199821 sectional outreach program staffed by CHWs to carryout case-management population Referred 142 positive readings for X-ray
California, activities for homeless people of Alameda County, California (8.3%) Referred 125 PPD positive homeless
USA people for X-ray Read 44 TB positive tests (12%)
Successfully followed through on 33 TB cases
Cavalcante cross CHWs Patients were offered DOTs when they presented to out- 24 months TB population Of the 1811 TB patients, 1215 (67%) were treated
et sectional patient clinics for an initial diagnosis. DOT was provided under DOT; among these, 726 (60%) received
al.2007276 survey in the clinic or in the community, using CHWs clinic-based treatment and 489 (40%) community-
Rio de based treatment. Patients offered community-based
Janeiro, treatment were more likely to accept DOT (99%)
Brazil than those offered clinic-based treatment (60%, P
_ 0.001). Treatment success rates for new smear-
positive and retreatment TB cases were significantly
higher among those treated with community-based
DOT compared to clinic-based DOT.

Table 11B – Characteristics and Description of outreach workers
training
Shargie et Didactic training Held monthly diagnostic Treated
al.2006251 on case-finding, outreach clinics at which they symptomatic
CHWs diagnostic procedures, obtained sputum samples patients and
outreach coordination, for sputum microscopy from encouraged
handling of sputum symptomatic TB suspects. them to visit
specimens, interview Also trained community the outreach
techniques, and promoters distributed leaflets team or a
record-keeping. and discussed symptoms of nearby health
TB during house visits and facility.
at popular gatherings.

Newell et health worker the DOTS strategy, 6 days discussed tuberculosis, the Ensuring No Evaluated
al.2006252 from every the treatment process treatment process, roles and treatment incentives by success
CHWs DOTS centre and its duration, the responsibilities in successful completion of rate
role of community treatment, side-effects of TB Counseling
supervisors in ensuring drugs, and the importance of
tuberculosis treatment immediately seeking advice
completion, the side from the treatment facility if
effects of tuberculosis side-effects arose. Discussion
drugs, and the process was supported by flipcharts
of referring patients for and leaflets designed for
their management. each strategy. Reminders
were given on all subsequent
visits to the health facility.
Walley et hHealth Didactic Orientation direct observation of ensured com-
al.2001253, workers provided by DOTS treatment by health workers pliance with
267 supervisor the complete
treatment of TB
Clarke et Adult farm Didactic Training five 1-week Provided care as DOT, in Assuring TB
al.2005264 dwellers Training modules (25 h weekly) case of self-supervision treatment
Western selected included becoming training LHWs played a mentoring compliance
Cape, South suitable an LHW, tuberculosis, during the role, visiting the patient &
farm-dwelling family health (including off-peak encouraging and monitoring
Africa peers for season
HIV/acquired treatment adherence
CHWs training as immune-deficiency regularly. In all cases, LHWs
Lay Health syndrome [AIDS]), first addressed treatment non-
Workers aid, and home-based adherence promptly through
care. TB focus within a process of particularized
primary health care & motivation. LHWs were
community develo- in a unique position to
pment principles understand the TB patients’
life situations, & consider
individual patients’ problems.
144
145
Study Edu- Recruitment Training Duration Certification Refreshers Role key compe- Supervision Incentive coverage Evaluation
cation Criteria Content / Ongoing tencies (if any) mode
training
Zwarenstein Community Trained to interview TB Provided supervision to
et al.2000255 lay health patients on treatment patients taking drugs
CHWs workers for treatment of TB
Rural health Practicum and didactic Acted as treatment Monitored Outcome as-
motivators Clinic-based training supporters with the patient treatment sessment was
sessions were run on visiting every day for direct adherence undertaken
how to support and observation of treatment. and notified by laboratory
observe TB treatment, defaulters to examination
and recording adhe- the diagnos- of sputum by
rence on a Treatment tic centre. technician
Supporter card.
Kamohan- Community Didactic training To Visited the patients’ homes: Transport Evaluated by
tanakul et provide TB treatment twice per month during the available cure rate
al.1999256 under supervision initial 2 months of treatment,
CHWs and assure treatment and once per month during
compliance. the remaining 4 months.
Chaisson former they were taught to counseling were given and Professional
et al. 2001 injection counsel and provide monthly supply of isoniazid health
268 drug user drugs to patients. And 300 mg tablets were also educator
also to arrange monthly given. They also met with
support meetings the peer counselor twice
during the first month of
therapy and once a month
thereafter. Arrange monthly
support group meetings
Niazi & Trained Didactic training 2 days Provided DOTS treatment Evaluated by
Al-Delaimi members the problem of TB of TB to ascertain patient cure rates,
2003257 of the Iraqi in general and on compliance; gave health treatment
CHWs (F) Women’s the treatment of the education to the patient compliance
Federation disease and close and his/her family about
supervision of DOTS TB and its transmission.
Chowdhury Illiterate Selected DIDACTIC They were 15–30 days 1 day per Tb control and treatment Treatment of TB, supervised small profit 1 CHW
et al. from BRAC trained for detecting month of of some infectious diseases common fever, by BRAC from the per 200
1997258 organization. TB patients, followed in-service along with improvement acute respira- physicians sale of drugs households
CHWs (F) them and provide training of water and sanitation. tory infections and field staff 100takka/
them TB drugs. , diarrhea, completed
Immunization, regimen /
family planning, patient 25
deworming Taka /case

training
Islam et Illiterate Community Didactic observed new patients Developing Supervised 125 Takas The role of
al.2002 260 locals swallow the drugs during patient by BRAC CHWs was
Rural the first 2–3 months, while compliance to paramedics evaluated
Bangladesh patients undergoing retreat- TB treatment by cure and
ment were observed for the treatment
entire period. After the initial success
2–3 month period, patients of TB.
collected drugs once a week
from the home of the CHW
Chowdhury mostly Women who Didactic training CHW identifies people The acid- evaluated
1999259 unschoo- received on the treatment of with chronic cough and fast-bacilli- by
training common illnesses sends samples of sputa positive cases consistent

CHWs (F) led
from BRAC including tuberculosis to a local BRAC laboratory are brought cure rates.
for microscopy. The CHW to treatment
provides the drugs, received immediately.
free from the government.
Ravichan- Village health Trained to ope- Provide operational Supervised
daran workers rate under specific support for the program by area
2003261 technical guidelines implementation and would manager
CHWs also generate patient related
information and data
Drobac et community Didactic training Provided all doses received Close
al.2006263 health worker Trained to provide outside the health center monitoring
CHWs close monitoring hours. Twice-daily dosing was for treatment
to children with observed 6 days per week compliance
multi-drug resistant throughout the course of and improved
tuberculosis treatment, also monitored for cure rates.
adverse events on daily basis
Mitnick et community Didactic specially Supervised outpatient TB surveillance Supervised
al.2003272, health worker trained in outpatient treatment and provided sur- and treatment by nurses.
273 treatment & surveillance for adverse effects.
CHWs veillance for adverse
events related to multi
drug resistant TB
Phomorphub Village health Didactic and practicum Screened suspected
et al.2008265 workers training topics included cases of tuberculosis and
CHWs general knowledge about TB followed up positive cases.
(cause, infectivity, symptoms,
transmission, treatment, &
prevention), roles of DOT
observer, anti- TB drugs, and
methods of self-protection.
Trained to screen people with
suspected TB symptoms
146
147
training
Cavalcante et Selected Didactic underwent Provided health services Improve the Supervised
al.2007276 through a training program &health education through care of TB by two
CHWs a written designed to teach home-based outreach and patients by nurses and an
test and them how to follow-up in the communities administrator
interviews. provide TB care in the they serve. Mainly involved
community, focusing in health promotion and
on TB control and education, immunization,
DOT administration. improvement of water & sa-
nitation, and family planning.

HIV/AIDS Prevention and
control Interventions
Background
HIV/AIDS alone has taken more than 20 million in nature44, 280-286, 288, 290, 292 except for the
lives, roughly 500,000 children younger than 15 Sanjana et al. where the training was based on
years died of the disease in 2008, and children theory and practicum, related to concepts and
accounted for 13% of new infections in 2004 methods of HIV counseling and testing and
(640,000 cases).277 Women accounted for nearly then testing of skills under supervision of an
50% of more than 37 million people living with experienced counseling and testing (CT) pro-
HIV worldwide and for 60 % in sub-Saharan vider.291 Certificate of completion of training
Africa. The HIV and AIDS pandemic threaten the was provided to these peer counselors.291 The
progress of many of the other MDGs, as it has TBAs in Wanyu et al. and Perez et al. were given
severe health consequence for individuals, fa- additional training on Prevention of Mother to
milies, and communities. At the same time HIV Child Transfer (PMTCT).288, 289 In Wanyu et al.
and AIDS slower the nation growth and act to 99% of the women were tested for HIV and 88%
damage social capital and lower GDP growth. In of the mothers and 86% of newborns were trea-
some studies annual reductions of GDP growth ted with single dose of medicine.288 In another
of about 2-4% have been noted in the countries study CHWs were trained to administer medi-
highly affected by HIV.278 cations to patients in their homes as DOTS and
also counsel the patient and contacts on stigma
In resource-limited settings, the CHW approach related to HIV and TB286 while in Zachariah et
has regained credibility in the last few years al. the CHWs were trained to counsel HIV/ AIDS
through its support of HIV/AIDS care, in par- patients for adherence to anti-retroviral therapy
ticular voluntary testing and counseling and (ART), anti-TB treatment and home-based care
treatment adherence support for people on HIV activities.44, 281 In Koenig et al. patients were also
and TB treatment.279 These emerging issues of provided with emotional support as a rehabili-
multi-drug resistant TB and HIV make commu- tative measure, apart from administering DOT-
nity health education and treatment adherence HAART.281 The CHWs in Ross et al. were trained
support imperative. Therefore, in this section we in the social marketing of condoms280 while
have assessed the role of community based in- those in Nasreen et al. worked for creating mass
tervention and the quality of CHWs in providing awareness of HIV/AIDS in the community.284 In
these interventions through evidence based Sox et al. and Mock et al. CHWs performed Pap
researches from all parts of the world. Smear in the community for STI detection.282,
283 The CHWs, TBAs and the PCs all promoted
Community Based Evidence preventive strategies280, 284, 290 against HIV and
counseled for treatment adherence in the pre-
We identified 17 studies which portrayed the sence of disease.44, 286 The role of TBAs studied
role of CHWs in the prevention and control of in a cross-sectional survey reported that they
HIV and STIs (Table 12A & 12B). The types of provided obstetric care to HIV positive pregnant
health workers involved in these studies were women and HIV exposed newborn287 while in
CHWs,44, 280-286 TBAs287-289 and PCs.280, 290- another study their level of awareness on princi-
292 Those recruited in these studies were either
ples of PMTCT of HIV were tested.289 The female
health workers, 280, 286 community educa- sex workers enrolled as PCs in Benezaken et al.
tors,290 volunteers44, 291 especially those with gathered data on the number of condoms sold
some background training in HIV/AIDS291 or weekly with detailed mapping of the “prosti-
female sex workers.292 tution spots” in town, carried out preventive
education assessment with 100 clients about
The training imparted to them was didactic ‘prostitution as work’, their motivation to seek

Conclusion
female sex workers, child prostitution and their The CHWs, TBAs and PCs proved to be an im-
views on the project.292 In this study, the results portant tool for the dissemination of awareness
of pre/post questionnaires show that there was related to HIV/AIDS. Their contributions can be
a significant change in behavior after awareness estimated from the increasing number of mo-
of HIV prevention methods, i.e., 95% from pre- thers and newborns getting medications and
viously 75% of the clients had changed their from the change in sexual behavior resulting
sexual behavior to prevent STIs/AIDS.292 from prevention awareness on STIs and HIV/
AIDS.
CHW Snapshot 15
Indonesia Community Health Workers
Program overview
Indonesia developed a framework in 1976 and started training and deploying community health workers with the title
KADER in West Java, Indonesia as a pilot project. In kader method trainer train trainee in exactly same manner as they were
trained by their trainer. By 1977 it was clear that kader should become an official component of Indonesian rural health
system.293

They are trained on role playing using counseling cards to practice Community health Workers, Indonesia
counseling or teaching precisely as trained village health promoter.
Education Compulsory education
These counseling cards include diagnostic algorithms and treatment
Training few days
methods. One kader usually worked with 10-15 households and the
training lasted for few days to few weeks. Their task involved treat- Refresher periodic
ment of number of common illnesses, weighing of children under Incentive none
5 years of age, nutrition, family planning and health education in-
cluding environmental hygiene and sanitation, and development of community health insurance scheme and referrals of
serious cases. 78

the survey in 1978 revealed that coverage of kader in Indonesia was up to 85% and 91% of the population had used kader
for illness care during previous 18 months and 87% reported hat they had visited their home in last 18 months.78, 293

Table 12A: HIV/AIDS Prevention and Control Interventions – Characteristics of Included Studies
Ross et cRCT CHWs The intervention had four components: No intervention in 46 months Adolescents. Only five HIV sero conversions occurred in boys,
al.2007 280 community activities; teacher led, control areas Aged > 14 years whereas in girls the adjusted rate ratio (intervention
Mwanza, peer-assisted sexual health education in versus comparison) was 0.75 [95% confidence
Tanzania years 5–7 of primary school; training and interval (CI) 0.34, 1.66]. Overall HSV2 prevalence at
Supervision of health workers to provide follow-up were 11.9% in male and 21.1% in female
‘youth-friendly’ sexual health services; participants, with adjusted prevalence ratios of 0.92
and Peer condom social marketing. (CI 0.69, 1.22) and 1.05 (CI 0.83, 1.32), respectively
Mitchell et RCT CHWs Arm 1: received information, education Routine government 24 months General adult Knowledge regarding AIDS was in-
al.2002 290 and communication comprising health services prevailed population creased in intervention arms.
Rural drama and video shows that includes in addition to com-
Uganda lessons on condom use, HIV testing, munity development
how HIV spreads and STD treatment and home-based care

seeking behavior Arm B: received initiated by the program
the same information, education
and communication combined
with improved STD management
Mock et RCT CHWs lay health worker outreach media-based 30 months Women Testing increased among women in both the
al.2006 283 plus media based education education only combined intervention (65.8% to 81.8%; P<.001)
Santa Clara, (combined intervention) and media-only (70.1% to 75.5%; P<.001) groups,
USA but significantly more in the combined intervention
group (P=.001). Significantly more women in the
combined intervention group obtained their first
Pap test or obtained one after an interval of more
than 1 year (became up-to date; 45.7% to 67.3%,
respectively; P<.001) than did those in the media-
only group (50.9% to 55.7%, respectively; P=.035)
Zachariah et Quasi RCT CHWs Community in intervention arm Community in control 20 months HIV positive patients For all patients placed on ART with and without
al.2007 44 received community support from arm did not receive community support, those who were alive and
Thyolo, community health workers community support continuing ART were 96 and 76%, respectively
Malawi (P < 0.001); death was 3.5 and 15.5% (P< 0.001)
The relative risks (with 95% CI) for alive and on
ART 1.26 (1.21—1.32), death 0.22 (0.15—0.33)
Sox et Quasi RCT CHWs CHWs were trained for risk assessment, Control arm did not 12 months Women at any age Overall, the mean proportion of women in the
al.1999282 history taking, patient education, in receive additional participating villages who had a Pap test increased
Alaska, USA breast examination, Pap tests, and services from CHWs from 0.44 at baseline to 0.48 at follow-up. During the
sexually transmitted disease tests same periods, the mean proportions in the compa-
rison villages decreased from 0.42 to 0.39 (p= 0.37).
Benzaken et pre/post PCs PCs were trained to promote the use of condoms, infor- 72 months high risk population Have you changed you sexual behavior to
al.2007 292 ming female sex workers and their clients about STD/ (sex workers) prevent STD/AIDS? 111 75.0 132 94.7 < 0.001
Amazon, AIDS. Peer educators have also resold condoms at low cost Have you had an anti-HIV test done yet? 29
Brazil and referred sex workers with suspected STD to special 19.6 64 46.0 < 0.001 Did you use condoms
outpatient clinics for medical consultation at the project last week? 62 41.9 107 78.0 < 0.001
headquarters, and to weekly supervised activities.
150
151
Wouters et Prospective CHWs Patients are requested to identify a ‘treatment buddy’, usually 36 months Patients with HIV After 24 months of ART, 76.4% of patients were
al. 2009 294 Cohort someone living in their household, who is aware of the patient’s classified as t treatment successes, compared with
Free state, status and who is willing to assist him/her with adherence issues. 64.1% at 12 months and 46.1% at six months. When
South The treatment buddy attends education sessions, signs the we examined the predictors of ART success, baseline
Africa consent to begin ART together with the patient, and reminds health and all three community support initiatives
and supports. the patient once ART has commenced. Patient had a positive effect on ART outcomes after six
mobilization and empowerment also include the support of months, whereas patient characteristics had little
an AIDS patient by fellow PLWHA. Peer-support groups, which effect. Six months later, patients with the support
are generally not exclusively for patients on ART, facilitate the of a treatment buddy, CHW, or support group
discussion of factors that may enhance or impede adherence, had better ART outcomes, whereas the impact of
such as adverse events, disclosure, and other psychosocial issues, baseline health had diminished. After two years of
and also act as forums for health promotion and education. treatment, community support again emerged as
the most important predictor of treatment success.
Nasreen cross CHWs The community-based HIV/AIDS education program was initiated 3 months adults and Of the total 4,055, about 99% (4,023) had heard
2005 284 sectional in 2002 to increase awareness of HIV/AIDS among community adolescents, about HIV. A significantly (P < 0.001) higher
Distrcits evaluation people. Five components include 1) mass awareness of HIV/ internal migrants, proportion of respondents (about 51%) said that
(Khulna, study AIDS in the community including couple education, 2) awareness drug-users and bro- if anyone infected with HIV, then he/she should
Madaripur, raising among adolescents in secondary schools as well as in thel-based CSWs not continue the occupational activities with the
the community, 3) preventing HIV and AIDS among the high-risk others. Majority of AIDS-aware population got
Jamalpur,
populations comprising brothel-based CSWs and drug-users, information from TV (72%) followed by BRAC (52%).
and Faridpur) 4) preventing HIV among internal migrants, such as transport CSWs mentioned BRAC (94%) followed by other
Bangladesh workers, and 5) supporting to the people living with HIV/AIDS NGOs (68%) as the main source of information
Walton et retros- CHWs Diagnoses of tuberculosis, HIV infection, and sexually transmitted 14 months general population Within a year, over 120 patients were receiving super-
al.2004 285 pective infections; the number of prenatal visits; and detailed encounter vised therapy with ARVs. More than 200 tuberculosis
Haiti observatio- reporting by service (pediatrics, women’s health, etc.) patients were identified and began receiving DOTS.
nal study
Sanjana et cross PCs Quantitative and qualitative data were collected by means of 1 months lay counselors Lay counselors provide up to 70% of counseling
al.2009 291 sectional semi structured interviews from all active lay counselors in each and testing services at health facilities. The
Zambia survey of the facilities and a facility manager or counseling supervisor data review revealed lower error rates for lay
overseeing counseling and testing services and clients. counselors, compared to health care workers, in
completing the counseling and testing registers.
Mukherjee Cross CHWs The model depends on community health workers 12 months General population HIV service utilization increased from 20 to 400
& Eustache sectional (CHWs) who supervise antiretroviral therapy (ART) and after the implementation of HIV- PHC model
2007 286 provide community outreach, including active case
Maitha, finding and outreach to marginalized populations
Haiti
Pelzer et Cross TBAs Information on the last delivery, contacts/relationship - postnatal care 31% of TBAs gave advice HIV and AIDS 31%
al.2009 287 sectional with TBAs, THP, HIV and AIDS, antenatal care, obste- clients with a child check baby 7% gave family planning
Cape Town, survey tric care, post-partum care, and counseling on safe less than 12 months
South infant feeding for HIV exposed newborn babies.
Africa

Kumar et al. cross CHWs The outreach workers recruit IDUs from No intervention in 18 months HIV patients Significant decline in injecting risk behavior was
1998295 sectional the street and provide various interven- control areas noted at 18-month follow-up from baseline for
Madras, tions at the street level. Apart from the the IDUs recruited from outreach locations.
India face-to-face education about acquired
immunodeficiency syndrome (AIDS)
and its transmission, these individuals
are provided with information on
decontamination of syringes. Bleach and
condoms are distributed by the outreach
team. Advice on medical and social pro-
blems and service information also are
provided, and outreach workers facilitate
the use of addiction treatment services.

Johnson cross CHWs hundreds of lay individuals have been trained as com- CHWs The role of CHWs continues to grow as
& Khanna sectional munity health workers to provide home-based care their responsibilities extend beyond care of
2004 296 to sick or dying HIV/AIDS clients in rural areas. the infected and affected and prevention
Nyanza, education in the communities studied.
Kenya
Wanyu et cross TBAs In 2002 TBAs were trained to provide prevention to mother to child 36 months pregnant pregnant 99% of all women were tested for HIV. 88% of women
al.2007 288 sectional HIV transmission services, including counseling, testing, performing mothers and 86% of newborn were treated with
rural study oral rapid HIV tests, and administration of single-dose Nevirapine single dose of medicine.
Cameroon, to HIV positive women, to be taken in labor & to their newborn.
Africa
Perez et Compa- TBAs Trained TBAs are defined as those who have received a short- 3 months pregnant women 45% of TBAs interviewed knew the principles of
al.2008 289 rative cross course of training through the modern health care sector to PMTCT and 8% delivered a woman with known
Mashonaland sectional upgrade their skills [35] and were in possession of a badge or HIV-positive status in previous year. Women
East, trained certificate which has been issued on completion of her training. who delivered at home were less likely to have
TBA vs. The criterion for recruitment of an untrained TBA was that she received more than one ANC service or have
Zimbabwe Untrained
should have delivered a woman not more than a year ago had contact with a health centre compared to
TBAs before the date of the survey and was not formally trained. women who delivered in a health centre (91.0% vs.
72.6%; P < 0.001). Also, 63.6% of the women who
delivered in a health centre had the opportunity
to choose the place of delivery compared to 39.4%
of women who delivered at home (P < 0.001).
Koenig et al. descriptive CHWs HAART was provided in the context of a comprehensive program 1 year after general population In the first year of program scale-up, over 8000
2004 281 of HIV, tuberculosis (TB), sexually transmitted disease (STD) of the scale up patients were followed for HIV, and over 1050 were
Haiti project, treatment and prevention, and women’s health services treated with DOT HAART. Adherence to HAART was
at four sites in the first year. At each site, the medical facility was very high, and clinical outcomes were excellent:
renovated, additional staff were hired as needed, and a network all patients responded with weight gain and
of accompagnateurs (community health workers) was established improved functional capacity, and fewer than 5%
throughout the surrounding villages to serve as a link with the required medication changes due to side effects.
community, and to provide directly observed treatment (DOT) Viral load was tested among a subset of patients
showing that 86% had undetectable viral loads
152
153
training
Ross et Four to five trained in the social Community mobilization community- The
al.2007 280 youth per marketing of condoms. followed by annual youth based condom impact was
PCs village were health weeks focused around promotion evaluated
elected by interschool competitions in a cohort
their peers and performances by local of 9645
Two to The provision of family 1 week youth groups, twice-yearly supervised adolescents.
CHWs four health planning services youth health days at health quarterly
workers per and improved case facilities, and quarterly video
government management of STI, shows linked to discussions
facility and also in the provi- that were open to all
sion of youth friendly community members.
sexual health services.
Mitchell et Community Didactic training Provided information, Inculcated HIV Evaluated
al.2002 290 educators Trained in giving education & communication and STD treat- by house
PCs lessons on condom comprising drama and video ment seeking to house
use, HIV- general shows that includes lessons behavior in the KAP &
information and on condom use, HIV testing, community serological
testing, HIV spread and how HIV spreads and STD surveys
STD treatment in local treatment seeking behavior
language Luganda.
Zachariah et Community formal theoretical 2weeks Made house-to-house visits PHC services Supervised Incentives
al.2007 44 volunteers training The curriculum equipped with a ‘home-based and HIV by a included
CHWs covered various care kit’ containing basic drugs counseling community rainboots,
aspects linked to & supportive material for condi- nurse. rain coats,
HIV/AIDS, adherence tions including diarrhea, fever, seed grain,
counseling for ART, common skin conditions & oral fertilizer
anti-TB treatment thrush. Detected ‘risk signs’ that for farms,
and home-based merit referral to a community &bicycles.
care (HBC) activities nurse or a health facility
Nasreen Didactic, used flip Mass awareness of HIV/ AIDS Creating
2005 284 charts and videos. in the community including awareness and
CHWs Correct knowledge re- couple education, adolescents counseling
garding HIV/AIDS, STI. in secondary schools as well as of HIV
in the community, preventing
HIV and AIDS among the high-
risk populations comprising
brothel-based CSWs and
drug-users, preventing HIV
among internal migrants,
such as transport workers,
and supporting to the people
living with HIV/ AIDS

training
Walton et Didactic training on Diagnoses of tuberculosis, quality AIDS
al.2004 285 side-effect manage- HIV infection, and sexually care and treat-
CHWs ment o and referral transmitted infections; the ment of STIs,
number of prenatal visits; TB treatment
and detailed encounter
reporting by servic
Sanjana et Literate selected Theory and Practicum 2 weeks Certificate provided pre and post-test Supervised CT record
al.2009 291 among classroom component theory and provided on HIV counseling as well by an keeping was
Zambia volunteers of the training 4weeks successful as HIV testing experienced evaluated as
preference includes instruction practicum completion CT provider. a qua-
was given to as well as role-plays of both lity assurance
PCs those with theoretical measure.
& case studies for
some level of better understanding and practical
background of the concepts training

training in and methods of
HIV/AIDS. HIV counseling and
testing. Practicum
included counseling
&testing skills under
the supervision of
an experienced
CT provider.
Mukherjee Community Didactic Training Supervised antiretroviral Critical inter- nurse data
& Eustache outreach trained to administer therapy (ART) and provided face between supervisor maintained
2007 286 workers medications to community outreach, patient, by TBAs were
CHWs patients in their homes including active case community cross checked
as (DOTS); provide finding and outreach to and the CBS. by health
prevention education marginalized populations. facility staff
to communities, to
minimize stigma &
to refer to the clinic
possible HIV and TB
contacts or those at
risk for infection.
Pelzer et recruited from Not trained in this Obstetric care
al.2009 287 existing lists study rather their of HIV posi-
TBAs of the traditio- attitudes towards tive pregnant
nal health HIV and care of HIV woman and
practitioner positive mother and HIV exposed
office newborn were studied. newborn
Wanyu et existed TBAs Didactic training they provided HIV counseling, HIV counseling nurse data
al.2007 288 in community additional training performed rapid oral fluid , testing and supervisor maintained
TBAs (F) was selected was given on HIV antibody test, and administration by TBAs were
PMTCT and HIV administered Nevirapine of drugs cross checked
to the mother and baby, by health
facility staff
154
155
training
Perez et Above 18 Tested on knowledge, attitude Awareness of
al.2008 289 years of age and practice with regards to principles of
TBAs (F) HIV/AIDS especially in regard PMTCT of HIV
to pregnant women and
the HIV exposed newborn
Mock et Trained for procedures 2 sessions, 3 the LHWs used the flip chart Vietnamese $1500
al.2006 283 and approaches to LHW hours each to give a 15- to 20-minute woman as
CHWs (F) outreach LHWs received presentation about cervical coordinator
Vietnamese-language cancer and Pap testing
flip charts and booklets and distributed booklets,
to use in their outreach reminder cards, posters,
to explain the causes of & reminder calendars
cervical cancer and the
Pap testing procedure.
Wouters et Person from Community support for ART HIV/TB worker
al. 2009 294 patient patients in the public sector
household represents a continuum that
stretches from more formalized
(even paid) community health
workers (CHWs) to informal
activities, including voluntary
support groups for people living
with HIV/AIDS (PLWHA) or
members of their social
networks who volunteer to act
as ARV treatment buddies. The
roles of these initiatives have
broadened with time, but are
generally oriented towards the
care and support of PLWHA,
rather than AIDS prevention
or the promotion of health
Sox et Didactic, practicum and 22 hrs Breast examination, Pap Preventive
al.1999282 field work. instruction on didactic smears and other STD tests, health
CHWs risk assessment, history Instructions, education and
taking, patient education, 16 hrs early detection
&indicated follow-up; 16 practical, 16 of Breast and
hours of skills acquisition hrs of field cervical cancer.
in breast examination, supervision
Pap tests, and STI tests in
the hospital outpatient
department; and up
to 16 hours of field
supervision in their
respective village clinics
within 1month of training

training
Benzaken et higher Didactic Female data gathering on the HIV
al.2007 292 level of sex workers, ease number of condoms sold counseling
education on communicative weekly, detailed mapping of
PCs (F) abilities and interest “prostitution spots” in town,
in the prevention preventive education asses-
planning practices sment interviews with 100
among the other sex clients (convenience sample)
workers of the town about “prostitution as work”,
and their clients their motivation to seek female
sex workers, child prostitution,
and their views on the project
Johnson A number of the CHWs 1-2 weeks
& Khanna recruited for the HIV!AIDS training
2004 296 Home-Based Care

program have previously
been CHWs with other
organizations, such
as Association for the
Formation and Support
of Development (AFAD)
and CARE Kenya-
organizations that work
with environmental
sanitation, educate com-
munities about proper
sanitation, and help to
prevent and treat diseases
(such as measles, cholera,
and eye infections). In
home-based care training
sessions, the CHWs learn
a variety of information
about HIV/AIDS, methods
of prevention, and care
and management of
the sick and dying.
Koenig et selected from Didactic trained During the daily visits, the
al. 2004 281 community concerning the impor- accompagnateurs ob-
for from the tance of confidentiality serve the patients taking their
health staff & emotional Support medications, and they then
for the patients. Also either leave the second dose
training regarding the of medication or return later
clinical presentation & to deliver that dose as well.
management of HIV &
TB, including the pro-
per use of medications
& their side-effects
156
Mental health Interventions
Background
The MDGs practically define health efforts in the Lester et al., were psychology graduates.301 The
21st century, but they apparently ignore non- training content was mostly didactic,140, 298,
communicable diseases such as mental health. 300 while the modality was didactic and practi-
In developing countries, conditions related to cum in Lester et al.2007301 and the one used in
mental health rank the top among all as physical Barnet et al. was didactic and interactive, using
health also relies on mental fitness of individual. role-plays, play activities and social and cultural
Mental health alone is the most important cause outings in the community.299 The disaggrega-
of sickness, disability and premature mortality ted analysis showed training with didactic and
and it contributes to the increased chances of interactive mode had an impact on the outco-
reducing the incidence of mother breastfee- mes of mental health299 as compared to those
ding their children and decreased likelihood where the mode of training was only didactic.
of seeking out care for physical illnesses.297
Although mental health has not been given its In most of these studies CHWs were trained
due significance in chalking out the Millennium on content related to neonatal behavioral
Development Goals, but it has clear implications assessment,298 psychological counseling for
in achieving targets like eradication of extreme depressed mothers,300 parenting behavior140,
poverty and hunger, reduction of mortality in 299, 300 and mental health counseling skills.301
children and improvement of maternal health. Some of them provided individual as well as
family counseling.299 In this way they played
The complete absence of mental health from an important role to prevent mothers from
the MDGs reinforces the position that mental depression which would eventually affect both
health has little role to play in major health the maternal and child healthcare promoting
development agendas. In this review we have psychosocial development of children.298
particularly included studies that have delivered
mental health interventions to understand the They also provided rehabilitative support to the
role of outreach worker in community mental already depressed mothers300 and to the peo-
and psychosocial health. ple with common mental health problems.301
Training of CHWs for mental health counseling
Community Based Evidence was meant to develop their core competency
in psychological counseling,140, 298, 300 howe-
We found paucity of studies which have applied ver, Morrell et al. study mentioned that their
mental health interventions in the community; CHWs were awarded with national vocational
therefore we merged studies specifically focused qualification at the end of their training140 but
on mental health of the community along with even that extensive training failed to create an
those that promoted parent child interaction impact on improving mental health outcomes
and bonding. We found 8 RCTs, 1 quasi-RCT and at six weeks of intervention.
two cross sectional studies in the section (Table
13A & 13B). Supervision of the CHWs was done by the com-
munity non-profit organization in Barnet et al. 299
The community health workers involved in the however in Lester et al. CHWs attended 1 hour
interventions of mental health were mostly of individual clinic supervision every week from
residents of the local village298, 299 however, a psychologist and also had ongoing training
non-residents were also involved in an interven- on a daily basis.301 This ongoing training was
tion by Rehman et al.300 These CHWs had a few conducted by the support groups as in service
years of schooling298, 300 while those trained in curriculum refreshers for the CHWs in Barnet et

al. 299 When level of supervision and provision by re-interviewing the mother,298, 300 some
of refresher in Barnet et al. was compared with mothers were issued questionnaires at 6 weeks
other studies (in which proper supervision and and 6 months postnatal.140 The CHWs in Lester
refresher training was missing), it was found that et al. intervention were evaluated from patient
it had a significant impact on improving paren- primary care records.301 However none of these
ting behavior, however no improvement was evaluations made a reinforcing impact on the
seen in parenting stress or mental health.299 outcomes of mental health interventions.
Most of the CHWs worked as volunteers in the

interventions reviewed,301 however the ones
who participated in Barnet et al. were paid $200
per year and this showed a positive impact on
the mental health outcomes in the community.
Several methods were used to evaluate the

performance of the CHWs working under the
domain of mental health. Some were evaluated
CHW Snapshot 16
Home Based Care Services – Tanzania
Program overview
Home based care model came into existence in Tanzania as a result of pilot project implemented during 2005/2007 in
57 communities. The prime aim of this program is to identify practical solutions to specific problem that older carer face.
The model is a community based approach to support older care givers and is based on components to collect baseline
information, training of old carer for home based care, initiating support groups for home based care, peer counselor, and
for self advocacy, and linking them to support services 302.
Home based carer was selected based on their willingness to work
Home Based Carer, Tanzania
and participate in community activities and who is acceptable to
community. The main component which is focused during selection Education basic level of literacy
is that they should have a previous experience of caring to sick child Training 21 days
and have good interpersonal skills and ability to provide feedback
and reports. They are trained on the national AIDS control program curriculum for training community home-based care
services providers as antiretroviral and DOTS. They were trained on general awareness about HIV/ AIDS, parenting skills ge-
neral hygiene and sanitation, communication and negotiation skills, psychological support skills, reducing pain, nutritional
needs and counseling skills, and proper and timely referrals.

Conclusion
The impact of mental health in the develop-
ment of a society cannot be underestimated.
It is essential especially for the maternal and
newborn healthcare and adequate growth of
the children. The interventions reviewed in this
regard have shown that the training modality
especially those trained in classroom teaching
along with interactive sessions had a positive
impact on their results.299 Also external evalua-
tion, financial incentives and regular refresher
training sessions for the CHWs can help achieve
desired health objectives.299, 301
CHW Snapshot 17
Nicaragua Brigadistas
Program overview
In 1981, Nicaraguan ministry of health began training community health workers called as brigadista de salud, or health
brigadier. They trained two types of workers one called as “jornada brigadistas” who were recruited to provide manpower for
the national health campaigns and the second group was called “primary health care brigadister” and they perform variety
of curative and preventive tasks 303.
these workers are typically chosen from community in which they Nicaragua Brigadistas
work and given a modest amount of training and perform variety of
preventive, promotive and sometimes curative tasks and are ultima- Training few days
tely accountable for community. Some workers works full time while Supervision nurse auxiliary
other work as part timer. Incentive paid

in 1983, jornada workers found in all 97 health areas while PHC workers were found in 33 of 97 health areas.

Table 13A: Mental health Interventions – Characteristics of Included studies
Rahman et cRCT CHWs In the intervention group, primary In the control group 24 months Married women At 6 months, 97 (23%) of 418 and 211 (53%) of 400
al.2008300 health workers were trained to deliver untrained health (aged 16–45 years) mothers in the intervention and control groups,
Gujar Khan the psychological intervention. The workers made an equal in their 3rd trimester respectively, met the criteria for major depression
& Kallar intervention consisted of a session number of visits to the with perinatal (adjusted odds ratio (OR) 0·22, 95% CI 0·14 to
Syedan, every week for 4 weeks in the last depressed mothers depression 0·36, p<0·0001) The differences in weight-for-age
Pakistan month of pregnancy, three sessions and height-for-age Z scores for infants in the
in the first postnatal month, and two groups were not significant at 6 months
nine 1-monthly sessions thereafter (−0·83 vs. −0·86, p=0·7 and −2·03 vs. −2·16, p=0·3,
respectively) or 12 months (−0·64 vs. −0·8, p=0·3
and −1·10 vs. −1·36, p=0·07, respectively).
Morrell et RCT CHWs Up to 10 home visits in the first Routine service provided women aged >17 At six weeks there was no significant improvement
postnatal month of up to three to control arm years delivered in health status among the women in the interven-

al.2000140
Netherlands hours duration by a community a live baby tion group. The women in the intervention group
postnatal support worker. were very satisfied with the support worker visits.
Lester et cRCT CHWs in intervention areas patients were No intervention for 35 months 18 to 65 years Patients in intervention practices had a higher mean
al.2007 301 provided with anxiety management for control group of age with a level of general satisfaction than those in control
Birmingham, people with common mental health diagnosis of a practices (difference between group scores of 8.3,
England problems, information, assessment, new or ongoing 95% confidence interval = 1.3 to 15.3, P = 0.023).
screening if required onward referral common mental The two groups did not differ in mental health
to the voluntary sector and support for health problem symptom scores or use of the voluntary sector.
self-help, and mental health promotion.
Cooper et Quasi RCT CHWs Interventions were delivered in women’s Women in control area 6 months Postpartum There was no impact of intervention on
al.2002298 home and each session lasted for an hour. were not visited by CHWs mothers maternal mood
Khayelitsha, In interventions they tried to improve the
South Africa psychosocial development of children
Barnett et iRCT CHWs Volunteers were recruited from the Women in control area 42 months Adolescents aged the home visitation group demonstrated signifi-
al.2002299 community and trained to implement were not visited by CHWs 12-18 years at > cantly better parenting behavior scores at follow- up
Baltimore, a parenting curriculum during 28wks gestation or than did the control group (P=.01) but showed no
USA weekly home visits. Each volunteer who had delivered differences in parenting stress or mental health.
was paired with one teenager. a baby in the
past 6 months
Bugental et RCT CHWs Home visitors that served as facili- Control group did not 24 Families at Lower levels of harsh parenting were found
al. 2002 304 tators, assisting parents in making receive interventions moderate risk among mothers in he enhanced home visitation
California, a causal appraisal of the possible of Child abuse, condition than among those in the unenhanced
USA reasons for an identified care giving expecting the birth home visitation or control conditions. Prevalence of
problem and in designing a strategic of a child or having physical abuse (percentage of mothers who were
plan for the future. Conducted recently given abusive) during the first year was 26% in the control
20 home visits in one year birth to a child. condition, 23% in the unenhanced home visitation
condition, and 4% in the enhanced home visitation
condition. Benefits were greatest in families that
included a medically at-risk child. A linear pattern of
benefits was found for child health; as program fea-
tures were added, benefits for child health increased
160
161
Bullock et RCT CHWs Women in the intervention group Control group did not 8.5 women recruited The intervention and control groups did not
al. 1995 305 received weekly telephone calls receive interventions from an antenatal differ significantly on the psychosocial measures at
New throughout their pregnancy. All clinic and general baseline. Comparisons at 34 weeks were made by
Zeeland women were interviewed initially and practice surgeries analysis of covariance using the baseline scores. The
at 34 weeks gestation. 8 check-off who were < 20 intervention group at 34 weeks had lower stress
questions to be asked weekly. weeks gestation scores than the control group (means 16.5 vs 18.4, p =
Referred women to health care & either single or 0.02), lower trait anxiety (means 35.2 vs 39.4, p = 0.04)
provider if there was medical problem in a relationship and less depressed mood (means 6.6 vs 8.1, p = 0.02).
and encouraged women to seek where the partner Self esteem was higher for the intervention group
assistance from community agencies. was unemployed (means 34.9 vs 32.5, p = 0.008). The intervention
failed to alter smoking but the intervention women
did report more use of community resources (p =
0.02) and were less likely to skip meals (p = 0.03)
Duggan et RCT CHWs Home visits were guided by an indivi- Control group did not 36 months Families at risk There was no significant overall program effect on
al. 2004 dual family support plan(family goals receive interventions for child abuse any risk or on at-risk mothers’ desire for and use of
Hawaii, USA and steps to achieve them). Supervisor and neglect community services to address risks. There was a
and home visitor identify key issues significant reduction in one measure of poor mental
by examining the family’s stress health at one agency and a significant reduction
checklist assessment and concerns. in maternal problem alcohol use and repeated
They decided what areas of concern incidents of physical partner violence for families
were appropriate for the home visitor receiving ≥75% of visits called for in the model. Home
to address with the family in addition visitors often failed to recognize parental risks and
to goals nominated by the family. seldom linked families with community resources.
The home visitor and supervision
referred to the goals at least every 2
months, the goals were updated by
the visitor and family every 6 months.
Dawson et RCT CHWs Home visitors sought to develop Received routine 14 Mothers that were Both home-visited women and controls made
al. 1989 306 trusting relationships with families, maternity and pae- expecting first good use of well- child care. Home-visited women
USA primarily mothers. Provided emotional diatric care including or second child, made greater use of sick-child care (p = 0.002),
support by listening to mothers, and nutrition and social were 20-26weeks most of which was appropriate. The greater
showing understanding. Provided services, occasional pregnant, were use of sick-child care was concentrated among
concrete help eg rides to clinics, visits by public health at least 16yrs. mothers with moderate or high family stress, with
babysitting provided information nurses and delivery at whom home visitors had closer relationships.
on pregnancy and infant care, university hospital
enhanced mothers informal and
formal social networks by helping
mothers access community resources
such as housing, food stamps, child
care, etc. They responded to what
mothers felt they needed to cope
better, discussed and encouraged
contraception, talked about infant
feeding and listened to mothers
description of childs minor illnesses

12 months
Barnett Observa- CHWs Primiparous women were screened on Control groups were Primiparous women only professional intervention l)ad a significant ef-
& Parker tional state and trait anxiety measures in the also reviewed for 12 (were screened on fect, Intervention successfully lowering state anxiety
1985 307 Prospective post-partum period; sub-groups of hi- months after being state and trait anxiety levels to a value comparable with the moderately
Sydney, Cohort ghly anxious (n =89), moderately anxious randomly selected. measures in the anxious mothers. Changes in anxiety levels for
Australia (n = 29), and minimally anxious (n = 29) post-partum period mothers not receiving an intervention were minimal
mothers were derived and subsequently over the study. In the high anxiety sub-groups, there
interviewed. The high-anxiety mothers was a 19% reduction in state anxiety levels for those
were randomly assigned to a professional receiving a professional intervention, a 12%reduc-
intervention, and to a non-professional tion for those receiving a non Professional interven-
intervention their progress was reviewed tion and a 3% reduction in the controls. A planned
over the following 12 months. contrast analysis determined that only professional
intervention l)ad a significant effect, intervention

successfully lowering state anxiety levels to a value
comparable with the moderately anxious mothers.
Heins et al. cross CHWs Resource mothers provided parenting - pregnant signifiant parental
1987308 sectional experience and knowledge to local women care in the
Carolina, community to reduce hazards associated intervention group.
USA with rural adolescent pregnancy (p=000001)
162
163
training
Rahman Secondary Non residents Didactic training trai- Conducted sessions with mo- Counseling in Evaluation
et al.2008 school of that village ned to deliver the psy- ther every week for 4 weeks in the perinatal done by
300 chological intervention the last month of pregnancy, depression re-inter-
CHWs to depressed mothers three sessions in the fi rst viewing the
postnatal month, and nine mother.
1-monthly sessions thereafter
Morrell et Didactic Trained in the 8 week achieved 10 home visits in the first Competence question-
al.2000140 care of young children their national postnatal month of up to in care of naires were
CHWs and intra-personal skills vocational three hours duration maternal issued at six
qualification young infant weeks and
and children six months
Lester et graduates psychology Didactic and 12 weeks plus ongoing Roles were defined in mental health received Voluntary Effectiveness
al.2007301 graduates Practicum 3 weeks prac- training on a accordance with the national counseling 1 hour of evaluated
CHWs Training included all tice-based day release guidance. Liaised with primary individual from patient
the knowledge, skills, induction basis. care team members, statutory & clinical super- primary care
and attitudes required non-statutory sector services, & vision each records
in their job description. specialized services for patients week from a
who are managed in PHC psychologist
Cooper Limited Community Didactic Training using Gave specific advices emotional Evaluated
et schooling workers Neonatal Behavioral on aspects of infant support and from the
al.2002 Assessment Schedule management(e.g. sleep regi- counseling mother’s view
298 to sensitize the men, crying, feeding) during
CHWs mother to her infant’s antenatal and postnatal visits
individual capacities
& sensitivities.
Barnet et older than Didactic training 16 hours Support made weekly 1.5 hrs of home Provided Supervised $200 per
al.2002299 21 years and counseling skills groups visits with the teenager and individual by the year
Baltimore, recruited through development conducted as other family members until and family commu-
USA from the local of a mentoring and as in-service the child’s first birthday, with counseling, nity nonprofit
CHWs community supportive relationship. curriculum an option to continue until case mana- organization
(female) via announce- Trained to discuss refresher the child’s second birthday. gement, and
ments, infant development, coordinated
newspaper engaging in age- linkages with
advertise- appropriate feeding community
ments, and or play activities, agencies when
churches. role-playing age- problems
Screened
appropriate discipline, were identified
their criminal
and taking social and
background
cultural outings in
the community.

training
Bugental et Were trained in Parents in the unenhanced
al. 2002 304 home methods home visitation condition
through the National received home visitation
Parents as Teachers consistent with the Home
program. Trained by visitation program (Duggan
Parents as Teachers 2004) supplemented with
Center in National information regarding
City California. Two existing community services.
trainers: one Caucasian Families in the enhanced
and one Latino condition received informa-
tion on existing community
services, combined with
methods used in the
Healthy Start program and

a brief attribution ally based
problem-solving discussion
at the start of each visit
(causal appraisal followed by
problem-focused appraisal).
Home visitors served as
facilitators, assisting parents
in making a causal appraisal
of the possible reasons for
an identified care giving
problem and in designing a
strategic plan for the future.
Barnett Social workers Guidelines for the social Professional intervention
& Parker worker suggested comprised assistance from a
1985 307 attention to: the social worker experienced in
provision of support; working with mothers and
specific anti-anxiety children, each social worker
measures; the pro- being Allocated six subjects.
motion of self-esteem
and confidence; a
reduction in intensity
of the mother-infant
interaction (if appro-
priate), and promotion
of mother father and
father-child interaction.
Dawson et 12 grade Training covering 30 hours
al. 1989 306 pregnancy, birth, infant
care, safety, nutrition,
child development,
community resources
and family life.
164
Interventions related to Non-
Communicable Diseases (NCDs)
Background
Non-communicable Diseases (NCDs) such mostly locals from the community.282, 312-317
as heart attack, stroke, cancers, diabetes, and The CHWs in Thompson et al. were either dia-
common injuries account for the vast majority betic themselves or had a family history of dia-
of all global deaths, but still do not lay in the betes and were required to have good interper-
domain of millennium development goals. sonal skills to participate in the intervention.314
Several of the MDGs are acting as determinants Those recruited in the Gary et al. intervention
of NCDs like lower levels of education leads were all local high school graduates, but had
to engagement in unhealthy life style and in no prior training in health care312 while those
turns results in developing NCDs.309 Likewise, in the Sankaranarayanan et al. were university
environment health hazards are associated with graduates. 318 In another study from Pakistan
causing respiratory diseases and some types CHWs had 8 years of schooling and were recrui-
of cancers. NCD also impose severe costs on ted in the pattern of how CHWs are selected for
national health-care systems and economies national LHW program.313 The training moda-
as a whole.310 NCD prevention is still not featu- lity used in all of the studies was didactic.312-320
red as a priority in most national public health The CHWs in the Krieger et al., Jafar et al. and
agendas. It is therefore essential to move from Gary et al. interventions were trained to counsel
programs to treat NCDs to risk factor prevention patients to adopt preventive care and adhere to
and initiatives for health promotion at every le- the treatment of hypertension.312, 319 313 They
vel (individual, family, community and national). were taught the risk factors for cardiovascular
Thus, primary control and prevention of NCD diseases and trained to conduct blood pressure
risk factors could help strengthen, rather than measurement.312, 319 313 The CHWs involved in
compete, with health-care interventions for Fedder et al. intervention were trained in case
infectious diseases and reproductive health.311 management of diabetes, like glucose monito-
During our review we found many studies in ring, medications, emergencies and complica-
which CHWs focused delivering interventions tions, besides their training in the management
related to prevention of NCDs and majority of of hypertension.315 In Thompson et al. the
them were from developed countries. Most of CHWs were given 30 hours training in the mana-
the NCDs driven interventions are targeted in gement of diabetes mellitus and depression314
developed countries as they have already or are while Ingram et al. intervention focused on trai-
in phase of achieving targets related to MNCH ning the CHWs in inculcating self-management
and communicable diseases. behavior in the diabetics.317 In another study
reviewed, the CHWs were trained in prevention
Community-Based Evidence strategies against lead poisoning.316 In Solomon
et al. the CHWs were trained in the diagnosis of
We also found the role of CHWs in delivering in- trachoma, its treatment with azithromycin and
terventions related to other non communicable proving information of the possible side effects
diseases like hypertension, diabetes and cancer. of the drug.320 on the other hand in Forst et al.,
We reviewed 25 studies that came across while farmers in the field were given education rela-
searching for studies particularly related to ted to protective eye care measures and were
MDGs and included in this review to evaluate distributed eye wear. 321
their dynamic roles in provision and manage-
ment of non-communicable health problems The educational level318 313 and the training
(Table 14A & Table 14B). content both seemed to have a positive im-
pact on the outcomes of all the interventions
The CHWs recruited in these interventions were reviewed. In Thompson et al. having a personal

experience of managing own illness or so- pression,314 lead poisoning,316 oral cancers,318
meone else in the family with diabetes resulted and protective eye care in farmers.321 They
in producing highly significant results through also offered therapeutic service as in case of
decreasing the levels of HBA1C in the people trachoma where they treated the disease using
under their coverage. When educational level azithromycin.320
of CHWs in Gary et al. and Sankaranarayanan
et al. were compared with studies which did Most of the studies under review of NCDs had
not mention education level of CHWs at all, we CHWs, who worked as volunteers, however
found no added advantage in the outcomes those in Fedder et al. and Jafar et al. were given
achieved, in fact in studies where CHWs were stipends.315 313 However the financial incentive
selected base on their educational level failed or the lack of it did not seem to have any impact
to show any impact on their study outcomes. on the outcomes of these interventions.
On the other hand, regular bi-weekly supervi- Conclusions

sion of the health workers not only served as
on-going training but also provided an oppor- The CHWs can play a great role in promoting
tunity to assess the problems encountered in preventive healthcare strategy in the commu-
the development of health seeking behavior of nity. The outcomes of interventions make it
the community.314, 315 This contributed to the evident that they can counsel patients towards
significant reduction in the glycosylated hemo- health seeking behavior and provide them mo-
globin of the diabetics in the community314 and tivation necessary for treatment compliance. It
in the decline of total emergency room visits by is therefore imperative to the achievement of
40%.315 MDGs that the CHW can be deployed to the
regions farther from the reach of physicians.
The role of CHWs in relation to the MDGs was
oriented towards promotion of health seeking
behavior in the community. They promoted
preventive strategies with regards to hyper-
tension, 312, 315, 319 313 diabetes,314, 315, 317 de-
CHW Snapshot 18
Nigerian Community Health Workers
Program overview
In 1982, the institute of child health and primary health, Lagos designed a primary health care service model for rural
population. The model decided to base the services in the villages by developing a cadre of volunteer village health workers
who will be utilized for referral. Supply and supervision.
Home Based Carer, Tanzania
Education no criteria
Initially village health committees were developed and those com-
Training 3 weeks
mittees nominated volunteers for training in accordance with criteria
Refresher 2 refresher courses
designed. These volunteers were recruited if they managed to show
a permanent residency in that community and had a responsible Supervision community health assistant
attitude. The courses covered curative, preventive and promotional (mid level PHC worker)
activities. Incentive sales of drugs

CHW Snapshot 19
South African Community Health Workers
Program overview
Implementation of community health workers program initiated in 1970s and 1980s following alma ata declaration. In 2002
the year was marked in the history o South Africa as the year of volunteer and a rapid growth was seen with the range of
lay workers, home based carer, lay counselors, DOT supporters etc. and term community health workers was introduced
under the umbrella concept of lay workers in the health sector and national CHW policy framework was adopted in 2003322
where these workers were all brought under the banner of an Expanded Public works Program (EPWP). In 2006, training
standardization and accreditation of CHW came into existence.

Recruitment and selection occurred mostly through calls for vo-
lunteers and sometimes via community-based organization and Community health Workers, South Africa
often through involvement of health facility staff. They are expected Supervision nurses
to work half a day and 20 hours per week. In 2005/06 the national Incentive R1000 per month
department of health allocated USD 10 million for their training and
involving them in HIV/AIDS and TB care and support activities. 14 CHWs were linked with each primary health facility center
in their community.

168
169
Table 14A: Non-Communicable Diseases Prevention Interventions – characteristics of included studies
Krieger et RCT CHWs The health workers followed a Participants in the usual- 28 months Persons with The enhanced follow up increased follow up by
al.1999 319 standardized sequence of activities care group were advised elevated blood 39% (95% CI: 14- 71% Relative to usual care. Follow
Seattle, USA until they reached a client: telephoning to see a health care pressure (140 mm up visits were completed by 65% Of Participants in
(up to 3 times), mailing a postcard provider for follow-up. Hg systolic or 90 intervention arm compared to 47% in usual care.
asking the client to contact the health Those without a provider mm Hg diastolic)
worker, making a home visit, and were given a list of public
contacting alternate persons who & community clinics
might know the location of the client.
Krieger et RCT CHWs Community health workers received usual care 24 months 4-12 year s of chil- The high-intensity group improved significantly
al.2005 323 provided in-home environmental dren with asthma more than the low intensity group in its pediatric
Seattle, USA assessments, education, support asthma caregiver quality-of-life score (P=.005) and
for behavior change, and resources. asthma-related urgent health services use (P=.026).
Participants were assigned to either Asthma symptom days declined more in the
a high-intensity group receiving 7 high-intensity group, although the across-group
visits and a full set of resources or difference did not reach statistical significance
a low-intensity group receiving a (P= .138). Participant actions to reduce triggers
single visit and limited resources. generally increased in the high-intensity group.
Gary et RCT CHWs The NCM was a registered nurse with Participants assigned to 24 months patients with Compared to the Usual care group, the NCM
al.2003312 a baccalaureate degree in training to the usual medical care type 2 diabetes group and the CHW group had modest declines
California, be a certified diabetes educator. NCM (control) group continued in HbA1c over 2 years (0.3 and 0.3%, respectively),
USA interventions were 45-min face-to-face on-going care from their and the combined NCM/CHW group had a
clinic visits and/or telephone contacts. own health professionals greater decline in HbA1c (0.8%. P _ 0.137). After
She provided direct patient care, adjustment for baseline differences and/or follow-up
management, education, counseling, time, the combined NCM/CHW group showed
follow- up, referrals, and physician improvements in triglycerides (_35.5 mg/dl; P _
feedback and prompting, which included 0.041) and diastolic blood pressure, compared to
advising regimen changes & implemen- the usual care group (_5.6 mmHg; P =0.042).
ting changes under physician’s orders.
Jafar et al. cRCT CHWs CHWs were trained to screen hyper- in control arm CHWS 24 months hypertensive pa- decrease in systolic blood pressure was significantly
2009313 tensive patients from the selected and GPS were not tients with 40 years greater in the HHE and GP group (10.8 mm Hg
Karachi, communities and modify their trained and they were of age and above [95% CI, 8.9 to 12.8 mm Hg]) than in the GP-only,
Pakistan behavior on healthy diet, exercise and receiving services from HHE-only, or no intervention groups (5.8 mm
smoking cessation and then GPs were local health facilities Hg [CI, 3.9 to 7.7 mm Hg] in each; P < 0.001).
also trained for pharmacological and
non pharmacological interventions
Sankarana- cRCT CHWs Subjects in the intervention group control group did not 36 months adult population Of the 63 oral cancers recorded in the cancer registry,
rayanan et will receive 3 rounds of screening receive any intervention 47 were in the intervention group and 16 were in the
al.2000318, consisting of oral visual inspection control group, yielding incidence rates of 56.1 and
324 by trained health workers at 3-year 20.3 per 100,000 person-years in the intervention
Kerala, intervals. Subjects in the intervention and control groups, respectively. The program
group were offered screening, and sensitivity for detection of oral cancer was 76.6% and
India
those with lesions suggestive of oral the specificity 76.2%; the positive predictive value was
leukoplakia, submucous fibrosis, 1.0% for oral cancer. In the intervention group, 72.3%
or oral cancer were referred for of the cases were in Stages I2II, as opposed to 12.5% in
examination by physicians the control group. The 3-year case fatality rates were
14.9% (7 of 47 patients) in the intervention group
and 56.3% (9 of 16 patients) in the control group.

Vetter et al. RCT CHWs Patients were given intervention Own going care 24 months Patient with Interventions group improved diabetes
2004 325 related to diet, physical acti- from patient own diabetes control compared to control group.
USA vity, foot care, vision care, blood health professionals
glucose self monitoring, blood
pressure control, adherence to
medications and appointments,
referrals, and smoking cessation
Taylor et al. RCT CHWs Four hundred and sixty individuals Control group did not 6 months General Population A total of 319 individuals responded to the follow-up
2009 326 who had never been tested for receive interventions survey (69% response rate). Medical records data
Seattle, hepatitis B were identified from verified hepatitis B testing since randomization for 9
Washington community-based surveys of Chinese (6%) of the 142 experimental group participants and
USA and conducted in Seattle, Washington, and 3 (2%) of the 177 control group participants (P = 0.04).
Vancouver, British Columbia. These At follow-up, a higher proportion of individuals in
Vancouver,
individuals were randomly assigned to the experimental arm than individuals in the control

Canada receive a hepatitis B lay health worker arm knew that hepatitis B can be spread by razors
intervention or a direct mailing of (P\0.001) and during sexual intercourse (P = 0.07).
physical activity educational materials
Srinivisan et RCT CHWs treated with either 1% chloramphe- No treatment 18 months Patients with 1365 people reported to VHWs with ocular injuries,
al. 2006 327 nicol and 1% clotrimazole ointment traumatic corneal of whom 374 with corneal abrasions were eligible
South India or 1% chloramphenicol and a abrasion for treatment. Of these, 368 (98.5%) abrasions healed
placebo ointment three times a without complications. 2 patients had mild localised
day for 3 days. Patients, doctors and allergic reactions to the ointment, 2 dropped out
VHWs were blinded to treatment. and 2 patients in the placebo group developed
microscopic culture-negative corneal stromal
infiltrates that healed in 1 week with natamycin drops.
Nguyen et RCT CHWs Both groups received targeted Media received media 36 months women aged The LHW_ME group increased receipt of mammo-
al. 2009328 Education. The intervention group education only >40 years graphy ever and mammography in the past 2 years
USA received two LHW educational (84.1% to 91.6% and 64.7% to 82.1%, p_0.001) while
sessions and two telephone calls. the ME group did not. Both ME (73.1% to 79.0%,
p_0.001) and LHW_ME (68.1% to 85.5%, p_0.001)
groups increased receipt of CBE ever, but the
LHW_ME group had a significantly greater increase.
The results were similar for CBE within 2 years. In
multivariate analyses, LHW_ME was significantly
more effective than ME for all four outcomes, with
ORs of 3.62 (95% CI_1.35, 9.76) for mammography
ever; 3.14 (95% CI_1.98, 5.01) for mammography
within 2 years; 2.94 (95% CI_1.63, 5.30) for CBE ever;
and 3.04 (95% CI_2.11, 4.37) for CBE within 2 years.
Simmons et RCT CHWs A pilot study (Vanguard Study) cohort No interventions 24 months patients with Those with IGT/IFG diagnosed (n 27) expe-
al. 2008 329 of 160 participants were weighed to control arm diabetes rienced significant weight loss after screening
New before and during MCHW intervention, and during the Vanguard Study (5?2 (SD 6?6)
Zealand and compared with fifty two partici- kg, paired t test P,0?01). Significant weight loss
pants weighed immediately before occurred during the Vanguard Study among
intervention and with 1143 participants all participants (21?3 (SD 3?6) kg, P,0?001).
from the same geographical area.
170
171
Cheroff et al. RCT CHWs The program, provided by “experienced Control group did not 12 months children aged 7 Analysis of variance demonstrated that the
2002 330 mothers” and child life specialists, receive interventions to 11 years with intervention had a significant main effect on post
Baltimore, included telephone contacts, face-to- diabetes mellitus, intervention adjustment controlling for baseline
USA face visits, and special family events. sickle cell anemia, scores (P=.01).Using a cutoff score indicating
cystic fibrosis, maladjustment, the percentage of experimental
or moderate to group children in the maladjustment range
severe asthma. fellfrom19%at baseline to10% after the interven-
tion; the percentage of control group children
in the maladjustment range rose from 15%
at baseline to 21% after the intervention.
Levine et al. RCT CHWs Community health workers were No interventions 48 months general population The primary results were a significant decrease
2003331 trained and certified in blood pressure to control arm in mean systolic and diastolic pressures after
USA management, monitoring, education and both levels of intervention, and a significant
counseling, social support mobilization, increase in the percentage of individuals with
and community outreach and follow up. controlled high blood pressure. Surprisingly, no
differences in results were observed between
the 2 levels of intervention intensity
Bird et al. Quasi-RCT CHWs Lay workers conducted 56 sessions on no interventions 36 months Vietnamese women In the intervention community, recognition of
1998332 general States, 86 on cervical cancer, screening tests increased significantly between
California, and 90 on breast can- cancer. Surveys pre- and post intervention surveys: CBE, 50 to
USA of 306 to 373 women were conducted 85%; mammography, 59 to 79%; and Pap smear,
in to develop cervical cancer. Further, 22 to 78% (P 0.001 for all). Receipt of screening
Vietnamese women the study tests also increased significantly: CBE, 44 to 70%
communities in 1992 and 1996. (P 0.001); mammography, 54 to 69% (P 5 0.006);
and Pap smear, 46 to 66% (P 0.001). Best-fitting
logistic regression models, adjusting for prein-
tervention rates and significant covariates, also
showed statistically significant odds ratios [9].
Only about half (50 and 53%) of Vietnamese
women for the intervention effect (P, .0001).
Forst et al. pre/post CHWs 786 workers on 34 farms were divided into three intervention blocks: - farmers Pre- and post-intervention questionnaires de-
2004 321 (A) CHWs provided protective eyewear and training to farm workers; (B) monstrated greater self-reported use of eyewear
Michigan, CHWs provided eyewear but no training to farm workers; (C) eyewear in all blocks after the intervention (P<0.0001),
USA was distributed to farm workers with no CHW present and no training. with Block A showing the greatest change
compared to B (P<0.0001) and C (P¼0.03); this
was supported by field observations. Block A
showed the greatest improvement in knowledge
on questions related to training content.
Fedder et compara- CHWs To ascertain the effect that trained CHWs had on the quality of life 39 months patients with type 2 Total emergency room (ER) visits declined
al.2003 315 tive cross (QOL) and level of healthcare utilization of Medicaid enrollees with diabetes with or wi- by 40%; ER admissions to hospitals declined
Baltimore, sectional DM, with or without HTN. Healthcare. CHWs alternated weekly home thout hypertension by 33%, as did total hospital admissions; and
USA study visits and phone contacts to teach patients to understand the need to Medicaid reimbursements declined by 27%.
control their illnesses, to follow both their therapy and behavioral regi-
mens, and to maintain appropriate visits to a primary care practitioner.

Davis compara- CHWs CHWS provided educational sessions to women for protective - All women ages The findings suggest that a church-based model
1994333 tive cross reproductive health 21 years & older of social influence can leverage the participation
Los sectional of minority women in cervical cancer control,
Angeles, provide access to underserved Hispanic women
USA in particular, and sustain cancer control activities
beyond the life of an intervention program.
Kegler & cross CHWs Trained lay health advisors, who then attended monthly meetings, 24 months children aged Mean childhood blood lead levels decreased
Malcoe sectional planned and engaged in outreach activities, and educated indivi- 1-6 years and selected preventive behaviors improved
2004316 survey duals in their social networks (average of 5.4 education/ outreach
Oklahoma, activities per month). During the 2-year intervention period, they
USA made nearly 27000 contacts and spent more than 5000 hours
conducting TEAL-related community education efforts.22 Topics
included sources of lead, the importance of blood lead screening,

strategies for removing lead sources, hand washing, playing in grass
rather than in dirt or mine tailings, good nutrition, & housecleaning.
Ingram et cross CHWs The model included a five-week series of free diabetes 36months patients with Random blood glucose measurement in Yuma,
al.2005 317 sectional education classes that assisted participants in gaining the Diabetes dropped from 224 mg/dL to 201 mg/dL, and,
Yuma study knowledge and skills necessary to be physically active, control in Santa Cruz, levels dropped from 197 mg/dL
and Santa diet, monitor blood sugar, take medications, and be aware of to 151 mg/dL. Among high-risk participants in
Cruz, USA complications. Central to the model was the use of commu- Yuma, systolic BP fell from 151 mg/dL to 137 mg/
nity health workers — or to conduct outreach, participate dL, & diastolic BP fell from 100 mg/dL to 84 mg/dL.
in patient education, and provide individual support. Among-high risk participants in Santa Cruz, systolic
BP fell from 153 mg/dL to 139 mg/dL, & diastolic
blood pressure fell from 102 mg/dL to 91 mg/dL.
Solomon et cross CHWs CHWs were trained to diagnose trachoma and to treat the 1 months General population The volunteers’ diagnostic sensitivity for
al.2001320 sectional disease using azithromycin. They were also informed of in households active trachoma was 63%; their specificity was
Daboya, survey the drug’s possible side-effects. Under supervision, each 96%. At the household level, their ‘‘decision to
Ghana volunteer then examined, and if necessary treated treat’’ was correct in 83% of households
Havas et al. Cross CHWs Principal components included physicien éducation, 36 months adults males, 51.5%of those referred had visited their physicians
1991334 sectional community based screenings, and follow-up. A lay or young, poor and within 2 to 4 months, increasing to 65.6% within 6
Massachusetts, professional educator provided counseling and referral less educated to 12 months. Older age (odds ratio [OR], 1.17 per
USA advice. Half of the subjects with high blood cholesterol additional decade), more education (OR, 1.17 per
levels received a reminder to see their physician additional level), higher blood cholesterol levels
(OR, 1.19 per additional 0.51 mmol/L), previous
knowledge of level (OR, 1.34), and receiving a
reminder (OR, 1.24) were significantly associated with
greater likelihood of referral completion, whereas
the type of educator providing counseling was not.
Singh et al. cross CHWs patients were given DOTS strategy 21 months patients with TB The proportion of patients with commu-
335 sectional
2004 nity volunteers increased significantly with
Haryana, time (13% in 2000 to 25% in 2002), even
India in the absence of financial incentives
172
173
Lam et al. cross CHWs education outreach to women by lay health workers 60 months Women in more understanding in intervention group that
2003336 sectional in the community community smoking and human papillomavius causes
California, cervical cancer
USA
Mock et al. cross CHWs lay health worker outreach plus media-based education 36 months Vietnamese Testing increased among women in both the
2006283 sectional (combined intervention) or media-based education only. American women combined intervention (65.8% to 81.8%; P<.001)
USA Lay health workers met with the combined intervention and media-only (70.1% to 75.5%; P<.001) groups,
group twice over 3 to 4 months to promote Papanicolaou but significantly more in the combined inter-
(Pap) testing. We used questionnaires to measure chan- vention group (P=.001). Among women never
ges in awareness, knowledge, and Pap testing. previously screened, significantly more women
in the combined intervention group (46.0%)
than in the media-only group (27.1%) obtained
tests (P<.001). Significantly more women in the
combined intervention group obtained their first
Pap test or obtained one after an interval of more
than 1 year (became up-to-date; 45.7% to 67.3%,
respectively; P<.001) than did those in the media-
only group (50.9% to 55.7%, respectively; P=.035).
Hiatt et al. cross CHWs The Breast and Cervical Cancer Intervention Study was a control- 36 months women general Seventy-six percent of women ages 40 and breast
2001337 sectional led trial of three interventions in the San Francisco Bay Area population and cervical cancer screening among uncover
California, from 1993 to 1996: (1) cercommunity-based lay health worker 89%). Rates were significantly lower for non-English-
USA outreach; (2) clinic-based provider training and reminder system; based research designed to develop and evaluate
and (3) patient navigator for follow-up of abnormal screening such speaking Latinas and Chinese women (56
results. Study design and a description of the interventions and 32%, respectively, for mammography), and
are reported along with baseline results of a household survey maintenance insights regarding previously unders-
conducted in four languages among 1599 women, aged 40–75 tudied popular screening (three mammograms
in the past 5 years) variations and multiple study
design challenges. The proven from 7% (non-En-
glish-speaking Chinese) to 53% effectiveness of
mammography and Pap smears in pre (Blacks).

175
training
Krieger predomi- Didactic training 100 hours BP measu- conducted BP measurements, blood Contact
et al. nantly Black on hypertension, rement provided referral to medical pressure activities were
1999319 (12/14) low the cardiovascular specialists care and, assistance in measurement monitored with
CHWs income system, risk factors locating a provider; took and linkage a computerized
neighborhood for cardiovascular appointments at health with health tracking system.
disease, community center; issued appointment facility and
reminder letter; follow-up client
to determine whether the
appointment was kept; a new
appointment for each missed
appointment (up to 3); and
assistance in reducing barriers
to care through referral
Gary et al. a local high enrolled in Didactic skills The CHW facilitated preventive blood pressure
2003312 school college part development care by offering to schedule measurement
CHWs (F) graduate time, and had training in preventive appointments and visits, mo- and linkage
no formal care, adherence to nitored participant and family with health
training in treatment recommen- behavior, reinforce adherence facility and
health care dation and reporting of to treatment recommenda- client
before the identifiable problems. tions, mobilize social support,
study. & provide physician feedback,
which included reporting on
identifiable problems such as
high blood pressure readings
Jafar et al. 8 years of from the Didactic training on 6 weeks pharmacologic (diet, exercise, salaried
2009 313 schooling same com- behavior change weight loss, and smoking
munity and communication of cessation) and pharmacologic
hiring as per diet, exercise and interventions, prescription
lady health smoking cessation of low-cost and appropriate
program generic drugs, preferential use
Pakistan of single-dose drug regimens,
scheduled follow-up visits
guided by blood pressure,
the stepped-care approach
for titrating drugs to achieve
target blood pressure, and
satisfactory consultation
sessions for patients, with
explanations of treatment
and use of appropriate
communication strategies.

training
Srinivisan et High Fluent in Trained to identify Dor to door survey and iden- Paid 3500-4000
al. 2006 327 school English corneal abrasions tify patients with traumatic workers population
education corneal abrasion using a
technique taught in training
Sankarana- university didactic training they visited household and oral cancer
rayanan et gradates they were trained given them training related counseling
al.2000318, to give anti tobacco to ant tobacco, they also and
324 health messages to performed screening of oral screening
community suring their visual inspection of anatomi- of oral
CHWs visits to household cal benign oral cancers and cancers in
(M & F)
provide referrals to them community

Thompson having 10 sessions of general Biweekly Acted as extenders of the
et al.2009 diabetes or Didactic training on meetings pro- medical staff to facilitate be-
314 having a fa- group facilitation, de- vided ongoing havior change, using patient
CHWs
mily member cision making, popular instruction centered counseling, walking
with diabetes, education methods, and support club, diabetes classes, and a
possessing making presentations, on topics psycho educational group
good inter- communication, and requested by for depression.
personal skills, analysis. Subsequently, the promoters,
they received 30 for the duration
hours of training in of the project,
diabetes management including
12 hours on
and the TTM.
depression.
Fedder et required Didactic Training Bi-weekly Alternated weekly home Developing provided
al.2003315 to have Received training supervision visits and phone contacts to Health an MTA bus
CHWs community in chronic illnesses, meetings were teach patients to understand seeking pass and
experience resource identification, held in which the need to control their behavior a monthly
to demons- and case management. new patient illnesses, to follow both stipend
trate their The initial training was assignments their therapy and behavioral (from $45
commitment 40 hours, and covered were given, regimens, and to maintain to $75,
to service, & to many topics related to forms were appropriate visits to a based on
either reside diabetes (eg, medi- distributed primary care practitioner. caseload)
in, or be able cations, emergencies and collected, for
to travel to, &complications, glucose and problems incidental
the catchment monitoring), and to addressed.
expenses
area. high blood pressure
incurred.
176
177
training
Kegler & respected training on sources 8 hours community edu- 40/ 27000
Malcoe people to of lead exposure cation efforts: contacts
2004316 whom others and lead poisoning Topics included
turned for prevention strategies sources of lead,
advice and the importance
help) were of blood lead
recruited from screening,
the Native strategies for
American removing lead
community resources, hand
washing, playing
in grass rather
than in dirt or
mine tailings,
good nutrition, &
housecleaning.
Ingram et Promotores Didactic Training by to pro- Collabora-
al.2005317 are indige- the hospital in each vide outreach, tively
Yuma nous to the county provided a CDE recruitment of developed
and communities to facilitate classes, participants, assist quantita-
in which in diabetes care, and participants in tive and
Santa they work work individually incorporating qualitative
Cruz, USA
with participants self-management instruments
behaviors into
their lifestyles,
& offer ongoing
support and
follow-up.
Solomon et CHWs were trained to They were

al.2001320 diagnose trachoma trained to
Daboya, and to treat the disease diagnose and
Ghana using azithromycin. treat trachoma.
They were also
informed of the
drug’s possible si-
de-effects. Under
supervision,
each volunteer
then examined,
and if necessary
treated

training
Forst et al. read and interest in promote safety 2 hours
2004 321 write Heath, have measures in the daily for
Spanish leadership & farmers including 2 weeks
communi- eye wear training
cation skills,
demonstrated
respect for
farm workers

178
Knowledge, attitude and practi-
ces of community health workers
Background
A CHW is a frontline public health worker who is functional status had significantly changed for
a trusted member of the community served and outreach activities, health education, environ-
is the backbone of the primary health care.338 mental health, MCH activities, EPI, birth and
The importance of CHWs in the provision of deaths registry, curative patients, school health,
health services cannot be overlooked because referrals and epidemic control.351 In Darmstadt
they are the solitary means of house-to-house et al. physicians independently evaluated all the
access of health system for the provision of neonates seen by the CHWs and the outcomes
basic health care and serve as a liaison between of this study showed that the sensitivity of CHWs’
health/social services and the community to evaluation of a very severe disease was 75% and
facilitate access to services and improve the specificity was 98%.347 In another study by Hadi
quality and cultural competence of service deli- et al. the assessment and management of ARIs
very. They also build individual and community by CHWs was assessed against the gold standard
capacity by increasing health knowledge and of physician assessment and diagnosis.345, 346
self-sufficiency through a range of activities The sensitivity of the diagnosis by the CHWs was
such as outreach, community education, infor- found to be 68% while the specificity was 95%
mal counseling, social support and advocacy. as compared to the diagnosis of a physician.345,
Therefore, only those CHWs who have good 346 The management of sick children according
knowledge, positive attitude and proper skills, to IMCI protocol and the role of CHWs was also
can help the community regarding primary studied in another cross sectional survey and it
health care and family planning. was found that a significant number of CHWs
were needed to meet the time requirement by
In the systematic search for the global evidence IMCI protocols.344
of CHWs, we also identified set of studies in
which their training and practices were eva- In Falle et al. the TBAs were trained and then
luated and reported in the form of Knowledge, evaluated on their antenatal support and de-
attitude and practices (KAP) studies. livery of the baby. They were trained to make
antenatal visits and convey advice on diet and
Community Based Evidence nutrition, immunizations (TT) and conduct
safe delivery and counseled on reducing the
We reviewed a total of 19 studies which as- workload during pregnancy.340 The outcomes
sessed the knowledge, attitude and practices of of this study showed that the trained TBAs were
the CHWs (Table 15A & Table 15B). The types of more likely to wash hands with soap before
health worker involved in the studies reviewed delivery and use a clean delivery kit, and advice
are TBAs339, 340 and the CHWs.341-351 The CHWs feeding colostrums to the newborn.340
in Darmstadt et al. were educated up to secon-
dary school or higher347 while some had had a Similarly the TBAs in another study were first trai-
few years of schooling345 or were just literate.340 ned in newborn care and then their knowledge
The training modality used where the CHWs and training was tested before and after trai-
were being trained was didactic340, 342, 343, 347, ning.339 The after training assessment showed
350 along with field work in few of them.339, 341,
statistically significant reduction in perinatal and
344-346, 348
neonatal deaths among deliveries conducted
by TBAs.339
The functional status of the CHWs in Ayele et al.
was assessed after providing them with refresher The CHWs in Afsar et al. were assessed on their
training of 5 days.351 It was observed that their primary health care delivery, family planning

services, maternal and child health care and significant improvement in the performance
referral practices.343 The outcomes of this study skills after learning from a pretested self learning
showed that the CHWs made 76.4% successful educational module with simulation method.348
referrals.343 In another study Afsar et al. found In Nigeria the Oganfowora & Daniel were inter-
that only 4% of the patients referred visited viewed by a self-administered questionnaire to
government facilities, the rest preferred private test their knowledge on neonatal jaundice, its
physicians and in-formal practitioners.342 causes, treatment and complications and the
results of this study showed that only 51% of the
The knowledge, attitude and skills of the CHWs respondents had correct knowledge of neonatal
with a job experience of more than 24 months jaundice and only 55% of them had adequate
revealed that their knowledge was above 36%, knowledge of its effective treatment.349
attitude score above 88% and skill assessment
score above 86%. The variables included in this In Zietz et al. it was found that the CHWs deve-
study were home visits, antenatal care, family loped the competency to correctly classify ARI,
planning, newborn care, vaccination, growth and their average score improved from 60% to
monitoring, common diseases, medicines and 83%, in a pre/post study after training them to
referrals.341 The CHWs in Mohanty et al. showed use the WHO ARI guidelines.350
CHW Snapshot 20
Pakistan Lady Health Worker Program
Program overview
In 1993, government of Pakistan started a National Program for Family Planning and Primary Health Care and soon the pro-
gram began to employ a cadre of salaried, female CHWs, called lady health workers, to provide health education, promote
healthy behaviours, supply family planning methods and provide basic curative services. Their duties include monitoring the
health of pregnant women, monitoring the growth and immunization status of children, and promoting family planning.
The lady health workers are provided with a kit that contains materials such as bandages, scissors, cotton, a thermometer,
health education posters and a child scale. The kit also contains contraceptives and drugs, including contraceptive pills,
condoms, paracetamol tablets and syrup, eye ointment, oral rehydration salts for diarrhea, Chloroquine for malaria and
antibiotics for respiratory infections.205
Lady Health Workers, Pakistan
Operational aspects and considerations Education 8th grade
Lady health workers are all women; 70 per cent are under the age of Training 3 months initial training
35 years, and 72 per cent are currently married or have been married. Refresher One week each month
The written requirements for a lady health worker are to be female, Supervision Lady Health Supervisor
educated to 8th grade, a permanent resident where she will serve, Incentive Rs. 1600 / month
20 to 50 years of age and preferably married. Their training covers
the basics of primary health care and comprises both classroom and clinical practice.205, 352 A supervisory visit to the lady
health worker’s community takes place every month, and monthly meetings are held at the health facility. According to an
evaluation 80% of the workers had supervisory visits in last 30 days.205 The lady health worker is responsible for recording
information about births and deaths in the community, use of family planning methods, immunization of children, diagno-
sis and treatment of her clients, and pregnancies and care provided. She also refers her clients to next-level facilities if they
need further care.

The program is currently employing approximately 69,000 lady health workers each being responsible for approximately
1,000 individuals. This coverage equals approximately one fifth of the entire population of Pakistan and one third of the
target population of the program. External evaluation of LHW program occurs periodically in every 3-5 years and up till
now 3 evaluations have been conducted. Program has achieved vaccination promotion coverage of 67% of children under
five, modern contraceptive usage of 20% and overall indicators of population served by LHWs were slightly better off than
National figures.

Conclusion
The review of studies on knowledge, attitude
and practices of the CHWs has brought us to
the conclusion that basic training and then
refresher trainings can significantly improve the
working of CHWs and TBAs and thereby make a
significant contribution to the health care sys-
tem of the community.

Table 15A: CHWs Knowledge, attitude and practices assessment studies – characteristics of Included Studies
Ayele et compara- CHWs previously trained CHWs received CHWs were not given 6 months CHWs their functional status significantly changed
al.1993 351 tive cross refresher course of 5 days and were the refresher training and for outreach activities, health educations,
Illubabor, sectional given monthly supervision was looked were not provided with environmental health, MCH activities, EPI, Birth
Ethiopia for providing higher functional status monthly supervision registries, deaths registered, curative patients,
school health, referrals, and epidemic control
Darmstadt et cross CHWs CHWs evaluated breastfeeding and symptoms and - Neonates CHWs evaluation of very severe disease was 75% and
al.2009347 sectional signs of illness in neonates during household visits at specificity of 98%. PPV was 57% and NPV was 99%
Rural study postnatal days 0, 2, 5, and 8. Neonates with severe disease
Bangladesh were referred to community based hospital. Physicians
independently evaluated all neonates seen by CHWs.
Hadi validation CHWs CHWs were given training and then their assessment and children 3-60 CHWS diagnosis of pneumonia was 67.6%
study

2001345 diagnosis of ARI in community over children were tested against months sensitive and 95.2% specific. Agreement
Rural gold standard of physician assessment and diagnosis. between CHWs and physician was 0.67.
Bangladesh
Hadi cross CHWs BRAC used community health volunteers as the frontline work- 3 months children between CHWs were evaluated in 1998-1999. The
2003346 sectional force at the grass roots level were trained in 1992. The health 3 years to < 60 health volunteers identified 221 (18.9%)
Rural survey volunteers were expected to detect cases and treat ARIs, but to months were inclu- children as having ARIs of any kind, while the
Bangladesh refer severe and complicated cases to nearby health clinics. ded in the study physicians identified 263 (22.6%) children the
estimated sensitivity of volunteer diagnosis
was 67.7%, with the specificity being 95.2%.
khan et cross CHWs All children seeking care from the CHWs and the paramedics during 1998 children under The average time needed to collect information
al.2000 344 sectional over the survey months constitute the sample for the study. 5 years of age for the IMCI approach, including the physical
Matlab, survey The time-input requirement survey was carried out at the CHW checkup of sick children, was found to be about
Bangladesh level only. Children treated by CHWs during their routine home 16.3 minutes IMCI strategy represents a significant
visits were not included in the sample. Since IMCI is a facility- increase in the time input of health workers.
based illness management strategy, medical care provided Using the additional time input requirement of
at doorstep should not be included in estimating the costs IMCI, Bangladesh needs to employ somewhere
between 2,700 and 4,100 health workers in rural
areas. The additional cost of employing these
health workers will be around 2.6 to 4.0 million US
dollars, about one to 1.5 percent of total health
sector budget of the Government of Bangladesh
Falle et Compa- CHWs TBAs were trained and then they were evaluated 12 months Pregnant women Trained used clean cord-cutting instrument (89%)
al.2009 340 rative cross and hand-washing before delivery (74%), were
Sarlahi,
sectional common Trained TBAs were more likely to wash
TTBA vs. hands with soap before delivery, use a clean
Nepal UTBA delivery-kit, and advise feeding colostrum
Afsar et Cross CHWs patients referred to different health care faci- 2 months General population Out of a total of 347 patients interviewed, 265 (76.4%)
al.2003---- sectional lities by the LHWs were interviewed were successful while 82 (23.6%) were unsuccessful re-
Karachi, ferrals. Multivariate logistic regression analysis showed
that objection to referral (Adjusted OR, 2.96; CI: 1.44-
Pakistan
5.52), never referred before (Adjusted OR, 1.25; CI: 1.34-
6.90), not visited the referral site before (Adjusted OR,
4.04; CI: 2.50-6.08) and no knowledge of who to meet
at the referral site (Adjusted OR, 1.30; CI: 1.01-2.96)
were the factors associated with unsuccessful referral.
182
183
Afsar et Cross CHWs patients referred to different health care facilities by the 1 months General population Only 4% of patients referred visited govern-
al.2005 342 sectional LHWs were interviewed ment facilities, the rest having visited private
Karachi, survey physicians and in-formal practitioners
Pakistan
Rodney et Cross CHWs In 1992, the Center for Healthy Communities in Dayton, Ohio 12-36 general population Eighty-five percent of respondents indicated
al.1998353 sectional developed a program to train as Advocates people indige- months that they were somewhat/very likely to
Ohio, USA nous to the communities in which they would be working. receive this information from friends, family,
The effectiveness of the program has been evaluated from or neighbors, while 73% were somewhat/very
three perspectives: the Community Health Advocates, the likely to receive information from the CHWs
managers/ directors of the community sites at which the
CHAs work, & the clients with whom the CHAs work.
Khan et Cross CHWs Lady Health Workers with a job experience of more than July 2005 LHWs Knowledge of lady health workers was
al.2006 341 sectional 24 months were interviewed to assess their knowledge, above 36%, attitude score above 88% and
Kohat, attitude and skills, in terms of variables according to their job skill assessment score above 86%.
Pakistan description. These variables included home visits, antenatal
care, family planning, newborn care, vaccination, growth
monitoring, common diseases, medicines and referrals
Stekelenburg Cross CHWs This study was conducted to identify the factors associated - CHWs The two most important factors are the irregular
et al. sectional with low performance of community health workers and unreliable supply of drugs and selection
2003 354 descriptive of the wrong people to be trained for commu-
Kalabo, nity health workers. Other factors, like inadequate
Zambia community support and inadequate supervision,
were entioned by many contributors.
Fatusi et al. Cross CHWs Fifty-six health workers offering delivery services in 7 months CHWs A total of 242 partograms of women in labor were
2008355 sectional primary health care facilities were trained to use the plotted over a 1-year period; 76.9% of them were
Osun, study partogram and were evaluated after 7 months correctly plotted. Community health extension
Nigeria workers (CHEWs) plotted 193 (79.8%) partograms
and nurse/midwives plotted 49 (20.2%).
Jacob et al. Cross CHWs The community health workers identified nine subjects as - CHWs The sensitivity and specificity of the commu-
2006356 sectional having dementia. This was compared against an educa- nity health worker diagnosis was 3.8% and 99.4%
India tion adjusted diagnosis of dementia made in accordance respectively. The false positive rate and positive
with the 10 ⁄ 66 dementia research group protocol. predictive values were 55.6% and 44.4%, respectively.
The false negative rate and negative predictive
value were 10.3% and 89.7% respectively.
Satischandra Compa- CHWs TBAs training were conducted and then knowledge and practices 12 months TBAs Pre intervention period (one year prior to the
et al.2009339 rative related to newborn care was tested before and after training training) and post intervention period (one year after
Karnatka, cross the training) showed that, there was a statistically
India sectional. significant (p<0.05) reduction in the perinatal deaths
TTBA vs. (11 to 3) and neonatal deaths (10 to 2) among the
UTBA deliveries conducted by TBAs after the training.
Mohanty et compara- CHWs Pretested self learning educational module with simula- - CHWs There was a significant improvement in
al.1994348 tive cross tion method was introduced in intervention group the performance skills between interven-
Varasani, sectional tion and control groups (p <0.001)
India study

Ogunfowora Cross CHWs Community health workers in this area were interviewed - CHWs Only 51.5% of the respondents gave a correct defi-
& Daniel sectional by means of a self-administered questionnaire which nition of NNJ. 75.8 % knew how to examine for this
2006349 survey focused on awareness and knowledge of neonatal jaun- condition while 84.9 % knew at least two of its major
Ogun state, dice and its causes, treatment and complications. causes in our environment. Also, only 54.5 % had
Nigeria adequate knowledge of effective treatment namely,
phototherapy and exchange blood transfusion.
Rather than referring affected babies to hospitals for
proper management, 13.4 %, 10.4 % and 3 % of the
participants would treat with ineffective drugs, natu-
ral phototherapy and herbal remedies respectively.
Zeitz et Pre/post CHWs CHWs were trained to use WHO ARI guidelines of taking 1 months CHWs An average of 88% (ranging from 71% to 100%
al.1993 350 history, physical evaluation, disease classification, assignment of for the three groups) had received formalized ARI
Bolivia treatment site, use of medication, education of mothers about training during the previous year. Only 59% (in a

appropriate home therapy and patient follow and record keeping range of 48% to 74% for the three groups) reported
having evaluated a case of ARI during the month
preceding the study the mean score for identification
of danger signs was only 10%, & the mean score
for knowing the correct treatment of ARI cases was
only 34%. The average score for classification of
ARI improved from 60% to 83%, while the average
score for ARI treatment rose from 34% to 76%
Frazão & cross CHWs A study to assess changes was conducted including 36 community 12 months CHWs Statistically significant differences between pre- and
Marques sectional health workers and a representative sample of homemaker ostintervention program were seen regarding oral
2009357 Rio survey literate women and mothers aged 25 to 39 years living in 3- to health knowledge among both health workers
Grande da 6-room dwelling in the city of Rio Grande da Serra, southeastern and women (p<0.05). The number of shared
Serra, Brazil Brazil. Data on oral health knowledge, self-reported practices, toothbrushes per family decreased. Frequency
and personal skills regarding self-examination, oral hygiene, of toothbrushing and fl ossing increased. Self-
number of people living in the same household, number of assessment of oral hygiene effi cacy increased.
individual and collective toothbrushes, and dental service access Changes in practices and personal skills improved
and utilization were collected using structured interviews. self-effi cacy. Women had more access to services
(p<0.000) and used them more regularly (p<0.000)
Rowe et al. cross CHWs In 1995, the non-governmental organisation CARE initiated 1 months CHWs The mean percentage of assessment, classification
2007 194 sectional a CHW program in Siaya district. The program trained CHW and treatment procedures performed correctly
Siaya, survey volunteers to assess (i.e. collect information on clinical for each child was 79.8% (range 13.3—100%). Of
Kenya signs and symptoms), diagnose and treat children <5 years the 187 children who required at least one
old according to the CARE Management of the Sick Child treatment or referral to a health facility, only
(MSC) guidelines, a modified version of the WHO/UNICEF 38.8% were prescribed all treatments (including
IMCI guidelines. Then later on they were assessed for the referral) recommended by the guidelines.
effect of multiple interventions on healthcare practices.
184
185
Study Education Recruitment Training Duration Certifi- Refreshers Role key compe- Supervision Incentive coverage Evaluation
Criteria Content cation / Ongoing tencies (if any) mode
training
Ayele 5 days monthly their
et al. refresher supervision functionality
1993351 was assessed
after 6 months
Darmstadt Educated Recruited Didactic sessions, videos 36 days Supervisor Observed to make sure that Counseling 1 supervisor Evaluation
et al.2009 to secon- through local and practice on sick conducted breast feeding technique is regarding for 6 CHWs done
347 dary school advertiseDi- and healthy newborn refresher appropriate. Managed and breast feeding. who met throughout
CHWs (F) certification dactic ments babies Manual content: training followed up minor conditions Managed and them the training,
or higher. were all pregnancy surveillance fortnightly facilitated transport and followed up fortnightly and their
female, 20–40 &registration; antenatal referred where disease severe. fast breathing, for 6 hours assessment of
years old. counseling on prepared- oral thrush, five neonates
ness for birth and new- localized bac- at the hospital
born care; management terial infection, was evaluated
of the neonate at birth, diarrheas with before they
including resuscitation; dehydration started field
continuing essential and diarrhea work.
newborn care; routine without
neonatal assessment dehydration
and illness classification;
and management of
illness according to the
Mirzapur CHW clinical
algorithm, including
referral to the hospital.
Hadi 2001 trained CHWs Didactic and Field they visited assigned ARI assess- study trained their
345 were selected work. already trained household with children ment and physicians assessment
CHWs (F) CHWs were selected and assessed and dia- management were super- & diagnosis
and trained for ARI gnosed ARI and provided vising these was checked
detection and manage- treatment to them CHWs gold standard
ment at community. (physician)
Hadi Most of Selected from Theory and field work 3 to 4 months Paramedics Volunteers visited their examination group of The diagnosis
2003 346 them had among the basic training in BRAC’s from BRAC assigned household(100-120 of pneumonia physicians and treatment
5 years of local area offices. content included provided rou- housholds/CHW) monthly cases, coun- and para-pro- were exami-
schooling basic anatomy and physio- tine refresher to identify, diagnose, and ting respiration fessionals with ned by the
logy of respiratory organs, training to treat children with ARIs. rate, advice on experience BRAC research
classification of ARIs, volunteers patient care, in managing physicians.
analysis of the causes and once a month use of and treating
factors that contribute to referral card, ARIs.
these infections, signs and target group
symptoms of pneumonia, identification,
examination referral and record
and record keeping. keeping.

training
khan et Didactic and practi- Used questionnaire to obtain Diagnosis of
al.2000344 cum Informtion on information about all the sick dehydra-
CHWs classification of illness children in the age range tion and
conditions according of 2 months to 5 years, and measuring
to IMCI module did physical examination, vital sings
management of sick child of patients
and advising and counseling
of mothers was recorded.
Falle et Literate reported Trained by health 3 days Refreshers after Delivered the baby placenta Antenatal
al.2009340 delivering centre, NGOs, district 12 months and cut the cord. During support
TBAs at least one public health office antenatal visits, provided and delivery
(female) baby within on issues related to advice on diet and nutrition, of baby
the 3months safe delivery and immunizations (TT), and

prior to antenatal care reducing the workload
recruitment. during pregnancy.
Fatusi et al. didactic sessions and 3 days

2008355 practical involved in
deliveries in the PHC
facilities participated
in the training, which
was conducted by the
investigators, most of
whom were specialist
obstetricians engaged
consistently in using
the partogram and
training health
workers in their
practices. The training
utilized the partogram
produced by WHO.
Afsar et Local resident Didactic Training to Delivery of primary health referral of

al.2003343 Lady Health provide PHC at the care, family planning patients
CHWs (f) Workers grass roots level. Trained services and maternal to the
to provide essen- and child health care. appropriate
tial maternal and child health
health & family planning facility
services, management
of common ailments
and provision of family
planning material and
health education.
186
187
Study Education Recruitment Training Duration Certifi- Refreshers Role key compe- Supervision Incentive coverage Evaluation
Criteria Content cation / Ongoing tencies (if any) mode
training
Afsar et Local resident Didactic training for ap- Delivery of primary health Appropriate
al.2005342 Lady Health propriate patient referral care, family planning services referrals and
CHWs (f) Workers and maternal and child health building
care. Management of common patient com-
ailments and appropriate pliance with it
referrals where needed
Khan et Lady Health Didactic and Practicum Paid home visits to pro- Primary health KAP assess-
al.2006341 Workers Trained in , antenatal vide antenatal care, family care and ment included
CHWs with a job care, family planning, planning, immunization appropriate home visits,
experience newborn care, vaccina- and growth monitoring of referrals
(female) of more than tion, growth monito- infants and for treatment
24 months ring, common diseases, of common ailments
medicines and referrals.
Satischandra Didactic and Practicum training conducted safe delivery Perinatal care, Post-test
et al.2009 included topics on content rein- and provided newborn care breastfeeding evaluation
339 techniques of conduc- forced during practices. advised correct counseling was done
TBAs ting safe delivery and monthly visits breast-feeding practices,
(female) newborn care practices. 5 months and immunization infor-
after the mation to the mothers.
training.
Mohanty et Anganwadi Didactic and Practicum Identified and managed Newborn and Evaluation
al.1994348 workers Topics included LBW babies, did growth infant care & done at 3, 6
Varasani, belonging recognition and mana- monitoring of infants, management and 9months
India to two ICDS gement of LBW babies, managed diarrhea and gave of diarrhea. after training.
blocks growth monitoring of ORT, taking body tempe-
infants, management rature, and referral of sick
of diarrhea and ORT,
taking body tempera-
ture, and referral system.
Ogunfowora To identify neonatal Identification Evaluation to

& Daniel jaundice and to provide neonatal judge their
2006 349 appropriate management. jaundice knowledge.
CHWs
Zeitz et Trained CHWs by the Refresher they were trained to take ARI mana- post test was
al.1993350 government of Bolivia training was history and manage cases gement in conducted
CHWs according to WHO ARI given for according to IMCI algorithm children to test their
management standards a day and knowledge
outdated ARI
management
training was
refreshed

training
Rowe et alteast 7 reside in the Lectures, role playing 10 days 6-15 days of re- diagnoses of childhood monthly volunteer
al. 2007 years of community + practicum The theory fresher to those illness acrodding to standard group
194 schooling program trained CHW and 5 days found weak criteria using flip charts and meetings
volunteers to assess of clinical then treatment with drugs
(i.e. collect information practice
on clinical signs &
symptoms), diagnose
and treat children <5
years old according to
the CARE Management
Falle et of the Sick Child
al.2009340 (MSC) guidelines, a
TBAs modified version of
(female) the WHO/UNICEF
(IMCI) guidelines

Frazão & The manual was 36-hour Their work included:
Marques developed through providing information &
2009357 the following steps: contribute to improve
identifi cation of people’s ability to manage
common oral health health; help oral health team
conditions in the to identify the most vulnera-
community; formu- ble families in need of more
lation of questions specifi c oral health actions;
about relevant issues &improve access &utilization
to the community; of PHC thus delayed dental
question selection care & reducing the need
and grouping into for urgent consultations
thematic blocks;
general design of
the manual; and
CHW evaluation of
proposed reading ma-
terials and illustrations
188
Short summary of the
global review
It is said that health workers are the backbone ractive sessions,126, 136, 145 practicum and field
of health care delivery. There are over 59.8 mil- work.282, 345, 346 The training was certified only
lion health workers in the world, two-thirds of in few of the studies and most of them were de-
which provide health services and the remai- ployed in rural areas where health care facilities
ning one-third are management and support were not easily accessible. After their training in
workers.358 The main task of a health worker the interventions, they developed several com-
is to share knowledge and teach people pre- petencies which ranged from behavior modifi-
ventive methods and self-care of common cation counseling as in promotion of exclusive
diseases so that they are tackled earlier with breastfeeding with consumption of colostrums
better outcomes.359 Owing to the strength of by the newborn,92, 101, 126, 134, 135 antenatal
the healing power of belief, many CHWs respect care,19, 38, 47, 125, 204, 205, 287, 340 family plan-
their people’s traditions and build on them, hel- ning,204, 207, 280, 341, 360 anxiety management
ping them use the safe traditional remedies and in depressed mothers301 and immunization of
gradually switching them to modern medicine both the mother and the child,41, 48, 51, 56-58, 339,
by increasing their level of awareness.359 340 to the sample collection and lab diagnosis of
malaria,226, 232 TB251, 256 and pap smears.62, 282
In this systematic review, we evaluated the role These CHWs were well trained to provide DOTS
of CHWs in various communities of the world for TB204 and ART44, 286 to ensure treatment
and assessed their compliance with the achie- compliance, and could also treat uncomplicated
vement of health and nutrition related MDG malaria219-222, 228 and ARIs in children.345, 350
targets, mainly Goals 4, 5 and 6. The clustering The CHWs involved in the maternal and birth
of included studies as mentioned earlier was and newborn care preparedness interventions
based on different subsets of these MDGs. The were also capable of providing emergency obs-
assessment of CHWs’ role in various interven- tetric care34, 37 and manage birth asphyxia by
tions across the globe revealed that few years bag-mouth and mouth-mouth resuscitation39,
of formal school education or more had a 97 besides being able to conduct safe and hy-
better impact on the working of the CHWs as gienic deliveries.45, 47, 51, 60
was evident from the attitude of CHWs towards
family planning43 and from the management of Their role in relation to the MDG targets has been
childhood illnesses by CHWs who had had a few versatile. They were agents of health education
years of formal schooling.171, 172, 177 Similarly the in the community to prevent them from STDs,
educated CHWs involved in the primary health malaria, TB and other non-communicable di-
care interventions showed effective performan- seases.89, 90, 101, 157, 160, 181, 190 They promoted
ce in their outreach services like breastfeeding antenatal, intrapartum and postnatal care,57, 94,
and colostrums counseling, antenatal care, 96 initiation of early and exclusive breastfeeding,
contraceptive usage and immunizations.204, 205 promoted use of colostrums92, 101, 126, 134, 135
This was also reflected by patient satisfaction in and growth monitoring of children.19, 20, 57, 348
an intervention where CHWs were psychology This promotive role played a significant role in
graduates who participated in anxiety manage- bringing down maternal mortality32, 33, 94 and
ment and treatment of common mental health under-5 child mortality rates in the communities
problems.301 they served.92, 94, 96, 361 Their role in preventive
medicine can be assessed from the emphasis
The training modality that seemed to be most that they laid in their communities regarding ap-
effective amongst all that were used in the in- propriate nutrition and to stay healthy. 15, 17, 18,
cluded studies, was didactic training with inte- 20 They also emphasized on usage of condoms

and change in sexual behavior, in HIV prevalent deployed, especially the level and amount of
communities.292 Infact some were trained in supervision provided to those workers, which
the social marketing of condoms.280 Besides ad- could have helped us in identifying the im-
vocating preventive strategies they also offered portance of this factor and its association with
treatment for uncomplicated malaria, pneumo- other outcomes. This information would be of
nia and treatment compliance was ascertained great relevance to policy and practice. The dura-
in case of TB and anti-retroviral therapy of HIV tion of training provided to CHWs was the only
as DOTS. As such the role and competencies of consistent information available from these
CHWs were compliant with the MDG targets studies but on its own, did not reveal any addi-
and did show up positive outcomes in the form tional impact on mortality outcomes. Additional
of declining maternal and under-five children information on the initial level of education of
mortality rates, decline in the incidence of ma- CHWs, content of training, provision of refresher
laria, TB and HIV. training, mode of training, balance of practical
or theoretical sessions, remuneration for work,
The supervision and ongoing refresher training amount of activities performed by CHWs would
of CHWs for performing their above mentioned have provided greater assistance in understan-
roles had a positive impact on their performan- ding the threshold effect, if any, of these factors
ce. Similarly the lack of incentives was found to on CHW performance in community settings.
be one of the major reasons behind dropout Importantly, community ownership and super-
rates. However, the provision of incentives vision of CHWs is a key characteristic which is
provided better motivation to work. In some insufficiently described and analyzed in availa-
studies the CHWs were promoted to the level ble literature. Finally, the diversity of studies,
of supervisor. small number of studies in each subgroup and
the limited intervention description precluded
In various studies, a very strong referral system examination of the relations between the cha-
was in place using which the health workers racteristics of the intervention and their effects.
would refer complicated cases to nearby health There is thus a clear need for additional research
care facility after initial management.44, 187, 214, at an appropriate scale with detailed descrip-
215, 218, 228, 285 tion of each intervention bundled in a form of
package.
The diversity observed in the services of CHWs
is a testimony to the wide range of health care We also tried to look at the impact of CHWs
services that they are capable of extending to intervention on the outcome achieved accor-
the community. Several pitfalls and shortco- ding to those who were paid and those who
mings were observed which acted as barriers were unpaid. The major limitation we faced in
to the outreach services of CHWs. However, evaluating this factor was the incomplete docu-
keeping in mind the significance of the role of mentation in the reviewed studies. Among all
CHWs in the achievement of the MDGs makes it 315 reviewed studies, only 32 mentioned that
imperative to address these shortcomings and their CHWs were paid either in terms of salary or
come up with practical recommendations to were getting reimbursement for their meals and
overcome these obstacles. transport cost. While, on the other hand, only 4
studies reported that their workers were unpaid
Notably, most of the reviewed studies when im- or working on voluntary basis. Comparison on
plemented, neglected to document the com- this factor was therefore not promising, and
plete description and characteristics of CHWs results were meaningless.

References:
1 Gray R. Impact of Peer Health Workers and 10 Lehman U, D S. Community health workers:
Mobile Phones on HIV Care [In Progress]. what do we know about them? . World Health
Organization
2 Chakaya JM, Klinkenberg E. Feasibility and http://www.who.int/hrh/documents/com-
Effectiveness of Community Based Isoniazid munity_health_workers.pdf Accessed on
Preventive Therapy in Kenya (IPT) [In Progress]. 14.10.2009; 2007.
3 More NS, Bapat U, Das S, et al. Study Protocol: 11 Haines A, Sanders D, Lehmann U, et al.
cluster-randomised controlled trial of commu- Achieving child survival goals: potential contri-
nity mobilization in Mumbai slums to improve bution of community health workers. Lancet.
care during pregnancy, delivery, postpartum 2007;369:2121-2131.
and for the newborn Trials 2008;9(7).
12 Gilson L. National Community health wor-
4 Rahman A. Integration and evaluation of a ker programmes. World Health Forum. 1990;
community-based maternal-focused approach 11(1):85-86.
to promote exclusive breastfeeding in rural
Pakistan: a cluster randomized controlled trial 13 Gilson L, Walt G, Heggenhougen K, et al. National
[In Progress]. community health worker programs: how can
they be strengthened? Journal of Public Health
5 Costello A. A cluster randomized controlled trial Policy. 1989;10(4):518-532.
of the impact of community women’s groups
and sepsis management by community volun- 14 Chhabra R, Rokx C. World Bank. HNP discussion
teers on newborn survival and maternal and paper: the nutrition MDG indicator - interpre-
infant nutrition [In progress] ting progress Washington: The World Bank May
2004
6 Gill CJ. Lufwanyama Neonatal Survival Project
(LUNESP) [In Progress] 15 Staten LK, Gregory-Mercado KY, Ranger-Moore
J, et al. Provider counseling, health education,
7 Azad K, Barnett S, Banerjee B, et al. The effect of and community health workers: the Arizona
scaling up women’s groups on birth outcomes WISEWOMAN Project. Journal of Women’s
in three rural districts of Bangladesh: a cluster- Health 2004;13(5):547-556..
randomized controlled trial 2009.
16 Hossain SMM, Duffield A, Taylor A. An evalua-
8 Tripathy P, Nair N, Barnett S, et al. Effect of a par- tion of the impact of a US$60 million nutrition
ticipatory intervention with women’s groups on programme in Bangladesh. Health Policy and
birth outcomes in Jharkhand and Orissa, India: Management. 2005;20(1):35-40.
the EKJUT cluster-randomized controlled trial
2009. 17 Kilaru A, Griffiths PL, Ganapathy S, Shanti G.
Community-based Nutrition education for im-
9 Barnett S, Nair N, Lewycka S, Costello A. proving infant growth in rural Karnataka. Indian
Community interventions for maternal and Pediatrics 2005;42:425-432.
perinatal health BJOG: an international journal
of obstetrics and gynecology. 2005;112:1170- 18 Tandon BN. Nutritional interventions through
1173. primary health care: impact of the ICDS in India.
Bull World Health Organ. 1989;67(1):77-80.

19 Winichagoon P. Prevention and control of ame- 27 Freedman LP, Waldman R, De Pinho H,
nia: Thailand experiences Journal of Nutrition. Chowdhury M, Rosenfield A. Who’s got the
2002;132:862-866. power?: Transforming health systems for women
and children: Earthscan/James & James; 2005.
20 Chowdhury S A, Mahmud Z. Intervening
Malnutrition in Rural Bangladesh: BRAC 28 WHO, UNICEF, UNFPA, World Bank. Maternal
Experience Bangladesh Rural Advancement Mortality in 2005 WHO, UNICEF, UNFPA, World
Committee (BRAC), 75 Mohakhali C/A, Dhaka Bank; 2006.
1212.
29 Campbell OM, Graham WJ. Lancet Maternal
21 Zuvekas A, Nolan LS, Tumaylle C. Impacts of Survival Series Steering Group. Strategies for
community health workers on access, use of reducing maternal mortality: getting on with
services and patient knowledge and behavior what works. Lancet. 2006;368:1284-1299.
Bureau of Primary Health Care, US Public Health
Services; 1998. 30 Kaseje MA, Kaseje DC, Spencer HC. The training
process in community-based health care in
22 Winch PJ, Gilroy KE, Doumbia S, et al. Operational Saradidi, Kenya. Annals of Tropical Medicine and
issues and trends associated with the pilot Parasitology. 1987;81 (Suppl 1):67-76.
introduction of Zinc for childhood diarrhea
in Bougouni District, Mali. Journal of Health, 31 Rice-Marquez N, Baker TD, Fischer C. The com-
Population and Nutrition. 2008;26(2):151-162. munity health worker: forty years of experience
of an integrated primary rural health care system
23 Macharia CW, Kogi-Makau W. A comparative in Brazil. Journal of Rural Health 1998;4(1):87-
study on the nutritional status of children (6- 100.
59 months) in a world vision project area and
a non-project area in Kathonzweni division, 32 Ronsmans C, Vanneste AM, Chakraborty J,
Makueni district, Kenya African Journal of Ginneken JV. Decline in maternal mortality in
Food Agriculture Nutrition and Development Matlab, Bangladesh: a cautionary tale. Lancet.
2005;5(1):1-13. 1997;350:1810-1814.
24 BRAC Annual Report. . Dhaka: Reproductive 33 Begum SF. Role of TBAs in improving maternal
Health and Disease Control Program 2000. and neonatal health in Bangladesh: a long-term
program need. 1987. Located at: High risk mo-
25 Ahmed SM. Taking healthcare where the com- thers and newborns, 3607 Thun 7 Switzerland:
munity is: the story of the Shasthya Sebikas of Ott Publishers
BRAC in Bangladesh. BRAC University Journal.
2008;5(1):39-45. 34 McPherson R, Baqui A, Winch P, Ahmed S.
Community-based maternal and neonatal care:
26 Macharia CW, Kogi-Makau W, Muroki NM. Dietary summative report on program activities and
intake, feeding and care practices of children in results in Banke, Jhapa and Kanchanpur districts
Kathonzweni division, Makueni district, Kenya from September 2005 - September 2007: USAID;
East African Medical Journal 2004;81(8):402- 2007.
407.
35 Xu Z. China, lowering maternal mortality in
Miyun County, Beijing World Health Statistics
192
Quarterly. Rapport Trimestriel de Statistiques 44 Zachairah R, Teck R, Buhendwa L, et al.
Sanitalres Mondiales. 1995;48(1):11-14. Community support is associated with better
antiretroviral treatment outcomes in a resource-
36 Padmanaban P, Raman PS, Mavalankar DV. limited rural district in Malawi. Transaction of the
Innovations and challenges in reducing maternal royal society of tropical medicine and hygiene.
mortality in Tamil Nadu, India. Journal of Health, 2006;101:79-84.
Population and Nutrition. 2009;27(2):202-219.
45 Greenwood AM, Bradley AK, Byass P, et al.
37 Purdin S, Khan T, Saucier R. Reducing maternal Evaluation of a primary health care programme
mortality among Afghan refugees in Pakistan. in The Gambia. I The impact of trained traditional
International Journal of Gynecology and birth attendants on the outcome of pregnancy
Obstetrics. 2009;105:82-85. Journal of Tropical Medicine and Hygiene.
1990;93:58-66.
38 Navaneetham K, Dharmalingam A. Utilization of
maternal health care services in Southern India 46 Alisjahbana A, Williams C, Dharmayanti R,
Social Science and Medicine. 2002;55:1849- Hermawan D, Kwast BE, Koblinsky M. An integra-
1869. ted village maternity service to improve referral
patterns in a rural area in West-Java. International
39 Bhuiyan AB, Mukherjee S, Acharya S, Haider Journal of Gynecology and Obstetrics. 1995:48
SJ, Begum F. Evaluation of a Skilled Birth Suppl. S83-S94.
Attendant pilot training program in Bangladesh.
International Journal of Gynecology and 47 Ahmed T, Jakaria S. Community-based skilled
Obstetrics. 2005;90:56-60. birth attendants in Bangladesh: attending de-
liveries at home Reproductive Health Matters
40 Stanback J, Mbonye AK, Bekiita M. Contraceptive 2009;17(33):45-50.
injections by community health workers in
Uganda: a nonrandomized community trial Bull 48 Swaminathan MC, Nadamuni AN, Krishna TP. An
World Health Organ. 2007;85:768-773. evaluation of DAI training in Andhra Pradesh.
In: Mangay-Maglacas A, Simons J, eds. The po-
41 Zeighami E, Zeighami B, Javidian I, Zimmer S. tential of the traditional birth attendant (Offset
The rural health worker as a family planning Publication No. 95). Geneva: World Health
provider: a village trial in Iran. Studies in Family Organization; 1986:22-34.
Planning. 1977;8(7):184-187 http://www.jstor.
org/stable/1965755. 49 T B, N H, S N. Private healthcare in Bangladesh.
Report prepared for the World Bank. Dhaka:
42 Bailey PE, Szászdi JA, Glover L. Obstetric compli- Bangladesh. July 2001.
cations: does training traditional birth attendants
make a difference? Rev Panam Salud Publica/ 50 Gabrysch S, Lema C, Bedrinana E, et al. Cultural
Pan Am J Public Health. 2002;11(1):15-23. adaption of birthing services in rural Ayacucho,
Peru Bull World Health Organ. 2009;87:724-729.
43 Douthwaite M, Ward P. Increasing contraceptive
use in rural Pakistan: an evaluation of the lady 51 Williams B, Yumkella F. An evaluation of the
health workers programme Health Policy and training of traditional birth attendants in Sierra
Management. 2005;20(2):117-123. Leone and their performance after training. In:
Mangay-Maglacas A, Simons J, eds. The poten-

tial of the traditional birth attendant (Offset ted areas of eastern Burma: perspectives from
Publication No. 95). Geneva World Health lay maternal health workers Social Science and
Organization 1986:35-50. Medicine. 2009;68:1332-1340.
52 Hussein AK, Mpembeni R. Recognition of high 60 Foord F. Gambia: Evaluation of the mobile health
risk pregnancies and referral practices among care service in West Kinag district World Health
traditional birth attendants in Mkuranga dis- Statistics Quarterly. Rapport Trimestriel de
trict, Coast Region, Tanzania Arfrican Journal of Statistiques Sanitalres Mondiales. 1995;48(1):18-
Reproductive Health 2005;9(1):113-122. 22.
53 Bailey PE, Szászdi JA, Schieber B. Analysis of the 61 Zhang T, Wu Y, Zhang X, et al. An Evaluation of
vital events reporting system of the maternal effects of intervention on maternal and child
and neonatal health project, Quetzaltenango, health in the rural areas of China Journal of
Guatemala. Mothercare Matters 1996;5(4):13- Sichuan University 2004;35(4):539-542.
22.
62 Shaheen M, Salman R, Al-Sabbah H. Improving
54 Foster J, Anderson A, Houston J, Doe-Simkins postpartum care among low parity mothers in
M. A report of a midwifery model for training Palestine 2003.
traditional midwives in Guatemala. Midwifery.
2004;20:217-225. 63 Zhang D, Unsculd PU. China’s barefoot doctors:
part, present, and future Lancet. 2008;372:1864-
55 Yadav H. Utilization of traditional birth at- 1866.
tendants in MCH care in rural Malaysia Kuala
Lumpur Institute of Keisihatan Uman Jalan 64 McCormick MC, Brooks-Gunn J, Shorter T,
Bangsar; 1987. Holmes JH, Wallace CY, Heagarty MC. Outreach
as care finding: its effect on enrollment in pre-
56 Emond A, Pollock J, Costa Nd, Maranhão T, natal care Medical Care 1989;27(2):103-111.
Macedo A. The effectiveness of community-
based interventions to improve maternal and 65 Couper I. Rural Primary Health care in Iran. The
infant health in the Northeast of Brazil. Rev South African Academy of Family Practice.
Panam Salud Publica/ Pan Am J Public Health 2004;46(5):Retrieved from
2002 12(2):101-110. www.safpj.co.za/index.php/safpj/article/
viewFile/81/81
57 Smith JB, Coleman NA, Fortney JA, Johnson
JD-G, Blumhagen DW, Grey TW. The impacts 66 Cesar JA, Mendoza-Sassi RA, Ulmi EF, Dall’Agnol
of traditional birth attendant training on deli- MM, Neumann NA. Diferentes estrategias de
very complications in Ghana Health Policy and visita domicilar e seus efecitos sobre a assisten-
Management. 2000;15(3):326-331. cia pre-natal no extremo sul do brasil [Effects
of differenthome visits strategies on prenatal
58 Diakite O, Keita DR, Mewbesa W. Guinea: village care in Southern Brazil. Cad. Saude Publica.
health committees drive family planning uptake 2008;24(11):2614-2622.
USAID 2009.
67 Fauveau V, Stewart K, Khan SA, Chakraborty J.
59 Teela KC, Mullany LC, Lee CI, et al. Community- Effect on mortality of community-based ma-
based delivery of maternal care in conflict-affec- ternity-care programme in rural Bangladesh

Lancet. 1991;338:1183-1186. 76 Mushi DL. Community-based safe motherhood
in Tanzania. Promoting access to obstetric care
68 Greenwood AM, Bradley AK, Byass P, et al. through community volunteers in Mtwara rural
Evaluation of a primary health care programme district, Tanzania: Universität Heidelberg; 2007.
in The Gambia. I The impact of trained traditional
birth attendants on the outcome of pregnancy 77 Bhiromrut P. Integrated birth spacing and MNCH
Journal of Tropical Medicine and Hygiene Program in Narratives Province Integration.
1990;93:58-66. 1990;24:28-32.
69 Fox-Rushby JA, Foord F. Costs, effects and cost- 78 Bailey JE, Coombs DW. Effectiveness of
effectiveness analysis of a mobile maternal an Indonesian model for rapid training of
health care services in West Kiang, The Gambia Guatemalan health workers in diarrhea case
Health Policy and Planning. 1996;35(2):123-143. management Journal of Community Health.
1996;21(4):269-276.
70 CDPHC. Improving postpartum care among
low parity mothers in Palestine: Frontiers Final 79 Wollast E, Renard F, Vandenbussche P, Buekens
Report Washington, DC Population Council May P. Detecting maternal morbidity and mortality
2003. by traditional birth attendanst in Burkina Faso
Health Policy and Planning. 1993;8(2):161-168.
71 Moore FI, Ballinger P, Beasley JD. Influence of
postpartum home visits on postpartum clinic at- 80 Ahluwalia IB, Schmid T, Kouletio M, Kanenda O.
tendance Public Health Reports. 1974;89(4):360- An evaluation of a community-based approach
364. to safe motherhood in northwestern Tanzania
International Journal of Gynecology and
72 Benara SK, Chaturvedi SK. Impact of training on Obstetrics. 2003;82:231-240.
the performance of traditional birth attendants
Journal of Family Welfare 1990;36(4):32-35. 81 Goodburn E, Chowdhury M, Gazi R, Marshall T,
Graham W. Training traditional birth attendants
73 The Mobile Obstetrics Maternal Health Worker in clean delivery does not prevent postpar-
Project (MOM): increasing access to reproduc- tum infection. Health Policy and Planning.
tive health services in eastern Burma The Bill 2000;15(4):394-399.
and Melinda Gates Institute for population
and Reproductive Health at the Johns Hopkins 82 Cordon O, Fonseca-Becker F. Mobilizing for
Bloomberg School of Public Health Impact: engaging Guatemalan communities to
save mothers USAID May 2004.
74 Mullany LC, Lee CI, Paw P, et al. The MOM project:
delivering maternal health services among in- 83 Save the Children 2001. State of the World’s
ternally displaced population in eastern Burma Newborns. http://www.savethechildren.org/
Reproductive Health Matters 2008;16(31):44-56. publications/newborns_report.pdf. (Accessed
on October 2009). 2001.
75 Bisika T. The effectiveness of the TBA programme
in reducing maternal mortality and morbidity 84 Hyder AA, Wali SA, McGuckin J. The burden of di-
in Malawi. East African Journal of Public Health sease from neonatal mortality: a review of South
2008;5(2):103-110. Asia and Sub-Saharan Africa. British Journal of
Obstetrics and Gynecology. 2003;110:894-901.

85 Stoll. Neonatal infections: a global perspective. 93 Baqui AH, Williams EK, Rosecrans AM, et al.
In: Remington JS, Klein JO (editors). Infectious Impact of an integrated nutrition and health pro-
diseases of the fetus, newborn and infants. gramme on neonatal mortality in rural northern
Philadelphia: WB Saunders; 2001. India. Bulletin of the World Health Organization.
2008;86(10):796-804.
86 WHO Reproductive Health: The Mother
Baby Package. http://www.who.int/repro- 94 Jhokio AH, Winter HR, Cheng KK. An intervention
ductive-health/publications/MSM_94_11/ involving traditional birth attendants and peri-
MSM_94_11_executive_summary.en.html. natal and maternal mortality in Pakistan. New
(Accessed on October 2009) 1994. England Journal of Medicine. 2005;352:2091-
2099.
87 Manandhar DS, Osrin D, Shrestha BP, et al. Effect
of participatory intervention with women’s 95 Bari S, Mannan I, Rahman MA, et al. Bangladesh
groups on birth outcomes in Nepal: cluster ran- Projahnmo-II Study Group. Trends in Use
domized control trial. Lancet. 2004;364:970-979. of Referral Hospital Services for Care of Sick
Newborns in a Community-based Intervention
88 Hadi A, Ahmed M. Saving newborn lives in rural in Tangail District, Bangladesh. Journal of Health,
communities: learning from the BRAC expe- Population and Nutrition. 2006;24(4):519-529.
rience Dhaka, Bangladesh BRAC Research and
Evaluation Division December 2005. 96 Darmstadt GL, Hussein MH, Winch PJ, Haws
RA, Gipson R, Santosham M. Practices of rural
89 O’Rourke K, Howard-Grabman L, Seoane G. Egyptian birth attendants during the antena-
Impact of community organization of women tal, intrapartum and early neonatal periods
on perinatal outcome in rural Bolivia. Revista Journal of Health, Population and Nutrition.
Pan-American de Salud Publica / Pan American 2008;26(1):36-45.
Journal of Public Health. 1998;3(1):9-14.
97 Bhutta ZA, Hafeez A, Soofi SB, Memon ZA.
90 Barnes-Boyd C, Fordham K, Nacion KW. Naushero Feroze Neonatal Survival Project: A
Promoting infant health through home visiting cluster randomized trial to determine the effec-
by a nurse-managed community worker team. tiveness of package of community based inter-
Public Health Nursing 2001;18(4):225-235. ventions to reduce neonatal deaths due to birth
asphyxia, low birth weight & neonatal sepsis. [in
91 Baqui AH, El-Arifeen S, Darmstadt GL, et al. progress]; 2009.
Effect of community-based newborn-care
intervention package implemented through 98 Julnes G, Konefal M, Pindur W, Kim P.
two service-delivery strategies in Sylhet district, Community-based perinatal care for disadvan-
Bangladesh: a cluster-randomized controlled tages adolescents: evaluation of three resource
trial. Lancet. Jun 7 2008;371(9628):1936-1944. mother program Journal of Community Health.
1994;19(1):41-53.
92 Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens
S, Martines J. Implementing community-based 99 Orimbia, Vincent. Community initiative in ma-
perinatal care: results from a pilot study in nagement of childhood illness: partnering with
rural Pakistan. Bulletin of the World Health communities for IMCI case management. Paper
Organization. 2008;86:452-459. presented at: Reaching communities for Child
health: advancing PVO/NGO technical capacity

and leadership for HH/C IMCI, 2001; Baltimore. trict, Bangladesh. Final Report USAID; 2007.
100 Kelly JM, Osamba B, Garg RM, et al. Community 107 Baqui AH, Arifeen SE, Williams EK, et al.
Health Worker Performance in the Management Effectiveness of home-based management of
of Multiple Childhood Illnesses: Siya district, newborn infections by community health wor-
Kenya, 1997-2001. American Journal of Public kers in rural Bangladesh. Pediatr Infect Dis J. Apr
Health. 2001;91:1617-1624. 2009;28(4):304-310.
101 Bolam A, Manandhar DS, Shrestha P, Ellis M, 108 Darmstadt GL, Kumar V, Yadav R, et al.
Costello AMdL. The effects of postnatal health Introduction of community based skin to skin
education for mothers on infant care and care in rural Uttar Pradesh, India. Journal of
family planning practices in Nepal: a rando- Perinatology. 2006;26:597-604.
mized controlled trial. British Medical Journal.
1998;316:205-211. 109 Kumar V, Mohanty S, Kumar A, et al. Effect of
community based behaviours change manage-
102 Turan JM, Say L. Community-based antenatal ment on neonatal mortality in Shivgarh, Uttar
education in Istanbul, Turkey: effects on health Pradesh, India: a cluster-randomised controlled
behaviours Health Policy and Management. trial. Lancet. 2008;372:1151-1162.
2003;18(4):391-398.
110 Osrin D, Mesko N SB, Shrestha D, Tamang S, Thapa
103 McPherson RA, Khadka N, Moore JM, Sharma M. S, Tumbahangphe KM, Shrestha JR, Manandhar
Are Birth-preparedness programmes effective? MK, Manandhar DS, Standing H, Costello AML.
Results from a field trial in Siraha district, Nepal. Implementing a community based participatory
Journal of Health, Population, and Nutrition. intervention to improve essential newborn care
2006;24(4):479-488. in rural Nepal. Transaction of the royal society of
tropical medicine and hygiene. 2003;97:18-21.
104 Moran AC, Sangli G, Dineen R, Rawlins B,
Yaméogo, Baya B. Birth-preparedness for ma- 111 Morrison J, Tamang S MN, Osrin D, Shrestha
ternal health: findings from Koupéla district, B, Manandhar M, Manandhar D, Standing H,
Burkina Faso. Journal of Health, Population, and Costello AML. Womens health groups to impro-
Nutrition. 2006;24(4):489-497. ve perinatal care in rural Nepal. BMC pregnancy
and child birth. 2005 5:6.
105 Baqui AH AS, Darmstadt GL, Ahmed S, Williams
EK, Seraji HR, Mannan I, Rahman SM, Shah R, 112 Wade A, Osrin D, Shrestha BP, Sen A MJ,
Saha SK, Syed U, Winch PJ, Lefevre A, Santosham Tumbahangphe KM, Manandhar DS,, Costello
M, Black RE. Effect of community based new- AML. Behaviour change in perinatal care practi-
born-care intervention package implemented ces among rural women exposed to a women’s
through two service-delivery strategies in Sylhet group intervention in Nepal. BMC pregnancy
district, Bangladesh: A cluster randomized and child birth. 2006;6:20.
controlled trial. Lancet. 2008;371:1936-1944.
113 Mannan I, Rahman SM, Sania A, et al. Can early
106 Baqui AH, Arifeen SE. Community-based in- postpartum home visits by trained community
terventions to reduce neonatal mortality in health workers improve breastfeeding of new-
Bangladesh. Projahnmo - I: Project for advancing borns? Journal of Perinatology. 2008;28:632-
the health of newborns and mothers, Sylhet dis- 640.

114 Baqui AH RA, Williams EK, Agrawal PK, Ahmed S, 122 WHO. World Health Organization expert commit-
Darmstadt GL, Kumar V, Kiran U, Panwar D, Ahuja tee report. Geneva World Health Organization
RC, Srivastava VK, Blacka RE, Santoshama M. NGO 2001.
facilitation of a government community-based
maternal and neonatal health programme in ru- 123 Achieving Millennium Development Goals: Role
ral India: improvements in equity. Health Policy of breastfeeding on child sruvival and beyond
and Planning. 2008;23:234-243. Updated Last Updated Date. Accessed on
October 2009
115 Syed U, Asiruddin S, Helal SI MI, Murray J.
Immediate and early postnatal care for mothers 124 Schafer E, Vogel MK, Viegas S, Hausafus C.
and newborns in rural Bngladesh. Journal of Volunteer peer counselors increase breastfee-
Health, Nutrition and Population. 2006;24(4):508- ding duration among rural low-income women
518. Birth. 1998;25(2):101-106.
116 Gonzales F, Arteaga E, Howard-Grabman L. 125 MacArthur C, Jolly K, Ingram L, et al. Antenatal
Scaling up the WARMI project: lessons learned peer support workers and initiation of breast
mobilizing Bolivian communities around re- feeding: cluster randomized controlled trial.
productive health. Bolivia Save the Children British Medical Journal. 2009;338:b131.
Foundation 1998.
126 Dennis C-L, Hodnett E, Gallop R, Chalmers B. The
117 Fullerton JT, Killian R, Gass PM. Outcomes of a effect of peer support on breast-feeding dura-
community-and home-based interventions for tion among primiparous women: a randomized
safe motherhood and newborn care Health controlled trial. CMAJ. 2002;166(1):21-28.
Care for Women International 2005;26:561-576.
127 Chapman DJ, Damio G, Young S, Perez-Escamilla
118 Walraven GEL, Mkanje RJB, Roosmalen J, Dongen R. Effectiveness of breastfeeding peer counse-
PWJ van, Dolmans WMV. Perinatal mortality in ling in a low-income, predominantly Latina po-
home births in rural Tanzania. European Journal pulation. Archives of Pediatrics and Adolescents
of Obstetrics and Gynecology and Reproductive Medicine 2004;158:897-902.
Biology 1995;58:131-134.
128 Mclnnes RJ, Love JG, Stone DH. Evaluation of
119 Jackson AA, Ashworth A, Khanum S. Improving a community-based intervention to increase
child survival: Malnutrition task force and the breastfeeding prevalence Journal of Public
paediatrician’s responsibility. Achieves of Disease Health Medicine 2000;22(2):138-145.
in Childhood. 2006;91(8):706-710.
129 Frank DA, Wirtz SJ, Sorenson JR, Heeren T.
120 UNICEF. The challenge: while progress to date Commercial discharge packs and breast-feeding
has been encouraging, significantly more than counseling: effects on infant-feeding practices in
half of the world’s children are not as yet being a randomized trial. Pediatrics 1987;80:845-854.
optimally breastfed. http://www.unicef.org/pro-
gramme/breastfeeding/challenge.htm: UNICEF 130 Agrasada G, Gustafsson J, Kylberg E, Ewald
2008. U. Postnatal peer counseling on exclusive
breastfeeding of low-birth weight infants: a
121 WHO/UNICEF. WHO/UNICEF, Global strategy for randomized, controlled trial. Acta Padiatrica.
infant and young child feeding. . 2003. 2005;94:1109-1115.

131 Leite AJM, Puccini RF, Atalah AN, Cunha ALAD, volunteer counselors for mothers conside-
Machado MT. Effectiveness of home-based peer ring breastfeeding. British Medical Journal.
counseling to promote breastfeeding in the 2004;328(26):doi:10.1136/bmj.1328.7430.1126.
northeast of Brazil: a randomized clinical trial
Acta Padiatrica. 2005;94:741-746. 139 Espejo, Luis, Tam L. Saving the lives of children
with pneumonia by linking health facilities with
132 Morrow AL, Guerrero ML, Shults J, et al. Efficacy the community in rural areas of Peru. Paper
of home-based peer counseling to promote ex- presented at: Reaching Communities for child
clusive breastfeeding: a randomized controlled Health: advancing PVO?NGO Technical Capacity
trial. Lancet. 1999;353:1226-1231. and Leadership for HH?C IMCI, 2001; Baltimore
133 Quinn VJ, Guyon AB, Schubert JW, Stone-Jienez 140 Morrell CJ, Spiby H, Stwart P, Walters S, Morgan
M, Hainsworth MD, Martin LH. Improving A. Costs and effectiveness of community pos-
breastfeeding practices on a board scale at the tnatal support workers: randomized controlled
community level: success stories from Africa trial British Medical Journal. 2000;321:593-598.
and Latin America Journal of Human Lactation.
2005;21(345):DOI: 10.1177/0890334405278383. 141 Bhandari N, Mazumdar S, Bahl R, Martines J,
Black RE, Bhan MK. and other members of in-
134 Haider R, Ashworth A, Kabir I, Huttly SRA. fant Feeding Study Group. Journal of Nutrition
Effect of community-based peer counselor 2004;134:2342-2348.
on exclusive breastfeeding practices in Dhaka,
Bangladesh: a randomized controlled trial 142 Guerrero ML, Morrow RC, Calva JJ, et al. Rapid
Lancet. 2000;356:1643-1647. ethnographic assessment of breastfeeding
practices in periurban Mexico city. Bull World
135 Bhandari N, Bahl R, Mazumdar S, Martines J, Health Organ. 1999;77(4):323-330.
Black RE, Bhan MK. and other members of Infant
Feeding Study Group. Effect of community- 143 Chapman DJ, Damio G, Pere-Escamilla R.
based promotion of exclusive breastfeeding on Differential response to breastfeeding peer
diarrheal illness and growth: a cluster randomi- counseling within a low-income, predominantly
zed controlled trial Lancet 2003;361(9367):1418- Latina population. Journal of Human Lactation.
1423. 2004;20(4):389-396.
136 Nankunda J, Tumwine JK, Soletvedt A, Semiyaga 144 Anderson AK, Damio G, Young S, Chapman DJ,
N, Ndeezi G, Tylleskar T. Community based Perez-Escamilla R. A randomized trial assessing
peer counsellors for support of exclusive the efficacy of peer counseling on exclusive
breastfeeding: experiences from rural Uganda breastfeeding in a predominantly Latina low
International Breastfeeding Journal 2006;1(19). income population. Archives of Pediatrics and
Adolescents Medicine. 2005;159:836-841.
137 Davies-Adetugbo AA, Fabiyi AK, Ojoofeitimi EO,
Adetugbo K. Breastfeeding training improves 145 Agrasada GV, Gustafsson J, Kylberg E, Ewald
health worker performance in rural Nigeria East U. Postnatal peer counseling on exclusive
African Medical Journal. 1997;74(8):510-513. breastfeeding of low-birth weight infants: a
randomized, controlled trial. Acta Padiatrica.
138 Graffy J, Taylor J, Williams A, Eldridge S. 2005;94:1109-1115.
Randomized controlled trial of support from

146 Caulfield LE, Gross SM, Bentley ME, et al. WIC- 156 Bang AT BR, Baitule SB, Reddy HM, Deshmukh
based interventions to promote breastfeeding MD. Reduced incidence of neonatal morbidi-
among African-American women in Baltimore: ties: effect of home-based neonatal care in rural
effects on breastfeeding initiation and continua- Gadchiroli, India. Management of birth asphyxia
tion. Journal of Human Lactation. 1998;14(1):15. in home deliveries in rural Gadchiroli: the effect
of two types of birth attendants and of resusci-
147 Coutinho SB, Lira PIad, Lima MdC, Ashworth A. tating with mouth-to-mouth, tube-mask or bag-
Comparison of the effect of two systems for the mask. Journal of Perinatology. 2005;25:S82-S91.
promotion of exclusive breastfeeding. Lancet.
2005;366:1094-1100. 157 Bang AT, bang RA, Morankar VP, Sontakke PG,
Solanki JM. Pneumonia in neonates: can it
148 Haider R, Kabir I, Hamadani JD, Habte D. Reasons be managed in the community? Archives of
for failure of breastfeeding counseling: mother’s Disease in Childhood. 1993;68:550-556.
perspective in Bangladesh. Bull World Health
Organ. 1997;75(3):191-196. 158 Bang AT, Bang RA, Baitule SB, Reddy MH,
Deshmukh MD. Effect of home-based neonatal
149 United Nations. Fact Sheet for Goal 4 End Poverty care and management of sepsis on neona-
2015 - Make it happen 2008 tal mortality: field trial in rural India. Lancet.
1999;354:1955-1961.
150 UN. Fact Sheet for Goal 4 End Poverty 2015 -
Make it Happen; 2008. 159 Daga SR, Daga AS, Dighole RV, Patil RP. Anganwadi
worker’s participation in rural newborn care
151 Walsh JA, Measham AR, Feifer CN, Gertler PJ. Indian Journal of Pediatrics. 1993;60:627-630.
The impact of maternal health improvement
on perinatal survival: cost-effective alternatives. 160 Dongre AR, Deshmukh PR, Garg BS. A communi-
International Journal of Health Planning and ty-based approach to improve health care see-
Management. 1994;9(2):131-149. king for newborn danger signs in rural Wardha,
India. Indian Journal of Pediatrics. 2009;76(1):45-
152 WHO. Essential newborn care: report of a tech- 50.
nical working group. Geneva: World Health
Organization; 1996. 161 Sloan NL, Ahmed S, Mitra SN, et al. Community-
based kangaroo mother care to prevent neona-
153 Stanton C, Lawn JE RH, Wilczynska-Ketende K, tal and infant mortality: a randomized, controlled
Hill K. Stillbirth rates: delivering estimates in 190 cluster trial. Pediatrics. 2008;121(5):e1047-e1059,
countries. Lancet. 2006;367:1487-1494. DOI: 1010.1542/peds.2007-0076.
154 Zupan J, Aahman E. Perinatal mortality for 162 Bang AT, Bang RA, Sontakke PG. Management of
the year 2000: estimates developed by WHO. childhood pneumonia by traditional birth atten-
Geneva: World Health Organization; 2005. dant Bull World Health Organ. 1994;72(6):897-
905.
155 Saleem S, Reza T, McClure EM, et al. Chlorhexidine
vaginal and neonatal wipes in home births 163 Bang AT, Bang RA, Reddy HM, Deshmukh MD,
in Pakistan. Obstetrics and Gynecology. SB B. Reduced incidence of neonatal morbi-
2007;110(5):977-1018. dities: effect of home-based neonatal care in
rural Gadchiroli, India. Journal of Perinatology.

2005;25:S51-S61. of Pediatrics and Adolescents Medicine.
2009;163(3):225-232.
164 Pfaff C. Midlevel primary health care workers in
Nepal Rural Health Issues 2004;46(2). 173 Stewart JC, Hood WR. Using workers from «hard-
core» areas to increase immunization levels
165 Bang AT, Reddy HM, Deshmukh MD, Baitule Public Health Reports 1970;85(2):177-188.
SB, Bang RA. Neonatal and infant mortality in
the ten years (1993 to 2003) of the Gadchiroli 174 Cauffman JG, Wingert WA, Fridman DB,
field trial: effect of home-based neonatal care. Warburton EA, Hanes B. Community health
Journal of Perinatology. 2005;25:S92-S107. aides: how effective are they? American Journal
of Public Health. 1970;60(10):1904-1909.
166 Bang AT BR, Baitule SB, Reddy MH, Deshmukh
MD. Effect of home-based neonatal care and 175 Arifeen SE, Hoque DME, Akter T, et al. Effect of the
management of sepsis on neonatal mortality: Integrated Management of Childhood Illness
field trial in rural India. Lancet. 1999;354:1955- strategy on childhood mortality and nutrition in
1961. a rural area in Bangladesh: a cluster randomized
trial Lancet. 2009;374:393-403.
167 Bang AT BR, Reddy HM, Deshmukh MD, Baitule
SB. Reduced incidence of neonatal morbidi- 176 Ali M, Emch M, Tofail F, Baqui AH. Implications
ties: effect of home-based neonatal care in of health care provision on acute lower respira-
rural Gadchiroli, India. Journal of Perinatology. tory infection mortality in Bangladeshi children
2005;25:S51-S61. Social Science and Medicine. 2001;52:267-277.
168 Brown B. Home-based neonatal care by village 177 Khan AJ, Khan JA, AKbar M, Addiss DG. Acute
health workers in rural India reduces deaths from respiratory infections in children: a case
bacterial infection. Digests 2000;26(2):92-93. management intervention in Abbottabad
district: Pakistan. Bull World Health Organ.
169 Bellamy C. The state of the world’s children 2005: 1990;68(5):577-585.
Childhood under threat: UNICEF; 2004.
178 César JA, Lima GSd, Houthausen RS. Evaluating
170 Barnes K, Friedman SM, Namerow PB, Honig J. the impact and cost of interventions with
Impact of community volunteers on immuni- community health workers on child health: a
zation rates of children younger than 2 years Brazilian experience. Boston: Harvard School of
1999;153:518-524. Public Health 1998.
171 Rodewald LE, Szilagyi PG, Humiston SG, Barth 179 Ghebreyesus T A, Witten K H, Getachew A,
R, Kraus R, Raubertas RF. A randomized study of O’Neill K, Bosman A, A T. Community-based
tracking with outreach and provider prompting malaria control in Tigray Northern Ethiopia.
to improve immunization coverage and primary Parassitologia. 1999;41:367-371.
care pediatrics 1999;103:31-38.
180 Chopra M, Wilkinson D. Vaccination coverage is
172 Fisher EB, Strunk RC, Highstein GR, et al. A higher in children living in areas with commu-
Randomized controlled evaluation of the effect nity health workers in rural South Africa. Journal
of community health workers on hospitaliza- of Tropical Pediatrics 1997;43:372-374.
tion for asthma: the asthma coach. Archives

181 Mtango FDE, Neuvians D. Acute respiratory in- Management of sick children by health workers
fections in children under five years. Control pro- in Ballabgrah: lessons for implementation of
ject in Bagamoyo district, Tanzania. Transaction IMCI in India Journal of Tropical Pediatrics. 2004;
of the royal society of tropical medicine and 50(1):41-47.
hygiene. 1986;80:851-858.
189 Alderman H, Ndiaye B, Linnemayr S, et al.
182 Pence BW, Nyarko P, Phillips JF, Debpuur C. The Effectiveness of a community-based interven-
effect of community nurses and health volun- tion to improve nutrition in young children
teers on child mortality: the Navrongo commu- in Senegal: a difference in difference analysis
nity health and family planning project New Public Health Nutrition 2008;12(5):667-673.
York, USA Population Council 2005.
190 Perry H, Cayemittes M, Philippe F, et al. Reducing
183 Curtale F, Siwakoti B, Lagrosa C, LaRaja M, Guerra under five mortality through Hospital Albert
R. Improving skills and utilization of community Schweitzer’s integrated system in Haiti Oxford
health volunteeers in Nepal. Social Science and University Press 2006.
Medicine. 1995;40(8):1117-1125.
191 Arifeen SE, Blum LS, Hoque DME, et al. Integrated
184 Congsuvivatwong V, Mo-Suwan L, Tayakkanonta Management of Childhood Illness (IMCI) in
K, Vitsupakorn K, McNeil R. Impacts of training of Bangladesh: early findings from a cluster-rando-
village health volunteers in reduction of morbi- mized study. Lancet. 2004;364:1595-1602.
dity from acute respiratory infections in child- 192
hood in Southern Thailand. Southeast Asian Black MM, Dubowitz H, Hutcheson J, Berenson-
Journal of Tropical Medicine and Public Health. Howard J, Starr RH. A randomized clinical trial of
1996;27(2):333-338. home intervention for children with failure to
thrive Pediatrics 1995;95:807-814.
185 Chaudhary N, Mohanty PN, Minakshi Sharma.
Integrated Management of Childhood Illness 193 Brugha RF, Kevany JP. Maximizing immunization
(IMCI) follow-up of basic health workers Indian coverage through home visits: a controlled
Journal of Pediatrics. 2005;72:735-739. trial in an urban area of Ghana. World Health
Organization. 1996;74(5):517-524.
186 Dawson P, Pradhan YV, Houston R, Karki S, Poudel
D, Hodgins S. From research to national expan- 194 Rowe SY, Kelly JM, Olewe MA, et al. Effect of
sion: 20 years’ experience of community-based multiple interventions on community health
management of childhood pneumonia in Nepal. workers’ adherence to clinical guidelines in
Bull World Health Organ. 2008;86:339-343. Siaya district, Kenya. Transactions of the Royal
Society of Tropical Medicine and Hygiene.
187 Winch PJ, Bagayoko A, Diawara A, et al. Increases 2007;101(2):188-202.
in correct administration of Choloquine in the
home and referral of sick children to health faci- 195 Black MM, Dubowitz H, Hutcheson J, Berenson-
lities through a community-based intervention Howard J, Starr Jr RH. A randomized clinical trial
in Bougnouni district, Mali. Transaction of the of home intervention for children with failure to
royal society of tropical medicine and hygiene. thrive. Pediatrics. 1995;95(6):807.
2003;97:481-490.
196 Fagbule D, A K. Case management by commu-
188 Anand K, Patro BK, Paul E, Kapoor SK. nity health workers of children with acute res-

piratory infections: implications for national ARI Evidence-led training and communication
control programme Journal of Tropical Medicine tools for lady health workers in Sindh, Pakistan:
and Hygiene. 1995; 98:241-246. Final Technical Report Sindh CIET in collabora-
tion with the National Programme for Family
197 Perry H, Berggren W, Berggren G, et al. Long-term Planning and Primary Health Care. Government
reductions in mortality among children under 5 of Sindh, Pakistan August 2002.
in rural Haiti: effects of a comprehensive health
system in an impoverished setting American 205 Oxford Policy Management. Lady Health Worker
Journal of Public Health. 2007; 97:240-246. Programme: External Evaluation of the National
Programme for Family Planning and Primary
198 Huicho L, Scherpbier RW, Nkowane AM, Victoria Health Care 1999-2002: Final Report: Oxford
CG. and the Multi-Country Evaluation of IMCI Policy Management March 2002.
Study Group. Lancet. 2008;372:910-916.
206 Sauerborn R, Nougtara A, Diesfeld HJ. Low utili-
199 Lindblade KA, Mwololo K, van Eijk AM, et al. zation of community health workers results from
Evaluation of the WHO Hemoglobin Color Scale a household interview survey in Burkina Faso
for diagnosis of anaemia in children and pre- Social Science and Medicine. 1989; 29(10):1163-
gnant women as used by primary health care 1174.
nurses and community health workers in wes-
tern Kenya. Tropical Medicine and International 207 Bukhari SIA, Gupta JP. Performance evaluation
Health. 2006;11(11):1679-1687. of health guides in a primary health cenre area.
200 Edward A, Ernst P, Taylor C, Becker S, Mazive E, 208 Reis T, Elder J, Satoto, Kodyat BA, Palmer A. An
Perry H. Examining the evidence of under-five examination of the performance and motiva-
mortality reduction in a community-based pro- tion of Indonesian village health volunteers
gramme in Gaza, Mozambique. Transaction of International Quarterly of Community Health
the royal society of tropical medicine and hy- Education 1991;11(1):19-27.
giene. 2007;101:814-822.
209 Omer K, Mhatre S, Ansari N, Laucirica J, Andersson
201 Hill AG, MacLeod WB, Joof D, Gomez P, Ratcliffe N. Evidence-based training of frontline health
AA, Walraven G. Decline of mortality in children workers for door-to-door health promotion: a
in rural Gambia: the influence of village-level pilot randomized controlled cluster trial with
primary health care Tropical Medicine and lady health workers in Sindh Province, Pakistan.
International Health. 2000;5(2):107-118. Patient education and counseling. 2008;72:178-
185.
202 Edpuganti R. The role of community health
agents in northeastern Brazil: an analysis of 210 Kauffman KS, Myers DH. The changing roel of vil-
health knowledge transfer in the community lage health volunteers in Northeast Thailand: an
New England Journal of Medicine. 2005. ethnographic field study. International Journal
of Nursing studies. 1997;34(4):249-255.
203 Wayland C. Acceptable and appropriate: pro-
gram priorities vs. felt needs in a CHW program 211 Colombo TJ, Freeborn DK, Mullooly JP, Burnham
Critical Public Health. 2002;12(4):335-350. VR. The effect of outreach workers’ educational
efforts on disadvantaged preschool children’s
204 Omer K, Ansari NM, Mhatre S, Andersson N. use of preventive services. American Journal of

Public Health. 1979;69(5):465. 220 Pagnoni F, Convelbo N, Tiendrebeogo J, Cousens
S, Esposito F. A community-based programme
212 Breman JG, Alilio MS, Mills A. Conquering the to provide prompt and adequate treatment of
intolerable burden of malaria: what’s new, presumptive malaria in children. Transaction of
what’s needed: a summary. American Journal of the royal society of tropical medicine and hy-
Tropical Medicine and Hygiene 2004;71:1-15. giene. 1997; 91:512-517.
213 Sachs JD, McArthur JW. The Millennium Project: a 221 Sievers AC, Lewey J, Musafiri P, et al. Reduced
plan for meeting the Millennium Development. paediatric hospitalization for malaria and
Lancet. 2005; 365:347-353. febrile illness patterns following implemen-
tation of community-based malaria control
214 Kouyaté B, Somé F, Jahn A, et al. Process and ef- programme in rural Rwanda. Malaria Journal.
fects of a community intervention on malaria in 2008;7(167):doi:10.1186/1475-2875-1187-1167.
rural Burkina Faso: randomized controlled trial
Malaria Journal. 2008;7(50):doi:10.1186/1475- 222 Spencer HC, Kaseje DCO, Mosley WH, Sempebwe
2875-1187-1150. EKN, Huong AY, Roberts JM. Impact on morta-
lity and fertility of a community-based malaria
215 Kidane G, Morrow RH. Teaching mothers to provi- control programme in Saradidi, Kenya Annals
de home treatment of malaria in Tigray, Ethiopia: of Tropical Medicine and Parasitology. 1996;81
a randomized trial Lancet. 2000;356:550-555. (1):36-45.
216 Mbonye AK, Bygbjerg IC, P M. Intermittent pre- 223 Kroeger A, Meyer R, Macheno M, Gonzalez M.
ventive treatment of malaria in pregnancy: a Health education for community-based ma-
new delivery system and its effect on maternal laria control: an intervention study in Ecuador,
health and pregnancy outcomes in Uganda. Bull Colombia and Nicaragua. Tropical Medicine and
World Health Organ. 2008; 86:93-100. International Health. 1996; 1(6):836-846.
217 Nsungwa-Sabiiti J, Peterson S, Pariyo G, Ogwal- 224 Thang ND, Erhart A, Hung LX, et al. Rapid des-
Okeng J, Petzgold MG, Tomson G. Home-based crese of malaria morbidity following the intro-
management of fever and malaria treatment duction of community-based monitoring in a
practices in Uganda. Transaction of the royal rural area of central Vietnam. Malaria Journal.
society of tropical medicine and hygiene. 2009;8(3):doi:10.1186/1475-2875-1188-1183.
2007;101:1199-1207.
225 Das LK, Purushothoman Jambulingam,
218 Delacollette C, Stuyft PVd, Molima K. Using Sadanandane C. Impact of community-based
community health workers for malaria control: presumptive Chloroquine treatment of fever
experience in Zaire. Bull World Health Organ. cases on malaria morbidity and mortality in a
1996;74(4):423-430. tribal area on Orissa State, India Malaria Journal.
2008;7(75):doi:10.1186/1475-2875-1187-1175.
219 Onwujekwe O, Dike N, Ojakwu J, et al. Consumer
stated and revealed preferences for community 226 Okanurak K, Ruebush TK. Village-based dia-
health workers and other strategies for the pro- gnosis and treatment of malaria Acta Tropica.
vision of timely and appropriate treatment of 1996;61:157-167.
malaria in southeast Nigeria Malaria Journal.
2006;5(117):doi:10.1186/1475-2875-1185-1117. 227 Okanurak K, Sornmani S. Community participa-

tion in the malaria control program in Thailand: 235 Jobert B. Populism and Health policy: the case
a review Southeast Asian Journal of Tropical of community health volunteers in India. Social
Medicine and Public Health. 1992;23 Suppl 1:36- Science and Medicine. 1985;20(1):1-28.
43.
236 Walt G, Perera M, Heggenhougen K. Are larger
228 Deressa W, Olana D, Chibsa S. Community parti- scale volunteer community health woker pro-
cipation in malaria epidemic control in highland grammes feasible? The case of Sri Lanka Social
areas of southern Oromia, Ethiopia. Ethiopian Science and Medicine. 1989;29(5):599-608.
Journal and Health Development. 2005; 19(1):3-
10. 237 Hathirat S. Buddhist Monks as community
health workers in Thailand Social Science and
229 Kolaczinski JH, Ojok N, Opwonya J, Meek S, Medicine. 1983;17(19):1485-1487.
Collins A. Adherence of community caretakers
od children to pre-packaged antimalarial medi- 238 Moyou-Somo R, Lehman LG, Awahmukalah S,
cines (HOMAPAK®) among internally displaced Ayuk EP. Deltamethrin impregnated bednets
people in Gulu district, Uganda Malaria Journal. for the control of urban malaria in Kumba
2006;5(40). Town, South-West Province of Cameroon.
The Journal of tropical medicine and hygiene.
230 Ruebush II TK, Godoy ZHA, Klein RE. Use of illi- 1995;98(5):319.
terate volunteer workers for malaria case detec-
tion and treatment. Annals of Tropical Medicine 239 Kroeger A, Mancheno M, Alarcon J, Pesse K.
and Parasitology. 1990;84(2):119-125. Insecticide-impregnated bed nets for malaria
control: varying experiences from Ecuador,
231 Menon A, Snow RA, Byass P, Greenwood BM, Colombia, and Peru concerning acceptability
Hayes RJ, ABH NJ. Sustained protection against and effectiveness. The American journal of tro-
mortality and morbidity from malaria in rural pical medicine and hygiene. 1995;53(4):313.
Gambian children by chemoprophylaxis given
by village health workers Transaction of the 240 Snow RW, Rowan KM, Lindsay SW, Greenwood
royal society of tropical medicine and hygiene. BM. A trial of bed nets (mosquito nets) as a mala-
1990; 84:768-772. ria control strategy in a rural area of The Gambia,
West Africa. Transactions of the Royal Society of
232 Mayxay M, Newton PN, Yeng S, et al. Short com- Tropical Medicine and Hygiene. 1988;82(2):212-
munication: an assessment of the use of malaria 215.
rapid tests by village health volunteers in rural
Laos Tropical Medicine and International Health. 241 Rowland M, Bouma M, Ducornez D, et al.
2004;9(3):325-329. Pyrethroid-impregnated bed nets for personal
protection against malaria for Afghan refugees.
233 Maru RM. The Community Health Volunteer Transactions of the Royal Society of Tropical
Scheme in India: an evaluation Social Science Medicine and Hygiene. 1996;90(4):357-361.
and Medicine 1983;17(19):1477-1483.
242 Källander K, Tomson G, Nsungwa-Sabiiti J,
234 Leslie C. What caused India’s massive com- Senyonjo Y, Pariyo G, Peterson S. Community
munity health workers scheme: a sociology referral in home management of malaria in
of knowledge. Social Science and Medicine. western Uganda: a case series study. BMC
1985;21(8):923-930. International Health and Human Rights

2006;6(2):doi:10.1186/1472-1698X-1186-1182. Asian countries Indian Journal of Tuberculosis
2009;56:30-43.
243 Nsabagasani X, Nsungwa-Sabiiti J, Källander K,
Peterson S, Pariyo G, Tomson G. Home-based 251 Shargie EB, Morkve O, Lindtjorn B. Tuberculosis
management of fever in rural Uganda: commu- case-finding through a village outreach pro-
nity perceptions and provider opinions Malaria gramme in a rural setting in southern Ethiopia:
Journal. 2007; 6(11):doi:10.1186/1475-2875- community randomized trial Bull World Health
1186-1111. Organ. 2006; 84:112-119.
244 Greenwood BM, Greenwood AM, Bradley AK, et 252 Newell JN, Baral SC, Pande SB, Bam DS, Malla P.
al. Comparison of two strategies for control of Family-members DOTS and community DOTS
malaria within a primary health care programme for tuberculosis control in Nepal: cluster-ran-
in the Gambia Lancet. 1988:1121-1126. domized controlled trial. Lancet. 2006;367:903-
909.
245 Sirima SB, Konate´ A, Tiono AB, Convelbo N,
Cousens S, Pagnoni F. Early treatment of child- 253 Walley JD, Khan MA, Newell JN, Khan MH.
hood fevers with pre-packaged antimalarial Effectiveness of the direct observation com-
drugs in the home reduces severe malaria mor- ponent of DOTS for tuberculosis: a randomized
bidity in Burkina Faso. Tropical Medicine and controlled trial in Pakistan. Lancet. 2001;357:664-
International Health. 2003;8(2):133-139. 669.
246 Lindsay SW, Alonso PL, Schellenberg A, et al. A 254 Clarke M, Dick J, Lewin S. Community health
malaria control trial using insectide-treated bed workers in South Africa: where in this maze
nets and targeted chemoprophylaxis in a rural do we find ourselves? South African Medical
area of The Gambia, West Africa. Transaction of Journal 2008;98(9):680-681.
the royal society of tropical medicine and hy-
giene. 1993;87(Supplement 2):19-23. 255 Zwarenstein M, Schoeman J H, Vundule C,
Lombard C J, Tatley M. A randomized controlled
247 Snow RW, Rowan KM, Greenwood BM. A trial of trial of lay health workers as direct observers for
permethrin-treated bed nets in the prevention treatment of tuberculosis. International Journal
of malaria in Gambian children. . Transaction of of Tuberculosis and Lung Disease. 2000;4(6):550-
the royal society of tropical medicine and hy- 554.
giene. 1987;81(4):563-567.
256 Kamolratanakul P, Sawert H, Lermaharit S, et al.
248 Rieder HL. Epidemiological basis of tuberculosis Randomized controlled trial of directly obser-
control. International Union against Tuberculosis ved treatment (DOT) for patients with pulmo-
and Lung Disease. Paris 1999. nary tuberculosis in Thailand Transaction of the
Royal Society of Tropical Medicine and Hygiene.
249 World Health Organization. Forty fourth World 1999;93:552-557.
Health Assembly, Resolutions and Decisions.
Resolution WHA 44.8. Geneva: World Health 257 Niazi AD, Al-Delaimi AM. Impact of commu-
Organization. WHA44/1991/REC/1. nity participation on treatment outcomes and
compliance of DOTS patients in Iraq Eastern
250 Chadha VK. Progress towards Millennium Mediterranean Health Journal. 2003;9(4):709-
Development Goals for TB control in seven 717.

258 Chowdhury AMR, Chowdhury S, Islam MN, Islam kers in malaria control in Philippines. Southeast
A, Vaughan JP. Control of tuberculosis by com- Asian Journal of Tropical Medicine and Public
munity health workers in Bangladesh Lancet. Health. 1992;23 (suppl 1):30-35.
1997;350:169-172.
267 Khan MA, Walley JD, Witter SN, Shah SK, Javeed
259 Chowdhury AMR. Success with the DOTS stra- S. Tuberculosis patient adherence to direct ob-
tegy. Lancet. 1999;353(9157):1003-1004. servation: results of a social study in Pakistan
Oxford University Press: doi:10.1093/heapol/
260 Islam MA, Wakai S, Ishikawa N, Chowdhury czi047; 2005.
AMR, Vaughan JP. Cost-effectiveness of com-
munity health workers in tuberculosis control 268 Chaisson RE, Barnes GL, Hackman J, et al. A
in Bangladesh. Bull World Health Organ. randomized, controlled trial of interventions
2002;80:445-450. to improve adherence to isoniazid therapy to
prevent tuberculosis in injection drug users. The
261 Ravichandran N. Tuberculosis control in de- American journal of medicine. 2001; 110(8):610-
veloping countries: a generalized community 615.
health worker based model. Ahmadabad, India:
Indian Institute of Management 2003. 269 Datiko DG, Lindtjorn B. Health extension workers
improve tuberculosis case detection and treat-
262 Wright J, Walley J, Philip A, et al. Direct observa- ment sucess in Southern Ethiopia: a community
tion of treatment for tuberculosis: a randomized randomized trial PloS One. 2009;4(5):e5443.
controlled trial of community health workers
versus family members Tropical Medicine and 270 Dudley L, Azevedo V, Grant R, Schoeman JH,
International Health. 2004;9(5):559-565. Dikweni L, Maher D. Evaluation of community
contribution to tuberculosis control in Cape
263 Drobac PC, Mukherjee JS, Joseph JK, et al. Town, South Africa. The International Journal of
Community-based therapy for children with Tuberculosis and Lung Disease. 2003;7(9s1):S48-
multidrug-resistant tuberculosis. Pediatrics. S55.
2005;117:2022-2029.
271 Adatu F, Odeke R, Mugenyi M, et al.
264 Clarke M, Dick J, Zwarenstein M, Lombard C J, Implementation of the DOTS strategy for tuber-
Diwan V K. Lay health worker intervention with culosis control in rural Kiboga District, Uganda,
choice of DOT superior to standard TB care for offering patients the option of treatment su-
farm dwellers in South Africa: a cluster rando- pervision in the community, 1998-1999. The
mised control trial. International Journal of International Journal of Tuberculosis and Lung
Tuberculosis and Lung Disease 2005;9(6):673- Disease. 2003; 7(9s1):S63-S71.
679.
272 Mitnick C, Bayona J, Palacios E, et al. Community-
265 Phomborphub B, Pungrassami P, Boonkitjaroen based therapy for multidrug-resistant tuber-
T. Village health volunteer participation in tuberculosis in Lima, Peru New England Journal of
culosis control in Southern Thailand Southeast Medicine. 2003; 348:119-128.
Asian Journal of Tropical Medicine and Public
Health 2008;39(3):542-548. 273 Shin S, Furin J, Bayona J, Mate K, Kim JY, Farmer
P. Community-based treatment of multidrug-re-
266 Lariosa TR. The role of community health wor- sistant tuberculosis in Lima, Peru: 7 years if expe-

rience [In press]. Social Science and Medicine. Alaska natives through community health aide
training Journal of Community Health 1999;
274 Khan MA, Walley JD, Witter SN, Imran A, Safdar 24(4):313-323.
N. Costs and cost-effectiveness of different DOT
strategies for the treatment of tuberculosis 283 Mock J, McPhee SJ, Nguyen T, et al. Effective lay
in Pakistan. Health Policy and Planning. 2002; health worker outreach and media-based edu-
17(2):178-186. cation for promoting cervical cancer screening
among Vietnamese American women. American
275 Floyd K, Skeva J, Nyirenda T, Gausi F, Salaniponi Journal of Public Health. 2006; 97:1693-1700.
F. Cost and cost-effectiveness of increased com-
munity and primary care facility involvement in 284 Nasreen HE. BRAC HIV and AIDS programme:
tuberculosis care in Lilongwe District, Malawi. the mid-term evaluation. Dhaka, Bangladesh
The International Journal of Tuberculosis and Research and Evaluation Division, BRAC
Lung Disease. 2003; 7(9s1):S29-S37. December 2005.
276 Cavalcante SC, Soares ECC, Pacheco AGF, 285 Walton DA, Farmer PE, Lambert W, Leandre F,
Chaisson RE, Durovni B. and the DOTS Expansion Koenig SP, Mukherjee JS. Integrated HIV preven-
Team. International Journal of Tuberculosis and tion and care strengthens primary health care:
Lung Disease. 2007; 11(5):544-549. lessons from rural Haiti. Journal of Public Health
Policy. 2004; 25(2):137-158.
277 UNICEF. Millennium Development Goals: 6.
Combat HIV/AIDS., malaria , and other diseases. 286 Mukherjee JS, E EF. Community health workers
http://www.unicef.org/mdg/disease.html as a cornerstone for integrating HIV and primary
[Accessed on October 2009]. healthcare AIDS care 2007; 19 (Suppl 1):S73-
S82.
278 Clarke HJ. International AIDS vaccine initiative.
h t t p : / / w w w . m d g - g a t e w a y . o r g / M D G - 287 Peltzer K, Phaswana-Mafuya N, Treger L. Use of
Blog/?p=286. traditional and complimentary health practices
in prenatal, delivery and postnatal care in the
279 Schneider H, Hlophe H, D vR. Community health context of HIV transmission from mother to
workers and the response to HIV/ AIDS in South child (PMTCT) in the Eastern Cape, South Africa
Africa: tensions and prospects. . Health Policy African Journal of Traditional, Complimentary
and Planning. 2008;23:179-187. and Alternative Medicines. 2009; 6(2):155-162.
280 Ross DA, Changalucha J, Obsai AIN, et al. Biological 288 Wanyu B, Diom E, Mitchell P, Tih PM, Meyer DJ.
and behavioral impact of an adolescent sexual Birth attendants trained in «prevention of mo-
health intervention in Tanzania: a community- ther-to-child HIV transmission» provide care in
randomized trial. AIDS. 2007;21:1943-1955. Rural Cameroon, Africa. Journal of Midwifery
and Women’s Health 2007; 52(4):334-341.
281 Koenig SP LF, Farmer PE,. Scaling-up HIV treat-
ment programmes in resource-limited settings: 289 Perez r, Aung KD, Ndoro T, Engelsmann B, Dabis
the rural Haiti experience. AIDS. 2004:S3:S21-25 F. Participation of traditional birth attendants in
prevention of mother-to-child transmission of
282 Sox CH, Dietrich AJ, Goldman DC, Provost EM. HIV services in two rural districts in Zimbabwe: a
Improved access to women’s health services for feasibility study BMC Public Health 2008;8(401).

290 Mitchell K, Nakamanya S, Kamali A, Whitworth 2002; 180:76-81.
JAG. Exploring the community response to
a randomized controlled HIV/AIDS interven- 299 Barnet B, Duggan AK, Devoe M, Burrell L. The ef-
tion trial in Rural Uganda AIDS Education and fect of volunteer home visitation for adolescent
Prevention 2002; 14(3):207*216. mothers on parenting and mental health outco-
mes: a randomized trial Archieves of Pediatrics
291 Sanjana P, Torpey K, Schwarzwalder A, et al. Task- and Adolescents Medicine 2002;156:1216-1222
shifting HIV counseling and testing services
in Zambia: the role of lay counselors Human 300 Rahman A, Malik A, Sikander S, Roberts C, Creed F.
Resource for Health 2009;7(44):doi:10.1186/1478- Cognitive behavior therapy-based intervention
4491-1187-1144. by community health workers for mothers with
depression and their infants in rural Pakistan:
292 Benezaken AS, Garcia EG, Sardinha JCG, Pedrosa a cluster-randomized controlled trial. Lancet.
VL, Paiva V. Community-based intervention to 2008; 372:902-909.
control STD/AIDS in the Amazon region, Brazil.
Rev Saúde Pública. 2007; 41 (Supl.2):1-8. 301 Lester H, Freemantle N, Wilson S, et al. Cluster
randomized controlled trial of the effectiveness
293 Berman PA. Village health workers in Java, of primary care mental health workers British
Indonesia: coverage and equity Social Science Journal of General Medicine 2007 57:196-203.
and Medicine. 1984;19(4):411-422.
302 Building bridgers: home-based care model for
294 Wouters E, Damme WV, Loon FV, Rensburg DV, supporting older careers of people living with
Meulemans H. Public sector ART in the free state HIV/ AIDS in Tanzania Dar es Salaam, Tanzania
provine, South Africa: community support as Help Age International: Leading global action
an important determinant of outcome Social on ageing; 2007.
Science & Medicine 2009;69:1177-1185.
303 Scholl EA. An assessment of community health
295 Kumar MS, Mudaliar S, Daniels D. Community- workers in Nicaragua Social Science and
based outreach HIV intervention for street-re- Medicine. 1985;20(3):207-214.
cruited drug users in Madras, India. Public Health
Reports. 1998;113(Suppl 1):58. 304 Bogental B, Ellerson DB, Crane P, et al. A cognitive
approach to child abuse prevention. Journal of
296 Johnson BA, Khanna SK. Community health Family Psychology. 2002;16(3):243-258.
workers and home-based care programs for HIV
clients Journal of National Medical Association. 305 Bullock LF, Welles JE, Duff GB, Hornblow AR.
2004; 96(4):496-503. Telephone support for pregnant women: out-
come in late pregnancy New Zeeland Medical
297 Miranda JJ, Patel V. Achieving the Millennium Journal 1995;108(1012):476-478.
Development Goals: Does mental health play a
role? PLoS Medicine 2005;2(10):962-965. 306 Dawson P, van Doorninck WJ, Robinson JL.
Effects of home-based, informal social support
298 Cooper PJ, Landman M, Tomlinson M, Molteno on child health. Journal of Developmental
C, Swartz L, Murray L. Impact of a mother-infant Behaviour Pediatrics 1989; 10(2):63-67.
intervention in an indigent peri-urban South
African context British Journal of Psychiatry. 307 Barnett B, Parker G. Professional and non-profes-

sional intervention for highly anxious primipa- West Baltimore city Medicaid patients with dia-
rous mothers. The British Journal of Psychiatry. betes, with out without hypertension Ethnicity
1985; 146(3):287. and Disease 2003;13.
308 Heins HC, Nance NW, Ferguson JE. Social Support 316 Kegler MC, Malcoe LH. Results from a lay health
in improving perinatal outcomes: the resource advisor intervention to prevent lead poisoning
mothers program. Obstetrics and Gynecology. among rural native American children American
1987;70:263. Journal of Public Health. 2004;94:1730-1735.
309 Travis P, Bennett S, Haines A, et al. Overcoming 317 Ingram M, Gallegos G, Elenes J. Diabetes is a
health-systems constraints to achieve the community issue: the critical elements of a suc-
Millennium Development Goals. The Lancet. cessful outreach and education model on the
2004;364(9437):900-906. US-Mexico border. Preventing Chronic Disease
Public Health Research, Practice and Policy 2005;
310 Haines A, Cassels A. Can the millennium de- 2(1):1-9.
velopment goals be attained? British Medical
Journal. 2004; 329(7462):394. 318 Sankaranarayanan R, Mathew B, Jacob BJ, et
al. for the Trivandrum Oral Cancer Screening
311 Gwatkin DR. Who would gain most from efforts Study Group. Early findings from a communi-
to reach the Millennium Development Goals for ty-based, cluster-randomized, controlled oral
Health. World Bank, December. 2002. cancer screening trial in Kerala, India Cancer.
2000;88(3):664-673.
312 Gary TL, Bone LR, Hill MN, et al. Randomized
controlled trial of the effects of nurse case ma- 319 Krieger J, Collier C, Song L, Martin D. Linking com-
nager and community health worker interven- munity-based blood pressure measurement to
tions on risk factors for diabetes-related compli- clinical care: a randomized controlled trial of
cations in urban African Americans Preventive outreach and tracking by community health
Medicine 2003;37:23-32. workers American Journal of Public Health.
1999; 89:856-861.
313 Jafar TH, Hatcher J, Poulter N, et al. for the
Hypertension Research Group. Community- 320 Solomon AW, Akudibillah J, Abugri P, et al. Pilot
based interventions to promote blood pressure study of the use of community volunteers to
control in a developing country: a cluster ran- distribute azithromycin for trachoma control in
domized trial. Annals of Internal Medicine 2009; Ghana. Bull World Health Organ. 2001;79:8-14.
151(9):593-601.
321 Forst L, Lacey S, Chen HY, et al. Effectiveness of
314 Thompson JR, Horton C, Flores C. Advancing community health workers for promoting use of
diabetes self-management in the Mexican safety eyewear by Latino farm workers. American
American population: a community health wor- journal of industrial medicine. 2004;46(6):607-
ker model in a primary care setting The Diabetes 613.
Educator 2007;33:159S.
322 Scheider H, Hlophe H, Rensburg Dv. Community
315 Fedder DO, Chang RJ, Curry S, Nichols G. The health workers and the response to HIV/AIDS
effectiveness of a community health worker in South Africa: tensions and prospects. Health
outreach program on health care utilization of Policy and Planning. 2008; 23:179-187.

323 Krieger JW, Takaro TK, Song L, Weaver M. The chronic illness: pediatric outcomes Archives
Seattle-King County Healthy Homes Project: of Pediatrics and Adolescents Medicine 2002;
a randomized, controlled trial of a community 156:533-539.
health worker intervention to decrease exposu-
re to indoor asthma triggers. American Journal 331 Levine DM, Bone LR, Hill MN, et al. The effecti-
of Public Health. 2005; 95(4):652. veness of a community/academic health center
partnership in decreasing the level of blood
324 Ramadas K, Sankaranarayanan R, Jacob BJ, et pressure in an urban African-American popula-
al. Interim results from a cluster randomized tion. Ethnicity & Disease. 2003; 13(3):354-361.
controlled oral cancer screening trial in Kerala,
India Oral Oncology. 2003; 39:580-588. 332 Bird JA, McPhee SJ, Ha N-T, Le B, Davis T, Jenkins
CNH. Opening pathways to cancer screening
325 Vetter MJ, Bristow L, Ahrens J. A Model for for Vietnamese-American women: lay health
home Care Clinician and home health Aide workers hold a key. Preventive Medicine 1998;
Collaboration Home Healthcare Nurse. 2004; 27:821-829.
22(9):645-648.
333 Davis DT, Bustamante A, Brown CP, et al. The
326 Taylor VM, Hislop TG, Tu S-P, et al. Evaluation of urban church and cancer control: a source of
a hepatitis B lay health worker intervention for social influence in minority communities Public
Chinese Americans and Canadians. Journal of Health Reports 1994; 109(4):500-507.
Community Health. 2009; 34:165-172.
334 Havas S, Koumjian L, Reisman J, Hsu L, Wozenski
327 Srinivasan M, Upadhyay MP, Priyadarsini B, S. Results of the Massachusetts model systems
Mahalakshmi R, Whitcher JP. Corneal ulcera- for blood cholesterol screening project JAMA.
tion in south-east Asia III: prevention of fungal 1991; 266(3):375-382.
keratitis at the village level in south India
using the topical antibiotics. British Journal of 335 Singh AA, Parasher D, Shekhavat GS, Sahu S,
Ophthalmology. 2006;90:1472-1475. Wares DF, Granich R. Effectiveness of urban
community volunteers in directly observed
328 Nguyen TT, McPhee SJ, Nguyen T, Lam T, Mock treatment of tuberculosis patients: a field report
J. Predictors of cervical Pap smear screening from Haryana, North India Notes from the Field.
awareness, intention, and receipt among The International Journal of Tuberculosis and
Vietnamese-American women. American jour- Lung Disease. 2004; 8(6):800-802.
nal of preventive medicine. 2002; 23(3):207-214.
336 Lam TK, McPhee SJ, Mock J, et al. Encouraging
329 Simmons D, Rush E, Crook N. Development and Vietnamese-American women to obtain Pap
piloting of a community health worker-based tests through lay health worker outreach and
intervention for the prevention of diabetes media education. Journal of general internal
among New Zealand Maori in Te Wai o Rona: medicine. 2003; 18(7):516-524.
Diabetes Prevention Strategy. Public Health
Nutrition. 2008;11(12):1318-1325. 337 Hiatt RA, Pasick RJ, Stewart S, et al. Community-
based cancer screening for underserved women:
330 Chernoff RG, Ireys HT, DeVet KA, Kim YJ. A ran- design and baseline findings from breast and
domized, controlled trial of a community-based cervical cancer intervention study Preventive
support program for families of children with Medicine 2001; 33:190-203.

338 Declaration of Alma Ata. Paper presented at: neonatal illness in rural Bangladesh. Bull World
International conference on Primary Health Health Organ. Jan 2009;87(1):12-19.
Care, Alma-Ata, 6-12 September, 1978; USSR.
348 Mohanty N, Mohapatra SC, Srivastava PS, Gupta
339 Satishchandra DM, Naik VA, Wantamutte AS, JNP. The measurement of performance skills
Mallapur MD. Impact of training of traditional of primary maternal child health workers-an
birth attendants on the newborn care. Indian Indian experiment Indian Journal of Community
Journal of Pediatrics. 2009;76(1):33-36. Medicine 1994;19(2-4):59-63.
340 Falle TY, Mullany LC, Thatte N, et al. Potential role 349 Ogunfowora OB, Daniel OJ. Neonatal jaundice
of traditional birth attendants in neonatal heal- and its management: knowledge, attitude and
thcare in rural Southern Nepal. Journal of Health, practice of community health workers in Nigeria
Population and Nutrition. 2009; 27(1):53-61. 2006;6(19).
341 Khan MH, Saba N, Anwar S, Baseer N, Syed S. 350 Zeitz PS, Harrison LH, Lopez M, Cornale G.
Assessment of knowledge, attitude and skills of Community health worker competency in
lady health workers Gomal Journal of Medical managing acute respiratory infections of child-
Sciences 2006;4(2):57-60. hood in Bolivia. Bulletin of Pan American Health
Organization. 1993;27(2):109-119.
342 Afsar HA, Younus M, Gul A. Outcome of patient
referral made by lady health workers in Karachi, 351 Ayele F, Desta A, Larson C. The functional status
Pakistan; 2005. of community health agents: a trial of refresher
courses and regular supervision. Health Policy
343 Afsar HA, Qureshi AF, Younus M, Gulb A, and Planning. 1993;8(4):379-384.
Mahmood A. Factors affecting unsuccessful
referral by the lady health workers in Karachi, 352 PC-I. National Programme for Family Planning
Pakistan. Journal of Pakistan Medical Association and Primary Health Care «The Lady Health
2003; 53:521-528. Workers Programme 2003-08. : Government of
Pakistan August 2003.
344 Khan MM, Ahmed S, Saha KK. Implementing IMCI
in a developing country: estimating the need for 353 Rodney M, Clasen C, Goldman G, Markert R,
additional health workers in Bangladesh; 2000. Deane D. Three evaluation methods of a com-
munity health advocate program Journal of
345 Hadi A. Diagnosis of pneumonia by commu- Community Health. 1998;23(5):371-381.
nity health volunteers: experience of BRAC,
Bangladesh Tropical Doctor. 2001;31:75-77. 354 Stekelenburg J, Kyanamina SS, Wolffers I.
Poor performance of community health wo-
346 Hadi A. Management of acute respiratory kers in Kalabo district, Zambia. Health Policy.
infections by community health volunteers: 2003;65:109-118.
experience of Bangladesh Rural Advancement
Committee (BRAC). Bull World Health Organ. 355 Fatusi AO, Makinde ON, Adeyemi AB, Orji EO,
2003;81:183-189. Onwudiegwu U. Evaluation of health worker’s
training in use of partograms Indian Journal of
347 Darmstadt GL, Baqui AH, Choi Y, et al. Validation Gynecology and Obstetrics 2008;100:41-44.
of community health workers’ assessment of

356 Jacob KS, Senthil Kumar P, Gayathri K, Abraham
S, Prince MJ. Can health workers diagnose de-
mentia in the community? Acta Psychiatrica
Scaninavica. 2007;116:125-128.
357 FrazãoI P, MarquesII D. Effectiveness of a com-

munity health worker program on oral health
promotion. Rev Saúde Pública. 2009;43(3).
358 WHO. The global shortage of health workers

and its impact April 2006.
359 Werner D. Where there is no doctor: Macmillan;

1985.
360 Chowdhury AMR. Rethinking interventions for

women’s health Lancet. 2007;370:1292-1293.
361 Baqui AH, Rosecrans AM, Williams EK, et al. NGO

facilitation of a government community-based
maternal and neonatal health programme in ru-
ral India: improvements in equity. Health Policy
and Planning. 2008;23:234-243.
362 Carlo WA, Goudar SS, Jehan I, Chomba E, Tshefu

A, Garces A, Parida S, Althabe F, McClure EM,
Derman RJ, Goldenberg RL, Bose C, Krebs NF,
Panigrahi P, Buekens P, Chakarborty H, Hartwell
TD, Wright LL, and the First Breath Study Group.
Newborn-care training and perinatal mortality
in developing countries. New England Journal
of Medicine 2010; 362: 614-23.

Annex 2:
After deriving out an evidence from a global
systematic review, an in-depth country specific
CHW program have been evaluated to further
appraise the typology, impact, and performance
assessment of the practices of CHWs deployed
at scale in eight countries across the world. The
eight countries investigated in this section were
chosen based on their high burden of disease
and low utilization of health services and most
importantly with the reason that they are far
off from reaching the targets of the MDGs set
for the year 2015. To understand the typology,
experience, training needs, program roll out
and assessments of CHWs to-date, we also
undertook case studies in eight representative
countries from Latin America, Africa and Asia,
with high burden of diseases. These countries
have been selected on the basis of existing CHW
programs in the public and non-governmental
sector and include:
1 South Asia (Bangladesh, Pakistan, Thailand)
2 Latin America (Brazil and Haiti)
3 Africa (Ethiopia, Uganda and Mozambique)

Table 16: CHW Program in selected eight countries
Country CHW Program Local name Year Numbers of Per HH/per Duration Female (%) Supervisor
Name for CHW Initiated CHWs Trained 10,000 pop of training (post name)
Pakistan Lady Health Lady Health Workers 1994 92 957 100-200 15 months 100% Lady Health
Worker Program HH / 1000 Supervisor (LHS)
population
Bangladesh Bangladesh Rural Shasthyo Sebika 1977 78 000 150-250 HH 3 weeks 100% Shasthyo Kormi (SK)
Advancement
committee- CHW
program
Thailand Village Health Village Health 1970 80,000 5-15 HH 3 weeks 700% Sr. Village health
Volunteer Program Volunteer volunteer
Brazil Programa Saúde Agentes comuni- 1994 240,000 12.57 per 10,000 12 weeks 95% Sr. Village health
da Familia tarios de Saúde population (na- volunteer
tional average)
Haiti Projeveye santé (Health agents, 1985 > 1,600 10/10,000 (Up 3 months - 50% (Senior health agents,
(Zanmi Lasante’s Women’s to a maximum health agents, Social workers, Doctors,
Community health agents, of six patients 2 weeks Public health nurses, HIV
Health Program) Traditional birth per CHW) -accompa- program Nurses, Senior
attendants (matrons) gnateurs, and Accompagnateurs
Accompagnateurs, 1 month-TBAs (Accompagnateur
Youth monitors, Leaders)
Agricultural agents
Mozambique Agentes Agentes Polivalentes 1978 < 1000 ~1 /20.000 6 months 60% Village CHWs
Polivalentes Elementares
Elementares
Program
Uganda Village Health Village Health 2003 -* -* 10 days About 50% health center worker
Teams and Team CHWs
CHWs Program
216
ASIAN Case -Studies
Pakistan – Lady Health Workers Program

Bangladesh – BRAC Community Health Workers
Thailand – Village Health Volunteer Program

1. Pakistan –
Lady Health Workers Program
Socio-economical and Political sector is rarely taken into account while making
the Health plans. Economic polarization as such
background has resulted in greater health inequalities.9 The
Pakistan is a profound blend of landscapes maternal mortality ratio is alarmingly high and
varying from plains to deserts, forests, hills, and is estimated to be 320 per 100,000 live births.10
plateaus ranging from the coastal areas of the The burden of diseases and service utilization
Arabian Sea in the south to the mountains of indicators has been summarized in Box 3.
the Karakoram range in the north with arable
land, water, and extensive natural gas and oil In order to cater to the health needs of larger
reserves as country’s principal natural resources. masses of the country, one major initiative to
The total population according to the World improve the accessibility to primary health care,
Health Statistics 2008 is 161,000,000.2 taken by the Government, was establishment of
the Lady Health Worker Program (LHWP).
The demographic and health scenario in
Pakistan is characterized by a high birth rate, Brief historical description of
a comparatively low death rate and a conse-
quent rapid growth in population. Total fertility
the LHW Program
rate per woman in 2007 is reported to be 4.1/ The Lady Health Worker Program originally
woman.3 Estimated crude death rate is 7.1 per designed in the early 1990s, later conceived in
1000, in which there has been a steady decline 1993 and finally launched in April 1994 as a fe-
from 16 per 1000 in 1970 to the current 7.1 per deral development program. The program was
1000.2 However the infant mortality rate is still originally officially called the Prime Minister’s
very high and estimated to be 91 per 1000 live Program for Family Planning and Primary Health
births.4 Care (PMP-FPPHC) and then later in 2000 was
changed to the National Program for Family
According to the World Health report 2004 the Planning and Primary Health Care (NPFP & PHC),
total health expenditure in Pakistan per capita but it is typically referred to as Lady Health
is $185 whereas the total health expenditure as Workers Program (LHWP)11 Under this program
a % of GDP is just 0.6% as reported by Pakistan paid Lady Health Workers (LHWs) are recruited
Social and Living Standards Measurement from local communities, especially in rural areas
Survey 2004-05.6 The private financing of health of the country, to provide services for family
care is estimated to be more than 75% as per planning and primary health care.
WHO 2006 report.7
Why this program for review?
Health System Overview In a developing country like Pakistan, outreach
Over the last decade the Government of Pakistan workers are essential for the delivery of health
and several non-government organizations care especially in the rural areas. Seventeen
have focused attention on improvement in the percent of all those who consult for an illness
health sector. In Pakistan the healthcare compri- report consulting the LHW first, and not a phy-
ses of public and private set ups. However, the sician.11 They play an important and increasing
private healthcare system serves the affluent role in the provision of preventive, promotive,
of the country, where the proportion of popu- and curative health care services. The program
lation below the national poverty line is 32.6%, has expanded manifolds since its inception and
according to the UN report.8 Besides, the private as such there have been some substantial im-

Recruitment Process
provements in the level of service delivery since The LHWs are the women residing in the same
the previous evaluation, particularly for family community for which they are recruited, accep-
planning services.11 Therefore reviews on this table to their communities, trained to deliver
program are necessary to further increase the family planning services, to promote positive
coverage of services, so that they reach all regis- health behaviors and deal with health problems
tered clients in compliance with the Millennium of individuals and the community through a
Development Goals. PHC approach.
The Lady Health Selection committee, which comprises of me-

dical officer in-charge First Level Care Facilities
Workers’ Program (FLCF), women medical officer-FLCF, lady health
According to latest Oxford Policy Management visitor/ female medical technician-FLCF, male
report on evaluation of Lady Health Workers technician/ dispenser, member nominated by
Program, there are now close to 90,000 LHW na- the local community preferably the local educa-
tionwide.11 Since its last evaluation in May 2000 ted union, council Nazim/ counselor, first identify
the LHWP has expanded rapidly. In view of its potential LHWs through contacting community
wide scope of work in terms of the population organizations if active in the area and in areas
and health problems covered, and widely ex- where community organizations do not exist,
panded infrastructure, in terms of health facili- the committee meet with key members of that
ties, staff, drugs and supplies etc. There is a need community, discuss and obtain their support for
for the program to have an efficient information the program. Selection committee also dissemi-
system, responding to the information needs nates information through print media, and
of various decision making levels of the health local announcements.
system. Selection of LHW is based on the following
Box 3: Burden of disease and service utilization indicators in Pakistan

Maternal Mortality Ratio 1 320
Neonatal Mortality Rate 1 53
Infant Mortality Rate 1 73
U-5 Mortality Rate 1 90
HIV / AIDS prevalence (%) 2 86
Malaria incidence (per 1000 population)3 0.75
Tuberculosis incidence ( per 100 000 population) 4 181
Tuberculosis prevalence (per 100 000 population) 4 263
Proportion children immunized for Measles 1 80
Proportion of births attended by skilled health personnel 1 39
Contraceptive Prevalence Rate 1 30
Antenatal care coverage (at least once) 1 36
Unmet need for family planning 1 33
Sources:
1 United Nations Population Division 2007
2 United Nations Program on HIV/ AIDS 2002
3 National Malaria Control Program, Ministry of Health, Pakistan 2006
4 World Health Statistics 2008

criterion:12
past experience in community development,
female (preferably married),
willing to carry out the services from her home
permanent resident of the area (for which she (designated health house that ensures effective
is recruited), linkage between the community and the public
health care delivery system)
minimum 8 years of schooling (preferably
matriculate), The age, marital status, residence and level of
education of current LHWs has been summari-
should be between 20 to 50 years (up to 18 zed in Box 3:11
years only if she is married),
The final selection of the LHWs is made after
Box 3: Characteristics of LHW careful scrutiny of the documents and the
residential status of the applicants and their
Age Distribution (%)
selection is approved on the recommendations
15-19 1.1
20-24 12.2 of council Nazim/ counselor and on approval
25-29 24.6 of Executive District Officer – Health (EDO-H).
30-34 27.7 LHWs are initially employed on contract for one
35-39 15.7 year but their services are likely to continue for
40-44 9.6 the life of the Program. The LHWs, at the time of
45+ 9.0 recruitment, are required to provide a notarized
Mean age 32.6
Mean age when recruited 25.5 affidavit stating that they would perform their
duties to the satisfaction of their supervisors for
Marital Status (%)
at least one year after the completion of their
Never married 25.6 full training and incase of failing the course, they
Currently married 65.8
Widow/divorced/separated 8.6 will have to return the salaries and equipment
(LHWS kit bag, weighing scales etc) they have
Years LHW has resided in Village/Mohalla (%)
received. The LHWs selected are then supervised
0-2 3.7
3-4 5.4 closely to ensure provision of quality services to
5-20 31.6 the communities. Those who do not fulfill the
More than 20 8.6 selection criteria or those not performing their
Since birth 50.7 duties satisfactorily are liable to termination of
Mean years resided 21.7 contract by the District Head of the health de-
Educational Level (%) partment i.e. EDO (H)/DHO.11
Less than 8 years 0.7
8 or 9 years
Matric (10-11 years)
35.7
44.4
The LHW Role
Intermediate (12-13 years) 15.1 The prime role of LHWs is to provide PHC servi-
Graduate (14+ years) 4.1 ces to the communities in her catchment area
Mean education Level (1-5) 9.84
% with class certificate seen and to organize community by developing wo-
and confirmed 77.2 men groups and health committees in her area.
She has to look after a population of 1000 indi-
Source: OPM LHWP Fourth vidual for whom she arranges meetings of these
Independent Evaluation, (2008) groups in order to effectively involve them in

family planning, primary health care and other well as anemic young children
related community development activities. In
these meetings they discuss issues related to Promote nutritional education with emphasis
better health, hygiene, nutrition, sanitation and on breast-feeding and weaning practices, ma-
family planning and emphasize their benefits ternal nutrition and macronutrient malnutrition
towards improved quality of life. They also act as
a liaison between formal health system and the Coordinate with EPI for immunization of mo-
people and ensure coordinated support from thers against tetanus and children against six
NGOs and other departments. LHWs routine preventable diseases and participate in various
activities are:11 campaigns for immunization against EPI target
diseases
Register all family members in the catchment
areas specially the eligible couples (married wo- Involve in the surveillance activities
men age 15-49 years) during their visits to hou-
seholds , and maintain up to date information Carry out prevention and treatment of common
ailments e.g. malaria, diarrhea diseases, acute
Visit 5-7 households every working day and en- respiratory infections, tuberculosis, intestinal
sure a re-visit every two months parasites, primary eye care, scabies, snake bites,
injuries and other minor diseases using essential
Keep in close liaison with influential women drugs and refer cases to nearest centers as per
of her area including lady teachers, traditional given guidelines
birth attendants and satisfied clients
Involve in DOTS and malaria control programs
Motivate and counsel clients for adoption and
continuation of family planning methods Disseminate health education message on indi-
vidual and community hygiene and sanitation
Provide condoms, oral pills to eligible couples as well as information regarding preventive
in the community and inform them about pro- measure against spread of AIDS
per use and possible side effects and also refer
clients needing IUD insertions, contraceptive Submit monthly progress report to incharge
surgery and injectable to the nearest FLCF in health center containing information regarding
the government or NGO sector all activities carried out by her including the
home visits, number of family planning accep-
Coordinate with local TBAs/midwives or other tors by methods and stock position of contra-
skilled birth attendants and local health facilities ceptives and medicines
for appropriate antenatal, natal and postnatal
services The LHWs role in curative care is substantially
larger in rural areas than in urban areas (0). As
Undertake nutritional interventions such as was found in the Third Program Evaluation,
anemia control, growth monitoring, assessing this is particularly true for rural women and
common risk factors causing malnutrition and girls; around a fifth of females who had been
nutritional counseling ill consulted a LHW, if they consulted any care
provider. It is interesting to note that the urban/
Treat iron deficiency anemia among all women rural differences are not so pronounced in the
especially pregnant and lactating mothers as current survey. However, having increased the

Integrated training:
(initial 3 months training)
coverage of services during a period of program The first phase of basic training is for five days a
expansion should be recognised as a significant week for three months. In this period, the newly
achievement.11 recruited LHWs are trained to cover the major
PHC subjects, which include immunization,
Initial Training of LHWs diarrhoea control, reproductive health including
maternal and child health and family planning,
The training of LHWs are conducted in two pha- nutrition, common ailments, personal hygiene
ses for a total of fifteen months using program along with education on community organiza-
training manuals and curriculum, which is then tion and interpersonal communication skills 11.
followed by continual training at the health fa-
cility along with refreshers. Their 15 months trai-
ning course is divided into integrated training
Task Based Training:
and task based training.11 (12 months training)
The second phase of training lasts for twelve
months with three weeks of fieldwork followed
Box 4: Consultations with the LHW by sick individuals by place of residence

2000 2008-All LHWs
Measure
Urban Rural Urban Rural
Individuals who were ill or injured in the previous
fourteen days
% who consulted the LHW – total 11 22 14.2 18.1
% who consulted the LHW – female 14 25 16.1 20.2
% who consulted the LHW – male 8 19 12.2 15.8
Individuals who were ill or injured in the previous fourteen

days and who consulted any health provider
% who consulted the LHW first - - 6.1 9.4
Children under 5 who were ill in the previous fourteen

% with diarrhea who consulted the LHW 10 15 14.9 19.9
% with respiratory infection who consulted the LHW 12 19 15.6 23.5

% with diarrhea who consulted the LHW first - - 2.7 13.1
% with respiratory infection who consulted the LHW first - - 8.8 16.2

days and who consulted LHW
% mothers reported that LHW gave advice about
how to prevent diarrhea in future - - 38.7 60.1
Source: OPM LHWP Fourth Independent Evaluation, Quantitative Survey Data (2008).

by one week of classroom training each month. months training of LHWs.11
This training gives special emphasis to fieldwork
and practical work on health center patients. Equipment and supplies
This training builds on the first three months to
strengthen the competence and skills of LHWs. The LHWs are basically provided with oral contra-
The training is job specific, focused on carrying ceptive pills and condoms and with a limited
out instructions/procedures related to the work range of inexpensive following essential drugs
of LHWs. The training of LHWs is linked to their for those health problems that are common.11
scope of work, to the problems they have to sol-
Paracetamol Tabs 500mg
ve and to their ability to carry out specified tasks.
The training is participatory and instrumental in Chloroquine Tabs 150mg
the process of helping LHWs to develop new Mabendazole Tabs 100mg
skills, acquire knowledge, and apply what they
are learning to their day-to-day working envi- Oral rehydration solution
ronment. During this phase, the LHWs also work Cotrimoxazole Syp.
in their communities for three weeks and come
to the training site for one week each month.11 Ferrous Fumerate 150mg + Folic Acid 0.5mg
Cotton Bandages 4” x 3m
On-going Training of LHWs Benzyl Benzoate Lotion
All LHWs attend their respective health facility/ Paracetamol Syp 120mg/ml
training center for one day each month to get
Chloroquine Syp 50mg/5ml
refresher training on an identified topic. In ad-
dition, problems faced by LHWs in providing Piperazine Syp 500ml/5ml
services are discussed with the trainers. LHWs Polymyxin “B” Sulphate Eye Ointment (4 Gram)
also submit their monthly report, and collect
supplies for one month. LHWs are not given any B.complex Syp Complex
refresher trainings, but in latest LHW program Antiseptic Lotion
PC-I report, this issue has been highlighted and
they have planned to provide LHWs with 15 days List of Non-Drug Items
training each year in addition to the continuing
education. They have also planned to remune- Cotton Wool (250 Gram)
rate these LHWs with Rs. 50 per day in addition Sticking Plaster 1” x 5m
to salary to cover travel costs and refreshment
Pencil Torch with Two Cells
etc.12 The summary of training duration and by
whom it was imparted has been summarized in Thermometer Clinical
Box 5. Scissors
LHW Kit Bags containing weighing scale etc.
Training of Trainers
Salter Scale with Trouser
Trainers of LHWs are FLCF staffs who are trained
by district trainers for a period of 9 days followed
by 3 days of assessment workshop to ensure the Supervision
quality of training. This training team is paid 20% The National Program for FP & PHC has an ela-
of their current salary per month during the 15 borate and multi tiered supervisory system. The

Box 5 :Training of LHWs
Proportion of LHWs who received initial (basic) training 99.8
Duration of initial training
Less than two months 0.0
Two months 0.0
Three months 94.1
More than three months 5.8
Total 100.0
Mean number of months of initial training 3.1
Training was imparted by
Medical doctor (male) 87.2
Medical Doctor (female) 16.5
Lady health visitor 68.7
Dispenser 24.5
Male medical health technician 16.4
Female medical health technician 4.5
Others 7.5
LHW training was given by any female trainers
Source: OPM LHWP Fourth Independent Evaluation, (2008).
cadre of LHW Supervisors has been developed Age: 22-45 years

to provide supervisory support to the LHWs on
daily basis. The LHS uses a structured checklist Education (In order of preference): LHV/Graduate
for monitoring purposes. The Program has a pro- or LHW Intermediate with one year experience
vision for one LHS for 25 LHWs i.e. a ratio of 1:25 as LHW or Intermediate
reference. At the Provincial level, Field Program Preferably one-year relevant experience
Officers (FPOs) are employed on contract to
Local resident of the area
monitor the program in two or three districts
and report back to the Federal, provincial or
LHS are employed on contract initially for one
district level program implementation unit on
year but their services are likely to continue
monthly basis. In the case of non-performance
for the life of the program. They are paid Rs.
the District Health Officer (DHO) has the autho-
3300 per month as training allowance for three
rity to end the LHWs contract. Feedback to the
months and later on the same amount is paid
DHO and the District Coordinator can occur via
as fixed salary. They are given an annual raise of
the community, the health facility, other DOH
Rs. 200 per month as an incentive. LHS are also
professionals, the LHS and the Field Program
provided with POL for the vehicles (800cc Pick-
Officer.11
ups) on an average of 70 liters per month. Those
LHS working without vehicles get Rs. 70 as fixed
LHS are selected based on the following
travel allowance per field visit day.11
criteria11:
Female LHS are trained for one year and their training is

Performance Evaluation
carried out in following three phases The program has carried out 3 evaluations. The
result showed that Program is having a significant
02 months training of trainer manual + 03 weeks impact on a range of health outcomes. Fourth
LHS manual + one week practical training 3rd party evaluations are in process. The mean
03 months field/on job training (First two weeks number of households registered by the LHWs
in the field and last two weeks of every month is highest in Punjab and lowest in Baluchistan.
class room training) on LHS manual with more The lower number of households registered by
emphasis on practical training with audiovisual LHWs in Baluchistan is understandable due to
support and role-play. the scattered population in this province. It is
also likely that LHWs will have lower number of
46 months training (first 3 weeks of every month
individuals registered due to the hilly terrain and
in the field and last week for class room training)
a scattered population in AJK/NAs and in some
more emphasis in practical training in the areas
parts of NWFP. All provinces have some house-
of EPI, pediatrics, Eye, midwifery/Gynae/ Obs.
holds that are registered with the LHW but do
not know they are registered, although this has
The LHS are trained on specially designed curri-
improved since 2000. The problem is smallest
culum and they use the program checklist du-
in Balochistan and largest in Punjab. In most of
ring field visits. Specific checklist and feedback
the activity measures, however, Balochistan and
report for LHS are also developed. Their main
Sindh show the poorest performance. Around
functions are to:
two thirds of LHWs in Balochistan and a third
Provide support and guidance of LHWs in Sindh reported working less than
15 hours in the preceding week. Two thirds of
Ensure adequate performance of LHWs regar- LHWs in Balochistan and a quarter of LHWs in
ding delivery of primary health care and family Sindh saw less than 10 clients in that week.11
planning services
In his report on evidence-led training and com-
Assess the level of community participation munity tools for LHWs in Sindh, Pakistan, pu-
and involvement in support of LHW and the blished in August 2002, K Omer et al concludes
program that use of traditional craft items to communi-
Identify deficiencies in communication skills cate health messages to the non-literate masses
proved quite effective. Results showed that a
Check whether the eligible couples have been woman shown a traditional ajrak with maternal
registered and contacted regularly for motiva- and child health care messages, was 61% more
tion and delivery of family planning services likely to avoid heavy routine work during pre-
and to find out reasons for non-acceptance and gnancy, was 60% more likely to breastfeed the
to assist in the motivation and service delivery infant and twice as likely to follow the exclusive
of hard-core cases breastfeeding guidance.13 The additional su-
pervision provided to the LHWs and their active
Provide support and supervise skilled birth
involvement due to the intervention also see-
attendants
med to improve their performance. The impact
Carry out corrective measures to improve the of the LHWs efforts was noted to be greater in
performance of LHWs as per given guidelines cases where either women had some degree
of formal education or if their spouse was
educated.13

In another study by Douthwiate et al. the role of and equipments, like that in growth monitoring
CHWs in promoting modern reversible contra- have been unavailability of functional weighing
ceptive methods was assessed as compared scale to the LHWs. Another factor affecting the
to the population not approached by LHWs. performance of LHWs has been the irregula-
The study showed that women served by Lady rity in the payments of salary and deduction
Health Workers are significantly more likely to in salaries due to untold reasons.11 One out of
use a modern reversible method than women ten LHWs has been reported to charge for the
in communities not served by the Program (OR services offered.11
= 1.50, 95% CI: 1.04–2.16, p =0.031), even after
controlling for various household and individual Incentives
characteristics.14 It also showed that continuous
support and monitoring by the supervisors en- During their initial training of three months they
sured successful results.14 are paid Rs. 50 per day for first three months fol-
lowed by Rs. 1600 (approx USD 20) per month.
Some areas of LHWs performance have howe- They are also given an annual raise of Rs. 100
ver stagnated or even decreased. Knowledge of as an incentive, whereas, their monthly salary is
mothers regarding at least one way to prevent Rs. 3090 (approx. USD 38). Other incentive they
diarrhoea has reduced; and growth monitoring receive is in the form of money which they earn
services continue to have a limited coverage.11 after selling contraceptives to their clients. They
The factors identified, leading poor performan- charge Rs. 3 per cycle of pills and Rs. 0.50 per
ce, are failures in supply systems of medicines condom.
Table 17: Performance Evaluation of LHWs

Program coverage Coverage is about 1 per thousand populations. 70% of the population
is covered
Preventive and promotive Vaccination promotion coverage: 68% of children under five
service delivery Contraceptive usage: 36% of all users of modern contraceptives
Curative service delivery 17.2% of all LHW seen and referred emergency case in previous fourteen
days
Support system for LHWs Recruitment: vast majority meet program selection criteria Training:
and their performance 99.8% received introductory training Knowledge: 86.8% of LHWs given
at least one correct answer Supplies and equipment: lack of stock, expired
stock, missing stock Salaries: one third had not been paid for over three
months Supervision and LHS: 85.3% reported supervisor meeting in last
30 days Support from FLCF: 50% doctors present and 50% facilities
lacked important medicines and supplies on the day of survey
LHW impact on health Indicators of population served by LHWs were slightly better off than
National figures
LHW costs – current and Actual level of funding is much lower than the levels originally planned
future
Source: OPM LHWP Fourth Independent Evaluation, (2008).

Community Involvement
Through the process of community organiza- to reward good performance or achievement.
tion for PHC and family planning, members of There are no paths planned to retirement for
the community are organized for participation LHWs.11
in health promoting activities. These activities
include participation in:11 Documentation and
Decision making during project planning/pro- Information Management
ject implementation at the local level In view of its wide scope of work in terms of
Monitoring and evaluation the population and health problems covered,
and widely expanded infrastructure, in terms
Various primary health care services (e.g. immu- of health facilities, staff, drugs and supplies etc.
nization, improved sanitation etc) there is a need for the program to have an ef-
ficient information system, responding to the
Possible approaches that are employed for
information needs of various decision making
initiating contact with community are through
levels of the health system. Procedures and
advocacy and awareness raising activities and
instruments are developed to collect data in
by establishing organizations like health com-
key areas having impact on the health status of
mittees, women groups and through health
the communities through the LHWs. Data are
care delivery outlets.
passed on to the FLCF, district, provincial and
federal level for compilation and analysis. The
Referral System federal, provincial and district program imple-
One of the important functions of the LHW is mentation units are equipped with computers
referral of patients to the appropriate health and printers for proper compilation and analysis
facility. LHWs provide motivation and referral of the reports on monthly, quarterly and annual
service to community for common ailments basis. The federal, provincial and district PIUs are
and to mothers for safe motherhood including linked through WAN or e-mail for timely and
ante natal, safe delivery and postnatal care. efficient transfer of data. LHW MIS system has
LHWs achieve this by close coordination with been placed for proper management of infor-
the nearest health facility, TBAs and other skilled mation; however, the HMIS in its present form is
birth attendants including midwives.11 limited to the FLCFs, without incorporating the
data from the community level. The different
kinds of tools used by LHWs are:
Professional Advancement
Professional advancement and promotions are Map of community
offered to LHW to learn new skills to advance Family (Khandan) register
their career as LHS and later on as Field Program
Community chart
Officer (FPO) on completion of minimum edu-
cation level (intermediate to become an LHS Treatment and family planning register & Diary
and Masters in any field to become an FPO) and Mother and child health card
experience (1 year work experience as LHW to
become an LHS and 2 years work experience as Referrals slips
LHS to become an FPO) required to reach the Monthly report of LHW
next level. Hence, advancement is intended

Table 18 – CHW Program Functionality Assessment Tool (CHW-PFA) – Pakistan
Component Level of Functionality: 0= non-functional; 1=partly Current
Definition functional; 2= functional; 3 = highly functional Level/
Evidence
0 1 2 3 (best practice)
1 Recruitment CHW not from community and CHW is not recruited from CHW is not recruited from com- Recruited from community
How and from where a plays no role in the recruitment. community but the commu- munity but the community is when possible. If not possible, 3
community health worker nity (reluctantly) accepts the consulted on the final selection. the community is consulted
is identified, selected, and identified CHW after selection. during the process and agrees
assigned to a community. on recruitment selection.
2 CHW Role Role is not clear or agreed upon No formal role of CHW exists Health system defines (policies Health system, community,
Alignment, design between CHW, community (no policies in place) General exist) the CHW role but without and CHW design the role/ 3
and clarity of role from and formal health system. expectations are given to community input. Role is clear expectations and policies
CHW (initial training) but to CHW and community but in place that support CHW

community, CHW, and
health system perspectives. are not specific. CHW and little discussion of specific role. Role and expectations
community do not always expectations. General agree- are clear to CHW and
agree on role/expectations. ment on role between CHW, community. Process for
health system, and community. update and discussion of
role/expectations in place
for CHW and community
3 Initial Training No initial training is provided. Minimal initial training is Initial training is provided to Initial training is provided
Training provided to provided (1 workshop, etc). all CHWs within the first year to all CHWs within the six 3
CHW to prepare for role Some CHWs attend works- of recruitment. Training does months that is based on
in MCH services delivery hops on specific topics. not include participation defined expectations for CHW.
and ensure he/she has the from community or from Some training is conducted
referral health center. in the community or with
necessary skills to provide
community participation.
safe and quality care. Training is consistent with
health facility guidelines for
community care and health
facility is involved in training.
4 On-going Training No ongoing training is provided Occasional, ad hoc visits On-going training is provided On-going training is provided
On-going training to by supervisors provide on a regular basis. Some super- to update CHW on new skills, 2
update CHW on new skills, some coaching. visors follow up with coaching. reinforce initial training, and
reinforce initial training, Note: Functional CHWs have ensure he/she is practicing
and ensure he/she is been trained (or updated) skills learned. Training is
within the last 18 months. tracked and opportunities
practicing skills learned.
are offered in a consistent
and fair manner to all
CHWs (not only some)
5 Equipment and Supplies No equipment and sup- Inconsistent supply and Supplies are ordered on All necessary supplies; no
Required equipment plies are provided. restocking to support a regular basis although substantial stock-out periods. 2
and supplies to deliver defined CHW tasks. No formal delivery can be irregular. Stock
expected services.. process for re-ordering. out of supplies essential for
defined CHW tasks occur at
a rate of x per year/mo
228
229
Evidence
6 Supervision No supervision or regular Supervision visits conducted Regular supervision visit at Regular supervision visit every
Supervision conducted evaluation occurs outside of between two and three times least every three months that 1-3 months that includes 3
on a regular basis to carry occasional visits to CHWs by per year to collect reports/ includes reviewing reports, reviewing reports, monitoring
out administrative tasks nurses or supervisors when data (or group meetings at monitoring of data collected of data collected. Data is
and to provide individual possible (1x/year or less). facility to turn in monitoring and occasionally provide used for problem solving
forms). No individual perfor- problem-solving support to and coaching. Supervisor
performance support
mance support offered on work CHW. Supervisors are not trained visits community, makes
(feedback, coaching, data- (problem-solving, coaching) in supportive supervision but home visits, provides skills
driven problem-solving). are facility based health workers. coaching to CHW. Supervisor
is trained in supervision
and has supervision tools
7 Performance Evaluation No regular evaluation of Once/year evaluation that is not Once/year evaluation that is not At least once/year evaluation
Evaluation to fairly performance by CHW. based individual performance based individual performance that includes individual 3
assess work during a set and includes only evaluation and includes only evaluation performance (local eva-
period of time. of coverage or monitoring of coverage or monitoring luation) and evaluation of
data. There are no rewards data (national /program coverage or monitoring data
for good performance. evaluation). Community is not (national /program evalua-
asked to provide feedback on tion) Community is asked to
CHW’s performance. There provide feedback on CHW
are some rewards for good performance. There are clear
performance, such as small rewards for good perfor-
incentive gifts, recognition, etc. mance, and community plays
a role in providing rewards.
8 Incentives No financial or non-financial No formal incentives provided Some financial or non-financial Financial and/or non-financial
Financial= salary and bonu- incentives provided but community recognition incentives are provided. incentives are partly based on 2
ses Non-financial= training, is considered a reward Examples of non-financial incen- good performance. Incentives
recognition, certification, tives include occasional formal are balanced and in line with
uniforms, medicines, etc. recognition, additional training, expectations placed on CHW.
and other small incentives. Examples of non-financial
incentives that engage
workers might include
(advancement, recognition,
certification process)
9 Community Involvement Community is not involved with ICommunity is sometimes Community plays significant Community plays an active
Role that community ongoing support to CHW involved (campaigns, education) role in supporting the CHW role in all support areas for 2
plays in supporting CHW. with the CHW and some people through mother’s groups, CHW, such as development
in the community recognize networks, etc. CHW is widely of role, providing feedback,
the CHW as a resource. recognized and appreciated for solving problems, providing
providing service to community. incentives, helps to establish
CHW as leader in community.

Evidence
10 Referral System No referral system in place: CHW CHW knows when to refer client CHW knows when to refer CHW knows when to
Is there a process for - might know when and where to (danger signs, additional treat- client (danger signs, additional refer client (danger signs, 1
determining when referral refer client, but - no logistics plan ment, etc) CHW and community treatment, etc) CHW and additional treatment, etc)
is needed logistics plan in place by the community for know where referral facility community know where referral CHW and community know
for transport/payment to emergency referral - information is but have no formal referral facility is and usually have where referral facility is and
is not tracked or documented process/logistics Referral is not the means to transport client have a logistics plan for
a health care facility when
tracked by community or CHW Client is referred with a slip of emergencies (transport,
required - how referral is paper and informally tracked by funds) Client is referred with a
tracked and documented CHW (checking in with family, slip of paper and information
follow up visit) but information flows back to CHW with a
does not flow back to CHW. returned referral form and/
or monthly monitoring.

11 Professional Advancement No professional advancement is Advancement (promotion) is Advancement (promotion) is Advancement (promotion) is
The possibility for growth, offered. sometimes offered to CHWs sometimes offered to CHWs offered to CHWs who perform 2
advancement, promotion who’ve been in program who’ve been in program for well and who express an
and retirement for CHW for specific length of time. specific length of time. Limited interest in advancement if the
No other opportunities training opportunities are offe- opportunity exists (advan-
are discussed with CHW. red to CHW to learn new skills cement might mean path to
Advancement is not related to to advance role. Advancement formal sector or change in
performance or achievement. is intended to reward good role) Training opportunities are
performance or achievement, offered to CHW to learn new
although evaluation is not skills to advance their role and
consistent (advancement might CHW is made aware of them.
mean path to formal sector or Advancement is intended to
change in role). No path to reti- reward good performance or
rement is made clear to CHWs achievement, and is based on
fair evaluation. Retirement is
encouraged and incentives
are provided to encourage
retirement at a set age.
12 Documentation, No process for documentation Some CHWs document their vi- CHWs document their CHWs document their
Information Management or info management is followed sits and group monitoring visits visits consistently and group visits consistently and group 2
How CHWs document to facility are attended by CHWs monitoring visits to facility are monitoring visits to facility
visits, how data flows to who bring monitoring forms. attended by CHWs who bring are attended by CHWs who
the health system and CHWs/communities do not see monitoring forms. Supervisors bring monitoring forms.
data analyzed and no effort to monitor quality of documents Supervisors monitor quality
back to the commu-
use data in problem-solving and provide help when needed. of documents and provide
nity, and how it is used at the community is made. CHWs/communities do not see help when needed. CHWs/
for service improvement data analyzed and no effort to communities work with
use data in problem-solving supervisor or referral facility
at the community is made. to use data in problem-sol-
ving at the community.
230
Table 19 – Community Health Worker Functionality Matrix – MCH Interventions – Pakistan
MCH INTERVENTIONS YES COMMENTS
1 ANTENATAL CARE
A Iron folate supplements
Counsel x
Provide commodity or intervention/ Assess and treat x
Refer for commodity, intervention, or treatment x
B Maternal nutrition
Counsel x
Provide commodity or intervention/Assess and treat o
Refer for commodity, intervention, or treatment o
C Counsel on birth preparedness/complication readiness x
D
* (includes counseling to use skilled birth attendant)
Tetanus toxoid
Counsel x
Provide commodity or intervention/ Assess and treat o
E Deworm
Counsel x
2 CHILDBIRTH and IMMEDIATE NEWBORN CARE
A Prevent Infection/Clean Delivery x
(Hand washing, clean blade +/or clean delivery kit)
B Provide Essential Newborn Care
a. Immediate warming and drying x
b. Clean cord care x
c. Early initiation of breastfeeding x
C Recognize, initially stabilize (when possible) and refer
for maternal and newborn complications
a. newborn asphyxia o
b. sepsis, o
c. hypertensive disorder o
d. hemorrhage e. prolonged labor and post-abortion o
complications
D Prevent PPH: AMTSL or use of uterotonic alone o
in absence of full AMTSL competency (e.g. oral
Misoprostol)
E Provide special care for Low Birth Weight newborns o
(Kangaroo Care)
3 POST-PARTUM and NEWBORN CARE
A Provide counseling on evidence-based maternal
newborn health and nutrition behaviors
a. clean cord care; o
b. exclusive BF through 6 months; x
c. thermal protection; hygiene; o
d. danger sign recognition; o
e. maternal nutrition, etc. o

B Assess for maternal newborn danger signs and provide o
appropriate referral.
C Provide Treatment for severe newborn infection (when o
community-based treatment supported by national
guidelines.)
4 EARLY CHILDHOOD
A Infant and young child feeding, IYCF: x
Provide counseling for immediate BF after birth; exclu-
sive BF < 6 months; age-appropriate complementary foods
B Promote growth monitoring, weighing infants and x
recording progress
C Provide community based management of acute mal- o
nutrition (CMAM) using Ready to Use Therapeutic Foods
(community-based recuperation of children with acute
moderate to severe malnutrition without complications)
D Community-based treatment of pneumonia o
Counsel re recognition of danger signs, seeking care/
antibiotics o
Assess and treat with antibiotics o
Refer for antibiotics o
Refer after treating with initial antibiotics
G Community-based prevention and treatment of diarrhea x
Counsel on hygiene x
Counsel on point-of-use water treatment o
Provide point-of-use water treatment o
Refer point-of-use water treatment x
Counsel on ORS x
Provide ORS o
Refer for ORS o
Counsel on Zinc o
Provide Zinc
Refer for Zinc
H Vitamin A supplements (twice annually children 6-59 months) x
Counsel x
Refer for commodity, intervention, or treatment
I Effectively assess and recognize severe illness in chil- x
dren (danger signs) with appropriate referral.
j Counsel on immunizations x
Mapping/tracking for immunization coverage o
Provide Immunizations:
-DTP x
-polio and or measles x
- +/- HIB o
- Hep B o
-Pneumovax o
-Rotavirus o
Refer for immunizations x

5 FAMILY PLANNING/HEALTHY TIMING AND SPACING
OF PREGNANCY
A Counsel on HTSP/contraceptives x
Provide contraceptives: o
- condoms x
- Lactation Amenorrheic Method (LAM) o
- oral contraceptives x
- depo o
Refer for contraceptives: x
- condoms o
- oral contraceptives o
- long-acting and permanent methods x
Provide FP counseling +/ x
- administer contraceptives (e.g.;Oral Contraceptives)
6 MALARIA (Optional - Dependent Upon Country)
A Insecticide-treated mosquito nets to pregnant women and children
Counsel x
B Intermittent preventive malaria treatment (IPTp)
Counsel o
C Community-based treatment of malaria (testing with
Rapid Diagnostic Test or presumptive treatment per
antimalarial per national guidelines.)
Counsel x
7 PMTCT (Optional - Dependent Upon Country)
A Healthy timing and spacing of pregnancy
Counsel o
B Antibody testing to pregnant women and mothers
Counsel o
C Prophylactic ARVs/HAART to pregnant women mothers
Counsel o
E Prophylactic ARVs/HAART to infants
Counsel o

F Early infant diagnosis
Counsel o
G Pregnant HIV-infected women tracking
Counsel o
H HIV-exposed infant tracking
Counsel o

Summary
The LHWP, launched in Pakistan in 1991, as a there is a need to follow the program design
concretion of the integrated health system, is with consistency for better outcomes and a
a highly beneficial program for the community need to overcome shortcomings resulting from
and has a major role to play in the provision of financial and supplies inadequacy. Despite of
primary health care and in reduction of burden the incentives and chances for professional ad-
of disease via preventive strategies and educa- vancement, 1 out of 10 LHWs charge their clients
tion of the masses, especially in the rural areas. for their services and drop outs have also been
The LHW program is composed by Lady Health observed. The reasons behind this were found
Workers and Lady Health Supervisors that work to be the irregularity in the payment of salaries
together, having families as their center of ac- to the LHWs the geographical constraints that
tion. Each LHW is responsible for enrolling and make travelling for home visits difficult for them
monitoring the health status of about 1,000 po- thus hampering their performance.
pulations living in an assigned area, providing
primary health care services, family planning Notwithstanding these challenges, LHW pro-
and making referrals to other level of care as gram is indubitably a global example whose
required. The LHW who is a member of commu- basic underlying principles can and should be
nity and at the same time is a health professional implemented in different settings, irrespective
paid by public sector. They are accountable for of the political and economic country level es-
the health of their own community, and play a tablished systems, on the basic stipulation of
liaison between community and health system. considering health as a fundamental right to
Their main tasks involves preventive and pro- be offered by a public sector minimally able to
motive activities related to maternal, newborn address the community needs.
and child health, plus therapeutic activities in
controlling diseases like malaria, tuberculosis
and other communicable diseases. They also 2. Bangladesh – BRAC
provide promotional and preventive messages
to community members and are expected to
Community Health
timely identify family members at risk or with Workers Program
early signs of diseases, and refer them for further
diagnosis and management.
Socio-economic and
Political Context
Based on these characteristics and through a Bangladesh is located in South East Asia between
combined central government support and India and Burma having a total area of 143,998
strong local committeemen, the LHW program square kilometers with mostly flat alluvial plain
expanded impressively, from a less than 20,000 and hilly areas in southeast region. It has a
workers in 1995 to more than 90,000 workers all population of 156,050,883 which is growing at
over the country in 2005-06, that are covering a rate of 1.3%.15 Children under the age of 14
currently about half of the Pakistani population. years comprise 36.4% of the population while
only 4% of the population is under the age of 65
There are convincing evidences about the im- years.15 Majority of the population are between
pact of the LHW program on health indicators the ages of 15-64 years. The total population sex
when compared with national figures as regard ratio according to the 2009 estimates of Central
to immunization coverage, modern methods Intelligence Agency is 0.93 males for every one
for family planning utilization, antenatal cove- female.15 Although the rate of urban population
rage, maternal, infant and child health. However

is increasing at 3.5% annually only 27.5% of the of public facilities at tertiary, secondary and
total population resides in the urban areas.15 primary levels. However in reality there is a mix
of public, private, NGO, and traditional providers
Bengali is the dominant ethnic group with the operating with variable population reach and
98% population who usually converse in Bengali quality. Less than 20% of the curative health
which is the official language whilst English is services are consumed from the public sector.
also used by some as the mode of communi-
cation15. Eighty three percent of the people are Traditional healers, quacks, qualified doctors
Muslims and 16% Hindus.15 working privately, and NGOs also have their
stake in the delivery of health services. Several
The GDP of Bangladesh has increased from doctors are into dual practice, i.e., both public
US$1300 to US$1500 from 2006 to 2009.15 and private.17 The private sector is the major
Conversely 45% of the population is below po- provider of curative services for both poor and
verty line in addition to 2.5% increase in annual rich, in both urban and rural areas.18
unemployment.15 Consequently, the life expec-
tancy at birth is merely 60.25 years with female The public sector is underfunded yet has poor
life expectancy is indistinctly higher than that absorptive capacity. The distribution of qualified
of males.15 Moreover, the death rate is 9.23 for staff seems to be biased and retaining them in
every thousand people yearly.15 The degree of rural postings is quite difficult. Ghost workers
risk due of major infectious diseases is also high. in the public sector19 and mushrooming of
These include food and water borne diseases private health care set ups are another serious
such as bacterial and protozoal diarrhea, hepa- problems.20
titis A and E, and typhoid fever; vector borne di-
seases like dengue fever and malaria and water The professional medical associations are parti-
contact disease which includes rabies.15 cularly opposed to make any attempts to tackle
the human resource deficit in rural areas, such
Health Systems Overview as by addressing the skills of semi-qualified
providers who are mostly consulted by the rural
Bangladesh is one of those low income coun- populations.20
tries which has made considerable progress in
improving the health and nutritional status of Bangladesh Rural Advancement Committee
its citizens during the last decade. In the poor (BRAC) is the largest national non-governmental
households of the country however, the issues organization that incorporates semi-voluntary
of preventable morbidity and mortality from CHWs. BRAC came into existence in 1972 as a
poor maternal and child health, malnutrition, relief organization. After a year of working, as a
communicable diseases are still major challen- relief team, realized that relief and reconstruc-
ges to be tackled. At the same time, there are tion efforts would only be limited to disaster
new concerns due to the rising rate of non- management measure. Thus in 1973, BRAC
communicable diseases, from environmental adopted the community development ap-
hazards such as air and water pollution and proach but due to the exploitation of the poor
from behavioral causes such as tobacco use, by the rural elites, lack of education and health
accidents and violence.16 care found their intervention to be insufficient.
BRAC then switched to the Health, Nutrition and
Bangladesh has a three tier health care service Population Programs in 1973 and a Non-Formal
delivery system with a comprehensive network Primary Education Program in 1985. In health

care outreach services BRAC has been corrobo- married having children not below 2 years of
rating with CHW programs in Bangladesh since age,
1977. It integrates essential health care and pro-
vides basic curative and preventive health care. few years of schooling,
Shastho Sebikas (SS) is an alternative term used willing to provide voluntary services,
for CHWs in Bangladesh. CHWs in Bangladesh
acceptable to community they serve,
are a class under primary health care approach.
They are selected by the community and are Preferably, they should not be living near a local
acceptable to them.21 health facility to avoid competition, and extend
basic health facilities coverage to places far
Besides designing interventions for the com- away from any health facility
munity, BRAC also focused on the sustainability
of the project and generated funds from both The SS Role
donors as well as through its own support en-
terprises and microfinance projects. SS works for 15 days a month, approximately six
days a week and on an average two hours a day
BRAC not only strengthened its roots in usually in afternoon, but they work quite exten-
Bangladesh but also expanded globally. It has sively in the community. Their specific roles are
been serving in Afghanistan since 2002, in Sri to: 23, 24
Lanka since 2004 and in Tanzania, Uganda and
Perform health education and promotion activi-
Southern Sudan since 2006. BRAC USA came into
ties in five essential components that consist of
being in year 2007, while the year 2008 marked
water and sanitation, immunization, health and
BRAC’s full-fledged operations in Pakistan.
nutrition education, family planning, and basic
curative services
Recruitment Process
Shasthya Sebika are recruitment from among Sell medicine, contraceptives, sanitary latrines,
the active village based BRAC credit and de- tube-wells and vegetable seeds
velopment group called Village Organization Diagnose, treat and provide health education on
(VO).22 VO is formed by the poor women in the diarrhea, dysentery, fever, common cold, worm
village and this organization extends small loans infection, gastric ulcer, allergic reaction, scabies
to members for income generating activities. and ringworm infection
Initially village organization discusses and Identify pregnant women
mutually nominates prospective SSs and then
Encourage pregnant women to utilize services
suggests nominated candidates to regional of-
in government facilities
fice members. Based on the recommendations
forwarded by that organization, final selection is Visits women at 42 days of delivery
done at BRAC regional office. In regional office,
a general meeting is held to ratify the nomina- Give special care to Low Birth Weight (LBW)
tion and finally the candidate has to undergo a babies
selection interview. Selection of SS is based on Organize income generating activities
the following criterion:
Prepare and submit monthly progress report
female (25-45 years),
Works on DOTS program

Initial Training of SSs Supervision
SSs are given fundamental and essential cura- Supervision of the SSs is done by the program
tive training for a period of 4 weeks, amounting officers at BRAC, the Shasthyo Kormis (SKs).
about four days per week at the regional office.17 SKs are paid health care workers associated
They are trained on following common illnesses: with BRAC and have a minimum of ten years of
anemia, angular stomatitis, common cold and school education. Each SK supervises 25 to 30
cough, diarrhea, dysentery, gastric ulcer, peptic SSs. An SK visits households three days a week
ulcer, ringworm, scabies, and worm infestation.25 during which time she reviews the work done
For specific programs such as DOTS, community by SS related to DOTS, family planning, and EPI
based ARI, and safe motherhood interventions, motivation and maintenance of their registers.
a subset of these workers are given additional In the remaining three days she provides ANC
training as and where necessary. and PNC services to women, manages health
forums and enrolls births. During this time she
On-going Training of SSs also reviews the activities of SSs with regard to
diverse services provided by the SSs. Thus, this
For the next two years, they are provided with helps her supervise the SSs. Each SS is visited by
refresher training sessions, once every month, a program officer (PO) at an average of three to
conducted by the program organizers. Refreshers four times a month. The visit of 25% of house-
are conducted in an interactive and problem holds by the PO is also a part of routine scree-
solving way, in which problems encountered ning. SKs are selected based on the following
during the month are discussed alongside the criteria:27
discussion of new health and nutrition aspects.
This keeps the knowledge of the SSs updated experienced,
about health innovations and management of selected from and by community,
diseases, and most importantly, it gives the SSs
willing to work,
the motivation to continue the work.17
age 30-45 years
Equipment and supplies These supervisors are given 2 weeks training on
After training, SSs receive essential drugs, other basic curative care for some common illness,
health commodities (e.g. contraceptives pills, family planning, MNCH, nutrition, immuni-
condoms) kit, delivery kit, sanitary napkins, zation, water and sanitation, communicable
soaps and iodized salt for performing their disease control, DOTS, ARI, communication,
tasks in the community. These drugs and health supervision and monitoring. Supervisors are
commodities are procured by BRAC in bulk and also paid with incentives of Tk.80 for providing
then supplies to the SSs at lower-than-market antennal and post natal care services to women
prices, which they sell with a small mark up.26 in community.
The essential drug kit contains:
Paracetamol Performance Evaluation
Vitamins Performance evaluation of CHWs and their im-
Antihistamines pact on service utilization has been observed
in BRAC internal reports. Evaluation has shown
Oral rehydration solution that 28, 29:
Antacids CHW are well recognized in community and
motivated
Anti helminthics

Patient compliance has increased Providing essential newborn care Tk. 100
Service provision and utilization has been Refer from home for complication Tk. 100
increased Inform the SK for ensuring birth weight if delive-
red at home Tk. 30
They made several efforts to spread awareness
of HIV/AIDS in the community and 94% of the Women receives ANC Tk. 5 for non VO member
Community sex Workers (CSWs) reported that and Tk. 3 for a VO member
the BRAC volunteers were their source of infor-
mation.30 It has also been observed that there Community Involvement
has been greatest reduction in low birth weight SSs perform their task in the community by in-
babies in the areas of BRAC volunteers 31. Their volving community in their tasks. They develop
diagnosis of pneumonia was found to be 67.6% community level advocacy and support groups
sensitive and 95.2% specific.32 Their efforts in TB where they discuss issues and influence them
control are reflected by treatment success rate to participate and help them in suggesting an
of 83.3%.33 action plan for specific problems and issues. SSs
also involve community in identifying patients
Incentives for referrals.35 They also enhance community
awareness through interactive communications
SS works as a volunteers and receives no salary,
in the form of folk music, theatre. Furthermore,
they basically earn income from the sale of drugs
SSs also aware local stakeholders about the com-
and health commodities and receive incentive
munity issues through advocacy workshops.
from certain performance based tasks 26.
Incentive mechanism in BRAC was started in
1984 particularly for TB control program for Referral System
detecting higher number of cases from the On identification of emergency case by SSs,
community. Until previously, the program was they verbally refer the child to an existing heath
based on voluntary mechanism and SSs were facility. Workers inform center’s health providers
benefiting from the sales of medicines and about case pre hand through mobile phone
commodities provided by BRAC and as a part of and then these workers ensure that these pa-
non monetary reward, motivational factors like tients are transferred to facilities through proper
enthusiasm to work for the betterment of the transport. They also follows patient at home on
community was involved and social prestige their arrival to community after treatment.35
and fame were important inspirational factors
that were involved. The subset of SSs who also Professional advancement
works for DOTS program receives Tk. 150 for the
Some CHWs accumulate experience and are
patient who completed the treatment for TB
under her observation.34 Under urban MNCH sometimes used to train others. There were
program, CHWs are also provided with incen- no cases of retirement reported and at the
tives for identification, referral and provision of moment there is no formal retirement plan for
services.34 Following incentives are provided for them documented.
specific MNCH tasks:
Pregnancy identification Tk. 30
Brining mothers to delivery centers Tk. 100

Table 20: Performance Evaluation of SSs
Program coverage Coverage is about 70%. Covered 46 districts out of total 64.
Preventive and promotive Vaccination promotion coverage: 87% of children under five, CPR 62%,
service delivery ANC (3 visits) coverage 62%, TT coverage 82%, under 5 vitamin A is 92%
Curative service delivery Tuberculosis Completion rate over 90%, and success rate is 89%
LHW services and the poor BRAC providing services to the poorest population of Bangladesh
LHW impact on health BRAC impact and coverage is better off than national figures.
TB prevalence in BRAC areas half the rate in other areas

241
Table 21 - CHW Program Functionality Assessment Tool (CHW-PFA) – Bangladesh
Evidence
community, CHW, and CHW (initial training) but to CHW and community but in place that support CHW
5 Equipment and Supplies No equipment and sup- Inconsistent supply and Supplies are ordered on All necessary supplies; no
Required equipment plies are provided. restocking to support a regular basis although substantial stock-out periods. 3
expected services. process for re-ordering. out of supplies essential for

Evidence
performance support
and has supervision tools.

data. There are no rewards data (national /program coverage or monitoring
for good performance. evaluation). Community is not data (national /program
asked to provide feedback on evaluation) Community is
CHW’s performance. There asked to provide feedback
are some rewards for good on CHW performance.
performance, such as small There are clear rewards for
incentive gifts, recognition, etc. good performance, and
community plays a role
in providing rewards.
9 Community Involvement Community is not involved with Community is sometimes Community plays significant Community plays an active
242
243
Evidence
is needed - logistics plan in place by the community for know where referral facility community know where referral CHW and community know
11 Professional Advancement No professional advan- Advancement (promotion) is Advancement (promotion) is Advancement (promotion) is
The possibility for growth, cement is offered. sometimes offered to CHWs sometimes offered to CHWs offered to CHWs who perform 0
No other opportunities training opportunities are offe- opportunity exists (advance-
are discussed with CHW. red to CHW to learn new skills ment might mean path to for-
Advancement is not related to to advance role. Advancement mal sector or change in role)
performance or achievement. is intended to reward good Training opportunities are
Documentation, No process for documentation Some CHWs document their vi- CHWs document their CHWs document their
back to the commu-
12 use data in problem-solving and provide help when needed. of documents and provide

Table 22 - Community Health Worker Functionality Matrix – MCH Interventions
1 ANTENATAL CARE
Counsel x
Counsel x
Provide commodity or intervention/Assess and treat x
D
* (includes counseling to use skilled birth attendant)
Tetanus toxoid
Counsel x
E Deworm
Counsel x
for maternal and newborn complications x
a. newborn asphyxia x
b. sepsis, x
c. hypertensive disorder x
d. hemorrhage e. prolonged labor and post-abortion x
complications
D Prevent PPH: AMTSL or use of uterotonic alone x
Misoprostol)
E Provide special care for Low Birth Weight newborns x
(Kangaroo Care)
a. clean cord care; x
c. thermal protection; hygiene; x
d. danger sign recognition; x
e. maternal nutrition, etc. x

B Assess for maternal newborn danger signs and provide x
C Provide Treatment for severe newborn infection (when x
guidelines.)
4 EARLY CHILDHOOD
B Promote growth monitoring, weighing infants and o
recording progress
D Community-based treatment of pneumonia x
antibiotics x
Assess and treat with antibiotics x
Refer for antibiotics x
Counsel on hygiene o
Provide point-of-use water treatment x
Counsel on ORS o
Provide ORS o
Refer for ORS o
Counsel on Zinc o
Provide Zinc o
Refer for Zinc
H Vitamin A supplements (twice annually children 6-59 months)
Counsel x
Provide Immunizations: o
-DTP o
-polio and or measles o
- +/- HIB o
- Hep B o
-Pneumovax o
-Rotavirus x
Refer for immunizations

OF PREGNANCY
- condoms x
- Lactation Amenorrheic Method (LAM) - o
oral contraceptives x
- depo o
- condoms o
- long-acting and permanent methods o
Provide FP counseling +/ - administer contra- x
ceptives (e.g.;Oral Contraceptives)
A Insecticide-treated mosquito nets to pregnant women and children
Counsel x
Counsel x
Counsel x
Counsel o
Counsel o
Counsel o
Counsel o

Counsel o
Counsel o
Counsel o

Summary
The health system in Bangladesh was crippled facilities run by NGOs. There is also consistent
after partition from Pakistan in 1971. At that evidence about clearly positive impact of NGOs
time the health system of Bangladesh was community based programs on reduction of
facing weak leadership, governance, and ac- TB and malaria morbidity and mortality and on
countability, and thus was unable to provide reduction of infant and child mortality, and on
minimum and decent level of health services to maternal and reproductive health indicators in
the majority of their citizens. BRAC initially came their catchment areas.
into existence in 1972 as a relief organization,
but after working for years they realized that The valuable effort of BRAC CHW program has
relief and reconstruction efforts would only be now been replicated in many regions of Africa,
limited to disaster management measure. Thus USA, UK and South Asia. Amongst all these
BRAC then switched to the Health, Nutrition and BRAC Afghanistan has been functional since last
Population Programs in 1973 and has been cor- 7 years which was initially started in response to
roborating with CHW programs in Bangladesh the conflict in Afghanistan and the flood of retur-
since 1977. The initiative and commitment of ning refugees in 2002. By implementing the ho-
CHWs from BRAC in taking responsibility of local listic strategy we have developed in Bangladesh
implementation of health and nutrition services and adapting it to suit the local context, BRAC
across the country allowed an impressive expan- Afghanistan quickly became the largest and
sion of the program, from a number of CHWs most sustainable of all the development orga-
less than 1,000 in 1990 to more than 78,000 in nizations in the country with program in 23 of
2008 in place currently. Each CHW is responsible the country’s 34 provinces and nearly 895,000
for following up 150-200 households. The CHW people are benefiting from the program.
receive training that privileges the determina-
tion and understanding of social, economic and With all these success, program is also facing
environmental characteristics of the commu- some local difficulty of high drop-outs that
nity, as well as epidemiological profile. They also need to be effectively discussed and addressed
receive promotional and preventive aspects to assure the sustainability of the program. The
of health, so that they are in good position of primary motivation to become a CHW is the
providing influential counsel to community economic incentive, with the meager income
members, for identifying timely family members earned by their activities, it is difficult to retain
at risk or with health problems and refer them them in the system and the drop-out rate is fair-
to the health facility for further assessment and ly high. The Shasthya Sebika work extensively in
management, if considered pertinent. Their role the community and drive their motivation not
in community health promotion is significant, as only from the financial incentive but also from
they are community members carefully selected the prestige that they gain in the community.
with the participation of community members An escalation in their financial incentives can
and BRAC leaders. improve their performance and as such the pri-
mary health care scenario of the country.
From the very outset, BRAC has provided
consistent evidence about the positive im-
pact on an increased coverage of health care
for MNCH, nutrition and TB, malaria patients
through home-based directly observed therapy
strategy conducted by CHWs, and also an in-
creased trust of community members on health

3. Thailand – Village Health
Volunteer Program
Socio-economic and
Political Context
des, i.e., the rate has dropped to 8 per 1000 in
The United Kingdom of Thailand is a moun-
year 2006.37 The system has been developed in
tainous country in the Southeast Asia, lying
such a way that the primary health care is roo-
southeast of Burma, bordering the Andaman
ted in the local communities and the volunteers
Sea and the Gulf of Thailand.36 It has a total area
play an important role to prevent the disease
of 513,120 square kilometers.36 The total po-
in the first place through preventive health
pulation of the country is 63,444,000,37 which
education.37
is growing at the rate of 0.6%.36 Majority of the
population (70.5%) are between the ages 15-64
In the year 2003, health care system in Thailand
years36 and the life expectancy in Thailand at
has been decentralized to provinces and the
birth is 73.1 years36 while the death rate is 7.3
districts as a result of Health System Reforms.40
deaths per 1,000 population.36
The program with its appreciable outcomes37
deserves a full functionality assessment.
The most dominant ethnic group of the country
is Thai followed by Chinese, comprising 75%
and 14% of the total population, respecti- The Village Health Volunteers
vely.36 Amongst them 95% of the people are Program (VHVs)
Buddhists.36 The official language of the nation
The VHV program has been launched in Thailand
is Thai36 and the country has a literacy rate of
at a national level after the Alma-Ata conference
92.6%36 where the government spends 4.2% of
in 1978.41 The two types of CHWs involved in
GDP on education.36
the primary health care are VHVs and the Village
Health Communicators (VHCs).41 Almost all
The GDP per capita of the country is $8,400,36
the villages in Thailand had trained VHVs and
and the total expenditure on health as % of GDP
VHCs by the year 1986.41 The CHW scheme
(2006) is 3.5.37 The World Bank listed Thailand’s
then became the most important activity of
economy as the lower middle income econo-
the National Primary Health Care program with
my.38 Thailand’s economic growth has fallen
the objectives of reaching out majority of the
sharply due to political crises that are there
population with low cost, equitable and easily
since 2005 36 and currently 10% of the total
accessible healthcare.41 In 1994, these two roles
population lives below poverty line.36
have been merged together and only VHVs are
trained.42
Health Systems Overview
Thailand has a multi-layered health care system Recruitment Process
beginning from self-reliant, self-care at the fa-
The VHVs are the respected members from
mily level to that of care offered by a medical
Thai village where they work. During the early
specialist.39 The dominant provider of the health
years of the system, VHVs were selected by the
care is the public sector although for profit and
primary health care centre officer using a “so-
not for profit private sectors also have their
cial matrix” method to identify potential VHVs
role in delivery of health services.39 There are 4
through informal surveys. This method involved
attending physicians per 10,000 population37.
selecting individuals who were respected by
The country has a very strong primary health
the community and had the social skills neces-
care system with CHWs as its backbone and it
sary to engage community members, including
has proven its success by a cut down of 80% in
good listening, communication and inter-per-
infant mortality rate during the last three deca-
sonal skills as well as motivation to help others.

The selected VHVs were usually village leaders background. 86.9% have no more than basic
or other respected villagers. primary school education. Only 7.3% were
college graduates and 1.0% holds a bachelor
Selection of VHV is based on the following degree. 51.1% were farmer and 13.4% worked
criterion:42 as waged labor.43
Able to read and write,
Live and work in the village,
The VHV Role
Every village in Thailand has at least one VHV,
Have shown regular participation in the village
who in turn are responsible for 5 to 15 house-
health community development program,
holds.40 The responsibility of VHV is to promote
Be trusted by village members, health and intervene in treating minor health
Have one’s own occupation to earn a living, problems. Their health promotive activities ran-
ge from advocating simple preventive measu-
Live in a house easily accessible to villagers, res to fostering wider health related community
Not to be government official or village development in areas such as literacy, housing,
headman sanitation and water supply and their health in-
terventions activities range from providing basic
The candidates who fulfill the above require- drugs and oral rehydration solution to endorsing
ments are approved by a government official and teaching family planning and conducting
(Provincial Health Officer) after going through routine childhood growth measurements.44
the following selection process:
Some important responsibilities of VHVs are
Public advertisement is posted by a primary to:42
health care centre for a specified period
Demonstrate a good role model in self-care
Completed application is received
Disseminate health information through com-
Official assignments are given by the district munity radio
health officer (who also serves as the supervisor)
after the basic training is completed Provide a health information corner in the pu-
blic health center
An informal pre-selection process is also fol- Meet with public health workers on the sur-
lowed in which potential VHVs are selected and veillance system of communicable diseases in
encouraged to apply by their village leaders and the community
the primary health care centre staff. This pre-
selection helps ensure the acceptability of the Educate the villagers on self and family preven-
VHV in the village once officially appointed by tion of communicable diseases
the provincial level. Senior VHVs also assist with Provide information on disease outbreak
the selection of new ones. VHVs often serve immediately
for life, once selected, and children of VHVs are
encouraged to participate once their parents Test blood for malaria and test specimen for
eventually retire. parasite when suspected
Provide basic health care
Existing volunteer workforces were found to be
comparatively low educational and economic Transfer the patient to an appropriate health
centre

Survey and collect sanitation and environment children aged 1 ½ to 2 years
data and send it to the district health worker Urge parents to take their children for dental
Raise awareness on environmental care
management Suggest to the villagers to avail the dental ser-
Improve public water supply vice when having a dental problem
Cooperate with community leaders and orga- Supply and sell toothbrush, toothpaste and
nize health promoting activities medication
Survey and collect data on children aged 0-5 Provide knowledge on mental health to
years, pregnant women, and post partum villagers
women Support to establish a society for the elderly
Inform the villagers on vaccine-preventable and provide knowledge on physical and mental
disease health of elderly persons
Cooperate with public health workers in organi- Organize mental-health-promoting activities

zing vaccination point Provide knowledge on AIDS to villagers on pre-
Weigh children aged 0-5 years every three vention and control
months and compare the children’s weight with Organize activities to promote National AIDS
standard and record Day
Measure nutrition intake of children every two- Supply condoms for villagers
three months
Survey villagers aged 40 and above for diabetes,
Spray iodine in salt for the villagers high blood pressure and vision problems
Promote selling of iodized salt in the Mobilize villagers to improve the environment
community and to reduce accidents
Supply concentrate iodine water to the Publicize on how to select good quality
villagers products
Promote prenatal care Demonstrate a good role model in buying pro-
Recommend to mothers to breastfeed till the duct showing registration number and expiry
child is at least four months old date and in reading the medical labels
Suggest to the mother to bring her child for a Cooperate with community leaders to ensure
medical checkup at the health centre that only good quality products are sold.
Follow up pregnancy, and post-pregnancy and Cooperate with the village committee in moni-
ensure that the infant gets a medical check-up toring the environment and to set up an envi-
Provide knowledge on family planning ronment protection club.
Suggest use of medication and herbal
medication
Supply and sell basic-needs medication
Promote the “My first toothbrush” campaign in

Initial Training of VHVs
Village health volunteers are trained in primary other VHVs and briefs them on any training or
health care aspect for 7 days and later on, spe- communication received.40
cialized on-the-job training is provided for 15
days.42 They are trained for motivation sessions, Performance Evaluation
concepts of primary health care, prevention
of disease including water supply, sanitation, There is no formal evaluation and monitoring
immunization and other controls, treatment system placed to assess the quality and impact
of health problems including first aid, sympto- of village health volunteers’ work. However
matic and supportive treatments and herbal studies have shown that the case detection of
medicine, promotion of health including nutri- tuberculosis done by the VHVs was compara-
tion, reduction of mental stress and family plan- ble to the trained staff of the hospital and the
ning.45 They are trained in the form of lectures, health center.46 Currently, they are providing a
demonstration and discussions by volunteered coverage to 12 million household in Thailand.47
professionals from medicine, nursing and public The knowledge and performance of VHVs are
health fields. evaluated by questionnaires and visits by pro-
fessionals while they are practicing in the com-
munity and are also re-evaluated when they
On-going Training of LHWs are on their refresher training.48 However VHVs
To sustain and upgrade the VHVs’ knowledge, reported a decline in the use of their services
regular meetings are held at the district health in regions bordered by urban areas where quite
office level. These meetings provides an oppor- advanced health facilities were available to the
tunity for refresher training, communication villagers.42 There is also a current shift in their
and networking among VHVs, health officials role to potential areas of work such as preven-
and health professionals. tion of domestic violence, alcohol consumption
control, and caring of the elderly. More health
Equipment and supplies activities were found in the villages where the
VHVs had a higher level performance than in
The VHVs are provided with simple non-pres- the villages where the VHVs had lower level of
cription medicines that are effective in treating performance.47
common illnesses. They also promote herbal
medications as an important way to address
health problems and the drug shortage.42
Incentives
There is no monetary incentive provided to the
Supervision VHVs, except for free health services for themsel-
ves and their immediate family members. More
VHVs work under the direct supervision of a specifically, VHVs are exempted from the annual
primary health care officer at the sub-district fee that is required for the universal coverage of
level, whereas the district health officer serves a health care or what is called the “30-baht heal-
second-level supervisor. There is no formal eva- thcare scheme”.49 They also have full and free
luation or performance monitoring to assess the access to health services at the district hospital.
quality of VHVs work. Each village has a lead VHV They also have special quotas for VHV families
who organizes the other VHVs into a team, and, to apply to government nursing. As a part of
in effect also serves as an informal supervisor. non monetary reward, VHVs receive public re-
They are usually the senior-most among VHVs cognition from both the community as well as
in the village. The VHVs leader also supervises the formal health sector. They also experience

enhanced social standing, greater respect from
their community and personal satisfaction, and
some of them have also been elected to the lo-
cal government. VHVs are treated as part of the
formal health system, and the district health ser-
vices use them in the out-patient department
at health centers, when there is a surge of work
or a personnel shortage. Furthermore, VHVs are
also acknowledged for their work in various
ways. The “best VHV of the year” is selected and
announced annually at a national ceremony
attended by all VHVs in the country on the 20th
of March, which is designated as “Village Health
Volunteer Day” to celebrate and recognize their
work.
Community Involvement
Whenever the health system requires com-
munity involvement, especially with regard to
prevention and health promotion activities, the
VHV is designated to communicate the messa-
ges and mobilize the community to participate
and suggest in developing an action plan.
Referral System
VHV knows when to refer a client and know
where referral facility is but have no formal re-
ferral process is place and referral is not tracked
by community or VHV.
Professional Advancement
The system encourages young village health
volunteers for further education and provide
them grants to study and return as public health
officers.40

Table 23 - CHW Program Functionality Assessment Tool (CHW-PFA)-Thailand
Evidence

5 Equipment and Supplies No equipment and supplies Inconsistent supply and Supplies are ordered on All necessary supplies; no
Required equipment are provided. restocking to support a regular basis although substantial stock-out periods. 2
254
255
Evidence
performance support

Evidence

back to the commu-
256
1 ANTENATAL CARE
Counsel x
Counsel x
(includes counseling to use skilled birth attendant)
D Tetanus toxoid
Counsel x
E Deworm
Counsel x
a. Immediate warming and drying o
b. Clean cord care o
c. Early initiation of breastfeeding o
for maternal and newborn complications o
b. sepsis, o
complications
D Prevent PPH: AMTSL or use of uterotonic alone o
Misoprostol)
E Provide special care for Low Birth Weight newborns o
(Kangaroo Care)
a. clean cord care; o
c. thermal protection; hygiene; o
d. danger sign recognition; o
e. maternal nutrition, etc. o

C Provide Treatment for severe newborn infection (when x
guidelines.)
4 EARLY CHILDHOOD
recording progress
antibiotics o
Refer for antibiotics o
G Community-based prevention and treatment of diarrhea
Counsel on point-of-use water treatment x
Refer point-of-use water treatment o
Counsel on ORS x
Provide ORS x
Refer for ORS o
Counsel on Zinc o
Provide Zinc o
Refer for Zinc
Counsel x
I Effectively assess and recognize severe illness in chil- o
Provide Immunizations: x
-DTP x
- +/- HIB o
- Hep B o
-Pneumovax o
-Rotavirus x
Refer for immunizations

OF PREGNANCY
- condoms x
- depo o
- condoms o
A Insecticide-treated mosquito nets to pregnant women and children x
Counsel o
B Intermittent preventive malaria treatment (IPTp) o
Counsel o
antimalarial per national guidelines.) x
Counsel x
A Healthy timing and spacing of pregnancy x
Counsel o
B Antibody testing to pregnant women and mothers o
Counsel o
C Prophylactic ARVs/HAART to pregnant women mothers x
Counsel o
E Prophylactic ARVs/HAART to infants x
Counsel x

F Early infant diagnosis x
Counsel x
G Pregnant HIV-infected women tracking x
Counsel x
H HIV-exposed infant tracking x
Counsel x

Summary
Thailand’s PHC system, one of the oldest and diseases like avian H5N1 from the published stu-
most successful in the world, grew from a 1966 dies. In addition, the decentralization of health
pilot program to a full-fledged program of care system in Thailand has proved the inherent
universal health care in 1980. Supporting the sustainability of the CHW program which conti-
concept of community involvement, the Village nues to show improvement in the health sce-
Health Volunteer (VHV) is the backbone of this nario of the country by consistently decreasing
health care delivery system. Thailand, which is at the burden of diseases prevalent in the country.
high risk of major infectious diseases, the preva- However, the referral system needs to be further
lence of HIV in the country and the occurrence strengthened and the formal evaluation of the
of H5N1 avian influenza makes it mandatory to CHWs should also be done on a regular basis
have a strong grass root level health care inte- to further improve their performance. We also
gration program which connect people in the recommend that the funding of CHW program
community to formal health care system. The which at times become insufficient to run trai-
village health volunteer program in Thailand ning programs be increased keeping in view the
was started in 1970 with the aim of training 1% crucial role played by the VHVs in the country’s
of the population as CHW managed to train and preventive and curative health care system.
deployed one volunteer in each village.
There are many factors that has contributed in the

sustainability of the program and that includes:
the perceived high value paid to these village
health volunteers by the government as well as
the community for their work and the way they
were chosen with full consensus of community
in their selection process. Furthermore, they are
also been empowered by the district level and
public health matters that directly affects the
community. Though volunteers receive modest
or no financial remuneration, they receive in-
kind incentives and acknowledgement as well
as social standing. It appears that membership
in a nationwide network, fulfillment of their
aspirations to help others, and security gained
for their family members in terms of receiving
health care benefits and some advantages in
educating their children are enough to sustain
the system. It has also been identified that many
of these retired volunteers have been replaced
by their own offspring or relatives which help in
supporting the program.
There is convincing evidence about the impact

of the VHV worker program on health indica-
tors such as malaria control, management of
Tuberculosis and HIV/AIDs and other infectious

L AT I N - A M E R I C A N
Case -Studies
Brazil – Programa Saúde da Familia

Haiti – Zanmi Lazante’s Community
Health Program

4. Brazil - Programa Saúde da
Familia improved water source is 91%, and literacy rate
is 89%,51 figures all substantially better than
Socio-economic and political years ago, but still hiding huge disparities.
context
Brazil is the largest country in South America Health System overview
with 191.6 million inhabitants, and covering The pattern of mortality in Brazil has changed
around half of the total surface area of the sub- markedly over the years, with a decline in some
continent. It is politically and administratively infectious diseases and a resurgence of others,
organized in 26 states, 5,561 municipalities, and and with a sustained increase in the frequency
the Federal District, seat of the federal govern- of some non-communicable diseases, such as
ment. There are five political and geographical heart disease (most notably cerebrovascular
regions: North, Northeast, Southeast, South, diseases and ischemic heart diseases), diabetes,
and Center-west. cancer, and deaths attributable to violence, par-
ticularly during the period 1996-2004.52
The Brazilian constitution establishes three in-
dependent branches: legislative, executive, and During the same period, childhood deaths due
judicial. Brazil has a democratic system relying to diarrheal disease and acute respiratory infec-
on general elections for a President and for tions have dropped substantially. Infants’ deaths
legislative representatives. Judges and other ju- have seen a decrease of 34%, the largest reduc-
dicial officials are appointed after passing entry tions being from meningitis (86.3%), HIV infec-
exams. The President is both head of state and tion (69.8%), and intestinal infections (65.1%).
head of government of the union and is elected Similarly, the proportion of infant deaths due to
for a four-year term, with the possibility of re- perinatal causes increased from 57.0% in 1996
election for one additional term. to 61.2%. In 2004, the risk that a child would die
before reaching the age of 1 year was 2.23 times
Brazil is an upper-middle-income country, with greater in the Northeast than in the South.51 The
an average GNP of US$ of 5,920 and an estima- states with the highest and lowest rates, respec-
ted 22% of the population below the national tively, were Alagoas (47.1 per 1,000 live births)
poverty line. It has made substantial advance- and Santa Catarina (13.6 per 1,000 live births).
ments in poverty fighting in the last years.50
However, several inequalities still persist, with In 2004, the average country maternal mortality
59 million Brazilians living on less than two dol- was estimated in around 76 deaths per 100,000
lars a day, with North and North East parts of the live births, whereas the figure was 44 deaths per
country concentrating the poorest segments 100,000 live births in the Federal District and 84
of the population, and showing comparatively deaths per 100,000 live births in Mato Grosso do
worse health, education and economic indica- Sul. More than half (61.4%) of maternal deaths
tors that need further improvement.50 were due to direct obstetric causes, notably
eclampsia and antepartum hemorrhage, and
According to the Human Development Report important indirect causes (such as preexisting
2005, Brazil ranks 63rd in the classification of conditions complicating pregnancy that in-
countries based on the human development clude infectious diseases, diabetes, anemia, and
index.51 Life expectancy at birth is 72 years, cardiovascular disorders).52
infant mortality rate is 19 per 1,000 live births,
child malnutrition prevalence is 4%, access to It is within the above described health profile

that the Brazilian health systems exists. It basi- of special services, such as indigenous health
cally faces the challenges of a country charac- care. Other parts of the federal government also
terized by an epidemiological and nutritional provide health services directly, notably the sys-
transition, and persisting inequalities in the tem of university hospitals, health care facilities
social determinants of health. operated by the Ministry of Education, and the
armed forces health services. The SUS carries
The health sector in Brazil comprises a complex out ongoing functions of coordination, plan-
network of services encompassing both pu- ning, linkage, negotiation, monitoring, control,
blic and private suppliers and financers.52 The evaluation, and auditing, which are incumbent
private sector includes for-profit providers and on the three levels of government.
nonprofit charitable organizations. The private
system of health plans and insurance covers There are three major sources of funding for
about 24.5% of Brazilians, 44% of the privately the Brazilian health system: the Government
covered population being primary beneficiaries (through taxes and social security contributions
of health plans and 56% dependents of primary collected by the three spheres of government),
beneficiaries.52 Most of the clientele of the pri- companies, and families.52 The World Health
vate system reside in the cities of the Southeast Organization estimates that in 2004 total health
and South regions. The private system unde- spending in Brazil amounted to 7.9% of GNP.53
rwent considerable growth during the 1990s, Private expenditure accounted for 51.9% of that
especially in the second half of the decade. total, and out-of-pocket spending by families
The public health sector, to which access is accounted for nearly 64% of private expen-
universal, is the sole provider of health care diture. For 2006, the total health expending
coverage for 75% of the population, in addition (public and private, all categories) was nearly
to providing public health services for the entire 90 billion dollars, which represented about 8%
population. Some of the population covered by of the GDP. Private spending on health inclu-
private health plans also uses the services of the des expenditures by families and companies,
Unified Health system (Sistema Unico de Saude, the latter through the provision or purchase
SUS), especially for highly complex or costly of insurance plans or through health plans for
procedures or treatments. Private contractors, their employees and their dependents, such
including both nonprofit and for-profit entities, coverage being voluntary, not mandatory. In
deliver through federal, state, and municipal 1996, 9% of consumer spending by families
government networks and SUS. The SUS inclu- was devoted to health (37% for drug purchases,
des subsystems at the level of each state (state 29% for payment of health plans and insurance,
SUS) and each municipality (municipal SUS). By and 17% for dental services). Spending by the
law, municipalities have primary responsibility richest segment of the population represented
for providing health care and services to their a significant portion of total health expenditure,
respective populations, with technical and fi- while spending by the poorest decile constitu-
nancial assistance from the federal government ted only a very small fraction. According to the
and the states. Nationally, the SUS is managed Periodic Family Budget Survey, the three weal-
by the Ministry of Public Health, which has thiest deciles accounted for 68% of total health
primary responsibility for regulatory and coor- spending, while the poorest 30% accounted for
dination functions and plays a major role in just 7%.54 There are also qualitative differences
financing of the system. The Ministry retains di- in expenditure by the richest and poorest seg-
rect responsibility for some areas, such as health ments: while drugs constitute the main item of
education, research, tertiary care, and delivery expenditure for the latter, among the highest-

income deciles, health plans accounted for an reform, Primary Health Care was chosen by
increasing proportion of spending, although in the Ministry of Health as the way to reach with
all income deciles spending on drugs accounted quality health services the neediest segments,
for a considerable proportion of total health ex- and eventually the whole Brazilian population,
penditures.52 In particular, in the poorest decile, and therefore Family Health Program (Programa
54% of health spending went to the purchase Saúde da Familia, PSF) was launched in Brazil
of drugs and 6% to payment for health plans, in 1994, in a context of active decentralization
while in the wealthiest decile 24% of spending and intense mobilization of municipal health
was for drugs and 33% for health plans.52 secretaries from all over the country in favor of
basic care.
Brief historical description of the
In the late 1980s, Brazil converted its federal
CHW Program public health financing system to a single natio-
The PSF was chosen as the target Program for nal health fund. In the mid-1990s, it instituted
this present country case study because it is a per capita payment for primary care services
by far the most important health care initiative that was distributed directly to municipalities,
in the country since several decades ago, and a reform that caused vast improvement in the
because it is a comprehensive health care deli- equity of the health care system. This capitation
very channel that emphasizes promotional and system was later enhanced by the PSF, through
preventive health activities performed mainly which the Federal Government transferred ad-
by CHW, while also paying attention to health ditional funds to the municipalities that agreed
facility-based care through other health pro- to implement a proactive primary health care
fessionals. In addition, the activities of the CHW model, provided resources were spent for
program, the predecessor of the current PSF, agreed purposes and municipalities fulfilled
have spanned more than four decades now and their agreed obligations. The PSF therefore is ba-
was a valuable experience on which PSF built sically implemented by the municipalities across
for accomplishing its objective of providing the country, in coordination with the Ministry of
integral and universal health. Another reason is Health, which has mainly a stewardship role.
that the PSF implementation reached impres-
sive expansion since its inception in 1994, and The PSF targets provision of a broad range of
there is compelling evidence about its positive primary health care services, delivered through
impact on several health indicators. a Family Health Team (Equipo de Saúde Familiar)
composed by at least one family doctor, one
The main health reform in Brazil was performed nurse, one assistant nurse, and six community
since 1988 through the development of the health agents or CHW,57, 58 although the num-
Brazilian unified health system (Sistema Unico de ber of CWs within each team varies at each
Saúde, SUS). This system was conceived on the municipality level. Some expanded teams in
principle of health as a basic right of all citizens, due places also include one dentist, one assis-
and with the aim to reach universal coverage, tant dentist, one dental hygiene technician,
emphasizing decentralization, equity, commu- and social work professionals.57, 58 Each team
nity participation, integration, shared financing is in charge of a specific geographical area,
among the different levels of government, and working actually in the Basic Health Units and
complementary participation of the private in the households themselves. The team is then
sector.55, 56 Shortly afterwards, as a concrete responsible for enrolling and monitoring the
way to making operational this fundamental health status of the population living in the

assigned area, providing primary care services, the PSF is a package designed by the Ministry of
and making referrals to other levels of care as Health, and its implementation requires volun-
required. Each team is responsible for following tary adhesion of a municipality administration,
about 3,000 to 4,000 and a maximum of 4,500 preferably with support from the state govern-
people. ment. Officially, the responsibilities across the
different spheres of government are defined
The PFS started in a few municipalities, reporte- in the following way:59 a) Federal Government:
dly in the poorest ones, but municipality cove- elaborates the basic health goals of national
rage expanded in a sustained way to more than policy; co-finances the system of “basic health
ninety percent in about fifteen years, as part of attention;” organizes the formation of human
an explicit effort from the central government resources in the area; proposes planning and
and due to strong local initiatives. Thus it is es- control mechanisms, regulates and evaluates
timated that currently PSF covers more than 85 the system of “basic health attention;” and main-
million people across the country. tains a national database; b) State Government:
follows the implementation and execution of the
The key characteristics of the PSF include: i) to PSF; regulates the inter-municipal relationships;
serve as an entry point into a hierarchical and coordinates policies of human resources quali-
regional system of health; ii) to have a definite fication in the state; co-finances the program;
territory and delimited population of respon- helps in the execution of the strategies of the
sibility of a specific health team, establishing system of basic health care; and c) Municipality
liability (co-responsibility) for the health care of Government: defines and implements the mo-
a certain population; iii) to intervene in the key del of the PSF; hires the labor force for use in the
risk factors at the community level; iv) to per- program; maintains the management network
form integral, permanent, and quality assistance; of basic health units; co-finances the program;
v) to promote education and health awareness maintains the information system; and evaluates
activities; vi) to promote the organization of the the performance of the basic health care teams
community and to act as a link between diffe- under its supervision.
rent sectors, so that the community can exercise
effective control of actions and health services The PSF has built in a significant proportion on
and develop strategies for specific health inter- the valuable lessons from The CHW Program
ventions; and vii) to use information systems to (Programa de Agentes Comunitários de Saúde:
monitor decisions and health outcomes.59 PACS) that had been active in Brazil for more
than 40 years, by going beyond those activi-
In fact, the PSF has been conceived as a fe- ties based in health facilities, relying for this on
deral program, and the responsibility of its CHW as an important part of the family health
implementation rests on each municipality. team. Thus in the Brazilian PSF, the cadre of
For an effective implementation therefore, an CHWs is integrated into the ministry of health
adequate coordination is required between the hierarchy, with strong links to health facilities
different government levels. Ideally, the concep- or other health agents, but also accountable to
tion of the program should involve all three their communities. The PACS was developed by
levels of government (municipality, state, and the former Fundacao SESP (Servicos Especias
central government). However, and this is also a de Saúde Publica) about 50 years ago, with the
demonstration of its flexibility, there are stories aim to reach poorest people, living mostly in
of local implementation without support or remote and rural areas of Brazil. In those places
interference of the state government.59 In brief, where there are only PACS, the situation can

The CHW Role
be considered as transitional through the de- The CHW should be well familiarized with the
finitive establishment of the PSF.60 community where he/she will work. His/her
work starts with the household registration and
Recruitment Process (selection a detailed information recollection, including
family composition, basic facilities (such as
committee, selection criteria) water and sanitation), schooling, literacy, job
situation and income of household members.
Compulsory requirements for being eligible as a This information will allow him/her the identifi-
CHW (profile): cation of household members needing priority
To have demonstrated leadership and solidarity attention, such as infants, children, pregnant
spirit; women, malnourished, members with diseases
such as hypertension, diabetes and other
To have 18 years old or more; conditions. This household information should
To be literate (reading and writing); since 2004, a be updated periodically, both for feeding the
minimum of 8 years of schooling is required, due Basic Care Information System and for serving
to a high demand for the CHW position and with as an orientation to CHWs activities. Specifically,
the aim of increasing the quality standards; the update of the information is made by the
CHW on a yearly basis, and whenever a family
To be resident of his/her own community by at arrives from another place or moves to another
least 2 years; geographical location.
To have enough available time for performing
the assigned activities; Other specific activities of CHWs include:
To take responsibility for the follow-up of maxi- Work with families of defined geographic areas
mum 150 families or 750 individuals of the Participate in the demographic diagnosis
community
Participate in the definition of socioeconomic
The selection process: level of community members
The CHW candidates do not need to have pre- Participate in the identification of cultural and
vious health knowledge, because if selected, religious characteristics of families
they will be trained and permanently supervised
Determination of risk micro-areas
by his/her assigned nurse instructor/superior.
Visits to risk micro-areas
The CHWs are choiced through a public selec- To adequate frequency of household visits
tion process with a strong presence of commu- whenever there are situations needing special
nity members. The corresponding municipality, attention
with support of the State Health Secretariat,
conducts the process. The Municipal Health Update the families’ information sheet
Council, as a way to guarantee transparency, Perform surveillance of children considered at
accompanies this process. Candidates are as- risk
sessed for their aptitude, posture, and attitudes,
during simulated community problems. Follow-up children 0-5 years old, through
measurement and registration of weight, hei-
ght, growth and development monitoring
Promote routine immunization of children and

pregnant women, encouraging their visit to of outbreaks or occurrence of conditions nee
health facilities
ding compulsory notification
Promote exclusive breastfeeding through edu-
cative activities Perform promotion and prevention activities for
the elderly
Monitoring of diarrheal diseases and promotion
of oral rehydration Identify persons with psychological or physical
impairment, orientating their families for
Monitoring of acute respiratory infections, iden-
tifying danger signs and asking the referral of providing support at home
pneumonia suspicious cases to referral health Incentive community members for acceptance
facilities. and social insertion of persons with psychologi-
Monitoring of dermatoses and parasitosis in cal or physical impairment
children Orientate families and communities for preven-
Orientation of adolescents and their families in tion of endemic diseases
prevention of STD/AIDS, premature pregnancy Perform educational activities for environmental
and drug misuse preservation
Identify and orientate pregnant women on im- Perform activities for increased awareness of
portance of prenatal care at the health facility families and communities on human rights
Perform periodic household visits for prenatal Promote community participation in actions
follow-up, identifying risk signs and symptoms, related to improved quality of life
orientating on feeding and mother preparation
for delivery, and promoting breastfeeding Perform other activities related to CHWs tasks,
to be further defined during local planning
Monitoring of newborns and mothers after
delivery Supervise together with families and encourage
treatment compliance at home by persons with
Performance of educational actions for preven- TB, leishmaniasis, AIDS, diabetes, hypertension,
tion of cervix and breast cancer, encouraging and other chronic diseases
period examinations at health facilities
Performance of educational activities on family Initial Training of CHWs
planning methods
The central level of the MoH proposes the trai-
Perform educational activities on menopause ning curriculum as a national reference, and the
Perform educational activities on family and Ministry of Education approves it. Then each
community dietary habits municipality prepares its own specific training
program, according to its particular epidemiolo-
Perform educational activities on oral and den- gical profile, social and economic context. Initial
tal hygiene, with emphasis on pediatric CHWs training consists of an 8-week residential
group course, with an additional 4 weeks of strictly
supervised fieldwork. However, training is a
Perform active search of carriers of transmissible gradual and continuous process that is adapted
diseases according to needs emerging during the daily
Support epidemiologic enquiries, investigation work. Nurses at the nearest public clinic provide
training, with the assistance of staff from the

State Health Secretariat based in the capital. The trally coordinated and funded by the Ministry of
whole Family Health Team also participates in Health, and the technical arm is the Fundacao
the training process. Oswaldo Cruz, in Rio de Janeiro. Teachers are
senior nurses who already have the experience
Initially, CHWs receive orientation for home of having been nurses of the PSF. There are cur-
visits and family census, including information rently more than 3,100 senior nurses at national
on cultural background of communities, so- level. Basic content of training of trainers cour-
cioeconomic conditions of the work area, and ses include themes as health and education
communication techniques. context, health and work, and the understan-
ding of social determinants of health. The feasi-
Then they are trained in specific themes on how bility of establishing a MA in Professional Health
to follow and orientate the group of women Education is being currently considered, as a
and children, considered a priority target for step forward that should strength the profile of
health care, with emphasis on identification and health professionals of the PSF.
prevention of risk situations.
Finally, a year ago it was established UNASUS, a
Gradually, the training is extended according to national level strategy that brings together aca-
the array of problems of the community: fight of demic institutions and health services, with the
endemic conditions, elderly care, adolescents, aim to establish and consolidate a critical mass
attention of groups with special needs, impor- of Family Health Specialists through an ad-hoc
tance of basic sanitation, amongst others. training process of health professionals, with
an initial emphasis on members of the PSF. This
On-going Training of CHWs initiative, thought to work as an open university,
is offering about 52,000 positions for applicants
After the initial 12-week period, ongoing educa- to the specialization course.
tion is provided during local monthly and quar-
terly meetings. This training is oriented toward
local concerns of the agents or clinical family
Equipment and supplies
health team. Standardized training is provided Basic equipment and supplies:
whenever new practices are instituted, such as - A distinctive dress and ID badge
care for acute respiratory infections or procedu- - A Clipboard
res for reporting causes of deaths. - A format of Basic Care Information System
- Bicycle, canoe or ship, if the CHW needs to
Training of Trainers reach remote places
- Scale for weighing children at home
Training of trainers (nurses) consists of a basic - Chronometer to verify respiratory rate
training module of 80 hours. Trainers can also - Thermometer
perform a further specialization program of 540 - Tape measure -Educational material
h, offered at the municipality level and at state
level through the Technical Schools. This ex-
tended course has a semi-presential modality.
Supervision
Nurses fulfilling this specialization requirements Periodically, the instructor/supervisor (a nurse)
course receive a title of Specialist in Professional brings together the CHWs, to evaluate their work
Health Education, which has national level and to reorient their activities. Alternatively, as
recognition. This specialization program is cen- for example, in Ceara, a nurse-supervisor visits

each agent under her charge at least once a Monthly follow-up of diagnosed pregnant wo-
month to review problem cases and collect men resident in micro-areas: 100%
services data. In addition, one of the nine staff Monthly follow-up of diagnosed hypertensive
members of the agent program at the central patients resident in micro-areas: 100%
office meets with each municipal supervisor
every 2 to 4 months. Monthly follow-up of diagnosed diabetic pa-
tients resident in micro-areas: 100%
Each nurse of the PSF generally spends half of Monthly follow-up of diagnosed TB patients
her time supervising an average of 30 CHWs, resident in micro-areas: 100%
doing bookkeeping, distributing supplies, and
compiling data for the health agents program. Monthly follow-up of diagnosed leprosy pa-
During the other half of her time she staffs tients resident in micro-areas: 100%
a clinic.61 However, where there are many Proportion of children younger than 4 months
agents, the nurses increasingly work full-time as old with exclusive breastfeeding: increasing
supervisors. trend
Proportion of deaths in children younger than 1
As part of the evaluation process of CHWs, a
year old: decreasing trend
working group must be established, composed
by representatives of partners in charge of Proportion of deaths due to diarrhoea in chil-
CHWs enrollment (the municipality and civil dren younger than 1 year old: decreasing trend
society organizations), in order to follow-up and Proportion of deaths due to respiratory infec-
guarantee the accomplishment of the goals tions in children younger than 1 year old: de-
established in the contract. creasing trend
During the evaluation process of performance Number of deaths in children younger than 1
of CHWs in relation to goals and activities de- year old: 0
fined, the following criteria are considered for
Accomplishment of CHW requirements and
each micro-area:
attributions: 100%
Proportion of families enrolled in each micro-
area: 100% Performance Evaluation of the
Mean monthly number of domiciliary visits per- PSF
formed by CHW to each family enrolled in the
micro-area: 1 Various external evaluation efforts of PSF have
been published. One of them resorted to an eco-
Systematic update of family enrollment in the logical design, using longitudinal secondary data
micro-area: 100% sources.62 It documented coverage of PSF from
Follow-up of children 0-5 years old resident in 1990 to 2002 and variation of infant mortality
micro-areas: 100% during the same time period, and then explored
possible association between coverage of PSF
Proportion of children younger than 2 years and infant mortality, controlling for contextual
weighed: 100% factors, including state level measures of access
to clean water and sanitation, average income,
Proportion of children younger than 1 year old
women’s literacy and fertility, physicians and nur-
with updated immunization: 100%
ses per 10 000 population, and hospital beds per

1000 population. Additional analyses controlled on reductions in mortality throughout the age
for immunization coverage and tested interac- distribution, but mainly at earlier ages. It further-
tions between PSF and proportionate mortality more found that municipalities in the poorest
from diarrhea and acute respiratory infections. regions of the country benefit particularly from
According to this report, from 1990 to 2002 IMR the program. For these regions, implementation
declined from 49.7 to 28.9 per 1000 live births. of the program is also robustly associated with
During the same period average Family Health increased labor supply of adults, reduced ferti-
Program coverage increased from 0% to 36%. lity, and increased schooling.
A 10% increase in PSF coverage was associated
with a 4.5% decrease in IMR, controlling for all As for the direct impacts, the results of the
other health determinants. The authors conclu- study showed that implementation of the PSF
ded that the PSF is associated with reduced IMR, was significantly associated with reductions
suggesting it is an important, although not uni- in mortality before age 1, between ages 1 and
que, contributor to declining infant mortality in 4, and between ages 15 and 59. Particularly,
Brazil. municipalities eight years into the program are
estimated to experience a reduction of 5.4 per
A more recent study analyzed the direct and in- 1,000 in mortality before age 1, as compared
direct impacts of Brazil’s Family Health Program to municipalities not covered by the program.
at country level and in different regions of Brazil, The estimated impacts are driven mostly by
by crossing municipality level data with the reductions in mortality due to perinatal period
Brazilian National Household Survey from 1995 conditions, infectious diseases, endocrine and
through 2003, and controlling also for contex- metabolic diseases, and respiratory diseases.63
tual factors such as presence of other public
health policies, education infrastructure, and In relation to changes in behavior that may
immunizations in each assessed municipality.63 be determined from improvements in health,
The authors also explored other possible sour- the analysis concentrates on the two poorest
ces of variation in the effects of the program, regions of the country.63 The study found that
such as initial level of mortality and geographic eight years of exposure to the program are as-
region. The main sources of variation used to sociated with a 6.8 percentage point increase in
identify the effects of the program included dif- the labor supply of adults between 18 and 55,
ferent timing of adoption across municipalities a 4.5 percentage point increase in the school
and different time of exposure. enrollment of children between 10 and 17,
and a 4.6 percentage point reduction in the
Direct impacts were related to the effects of the probability that women aged between 18 and
program on health outcomes. Indirect impacts 55 experience a birth over a given 21 month
refer to the effects of the program, through interval.63
changes in health, on household behavior rela-
ted to child labor and schooling, employment of The PSF seems to be most effective in the
adults, and fertility. In the analysis of the health North and Northeast regions of Brazil, and
impacts of the program, the unit of observation also in municipalities with a higher fraction of
is a municipality at a point in time. In the analy- rural population, and lower coverage of public
sis of the impacts of the program on individual health infrastructure (access to treated water
behavior, the unit of observation is an individual and sewerage system).63 For example, a munici-
within a municipality at a point in time. The pality eight years into the program is estimated
study found consistent effects of the program to experience a reduction in infant mortality of

15 per 1,000 in the North and 14 per 1,000 in the effective tool for improving health in poor areas,
Northeast, as compared to the 1993 national although a formal cost-effectiveness study was
average of 27 for this variable. not performed.
On the other hand, the yearly cost of main- Incentives

taining a PSF team has been estimated to be
between US$ 109,610 and US$ 173,400 in 2000. In Brazil, the CHWs are considered sui generis
On the assumption that each team coverage employees of the ministry of health, selected
capacity reaches about 3500 individuals, this with an active participation of the community,
would correspond to a yearly cost between US$ paid by the public sector, and accountable both
31 and US$ 50 per individual covered.59 The to their communities and to the public sector.
authors concluded that the evidence suggests They are in charge of actively making the sur-
that the Family Health Program is a highly cost- veillance of the whole social, economic and
Table 25- Performance evaluation of CHWs

Program coverage (%) >90% of Brazilian municipalities, and more than 85 million people
(Ref: 15), or about half of Brazilian population..
Preventive and promotive Vaccination promotion coverage (%): 100 % of children under five in the
service delivery assigned area of each CHW Contraceptive usage: there is not a specific
goal of the PSF for CHWs for this particular aspect
Curative service delivery % of all CHW seen and referred emergency case in previous three
months : 100%
Support system for CHWs Recruitment: approximate proportion that meet program selection cri-
and their performance teria: variable from municipality to municipality Training: 100 % CHWs
received introductory training Supplies and equipment: provided
regularly. No stock problems Salaries: all CHWs receive regularly their
salaries Supervision: 100 % CHWs attend monthly a supervisory meeting
CHW services and the poor Approximate overall poor coverage of the program: (%): hard to estimate.
Although initially focused on poorest regions of the country, the PSF is
currently aimed at reaching all the Brazilian population. With 30,000
Family Health Teams active across the country, it currently covers half
of the Brazilian population.
CHW impact on health Indicators of population served compared with national figures?
Difficult to ascertain. The average current coverage is more than 95% of
country municipalities, but this hides great disparities from municipality
to municipality (there are still municipalities with less than
10% coverage)
CHW costs – Actual level of funding is increasing compared with the originally
current and future planned budget, but is not enough due to the magnitude of expansion
of the PSF

social situation of families, and of serving as a formation, has been able to integrate CHWs into
link between the community and the health its primary health care services and has institu-
system. As health professionals, whose role in tionalized Community Health Committees as
the PSF is so important, CHWs receive a financial part of the municipal health services to sustain
incentive, earning the official national minimum social participation, meaning that community
wage, which is about US$ 112 per month. This participation does not become an alternative
is about twice the average local monthly in- but an integral part of the state’s responsibility
come for rural workers, but the specific amount for health care delivery. With decentralization,
varies in fact from municipality to municipality, municipalities are now responsible for delivery
through negotiations between CHWs associa- of health services at primary level. Municipalities
tions and municipalities. The Ministry of Health are also in charge of actively ensuring the exis-
pays them, but there is a co-financing between tence of Community Health Committees, incor-
federal government, state, and municipal go- porating in this way the voice of community
vernment levels. Importantly, selection and members. Public service regulations regarding
participation of the state government in salary the national advertising of civil service posts have
payment prevents local politicians from mani- been amended to ensure that health agents
pulating the program. Central funding has also come from and serve their own communities.
been key to the local leaders’ accepting the Moreover, one of the key characteristics of the
program, which employs 30–150 local residents PSF is that it is explicitly committed to promote
per municipality. the organization of the community and to act
as a link between different sectors, so that the
A unique operational aspect of the both the community can exercise effective control of ac-
PACS and PSF is the way they have been intro- tions and health services and develop strategies
duced into new municipalities. In the PACS the for specific health interventions.
state government would pay the CHWs’ salaries
only if the municipal government agreed to pro- Referral System
vide a salary for a nurse supervisor, contributing
thus to the assembly of the Family Health Team, The CHW performs a monthly visit to each family
and avoiding to promote isolated activities of in his/her catchment area, and on a daily basis
CHWs. Similarly, in the PSF a municipality must whenever he/she finds a member at risk or sick.
apply to the federal government and agree to In this last case, he/she immediately reports the
partial financial responsibility for the program. finding to the nurse auxiliary or to the nurse of
This scheme ensures local commitment before the family health team, for further evaluation.
the government initiates the program in that Depending on the severity of the case, a referral
area. The program generally employs 30 to 150 to the nearest health facility may be formally
local residents per municipality as CHWs. They made, with the CHW accompanying the patient
are paid out of central state funds, making the and permanently maintaining the contact with
program attractive to local leaders. the family. Once the patient is discharged, the
CHW continues the follow-up until the resolution
of the problem, maintaining the link between
Community Involvement the health system and the family and the com-
A key challenge for assuring the sustainability munity. The CHW keeps a written record of each
of CHW programs lies in institutionalizing and family at risk and of those patients referred for
mainstreaming community participation. The further assessment and treatment. Such a writ-
PSF, which is part of a large-scale political trans- ten record is monthly presented by the CHW to

the family health team. By interacting on a sys- the PSF think that encouraging the systematic
tematic basis with the same families, through promotion of CHWs by the PSF would risk them
a close supervision by a nurse, and in coordi- becoming employees of the public sector, wi-
nation with the Family Health Team, CHWs are thout real incentives for working with a genuine
able to detect early symptoms that may require interest in their communities, and thus it would
a more specific type of care, but they are also jeopardize the very basic tenets of PSF. This
instrumental in increasing the accountability of trade-off between the programmatic needs of
the health system to the community, and also the PSF and the legitimate aspirations of CHWs
in empowerment building and maintenance for professional development is an important
of the community with regards to the health as challenge that needs to be faced adequately.
a right. The network of PSF professionals, once
established in a certain area, can be used to Documentation and
implement any type of health intervention that
demands some degree of coordination across Information Management
large areas or different agents (immunizations, The PSF maintains an information system aimed
campaigns against endemic conditions, etc). at monitoring decisions and health outcomes.
Data related to implementation of the program
Professional Advancement at the municipality level are available from the
Brazilian Ministry of Health, through its Basic
The CHW is a unique professional, who is aimed Attention Department (“Departamento de
at working only for the PSF. Therefore, there are Atenção Básica”). These data provide the date of
no mechanisms for promoting them to nurse implementation in each municipality (starting
auxiliaries or nurses, or other health specialist from 1996). The Family Health Team, including
titles. Of course each individual CHW is free to the CHW, is required to systematically collect
pursue any professional development path, and and report geographical, demographic, and
most frequently, the previous training and expe- health information on the assigned families, and
rience gained is an asset that allows him/her to also to use such information for monitoring their
achieve his/her expectations. Although there is own activities and performance, so as to make
an official referential national minimum wage for the adjustment decisions deemed pertinent.
CHWs, they are organized locally, and nationally,
and are therefore empowered for negotiating However, there are remaining challenges.
with national and local authorities the range of Currently the information systems at health
salaries at each local setting. In addition, there facilities that are part of the PSF have Internet
are performance-based financial incentives for access, and allow access to data integrated to a
the family health team at some municipalities. unified database of the Ministry of Health. There
The issue of professional advancement has are available indicators on the health team
been largely discussed, and the decision of not activities and on management. The under-re-
promoting it as a program is based on the fun- gistration has decreased in the last years, but
damental philosophy of PSF of building a strong there is still resistance of health workers to use
family health team with empowered, motivated the information systems, as they are perceived
and passionate CHWs, committed not only to the as being basically related to management and
health of the community to which they belong, financing support systems, and not related to
but also and more generally, contributing to the clinical activities. There are ongoing efforts at
development of citizenship and of human and municipality level for developing software that
social capital. Champions and implementers of should allow registration of data useful for both

managing and evaluation of clinical activities,
including the development of a digital clinical
record.

277
Table 26 - CHW Program Functionality Assessment Tool (CHW-PFA)-Brazil
Evidence
and clarity of role from and formal health system. expectations are given to community input. Role is clear expectations and policies Although significant
community, CHW, and CHW (initial training) but to CHW and community but in place that support CHW progress has been
health system perspectives. are not specific. CHW and little discussion of specific role. Role and expectations made along the
community do not always expectations. General agree- are clear to CHW and years in defining
agree on role/expectations. ment on role between CHW, community. Process for the role of CHW, this
health system, and community. update and discussion of is still a challenge
role/expectations in place needing further
for CHW and community improvement

Evidence
performance support

Financial= salary incentives provided but community recognition incentives are provided. incentives are partly based on 3
and bonuses is considered a reward Examples of non-financial incen- good performance. Incentives With progressive
Non-financial= training, tives include occasional formal are balanced and in line with empowerment
recognition, certification, recognition, additional training, expectations placed on CHW. of CHWs asso-
and other small incentives. Examples of non-financial ciations, they are
uniforms, medicines, etc.
incentives that engage now in a better
workers might include position to ask for
(advancement, recognition, better salaries
278
279
Evidence
advancement, promotion who’ve been in program who’ve been in program for well and who express an As explained
and retirement for CHW for specific length of time. specific length of time. Limited interest in advancement if the above, this
No other opportunities training opportunities are offe- opportunity exists (advance- particular type
are discussed with CHW. red to CHW to learn new skills ment might mean path to for- of professional
Advancement is not related to to advance role. Advancement mal sector or change in role) advancement is
performance or achievement. is intended to reward good Training opportunities are not promoted
performance or achievement, offered to CHW to learn new by the PSF as
although evaluation is not skills to advance their role and a program, for
consistent (advancement might CHW is made aware of them. the explained
mean path to formal sector or Advancement is intended to fundamental
change in role). No path to reti- reward good performance or reasons
back to the commu-

Table 27- Community Health Worker Functionality Matrix – MCH Interventions
1 ANTENATAL CARE
Counsel x
B Maternal nutrition Provides counsel and refers if he/she identifies a
Counsel x nutrition problem or risk
D Tetanus toxoid
Counsel x
E Deworm
Counsel x
A Prevent Infection/Clean Delivery o CHW provides counseling and education on
(Hand washing, clean blade +/or clean delivery kit) prenatal care, safe delivery and need of imme-
diate newborn care at a health facility, but does
not provide any care intervention
B Provide Essential Newborn Care CHW provides counseling and education on
a. Immediate warming and drying o prenatal care, safe delivery and need of imme-
o diate newborn care at a health facility, but does
b. Clean cord care not provide any care intervention
c. Early initiation of breastfeeding o
for maternal and newborn complications o CHW provides counseling and education on
o prenatal care, safe delivery and need of imme-
a. newborn asphyxia diate newborn care at a health facility, but does
b. sepsis, o not provide any care intervention
complications
D Prevent PPH: AMTSL or use of uterotonic alone CHW provides counseling and education on
in absence of full AMTSL competency (e.g. oral o prenatal care, safe delivery and need of imme-
Misoprostol) not provide any care intervention
E Provide special care for Low Birth Weight newborns CHW provides counseling and education on
(Kangaroo Care) o prenatal care, safe delivery and need of imme-
not provide any care intervention
x
a. clean cord care;
x
b. exclusive BF through 6 months;
x
c. thermal protection; hygiene;

B Assess for maternal newborn danger signs and provide
appropriate referral. x
C Provide Treatment for severe newborn infection (when
community-based treatment supported by national o
guidelines.)
4 EARLY CHILDHOOD
recording progress
Counsel re recognition of danger signs, seeking care/ o
antibiotics x
Refer for antibiotics
Counsel on ORS o
Provide ORS x
Refer for ORS x
Counsel on Zinc o
Provide Zinc x
Refer for Zinc
Counsel x
I Effectively assess and recognize severe illness in chil- x Although the CHW is not expected to
make a specific classification or dia-
dren (danger signs) with appropriate referral. gnosis, he/she should recognize dan-
ger signs and make the corresponding
referral
j Counsel on immunizations o
Mapping/tracking for immunization coverage x
-DTP o

- +/- HIB o
- Hep B o
-Pneumovax o
-Rotavirus o
OF PREGNANCY
- condoms o
- depo o
- condoms o
Provide FP counseling +/ - administer contra- o
A Insecticide-treated mosquito nets to pregnant
women and children
Counsel x
Counsel x
Counsel x
Counsel x
B Antibody testing to pregnant women and mothers x
Counsel o
C Refer for commodity, intervention, or treatment
Prophylactic ARVs/HAART to pregnant women mothers x
Counsel o

INTERVENTIONS YES COMMENTS
Counsel x
Counsel x
Counsel x
Counsel x

Summary
Brazil has experimented significant social, eco- phical area, performing their activities actually
nomic and health changes in the last years, with in the basic health units and in the households
substantial reductions in country average po- themselves. The team is specifically responsible
verty, improvements in life expectancy at birth, for enrolling and monitoring the health status of
and reductions in several health indicators. the population living in the assigned area, pro-
Important inequities persist, however, which viding primary health care services, and making
need to be addressed if the gains are to be sus- referrals to other levels of care as required. Each
tained. In 1988 the Brazilian government laun- team is responsible for following about 3,000 to
ched the Unified Health System (Sistema Unico 4,000 and a maximum of 4,500 people.
de Saúde), with the declared aim to provide
universal health services to Brazilians, empha- The CHWs receive a training that privileges the
sizing decentralization, equity, community par- determination and understanding of social, eco-
ticipation, integration, shared financing among nomic and environmental characteristics of the
the different levels of government, and comple- community, as well as the epidemiological pro-
mentary participation. Primary Health Care was file. They also receive training on promotional
considered to be key tool in achieving the goal and preventive aspects of health, so they are in
of universal access to health care, and it was a good position for providing influential council
made operational through the implementation to community members, for identifying timely
of the Family Health Program (Programa Saúde family members at risk or with health problems
da Família, PSF) in 1994. The PSF was conceived and refer them to the family health team for fur-
as an integral approach to community health ther assessment and management, if deemed
needs, with a particular emphasis on promotio- pertinent. The CHWs follow-up closely those
nal and preventive activities and with an equity families at risk and those with a sick member,
lens, prioritizing first the poorest regions of the providing support, counseling, supervising and
country. The initiative and committment of encouraging treatment compliance, whenever
municipalities for taking responsability of local needed. The role of the CHWs within the Family
implementation of PSF across the country al- Health Team is seemingly critical, as they are
lowed an impressive expansion of the program, community members carefully selected with
from a few municipalities covered in 1994, to participation of community members, the mu-
more than 95% of all municipalities with PSF in nicipality, and the Ministry of Health. The parti-
place currently, although this figure hides great cipation of the CHWs in the team facilitates an
disparities, as there are still municipalities with integral approach to health, with an increased
less than 10% of PSF coverage. understanding of social determinants, linking
more closely the whole Family Health Team
The PSF has been implemented as an initia- to an empowered community demanding for
tive aimed to provide a broad range of primary more and better health, but also taking respon-
health care services, delivered through a Family sibility for adopting healthy life styles.
Health Team (Equipo de Saúde Familiar), com-
posed by at least one family doctor, one nurse, The PSF started in 1994 in a few pilot munici-
one assistant nurse, and a variable number o palities and then has reached an impressive
community health agents or CHW in each mu- expansion, having currently about 30,000 family
nicipality. Some expanded teams also include health teams and more than 240,000 CHWs that
one dentist, one assistant dentist, one dental cover half of the country, whereas the other half
hygiene technician, and social work professio- is still basically covered through the traditional
nals. Each team is in charge of a specific geogra- health facility-centered model. Although the

PSF initially prioritized the poorest regions of by a public sector minimally able to address the
the country, it is not to be conceived as an in- community needs.
tervention for poor people, but as an innovative
integral promotional and preventive health mo-
del aimed at covering the entire Brazilian popu- 5. Haiti - Zanmi Lazante’s
lation instead. There is compelling evidence on Community Health Program
PSF impact on health indicators such as infant,
child mortality and maternal health, as well as Socio-economic and
on behavioral indirect household outcomes
including increased child schooling, reduction
political context
of female fertility rate and improved adult labor Haiti is one of the poorest countries in the
enrolment. These improvements can be attribu- world and reportedly the poorest country in the
ted in a substantial proportion to a wide country Western hemisphere,64 and it has suffered seve-
level implementation to PSF, although other ral decades of social unrest and political instabi-
health and crosscutting interventions have also lity. Despite several efforts made, vast segments
surely played an important role. Remaining of the population remain poor and this situation
challenges for sustaining and further increasing has even worsened, as well as inequalities in
this implementation at scale of PSF and for access to basic services such as health and edu-
improving quality are huge, however, including cation. Due to this gloomy situation, the United
among others a still “medicalized” narrow and Nations placed a special peace keeping force
vertical training of CHWs and other members of (MINUSTAH) in the country in 2004, and they are
the family health team, with a still relatively weak still in place now. Security has improved since
emphasis on social determinants of health and then, although crime and violence continue
on health understood as a fundamental right undermining Haiti’s development.64
to be demanded by empowered communities
and provided by the government, a continued Haiti is a mountainous country. It has about 9.6
resistance of powerful health professional million inhabitants, 5 million of whom live in ru-
corporations to the PSF innovative approach, ral areas.65 Some social indicators are among the
difficulties in enrolling capable and committed weakest in the world in Haiti,64, 66, 67 including
family doctors, nurses, CHWs and other health a GNI per capita of only US$560, life expectancy
professionals, and trade-offs between mana- at birth of 60 years, infant mortality rate of 60 for
gerial objectives of keeping solid family health every 1,000 live births, 2.2 percent of HIV preva-
teams with minimal leakages and legitimate lence among the population (aged 15-49), and
expectations of CHWs for further professional literacy rate of 43 percent. Haiti ranks 146th out
development. There are also several local dif- of 177 countries on the United Nations Human
ficulties that need to be openly, honestly and Development Index, and 54 percent of Haitians
effectively discussed and addressed to assure live on less than US$1 a day and 78 percent on
the sustainability of the program. less than US$2 a day.
The PSF is undoubtedly a global lesson whose The country has been hit very recently by soaring
basic underlying principles can and should be world prices for food and fuel, followed by natural
adopted in different settings, irrespective of the disasters such as tropical storms and hurricanes
political and economic country level prevailing since August 2008, which took the lives of several
systems, on the basic condition of considering hundred people and left about a tenth of the total
health as a basic human right to be provided population needing humanitarian assistance.64

Health systems overview
Haiti has witnessed recently three successive The Haitian health system includes the public
years of economic growth since 2004, when sector (Ministry of Public Health and Population
the economy contracted by 3.5 percent, and is and Ministry of Social Affairs); the private for-
still set to post modest growth for the country’s profit sector (all health professionals in private
2008 fiscal year. However, growth estimates for practice); the mixed nonprofit sector (Ministry
fiscal year 2009 and beyond are being revised of Health personnel working in private insti-
downwards to reflect the impact of the recent tutions (NGOs) or religious organizations); the
natural disasters.64 private nonprofit sector (NGOs, foundations, as-
sociations); and the traditional health system.66
According to a recent World Bank country brief, A number of central bureaus execute the health
Haiti requires continued strong support from programs (except AIDS and tuberculosis, directly
its international partners for relief, recovery, and under the Office of the Director General). There
rebuilding, and to safeguard the considerable are also 10 directorates (one for each depart-
progress made since 2004.64 This country brief ment and for the Nippes Coordination), under
states that Haiti has improved economic and so- which come the UCSs. Due to the country’s
cial stability, democratically elected a president political problems, there has been no recent
and parliament and launched wide-ranging progress in health legislation. The Ministry of
reforms, particularly in the area of economic Health coordinates all health system institu-
governance, notably in budget formulation, tions. This sector has been unable to assume its
execution and reporting.64 leadership role in the recent past, as the eco-
nomic embargo directed resources toward the
Although there is currently an apparent stabi- nonprofit sector. The health services reach 60%
lity, the political situation is always volatile, and of the population.
rapid changes in leadership affect governance,
continuity of policy-making and progress in all In 2000, after irregularities in legislative elections
sectors. Haiti still struggles with major political, were reported, the US and European Union im-
economic and social challenges. An always-weak posed an economic embargo and more than
leadership and governance jeopardizes pre- US$ 500 million of blocked loans were earmar-
sence of state across the country and provision ked for health, education, water and roads.67
of even basic services, which are in a significant During the following five-years period, the only
extent in the hands of civil society organizations. aid coming from these regions for health was
As a dramatic illustration, barely 55.2 percent of channeled through non-governmental organi-
the Haitian population has access to an impro- zations, further weakening the already crippled
ved water source, while almost 70 percent does health system in Haiti.67 Thus it is not surprising
not have direct access to potable water. Water that the Haitian government spends less than
supply is intermittent in virtually all urban areas, US$2 dollars per capita on health per annum.
whereas in rural areas access to water becomes Moreover, less than 40% of health expenditures
a real prowess during the dry season. Moreover, occur in the public sector,68 and the remaining
only 27 percent of the country has access to 60% of health expenditures occur in the private
basic sewerage, and 70 percent of households sector, including both the for-profit and not-for-
in Haiti have either rudimentary toilets (34.9 profit health sectors.68 Notably, of the private
percent) or none at all (34.7 percent). It is not sector spending, 70% is out-of-pocket expendi-
difficult therefore to imagine that fecal contami- ture, which is a tremendous barrier to healthcare
nation of the water supply is a leading cause of in one the most impoverished countries of the
disease in Haiti. world.

According to a recent PAHO report, there are the country, and points to a problem that should
only 371 health posts, 217 health centers and be taken into account by the government, do-
49 hospitals in Haiti.69 It is estimated that 40 % nors and the private sector, if the objective of
of the population relies on traditional medicine, strengthening the health system is to be effecti-
mostly in rural areas. vely pursued in practice.
Haiti lacks evidently the minimal financial, infras- Currently the World Bank is in the preparatory
tructural, and human resources to deliver basic phase of a two-year program of non-lending
preventative health and medical services to its technical assistance for Haiti to improve the
citizens.70 It has only 25 doctors, 11 nurses, and capacity and effectiveness of nutrition-related
one dentist per 100,000 people, a paltry figure programs that address the negative impact of
when compared even with the least developed severe and chronic malnutrition among the
countries in Latin America. most vulnerable on human and social capital
development. There are ongoing discussions
Community Health Workers on how to involve CHWs in this program so as
to take advantage of their experience. However,
Programs in Haiti the level of involvement of the Ministry of Health
The role of CHW is critical in a country like Haiti, is rather weak, and therefore the prospects of
with a weak public sector unable to provide the constructing strong and sustainable links with
necessary amount of capable and motivated the public health system through this program
health workers to vast segments of the popu- seem to be very limited, unless the presence of
lation, particularly to rural areas such as central public sector is effectively increased, and real
Haiti. Not surprisingly, as an alternative to the actions aimed at strengthening the health sys-
failing public health system in the country, tem in the long-term are taken.
non-governmental organizations that cover a
substantial proportion of health care provision We chose Zanmi Lazante’s CHW Program for
have resorted to CHWs, in the attempt to com- a full functionality assessment because it is by
pensate the deficiencies of the formal system. far the most consistent effort that relies on the
participation of CHWs for providing access of
A review of the National Health System Reform health care to poor rural and remote areas of
Strategic Plan 2005-1010 from the Ministry the country.
of Health and Population (Plan Stratégique
National pour la Réforme du Secteur de la Santé Brief historical description
2005-2010 –Ministère de la Santé Publique et
de la Population),71 shows that CHWs are barely
of the Zanmi Lazante’s CHW
mentioned. Another document of the Ministry Program in Haiti
of Health on a Minimum Health Package,72 Zanmi Lasante was founded in 1985 by a group
considers the role of the various types of CHWs of Haitians and Dr. Paul Farmer of Partners In
active in the country, but fails to specify what Health, a non-governmental organization affi-
the relationship of CHWs Programs is with the liated with the Harvard Medical School. Partners
wider health system, in particular of those ini- In Health (PIH) (or Zanmi Lasante in Haitian
tiatives run by NGOs and faith organizations. Creole) founded the Clinique Bon Sauveur (CBS)
This reflects surely the weak stewardship of the in 1985. Partners In Health is a non-govern-
public sector for bringing together the various mental organization affiliated with the Harvard
sub-systems and delivery channels operating in

Medical School that has been at the forefront of Agricoles). The CHWs thus have become a criti-
HIV service provision in Haiti since the first case cal interface between patient, community and
of HIV was detected in Haiti’s central plateau the CBS in Haiti.
in 1986. It has done so within a framework of
wider primary health care services for the range Recruitment Process
of public health problems affecting low-income
households. We emphasize from here onwards on Health
Agents as they constitute the most important
CHWs have served to bridge gaps in access to cadre of CHWs of Zanmi Lasante, and unless
care that arise from lack of communication for otherwise stated, when we talk of CHWs we are
patient follow-up and long distances for pa- referring to Health Agents. CHWs are chosen by
tients to travel for health problems. CHWs are lay patients or their communities, thus the hiring
people who are selected by the community to policy involves a strong communal component.
be trained and employed as health agents. Such It happens that more than one candidate may
cadres had been involved in directly observed be eligible for final selection. In such cases,
administration of tuberculosis treatment since members of the community get together and
the mid 1980s in Haiti. In 1999, modeled after the elect one of them. This is an informal process
successful outpatient treatment of tuberculosis, that involves a lot of discussion and negotiation
access to highly active antiretroviral therapy in case the selection of a health agent is in play.
(HAART) was expanded through a community- The process of selecting an accompagnateur
based program called the HIV Equity Initiative. A is less complex as it only involves the program
cadre of CHWs was trained to administer HAART nurse, the social worker and the HIV or TB
to patients in their homes as directly observed patient. Moreover, due to the particular vulne-
therapy (DOT). The CHWs were also trained to rability of women in face of the HIV epidemic,
provide preventive education to communities, more than fifty percent of accompagnateurs
to minimize stigma and to refer to the clinic are women. Given the demographics of Zanmi
possible HIV and TB contacts or those at risk for Lazante’s CHWs workforce, they have an innate
infection. understanding of the socioeconomic and health
concerns of the communities they serve.
Later on, Zanmi Lasante has expanded its
network of lay community members serving General Requirements:
as CHWs, involving them in a wider range of The CHW must be an adult (usually over 18 years
activities such as encouragement of voluntary of age) and preferably literate.
HIV testing, HIV, TB and other chronic diseases
treatment supervision, health education, edu- Since the CHW is in daily contact with patients
cational and psychological support to families in their homes, he or she should live in or close
of affected patients, reproductive health, and to the community served; having lived in the
assessment and management of maternal community for a specific number of years is
and child health problems. This network the- often required.
refore includes currently several groups of The CHW should have a background that is si-
CHWs with different names and roles (Health milar to the background of the patients so that
Agents: Agents Sante; Women’s Health Agents: they feel comfortable sharing their concerns.
Agents de Femmes; Youth Monitors, The This also enables the CHW to have first-hand
Accompagnateurs, Traditional Birth Attendants: knowledge of the problems and obstacles pa-
Matronnes; and Agriculture Agents: Agents tients face every day. In some cases, CHWs are

The CHW Role
themselves HIV positive or former TB patients. CHWs have traditionally been used in the deli-
They frequently know someone who has HIV or very of tuberculosis medicines and in national
TB in their community. vaccination strategies in Haiti. Less often have
CHWs been used in the management of chro-
Motivation and character are critical requi-
nic medical illnesses such as HIV, diabetes and
rements. A CHW must be a trustworthy and
chronic heart failure. Depending on the spe-
respected member of the community, with a
cific subgroup of CHWs involved and on the
strong desire to help the needy and a strong
education they receive, their responsibilities
sense of empathy with those who are vulnerable
range from general preventive services to the
and sick. A CHW’s work is not only focused on
provision of drugs and medicines and health
improving health status, but also on social jus-
education and agricultural techniques.
tice and solidarity with the community, through
working to support affected individuals and
Broadly speaking, Zanmi Lazante’s CHWs in Haiti
households and reduce social isolation.
serve as counselors, educators, treatment super-
visors, and advocates experienced in identifying
Interviewing CHW candidates:
the needs of their communities. They:
The clinical team usually interviews people who
wish to become CHWs to see if they meet the Provide home-based care
above requirements. Team members that may Provide psychosocial support to patients under-
be involved in the interview process include going treatment
doctors, nurses, social workers or program ma-
nagers. The candidate may be asked to take a Act as the link between the patient and the
basic literacy test. He/she may also be called health center
upon to read a medication label or write his/ Carry out active case-finding
her name, to distinguish medications by color
and size and to count the number of pills in a Educate the community on a variety of health
month’s supply. In some specific programs, topics
preference is given to candidates who are extre-
mely poor and could therefore particularly use In fact, however, as we already outlined above,
the additional income and skills-training. As sta- Zanmi Lazante’s CHWs network includes several
ted previously, given the specific vulnerabilities groups, with different names, training profiles
of women in face of the HIV epidemic, women and roles.
may be preferentially selected.
Health agents (Agents Santé, Ajan Santé in
Pairing a patient with a CHW creole) are the most educated and provide
Patients themselves play an active role in selec- basic health services, vaccination, health edu-
ting CHWs. In the case of an established pro- cation, family planning, and hygiene education,
gram, a patient may already know a CHW in his collect socio-demographic information about
community, and may even have been referred communities can provide basic treatment for
to the health center by him/her. If the patient malaria, diarrhea and other non-complex health
does not know any CHW, or doesn’t feel com- problems.
fortable with the one(s) he/she knows, then the
clinical team suggests another possible candi- Women’s health agents (Agents de Femmes,
date from those CHWs who live in the vicinity Ajan Fanm in creole) focus on reproductive
of the patient. health counsel, and provide modern contra-

ceptive methods except Norplant and surgical provision of health care services, are a key com-
methods. They are also involved in support ponent of Zanmi Lazante’s network.
PMTCT mothers by providing psychosocial sup-
port and the provision of HIV prophylaxis. Initial Training of CHWs
The Accompagnateurs are focused on HIV,AIDS, Organization:
and TB. They are in charge of directly observed Before they begin supporting patients, CHWs re-
treatment (DOTS) for HIV/TB, and provide psy- ceive an orientation from the clinical staff at the
chological support to families. These tasks have health center as well as participate in a rigorous
been expanded to other diseases, and they also training program designed by Sanmi Lazante.
supervise treatment compliance for chronic Its current curriculum for CHWs comprises 15
diseases, making sure that patients comply units, with a focus on AIDS and tuberculosis.
with anti-diabetes and hypertension drugs, for The training is tailored to be given over seven
instance. consecutive or separate days. Each training
day consists of 6.5 hours of training, 1 hour for
Youth monitors provide education and peer lunch, and two 15-minute breaks. The number
support to young groups on HIV, sexually trans- of participants varies according to need; 25 par-
missible diseases (STDs), sexual issues and other ticipants or fewer are ideal. All participants are
reproductive health problems such as early provided with meals and a stipend. Trainers and
pregnancy. facilitators are drawn from the staff at the health
centers and should have experience in training
Traditional birth attendants (TBA) (Matronnes) or education to ensure that they are knowled-
play an active role in the referral of pregnant geable about and competent in participatory-
women at any stage of their pregnancy, but pro- based learning and training methods suited
vide also HIV drugs as part of the prevention of to low-literate adult learners. Regardless of the
maternal-to-child transmission of HIV (PMTCT) specific content areas covered, the primary
to mothers. They are trained to recognize signs objective of CHW training is consistent: to instill
and symptoms of pregnancy complications and a sense of solidarity and social justice in suppor-
accompany affected pregnant women to the ting patients, households and the community.
clinics.
Specific training goals include:
Agricultural agents (Agents Agrikol in creole)
teach agricultural techniques to communities Providing correct information about treatment,
and educate them on how to improve their prevention, and risk factors for HIV, TB, malaria,
production. Community members are suppor- and other infectious and chronic non-transmis-
ted for to produce nuts for instance, and selling sible diseases.
them. In this way consumption of nutritious Defining the roles and responsibilities of CHWs.
products is promoted, along with and increased
family incomes. This activity of agricultural Helping CHWS recognize and reduce stigma
agents is key, because most of CHWs trained and discrimination in their communities.
by Zanmi Lasante are farmers, and HIV and TB
Developing CHWs’ competence in active case
patients go back to their communities and they
finding for diseases and social needs.
are expected to be reinserted in the productive
activities, mainly agriculture. Agricultural agents Helping CHWs improve their skills related to
therefore, even if they are not directly related to effective communication and psychosocial

support. accompagnateurs, and often testimonies of
expert patients. Modules include HIV, TB and
Directing CHWs to additional resources or peo-
STDs topics as well as psychological matters,
ple at the health center and in the community,
counseling and individual and group support,
who can guide or assist their work.
and daily monitoring of patients through the
accompagnateurs’ form.
Training principles:
Based upon adult learning principles, the CHW
training curriculum presented here incorpo- On-going Training of CHWs
rates a variety of participatory approaches to Continuing education:
teaching and learning that build upon the exis- After the initial program, CHWs participate in on-
ting knowledge, skills, and experiences of the going monthly education sessions for one year
participants, including: and beyond, with additional training in areas
Large- and small-group activities and such as nutrition, malaria, pediatric HIV/AIDS,
discussions diarrhoeal disease, family planning, active case-
finding, worms and parasites, chronic diseases,
Role plays
first aid, the role of traditional healers, and oral
Case studies hygiene. Health center staff or other available
Brainstorming teachers lead trainings.
Panel discussions Shadowing a CHW:

Peer teaching After completing his/her initial training, the
new CHW joins a veteran CHW in conducting
According to the specific group of the network, patient visits. This provides a practical, hands-on
discussion and teaching topics and issues offe- learning experience and helps the new CHW
red during initial training vary in length, modules develop a support network of fellow CHWs.
and even locations of training. Health agent is
the group who receives the most advanced trai- In fact, the process for on-going training is
ning in diverse issues, from infectious diseases also quite different from one group to another.
to hygiene and sanitation, and includes com- Health agents and women’s health agents meet
munication skills, counseling and reproductive on a monthly basis for programmatic follow-up.
health and preventable diseases for children These meetings serve as an opportunity for
and vaccination. Women’s health agents focus continuing education. New topics or refresh-
on reproductive health and HIV/AIDS. Youth ment courses are taught. Accompagnateurs
monitors address youth issues, sexuality and receive refreshment courses on a yearly basis as
responsible behavior in the era of STDs and their group makes the majority of ZL network
civic actions. TBAs are trained in danger signs of CHW.
recognition and referral of women in labor and
beyond. Agricultural agents address agricultu- On-going training characteristics for Youth
ral techniques for improving production, grow, Monitors, TBAs, and Agricultural Agents has to
harvest and education including nutrition mat- do with refreshment courses and discussions of
ters. Initial training for Accompagnateurs is very new matters that are not systematically taught
participatory, comprising various methodolo- in initial training such as hygiene, new agricultu-
gies from theory presentations to discussions, ral techniques, sexuality, STIs or new monitoring
case studies, and visits to patients with expert and evaluation issues that may arise from do-

nors such as new forms and new indicators to kers to Senior Health Agents/Accompagnateurs
report. to the rest of each group. The system is orga-
nized around the monthly meetings during
Training of Trainers which supervision activities and continuing
training are provided together. In addition to
Training of trainers (TOT) has not been formally that, unplanned and planned field supervision
offered to CHWs until recently. In 2009, formal visits are carried out by the each level of su-
TOT was delivered to a group of CHW among pervision. Unplanned supervision visits during
the best ones. The Training center is committed health posts and vaccination day are provided
to carrying out more TOTs targeting this group. as well. Historically, CHWs have been directly
supervised by clinical staff, usually a doctor or
Equipment and supplies nurse involved in the care of HIV or TB patients.
As Zanmi Lazante programs have grown, there
Supplies are provided to each CHW according was increasing awareness on the need for more
to their respective responsibilities and compe- formal supervision structures that take advan-
tencies. The stocks are provided mainly on a tage of the experience and skills of more senior
monthly basis. CHWs. Recently, the role of Accompagnateur
Health agents: dressing kits, flip chart and flyers Leader has been introduced at several of the
for education, vaccines (Polio, DTP, TT, BCG), sy- program sites.
ringes, ORS, weigh scales, centimeters, thermo-
meters, boots, rain coats, road to health charts, CHW leader (Accompagnateur Leader): Most
data collection forms, monthly and daily report often, the leader is an existing CHW who has
forms, and irregular provision of phone cards been chosen based on the high quality of his/
Women’s health agents: pills, boots and rain her work, leadership qualities and standing in
coats, data collection forms Youth monitors: flip the community. The length of time the CHWhas
charts, raincoats, and pens Accompagnateurs: been working as an accompagnateur and his/
boots, raincoats, pens, data collection forms her level of education are also factors taken in
Agricultural agents: agricultural materials, flip consideration for their promotion to CHW lea-
charts TBAs: boots, rain coats, a delivery kit ders. The number of CHWs supervised by each
(clean gloves, scalpels, cotton, gauzes and refer- CHW leader varies. In Haiti, a CHW leader may
ral forms). oversee up to 50 CHWs.
CHWs receive monthly stocks of specific sup- Roles and responsibilities of the Accompagnateur
plies or commodities such as condoms, SROs, Leader:The primary responsibility of the CHW
Iron, Folate, and vitamin A. Vaccines, however, leader is to ensure that the CHWs are visiting
are provided the day before or the same day of their patients daily, administering medications
vaccination, as cold chain may be a major issue correctly, and vigilantly monitoring patient
in Haiti. health. The leader also helps the clinical team
by answering patients’ questions, joining the
Supervision team on patient visits, and identifying problems
The supervisory system is built involving all between CHWs and patients. Another point of
levels of hierarchy of each institution. It starts supervision is at the pharmacy, which CHWs
from the head of the Commune (city) to public visit regularly to pick up medications for their
health nurses, HIV program nurses/ Social wor- patients. Pharmacy logs and interactions with
the pharmacist are important points of super-

vision. The CHW leader and other members of external debt, all must constitute long-term
the health center identify problems between objectives for the effective and sustainable de-
CHWs and patients through unannounced visits livery of health services in Haiti. Without them,
to patients’ homes. When a conflict does arise, it is doubtful that Haiti will reverse the gloomy
the CHW is called to the health center to discuss health situation that most of their citizens’ face.
the situation. CHW leaders meet regularly with
health center staff to exchange information and Incentives
discuss common issues. CHWs meet monthly
with health center staff for ongoing training and All the groups within the network are paid in
to discuss any problems or concerns. addition to other social benefits. Monthly salary
ranges from USD 50 -130. Agents Sante are full-
time employees (8 hours a day, five days a week),
Performance Evaluation and receive a monthly payment of about US 100
There are several assessment publications on (one USD=40 goudes). Agents de Femmes focus
Zanmi Lazante’s CHW Program impact. They on reproductive health) mostly offer counseling
basically show an increased coverage of health on family planning, and provide some methods:
care for HIV/AIDS and TB patients, specifically condoms, pills. Very few of them can give in-
increased coverage of voluntary HIV testing jections of Deproprovera. Full-time Monthly
and HIV/TB treatment adherence in Zanmi salary: 75. The Accompagnateurs work on a
Lazante’s influence areas, through home-based part-time basis (about 1-3 hours a day, 7 days
directly-observed therapy strategy conducted a week, because they should not work more
by CHWs, and also an increased trust of com- than 30 minutes for each patient they visit, as
munity members on health facilities run by they need to move long distances from one
committed and capable organizations such as patient to the next one), receive a payment that
Zanmi Lasante and other NGOs. There is also ranges between USD 40-60/month, depending
consistent evidence about a clearly positive on the number of patients they see. Matronnes
impact of NGOs community-based programs (TBS): they work part-time and receive a case-by
on reduction of TB and HIV morbidity and case payment that is US 5 for each institutional
mortality, and on reduction of infant and child delivery. Agricultural agents are full-time em-
mortality, and on maternal and reproductive ployees and are paid the equivalent of US $ 100
health indicators in their catchment areas.73-78 a month, almost the same as CHWs. Youth mo-
These findings highlight the fact that more nitors are part-time and school fees are paid for
than 20 years experience of work with CHWs in them, as well as training and provision of some
Haiti constitutes a unique potential on which to equipments.
build for scaling up and for strengthening the
Haitian health system. However, to date there is Community Involvement
not yet compelling evidence about the overall
impact of CHWs Programs on Haiti key health CHWs are local people selected by community
indicators at country level. Improved levels of members and ZL staff. They have an innate un-
coordination between NGOs, the stimulus of the derstanding of the local population. They are not
vital stewardship role of the public sector, the only focused on HIV care but community health
critical need of strengthening capacity, gover- and serve as liaisons between the community
nance and accountability of the public sector, and clinics, which helps to prioritize needed ser-
and an effective tackling of social determinants vices beyond clinical care, such as water projects
of health including factors such as poverty and and vaccination campaigns. CHWs attend clinic

staff meetings bringing a community voice to the clinics any patient suffering with any kind of
decision making, from planning events such disease. All referrals are made through written
as World AIDS Day to structuring clinic visits. referral forms that are completed by CHWs.
Employing local residents creates trust between
the community and clinic, decreases stigma Professional Advancement
and generates self-confidence in community
members. Professional advancement still needs to be
improved and better structured. CHWs who
have demonstrated a good performance re-
Referral System cord are promoted to positions of supervision
The referral system is very active and all groups (Accompagnateur Senior).
refer to the clinics. Referral forms are available
between sites. CHW refer to the clinics and of- Additional incentives for advanced CHWs may
ten accompany the patients to make sure that reach a 30% of their salary when they become
they get the care they need. Feedback is most supervisors. A motorcycle is also provided for
often provided to them, facilitating in this way each site for supervision. In addition they receive
follow-up of patients. In brief, a CHW refers to calling cards for about US $15 a month.
Table 28 – Performance evaluation of CHW program

Program coverage (%) 15% (About 1.2 million people –Overall population 9 million)
Preventive and promotive Vaccination promotion coverage: 90%. Proportion of children with basic
service delivery vaccination: 80% Contraceptive usage: 24% of all users of modern
contraceptives
Curative service delivery 100 % of all CHW seen and referred emergency cases in previous
three months
Support system for CHWs Training: 98% who received introductory training Knowledge: 95 % of
and their performance CHWs given at least one correct answer Supplies and equipment: Few
lack of stocks. No expiration of stock was reported in the last 5 years.
Salaries: example: 100% paid over three months Supervision: Each CHW
supervisor makes a visit at least once a month to all the CHWs under
his/her supervision. Public health nurses supervise once a week at least
a major CHW health post. A doctor, like the nurse, supervises once a
week a CHW health post or mobile clinic. 0% facilities lacking important
medicines and supplies on the day of survey
CHW services and the poor Approximate overall poor coverage of the program: 90%
CHW impact on health IIndicators of population served compared with national figures?
1.2 millions In Central Plateau and half of the Artibonite region.
CHW costs – Actual level of funding is enough than originally planned? More funds
current and future are needed to support the program. The program grew so fast that
actual level of funds is not sufficient.
294
Documentation and
Information Management
Monthly data collection forms are provided to
health agents. Daily and monthly forms are also
given to all the other groups. Forms to collect
information about health posts, special vaccina-
tion days, and routine vaccination are handled
as well. Accompagnateurs handle forms to
report on HIV drugs, adverse reactions and any
remark they may have.
Recently, Zanmi Lazante has set up a web-based

medical record system linking remote areas in
rural Haiti.79 It comprises an information system
and medical record to support HIV treatment
and it is used to track clinical outcomes, labo-
ratory tests, and drug supplies and to create
reports for funding agencies. Future work will
focus on refining the system and developing
a core data set and functions to support other
HIV treatment projects, including incorporation
of data representation and exchange standards.
It is acknowledged that common standards for
creating computerized guidelines are also im-
portant to allow sharing of knowledge between
projects and information systems.
Zanmi Lazante is aware that HIV treatment does

not occur in isolation, and that the infrastruc-
ture this organization has developed in central
Haiti is augmenting the care of other acute and
chronic diseases, including tuberculosis and
heart disease. The similar web based tubercu-
losis electronic medical record in Peru provides
important support for treatment, drug supply,
and research with more than 2,500 complete
patient records entered to date. Zanmi Lazante
has been planning to make our HIV-EMR
available to other organizations once it is com-
plete, using an open source model for software
distribution.

Table 29 - CHW Program Functionality Assessment Tool (CHW-PFA) - Haiti
Evidence

CHW to prepare for role Some CHWs attend works- of recruitment. Training does months that is based on Remember that
in MCH services delivery hops on specific topics. not include participation defined expectations for CHW. groups such as
and ensure he/she has the from community or from Some training is conducted Accompagnateurs
referral health center. in the community or with and Youth
community participation. Monitors be
safe and quality care. Training is consistent with trained in
health facility guidelines for specific topics
community care and health related to MCH
296
297
Evidence
performance support
and bonuses is considered a reward Examples of non-financial incen- good performance. Incentives Zanmi Lasante’s
Non-financial= training, tives include occasional formal are balanced and in line with program involves
recognition, certification, recognition, additional training, expectations placed on CHW. all aspects of
and other small incentives. Examples of non-financial incentives, both
incentives that engage financial and
workers might include non-financial

Evidence
determining when referral refer client, but - no logistics plan ment, etc) CHW and community treatment, etc) CHW and additional treatment, etc) But with
is needed - logistics plan in place by the community for know where referral facility community know where referral CHW and community know little irregularity
for transport/payment to emergency referral - information is but have no formal referral facility is and usually have where referral facility is and concerning for-
is not tracked or documented process/logistics Referral is not the means to transport client have a logistics plan for mal feedback to
tracked by community or CHW Client is referred with a slip of emergencies (transport, be sent to CHW

11 Professional Advancement No professional advancement Advancement (promotion) is Advancement (promotion) is Advancement (promotion) is
The possibility for growth, is offered. sometimes offered to CHWs sometimes offered to CHWs offered to CHWs who perform 2
Documentation, No process for documentation Some CHWs document their CHWs document their CHWs document their
Information Management or info management is followed visits and group monitoring visits consistently and group visits consistently and group 3
How CHWs document visits to facility are attended by monitoring visits to facility are monitoring visits to facility
visits, how data flows to CHWs who bring monitoring attended by CHWs who bring are attended by CHWs who
the health system and forms. CHWs/communities do monitoring forms. Supervisors bring monitoring forms.
not see data analyzed and no ef- monitor quality of documents Supervisors monitor quality
back to the commu-
12 fort to use data in problem-sol- and provide help when needed. of documents and provide
nity, and how it is used ving at the community is made. CHWs/communities do not see help when needed. CHWs/
298
1 ANTENATAL CARE
Counsel o
Provide commodity or intervention/ Assess and treat
B Maternal nutrition Note that CHW are also involved in some as-
Counsel o pects of the treatment as they have to follow-
Provide commodity or intervention/Assess and treat x up the treatment prescribed at the clinics.
D Tetanus toxoid
Counsel o
E Deworm
Counsel o
A Prevent Infection/Clean Delivery x Mostly TBAs and Health agents

b. sepsis, o
complications
D Prevent PPH: AMTSL or use of uterotonic alone
in absence of full AMTSL competency (e.g. oral o
Misoprostol)
E Provide special care for Low Birth Weight newborns
(Kangaroo Care) x

newborn health and nutrition behaviors This is the critical role of TBAs and
x Women’s Health Agents.
a. clean cord care;
x
x

guidelines.)
4 EARLY CHILDHOOD
recording progress
C Provide community based management of acute mal- x
Counsel re recognition of danger signs, seeking care/ x
antibiotics x
Assess and treat with antibiotics x
When they have to refer for ORS, it oc-
G Community-based prevention and treatment of diarrhea curs only in case they have a stock out
Counsel on hygiene x of ORS in the community
Counsel on point-of-use water treatment x
Counsel on ORS x
Provide ORS x
Refer for ORS x
Counsel on Zinc o
Provide Zinc x
Refer for Zinc
Counsel x
j Counsel on immunizations x Only Health Agents are authorized to
Mapping/tracking for immunization coverage x provide immunization routinely. Some
Provide Immunizations: members of other groups if they are
-DTP x deemed competent to do so.
- +/- HIB o
- Hep B o

-Pneumovax o
-Rotavirus o
OF PREGNANCY
Provide contraceptives: x
- condoms x
Some competent senior CHWs
- Lactation Amenorrheic Method (LAM) x can provide Depo
- depo x
- condoms x
- Lactation Amenorrheic Method (LAM) x
A Insecticide-treated mosquito nets to
pregnant women and children o
Counsel o
B Refer for commodity, intervention, or treatment
Intermittent preventive malaria treatment (IPTp) o They are active in the distribution
o of impregnated bed nets in the
Counsel communities
C Refer for commodity, intervention, or treatment
Community-based treatment of malaria (testing with
Counsel o
Counsel x
Counsel x
Counsel x
x

Counsel o
Counsel o
Counsel o
Counsel o

Summary
Haiti faces a dramatic lack of a minimal strength efforts in place in Haiti and playing an effective
of the state to accomplish its responsibilities stewardship role, each organization will continue
for providing essential education and health executing its own agenda, while countless citi-
services to the great majority of Haitian citizens will continue suffering as a consequence.
zens. Non-governmental organizations have There is no way of turning a CHW Program, no
been instrumental in providing such services matter how successful has been in its particular
to poorest areas in Haiti, most notably for a ti- geographical catchment area, into a country
mely diagnosis and treatment of HIV/AIDS and level example of successful health delivery if the
TB, utilizing for these activities the potential of country health system is dysfunctional, and in
community members themselves. this task the government responsibility is essen-
tial, but donors and private providers need also
Several decades of valuable experiences with to take seriously their own participation quota.
CHWs in Haiti are in place for helping to build a
functional health system at country level. It is up Coordinated CHW Programs like Zanmi
to the international community, to government Lasante’s, if they are effectively inserted into
spheres and to civil society members to turn the wider health system activities, have a real
this accumulated capacity into effective health potential for making a difference. It is within
interventions for all Haitians. CHWs Programs the broader Haitian social, economic and health
implemented by capable and commited non- system context that we present here the expe-
governmental organizations such as Zanmi rience and contribution of Zanmi Lasante’s CHW
Lasante’s have provided consistent evidence Program.
about the positive impact on an increased
coverage of health care for HIV/AIDS and TB
patients, specifically on coverage of voluntary
HIV testing and HIV/TB treatment adherence in
the NGOs influence areas, through home-based
directly-observed therapy strategy conducted
by CHWs, and also an increased trust of commu-
nity members on health facilities run by NGOs.
There is also consistent evidence about a clearly
positive impact of NGOs community-based
programs on reduction of TB and HIV morbidity
and mortality, and on reduction of infant and
child mortality, and on maternal and reproduc-
tive health indicators in their catchment areas.
The evidence clearly shows that it is feasible to

expand such experiences. There is not excuse
for not doing so. It is not enough to have patchy
success stories. Without country level sustained
scaling up of effective interventions there is no
hope for a real change in the quality of life of
Haitians. Without a full presence of the public
sector in the health sector reform, coordina-
ting efficiently the diverse public and private

AFRICAN Case Studies
Ethiopia – Health Extension Program

Uganda – Uganda Village Health Teams
Mozambique –Agentes Polivalentes
Elementares Program

6. Ethiopia - Health Extension
Program
George W. Pariyo (Dept of Health Policy, Planning Under 5 mortality fell from 204 per 1,000 live
and Management, Makerere University School births in 1990 to 119 per 1,000 live births in 2007.
of Public Health) & Kora Tushune (Dept of However, up to 47% of the under five children
Community Medicine, Jimma University) experience moderate to severe stunting.
Socio-economic and Economic and social reforms have been under-

taken and the economy registered an impres-
political context sive double digit growth rate in recent years, ac-
Ethiopia is a Sub-Saharan African country loca- companied by falling poverty rates and a 83.4%
ted in the Greater Horn region of East Africa. It increase in net enrolment in primary school. 80
has an area of 1.1million km2 and shares borders
with five countries: Kenya to the South, Somalia Life expectancy at birth is estimated at 53 years.
and Djibouti to the East, Eritrea to the North and Only 42% of the total population has access to
The Sudan to the West. It is an ancient civilization improved drinking water sources, while only
with recorded history of more than 300 years. 8% of the rural population was using improved
sanitation facilities by 2006. By 2007, only 10%
Ethiopia is a federal republic that has nine states of children under five with fever were estimated
and two city administrations. It is further divi- to be accessing antimalarial drugs. There is an
ded into 819 woredas (districts) and more than estimated HIV prevalence rate of 2.1% in the
15,000 kebeles (sub districts), 10,000 of which population age-group 15-49 years.81
are rural and 5,000 urban. The country is di-
verse in its climatic, ethnic, cultural and religious Health Systems Overview
make up all of which have implications for the
organization of the health system. A substantial The national health system is organized in four
part of the country has challenging topography tiers with primary health care unit (PHCU) -
full of ragged mountains and arid and semi-arid consisting of one health center and five satellite
areas that are difficult to access and expensive health posts that serve a population of 5,000
to cover with infrastructural development. being the first tier interfacing the health system
with the community. Next is the district hospi-
Though the country has a long history of inde- tal that serves a population of 250,000 and the
pendence, internal conflicts and civil wars punc- third is a zonal hospital that covers a population
tuated by occasional drought and famine have of 1 million. The final tier is a specialized referral
had a detrimental effect on socio-economic hospital that serves a population of 5 million
development of the country. With a population (figure 1).
of nearly 80 million people and a population
growth rate of 2.9%, Ethiopia is one of the poor The health system is generally considered weak,
countries in sub-Saharan Africa with low indica- underfunded, inequitable and inefficient. The
tors of development. The majority of its people infrastructure is underdeveloped and facilities
(85%) live in rural areas where infrastructure is poorly staffed.
poor, 23% of the population live on less than $1
per day. It has a GNI per capita of $ 220 (2007), The health system suffers from shortage, mal-
total adult literacy is 36% and net enrollment/ distribution and gender imbalance of the health
attendance in primary schools is 45%. The workforce. The motivation and performance of
economy is dependent on primary agricultural the workforce working in the public sector is
products. low. As a result the performance of the system

is also poor. The health sector has a 20 year sec- The health status of the Ethiopian population is
tor development strategy divided into a series also a reflection of the reality described above:
of five-year rolling plans called Health Sector Infant mortality rate is 77 per 1,000 live births;
Development Program (HSDP), and is currently maternal mortality ratio is 673 per 100,000 live
implementing HSDPIII (2005/6-2009/10). births; under-five mortality stands at 123 per
1,000 live births; coverage of deliveries attended
Health services are financed from four main by skilled staff (6%); antenatal attendance (27%)
sources: Government (federal and regional) and access to post-natal services (11%). The
28%; multilateral and bilateral donors (through EPI coverage is estimated at 81%, the increase
grants and loans, nongovernmental organi- mainly attributable to the recently implemented
zations (NGOs) - international and local) 37%; health extension program. Seventy to eighty
and private contributions (e.g., out-of-pocket percent of health problems are preventable,
spending) 31%. Per capita health expenditure is occurring mainly due to infections and nutritio-
US$7.14 and health expenditure is estimated at nal disorders. Access and utilization is very low
US$522 million p.a. (5.6% of GDP). especially among rural and vulnerable groups
of the population. Malaria, Acute respiratory
Figure 1: Organization of the health care system in Ethiopia

Health Service Delivery System of Ethiopia
SPECIALIZED
REFERRAL HOSPITAL
5million population
ZONAL HOSPITAL (ZH)

1000000 population
DISTRICT HOSPITAL (DH)

250000 population
PRIMARY HEALTH CARE UNIT (PHCU)25000 population or 5000HHs

1 health center 5 health posts
10 HEWs 100 VCHWs
(2 HEWs 20 VCHWs per kebele for 5000 population or 1000HHs)

infections and helminthiasis are the top causes major breakthrough in terms of equitable access
of outpatient visits whereas deliveries, malaria to PHC during the socialist regime and even in
and bronchopneumonia are the leading causes the immediate aftermath of its downfall in 1991.
of admissions.82 However the foundation for the Health Service
Extension Program (HEP) can be traced back to
The administration of the health services is the National Health Policy of the country that
decentralized along a federal system of govern- was issued in 1991. The Policy gave emphasis to
ment that was introduced in Ethiopia following prevention aspects of health service and promo-
the 1991 overthrow of the socialist government. ted self-reliance as a way forward for Ethiopia.
The federal ministry of health (FMOH) has taken Following the Policy the country adopted a 20-
up the roles of policy making, regulation, tech- year Health Sector Plan as part of the national
nical support and standardization of services development strategy of the country. The plan
while Regional Health Bureaus (RHB), which is is further divided into five-year rolling plans cal-
accountable to respective state governments, led Health Sector Development Plan (HSDP).83
assumed the role of provision of services and
management of the workforce and health The Health Extension Program (HEP) was star-
facilities. ted in 2004 during the second five year plan
(HSDP II 2002/03-2004/05) after evaluation of
Ethiopia Health the implementation of the first five year plan
(HSDP I) revealed that necessary basic health
Extension Program services had not reached the people at the
Even though the importance of improving the grass roots level as envisaged and desired, due
coverage of basic health services was recogni- to the nature of services being given by the
zed much earlier in Ethiopia the significance health system and the health service indica-
of PHC strategy received emphasis after the tors especially those related to MDGs were not
Alma Ata Declaration of 1978. The earlier shift showing improvement or the improvements
towards socialist ideology in the country also were negligible at the best. To implement the
favored the adoption of PHC. Two years before HEP government launched a strategy known as
the adoption of PHC, in 1976 The Revolutionary Accelerated Expansion of Primary Health Care
Democratic Program of the socialist regime had Coverage (AEPHCC) that guided the investment
also endorsed primary care, rural health services, plan. The strategy document was a blue print
prevention and control of common diseases, for government investment in construction of
self reliance and community participation as a health posts and health centers and investment
policy direction of the new Ethiopia. in the workforce including the Health Service
Extension Workers (HEWs).
In spite of early adoption of PHC and deploy-
ment of CHWs, who were the key workforce, Health service extension program is “a package
the achievements were not as expected pri- of basic and essential promotive, preventive
marily because of challenges faced by similar and selected curative health services, targeting
programs in many other developing countries; households in the community, based on the
i.e., constrained resources and institutional en- principles of primary health care to improve
vironments, problems of sustaining a volunteer the health status of families with their full par-
workforce, logistics and supply chain difficulties, ticipation, using local technologies and the
training and supervision needs and the required skill and wisdom of the communities”. It forms
multi-sectoral support. As a result there was no the bottom part of the national health system
308
Recruitment Process
mainly focusing on preventive aspects of health HEWs are recruited for the training from the
services and promotion of healthful living in community in which they live and would serve
the community. The HEP was initiated from after completing the training. The criteria used
high level political leadership of the country, to select HEWs are that they have to:
inspired by the enhanced implementation and Be female of 18 years of age and above
performance of agricultural extension program.
The philosophy behind the program is that Complete grade 10 secondary education with a
households can produce their own health like grade good enough to allow them to join voca-
they produce agricultural outputs for their tional training, TVET (1.6-1.8 grade points)
consumption provided they are given the right Be from the target community
information, supported in health actions and
mobilized. As a result communities, households Respected by the community (recommenda-
and individuals are empowered to take care of tion from the village) and willing to live in and
their own health in the spirit of ownership and serve the community after the training
self-reliance.84 A member nominated by local community, re-
presentative. Selection is done by a committee
The package (HEP) is implemented by the comprised of woreda (district) health office,
Health Extension Workers (HEWs), who receive capacity building and education offices.
training for one year. HEWs are a new cadre of
community based health workers in Ethiopia. The above criteria are reconsidered in recruit-
They are selected by the community in which ment of the pastoralist HEWs due to problem
they live (in collaboration with wereda adminis- of finding persons who have reached the 10th
tration), to provide, after completing one year grade in general, and especially among wo-
training, promotive, preventive and selected men in particular. As a result the educational
curative health services to the community of requirement is reduced to 6th – 8th grade;
their origin based on the values and principles training duration reduced to six months and
of primary health care. Two HEWs are deployed gender criterion is also relaxed to allow men to
in every village with population of 5000. They be recruited where it is difficult to find women
are supported by a number of volunteer CHWs due to educational or cultural situation of the
selected by the community with ratio of one community.
VCHW for every 250 population.
This program was selected for review as it is

The CHW Role
the main officially recognized nationwide CHW According to the implementation guidelines
program that Ethiopia has developed and is of the Health Service Extension Program (HEP)
implementing. It is the only CHW program that health service extension workers are expected
is well structured, and with clear curriculum and to carry out responsibilities in four major areas;
training materials agreed on by all the partners. a) administrative duties, b) promotive and pre-
All other programs are rather ad hoc in nature ventive activities, c) basic treatment and referral
and not nation-wide, and are being phased out services, and d) essential IEC activities which are
or should work under overall co-ordination of cross-cutting.
the HEP. 85
Administrative duties
HEWs are responsible for:

collecting and recording basic demographic excreta disposal, solid and liquid waste mana-
and health related information of the kebele gement, safe water supply and handling, food
hygiene, environmental sanitation, pest and ro-
planning, coordinating and leading the HEP in dent control, prevention and control of malaria
kebele in collaboration with kebele administra- and TB, prevention and control of HIV/AIDS and
tion, the community, voluntary health workers STD
(VHWs) and partners
train community members in becoming health
availing and managing inputs for implementa- promoters
tion of HEP
mobilize communities and organize campaigns
strengthening the implementation of the refer-
to promote health services
ral system and
understand and implement policies, strategies
ensuring the availability of registers and forms and the Health Sector Development Plan (HSDP)
and using them of the FMoH.
establishing and strengthening the documen-
tation and filing system Basic treatment and referral services
HEWs also provide Basic curative and referral
requesting medicines, medical equipment and services which include to:
supplies in a timely manner, collecting them, re-
gistering in accordance with official guidelines relieve pain,
managing medicines and medical equipment treat common health problems such as mala-
carefully in order to avoid damage or waste, and ria, diarrhea, intestinal parasites, trachoma and
report expired and unwanted medicines to the scabies,
Woreda Health Office (WrHO). Refer cases beyond their capacity to the nearest
health centre.
Preventive and promotive activities
Under this the HEW roles include: IEC activities
organize, train and coordinate volunteer com- Another important task of a HEW is IEC activities
munity health workers (VCHWs) which are cross-cutting in nature and included
in nearly all other roles of the HEW. They are
conduct regular house-to-house visits tailored to the local socio-cultural situation of
identify defaulters and help them use services the community to convey health messages
using inter-personal communication, role plays,
implement and/or support vaccination, family folklore, poetry, proverbs, demonstrations and
planning, health and nutrition, complementary the like. Theses duties and responsibilities which
feeding, feeding the sick child, growth monito- are categorized in four areas are prepared and
ring, identification of nutritious foods, nutrition delivered in 16 packages each having its own
counseling for pregnant women, and lactating guideline booklets prepared in different langua-
mothers, distribution of micronutrients (Vitamin ges. Box 6 shows the 4 components of the HEP
A and zinc), prenatal care, intra-partum and and the 16 packages implemented by HEWs.
post-partum and newborn care, infant and
integrated maternal and newborn child health
care, adolescent reproductive health services,
disease surveillance, personal hygiene, human

These services are provided to the target com- Identifying sicknesses and referring to the next-
munity using three modalities. These are: level health facility
Providing appropriate treatment for children
Health post based services and other members of the community
Health education Vitamin A supplementation for the target
Vaccination to mothers and children groups
Clean delivery and postnatal care and Health education and demonstration in
counselling schools
Child growth monitoring and nutritional Training and regular meeting with volunteer
counselling community health workers (VCHWs)
Malaria prevention and control activities where Documentation, compiling records, files and
needed reports
Treatment of trachoma using tetracycline eye Displaying health information using graphs and
ointment and counselling on face washing charts and posting them on the wall
Prevention and control of scabies Antenatal Care
Treatment of diarrhoea using ORS Delivery and postnatal care
Box 6 : Components and packages of the Ethiopian health extension program.

HEP Components Health Service Packages
Hygiene and Environmental Sanitation Excreta disposal
Solid and liquid waste disposal
Water supply and safety measures
Food hygiene and safety measures
Healthy home environment
Control of insects and rodents
Personal hygiene
Family Health Service Maternal and child health
Family planning
Immunization
Nutrition
Adolescent reproductive health
Disease Prevention and Control HIV/AIDS and sexually transmitted infections (STIs)
and TB prevention and control
Malaria prevention and control first aid emergence
measures
Health Education and Communication (cross- Crosscutting (Advocacy,Social mobilization, IEC/
cutting component) BCC (IPC & counseling), Community conversation
and Social marketing

Immunization Monitor child growth and counsel on child
feeding
Growth monitoring
Assess nutritional status of children and pre-
Family Planning
gnant women and counsel
Nutritional advice, vitamin A supplementation
Drain and eradicate mosquito breeding sites in
Diagnosis and treatment of malaria malaria areas
Treatment of eye and skin infections with Observe use of bednets and demonstrate pro-
ointment per use
Health education Provide treatment to patients with malaria
First aid and referral of difficult cases Treat trachoma with tetracycline ointment and
counsel on face washing
HEWs generally spend about 25% of their time
Prevent and control scabies
at the health post conducting facility-based ser-
vices and use about 75% of their time outside Treat diarrhoea with ORS and other homemade
the health post delivering family and commu- fluids
nity packages. Identify sick family members abd refer to next
level health facility
Family packages
These include training of model families (2hrs/ Provide vitamin A supplementation
day, total 96hrs) and home visit (4-6HH/day. Provide first aid treatment
Model families are selected and trained in three
phases graduating at the end of the training. Follow up of HIV/AIDS and TB patients
All families in the kebele are eventually reached Provide training, support and encouragement
with the training as a result of rounds of training for community health workers and coordinate
sessions. During home visits HEWs provide the their activities
following services:
Facilitate care and support for HIV/AIDS patients
Educate and demonstrate household waste ma- and facilitate support for orphans and vulnera-
nagement, personal hygiene and other health ble children
practices
Assist families on how to use and properly han- Community based health packages
dle latrines These deal with communication of health infor-
mation to the community using traditional and
Communicate and demonstrate how to keep indigenous community associations which in
the home and compound clean the Ethiopian situation are called “idir”, “mahber”
Advise to separate human quarters from where and “ekub”, and community based organizations
animals stay such as schools, women and youth associations
and religious institutions. As part of this effort
Provide family planning services HEWs carry out community mobilization, com-
Provide antenatal, intra-partum and postnatal munity-based organization mobilization and
care services and counselling provide services at 3-4 outreach sites. Services
HEWs provide at the outreach setting are:
Demonstrate essential newborn care practices
312
Initial Training of CHWs
Health education After recruitment the HEWs are sent to one of
Vaccination of mothers the technical and vocational training schools
(TVETS) in the country for one year training, in
Family planning services case of agrarian HEWs. The HEP was designed
Antenatal care and counselling to use about 40 such training schools in various
parts of the country to train HEWs for agrarian
Child growth promotion and nutritional and pastoralist communities. Once they are
counselling back to their communities, the HEWs then
Nutritional assessment of pregnant women and train volunteer CHWs that can support them in
counselling providing the services to the households and
individuals.
Malaria prevention and control activities where
needed Recently the government has launched a variant
Treatment of trachoma using tetracycline oint- of HEP for urban setting which trains registered
ment and counselling on face washing nurses for three months before deployment to
urban communities. The HEP for urban setting
Prevention and control of scabies has just started and the first batch of trainees is
Treatment of diarrhoea with ORS still undergoing training.
Identification of sick children or members of the
Agrarian HEWs are trained for one year, 30% of
family and referring to the next-level facility
the time in theoretical courses and 70% of the
Vitamin A supplementation for the target time in practical training including apprenti-
groups ceship attachment to health centers and project
First aid attachment to the community. Attachment to
health facilities and community is for about three
Health education and demonstration in months. The training syllabus and breakdown is
schools shown below:
Box 7: Content and Structure of Training Program for HEWs

Course Structure of Health Service Extension Workers
Theoretical training Practical training
Community documentation Practical works
Family health care Models training
Disease prevention and control Group assignment
Environmental health promotion 30% Demonstration and role play 70%
Supportive courses Apprenticeship
Common courses Health facility attachment
(English, mathematics,
IT and entrepreneurship)
Community attachment

Deployment
But duration of training for HEWs intended to HEWs are deployed in the health post, a com-
work in the pastoralist community is only six munity level health facility that serves a popu-
months due to the problem of finding trainees lation of about 5000 people. The health post is
that meet the criteria laid out in the HEP gui- the lowest level health facility. Five such health
delines and using a slightly changed (lighter) posts together with a health center constitute a
curriculum.By the end of 2008, 30,190 HEWs had primary health care unit of the Ethiopian health
been trained in 32 TVETS distributed throughout care delivery system. There were 9914 health
the country, 18 in Oromia, 3 in Amhara, 7 in posts constructed in the country in 2007. Two
SNPPR, and one each in Gambella, Benishangul HEWs are deployed in each health post and
Gumuz, Somali and Afar regions. are supported by village community health
workers (VCHWs) in each kebele. The number of
Till recently the training of HEWs focused prima- VCHWs in a kebele usually ranges between 10
rily on agrarian and pastoralist HEP. However in and 25. As a result HEWs to population ratio is
2009 training package for urban HEP has been usually 1:2500. Health posts are built either by
launched and urban HEWs are expected to be the health system or the community and will
deployed after graduation of the first round usually have at least two rooms.
trainees. The HEWs are trained at the certificate
level. They are able to upgrade to higher levels On-going Training of CHWs
of health professional status through training
and growth in the career path prepared by the In HEP the HEWs are expected to attend a se-
MoH and the government. The Urban HEWs ries of integrated refresher training (IRT) to im-
are registered nurses who are trained for three prove their skill and sustain their motivation and
months on urban HEP packages. Figure 3 shows contribution. The district health office identifies
the annual build up of HEWs since the begin- gaps in knowledge and skills of HEWs through
ning of the Program: regular supervision visits.
Figure 3: Cumulative number of HEWs Trained and Deployed (2004 – 2008)
35000
30000 30786
No. of HEWs Trained
25000
24751
20000
17653
15000
10000 9900
5000
2737
0
2004 2005 2006 2007 2008
Year
Data source: Abaseko, 2009
314
Trainers of HEWs are based at Technical and years, there has not been many comprehensive
Vocational Training Schools (TVETS). These TVETS evaluations of the national HEP/HEWs program
are under the Ministry of Education (MOE) and of Ethiopia. The only comprehensive evalua-
are distributed throughout the country, in diffe- tion was carried out by CNHDE and The Earth
rent regional states. However, the trainers, who Institute of Columbia University in 2007 and the
are environmental health workers and nurses by findings were released in 2009. This evaluation
profession, are recruited by the MOH and then was done after about one and a half years of im-
transferred to MOE institutions and trained for plementation and the findings may not reflect
three months before assuming their new role the performance of the program when it is fully
of training HEWs. Their instructors were drawn implemented and fairly resourced. Some of the
from the health sector. challenges identified in the report are being
addressed already. The CHNDE evaluation study
Equipment and supplies which had a before and after design, looked into
three aspects of the HEP: effect of the program
The basic equipment and supplies available to on health and related aspects of the households,
the HEW are shown in Box 8 (Center for National HEWs’ performance in provision of the health
Health Development in Ethiopia, 2008c). service packages and the performance of HPs
in terms of facilities and productivity. Reports
Supervision of the study released in three volumes corres-
ponding to three aspects of the program. The
The importance of supervision has received
repeated cross-sectional study compared the
more emphasis recently as a reaction to gaps
baseline study information that was collected
identified from early assessment of imple-
in 2005 with the findings of the follow-up study
mentation of the program. In response to the
conducted between November 1-December 30,
problem government launched a strong super-
2007 from the HEP communities. Table 8 shows
visory system. The supervisors are either nurses
some of the findings of the evaluation.86-88
or environmental health professionals who are
trained for two months on supervisory skills
to support the HEP. So far about 3200 HEW su- Incentives
pervisors have been trained. The supervision is Like many developing countries Ethiopia has
linked with integrated refresher training (IRT) to experimented with volunteer CHWs after the
address the skill and knowledge gaps identified PHC declaration of Alma Ata. One of the lessons
during supervisory visits. There is one supervisor from the past was that incentive is a crucial
for ten HEWs and five health posts. A Checklist is factor in sustaining community based health
used in the supervisory visit and HEWs are pro- services provided by volunteers. Therefore, in
vided supportive supervision. The supervisors the national HEP, Ethiopia has tried to address
are health center-based and are accountable to this problem by introducing paid HEWs who are
the District Health Management Office (DHMO). no more volunteers but civil servants paid from
The DHMOs are in turn supported by Regional the treasury of state governments. The monthly
Health Bureaus (RHB), which are also visited salary has slight variation from region to region
every 3 months by the FMOH. ranging between Birr 530 (about USD 45) and
760 (about USD 63) with majority getting Birr
Performance Evaluation 670 (about USD 56). This is a fairly reasonable
stipend by Ethiopian standards. However,
Primarily due to its short life of just about five
according to a 2007 evaluation by The Center

for National Health Development in Ethiopia and community based organizations such as
(CNHDE) and The Earth Institute at Columbia schools, women and youth associations and
University, about half of the HEWs do not feel religious institutions. As part of this effort HEWs
that the level of payment is adequate and/or carry out community mobilization, community-
commensurate with the workload and training based organization mobilization and provide
duration that they undergo (Center for National services at 3-4 outreach sites.
Health Development in Ethiopia, 2008b).86
Referral System
Community Involvement The HEW screens patients who need treatment
Communities are involved in selecting the beyond first aid and refers them on to the
HEW who will work in their area. They are also health centre or the nearest available health
involved in supporting the work of the HEW in facility. She also helps to follow up patients in
communication of health information to the the community on long-term treatment such as
community using traditional and indigenous HIV/AIDS and TB patients and links them to the
community associations which in the Ethiopian health facility.
situation are called “idir”, “mahber” and “ekub”,
Box 8: Basic Equipment and Supplies Available at the Health Post for Use by the HEW
Service area Furniture and equipment
ANC and delivery Adult weighing scale, ANC kit, Blood pressure apparatus,
Foetoscope Delivery kit, Delivery table, Neonatal resuscitation
mask & bag
Child care Baby weighing scale, Measuring tap (1.5mt, Measuring board
Graduated measuring jar Spoons
Immunization Refrigerator , Vaccine carriers (ice bags) , Ice box
First aid care Gowns, Examination bed, Stretcher, Stethoscope, Thermometer
Others Spatula, Torch light
HEALTH POST ESSENTIAL MEDICINES
Service areas Essential medicines
Antimalarial Drugs Coartem(ACT), Chloroquine, Both ant malarial drugs
Diarrheal control ORS
Contraceptive methods Oral contraceptives, Depo-provera injection, At least one method
Both contraceptive methods
Micronutrient Supplementation Iron Tablet , Folic Acid, Vitamin A, Capsule 100,000 IU Vitamin A,
Capsule 200,000 IU
Others Analgesics -Aspirin/Paracetamol, Ergometrine-500mg, TTC eye
ointment Baby Lotion (Bottle
HEALTH POST SUPPLIES
General supplies
AD Syringes and needles, Mixing Syringes , Syringes and needles,
Gloves Gauze, BCG OPV, DPT, Measles, TT, Alcohol, Savlon, Iodine ,
GV, Disinfectants , Cord Ties , RDT for Malaria , Condoms

Professional Advancement and
career path for HEWs
HEWs are also entitled to upgrading programs as, bachelors, masters and PhD degrees subject
that would raise their level of education from to their fulfilling university entry requirements.
certificate to diploma level as registered nurses.
The method of upgrading is designed in a dis- Documentation and
tance course mode with a period of hands-on
training. Guidelines are being developed to
allow them to continue their professional career Basic records are kept by the HEW on cases seen
even into higher degrees of qualification such or referred and items dispensed or used.
Table 31: Summary of Selected Performance Indicators from Evaluation Reports

Program coverage Coverage is about 100%
Preventive and promotive Vaccination promotion coverage: BCG coverage is 57.1%, and measles
service delivery 39.5% Contraceptive usage: CPR is 24.8%
Support system for CHWs Recruitment: 80% that meets program selection criteria Training: 100%
and their performance received introductory training Knowledge: 38% of HEWs had compre-
hensive knowledge on ANC. Skills and knowledge gaps exist especially
related to pregnancy, delivery and care of the newborn, Supplies and
equipment: 22.6% of health posts had at least 60% of the minimum set
of medical equipment, only 7.5% had 80% of minimum medical equipment,
81% had vaccine carriers, 30.2% of health posts were equipped to carry
out static immunization services, 67% of posts had first aid kits. Salaries:
HEWs get regular payment from the district Supervision and LHS: 50%
reported supervisor meeting in last 30 days Support from health care
delivery system: % facilities that lacked important medicines and
supplies on the day of survey (other drug availability or stock out infor-
mation) 36% of health posts lacked Coartem, 41% lacked ORS; 45% of
health posts reported not having had stock out of Coartem for the 3
months preceding the survey
CHW services and the poor As HEP services involve all households in the community and are free of
charge the poor will have equal access to the services through the home
visits, one-on-one conversation with mothers and husbands, community
packages and health post based services in the community. But the poor
may not comply with the referral of the HEWs.
IIndicators of population served compared with national figures?
1.2 millions In Central Plateau and half of the Artibonite region.
CHW impact on health Any information on how CHWs impact on health areas served compared
to those not served? Improved knowledge and use in HEP areas compa-
red to non-HEP areas in improved sanitation (75.6% of 36.3%), proper
human waste disposal (57.6% of 34%), hand washing facilities present
(55.7% of 39.9%). There was less improvement in CPR (24.8% of 21.7%).
CHW costs – The program has reliable funding for salary of HEWs. But supplies,
current and future supervision and training seemed to face some challenges.

Table 32 - CHW Program Functionality Assessment Tool (CHW-PFA)-Ethiopia
Evidence
318
319
Evidence
performance support
and bonuses is considered a reward Examples of non-financial incen- good performance. Incentives
Non-financial= training, tives include occasional formal are balanced and in line with
recognition, certification, recognition, additional training, expectations placed on CHW.

Evidence

back to the commu-
320
Table 33- Community Health Worker Functionality Matrix – MCH Interventions
1 ANTENATAL CARE
A Iron folate supplements Comprehensive knowledge levels on ANC
Counsel x found to be low
Counsel x
Provide commodity or intervention/Assess and treat x
(includes counseling to use skilled birth attendant) o
D Tetanus toxoid
Counsel x
E Deworm
Counsel o
(Hand washing, clean blade +/or clean delivery kit) o

C Recognize, initially stabilize (when possible) and refer Skills levels were found in evaluation to be low
for maternal and newborn complications x in these areas that deal with pregnancy, deli-
a. newborn asphyxia x very, and care of the newborn.
b. sepsis, x
complications
Plans are underway to introduce Misoprostol
Misoprostol)
(Kangaroo Care) o

x
a. clean cord care;
x
x

C Provide Treatment for severe newborn infection (when They only provide first aid then refer
guidelines.)
4 EARLY CHILDHOOD
recording progress
C Provide community based management of acute mal- o They provide advice on nutritional
nutrition (CMAM) using Ready to Use Therapeutic Foods practices and nutritious foods.
antibiotics x
G Community-based prevention and treatment of diarrhea
Counsel on ORS o
Provide ORS x
Refer for ORS x
Counsel on Zinc o
Provide Zinc o
Refer for Zinc
Counsel x
Mapping/tracking for immunization coverage x
-DTP x

- +/- HIB o
- Hep B o
-Pneumovax o
-Rotavirus o
OF PREGNANCY
Provide contraceptives: x
- condoms x
- Lactation Amenorrheic Method (LAM) x
- depo x
- condoms o
A Insecticide-treated mosquito nets to pregnant
women and children
Counsel x
Counsel x
Counsel x
Counsel x
B Antibody testing to pregnant women and mothers x
Counsel o
Counsel o

Counsel x
Counsel x
Counsel x
Counsel x

Summary and Conclusions
Ethiopia is implementing a nation-wide health of a total of 34 on the MNCH matrix. There are
extension program which is dependent on the clear national policies and guidelines for su-
health extension workers for implementation. pervision, referral and linkage with the formal
The country has prioritized the development of health care delivery system, which carries out
the HEP as a strategy to increase access to es- regular supervision. The career pathway and
sential health services for her people. The HEW opportunities for personal growth of the HEW
is at the centre of this effort. This is being imple- are built into the program.
mented with a unified strategy, curriculum and
uniform training and supervision guidelines. The
HEW are considered an extension of the formal
7. Uganda Village
health system and receive a regular pay. There Health Teams
are also clear structures for their supervision George W. Pariyo, Elizeus Rutebemberwa, Saul
and linkage with the health department. They Kamukama (Dept of Health Policy, Planning and
have the opportunity to upgrade their skills and Management, Makerere University School of
advance in their careers. The program is well Public Health)
established and a first evaluation has shown
positive results in terms of increased access to
Socio-economic and
basic care services and improving coverage of political context
key interventions. The HEW works as part and as Uganda is located in East Africa land locked
an extension of the health care delivery system with Kenya to the east, Sudan in the north, the
and are considered civil servants. The program Democratic Republic of Congo to the west, and
is well accepted by all stakeholders and enjoys Rwanda and Tanzania to the south. It covers an
strong government leadership and funding area of 241,139 square kilometers of which 18%
through established budgetary mechanisms. An is covered by open water and swamps. Uganda
assessment of the context shows that the HEP/ gained independence from Britain in 1962 and
HEW program is reasonably well established has had military dictatorships for many years. The
with a score on the total program functionality current government took over after a protracted
matrix of 27 (Min 24, Max 36). However, there guerilla war from 1981 to 1986. According to the
is still much scope for improvement particu- UNDP report of 2007/2008, Uganda has a per
larly with regard to the scope of MNCH services capita of 1454 US $ and this gives the country
being offered. The program would score 17 out a rank of 154th out of 177 countries whose data
Box 9: The structure of the Uganda National Health system

Health unit Physical structure Location Population
Health Centre I None Village 1,000
Health Centre II Outpatient services only Parish 5,000
Health Centre III Outpatient services, maternity, Sub-county 20,000
General Ward and laboratory
Health Centre IV Outpatients, Wards, Theatre, County 100,000
Laboratory and blood transfusion
General Hospital Hospital, laboratory and X- ray District 100,000 – 1,000,000
Regional Referral Hospital Specialists services Region (3 – 5 districts) 1,000,000 – 2,000,000
National Referral Hospital Advanced Tertiary Care National Over 20,000,000
Source: Adapted from Government of Uganda, Health Sector Strategic Plan, 2000/01 – 2004/05

Uganda Village Health Teams
was used. The same report quotes the physician
and CHWs Program
to population ratio of 8:100,000. 89 The need to meet the Poverty Eradication
Action Plan (PEAP) targets and the Millennium
The total population of the country was esti- Development Goals (MDGs) necessitated the
mated at 29.6 million by 2008. With an annual harmonization and universalisation of efforts
population growth rate of 3.24%, the country towards community empowerment and mobi-
is expected to have about 39 million people lization for health (CEMH). Because of this, the
by 2015. The median age is 15.6 years accor- National Health Policy of 1999 and the Health
ding to the 2002 national census. The infant Sector Strategic Plan (HSSP) 1 (2000/2005) and
mortality rate stands at 76/1000 live births and HSSP II (2005/2010) included the CEMH as
a child mortality rate at 137/1000 according to one of the elements of the Uganda National
the 2006/07 Uganda Demographic and Health Minimum Health Care Package (UNMHCP). It
Survey of 2006/07. The maternal mortality ratio was, however, the Home Based Management
per 100,000 live births is 435, total fertility rate of Fevers (HBMF) program, rolled out after the
6.7, percentage of stunted children under five Abuja Declaration 2000 that demonstrated the
38% and life expectancy 50.4 years.90 practicality and massive benefits of a sustained
universal community empowerment and mo-
The Uganda health care system bilization intervention in Uganda. When this
was added to successes of more focal commu-
Uganda operates a decentralized health system nity efforts, such as Guinea worm Eradication
where the health sector structure follows the Program, CB-DOTS, Ivermectin distribution, it
administrative structure as indicated in the ta- became clear that an all embracing integrated
ble below. community empowerment and mobilization
strategy, the village health team (VHT) strategy
The national head quarters has the function of could indeed be practicable and synergistically
setting policies and guidelines for programim- more beneficial.93, 94 The VHT strategy rolled
plementation and service delivery, capacity out started in 2003.95, 96
building, monitoring, evaluation and support
supervision, resource mobilization and coordi- This program was selected for review as it is
nation while the planning and implementation the main officially recognized nationwide CHW
of the health sector is at the district level. The program that Uganda is developing/ imple-
community health workers (CHWs) function at menting. It is the only CHW program that is well
village level under the virtual health centre I.91 structured, and with clear curriculum and trai-
ning materials agreed on by all the partners. All
The private health care providers comprise other programmes are rather ad hoc in nature
about 80% of the outpatient health care pro- and not nation-wide. The government is consi-
vision. Approximately a quarter of the health dering the use of only VHT members in every
facilities are owned by the Private-Not-For-Profit community based health intervention.97, 98
which are mainly faith based and are located
in the hard to reach areas. The majority of out-
patient care is offered by private providers and
Recruitment Process
37% of the total health expenditure was out-of- The selection of CHWs follows a face to face
pocket household payments according to the sensitization session where the community
WHO statistical information system 2005.92 members are first educated about the program
and the need to have volunteers. The session fa-
326
cilitator who might be a technical person from quality attributes remain the same and there is
the District Health Team or the nearest Health an added value of better service delivery since
Centre (II or III) explains the kind of people they the drug distributors are serving a smaller area
would prefer on the program. and fewer people to whom they have a kinship
attachment 101, 102.
For the VHT, selection is done by a popular vote
after sensitization and consensus building of all This approach has proved to be more effective
stakeholders in the village and from all house- than the classic-community directed treatment
holds and below is the criteria: with ivermectin in terms of treatment coverage,
decision on treatment location and mobilization
Maturity (above 18 years of age)
for CDTI activities.
A resident of the village
Ability to read and write at least in a local To ensure sustainability and to avoid parallel
language programs, development partners rarely create
new structures of community health workers.
A good community mobilizer and Partners like NGOs build on the existing resour-
communicator ce persons given that their activities are short
A dependable and trust-worthy person lived.
Someone interested in health and Community health workers are usually taken as
development volunteers within the community they hail from.
Willingness to work for the community They are not salaried or transferred from one
(showing the spirit of voluntarism) place to another. They are not given a written
contract spelling out the terms of service and
Preference is given to people already serving as payment. They may, however, be rejected by the
CHWs especially if they have served well 95, 98 community when the community members do
not use their services and through their leaders
In the case of community medicine distributors cause to have another one appointed as a repla-
(previously called community drug distribu- cement for the one who falls out of favour with
tors), the Health Assistant from a Health Centre the community. If they do not fulfill their obliga-
III would organize a meeting of village mem- tions to the supervisors at the health facilities,
bers through the Local Council (LC) I Chairman. the latter can also have them replaced. They can
Together with a member of the District Health migrate to other places but they would cease to
Team, a sensitization about the program would function as CHWs unless they are again selected
be conducted and the community members to be CHWs by their new host communities.
briefed on the selection criteria for the commu-
nity medicine distributor (CMD) 99, 100.
The CHW Role
In the case of Ivermectic distribution, the The roles of Community Health Workers are
Kinship-enhanced community directed treat- explained well in the guidelines. For the VHT
ment with Ivermectin is being used in districts strategy which is an all inclusive approach, the
of Uganda where there is Onchocerchiasis. In selection process tries to mix different portfolios
this model, the community is divided around like the community medicine distributors, some
kinships and these kinships select the distribu- extension workers (for the hygiene and sani-
tors of ivermectin from amongst themselves. The tation), peer educators (for health education),

some traditional birth attendant and some to fill in the registers. Technical issues include
member of the water source committees etc. the diagnosis and treatment (handling and ad-
Out of the nine VHT members, efforts are made ministration of drugs).
to include different categories of community
health workers. There are guidelines explaining The District Health Team then takes it upon itself
the roles of community volunteers including to train the trainers. The trainers are usually invi-
those who may not fall under health. For exam- ted from Health Centres (levels III and II). Because
ple the Ministry of Water and Environment of understaffing at health centre IIs, trainers are
through the Directorate of Water Development usually drawn from the Health Centre III. The du-
has guidelines specifying the selection and the ration of the training depends on the resources
roles of water source committee members. available (including the capacity of the training
agency) and context.
The roles can range from community mobili-
zation and sensitization for activities like im- In the case of the VHT strategy where all the
munization, pregnancy monitoring to ensure other categories of community health workers
compliance with safe motherhood for traditio- are being integrated, the training manual is so
nal birth attendants, drug distribution, referring comprehensive that it tackles almost all com-
patients, filling the registers (Community Based munity health aspects and the initial training is
– HMIS), organizing health education events, supposed to last 10 working days. The others are
participating in outreaches etc. In the VHT, al- needs based sessions which are conducted du-
though the members are drawn from different ring the quarterly meetings at the health facility
portfolios, the training is done in such a way or as these members collect the supplies. The
that every member acquires skills to handle all contents of the VHT training manual, divided
these roles at the end of the training. into modules are as below:97
Initial Training of CHWs MODULE1: THE VILLAGE HEALTH TEAM (VHTS)

CONCEPT
The training of community health workers is Topic 1 The Village Health Teams (VHTs)
conducted in a cascading manner whereby the Topic 2 Key actors in the VHTs implementation
district leadership is first sensitized about the and sustainability
program or strategy to be used. This is done by
national level facilitators who might be from the MODULE 2: COMMUNICATION
Ministry of Health or any other development Topic 1 Communication
partner like the NGOs. Topic 2 Interpersonal Communication (IPC)
Topic 3 Counseling
Because of resource constraints, the Ministry of Topic 4 Adult–learning and facilitation skills
Health and the districts have been unable to roll Topic 5 Provision of basic health messages
out the VHT strategy and this has called for sup- (Health Education)
port from the Development Partners. There are
training guidelines for the VHT strategy which MODULE 3: COMMUNITY MOBILIZATION
were developed by the Ministry of Health and AND EMPOWERMENT
these guidelines have management and tech- Topic 1 Community mobilization and
nical issues that the VHT members have to be empowerment
trained on. Management issues include; plan- Topic 2 Community situation analysis
ning, coordination, data management like how Topic 3 Community participation and

involvement Topic 3 Home visits
Topic 4 Participatory planning
Topic 5 Resource mobilization and management
Topic 6 Community–based health information
On-going Training of CHWs
management system Continuous training of CHWs is largely through
needs based sessions which are conducted du-
MODULE 4: CHILD GROWTH AND ring the quarterly meetings at the health facility
DEVELOPMENT or as these members collect the supplies.
Topic 1 Home Based Management of Fevers
Topic 2 Immunization Training of Trainers
Topic 3 Control of diarrhea
Topic 4 Food and nutrition The trainers are mixed in such a way that both
Topic 5 Breast feeding the management and technical aspects in the
training manual are handled. Development par-
MODULE 5: CONTROL OF COMMUNICABLE tners rely on the district health personnel from
DISEASES the Health Centers II, III, or the District Health
Topic 1 Sexually transmitted diseases (STDs) Team for the technical personnel to handle the
Topic 2 HIV/AIDS technical aspects. Where there is need, different
Topic 3 Malaria trainers who may not necessarily be health
Topic 4 Tuberculosis (TB) workers come in to handle the management
aspects. Where Development Partners are invol-
MODULE 6: SEXUAL AND REPRODUCTIVE ved, these may be the project staff or consul-
HEALTH tants. The sensitization about the strategy is
Topic 1 Family planning (Child spacing) done at the district, Sub County and Parish level
Topic 2 Pre-conception and antenatal care and it is usually from these Health Centres (II and
Topic 3 Care given after delivery III) that trainers are identified. They then attend
Topic 4 Adolescent sexual and reproductive the training at the Sub County level to come
health back and train the selected VHT members.
Topic 5 Gender-based violence
MODULE 7: ENVIRONMENTAL HEALTH
Topic 1 Sanitation Community Health Workers are provided with
Topic 2 Water different equipments and supplies depending
Topic 3 Personal hygiene on the program and the availability of resour-
Topic 4 Domestic hygiene ces. In districts where development partners are
Topic 5 School hygiene actively participating, the facilitation can stretch
Topic 6 Food hygiene up to provision of bicycles, umbrellas, T-Shirts,
Gum-boots, sometimes allowances etc.
MODULE 8: COMMON NON-COMMUNICABLE
DISEASES These are, however, not affordable for commu-
Topic 1 Mental health nity health workers who are purely facilitated by
the government and this creates competition
MODULE 9: MONITORING for these community health workers.
Topic 1 Monitoring
Topic 2 Record keeping Under the Public Private Partnerships for health

policy, the Project Steering Committee is sup- conduct a spot check. The other way in which
posed to allow those development partners faults are found is when the registers have some
who are coming in to fill gaps in the use of shortcomings. In cases of failure, a replacement
VHTs. is sought. Cases of community health workers
“If you have a project that facilitates community charging fees for the services, delayed referrals,
health workers and leaves out others, those left out discrimination, extra have all been rectified
plus the community will refuse to own the project though this joint supervision.
and they will always say that those are AMREF
VHTs” (KI, AMREF). The support supervision is built within the com-
munity and the health system. The community
With the old system of each program having passes some form of bye-laws that can be based
its community health workers, there has been on how to handle beneficiaries who do not
attempts to adopt cost effective models like comply for like the case of latrine construction;
the home based care of TASO was initially very there is a fine which the culprit pays to the local
expensive until they adopted the drug distribu- council. The health worker provides support
tion points where patients go for drug refills and supervision on the weaknesses identified in the
the use of a community nurse to offer home reports, complaints from the community and
based care to the bed ridden clients. Some of questions or challenges presented by the com-
the drugs distributed at home include Coartem, munity health workers themselves. It is usually
Amoxycillin and Paracetamol. during the quarterly meetings, escorted referral,
on outreaches or when collecting supplies that
Supervision community health workers and the health wor-
kers interface.
The CHW supervisors main functions are to:
Provide support and guidance “The requirement for quarterly meetings helps to
rejuvenate the competences of these community
Monitor patients in case of adverse reactions to health workers. This could be based on the way
drugs data is recorded in registers or the experience sha-
Provide the necessary supplies ring in a meeting of community health workers”
(KI, UNACOH).
Monitor the performance of the program
Tracking the medicines and other supplies re- In the case of Ivermectin distributors, there are
leased to these VHTs supervisors at community level to supervise
the kinship distributors, 2 supervisors at parish
Supervision of community health workers is level (one community member and a Chairman
done in both a supportive and fault finding LC II or the Parish Chief ). In addition, the Health
way. In the sensitization meetings with the Assistant at the HC III supervises the activities of
village members, there is some form of yard all the above persons.
stick establishment which can be used to hold
these community health workers responsible Performance Evaluation
and accountable. The beneficiaries report their
complaints to the local council leadership or the The Ugandan VHT program is still new and no
nearest health facility. Also the nearest health evaluation has been done as yet. However, there
facility which is supposed to supervise the ac- have been isolated evaluations of various NGO
tivities of these community health workers can programs that involve CHWs. UNICEF conducted

an assessment of Home Based Management of referred by the CHW” (KI, MoH)
Fevers using the CORPs (Community Owned
Resource Persons).103, 104 Professional Advancement
Some community health workers accumulate
Incentives experience and are sometimes used to train
The Ugandan CHWs officially do not receive a others. There were no cases of retirement repor-
stipend and mechanisms to support them are ted except those who get opportunities outside
left at the discretion of the communities they the community and they are replaced. Attrition
serve as well as NGOs operating in their areas. is high among the youth because they are likely
Some projects provide CHWs with T-shirts, to get married or leave the village in search of
gum-boots, rain jackets, bicycles, transport allo- jobs. At the moment there is no formal certifica-
wances and lunch allowance. tion program for CHWs.
Community Involvement Documentation and

Community involvement happens through Information Management
the community selecting their CHWs and also The records do vary according to the program.
monitoring their performance in relation to ex- In the updated VHT strategy which will com-
pectations from the community. As mentioned mence in January 2010, these data tools have
before, the community can cause their CHW to been harmonized to be used by any community
be replaced if they are dissatisfied with his/her health worker.
performance. The community gets linked to the
activities of the health facility through the CHW We have even adopted new registers and we do
interacting with the local health facility staff who not want for example the Community Medicine
have the responsibility to supervise the CHWs. Distributors having different registers from other
VHT members we want them to have a harmo-
Referral System nized register. We now need a VHT register that is
standardized for all these community health wor-
The CHWs are not considered a part of the kers. (KI, UNICEF).
formal health system. In areas where they are
active, they are known to the health staff ope-
rating there, and they freely refer. CHWs are
Records are kept by CHWs
mainly involved in the prevention of diseases CHWs are expected to maintain basic health
through health promotion. They are involved records on curative activities e.g., how many
in curative services only when they have been cases of malaria or pneumonia seen in the
provided with basic medicines which they can month, how many doses of treatments given
administer to patients in the community. For out, any treatment complications, any referrals.
the bed ridden patients, a referral is made to the These records are reviewed by their supervisors
appropriate service provider. In the case of HIV/ when they come to visit. In addition, CHWs
AIDS for example, the referral system involves provide monthly returns to the health facility as
calling a health worker to come to the patient accountability for the drugs dispensed, on basis
and provide home based care. of which new drugs and supplies are provided.
The same records are used by health workers
“For the mothers, when you are taking the child to monitor patients. For the HIV/AIDS service
for treatment at a health centre, you feel confident delivery, adherence to ART and cases of drug
because you are not going to suffer with the health misuse are monitored through such records.
workers who do not know you once you have been

Table 34 - CHW Program Functionality Assessment Tool (CHW-PFA) – Uganda
Evidence

332
333
Evidence
performance support

Evidence

back to the commu-
334
Table 35- Community Health Worker Functionality Matrix
1 ANTENATAL CARE
Counsel o
Counsel x
C Counsel on birth preparedness/complication readiness
D Tetanus toxoid
Counsel x
E Deworm
Counsel o
A Prevent Infection/Clean Delivery

for maternal and newborn complications x
b. sepsis, o
complications
Misoprostol)
(Kangaroo Care) x

x
a. clean cord care;
x
x

e. maternal nutrition, etc.
guidelines.)
4 EARLY CHILDHOOD
recording progress
antibiotics o
Counsel on ORS o
Provide ORS
Refer for ORS o
Counsel on Zinc o
Provide Zinc o
Refer for Zinc
H Vitamin A supplements (twice annually children 6-59 months) o
Counsel o
-DTP o

- +/- HIB o
- Hep B o
-Pneumovax o
-Rotavirus o
Refer for immunizations o
OF PREGNANCY
A Counsel on HTSP/contraceptives o
- condoms o
- depo o
Refer for contraceptives: o
- condoms o
Provide FP counseling +/ - administer contra- o
pregnant women and children
Counsel x
Counsel o
Counsel o
Counsel o
B Antibody testing to pregnant women and mothers o
Counsel o
C Prophylactic ARVs/HAART to pregnant women mothers o
Counsel o

Counsel o
Counsel o
Counsel o
Counsel o

Summary and Conclusions
The Ugandan CHW program is being imple- a poor country with many problems but the
mented as part of the wider Village Health Team social indicators are improving. For instance,
(VHT) strategy. Although the idea was initiated under 5 mortality fell from 235 per 1,000 live
way back in 2003, implementation has been births in 1990/92 to 138 per 1,000 live births in
slow, mainly due to lack of resources. Hence, the 2008. Economic and social reforms have been
program is still in its infancy. The total program undertaken and the economy registered an
functionality score was 20 (Min 24, Max 36) and impressive 8% growth rate between 1996 and
the score on the MNCH matrix was only 8 out 2008, accompanied by falling poverty rates
of a total score of 34. There has been slower and a 76% increase in net enrolment in primary
than expected progress. However, most sta- school.105
keholders have now bought into the idea and
nationwide implementation is being rolled out. However, life expectancy at birth is estimated at
An assessment of the context shows that the re- 42 years and total adult literacy is estimated at
cruitment and initial training of the community 44%. Only 42% of the total population has access
health workers is highly functional. The clarity of to improved drinking water sources, while only
role, supervision, performance evaluation and 19% of the rural population was using improved
community involvement, documentation, in- sanitation facilities by 2006. By 2007, only 15%
formation and management are functional but of children under five with fever were estimated
gaps still remain. Ongoing training, supply of to be accessing anti malarial drugs. There is an
equipment and supplies, provision of incentives estimated HIV prevalence rate of 12.5% in the
and integration in a referral system are not ade- population age-group 15-49 years.106
quately done. Worse still, there is no professional
advancement offered. Health Systems Overview
8. Mozambique Agentes The health sector in Mozambique is led by the
Ministry of Health, “Ministério de Saúde” (MISAU).
Polivalentes Elementares Health facilities include hospitals, health centres
Program and health posts. The health services are orga-
nized at 3 levels; national, provincial and district
Socio-economic and level.
political context
Mozambique has 3 main Central hospitals in
With a population of about 20 million,
each region located in Maputo (which is also the
Mozambique has over the years registered an
final referral hospital for the whole country) for
impressive recovery from civil and political un-
the Southern region, Beira for the Central region
rest. It gained independence from Portugal in
and Nampula for the Northern region.
1975 and endured a civil war between FRELIMO
and RENAMO. A new constitution was appro-
The lowest level of care is provided by Health
ved in 1990 and civil war ended in 1992. Since
Posts (1 per about 28,000 people). Other health
then, the country has held regular multi-party
facilities include:
elections and experienced peaceful change of
leadership. Multiparty politics has been esta- Health Centres (1 per about 35,000 people)
blished and the country is stable. Rural Hospitals (1 per about 700,000 people)
At GNI per capita of $340, Mozambique is still Provincial or General Hospitals (1 for every
1,500,000 people).

greater emphasis on policy and strategy deve-
The main challenges that Mozambique faces lopment and lowering the transaction costs of
with regards to health are: foreign assistance.
Low access to health care. Between 30-50% of
A total of 26 partners participate in the Health
the population have access to basic preventive
SWAP structure to enhance strategic dialogue
and curative health services; i.e., those living
among partners and between the Ministry of
within 10kms of a health facility,
Health and partners on sector policies, priorities
High level of Communicable Diseases (e.g., and performance in the context of Absolute
about 13% of adults are living with HIV/AIDS; Poverty Reduction Plan of Action (PARPA) and
annually there are about 18,000 cases of Malaria delivery of the sector strategic plan (PESS). Up to
per 100,000), 30% of external funding is channelled through a
Lack of health staff and low health worker den- Common Fund Mechanism (Prosaude).107
sities (0.027 physicians per 1,000; 0.322 nurses/
midwives per 1,000; 0.029 environmental and Mozambique Agentes
public health workers per 1,000) Polivalentes Elementares
General lack of material and financial resources Program
(only $9 per capita in 2001, $12 pc in 2003).
Mozambican total health expenditure as per- Mozambique gained independence from
centage of GDP was estimated at 4.7% (2003). Portugal in 1975. Immediately after this,
Per capita total expenditure on health is about Mozambique adopted the primary health
$12 p.c. ($7 from government). Close to 40% care approach as strategy to provide health
of household expenditure on health is out of care to the population. In 1978 the Ministry of
pocket. The share of national budget allocated health started the Community Health Workers
to health is at about 11%, still shy of the 15% Program here known as Agentes Polivalentes
committed at Abuja. Elementares (APE). The objective of this program
was to rapidly expand health care to the rural
The major causes of death among children un- areas which had been underserved during the
der 5 years include; neonatal causes (29%), HIV/ colonial period. Between 1978 and 1988 a total
AIDS (13%), diarrheal diseases (17%), malaria of 1,500 APEs were trained under this program.
(19%), and pneumonia (21%). As a result of civil war between 1977 and 1992,
the training process and supervision were done
With the successful peace process and ensuing under a lot of constraints. In 1983 the program
stability with regular elections, a large number started to decline. In 1989 the Ministry of Health
of international development partners came officially declared that the program was being
to provide support to Mozambique, especially interrupted. From then up to date the Ministry
in the health sector. In 2007, foreign aid contri- of Health has not been able to implement it in
buted to 70% of the health sector’s budget and a structured manner. Despite the fact that the
this was expected to increase to 73% in 2008. Ministry did not train new APEs during this
period, it continued providing medicine for the
Mozambique adopted a “Sector Wide Approach” group. In several provinces NGOs had carried
(SWAp) to the health sector in 2000 with the aim out the training for new APEs. However, most
of improving the performance of the sector, of these workers have disappeared from the
strengthening government leadership, putting system, calling into question sustainability of

the program. is recruited),
Now, the Ministry of Health is undertaking a
plan to restore functionality of the APE program The candidate must have the ability to read
using a new model.108 The rest of this document and write Portuguese and have basic notions of
focuses on the proposed new approach. arithmetic
Should be between 18 to 35 years,
This program was selected for review as it is
past experience in community development,
the main officially recognized nationwide CHW
programthat Mozambique is developing/ im- willing to carry out the services from her home
plementing. It is the only CHW programthat is Able to relate well both with the community to
well structured, and with clear curriculum and be served and with the health care system.
training materials agreed on by all the partners.
All other programmes are rather ad hoc in na- The final selection of the APEs will be done
ture and not nation-wide. The APE programis after the candidates undertake a reading and
part of Mozambique’s strategy to contribute to writing test. The proposal is that all the APEs will
objectives of MDG 4 and 5.109, 110 have a contract with the local Government and
will receive a stipend in line with the country’s
Recruitment Process (new minimum wage (equivalent to about 50 USD).
proposed model) Guidelines and instruments to be used for su-
pervision are under development.
The new APEs will be selected from the same
community where they will work. Preference The contract will be signed on an annual basis.
will be given to female candidates. The selec- In case of lack of satisfactory performance of
tion process will be managed by the District their duties the contract will be terminated if at-
Health Directorate in conjunction with the tempts to correct the situation are unsuccessful.
community where the health professionals in The community will be involved in this process.
the area will play a facilitative role in the selec- 111, 112
tion process. As a measure to divert the APEs
from the current tendency to mainly focus on
providing curative services, the new approach The APE’s Role
recommends that most of the training should The prime role of the APE is to carry out health
happen outside the health institutions. Also, it promotion and preventive activities for the
is recommended in this model that the training Population within the catchment area. Each APE
process must be carried out in the community is expected to serve a population of 500 up to
where the APE will develop his/her activities. 2,000 inhabitants. The APEs establish the linkage
The candidate interested in becoming an APE between the national health care delivery sys-
must demonstrate his/her willingness to work tem and the community, and will be responsible
in his/her community. The information will be for mobilizing the community to participate in
disseminated through the health facilities and health services and health activities.113
community radios. Selection of CHW is based
on the following criterion: The APE’s routine activities are to:111-113
Preference for females (at least 60% should be Describe and Map the health area under his/her
women), responsibility
permanent resident of the area (for which she Register all family members in the catchment

areas during their visits to households, and suspected cases of AIDS, Tuberculosis and other
maintain up to date information (this is to be conditions.
started within the towns) Disseminate health education messages on
To develop community awareness on the individuals and community hygiene and sanita-
importance of the individual and community tion as well as information regarding preventive
hygiene measures against spread of AIDS
To disseminate messages on the importance of Submit monthly progress reports to in charge
protecting water sources health center containing information regarding
all activities carried out by him/her
Visit with regularity the households under his/
her responsibility To use rationally the medicine contained in the
kit under his/her control.
Keep in close liaison with influential women
of her area including lady teachers, traditional
birth attendants Initial Training of APEs
Motivate and counsel clients for adoption and The training of APEs will be conducted in 4
continuation of family planning methods blocks for a total of 18 working weeks using pro-
To promote the deliveries within the health gram training manuals and curriculum, which
facilities is then followed by continual training at the
health facility along with refreshers. After each
Participate in outreach activities from health block of lectures the trainees will be involved
facilities, promoting growth monitoring, asses- in practical activities in the field. After the first
sing common risk factors causing malnutrition block, the task consists of learning how to design
and nutritional counseling the catchment area and how to identify, along
Promote nutritional education with emphasis with the community leaders, the main health
on breast-feeding and weaning practices, ma- problems in a given health catchment area.
ternal nutrition and macronutrient malnutrition After the second block, the task is to identify in
the catchment area other community health
Coordinate with EPI for immunization of mo- workers and develop with them 3 sessions of
thers against tetanus and children against health education. The third practical activities
vaccine preventable diseases and participate in consist of identifying health workers working
various campaigns for immunization against EPI in preventive activities and developing 3 ses-
target diseases sions of health education. After the last block,
Get involved in surveillance activities the trainee has the opportunity to work within
the Health Facility to learn how to deal with the
Carry out prevention and treatment of com-
short list of diseases for which he/she has been
mon ailments e.g. malaria, diarrhea diseases,
trained. 111, 112
acute respiratory infections, intestinal parasites,
scabies, snake bites, injuries and other minor
Initial training (Block 1: 80 hours training)
diseases using essential drugs and refer cases to
The first block of basic training will take a total
nearest centers as per given guidelines
of 80 hours. In this period, the newly recruited
Get involved in DOTS and malaria control APEs are trained to understand:
programs
The role and the APE’s responsibility within the
Identify and refer to the health facilities the Community

The relation between the community, APE and How to register the activities developed in the
the health System community and to fill the existing forms and to
prepare the activity reports
The role of the leaders within the community
on the health issues The importance of washing hands and personal
hygiene for disease prevention
How the health system is organized including
the different levels of care The importance of health sanitation in disease
prevention
How the primary health care team is composed
including the exact role of the community The importance of water conservation to pre-
health worker within this group vent common diseases
The basic principles of communication for The basic mechanism of transmission of: ma-
change laria, diarrheal diseases, STIs, Tuberculosis and
other respiratory infections.
The basic principles of professional ethics
The basic principles for prevention of malaria
The concepts of health and disease transmission and other infectious diseases
The notion of health determinants within a gi-
Block 3: (120 hours training)
ven community
The second block follows the field practical acti-
How to do a community health status assess- vities. In this block, it is expected that at the end
ment based on a guideline the trainee will be able to:
Manage non complicated malaria cases with
Block 2: Health promotion activities (120 hours of
first line drugs
training)
The objectives of this block are to provide the Manage non complicated cases of diarrhea
trainee with the understanding on: using oral re-hydration salts
Why the mothers have to follow antenatal and Identify cholera cases in the community and
postnatal care in health facilities refer them to health facilities
The potential risk of lack of antenatal care and Manage non-complicated cases of Acute
home delivery Respiratory Infections in children under five
years old
The main methods for HIV prevention
Provide first aid observing bio-safety best
The importance of vaccination of children and
practices
women
Identify suspected Tuberculosis cases, Leprosy
The importance of exclusive breastfeeding
cases, AIDS and other transmitted infection ca-
How to best use the locally available nutrients ses and refer them to the health facilities.
The importance of family planning for child Correctly use the protocols for patient referral
survival and transference
The importance of monitoring child growth and Block 4 (40 hours)
development This block is dedicated for practical activities in
How to use the material provided for commu- the community, to revise what has been cove-
nity health education red and to do evaluation of the training.

On-going Training of CHWs Salter Scale with Trouser
From time to time the health authorities will
organize a refreshment training based on the Supervision
training needs identified during the supervision
There is as yet no pool of supervisors trained.
process.
These supervisors are expected to be drawn
from existing health facilities. These facilities are
in turn routinely supervised by the health teams
There is a national pool of about 20 CHW trai-
from the district and provincial levels. The health
ners who are expected to train other trainers at
workers at the health units will be responsible
provincial and district levels. Training guidelines
to supervise the APEs close to their facilities.
are being developed. A training of trainers will
be carried out and these trainers will in turn be
The supervisors are public servants on a month-
responsible to train and supervise local health
ly salary. However, during the supervision visits
facility staff that will be in day to day contact
they receive a per diem allowance. The health
with the APEs.
facilities are responsible to provide the means
of transportation. Usually they use the vehicle
available at the health unit.
The CHWs are basically provided with essential
medicines and supplies (in Kit C) including the
following: Performance Evaluation
Paracetamol Tabs 500mg An evaluation of previous CHW activities is re-
ported to have been conducted by the Swiss
Coartem co-operation. The evaluation noted that the trai-
Mebendazole Tabs 100mg ning was unstructured, ad hoc, involved mainly
NGOs, was often localized in small areas and va-
Oral rehydration solution
ried in duration and quality. 111, 112 Specific data
Cotrimoxazole Syp. on program coverage, service delivery, support
Ferrous Fumerate 150mg + Folic Acid 0.5mg systems, impact on health and costs were not
available.
Cotton Bandages 4” x 3m
Benzyl Benzoate Lotion In 2007, a national meeting on community
involvement was convened and made the fol-
Paracetamol Syp 120mg/ml lowing observations: 111, 112
Antiseptic Lotion Community involvement is still not well un-
List of Non-Drug Items: derstood by health sector staff at all levels, who
are not ready to develop community outreach
Cotton Wool (250 Gram)
activities;
Sticking Plaster 1” x 5m
Most of the community outreach initiatives in
Pencil Torch with Two Cells the provinces are carried out by NGOs;
Thermometer Clinical There is no clear guidance regarding implemen-
Scissors tation of community outreach activities;
CHW Kit Bags containing weighing scale etc. The charges for consultations and sale of drugs
by community health workers are not any diffe-

rent from those of private practice Very often within the community there are
other kinds of health activists and volunteers.
The training for community health workers and
The APE has the role to coordinate and in some
paramedics does not follow uniform criteria des-
cases supervise these groups. These agents and
pite being carried out by the Provincial Health
activists are being supported by among others
Directorate in partnership with NGOs; and
NGOs, the Red Cross, women groups and others.
There are inequalities in the payment of incenti- It is proposed that all these will come under the
ves to community health workers. overall supervision and co-ordination of the APE
who will also act to link them up to the national
This national meeting also noted that data that health care system.
are sent are often unreliable and that HIV/AIDS
“counselors” are starting to exert pressure to be-
come integrated into the NHS. 111, 112
Referral System
The APEs are recognized by the health facilities.
Incentives The APE can refer all patients with complicated
conditions to the nearest health facility. In some
During training the APE will receive a small areas the APE has a station where he/she does
amount of money for basic needs. This amount see patients. In that place usually he/she works
is not yet established. As soon as they start to together with the TBA to assist the deliveries
work, they will have a contract with the local happening at the community level.
government and they will receive the equi-
valent of the minimum wage in the country Professional Advancement
(about USD 50). All medicines will be free under
the new model. The APE is still not considered as part of the for-
mal human resources for health. He/she doesn’t
Community Involvement fit within the human resources for health career
pathways. Because of this, even within the new
One of the roles of the APE is to establish the model, APEs are not considered part of the pu-
linkage between the health system and the blic system and even though they have access to
community. In this role, the APE is in charge of a retirement plan. In other to favor their growth
mobilizing the community to be involved in within the system, all APEs are encouraged to
several activities oriented to promoting better continue with studies to upgrade their level.
health. The community usually participates in When the APE achieves the recommended
sanitation activities e.g., to build community level to start formal training as a health worker
water and sanitation facilities. 111, 112 he/she will have priority for selection. This is the
only way for an APE to become part of the for-
When the health team organizes outreach ac- mal system and enter a career pathway.
tivities, it is a primary responsibility of the APE
to mobilize the community to participate. The It is planned that those who are trained accor-
outreach package in Mozambique includes: ding to the new CHW profile and curriculum
Antenatal care, postnatal care, family planning, will be recognized by the Ministry of Health and
immunization, growth monitoring, follow-up of all partners.
chronic diseases treatment (Tuberculosis and
Leprosy).

Documentation and
Basic records that will be kept by the APE will
include numbers and types of patients seen,
medicines given out, and health activities car-
ried out. It is on the basis of submission of these
reports that the APE will receive a new Kit C.

347
Table 36 - CHW Program Functionality Assessment Tool (CHW-PFA) – Mozambique
Evidence

Evidence
performance support

348
349
Evidence
back to the commu-

Table 37 - Community Health Worker Functionality Matrix
1 ANTENATAL CARE
Counsel o
Counsel x
D Tetanus toxoid
Counsel x
E Deworm
Counsel x
A Prevent Infection/Clean Delivery o Kit provided only for TBAs
(Hand washing, clean blade +/or clean delivery kit) o
B Provide Essential Newborn Care They do not provide but promote these
practices especially as part of the Integrated
b. Clean cord care x Maternal and Newborn and Child Health.
b. sepsis, x
complications x
Misoprostol)
(Kangaroo Care) x

x
a. clean cord care;
x
x

C Provide Treatment for severe newborn infection (when o They refer when infection recognised
guidelines.)
4 EARLY CHILDHOOD
B Promote growth monitoring, weighing infants and x They recognize and refer
recording progress
C Provide community based management of acute mal- o They recognize and refer to health
nutrition (CMAM) using Ready to Use Therapeutic Foods facility
D Community-based treatment of pneumonia o Started in some provinces to provide
Counsel re recognition of danger signs, seeking care/ o treatment using cotrimoxazole
antibiotics o
Refer after treating with initial antibiotics There are plans to introduce zinc
G Community-based prevention and treatment of diarrhea o supplementation
Counsel on ORS x
Provide ORS o
Refer for ORS o
Counsel on Zinc o
Provide Zinc
Refer for Zinc
Counsel o
APEs participate to help the health
worker in carrying out these activities
but not by themselves
-DTP o

- +/- HIB o
- Hep B o
-Pneumovax o
-Rotavirus o
Refer for immunizations o
OF PREGNANCY
Provide contraceptives: o Oral contraceptives being provided
- condoms x in some areas
- depo o
- condoms o
pregnant women and children Government provides ITNs within
Counsel x health facilities Treatment for malaria
Provide commodity or intervention/ Assess and treat x provided as part of home manage-
ment of malaria
Counsel x
C Community-based treatment of malaria (testing with Rapid Diagnostic Tests (RDTs) are
Rapid Diagnostic Test or presumptive treatment per being introduced in some areas.
Counsel x
Counsel x
B Antibody testing to pregnant women and mothers x Discussion are going on to introduce
o community level testing for HIV
Counsel
Counsel o

E Prophylactic ARVs/HAART to infants x
Counsel o
F Early infant diagnosis x
Counsel o
G Pregnant HIV-infected women tracking x
Counsel o
H HIV-exposed infant tracking x
Counsel o

Summary / Conclusions
Mozambique has chosen to develop and im-
plement a preferred unified program of com-
munity health workers, Agentes Polivalentes
Elementares (APE), as a means to increase access
to basic health services to its people. Although
CHW training is said to have started way back in
1978, the APE program is still considered to be
under development and national plans, strate-
gies, curricula and guidelines have only recently
been put in place. Implementation is still in its
early stages. This is further seen in the fact that
the APE only scores 19 (Min 24, Max 36) on the
CHW program functionality score. It is also clear
that they are only offering a narrow scope of
MNCH activities. The APE score on the MNCH
functionality matrix was only 10 out of possible
total of 34.
The APEs are expected to come from the com-

munities which they will serve and communi-
ties are to be fully involved in their selection
and monitoring their activities. An assessment
of the context shows that while plans for their
training as well as content seems to be clear
and guidelines developed and in place, the
link they will have with the formal health care
delivery structures, their supervision, and career
development are not yet well articulated. The
APE are expected to work as part and as an
extension of the health care delivery system
and will receive a monthly remuneration close
to the minimum wage, effectively making them
civil servants. The program design was informed
by wide scale reviews and consultation with the
majority of the health stakeholders and thus has
wide buy in. How effective the APE program will
be in reaching the people with the impressive
essential package of services that is being plan-
ned remains to be seen.

Table 38: Scoring Chart for Functional CHWs.
Country CHW Program Region/ Total Program Total Program Number of CHW’s in Program
Department Functionality Functionality
Score (Min: 24/ Score (Min: 24/ Baseline New/newly
Max: 36) Max: 36) functional CHWs
Pakistan Lady Health Workers National Level 28 13 < 20,000 in 1994-95 > 92,957 in
Program – Pakistan 2005-06
Bangladesh Bangladesh Rural NGO organization 25 18 1,080 in 1990 78,000 in 2008

Advancement Committee given coverage to the
whole Bangladesh
Thailand Village Health Volunteer National Level 20 10 500,000 in 1970 1,200,000 in 1996
Program Thailand

Brazil Programa Saúde da Família National Level 34 4 5,000 in 1994 1240,000 in 2009
(Agentes Comunitários da Saúde)
Haiti Zanmi Lazante’s CHW Program Mountainous Central 31 12 < 30 in the village > 1,600 in 2009
Plateau of Haiti and half of Cange in 1985
of the Artibonite region
(Lower Artibonite)
Ethiopia Health Extension Program Country-wide 29 17 - 30,190

implementation
Uganda Uganda Village Health Proposed country-wide 20 8 - have trained up to

Team CHW Program implementation 7,000 as of 2009
Mozambique Agentes Polivalentes Proposed country-wide 19 10 - <1,000 trained

Elementares CHW Program implementation as of 2009
356
Summary of Country
Case Studies
We summarized a typology of CHW programs effectively strengthened. They have shown a
based on the country case studies performed, positive impact on utilization of health services
taking into consideration the context and and on infant mortality in the influence area of
the diversity of training program (including the running NGOs.
duration and content of training, supervision
activities, and tasks assigned to CHWs), while Long duration training programs with preventive
acknowledging the existing limitations in the and basic curative tasks for CHWs, with a relatively
available information and in the methods used weak supervision system, and within a weak health
(Functionality assessment tool, desk review and system: Ethiopia Health Extension Program
interviews with key informants during country (HEP) and Mozambique Agentes Polivalentes
visits). Elementares (APE) Program. In Ethiopia, initial
training lasts one year and includes diverse
Typology of CHW programs aspects such as community documentation,
family health care, disease prevention and
based on training, supervision, control, environmental health promotion, sup-
task assignment characteristics, portive courses and common courses (English,
and on strength and profile of mathematics, IT and entrepreneurship). Practical
health system lessons are based on models training, group
assignment, demonstration and role play, and
Short to intermediate duration training programs, there are also apprenticeship activities related
with preventive and basic curative tasks for CHWs, to health facility attachment and community
with relatively strong supervision activities, and attachment. As for on-going training, the CHWs
within a weak health system: Haiti. Initial training are expected to attend integrated refresher trai-
lasts 3 months for health agents, 2 weeks for ning courses to improve their skill and sustain
accompagnateurs, and 1 month for traditional their motivation and contribution, and the dis-
birth attendants, and on-going training is per- trict health office identifies gaps in knowledge
formed during one year on a monthly basis. and skills of CHWs through regular supervision
Content of training privileges promotional and visits. Supervision activities are receiving further
preventive activities, with inclusion of theoreti- attention, although they need still substantial
cal and practical lessons, and through the use improvement. In Mozambique, initial training
of a problem-based learning methodology. lasts 18 weeks, and on-going refreshment trai-
Specific training content varies depending on ning activities are organized from time to time
the type of CHW. The supervisory system is by health authorities, based on the training
well organized and involves all levels of hierar- needs identified during the supervision process.
chy of each institution, starting from the head Content of training is basically the same to that
of the Commune to public health nurses, HIV in Ethiopia, with emphasis on promotive, pre-
program nurses/ social workers to senior health ventive and basic curative messages to be lear-
agents/accompagnateurs to the rest of each ned through theoretical and practical lessons.
group. These CHW programs are implemented Supervision is not well structured and planned.
by NGOs in the context of a weak health sys- These programs are implemented in Ethiopia
tem, and they have a weak link with the health and Mozambique within weak health systems,
system, being restricted therefore to the NGO and their link with the health system is incipient.
geographical influence area. Scaling-up of this For Ethiopia, there is an external evaluation
kind of programs is unlikely to happen across which is suggesting an association between
the country, unless the public health system is the program implementation and increased uti-

lization and coverage. Whereas, in Mozambique Lady Health Workers (LHW) Program. This is
there is no evidence that they have an impact implemented by the central government wi-
on coverage and utilization of health services, thin a mixed public and private health system.
let alone on health outcomes. Initial training lasts 15 months. As for on-going
training, all LHWs attend their respective health
Short duration training programs with preventive facility/ training center for one day each month
and basic curative tasks for CHWs, with a relatively to get refresher training on an identified topic.
strong supervision system, and within a weak Training courses are divided into integrated
health system: Uganda Village Health Teams. training and task based training. Primary health
This program is relatively new and is being im- care topics receive emphasis during the first
plemented by the public sector with important period and field work is privileged during the
support from donors. CHWs are not considered second period. Major promotive, preventive
part of the health system and therefore there is and basic care topics are included during the
no formal link with it. Initial training lasts 10 days. whole training program. There is a well structu-
Continuous training of CHWs is largely through red supervision system. The program link to the
needs based sessions which are conducted wider health system is quite strong, as revealed
during the quarterly meetings at the health fa- by a formal referral system and a continued
cility or as these members collect the supplies. political and budgetary support by the public
Content of training courses include aspects sector. This LHW program is being implemented
of community mobilization and sensitization within a relatively weak health system. There is
for activities like immunization, pregnancy quite convincing evidence that this type of
monitoring to ensure compliance with safe CHW program has an impact on health outco-
motherhood for traditional birth attendants, mes, although several health system limitations
drug distribution, referring patients, filling the should be addressed to guarantee an effective
registers, organizing health education events, scaling up.
and participating in outreach activities, as well
as diagnosis and management of prevalent Short duration training programs, with mostly
maternal, neonatal and childhood problems. promotional, preventive and basic curative tasks
Supervision activities are well structured and are for CHWs and with a relatively strong supervision
aimed to happen as both supportive and fault system, within a relatively strong health system:
finding ways. No evaluation studies have been BRAC in Bangladesh, run by the private sector.
performed yet. Although the Uganda Village Context: This program has been implemented
Health teams program receives continued within a context of relatively strong health
support from the government, there are several systems. There is evidence showing that im-
drawbacks needing improvement, which inclu- plementation of BRAC is related to increased
de deficient on-going training, irregular supply coverage and utilization of health services in
of provision equipment and supplies, and ina- Bangladesh. It has been replicated in other
dequate provision of incentives and integration countries such as Afghanistan. A high drop-out
in a referral system, as well as lack of clear plans rate is the main limitation of the BRAC program.
for professional advancement. However, the referral system needs to be further
strengthened and the formal evaluation of the
Long duration training programs, with promotio- CHWs should also be done on a regular basis to
nal, preventive and basic curative tasks for CHWs, further improve their performance.
with a relatively strong supervision system, and
within a relatively weak health system: Pakistan’s

Short duration training programs, with mostly larly performed by health professionals. They
promotional, preventive and basic curative tasks are expected instead to timely and adequately
for CHWs and with a relatively weak supervision identify families and individuals at risk and refer
system, within a relatively strong health system: them to the family health team. Supervision ac-
The Village Health Volunteers Program (VHV) tivities are regularly performed. Periodically, the
in Thailand, run by the public health sector. instructor/supervisor (a nurse) brings together
Context: this program has been implemented the CHWs, to evaluate their work and to reorient
within a context of relatively strong health their activities. Alternatively, a nurse-supervisor
systems. CHWs activities are strongly linked to visits each agent under her charge at least once
the wider health system, although supervision a month to review problem cases and collect
activities in Thailand are rather limited. There is services data. In addition, one of the nine staff
convincing evidence about the impact of the members of the agent program at the central
VHV worker program on health indicators such office meets with each municipal supervisor
as malaria control, management of TB and HIV/ every 2 to 4 months. The FHP is being imple-
AIDs and other infectious diseases like avian mented within a relatively strong and unified
H5N1. In addition, the decentralization of health health system. CHWs activities are strongly
care system in Thailand has proved the inherent linked to the wider health system. Specifically,
sustainability of the CHW program which conti- CHWs are a key part of Family Health Teams, and
nues to show improvement in the health sce- all their activities are integrated to such family
nario of the country by consistently decreasing teams. There is compelling evidence about
the burden of diseases prevalent in the country. the positive impact of the FHP on health cove-
However, the referral system needs to be further rage, utilization and various health outcomes.
strengthened and the formal evaluation of the Challenges to be overcome include develo-
CHWs should also be done on a regular basis to pment of effective recruitment and retention
further improve their performance. strategies, balance between CHWs personal
expectations and managerial objectives aiming
Long duration training programs, with mostly pro- at reducing leakage of human health resources,
motional and preventive tasks, and very restricted need to change training from a narrow “medica-
and basic curative tasks for CHWs, with a strong lized” vertical approach to further emphasis on
supportive supervision, and within a relatively social determinants of health, and a continued
strong health system, such as the Family Health resistance of professional corporations to the
Program (FHP) in Brazil. Initial training lasts 3 FHP innovative approach.
months, and on-going education is provided
during local monthly and quarterly meetings. Synthesis of country
This training is oriented toward local concerns
of the agents or clinical family health team.
case studies
Standardized training is provided whenever Evidence shows that human force drives
new practices are instituted, such as care for health system performances. Throughout his-
acute respiratory infections or procedures for tory, periods of acceleration in health have been
reporting causes of deaths. The content of sparked by popular mobilization of workers in
training privileges understanding of social and society. Higher worker density and better work
environmental determinants of health, as well quality improve population based health and
as promotive and preventive aspects. Curative population survival. In this section we took an
topics are restricted to vary basic aspects, as in-detail ride of eight different CHW programs
CHWs are not expected to replace tasks regu- across the world.

A lot of similarities were found across these ought to be extensive, thorough and complete
programs with very few differences which were which should always be appraised by the exam
rather existed to meet the country specific or viva, so that it assures their competency in
targets and goals. According to the paramount working in the community. The period of initial
functionality of CHWs program, CHW must be training varied in these programs, and ranged
from the community and it even becomes the from 10 days in Uganda to 18 months in Pakistan,
best if CHWs are chosen by the community. All while none of the program has outlined any re-
these programs that we reviewed followed the fresher courses. CHWs are usually given updates
best practice criteria and recruited CHWs from in monthly supervisory meetings. The basic role
the community. In Brazil, Haiti, Ethiopia, Uganda of CHWs in primary health care services is same
and Mozambique, community is involved in throughout these programs but it varied a lot
their final selection; whereas in Pakistan and in more specified and focused delivery of inter-
Thailand, they are chosen by community leaders; ventions related to MNCH, Malaria, TB and AIDS
and in BRAC Bangladesh, they are nominated control and other non communicable diseases.
by village health organization. Apart from these Overall, the role of CHWs in services delivery for
characteristics, CHWs in all these programs are MNCH, nutrition, malaria, tuberculosis is pro-
also scrutinized on their age limits, sex, marital found and showed improved maternal and
status, occupational status etc. taking into child health and reproductive health indicators
considerations their culture and social values. in their catchment areas, but interventions
initiatives for the control and treatment of HIV/
The literature also shows that merely being AIDS are in infancy in many of these programs
a person from community is not enough to particularly in Asia. Programs from Latin America
ensure that they can create an impact on the and Africa have given special attention to the
health and social wellbeing of community, prevention, control and treatment of HIV/AIDS,
education has its own imperative effects. The and several pieces of evidence showed consis-
educated person gives responsible direction to tent results of benefits under supervised inter-
the community and at the same time has his/ ventions. All in all, their roles in relation to MDGs
her own social standing and respect in commu- were promotive, preventive, therapeutic and in
nity, which makes his/her role easy in imparting few cases rehabilitative.
knowledge and bringing up healthy modifica-
tions in attitudes and practices. In Thailand, Haiti, For a competent program, investment in pro-
Uganda and Mozambique, CHWs are selected if vision of proper supervision, equipment and
they are able to read and write, while the educa- supplies, and linkages with health system in
tional criteria was updated from read and write also required to compliment their training.
to 8 years of schooling in Brazil after 2004. CHWs Supervision has proven to be effective in im-
in Pakistan and Ethiopia are only given a privi- proving the impact of CHWs driven interven-
lege to become a worker if they have 8 years or tions. Pakistan, Bangladesh and Ethiopia have
above school education. trained and deployed assigned supervisors
for CHWs who also work and support them in
Training is the most crucial element in the im- community, but there are programs in Haiti and
plementation of the program. This is the phase Mozambique which are utilizing the services
where the much touted transfer of knowledge of health care staff like doctors and nurses for
from professionals to community representati- supervising CHWs. They are all fully equipped
ves takes place. Though universal guidelines for with necessary equipment and essential sup-
the extent of training are not laid down but it plies but major shortages in the stock has been

recorded and reported in almost all of these program must score at least level 2 in each of
programs because of intermittent deficiency in the 12 components in order to be considered
the overall funding and lack of proper logistic minimally functional, as we can observe coun-
management in the program. The services from tries had scored less than 2 in different compo-
CHWS with proper skills and handful supplies nents showing their limitation in those areas.
can be further enhanced if they work hand to In the bullets below we have identified some
hand with formal health system. The role of common limitations across these countries.
CHWs in the community would be incomplete
if they work in isolation, without creating a link Most of the programs have shortages or lack
with health care system. Key functional areas for of medical equipment for patient examination,
CHW activity include creation of effective linka- and drugs/ supplies useful for promotive, pre-
ges between communities and the health care ventive and curative health services. Irregularity
system, where they can refer cases. Across all in the supply of vaccines, drugs, and necessary
these countries that we reviewed had created a equipment has been reported and their availa-
link with health system. bility and sustainability of resources is a major
concern.
The main programmatic advantage to cash
incentives is lower attrition rate among CHWs. Lack of opportunities for upgrading and training
One of the most critical problems for CHW pro- and refresher courses on relevant areas such as
grams is the high rate of attrition which leads to delivery services, counseling for HIV/AIDS etc. In
a lack of continuity in the relationship between some countries assessments showed that the
a CHW and community, and increased costs in CHWs had lower competence in interventions
selecting and training CHWs. Indeed, the very related to some curative services including ma-
effectiveness of CHW work usually depends laria control and acute respiratory infection.
on retention. CHWs in Pakistan, Brazil, Haiti,
Ethiopia, and Mozambique are paid workers Lack of promotion, and professional
but drop-outs among them are still their main advancement
concern. On the other hand, BRAC has allowed
their CHWs to earn meager amount from the The curriculum and the modules for CHWs trai-
sales of drugs and are given performance based ning needs to be revised according to country
incentives for referring patients for complica- specific MDGS goals and targets. Also the
tions during pregnancy and bringing women to curriculum had more time for theory beyond
health care center for delivery. Apart from mo- the needed skill they would implement in the
netary rewards, in countries where these CHWs future, but with less time for acquiring practical
are volunteers, they are given non-monetary skills due to little time for hands-on practice.
rewards in terms of career advancement, and
recognition and rewards for their services. Countries had also reported deficiencies in the
practical training of CHWs particularly on skilled
Countries under review from South Asia, Sub delivery and key clinical skills due to limited fa-
Saharan Africa, and Latin America have surely cilities for large numbers of trainees.
reached impressive health and social gains from
their CHWs programs. However, these achie- Within countries time use of CHWs and working
vements are not exempt of challenges and schedule are not harmonized and varied from
difficulties. As discussed earlier, according to one place to the other place.
program functionality assessment criteria, CHW

There are no clear guidelines for working rela- Creating practical linkages with the health cen-
tionship between CHWs and the other com- ters and hospital services and ensuring effective
munity based heath workers (if any) trained and regular support from the higher levels of
previously, such as the community mobilizers the system is also a challenge.
and TBAs.
The necessary working and living conditions
In some countries, CHWs are expelled on migra- for CHWs are not created in most of the cases
ting from deployed area. In order to overcome which is compounded by poor communication
such issues, guidelines needs to be set on the and transportation system and long distances
outset regarding their transfers, leave of ab- from health centers.
sence, and career structure.
The resources needed to support the training,
Documentation and reporting are not instituted supplies and equipment, to pay the salary and
properly. to conduct regular supportive supervision re-
quires sufficient funds. By the time the targets
Referral system and linkage with the health are achieved they will make nearly half of the
system is weak. The CHWs do not have good workforce and the financial implications of
relationship with health workers working in achieving these would be huge.
higher level health institutions. Moreover, com-
munities’ attitude towards the CHWs is not to
the desired level due to their failure to assist in
some curative and some preventive health ser-
vices. The continued demand for curative care
services with weakened referral system may
compromise community’s confidence in CHWs.
The other challenge is the limited capacity of
health systems to support the CHW program.
Table 39: Summary of CHW Program Functionality Assessment Across Selected Countries
CHW-PFA Pakistan Bangladesh Thailand Brazil Haiti Ethiopia Uganda Mozambique
Recruitment 3 3 3 3 3 3 3 3
CHW Role 3 2 3 2 3 3 2 2
Initial Training 3 2 3 3 3 3 3 3
Ongoing Training 2 3 2 3 2 2 1 1
Equipment and Supplies 2 3 2 3 2 2 1 2
Supervision 3 3 0 3 3 3 2 2
Performance Evaluation 3 2 0 3 2 2 2 1
Incentives 2 2 2 3 3 2 1 0
Community Involvement 2 3 3 3 2 2 2 2
Referral System 1 1 1 3 3 2 1 1
Professional Advancement 2 0 1 2 2 2 0 2
Documentation, Information System 2 1 0 3 3 3 2 0
Aggregated Total Score 28 25 20 34 31 29 20 19

363
Table 40: Summary of CHW Contextual factors across eight selected countries
Recruitment Educational Training Certifi- Deployment Key com- Pathways & role Monitoring Volunteer/ Perfor- Career Referral
(open merit, criteria for content, cation (Public petencies in relation to super- salaried mance pathway system
community entry? duration & process sector, NGO, (MNCH/ MDG Promotive, vision & (US$) / incentives & deve- (linkage
recommen- role (initial (exam, private) HIV/ TB/ preventive, evaluation reimbursed (if any) lopment with health
Country
dations, & ongoing) course Nutrition Therapeutic, system)
others ) completion / Malaria) Rehabilitation
Recommen- 8 years of Initial: 18 months course public sector MNCH, Promotive, Lady health salaried Rs. Rs. 3 per on linkages
dations by schooling Ongoing: once completion nutrition, Preventive and supervisors 3090 Full time cycle of pills completion between local
local counselor per month Malaria, therapeutic 1LHS : employment and Rs. 0.5 of minimum teachers, TBA
Applicant key Role TB, AIDS 25 LHW per condom education and health
must be MNCH= coordi- (preventive evaluation 4 for system
nate ANC, IP and PNC; part) third party supervisor
-20-50 years
deliver FP services (external) they promo-
of age - evaluations ted as
(oral and injectable)
from & immunization has been supervisors
community Nutrition= growth conducted on
Pakistan
-female monitoring, completion
-permanent nutritional counse- of minimum
resident final ling, promotion of education
selection by BF, anemia control, for FPO
local counselor treat iron defi- promoted
ciency Malaria, TB= as FPO
and EDO-H
prevention, control
and treatment AIDS=
raise awareness PHC=
water, sanitation
Recommen- few years of Initial: 4 weeks course NGO MNCH, Promotive, Shasthyo volunteer -Pregnancy - linkages with
dations by schooling Ongoing: once completion nutrition, Preventive and kormi 1LHS part time identifica- local health
local village per month Malaria, therapeutic : 25-30 LHW employment tion Tk.30 centers
organization key Role TB, AIDS evaluation -Brining
Applicant MNCH= coordinate (preventive regular mothers for
ANC, IP and PNC; part) internal deli-
must be
deliver FP services evaluation very Tk.100
-25-45 years -Providing
&immunization
of age Nutrition= GM, ENC Tk.100
-female nutritional counse- -Refer Tk.100
-married and ling, BF promotion - ensuring
with no children Malaria, TB= birth wt
Bangladesh
less than 2 prevention, control Tk.30
years of age and treatment PHC=
-acceptable to water, sanitation etc.
community and treatment for
common ailments

Country
selected by read and write Initial: 7 days + 15 course public sector MNCH, Promotive, no direct volunteer - on linkages with
village leaders days on-the-job completion nutrition, Preventive and supervisor free health completion health facility
Applicant Ongoing: once per Malaria, therapeutic Health center facility of further
must be month key Role TB, AIDS staff super- education
-have own MNCH= coordinate vises them they are
ANC, IP and PNC; de- no formal hired as
occupation
liver FP services & im- evaluation public
to earn system health
munization Nutrition=
- not govern- growth monitoring, officers
ment official nutritional counseling,

living in the promotion of BF, pro-
community motion of Malaria, TB=
Thailand
prevention, control
and treatment PHC=
water, sanitation etc.
and treatment for
common ailments,
dental hygiene NCDs=
screening of hyper-
tension, diabetes and
vision problems
Recommen- read and write Initial: 8 weeks course public sector MNCH, Promotive, local health salaried USD - - linkages with
dations by or minimum Ongoing: once per completion nutrition, Preventive and center nurses 112/month local health
community 8 years of month key Role Malaria, therapeutic frequent centers
Applicant must education MNCH= coordinate TB, AIDS external
be ANC, IP and PNC; (preventive evaluation
deliver FP services part)
-minimum 18
and immunization
years of age
Nutrition= growth
-resident of monitoring,
the same nutritional coun-
community seling, promotion
of BF Malaria, TB=
prevention, control
Brazil
and treatment PHC=
and treatment for
common ailments,
dental hygiene
NCDs= screening
of hypertension,
diabetes and
vision problems
364
365
Country
chosen by literate Initial: 7 days course public sector MNCH, Promotive, doctors of salaried USD - - linkages with
community Ongoing: once completion nutrition, Preventive and health 50-130 local health
Applicant must per month k Malaria, therapeutic centers centers
be ey Role TB, AIDS
- minimum 18 MNCH= coordi- (preventive
nate ANC, IP and PNC; part)
years of age
deliver FP services
-from the com- and immunization
munity where Nutrition= growth
they will work monitoring, nutritio-
Haiti
-patients nal counseling, pro-
with TB and motion of BF Malaria,
HIV are also TB, AIDS (PMTCT)=
encouraged to prevention, control
be a worker and treatment PHC=
and treatment for
common ailments,
dental hygiene
involvement of 10 years of Initial: 6-12 months course public sector MNCH, Promotive, village CHWs salaried USD - upgrade linkages with
community in schooling Ongoing: frequent completion nutrition, Preventive and External 40-63 them as local health
their selection key Role Malaria, therapeutic evaluation nurses centers
Applicant must MNCH= coordinate TB, AIDS has been
be ANC, IP and PNC; (preventive conducted
-18 years
and immunization
or above Nutrition= growth
-female willing monitoring,
to live and serve nutritional coun-
community seling, promotion
Ethiopia
of BF Malaria, TB,
AIDS (PMTCT)=
prevention, control
and treatment PHC=
and treatment for
common ailments,
dental hygiene

Country
involvement of read and write Initial: 10 days course public sector MNCH, Promotive, CHW volunteer - they train linkages with
community in Ongoing: need based completion nutrition, Preventive and supervisors others local health
their selection key Role Malaria, therapeutic still no formal centers
Applicant must MNCH= coordi- TB, AIDS evaluation
be nate ANC, IP and PNC; (preventive has been
deliver FP services part) conducted
-18 years
and immunization
or above Nutrition= growth
-willing to live monitoring, nutritional
in and serve counseling, promo-

community tion of BF Malaria,
Uganda
TB, AIDS (PMTCT)=
prevention, control
and treatment PHC=
and treatment for
common ailments
involvement of read and write Initial: 18 weeks course public sector MNCH, Promotive, health Salaried USD - - linkages with
community in Ongoing: need based completion nutrition, Preventive and workers 50 still under local health
their selection key Role Malaria, therapeutic from health consideration centers
Applicant MNCH= coordinate TB, AIDS centers su-
must be ANC, IP and PNC; (preventive pervise them
-18-35 years
and immunization no formal
of age Nutrition= growth supervision
-preferably monitoring, mechanism
female -perma- nutritional coun-
nent resident seling, promotion
of BF Malaria, TB,
Mozambique
of community
AIDS (PMTCT)=
prevention, control
and treatment PHC=
and treatment for
common ailments
ANC: Antenatal Care PNC: Postnatal Care PMTCT: Prevention of Mother to child Transfer ENC: Essential Newborn Care
FP: Family Planning IP: Intrapartum TB: Tuberculosis
366
References:
1 Crigler L, Hill K. Rapid assessment of community Pakistan August 2003.
health worker programs in USAID priority MCH
countries USAID Health Care Improvement 13 Omer K, Ansari NM, Mhatre S, Andersson N.
Project 2009. Evidence-led training and communication
tools for lady health workers in Sindh, Pakistan:
2 Zeitz PS, Harrison LH, Lopez M, Cornale G. Final Technical Report Sindh CIET in collabora-
Community health worker competency in tion with the National Programme for Family
managing acute respiratory infections of child- Planning and Primary Health Care. Government
hood in Bolivia. Bulletin of Pan American Health of Sindh, Pakistan August 2002.
Organization. 1993;27(2):109-119.
14 Douthwaite M, Ward P. Increasing contraceptive
3 World Health Statistics September 2009. use in rural Pakistan: an evaluation of the lady
health workers programmes Health Policy and
4 Ayele F, Desta A, Larson C. The functional status Management. 2005;20(2):117-123.
of community health agents: a trial of refresher
courses and regular supervision. Health Policy 15 Ensor T, Cooper S. Overcoming barriers to health
and Planning. 1993;8(4):379-384. service access: influencing the demand side.
Health Policy and Planning. 2004; 19:69-79.
5 World Health Report 2004
16 Health Policy, Programmes and System in
6 Pakistan Social and Living Standards Bangladesh 2008.
Measurement Survey 2004-05. June 2005.
17 Standing H, Chowdhury AMR. Producing
7 PAKISTAN : National Expenditure on Health effective knowledge agents in a pluralistic en-
August 2007. vironment: What future of community health
workers? Social Science and Medicine 2008;
8 Millennium Development Goals Database 66:2096-2107.
2009.
18 Begum T, Hossain, N., & Nadiya, S. Private heal-
9 Shaikh BT, Hatcher J. Health seeking behavior thcare in Bangladesh. Report prepared for the
and health service utilization in Pakistan: chal- World Bank. Dhaka: Bangladesh. July 2001.
lenging the policy makers. J Public Health (Oxf ).
Mar 2005;27(1):49-54. 19 Hammer JS, & Chowdhury, N. Ghost doctors:
Absenteeism in Bangladeshi health facilities.
10 United Nations Population Division 2007. Dhaka: World Bank. November 2002.
11 Oxford Policy Management. Lady Health Worker 20 Peters D, & Kayne, R. Bangladesh Health Labor
Programme: External Evaluation of the National Market Study. Dhaka: Canadian International
Programme for Family Planning and Primary Development Agency. June 2003.
Health Care 1999-2002: Final Report: Oxford
Policy Management March 2002. 21 UNICEF. What works for children in South Asia:
Community Health Workers Regional Office for
12 PC-I. National Programme for Family Planning South Asia The United Nations Children’s Fund
and Primary Health Care «The Lady Health (UNICEF); 2004.
Workers Programme 2003-08. : Government of

22 Ahmed SM. Taking health care where the com- 31 Chowdhury S A, Mahmud Z. Intervening
munity is: the story of the Shasthya Sebikas of Malnutrition in Rural Bangladesh: BRAC
BRAC in Bangladesh BRAC University Journal Experience Bangladesh Rural Advancement
2008;5(1):39-45. Committee (BRAC), 75 Mohakhali C/A, Dhaka
1212.
23 Chowdhury AMR. Rethinking interventions for
women’s health Lancet. 2007;370:1292-1293. 32 Hadi A. Diagnosis of pneumonia by commu-
nity health volunteers: experience of BRAC,
24 Winch PJ, Gilroy KE, Wolfheim C, et al. Intervention Bangladesh. Vol 31: Royal Society of Medicine;
models for the management of children with 2001:75-77.
signs of pneumonia or malaria by community
health workers Health Policy and Management 33 Islam MA, Wakai S, Ishikawa N, Chowdhury
199-212 2005;20(4). AMR, Vaughan JP. Cost-effectiveness of com-
munity health workers in tuberculosis control
25 BRAC. Health Programmes. http://www.brac. in Bangladesh. Bull World Health Organ.
net/health.html. Accessed August 11, 2009. 2002;80:445-450.
26 Ahmed F. Health system strengthening using 34 Chowshury T. Pay for Performance of Community
Primary Health Care approach. Panel D: Societal Health Workers (CHW): BRAC’s experience Paper
partnership and local development to im- presented at: Pay for Performance Workshop,
prove health. Topic: Community empowerment Jan 19-23; Cebu, Philippines
through micro-credit scheme to improve com-
munity health Paper presented at: Revitalizing 35 Afsana K. Strengthening the health system for
Primary Health Care, 6-8 August 2008; Jakarta, maternal, neonatal and child health: An initiative
Indonesia to achieve the MDGs: BRAC; October 2006.
27 Afsana K, Chowdhury M, Ahmed F. Community 36 Daga SR, Daga AS, Dighole RV, Patil RP. Anganwadi
empowerment and participation: BRAC’s ex- worker’s participation in rural newborn care
perience in maternal and child health BRAC; Indian Journal of Pediatrics. 1993;60:627-630.
October 2007.
37 WHO. Thailand. World Health Statistics
28 Mahbub A. a documentation on BRAC’s Shastho [September 2009;
Shebika: exploring the possibilities of institutio- http://w w w.who.int/countr ies/tha/en/.
nalization. Dhaka: BRAC Research and Evaluation Accessed 17-10-2009.
Division 2000.
38 Bank W. World Bank List of Economies.
29 Salam SS. A study on the status of interper- http://web.worldbank.org/WBSITE/EXTERNAL/
sonal health communication under Essential DATASTATISTICS/0,,contentMDK:20421402~
Health Care Program of BRAC. Dhaka Masters of pagePK:64133150~piPK:64133175~theSite
Development Studies, BRAC University 2006. PK:239419,00.html#Lower_middle_income.
Accessed 17-10-2009.
30 Nasreen HE. BRAC HIV and AIDS programme:
the mid-term evaluation. Dhaka, Bangladesh 39 World Health Organization. Forty fourth World
Research and Evaluation Division, BRAC Health Assembly, Resolutions and Decisions.
December 2005. Resolution WHA 44.8. Geneva: World Health
368
Organization. WHA44/1991/REC/1. health workers in Thailand Social Science and
Medicine. 1983;17(19):1485-1487.
40 WHO. Role of Village Health Volunteers in Avian
Influenza Surveillance in Thailand New Delhi: 49 Kauffman KS, Myers DH. The changing roel of vil-
World Health Organization: Regional Office for lage health volunteers in Northeast Thailand: an
South-East Asia January 2007. ethnographic field study. International Journal
of Nursing studies. 1997;34(4):249-255.
41 Luechai Sringernyuang TH, Penchan Pradabmuk.
Community Health Workers and Drugs 1995. 50 The World Bank. Brazil at a glance. Available
from: devdata.worldbank.org/AAG/bra_aag.pdf
42 Kauffman KS, Myers DH. The changing role of vil- [accessed on 08 October 2009).
lage health volunteers in Northeast Thailand: an
ethnographic field study. International Journal 51 United Nations Development Programme.
of Nursing studies 1997;34(4):249-255. Human Development Report 2005.
43 Chuengsatiansup K. Health Volunteers in the 52 Pan American Health Organization. Health in

context of changes: assessing the roles and po- The Americas. Volume II. Countries. Brazil. 2007.
tentials of village health volunteer in Thailand.
www.aaahrh.org/.../Thailand-Komatra%20 53 Organization Mundial de la Salud. 2002–2004.
Village%20Health%20Volunteers.rtf Available from: www.who.int/nha/country/BRA
[accessed on Nov 2009]. Thailand Ministry of [Accessed on 09 October 2009].
Public Health
54 Brasil, Instituto Brasileiro de Geografia e
44 WHO. Newborn and child health in the South- Estatística. Pesquisa de Orçamentos Familiares,
East Asia region. Regional Office of South-East 1995–1996.
Asia World Health Organization 2005.
55 Brazil. Constitution of the Federative Republic of
45 Hathirat S. Buddhist Monks as community health Brazil. (In Portuguese). Brasilia, Brazil. 1988.
workers in Thailand Social Science and Medicine
1983;17(19):1485-1487. 56 de Andrade LOM, Pontes RJS, Martins Junior T. A
descentralizacao no marco da Reforma Sanitaria
46 Phomborphub B, Pungrassami P, Boonkitjaroen no Brasil. Rev Panam Salud Publica/ Pan Am J
T. Village health volunteer participation in tuber- Public Health. 2000;8:85-91.
culosis control in Southern Thailand Southeast
Asian Journal of Tropical Medicine and Public 57 Ministerio da Saude. Programa Saude da Famılia.
Health 2008;39(3):542-548. Brasılia, DF: Ministerio da Saude. 2001.
47 Sompoch R. Village health volunteers participa- Ministerio da Saude. Programa Agentes

tion in the universal coverage health insurance Comunitarios de Saude. Brasılia, DF: Ministerio
program in Nonghaburi province: Masters in 58 da Saude, . 2001.
Primary Health Care Management, Nakhon
Pathon: Faculty of Graduate Studies Mahidol 59 Brazilian Ministry of Health. Atenção Básica e a
University 2003. Saúde da Família. Ministério da Saúde –Brasil,
Departamento de Atenção Básica, Brasília.
48 Hathirat S. Buddhist Monks as community Available from:

http://dtr2004.saude.gov.br/ dab/atencaoba- 68 WHO Statistical Information System (WHOSIS)
sica.php (2005). World Health Statistics 2005. Available
[accessed on 09 October 2009]. from:
http://www3.who.int/whosis/country/indica-
60 Brasil, Ministério da Saúde; Organização tors.cfm?country=/hti
Panamericana da Saúde. Painel de indicadores [accessed 05 July 2009].
do SUS. Año 1,No 1; . 2006.
69 Pan American Health Organization. Health
61 Cufino Svitone E, Garfield R, Vasconcelos MI, situation analysis and trends summary. – Haiti.
Araujo Craveiro V. Primary health care lessons Available from:
from the Northeast of Brazil: the Agentes http://www.paho.org/english/dd/ais/cp_332.
de Saúde Program. Pan Am J Public Health. htm [accessed on 05 July 2009].
2000;7:293-302.
70 The Center for Human Rights and Global Justice,
62 Macinko J, Guanais FC, de Fátima M, de Souza The International Human Rights Clinic at NYU
M. Evaluation of the impact of the Family Health School of Law, Partners in Health – Zanmi
Program on infant mortality in Brazil, 1990-2002. Lasante, The Robert F. Kennedy Memorial Center
J Epidemiol Community Health. 2006;60:13-19. for Human Rights. The denial of the right to wa-
ter in Haiti. 2008. Available from:
63 Rocha R, Soares RR. Evaluating the Impact http://www.pih.org/inforesources/news/IDB_
of Community-Based Health Interventions: Haiti_report.html
Evidence from Brazil’s Family Health Program. [accessed on 05 July 2009].
Discussion Paper Series. IZA DP No. 4119.
Discussion Paper No. 4119. Bonn, April 2009. 71 Ministère de la Santé Publique et de la Population.
Plan Stratégique National pour la Réforme du
64 World Bank: Haiti Country Brief. 2009. Available Secteur de la Santé, 2005-2010 .
from:
http://web.worldbank.org/WBSITE/EXTERNAL/ 72 Ministère de la Santé Publique et de la Population.
COUNTRIES/LACEXT/HAITIEXTN/0,,contentMD La Paquet Minimum de Services (PMS) – Cadre
K:21040686~pagePK:141137~piPK:141127~t Conceptuel.
heSitePK:338165,00.html [accessed on 05 July
2009]. 73 Perry H, Berggren W, Berggren G, et al. Long-term
reductions in mortality among children under
65 Haiti Technical Secretariat of the Preparatory age 5 in rural Haiti: effects of a comprehensive
Committee for the DSNCRP, Ministry of Planning health system in an impoverished setting. Am J
and External Cooperation. Growth and poverty Public Health. 2007;97(2):240-246.
reduction paper (2008-2010). Making a qualita-
tive leap forward. . 2007. 74 Koenig SP LF, Farmer PE,. Scaling-up HIV treat-
ment programmes in resource-limited settings:
66 UN Development Program (UNDP), Human de- the rural Haiti experience. AIDS. 2004:S3:S21-25
velopment Report 2007/2008 2007
75 Farmer P LF, Mukherjee JS, Claude M, Nevil P,
67 Farmer P, Smith Fawzi MC, Nevil P. Unjust em- Smith-Fawzi MC, Koenig SP, Castro A, Becerra
bargo of aid for Haiti. Lancet. 2003;361:420-423. MC, Sachs J, Attaran A, Kim JY. Community-based
approaches to HIV treatment in resource-poor

settings. Lancet. 2001;358:404-409. 2005/06 – 2010/11 (GC), (1998 – 2003 EFY). Mid-
Term Review, 05th May – 5th June 2008, Volume
76 Farmer P LF, Mukherjee J, Gupta R, Tarter L, I, Component Report, Final Report, Addis Ababa,
Kim JY. Community-based treatment of ad- 17th July 2008. 2008.
vanced HIV disease: introducing DOT-HAART
(directly observed therapy with highly active 84 Ethiopia, Federal Ministry of Health. Health
antiretroviral therapy). Bull World Health Organ. Extension Program in Ethiopia: Profile. Addis
2001;79:1145-1151. Ababa 2007.
77 Walton DA FP, Lambert W, Léandre F, Koenig 85 Hussein AM. Scaling Up Education and Training
SP, Mukherjee JS . Integrated HIV prevention Human Resources for Health, Ethiopia. Moving
and care strengthens primary health care: Towards Achieving Universal Access and MDGs.
lessons from rural Haiti. J Public Health Policy. Case Study on Scaling Up Education and Training
2004;25:137-158. of Health Workers: Global Health Workforce
Alliance, WHO, Geneva, Switzerland. 2009.
78 Berggren G MH, Genece E, Clerisme C,, . A pros-
pective study of community health and nutri- 86 Center for National Health Development in
tion in rural Haiti from 1968 to 1993. Available Ethiopia. Ethiopia Health Extension Program
from: http://www.unu.edu/Unupress/food2/ Evaluation Study, 2005-2007, Volume II: Health
UIN09E/uin09e0j.htm Extension Workers Performance Study. Addis
(Accessed October 28, 2009). Ababa, Ethiopia: Center for National Health
Development in Ethiopia. . 2008.
79 Fraser HS, Jazayeri D, Nevil P, et al. An informa-
tion system and medical record to support HIV 87 Center for National Health Development in
treatment in rural Haiti. British Medical Journal. Ethiopia. Ethiopia Health Extension Program
2004;329:1142-1146. Evaluation Study, 2007, Volume-III: Health Post
Performance Survey. Addis Ababa, Ethiopia:
80 World Bank. Ethiopia Data and Statistics. Center for National Health Development in
http://web.worldbank.org/WBSITE/EXTERNAL/ Ethiopia. 2008.
COUNTRIES/AFRICAEXT/ETHIOPIAEXTN/0,,men
uPK:295939~pagePK:141132~piPK:141107~the 88 Center for National Health Development in
SitePK:295930,00.html. Ethiopia. Ethiopia Health Extension Program
(Date accessed 03 November 2009). . 2009. Evaluation Study, 2005-2007, Volume-I:
Household Health Survey. Addis Ababa, Ethiopia:
81 UNICEF. Ethiopia Statistics. Center for National Health Development in
http://www.unicef.org/infobycountry/ethio- Ethiopia. 2008.
pia_statistics.html.
Date accessed 23 October 2009). 2009. 89 UNDP. Human Development Report 2007/2008,
Fighting Climate Change: Human Solidarity in
82 Ethiopia, Federal Ministry of Health, Planning a divided world, New York, Palgrave Macmillan.
and Programming Department. Health and 2007.
Health Related Indicators. Addis Ababa 2008.
90 Uganda Bureau of Statistics (UBOS) and ORC
83 Independent Review Team. Ethiopia Health Macro. Uganda Demographic and Health Survey
Sector Development Programme, HSDP III, 2006. Calverton, Maryland, USA: UBOS and ORC

Macro. 2007. women in community-directed treatment
with ivermectin for onchocerciasis control in
91 Kiggundu Colette. Delivering an integrated Rukungiri District, Uganda. Health and Social
package of community-based interventions Care in the Community. 2002;10(5):382-393.
through village health teams in Uganda: The
pilot model in Mpigi district, Process documen- 100 Katabarwa MN, Richards FOJ. Community-
tation. Kampala. 2006. directed health (CDH) workers enhance the
performance and sustainability of CDH pro-
92 Government of Uganda. A Training Manual for grammes: experience from ivermectin dis-
Village Health Team (VHT), Health Education tribution in Uganda. Ann Trop Med Parasitol.
and Promotion Department. Kampala: Ministry 2001;95(3):275-286.
of Health. 2005.
101 Katabarwa MN, Peace Habomugisha, Anguyo S,
93 Government of Uganda. National Health Policy. et al. The traditional kinship system enhanced
Kampala: Ministry of Health;. 1999. classic community-directed treatment with
ivermectin (CDTI) for onchocerciasis control in
94 Government of Uganda. Health Sector Strategic Uganda. Undated.
Plan 2000/01-2004/05. Kampala: Ministry of
Health; . 2000. 102 Katabarwa MN, Richards FOJ, Ndyomugyenyi
R. In rural Uganda communities the traditional
95 Ssekimpi DK. Report on study of community kinship/clanship system is vital to the success
health workers in Uganda (with focus on village and sustainment of the African Programme for
health team strategy - VHT). Kampala: Uganda Onchocerciasis Control. Ann Trop Med Parasitol.
National Association of Community and 2000;94(5):485-495.
Occuaptional Health; 2007.
103 Iannotti L, Gillespie S. Successful Community
96 Ssekimpi DK. Report on study of community Nutrition Programming: lessons from Kenya,
health workers in Uganda (with focus on village Tanzania and Uganda. Kampala: LINKAGES,
health team strategy - VHT). Kampala: Uganda Regional Centre for Quality of Health Care,
National Association of Community and UNICEF; 2002.
Occuaptional Health. 2007.
104 Uganda National Association of Community
97 Government of Uganda. A Training Manual for and Occupational Health (UNACOH). Improving
Village Health Team (VHT), Health Education and sustaining immunization coverage in Kyaka
and Promotion Department. Kampala: Ministry Health Sub-District, Kyenjojo District, Uganda;
of Health; Undated. 2008.
98 Kiggundu Colette. Delivering an integrated 105 World Bank. Mozambique Data and Statistics.
package of community-based interventions http://web.worldbank.org/WBSITE/EXTERNAL/
through village health teams in Uganda: The COUNTRIES/AFRICAEXT/MOZAMBIQUEE XTN/0
pilot model in Mpigi district, Process documen- ,,menuPK:382158~pagePK:141132~piPK:14110
tation. Kampala; 2006. 9~theSitePK:382131,00.html.
(Date accessed 31 October 2009) 2009.
99 Katabarwa MN, Peace Habomugisha, Stella
Anguyo. Involvement and performance of

106 UNICEF. Mozambique Statistics. 113 República de Moçambique, Ministério da Saúde.
http://www.unicef.org/infobycountry/mozam- Direcção Nacionale de Saúde. Programa de
bique_statistics.html. formação dos agents polivalentes elementares
(Date accessed 23 October 2009). 2009. (APE’s).
107 World Health Organization. Mozambique’s

health system. WHO Country profile.
http://www.who.int/countries/moz/en/.
(Date accessed 31 October 2009). 2009.
República de Moçambique, Ministério da Saúde.

108 National Plan for Health Human Resources
Development (NPHHRD) 2008–2015. Ministry
of Health. National Directorate of Human
Resources. National Plan for Health Human
Resources Development (NPHHRD). 2008.
República de Moçambique, Ministério da Saúde.

109 Plano Integrado Para o Alcance dos Objectivos
4 e 5 de Desenvolvimento do Milénio (2012
2015). Maputo, Dezembro de 2008. 2008.
110 República de Moçambique, Ministério da Saúde.

Sufficient and Competent Health Workers for
Expanded and Improved Health Services for
the Mozambican People. Ministry of Health
2008. National Directorate of Human Resources.
National Plan for Health Human Resources
Development. 2008.
111 Capacity Project/USAID. Plano Operacional

para Re-Vitalização do Programa dos Agentes
Polivalentes Elementares. República de
Moçambique, Ministério da Saúde. Março de
2009. 2009.
112 Capacity Project/USAID. Operational Plan and

Curriculum Development for Community Health
Interventions Support to the Government of
Mozambique Ministry of Health (MISAU) for the
Revitalization of the Existing Agentes Polivantes
Elementares De Saude (APE) or Community
Health Worker Programme. Currículo Para
Formação Dos Agentes Polivalentes Elementares.
Final Draft. 2009.


Global Change

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Global Change

Enviado por

Direitos autorais:

Formatos disponíveis

Global Experience of Community Health Workers for

Delivery of Health Related Millennium Development Goals:

Zulfiqar A. Bhutta, Zohra S. Lassi, George Pariyo* and Luis Huicho**

Global Evidence of Community Health Workers

Global Evidence of Community Health Workers

GHWA should also facilitate in undertaking

Performed situation analysis

Review Results (Global Consultation)

Set country priorities

Update CHW programs

Define indicators with targets

Develop a strategic plan within

Global Evidence of Community Health Workers

The following search strategy was modified Country Case Studies

MCH roles Interventions are grouped by cate-

Global Systematic Recommendations

Input Process Output

Global Systematic Review Summary

Global Evidence of Community Health Workers

Global Evidence of Community Health Workers

community deficiency for mothers and children awarded with

they should be evaluation and newbor the next level.

Global Evidence of Community Health Workers

Child Health CHW

Global Evidence of Community Health Workers

Malaria control CHW

-permanent resident a certificate

Global Evidence of Community Health Workers

HIV/AIDS Care CHW

38 Global Evidence of Community Health Workers

During the course of undertaking this review, we

Global Evidence of Community Health Workers

25 Rocha R SR. Evaluating the Impact of Community-

26 Oxford Policy Management. Lady Health Worker

42 Global Evidence of Community Health Workers

Box 2: Included studies by continent and country

Bangladesh 29 Burkina Faso 6 Netherlands 1 Bolivia 4 Australia 1

Global Evidence of Community Health Workers

1060 were retrieved for full text review

315 Papers (276 original papers) included for review

By type of outreach worker By design By Target MDGs

CHWs 230 cRCT / RCT 76 MDG 1: Nutrition 10

TBAs 39 Quasi RCT 42 MDG 4: Child Health 87

Community mobilizers 7 Pre/post 34 MDG 5: Maternal Health 73

Peer counselors 19 Descriptive 147 MDG 6: Malaria/TB/HIV/NCD

Global Evidence of Community Health Workers

Global Evidence of Community Health Workers

CHW programs have been said to be able to Mental Health interventions

48 Global Evidence of Community Health Workers

Operational aspects and considerations

Coverage and eﬀectiveness

Global Evidence of Community Health Workers 49

In an intervention by Winch et al., the CHWs pro-

Other contextual factors related to CHWs were

Thus we cannot comment on the effect of these

50 Global Evidence of Community Health Workers

Operational aspects and considerations Shastho Sebika, Bangladesh

Coverage and eﬀectiveness

Global Evidence of Community Health Workers 51

Global Evidence of Community Health Workers

Global Evidence of Community Health Workers

Global Evidence of Community Health Workers

Global Evidence of Community Health Workers