Hello, welcome back everyone and now we're beginning our lecture for week 4 of our course 0 express health for all through primary health care. This week we're going to be listening to full lectures, the first 2 of these are the lectures that I gave and a course. That we call here, health systems in low and middle income countries. And we'll be talking in this beginning part in the first two segments of this lecture for this week about community health workers. In the beginning, we'll be reviewing some of the historical development of the concept. Community health workers and resource constraint settings. And then in the second part of this we'll be discussing a document that has just been released in the last year or so, which is a proposal for community health workers throughout Africa. And, in fact, it's a proposal for 1 million community health workers in Africa. But it gives a sense of, what people are thinking about the role of community health workers in resource constraint settings. Given our emerging technology and the newer interventions that are now being shown to be effective as provided by community health workers. And then we'll move from that to discuss a little more specifically the role of community health workers in several specific projects that will give you a little more concrete sense of the role of community health workers in primary health care. And then finally in the third part of this I wanted to share with you specific projects that BRAC operates in the urban slums of Bangladesh which relies heavily on their community health worker program, the Shasthya Sebikas. And this is one of the really exciting programs in global health today becasue as we all know the urbann slum setting is now, and will be even more so in the future such an important setting for improving health. And finally, I want to wrap up this weeks lecture by talking about another very exciting story, which is the development of Primary health care in Brazil. And what that's meant for the people of that country, and with a few concluding thoughts, this will wrap up our 4th and final week of lectures, so, enjoy. Health systems have not always considered communities as an essential part of what a health system is. But I think increasingly people are recognizing that the health system itself has to Interact in some meaningful way with the community and involve the community if the health system is going to be effective and to really make a difference in the health of the people that it serves. And this has been recognized recently by the Global Fund to fight AIDS, Tuberculosis and Malaria. Which is now devoting a lot of energy and thought in how to engage communities into the fight against AIDS, and TB and Malaria. This is a scheme that they have developed that shows the importance of communities and community actors and community system. Withheld systems for the goals that we all are concerned about in terms of improving health in populations. The community health worker movement really began back in China in Ding Xian, a place about a hundred miles from Beijing. Where the founder of primary healthcare, John Grant working with two Chinese professionals, Jimmy Yen and C.C.Chen Chen. Developed a primary healthcare project that was very innovative and It was a whole new approach to thinking about had to develop a health program in an area with very, very limited resources, for the population was essentially illiterate. And they came up with the idea of training farmer scholars, as they called them, to record vital events vaccinate against smallpox, administer simple treatments, give health education talks and maintain wells. These were needs that have been identified through surveys that they carried out in these very, very underdeveloped areas of China back at that time. This was so successful that it became the basis for the very famous barefoot doctors approach, which was developed sometime later. Then communist China as part of China's rule transformation. But this very famous project is considered to be the first primary health care project in the international health or global health context as we think about primary health care which is very different of course from the notion of primary medical care that we know of in developed countries. By the time this work was moving forward, there was also growing interest in other areas of the world in new and innovative approaches to providing basic health care services, where health care providers were very few and far between. And this led to a very important book that was published in 1975 by the World Health Organization, called Health by the People. It's a compilation of community health projects, that were known, at that time, to be outstanding. And where written up as a series of key studies and you see here, of course, in the first chapter, the healthcare delivery system in China is the first chapter in this book. And it focuses on the barefoot doctor. But other, very important, primary healthcare projects that use community health workers are highlighted here. One of the most important of these is the Jamkhed comprehensive rule health project. You see a chapter in here. The enrollees are distinguished graduates of our department and our school, and there work has become very important. I'm going to be mentioning a little bit more about that as we go ahead. But this book Health by the People became the foundation of the international conference on primary health care, which was held in Alma Ata, Kazakhstan in 1978. This was a watershed event, in the history of global public health. It. Brought together leaders and health from 180 different countries around the world. It was the largest health assembly that had been held to date, and it focused on primary health care. And we now know of the Alma Ata Declaration which came out of this. And this declaration provided a very strong boost for the concept of community health workers as an essential part of reaching very poor populations with basic needed services. The Alma Ata concept of primary health care, as you here on your slide, and as I mentioned just a second ago is, is a very different concept from what many of us normally think of when we think of primary cure and that is we're thinking of primary medical cure in the United States. But the concept of our primary health care is defined at Alma Ata was one in which primary health care was considered to be the basic and fundamental approach to getting services that will improve the health of people in developing countries. And it wasn't so much focused on provision of curative services, although that was certainly part of it, but it was also focused on the social and economic factors that influence health. And a multi subtle approach to health improvement using the resources at hand. And Margaret Chan in a very insightful editorial that she wrote in the lancet in 2008 actually stated that this whole approach to health was a radical attack on the medical establishment and then the biomedical model of modern medicine. In the sense that it broadened the medical model to focus on social and economic factors as well. And it did this by bringing in the community as an essential partner in the process of health improvement which, Which really is rather foreign to the notion of primary medical care as we think of it here in developed countries. And as Margaret Chan so rightly mentioned the, the whole spirit of the Alma Ata definition of primary health care, honored the resilience and the ingenuity of the human spirit and made space for solutions created by communities, owned by them, and sustained by them. So within this context, of course, there was an important role and vision for community health workers. And this statement that you see on your screen here, focuses on the broad set of health personnel that were envisaged through this declaration in order to improve the health of poor communities. And as you see here, it talks about having a whole array of health workers. A team of people, who can provide services to those who need them. Physicians, nurses, midwives, auxiliaries, as well as community workers. And even traditional workers. Traditional practitioners. In order to respond to the expressed health needs of the community using the limited resources available to do so. The Jamkhed project, as I mentioned and as I'm going to explain more in just a second, was one of the foundations of the Spirit of Alma Ata and the concept of community health workers. And I'll be describing in a few minutes, a little bit more about their community health worker program. But the book that the enrollees wrote in 1994, which was obviously a number of years after the Alma Ata declaration and the conference in 1978. But this book I think highlights the spirit of what is behind the declaration of Alma Ata. This quotation that the Aroles wrote from this book I think expresses the sense of the role of community health workers that underlies a lot of the Alma Ata movement. They said that health services, no matter how efficient, cannot change the condition of the marginalized people unless they are helped to become self-reliant and the root problems addressed. People who are poor and illiterate are like uncut gems hidden under the dirt and stone. Given the opportunity, they can reach their full potential and live as responsible, sensitive human beings, possessing self reliance and the liberty the shed those old customs and traditions that impede health and development. And as you'll see in just a minute, the Aroles were able to do this in such an extraordinary way working with the community health workers and Jamkhed. After the International Health Conference at Alma Ata in 1978 there was a lot of enthusiasm for large scale community health worker programs in developing countries. And it is sad to say, but nonetheless true that these programs, by and large failed miserably. I was tragic in a sense but the reasons that they failed, I think, are terribly important. And as you see here in this slide there were some important factors that underlay this problem. One of them was that in a lot of countries the persons who were selected to be community health workers were attracted in or recruited into this whole process, because of political considerations. Rather than trying to attract people who really had a strong motivation to serve people. And were really competent local care givers. These programs, as they scaled up quickly, did not have the financial support they needed to make them work well and they didn't have planned the adequate supervision and support that community health workers need in order to function well and continue to function well. And then, unfortunately, there was a lack of rigorous assessment of these programs. And no evidence to demonstrate their impact. And a lot of anecdotal evidence that they weren't working well. And without this lack of evidence that could have perhaps, helped these programs to get back on track. The whole process just imploded in so many different countries. I was working as I mentioned earlier in Bolivia, and an early 1980s and I was in touch with high-level people in the ministry of health who were involved in scaling up a community health worker program there. And, I know that in the case of Bolivia, and I've heard of a few other similar cases that, what actually happened was that as the plans for these community health worker programs were ready to be implemented. Sort of at the last minute there was a lot of concern within the Ministries of health that by rolling out these large programs. It could lead to a very disastrous situation for ministries of health because while these people were originally anticipated to work as volunteers, they were afraid that these groups would mobilize and unionize, and, and force ministries of health to provide salaries that they didn't have the resources to provide, so that was another political problem that, complicated the whole situation. Now, here we are 3 decades after this early effort for scaling up community health workers. And during the meantime, of course I don't have the time to really talk about this. But in the meantime, in spite of the fact that so many of these large scale programs failed. There were many smaller examples of great successes using community health workers. And increasing documentation and scientific studies of very strong affects that community health workers could make in improving the health of very poor communities. And so, that led to a growing interest in expanding the role of community health workers again, in spite of the problems that were experienced in the 80's. And one of the review articles that pulls a lot of this together was published in the Lancet in 2007 which cited the evidence that I mentioned and also stated that perhaps it is time to get serious about community health workers again. But they, as you see if you read this abstract here, they make it very clear that unless community health systems are able to provide proper training and proper supervision in engagement with the communities, programs are going to fail again. So a lot of the interest now is regarding how we can again develop these programs without the failures existent in the 80's. There was a Cochrane review of the role of lay health workers in maternal and child health and management of infectious diseases that was completed in 2010. This was a review of only randomized control trials. So, it's very rigorous and it, it doesn't have the Real depth and enthusiasm that has been generated for community health workers because the evidence that they were able to come up with was rather limited. But still they did find that there was evidence that community health workers played important role in promoting immunization uptake. Promoting breastfeeding and improving tuberculosis cure rates. But a lot of this data was from developing countries, where there's obviously more funds available for research. There also was evidence that they sited that community health workers can increase the likelihood of mothers seeking care for childhood illness and reduction of child morbidity and mortality and neonatal mortality. And I'll get to more of this in just a second. There also was released in 2010, a very important document that was sponsored by the World Health Organization and the Global health workforce alliance. And this is a global review of a number of large scale community health care worker programs and sort of a series of case studies about what has been done. But with a very critical look to thinking about how these programs could be made stronger. This review is based on work in eight countries. And it talked about the types of services that community health workers provide. And maternal and child health and tuberculosis programs, malaria and HIV. And they emphasized that the community health workers need to be a fundamental and important part of the health system. Not just in separate add on that's unrelated to the health system. And they also made the point that it's critical that the community health workers have a link within the community. And that they are not just a part of the health system, the broader, higher up health system, but they're also an integrated into the community as well. And then, finally they concluded that the community health workers were essential for delivering interventions that are now seen as essential for achieving the millennium development goals for mothers and children, and for TB, malaria, and HIV. Usaid also in 2010 carried out a review of the literature of community health worker programs. And they were able to obtain information about 18 community health worker programs from around the world. And the challenges that they found in the community health worker programs that they reviewed are shown on this slide, and there as follows. A lot of them have been poorly planned. There were unrealistic expectations and ill-defined roles. Ambiguity on what the community health workers were supposed to do. In some cases the communities weren't involved in this like they should be. The training wasn't always adequate. Some of these programs were not scalable. They were too expensive or they required too intensive resources that couldn't be applied on a larger scale. Some programs had resources, and then they had no resources, and then they had resources again. So you have to maintain something at a steady pace over a long period of time if it's going to really have stability. And then there's the whole issue about incentives for community health workers, and this is an area that has a lot of debate about it. What kind of remuneration community health workers should get, or should they work as volunteers? Should they get a salary? Should they get some other kind of incentive that doesn't represent a salary and in some cases community health workers have not received adequate incentives. And then the whole issue of providing adequate supervision and logistical support is certainly an issue too. And so their review concluded that these factors, combined with weak management and organizational structure, contribute to higher rates of attrition, absenteeism, low work morale, and poor quality of work for community health workers. So I think this gives us a sense of some of the challenges that are involved in setting up community health worker programs and making them work effectively over a long period of time. Even though the idea seems so simple and seems so appropriate. I think maybe now is a good time to take a quick break and give you a chance to get a cup of coffee or some water and I'll take a little break and rest my voice and we'll get back here to continue on with a few other reviews that have just been completed. And then talk about some of the examples of 3 outstanding programs.
