>> Welcome back, everybody. Here, we see a report that was released in May of 2011. This is the most recent of these reports. This was a review, and a very high level report that I was very pleased to be a small part of. It's entitled One Million Community Health Workers, and it was pulled together by the Earth Institute for the United Nations. The basic idea behind this report is that Africa needs a major boost to get back on track to achieve the Millenium Development Goals for health. And the way to do that is to greatly expand the availability of community health workers in these communities around Africa. And they came with the notion of one million community health workers because if one community health worker were trained for every 650 rural inhabitants in Africa that would be one million community health workers. And the whole premise of the report here is that there is overwhelming evidence of the effectiveness of community based interventions as a platform to extend health care delivery and improve health outcomes and through these community based programs. We're going to be able to achieve the health related MDG's and sort of unstated here is that there has been a lack of emphasis on the community based approach in health programs around the world and therefore it's time to ramp this up. So I commend this document to you, you can download it off the internet. And it's a very fine piece of work. These are a couple of slides from that document. Figure one here shows their vision of a health system that has a strong community health worker base to it. And obviously built into this is the strong supervision of community health workers in this process and how this links into the remainder of what we Typically think of as the health system. Figure 2 shows the various things that they envision a community health worker being able to do, which is, in fact, based on scientific evidence of specific studies where community health workers have carried out, on smaller scales, all of these various interventions that you see at the bottom left of the slide. Interestingly enough, two of the interventions that are very important, that aren't mentioned in this particular slide, are provision of family planning services and immunizations. But they're also, in many settings critical roles that community health workers play. I've also been involved with a review which still at this point hasn't been published but will be before too long. But it is a review of the effectiveness of community based primary health care in improving child health and the role of community health workers in that process. And in our work we've identified 40 studies or projects some of them published in the scientific literature others are just documents describing the outcomes of these projects but we found 40 of these in which there were 3 child survival interventions implemented over at leats 4 years and in some cases longer And in these projects they had a very clear evaluation of the impact of the interventions on the health of children as defined in this slide here. And for these 40 projects. They were in substantial populations, although not large scale. The median population served in these projects was 158,00 people and they were various types of projects, 2 3rds of them were USAID child survival grants to PVOs, US based in GOs, private voluntary organizations but a series of other types of projects too. And what we found is that in every case, these projects all of which showed substantial improvement in child health. They all used some type of community based outreach agent. And they all had strong community involvement engagement immobilization of some sort. And at the same time they were also involved in every case strengthening health system capacity. And in these projects there were a whole range of different types of community workers use, there are all types of different names, they all had different kinds of roles. But the main point here is that in all cases there were some kind of community worker that was identified that was essential towards making this activity be effective in improving the health of children in these communities. The other interesting thing about these projects is that they all were engaged in some type of identification of every household in the community, family registration, mapping of households censusing the community. And routine home visitation was a very common part of these programs that were successful. And then, related to that, were. Innovative approaches to engaging communities in the kinds of health education activities that are, that are essential. Using drama, and dance, and songs, and puppet shows, and so forth. There was strong community engagement beyond community workers as shown here in this slide. Various types of committees were established, engagement with leadership structure in the community; and also formation of groups of mothers, women's groups, etc. Again, a broad variety of these, but they were all important parts of these programs and essential to their success. The health system's strengthening activities that these projects carried out involved training of health system staff at the higher level. Provision of logistics often fuel, a repairing motorbikes and so forth. It enabled the ministry of health staff to get out the communities that otherwise wouldn't have the ability to do it. Working on ways to facilitate referral of people from the community who need higher levels of care, and referral of those patients back into the community. Promotion of visits of the health staff at the higher levels in the ministry of health to visit these model community health programs. And then, facilitating meetings between members of the health staff at higher levels in the system with the community leaders which very rarely actually takes place in health systems of these developing countries, which is unfortunate. And also, providing a way to facilitate messages that would go back and forth between communities and first level health facilities. But the important thing about that is through all these activities there were marked improvements in the coverage of key child survival interventions. Average improvement of coverage of 24% for key activities like hand washing, exclusive breast feeding, immunization referral of children with signs of pneumonia and so forth. And for those projects that were able to measure mortality over time, for those that had it, there was a 55% reduction in the mortality of children. So these are very impressive results. And I think they demonstrate the potential that community health workers have in this broader approach as I think of the Alma-Ata approach to primary health care and improving the health of communities. Let me go on now and give you three examples of community health worker programs that I think you find interesting. This first one is from Bangladesh. These are Shasthya Shebikas women who work in communities throughout Bangladesh. If you haven't heard of BRAC I always urge people to look it up on the website, and read about it. It's one of the most exciting global health organizations in the world. They're the largest national ngo in Bangladesh and serve a 110 million people, believe it or not. And they have 70,000 of these community health workers. And they provide this very broad range of services, these women. Are local residents. And they have six weeks of formal training and then they have ongoing continuing education as well. And they have very strong supervision, and they're able to carry out this work on a long term basis because they receive a small profit. From selling various commodities in the community, oral rehydration salts, pain medication, sanitary napkins, soap, and so forth. And BRAC has developed a very innovative system for making this work. So with a small amount of money that these women are making they're very happy and doing this kind of work. In this photograph here you see one of the Shastya Shebikas giving directly observed therapy for tuberculosis to one of the women in the neighborhood, and she has a whole system for detecting and treating TB patients that's very closely supervised by a number of levels that go up above her to make sure the diagnosis correct and that the drugs reach her and reach the patient and they have a Perhaps one of the best TB programs in the world. As a second example of community health workers, I wanted to share with you this brief video clip that provides a very graphic entry into Jamkhed and the community health workers there and. You'll see some of the community health workers in this video and. These have been working there for 30 years now and they were the original community health workers that were described in the book, Health by the People, that we discussed at the very beginning of this. I think you'll find this intriguing and meaningful as well. You'll see some instructions on the screen here to follow, and please do that and we'll be back in just a minute after you've seen this video. I've had the privilege of visiting Jamkhed 6 or 7 times now, and I've had a chance to talk with the community health workers there and watch how the program functions. One of the interesting things about the program in Jamkhed is that The community health workers that you saw in the video, they returned back to Jamkhed once a week and they spend the night there and they've all over 30 year period of time they've become very close friends and they have a lot of social support. And when they come back each week for their continuing education. Related to their own work they also have time to strengthen their friendship and their social life as well which is one of the things that's made this such a successful program over a long period of time. The third example of community health workers I wanted to share with you very briefly is from Nepal. Nepal has a very famous national program of community health workers called, female community health volunteers. There are a number of things that are interesting about this. The first one is that the national community health worker program that started in Nepal was in the early 80s, it was one of these national Programs that I mentioned and, it started up with a great flair, a lot of interest, enthusiasm. But within only a couple of years the government had no money to pay for the program and so the program just, failed right there in front of everybody. And that's one of the sad stories of which there are many unfortunately. But these trained community health workers were out there without any formal role or any connection to the health system. And then, in the 1980s, there was a big push for distribution of vitamin A tablets around the country, and so. A very innovative Nepalese man realized that this resources was not in the communities and so he said, well why don't we engage these people as volunteers. And the national distribution of vitamin A tablets to children. And so this was a wonderful thing for these community health workers because they'd been trained and then they were totally abandoned and now they have something useful to do and they were happy to do this work as volunteers. And Napal became very famous because they had virtually 100% coverage of their Vitamin A distribution program which did not exist in other countries. And with the enthusiasm for that, these female community health volunteers began to take on other tasks as volunteers: community case managers of pneumonia and diarrea, nutrition education, promotion of immunization, family planning promotion And now home based neonatal care and they're also moving into a very exciting community based intervention called Misoprostol administration which I don't have time to tell you about but it prevents postpartum hemorrhage for women who deliver at home. So one of the exciting new interventions in global health. But they've also developed very innovative scheme for financial support which is a very small amount of money but the communities now have a small endowment that pays i think 50 dollars a month That they can use to provide support for these female community health volunteers. So it's another innovative way of providing financial support that encourages these people to be engaged. I have been involved with some other people in developing a framework for community health worker activities that kind of excited about. In our review that we've carried out on the effectiveness of community-based primary healthcare and improving child health, we've determined that there are 4 different kinds of activities that are involved in making interventions effective and improving child health at the community level. These are routine systematic home visitations, participating women's groups, community case management of specific diseases like diarrea, malaria, pneumonia and outreach services provided by mobile health teams that are based at a health center who go out to communities. But through these processes, community health workers can play a very important role in getting essential interventions to families, mothers and children in particular to improve their health. And we don't have time to discuss this further but, I think you might find this of interest as you move ahead in your studies, in your work. The bottom line in all of this is that the world of global health is moving rapidly towards a new framework of health systems. In which the real foundation of a health system is what takes place in the community. And, I think we're also moving into a situation in which rather than simply having one community health worker for 2 or 300 households, I think we're going to be seeing systems in which we have two levels of community workers. One, the traditional paid community health worker. And then a lower level volunteer worker who has a smaller number of households, and who does a very specific set of tasks. But as we move forward with this, and as these larger scale programs become rolled out and they have an opportunity to be evaluated. Making sure that the workload is reasonable in relation to the training and the incentives of the salary provided is terribly important. Looking for creative ways to embed these people in the community, while at the same time maintaining a strong link to the health system is terribly important. Finding creative financial incentives that make these programs sustainable in the longer term without external donor support is a critical element as well. My friend, Ram Shrestha, who is the person who spearheaded the reactivation of the. Female community health volunteer system in Nepal says that a community health system is like a piped water distribution system and if you get the system developed then you can add new interventions onto the system very easily but if you don't have the system, you can't do it. He also likes to talk about what is not a community health system. And he refers to something that is not a community health system is a stack of pipes that are not interconnected with one another. So, looking to ways for developing functioning community health systems is one of the great exciting challenges for the future, I think. I happen to believe as Ram Shrestha has said that a health system that lacks interface with a strong functioning community health system is bottomless and doesn't have a foundation. I think this is a new concept for health systems. That is a fundamental one but I hope that you will consider as you continues through the course. One of the things that's always interest me is that the availability of health facilities in developing countries, is a fundamental problem, and the further away you live from a health facility, the less likely you are to use it. In fact There's an exponential drop off in utilization of services from the health facility with their distance away from it and so this has been known since 1966 but we've been very slow in developing strong community systems that don't rely on health systems but I think we're Now moving into this in a big way now. So I hope that this lecture has helped you to get some sense of the potential role of community health workers and the challenges involved in setting up these programs. Thinking of communities as a resource, not simply a passive target of services, I think, is a fundamental Idea that's terribly important here. And learning how to access these resources for the benefit of the health of the community is one of the great challenges of global health today. And this final diagram, I think conveys a lot of these ideas as well. No matter how good the technical intervention is If you don't have the engagement of the community with these types of interventions which are essential for improving the health of people. The outcomes will not be what they potentially could be without the engagement of communities through these kinds of activities that I've been talking about. We've covered a broad canvas here in this lecture historically and geographically. And as I think about this I reflect back on my own early experience in Bolivia in the 1980s, when I had a chance to work with these community level people, and we started. Programs of visiting households and we began to see the impact of this kind of work and its continues to be a source of great enthusiasm and passion for me and its just wonderful for me to plan my career to see these kinds of ideas really taking hold on a much broader scale. So, thank you very much.