COMMUNITY HEALTH WORKERS A Report of the World Health Organization Inter-Regional Study and Workshop 4-8 July 1983, Manila, Philippines
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- Title
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COMMUNITY HEALTH WORKERS
A Report of the World Health Organization Inter-Regional Study and Workshop 4-8 July 1983, Manila, Philippines - extracted text
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WORLD HEALTH ORGANIZATION
SHS/HMD/84.1
ORGANISATION MONDIALE DE LA SANTfi
ORIGINAL: ENGLISH
GILL TREMLETT
COMMUNITY HEALTH WORKERS
ft Report of the World Health Organization Inter-Regional Study and Workshop
4-8 July 1983, Manila, Philippines
i
I
WORLD HEALTH ORGANIZATION
SHS/HMD/84.1
ORGANISATION MONDIALE DE LA SANTE
ORIGINAL ENGLISH
INTER-REGIONAL STUDY ON
COMMUNITY HEALTH WORKERS
A Report of the World Health Organization Inter-Regional
Study and Workshop, 4-8 July 1983, Manila, Philippines
CONTENTS
Page
Preface . .
Introduction
Chapter 1. iOutcome of country experiences
............
- The Community Health Worker
- Community support for the CHW
- Preparation of the community
....... .
- CHW’s job description, tasks and coverage . . . .
- Traditional practices and drugs
. . . .
- Training of the CHWs
.
- Supervision
........... ..............
- Information systems
. . . . . . T . . .
- Patterns of financing
- Conclusions and Recommendations regarding the
Community Health Worker and his/her community . .
Technical aspects of the CHW . . . .
- Nutrition
- Expanded Programme on Immunization
- Control of Diarrhoeal Diseases . .
31
32
33
34
Chapter 3.
Urban Primary Health Care - the Manila field trip
35
Chapter 4.
Recommendations and Follow-up Actions
37
Annex 1.
List of participants
39
Annex 2.
Revised Agenda
41
Annex 3.
Diagrams illustrating processes for primary health
care development as part of national health systems
and community development (Philippines, WPR) . . .
43
CHW basic data
........................................
CHW support groups
. .
...........
CHW job descriptions
CHW’s relationships with traditional practices and
practitioners
. , .
Drugs prescribed by CHWs
CHW training
CHW supervision in the community
Community financing
Table 5.
Table 6.
Table 7.
Table 8.
issue
formal
or
It
quoted
the
World
are
responsible
Health
for
5/6
8/9
14
16/17
18/19
20
24
27
should
not
be reviewed,
Ce document ne constitue pas une publication,
II ne doit faire I'objet d'aucun compte rendu ou
without
the
agreement of
resume
this document does not constitute
of
publication.
abstracted
articles.
30
Chapter 2.
Table 1.
Table 2.
Table 3.
Table 4.
The
2
3
4
4
7
12
13
15
15
23
25
26
Organization.
views
ni
d'aucune citation sans I'autorisation de
Authors
alone
I'Organisation mondiale de la Sante.
in
signed
exprim^es
expressed
dans
leurs auteurs.
Les opinions
les articles sign6s n'engagent que
SHS/HMD/84.1
page 2
Preface
The eleven participating countries who attended the Manila Workshop,
4-8 July 1983, are grateful to the World Health Organization for this
opportunity to continue sharing learning experiences in order to improve their
country programmes. It is during such scientific meetings that we can debate
the strengths and weaknesses of our programmes and develop alternatives to
improve our health delivery systems.
The participants are particularly indebted to the Regional Director for
the Western Pacific Region and his staff for organizing such a meeting; to the
Philippine Urban Primary Health Care team, and to the consultants for their
active participation and valuable contribution to this Workshop.
The participants also wish to thank their respective governments for
giving them the opportunity to attend the meeting.
Manila, Philippines, 1983.
SHS/HMD/84.1
page 3
INTRODUCTION;
Following the WHO/UNICEF sponsored International Conference in Alma Ata in 1978, the
Primary Health Care (PHC) approach was unanimously accepted by the member states as the most
r-■
r
i ■
■
iin.-ix-L.
effective
way of
achieving
"Health rfor ait
All by the Yearonnn
2000.”
One of the guiding principles in this approach was the utilization of Community Health
Workers (CHW) to extend health services to the population, to support the community in
identifying their own health needs, and to take the necessary actions to solve their own
problems. This innovative concept of involving the community gave a new dimension to the
management of health care, and provided member states with a baseline for rethinking
practical means to deal with their respective situations.
The Conference also stressed the need to clarify and define the functions, define the
required training, establish the remuneration and other related aspects of the Community
Health Worker so that countries could put them to use in promoting and improving primary
health care programmes. Recognizing that the health needs and health delivery systems
differ in the various countries, the conference underlined the importance of a comprehensive
exchange of experience and information in order to avoid previous mistakes. The first
workshop organized to that end was held in Jamaica in 1980, and was attended by 13 member
states. The result of this workshop was an extensive list of "guiding principles" which
could be used as a reference for the development of community health worker activities in
different countries. However, it was felt that a more in-depth evaluation of some of the
key issues on CHWs was also needed. Thus, as a follow-up to the Jamaica workshop, an
initial framework which was prepared in 1981, covered 3 main issues, as regards the position
of the Community Health Worker, namely: his/her community; his/her training; his/her
support. This framework would serve as a model structure for a multi-country research and
development activity on CHWs. Eleven countries (Benin, Botswana, Colombia, India, Jamaica,
Liberia, Papua New Guinea, Philippines, Sudan, Thailand and Democratic Yemen), were invited
to a consultation in early 1982 to review the framework and the methodology proposed for
such an activity.
The participants, who were designated as Principal Investigators, began to implement the
research and development activity in their respective countries. They adopted the
working-team approach in order to benefit from mutual experience, thus providing added
information and dictating further action and study. The working teams were composed of
health workers, volunteers, sociologists, students and other personnel from participating
agencies, thus demonstrating intersectoral collaboration in the Primary Health Care approach.
In the course of 1982, the country research and development activities were implemented
and, by the beginning of 1983, reports from the various countries were submitted to WHO.
These were then tabulated to summarize the main descriptive aspects of CHW activities in the
different countries. An analysis of the key issues was added forming the basis of a meeting
involving the Principal Investigators of the member states, which took place in Manila from
4 to 8 July 1983. The objectives of this meeting were: to identify the problems facing CHW
programmes and recommend alternative measures for action through a learning-by-doing
process; to investigate alternative processes for a periodic revision of CHW activities and
their impact at the national level; to agree on follow-up activities providing exchange and
dissemination of effective innovative experiences.
This report presents a summary of the discussions held (Chapter 1), with the major
recommendations deriving from these discussions. Chapter 2 deals with several technical
aspects of the CHW's responsibility, namely nutrition, immunization and control of
diarrhoeal diseases.
In Chapter 3 is included a description of a field trip to an urban
Primary Health Care project in Manila, to observe and learn from the management of the
community by the community. This trip provided a rich and tangible experience for
participants, from which they could learn, compare and relate aspects of the programme to
their own demands and thus, strengthen their country programme by improved leadership and
motivation. Chapter 5 presents a summary of the expected follow-up activities for study and
improvement of CHW programmes.
SHS/HMD/84.1
page 4
CHAPTER ONE
OUTCOME OF COUNTRY EXPERIENCES
THE COMMUNITY HEALTH WORKER
Due to the extensive requirement and use of CHWs by communities, it is important to
choose CHWs in function of those characteristics which would contribute to their maximum
effectiveness, such as the type of person who should be selected;
the tasks they would be
expected to perform; would CHWs be full-time or part-time workers, The various contexts of
cultural, political and geographical realities and the size of the population are also to be
considered when selecting these CHWs.
It was suggested that either a programme be
established to provide guiding criteria for selection, or that such decisions be left to the
community Support Group (SG).
Despite the different experiences of the represented countries, it was generally felt
that the final decision on CHW selection should be made by the SG, (or, as in the case of
Benin, by the entire village), although in some countries such as the Philippines, this is a
joint decision to be taken with the health sector.
As regards the sex of the CHWs in the study countries it was reported that out of 11
countries, one of them (Jamaica) had all female CHWs; 3 of them (Botswana, Colombia,
Philippines) mostly female; 5 mostly male; another (India) had mostly male CHWs but the
requirement has recently changed to female; and the last country (Benin) has 2 CHWs of whom
one is female and the other male or female.
In India, an interesting development was observed. When the CHW programme first came
into action, the sex of the CHWs was not mentioned in the criteria, thus allowing
communities to select both male and female workers. In fact, very few women were selected.
After programme implementation was under way, an evaluation of the effectiveness of the
female CHW showed that, in general, they were performing much better than their male
counterparts. On this basis, the selection criteria were modified to encourage - but not
require - each community to select a woman. The proportion of women then selected increased
slightly, without, however, reaching 10% of the total number. A second
effectiveness-evaluation was carried out, and again the results were in favour of female
CHWs. Once more the selection criteria were modified to require the selection of a woman
unless "a suitable woman candidate is not available or not willing to work".
According to the different country reports, the tendency is to use somewhat older CHWs
(from 35 to 55 years), as shown by the more effective - less effective scale established in
countries such as the Philippines, Thailand, India, and Jamaica. Based on empirical
evidence, it has been found that most of the other countries agree that older individuals
tend to perform more effectively. However, no decision was reached as to whether a minimum
of 25 or even 30 years of age should become a requirement or only a recommendation to SGs.
Colombia and Papua New Guinea on the other hand, consider a younger age group of CHWs (17 to
25 years) to be preferable.
The level of education of CHWs ranges from no education at all to college graduation,
In general, the educational level of CHWs is equal to
although both extremes rarely occur,
or slightly higher than that of their community, The various reports generally agree that
this is appropriate and should be maintained.
Opinions vary considerably about the selection as CHWs of traditional birth attendants
(TBAs) and practitioners of traditional medicine (PTMs). The existing situation differs
considerably from country to country, ranging from cases such as Thailand where TBAs and
PTMs are virtually non-existent to cases such as Benin where several operate in nearly every
village. Although it was generally felt that TBAs and PTMs should be encouraged to become
CHWs, there are serious obstacles which can hinder this process. In Botswana, for example,
attempts to enlist PTMs have proved virtually impossible, due to both the secretive and
lucrative aspects of their positions. In India, an earlier positive view of PTMs has been
altered, and villages are currently discouraged from selecting them because "it was found
that their own interests were in conflict with the objectives of the CHW scheme."
TABLE 1.
Title
of
CHW(s)
Country
Fulltime (FT)
or
Part time (PT)
Coverage
Sex
CHW BASIC DATA
Duration of
pre-service/
basic/initial
training
Paid(P)
or
Voluntary(V)
by
govt.
If paid
by
by
project community
Traditional Midwife
(TBA)
two PT
1-4 hrs. per
day: one-am
othevpni
500-1000 av.
(1000-2000 by
two TBAs)
F
4 weeks
P+V
/(but some
do not
pay)
First Aid Worker
two PT
1-4 hrs. per
day: one—am
other-pm
500-1000 av .
(1000-2000 by
two FAWs)
M or F
4 weeks
P+V
^(but some
do not
pay)
500-1000
mostly
F
11 weeks
P
paid very
well
750-1000
(max. travel:
one hour)
mostly
F
urban/rural 13-14 wks.
ind igenous8 wks.
Health
Prom - P
Responsible
for Health-V
J
mos tly
200 hrs in 3
P - but much
M but
mo. (c. 33 da) lower than
now F
'real' salary
required
✓
Benin
FT
Bot swana
Family
Welfare
Educator
Colombia
a) Health Promoter
b) Responsible
for Health
Ind ia
Health Guide
PT
1000
Jamaica
Community Health
Aide
FT
2000
Liberia
CHW/VHW
PNG*
Aid Post Orderly
Health Prom-FT
Resp. for
Health-PT
PT
2-5 hrs. per
day
FT
F
8 wks
100-1000
(15-150 house
holds)
mostly
M
6 wks
50-1000
mostly
M
2 yrs
/
(local gov't - but not
same as community
Notes
If CHW is paid, it is a
small amount, not fixed,
may be either in cash
or in kind. Funds
are given on an
individual basis as
payment for service but
is strictly voluntary
(non-payment would have
no effect on the
quality of service).
Paid by local gov't
authorities, with funds
from the central gov't.
In some States, funds
come from the community.
In most instances, funds
are from central and/or
state gov'ts. About
10-20Z of programmes
are supported by
voluntary organizations.
P
P - but much
lower than
'rea1'
salary
P
✓
✓
X)
Cb
0Q
Philippines varies - mostly
Barangay (Village)
Health Worker
PT
500-1000
a) F+M
b) M+F
c) F
•it’k'k
a) 2 wks
b) 4 wks
c) 1 da/wk
x 15 mo.
***
some P,
others V
(if paid)
Gov't or private
agencies pay in some
projects; others are
voluntary. Some also
profit from village
drug store.
rc
cn
X
tn
I
OO
0Q
tn
X
(T>
00
TABLE 1.
Title
of
CHW(s)
Count ry
Fulltime (FT)
or
Part time (PT)
Coverage
Sudan--"
CHW
FT
set tled
nomad ic
Thai Land
Vil. Hlth. Volunteer
PT
Vil. Hlth. Communi
cator
PT
Health Guide
PT
Yemen
CHW BASIC DATA (continued)
Sex
Duration of
pre-service/
basic/initial
t raining
Paid(P)
Voluntary(V)
mostly M 1 year
P - about
twice mini
mum wage
500-1000
mostly M 15 da.
V
50-100
mostly M
5 da.
V
250-300 actual
300-1000 plan
mostly M 3 months
4000
1500
by
govt.
If paid
by
project
by
community
Notes
J
CHWs receive free
medical care. Some
also make a small profit
from village drug
cooperatives.
V
••The general consensus was that the Aid Post Orderly in PNG is more comparable to a health centre paraprofessional than to a designated Community Health
Worker.
The two-year training period would certainly not be sustainable if APOs were to be introduced into every village.
In fact, PNG is currently
beginning; a small scale tryout of another type of worker - with much shorter training - who is more of a designated CHW.
**Sudan also has a Trained Midwife who would qualify as a Community Health Worker by the definition used in this study.
category of worker was not included in the country report; they receive a small salary.
"*"Phi1i pp i nes:
3,
b, c refer to three different projects.
However, information on this
SHS/HMD/84.1
page 13
All countries agreed that sufficient time be allocated for such a process. The length
of time varies according to the receptiveness and existing level of knowledge of each
community, from one week to six months - too broad a range for meaningful planning.
If decision-making is left to the communities, one logical and inescapable conclusion is
that they should have the right to reject the programme completely. In such cases, however,
it was felt that health centre staff should continue to keep the option open, rather than
view the community's rejection as final. Such communities might for example be encouraged
to develop alternative approaches for the achievement of the same goals, or might even be
encouraged to visit an effective CHW in another community and then reconsider their decision.
In addition to the preparation of community leaders, it was felt to be important to try
and help the entire community to understand the programme even before CHW selection. This
is currently being done in the Philippines via meetings of the village assembly
a
gathering of all village adults/elders. A number of reasons were given in favour of
approaching the whole community rather than only the leaders. It was felt that the health
sector personnel was better placed to present the programme to the villagers than the
leaders who had just been introduced to it themselves. The personnel could assist the
leaders in understanding the programme by bringing about a confrontation between themselves
and the villagers and allowing the leaders to benefit by attending this interaction.
Approaching the entire community would stimulate the villagers' motivation and acceptance,
as well as incite people other than leaders to formulate their ideas and questions. Such an
approach would also ensure that all potential CHW candidates are fully aware of the
programme.
CHW's JOB DESCRIPTION, TASKS AND COVERAGE
Job description:
’’ j as to what they are expected
CHW job descriptions should be reasonably accurate guides
is
extremely
important
for
support
group
members as well as health
to do. As such, it i_ .
,
’
’
, and to use them as a means of
sector personnel to be familiar with these job descriptions,
It was also suggested that SGs review those
assisting and assessing their CHWs.
descriptions periodically, both as a source of information for a revision of the national or
programme-wide job-description and as a basis for modification of their own CHW's tasks, in
the
local health staff,
in order to deal with the specific needs of the
conjunction with -- ------------community.
Number and types of tasks:
The major tasks CHWs are expected to perform are listed by country in Table 3. There is
great consistency from one country to another, as shown by the fact that 14 out of the 23
tasks are carried out in at least 10 countries. However, there appears to be a slight
difference between programmes with part-time CHWs (with an average of 17.7 tasks) and those
with full-time CHWs (19 tasks).*
Certain tasks require CHWs to take action more immediately, rather than just inform or
advise, namely: give first aid treatment in case of accidents or minor illnesses; dispense
drugs; deliver babies; take care of nutrition; give injections; distribute family planning
supplies; start dealing with communicable diseases. Of these tasks, full time CHWs perform
an average of 5.2, while part-time CHWs perform only 3.7, thus accounting for 2/3rds of the
difference between full-time and part-time performance of workers.
In general, it was felt that CHWs were asked to do too much, especially the part-time
workers. It should be possible to decreasei the number of tasks according to the priority
the terrain and the technology available.
health problems, the distance to travel, U.
*Tasks which are performed "irregularly"
irregularly" or "occasionally" are also included, since CHWs
would still need to be trained to perform them.
T5 W
0) X
oq
cn
(T> \
TABLE 3.
CHW JOB DESCRIPTIONS
00
TASK SUMMARY
BENIN
BOTSWANA
1 - First aid, treat accident and simple
i 1 Iness_________
2 - Dispense drugs
✓
y
3 - Pre, post-natal advice, motivation
4 - Deliver babies
COLOMBIA
INDIA
y
y ( i nc 1.
injections)
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
X
y
X
X
X
X
X
X
X
X
5 - Child-care advice, motivation
y
J
y
y
y
y
y
y
y
y
y
6 - Nutrition motivation, demonstration
y
y
y
\/
y
/
y
y
y
y
y
7 - Nutrition action (W = weigh children,
maintain chart; F = distribute food
supplements)____________________
8 - Immunization motivation, assistance
during clinic
_______________
9
Immunization - give shots
F
W
W
X
W, F
X
w
W, F
F
W, F
X
>/
y
y
y
y
y
y
/
y
y
y
X
X
y
X
JAMAICA
LIBERIA
PNG
PHIL
✓
/
y (incl.
injections)
y
SUDAN
y
THAILAND
YEMEN
y
y
y (vhv
y
only)
X
X
y
“X
y
X
X
10 - Family planning motivation
y
y
./
y
y
y
X
y
y
y
y
11 - Family planning - distribute supplies
X
y
y
y
X
X
X
y
y
y
X
12 - Environmental sanitation, personal
hygiene, general health habits motivation___________
13 - Communicable disease screening,
referral, prevention, motivation_______
14 - Communicable disease follow-up,
motivation of confirmed cases
15 - Communicable disease action (D=provide
drug resupply; M=take malaries slide)
16 - Assist Health Centre clinic
activities (i.e. not in village)________
17 - Refer difficult cases to Health
Centre or Hospital
18 - Perform school health activities
______ regularly_______ _______________
19 - Collect vital statistics
~
y
y
/
y
y
y
y
y
y
y
y
/
y
</
y
X
y
y
y
y
y
y
y
y
y
y
X
irreg.
X
D
D, M
M
X
X
D, M
occasiona 1 ly______
y
occasionally
X
y
X
y
y
y
X
X
y
y
X
y
y
y
y
irreg.
TB sputum
smear___
D
X
D
y
X
occasion
ally______
X
X
y
y
y
y
y
y
X
X
X
X
y
X
y
X
y
y
y
X
y
X
y
y
y
y
20 - Maintain records, reports
y
y
y
y
y
y
y
y
y
y (vhv
y
21 - Visit homes on a regular basis
y
y
y
y
y
irreg.
y
y
4
y
X
22 - Perform tasks outside health sector
(e.g. agriculture)________
23 - Participate in community meetings
y
y
X
y
X
y
X
y
y
y
y
y
y
y
y
y
y
y
y
y
y
y
KEY:
y = task performed by CHW
X - task not performed
only)
SHS/HMD/84.1
page 11
Two of the common requirements for SGs are activity planning and financial management.
Both were considered to be essential tasks for an effective SG. Planning of community
health activities is a creative task in which SG members, using simple methods, learn to
study their community and evaluate existing activities, decide what the problems are,
establish priorities and consider alternative actions, before developing a work plan.
Financial management (wherever funds are raised by the community) requires decisions on how
to obtain funds and an acceptable scheme for controlling the flow of funds and ensuring
their accountability.
If a SG is able to perform these two functions well, it is likely to
remain interested, active and effective. Unfortunately, most SG members lack the skills
needed to perform these functions adequately. None of the countries are currently doing
this, but all agreed that major emphasis should be placed upon the need to provide training
to SG members in each of these areas - an appropriate type of training, with each of the
skills taught by a simplified, relevant and understandable method.
Another area in which it was felt SGs should be knowledgeable concerns more technical
aspects of their role; health content and more general community development content which
need greater attention during the preparation of a SG.
Finally, and perhaps most important, it was felt that many SGs lack the required
motivation.
In part, this may be due to a history of government paternalism in which health
services have been handed down to the people, who thus have come to believe that it is
unnecessary for them to take action.
'Social preparation' of the SG, or motivating them to
recognize and accept the necessity of community participation in understanding and solving
health problems is a basic pre-requisite to the success of these groups.
In the Philippines and Thailand, some CHWs operate community drug sale projects.
In
these countries, the SG plays an important role as monitor of the system, ensuring that the
funds raised by the CHW are collected and used appropriately. However, in three other
countries in which CHWs raise funds from drug sales - Benin, Botswana and Colombia - it was
not considered appropriate to involve the SG in this process.
Relationship with the health sector;
Several of the points raised in the previous sections lead to one of the most repeated
and most important conclusions of this report; the need to train SG members by the health
sector, that is, usually by the health centre staff. This training should be given m such
fields as social preparation/adaptation, activity planning and management, financial
management when needed, specific related health topics, community development, drug sale
_£-«..•--- 1 The SGs should also have some
management as required, planning
and conducting of
meetings,
knowledge of the existing health services iand
-- of
_ the functions and job description of the
CHW within the programme. It was understood that priorities would be established for a
series of short-term training/orientation sessions,, as all these topics could not be covered
during a single training course. No decision
-------- was
-- -reached as to the length of the series of
sessions.
However, if health centre staff are to train SG members effectively, they themselves
will require training, All countries felt an urgent need to provide training for health
______ They also felt that it was necessary to
centre staff in the various areas mentioned,
publicize and inform the population in general of the value of preventive activities, of
community participation, and of CHWs. As regards preventive activities, it was suggested
that the distinction between preventive and curative tasks should not be underlined as yet,
but rather that all the functions related to a specific disease or condition be integrated
into a comprehensive approach. For each disease or condition, it was suggested that a very
simplified presentation be devised - first, to ensure that health centre staff themselves
have a clear understanding of the disease, its cause and prevention, then for them to convey
this understanding to SG members.
Regarding community participation and the CHWs, several countries noted the difficulty
of convincing health centre staff that the exercise of power and the performance of tasks by
villagers should be viewed positively, as an enhancement rather than as a loss of their own
influence. Greater involvement by health centre staff in the initial training of CHWs, as
SHS/HMD/84.1
pa^e 12
well
11 as the training/orientation of SG members, should help to improve health centre staff
attitude; additional training of health centre staff by higher level personnel was
considered to be equally necessary.
Another weakness noted in the relationship between health centre staff and the
communities they serve is that health personnel tend to have an inadequate understanding of
the cultural and economic implications of their various recommendations for the improvement
of health. For example, recommending that mothers of malnourished children feed them
certain more nourishing foods is not a helpful suggestion to a mother who cannot afford to
purchase the suggested items. With a greater understanding of the life of the poorer people
in the community, health centre staff are more likely to limit themselves to realistic,
credible recommendations.
It was also suggested that health centres need to serve not only as medical, but also as
multi-sectoral problem referral points.
If, for example, a SG or a CHW needs information or
materials for construction of a water system, and the health centre can serve as a link to
other government or private resources, then the health centre’s credibility in its major
areas of expertise will be considerably enhanced.
Finally, another suggestion was for health centre staff to assist SGs in comparing their
accomplishments and achievements to those of neighbouring communities. This could be done
in 2 ways; either by consolidating data from different communities so that comparisons can
be made readily; or by identifying the communities in which SGs and/or CHWs are performing
better than average, and then helping other SGs to learn from them.
PREPARATION OF THE COMMUNITY
One of the weaknesses of many country programmes is that the selection of the CHW although done by leaders of the community - occurs at a time when the community as a whole
has no understanding of what a CHW is supposed to do, and the community leaders have only an
unclear, preliminary understanding. As a result, the individual selected to become a CHW
may not be the best possible candidate. Another consequence of this lack of understanding
is a general lack of interest, expectation and involvement of the community in their CHW and
in what he can do for their own welfare.
These problems could be considerably alleviated if more attention were paid by the
health sector to the preparation of the community during the period preceding CHW
selection. All countries felt this to be extremely important. Only one country (Benin),
where "efforts are made to arouse the interest of the whole village, (to make the) whole
population aware of the criteria for selecting the CHW and the conditions under which he or
she will work" reported that the current process is adequate; in some other countries ( e.g.
Colombia, Botswana), this process is sometimes used, but in all countries it was felt that
more emphasis should be placed on this social preparation stage.
Throughout the study, considerable attention was paid to answering the following
questions; how to "sensitize" the population to the value of CHWs; how to spur interest in
the programmes; what role should health centre staff be called upon to play.
It was agreed that it is essential for health centre staff to visit each village several
times during this preparatory stage. Through a series of formal and informal discussions
with community leaders, they can introduce the programme, then facilitate both an
understanding of it and decisions concerning it by community leaders. Considerable emphasis
was placed upon the importance of health centre staff not making decisions, but rather
limiting themselves to providing technical advice while encouraging decision-making by the
qommunity itself,
In this context, the Manila City Project which participants visited was
c ited as an excellent example: throughout a phased process of drawing up a questionnaire,
implementing a survey, analyzing the survey results, then establishing the initial aspects
of an action project, the health sector personnel has acted as facilitators and technical
consultants, while the community provided most of the information and made the decisions;
only after the community has developed an understanding of its health problems was the idea
of a CHW introduced and discussed; and only after this lengthy process (two months) were the
CHWs selected.
SHS/HMD/84.1
page 7
COMMUNITY SUPPORT FOR THE CHW (CHW Support Groups)
During the first phase of this project, one of the "guiding principles" which was
suggested to promote the development of the CHW programme was expressed in the following
terms:
"Some form of
relationships
including the
personnel and
viable community organization is necessary to establish operational
between the community and the government's developmental agencies
health sector, thus promoting a new partnership between government
the community. ii
Building upon this earlier consensus, the second phase of this project no longer
questioned whether or not such community organizations or support groups were needed.
Instead, it focused on their characteristics: what aspects, and what factors of the local
organizations supporting the CHWs contribute to their success?
The basic structure of these SGs tends to vary, but in most instances - reference Table
2 - these either constitute the local village council or are part of a sub-committee on
health. Since decisions about the framework and functions of the SG are so closely linked
to the political structure of each country (thus placing the SGs beyond the exclusive
responsibility of the health ministry), it was not considered necessary to seek alternative
types of SGs. However, if SGs are not an integral part of the local village council, then
strong linkage with this formal community leadership needs to be established and
maintained. In Thailand for example, it was felt that one of the weaknesses undermining the
effectiveness of the SGs, and therefore that of the CHWs, was the lack of proper
representation of the Village community in the various SGs. In one other country, the SGs
benefit from satisfactory organization; however, a proper backing from higher echelons at
state level is missing.
The various country reports focused on 4 areas of importance concerning the SGs, namely,
the question of membership, the frequency of meetings, the responsibilities and functions of
the SG, and its relationship with the health sector.
Membership
CHW Support Groups should, undoubtedly, be representative of the communities they
serve. However, as can be seen from Table 2, there are many different interpretations of
what is meant by representative: among the criteria used are occupation (Benin, Colombia),
caste (India), sex (Benin and India require that at least one woman be included; Colombia
shows a 1:1 ratio in general; Botswana and Jamaica include a majority of women), religion
(Benin, Philippines) and political affiliation (Yemen, Benin). Another representative
member may be chosen on the basis of a geographical sub-unit of the community, although this
was not a criterion taken into account by the member states as yet.
It was generally felt
that at least some of the members of the SG should be elected, either by the community as a
whole or by a particular constituency. Election not only ensures adequate representation of
the SG, but also serves as a valuable mechanism for educating the community about the
functions of the SG and the CHW.
One of the more controversial aspects of SG membership is the role of women and of
'vulnerable' groups ktne
(the poor, tne
the illiterate, certain ethnic groups or castes in some
countries). The latter urgently require the services of the CHW among other needs, but tend
to be badly represented at governing councils. The question was whether special efforts
should be made to include them in CHW Support Groups.
It was generally agreed that there
could not be a single answer: in some contexts, requirement or encouragement for women
and/or 'vulnerable' groups to be SG members may be feasible;
in other contexts, however,
alternative means need to be found to ensure that their interests at least are represented.
Also regarding 'vulnerable' groups, it was noted that if these occurred in urban areas,
where the population is much more heterogeneous than in rural areas, there would be greater
difficulty in involving them in the Support Groups.
X)
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TABLE 2.
(Z)
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CHW SUPPORT GROUPS
CO
BENIN
Type of support group
Number of members
Type of members
CHW role in meeting
Frequency of meetings
Responsibilities/
func t ions
- Village Health
Committee - new group
7-10
BOTSWANA
- Village Health
- Community Action Board
Committee - new group- Also, some communities
97Z of villages had VHCs
have health committees,
- VHC is sub-committee
either subordinate to,
of Village Development
or independent of CAB
Committee
- Some have no SG
20
- Should be:
- About 2/3 female
- Village delegate
- Selected by village
CHWs
as a whole with
members: local
concurrence of chief
revolutionary council - Many members have
- 3 members other groups
experience in other
- TMP representative
organizations
- religious leader
- extension worker
- teacher
-All VHCs include 1 woman
- About half literate
- Some are elected_______
active
active
monthly or quarterly
monthly or more
frequently
- All the vi1lage1s
- Planning
health problems
- Implementation
- Does not select CHW- Keep community vege
done by village assembly
table garden to feed
- Looks after CHW's
malnourished children
land during training
- Motivate community on
- Administrative super
environmental sani
vision of CHW (schedule,
tation, etc.
identification of
- Home visits for
health problems)
treatment, follow-up,
- Health programme
elderly, destitute,
implementation
hand icapped
(e.g. construction of
- Evaluation
latrines)
- Vital statistics
- Programme planning
- Financial management
(but not common)
- VHC members work
10-20 hours per month
COLOMBIA
5-8
- Peasants
- Manual workers
- Housewives
- Both M and F
- Leaders of community
INDIA
JAMAICA
- Varies considerably
from state to state
mostly functioning
poorly
- Plan to establish
Village Health
Committee (remainder
of this column
refers to plans
not reality)_______
5
- Either deriving
from an existing
group or initiated
by health team
- Affiliated with
formal village
counc i1
- 1 woman
- 1 scheduled caste
or tribe
- Varies, but
representative of
entire community
- Majority are women
- 3 others members
24
Once every 3
meetings, medical
officer attends to
"explain to the VHC
action taken on the
previous decisions
of the VHC"
active
monthly
- Coordinating activi
ties/ implementation
- Supervising and
promoting health
- CHW selection
- No financial
responsibilities
active
monthly
- Support functioning
of CHWs
- Assess health needs
of community
- Convey VHC meeting
results to medical
officer
ac t ive
monthly or more
f requently
- Identify
health needs
- Develop/implement
activities to over
come health
problems
- fund raising
- maintenance of
health centre
- best-kept home
competition
- community health
education
TABLE 2.
Type of support
group
Number of
membe rs_______
Type of members
CHW role in
meeting
LIBERIA
PAPUA NEW GUINEA
- Where Vi 1lage
Council exists Village Health
Committee (sub
committee of VC)
- Where no Village
Council exists Village Development
Counc i1___________
7-15
None
- Some fairly evenly
divided among men,
women, youth
- Others mostly older
men or younger boys
active
(usually)
Frequency of
mee t ings
Range from 2-12 per
year. Considerable
variety
Respons ibi1it ies/
funct ions
- Selection of CHWs
- Review of CHW
activities (esp.
administration)
- Planning
- Implementing
- Raising funds for
development
act ivi t ies
- Mobilizing people
- CHW accountability
CHW SUPPORT GROUPS (continued)
PHILIPPINES
Health Committee
of Village Council
7-10
- Chairman of Health
Committee is member
of Village Council
- Teachers
- Purok (sub-village)
leaders
- Representatives of
local civic
organizations_____
Active in Health
Committee meetings,
but not in Village
Council meetings
1 per month and
when necessary
- Selection of CHWs
done by varying
mix of Village
Council, midwife,
community leaders,
project leaders
- Civic inspirational
talks at training
course opening and
closing ceremonies
- Collection, dis
bursement of funds
- Admin, supervision
- Planning village
health programmes
- Involvement in
mot ivat iona1
campaigns
- Review progress
SUDAN
THAILAND
YEMEN
- Health Committee
of Village Council
or ad hoc Health
Committee
- Varies. About
half of SGs are
not functioning
- Some have MOPH
VHDCs
- Some have health
sub-committee of
Village Development
Committee_________
7-10
- Village Council
(People's Defense
Committee)
- Party unit also
exercises some SG
func t ions
- MOPH-structured
committees have
only VHVs and VHCs
(the two types of
CHWs)
- Other health
committees usually
do not include
CHWs_____________
see above
- Secretariat of local
PDC
- Party representative
- Representatives from
agriculture, educa
tion, etc. sectors
VC - 24
HC - 5-8________
- Teachers
- Headman
- CHW
- Others
- Women: 25% of
VC; they are
usually represented
on HC.
active
6
Active when topic
concerns health
3-4 times per year
3-12 per year
At least 1 every
3 months
- Collect funds
- Construction,
furnishing of
Primary Health
Care Unit
- Admin, supervision
- Logistical support
- Maintenance
- Active when a
specific task needs
to be done
- Participation in
implementation of
campaigns (nutri
tion, health
education,
sanitation, etc.)
- Planning
- Support (esp.
fund raising)
- Follow-up
- Overall development
- Selection of CHW
- Implementation tasks
(digging wells,
building health
units, etc.)
XJ
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SHS/HMD/84.1
page 10
Meetings;
In
The effectiveness of the SG is directly related to the frequency of their meetings,
general, it is reported that the more often the SGs meet, the more effective they are, as is
It was emphasized that SGs should be
the case in Liberia, Benin and Botswana for example,
encouraged to meet at least once each month.
In every country the CHWs are reported to play an active role in SG meetings. It was
suggested that, where they are not currently doing so, they be encouraged to propose topics
for discussion during meetings. One way of doing this might be a CHW monthly report on the
community's health status, the CHW's activities and problems. Ideally, the CHW, in addition
to his/her role as information-provider during SG meetings, should also serve as a
facilitator, helping to elicit and organize the ideas of other SG members. This is not,
however, an easy role to play and the CHW will usually require outside assistance for
training and supervision.
In Liberia, Benin, Sudan, the Philippines and Jamaica, it was noted that the atmosphere
of the meeting was a democratic rather than an authoritarian one - and that this factor
contributed to the success of SG meetings. Others tended to agree, although some cautioned
that in many cultural contexts - especially in rural areas - this might prove difficult to
implement.
Finally, it was suggested that in some cases the quality of SG meetings would improve if
the SG leader could receive training on the preparation and process of an effective meeting.
Responsibilities/Funclions
An overview of the responsibilities of a CHW Support Group suggests that they may range
from broad community development topics - including but not limited to health - to the
support of CHWs. Figure 1 presents the most common situation; an SG is responsible for all
aspects of the community's wellbeing - including but not limited to the CHW's activities.
It is interesting to note that in no country is the SG limited only to support of a CHW.
(Such a limitation undoubtedly would prove objectionable to such an SG and would probably
render it ineffective even for its limited goal).
Figure 1:
CHW Support Group Responsibilities;
A Continuum
Responsibility;
health, education,
agriculture, other
community development
All health
activities
Current pattern
in;
Yemen
Colombia
Liberia, Philippines,
Sudan, Thailand,
Jamaica, India (not yet
operational), Botswana,
Benin.
CHW support
only
In some instances, an SG, although not responsible for projects unrelated to health,
nevertheless interprets its responsibilities broadly.
In Botswana, for example, many of the
village health committees maintain a community vegetable garden to help feed malnourished
chi Id ren.
one, the SG's initial responsibility is the selection of the CHW In all cases but one,
either solely or, as in the Philippines, in conjunction with health sector personnel, The
one exception is Benin, in which the entire village assembly rather than the health
committee alone selects the CHW - a process found to be very effective, both to identify
better candidates and to inform the population.
SHS/HMD/84.1
page 15
One type of task (No.22), which requires the CHW to deal with aspects unrelated to
health, and which is included in 8 of the 11 job descriptions of the different countries,
was considered as a potentially constraining task. It was then suggested that CHWs not be
expected to perform such tasks as gardening, maintenance of water supply, literacy classes,
income-generating activities, but rather to limit their action to serving as a link between
resources and to help coordinate the various activities. Another solution, if CHWs are to
perform health tasks, would be to reduce the size of the population they are meant to cover.
Population Coverage;
CHW coverage currently ranges from 50 to 4000 people.
In 4 countries however (Yemen,
Liberia, PNG, and Thailand) the coverage amounts to less than 500 people per CHW. This
issue was discussed at length, and two somewhat different approaches emerged; one side
suggested that each CHW in a rural area be responsible for a maximum of 750 people and in an
urban area, the maximum was to be a thousand; the other side preferred to distinguish
between full-time and part-time workers, responsible for a maximum of 500 and 300 people
respectively. However, the most important factor determining the number of people a CHW can
cover depends on the kind of tasks he/she is expected to perform; the fewer or less
time-consuming they are, the larger the population to cover and vice-versa.
TRADITIONAL PRACTICES AND DRUGS
The CHWs’ position concerning traditional practices and drugs was one of the most
puzzling aspects of this study. All countries agree that where a traditional practice is
known to be harmful, it should be discouraged (Examples of this were placing cow-dung on a
freshly-severed umbilical cord, denying liquids to a child with diarrhoea, the belief that a
child who eats eggs grows up to steal). But often - as reported by Benin, Botswana and
Jamaica - CHWs and health sector personnel themselves may not be certain whether a practice
is harmful, harmless or helpful.
It was suggested that it is unfair to instruct a CHW to
oppose harmful practices without clearly explaining which are truly, harmful.
Anthropological studies might be conducted to identify the most common traditional
practices, then a careful assessment of each of these conveyed to the CHWs.
A similar situation exists for traditional drugs. Currently CHWs are authorized to
distribute them in some countries (e.g. Thailand), forbidden in others (e.g. Papua New
Guinea) and neither authorized nor forbidden in most. Much more investigation is needed to
determine which traditional drugs are useful, and which of these a CHW should distribute and
how to obtain/prepare them.
Essential Drugs:
Table 5 lists an extraordinary range of drugs which CHWs may distribute - from 6 to 74
In all countries, CHWs do spend at least part - if not most - of their working time
items.
It was generally felt that this is
seeing patients and giving (or selling) drugs,
desirable, even if it is essentially a curative rather than a preventive or promotive task.
It was suggested that, within the limits imposed by the health policies of the country, the
influence of the medical profession, and the level of their training and logistics
constraints, CHWs should be provided with drugs to alleviate certain high-priority problems,
such as TB, yaws, malaria and other infections.
TRAINING OF THE CHWs
Trainers;
The performance of the community health worker is related to the type of trainers who
conduct the initial training sessions for CHWs. As shown in Table 6, there is no consistent
pattern for the recruitment of trainers for CHWs in the initial stages of the programme,
In
some cases (Botswana, Liberia, Papua New Guinea, Sudan), CHWs are trained in a
T3 cn
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TABLE 4.
CHW'S RELATIONSHIPS WITH TRADITIONAL PRACTICES AND PRACTITIONERS
OO
BENIN
Traditional practices
to be overcome
CHW' s und e rs t and i ng
of traditional
prac tices
- child who eats meat
will become thief
- child with diarrhoea
should not eat
- child with malnutrition
should not eat eggs,
fish, fresh meat
- child with measles should
not be bathed or eat
fresh meat, fresh fish,
ground nuts
- pregnant women should not
eat fruit as this will
make labour difficult
and cause dermatoses
- pregnant women should not
eat eggs, as this will
harm her ovum.
- etc.
CHWs taught some traditional
drugs, but extent of know
ledge of traditional
practices not clear.
BOTSWANA
- traditional drugs
- faith healing
- religious sects which
oppose use of medicine
- food taboos
- use of cow-dung, ashes
crushed egg shells on
freshly cut umbilical
cord
- breast feeding only
allowed if permitted by
traditional doctor
(following cured breast
abcess, death of
earlier infant)
COLOMBIA
INDIA
- disease causation
- herbs, witchcraft
to cure illnesses
- other practices
examples
- mother fasting for
recovery of sick child
- denying liquids in case
of vomitting, diarrhoea
- massaging abdomen for
abdominal pain
- bottle feeding
- belief that some
illnesses caused by
witchc raft
- non-use of contra
ceptives
- selecting food for
status rather than
nutritional purposes
- poor environmental
sanitation
- TBA practices
- As villagers, CHWs
know traditional
practices. In training
they are taught which
- Not clear, but a
module on ethno
medicine recently
introduced in one
supervisor/trainer
training school
- disease causation
- CHW, as a villager,
knows traditional
practices. Not clear
if she learns which
are harmful/helpful
(a) encourage
(b) discourage
(c) ignore
- CHWs also taught use
of specific non
western drugs
Pervasiveness, types
of traditional prac
titioners (TBAs and
PTMs)
Relationships between
CHWs and traditional
practitioners (TBAs
and PTMs)
TBAs and PTMs very
pervasive (av.2-4
per village), very
influent ial
- They cooperate only where
CHW is more influential
(about 2/3 of villages).
Often their relationship
is competitive.
JAMAICA
- Very pervasive
- Faith healing is
increasing
- CHW does not promote
or use traditional
medicine, but neither
does he condemn PTMs
- CHW tries to educate
PTMs
- CHW not perceived as a<
threat to income or
status of PTMs
- Totally pervasive,
including TBAs and
practitioners of other
systems of medicine
(Ayurvedic, Unani,
Siddha, Homeopathy)
- PTMs not an obstacle - Competitive, but CHW
to CHW acceptability
position is stronger
- CHWs provide
training to
traditional
practitioners
- In about 30% of rural
areas, 10% of urban
areas
- CHWs not expected to
collaborate
- PTM has little or no)
influence on CHW
TABLE 4.
LIBERIA
CHW'S RELATIONSHIP WITH TRADITIONAL PRACTICES AND PRACTITIONERS
PNG
PHILIPPINES
(continued)
SUDAN
- female circumcision
- food taboos
- use of TBAs instead
of trained midwives
- wound treatment with
cow-dung or soil
THAILAND
- cutting umbilical
cord with a piece
of bamboo
- sprinkling holy
water to treat
diseases
- Pepper enema to
children with
diarrhoea
- leaves, cow-dung
on freshly-cut
umbilical cord
- child who eats
eggs will be thief
- child who eats
meat will have
worms
- husbands should
receive best part
of any meal
- measles caused by
witchcraft
- desire for many
child ren
- etc.
- harmful practices
of TBAs, PTMs
- food taboos
examples
- fish causes
parasites in
children
CHW's understanding
of traditional
pract ices
As they relate to a
particular environ
ment - but not taught
- As villager, CHW
knows traditional
practices.
During training,
they are taught
which are harmful
heIpful
- As villager, CHW
knows traditional
practices and PTMs.
- He is taught that
certain practices
are harmful
- Taught traditional
practices during
initial in-service
training
- Some traditional
medicine (usually
herbal) being
included in
standard drug list
to be prescribed
by the CHW
Pervasiveness, types
of traditional prac
titioners (TBAs and
PTMs)
- Only 2 of 10
surveyed
villagers had
PTMs.
- Becoming less
common
- Wisemen, Wise-women
- Not so common
- Western medicine
preferred
- Local druggist
most common type
but also injectionists, quacks,
traditional
doctors exist.
Relationships between
CHWs and traditional
practitioners
(TBAs and PTMs)
- Villages with PTMs
among the most
successful CHWs
(not clear why)
- TBAs' poor prac
tices are being
overcome via MOH
training, so CHWs
and TBAs do
collaborate
- Relatively few PTMs
in surveyed
villages
- Presence of a PTM
- Some CHWs mentioned
frankly that it con
in village defi
fuses them to be
nitively has nega
told to seek peaceful
tive effect on
CHWs effective
co-existence with
traditional healers
ness
when they feel it is
their duty to overcomt
their practices
- CHW is threat to
status and income
of PTM«
Traditional practices
to be overcome
food taboos
- massaging pregnant
women
- eating fish after
delivery makes
breast milk smell
bad
- Not very
pervasive
No relationships
- TBAs
- herbalists
- religious healers
- bone setters
All very pervasive
YEMEN
- treatimg hepatitis
by cutting under
the tongue
- TBAs not tying
umbilical cord
- treating epistaxis
by lowering and
striking lightly
the patient's head
- belief that ea ting
fish can make
children forget
their lessons
CHWs are asked to
report about the
traditional practi
ces then discuss
with Health Centre
personnel who
explain which are
harmful. The CHWs
reports, however,
cannot include all
the traditional
practices in their
villages
- TBAs only; others
not common
- CHW is supposed
to help and com
plement the
functions of the
TBA wherever
needed and
possible
T3 CZ>
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TABLE 5.
TJ
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CD
DRUGS PRESCRIBED BY CHWs
00
BENIN
BOTSWANA
COLOMBIA
Nivaquine
Aspi rin
Gan idan
Mu 11 ivi t amins
90° alcohol
Boric alcohol
Iodized alcohol
Su 1 fani1 amide
powder
Argyrol
Mercurochrome
Methylene Blue
Gomenol oil
Standardized
list o£ drugs, but
not specified in
report. Some
experienced CHWs
also have sulfa
drugs, antibiotics
( includ ing
penic iIlin
injections),
malaria drugs
Anti-parasitics
Ant i-mala r ia1s
Metronidazole
Expectorants
Aspirin
Magnesium sulphate
Papave rol
Contraceptives
Sulphones
Anti-TB
INDIA
JAMAICA
A. Essential
15. Benzoic salicylic ointment
Zinc oxide
1. Chloroquine phosphate
16. Benzyl Benzoate emulsion
paste
Tablets
17. Terramycin eye ointment
Savlon
2. Primaquine Tablets
Aspirin
3. Iron and folic acid
List of medicines which may
Ac riflavine
tablets (for adults
also be considered for inclu
Alcohol
and children)
sion in the medicine kit of
Supersan
4. Vitamin A
the CHW. It is desirable
5. Dapsone tablets
that there be an ISM Physician
6. Multivitamin tablets
who can guide the CHW regard
7. Nirodh-Depot holder pack
ing the proper use of these
(in case "Depot holder
med ic ines.
free supply pack may be
available, free supply
1. Allopathic system
provided)
1. Antispasmodic tablets
8. O.R.S. Packets
2. Anti-histaminic tablets
B. Optional
3. A.P.C. tablets
(The list can be modified
4. Cough mixture
by the State Government
5. Anti-diarrhoeal tablets
as per their requirements.
In case the list is modi
2. Ayurvedic system
fied, chapter No. 9 of the
1. Lasmirhasa pata (for common
manual on the treatment of
cold, headache, influenza)
minor ailments, giving the
2. Ativisha Mishrani (infantile
detailed instructions about
diarrhoea, digestive disorders)
the use of these medicines
3. Panchguna taila (for external
should be modified
use in burns, ulcers, wounds
accordingly.)
and skin infection)
a) For internal use
1. Lashunadi vati (flatu
3. Unani system
lence, indigestion)
1. Qurs Mubarak (for fever)
2. Jetiphaladi (for
2. Qura Tinkar (for constipation)
diarrhoea, dysentry)
3. Arq Ajasb (for headache, earn
ache, toothache)
|
3. Mahayograj Guggulu
(body and joint pains)
4. Marham Khaxish (for external use)
4. Cina 30 (worms in
intestines)
4. Homeopathy system
5. Calocymus 6 and Maghpos
1. Colorynth 12 and Magphos 6x
6x (colic, abdominal pain)
(for abdominal colic)
6. Belladonna 30 and Merc
2. Cina 200 (worms)
sal 30 (dry cough with
3. Nuxvomica 30 and Matphos 6x
fever, toothache, swelling gums)
(for indigestion)
7. Kaolin pectan suspension
4. Chamomilla 30 and cal. Phos ox
(diarrhoea)
(dentition trouble)
8. Paracetamol tablets
5. Arnica Montana 200 (after
(fever, headache)
delivery)
9. Magnesium hydroxide
6. Cantheris ointment (for
tablets (constipation,
external use in burns)
acidity)
7. Calandula ointment (wounds
b) For external use
and injuries)
10. Antiseptic ointment
11. Menthol and eucalyptus ointment
12. Sulfacetamide eye and ear drops
13. Zinc boric acid dusting powder
14. Gauze and bandages
LIBERIA
Chloroquine
Acetyl sali
cylate acid
Triple sulfa
Gentian
violet
Eye ointment
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Coordination existing structure
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Intersectoral coordination
Child weighing
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Environmental sanitation campaign
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Organizing
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Sewing/cooking
Income generating activities
Organizing
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Manpower
Fund raising
Contribution to
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Mobilizing
Local
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Selection of VHW
Election of village network members
Provide manpower
for community
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DESIGN FOR DEVELOPMENT OF
PRIMARY HEALTH CARE AT
COMMUNITY LEVEL (WPR)
Government
and
Private Agencies
Problem area 2
Problem area 3
Problem area 1
Technical support
Referrals
Monitoring
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- Continuing education
Intrasectoral
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Strengthening
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- Management and technical series
- Improvement planning processes
- Improvement logistics/referral system
Basic needs
development
food/water/shelter
- Income generating activities
- Improvement of food/water/housing facilities
Intersectoral
coordination
Research and
Development
Environment
- Human and solid waste disposal
- Improvement of living condition
Health information
Monitoring change
- Development of lay reporting system
on health and development
Generation of
Health related
information
- Interrelationship of health/disease and
other factors: social, cultural, economic
and seasonal
Community
organization/
participation
- Development of community network, community
diagnosis. Understanding community
dynamics
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Process for Primary Health Care Development
to achieve Health for All (Philippines, WPR)
Health Manpower
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Strengthening
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Village
Development
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PARTNERSHIP
Organizing
Mass
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Organizing
Educational
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Intersectoral
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Provide manpower
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SHS/HMD/84.1
page 42
Annex 2
2.
For Session 6, WHO officers responsible for immunization, diarrhoeal diseases ana
and
nutrition programmes will be available to help participants to clarify the relationship
between these areas and the CHW’s job. These discussions will be initially conducted in
small groups, then conclusions will be presented in a plenary session.
SHS/HMD/84.1
page 41
Annex 2
SECOND INTERREGIONAL WORKSHOP ON
COMMUNITY HEALTH WORKERS
Manila, Philippines, 4-8 July 1983
REVISED AGENDA
Monday, 4 July
DAY 1;
a.m.
9:00 - 9:30
09:45 - 10:15
10:15 - 12:30
1.
2.
3.
Opening session
Review and adoption of the Agenda
The Community Group Supporting the CHW
3:00
4:30
3.
4.
The Community Group Supporting the CHW (continued)
The CHW
p .m.
1:30 3:15 DAY 2:
Tuesday, 5 July
a.m.
8:30
12:30
5.
The CHW's Job - Management
1:30 -
4:30
6.
The CHW's Job - Technical aspects of the programme
7.
Field Trip. Departure at 8:00 from the Regional Office
8:30 - 9:30
9:30 - 11:30
11:30 - 12:30
8.
9.
10.
Learning experiences from the Field Trip
Other health sector support activities
Financing the CHW's activities
3:00
4:30
10.
11.
Financing the CHW's activities (continued)
Other National Policies and Actions
9:30
12.
9:30 - 12:30
13.
Follow-up Action : Regular review of national
activities
Follow-up Action : Specific improvements
1:00
14.
Closing session.
p .m.
DAY 3: Wednesday, 6 July
8:00am - 4:00pm
DAY 4: Thursday, 7 July
a.m.
p.m.
1:30
3:00
Friday, 8 July
DAY 5:
a.m.
8:00 -
p .m.
12:30
N.B.
Coffee breaks at 10:15am and 3:00pm
Remarks;
1.
For
Sessions 3-5
3-5 and
For Sessions
and 9-11,
9-11 the following general procedure is planned: First, in a
plenary session, the basic national information concerning the topic of the session will be
reviewed and problems identified. Then, in small groups, participants will exchange
national experiences when dealing with each problem and develop possible solutions, These
solutions will then be presented in a plenary session, discussed and finalized as
recommendations for national follow-up action.
SHS/HMD/84.1
page 40
Annex 1
PHILIPPINES
Dr R.A. Estrada
Associate Director
Institute of Community and Family Health
11 Banawe
Quezon City
Philippines
SUDAN
Dr Ali Beily
Director-General
Primary Health Care and Rural Health
Ministry of Health
Khartoum
Sudan
THAILAND
Dr Uthai Sudsukh
Principal Medical Officer
Ministry of Public Health
Devavesm Palace
Bangkok 2
Thailand
DEMOCRATIC YEMEN
Dr Ahmed Ali A. Lateef
Director-General
Primary Health Care
Ministry of Health
P.O. Box 4200
(Aden) Khormaksar
Democratic Yemen
Consultant
WHO Staff
Dr Don Chauls
Staff Associate
Training/Community Involvement
Management Sciences for Health
165 Allandale Road
Boston, Mass. 02130
U.S.A.
Dr Sombhong Kutranon, SEARO
Miss M. Hamunen, EPI/HQ
Dr G. Oblapenko, CDD/HQ
Dr A. Pradilla, NUT/HQ
Dr D. Flahault, HTD/HQ (Co-secretary)
Dr A. Hammad, IAH/HQ (Co-secretary)
Dr Y. T. Kuo, HSD/WPRO
Mr H. S. Dhillon, CHR/WPRO
Dr G. Nugroho, PHC/WPRO
SHS/HMD/84.1
page 39
Annex 1
2ND INTER-REGIONAL WORKSHOP ON
COMMUNITY HEALTH WORKERS
MANILA, 4-8 JULY 1983
LIST OF PARTICIPANTS
Principal Investigators
BENIN
Docteur S. Raimi Osseni
Directeur Provincial de la Sante du Borgou
B.P. No.2
Parakou
Benin
BOTSWANA
Mrs K.M. Makhwade
Director of Nursing Services
Ministry of Health
Private Bag 0038
Gaborone
Botswana
COLOMBIA
Dr R. Ruiz Medina
Jefe, Division de Programacion y Evaluacion
OPS/OMS
Apartado Aereo 29668
Bogota
Colombia
INDIA
Dr M.D. Saigal
Deputy Director-General
Rural Health Services
Government of India
Nirman Bhavan
New Delhi 110011
India
(Principal Investigator for study but unable to
attend the meeting)
JAMAICA
Mrs Eugene McFarquhar
Nursing Officer, Public Health
Ministry of Health
Caledonia Ave., Cross Roads
Kingston 5
Jamaica
LIBERIA
Dr S. Benson Barb (Chairman)
Primary Health Care Project leader
Maryland County
P.O. Box 1926
Monrovia
Liberia
PAPUA NEW GUINEA
Mr Kelevi Atasoa
APO Training School
Butuwin
P.O. Box 149
Kokopo
East New Britain Province
Papua New Guinea
SHS/HMD/84.1
page 38
PHILIPPINES:
Financing of primary health care
Improving training methodology
Expanding supervision
Extending village organization
SUDAN:
Initial curriculum development and modular form for pre—service
and in-service training
Formulating job descriptions in conjunction with representatives
of all levels and groups concerned
Supervision and Community participation
THAILAND;
Extension of coverage of Primary Health Care activities by 1986
Programme review for improvement
DEMOCRATIC YEMEN;
Training methodology and contents
Supervision and delegation.
Two topics are highlighted in nearly every country report;
Community participation in view of the social preparation of both the SG and the
community as a whole, and
training of the health centre staff (who, in turn, train and/or supervise the CHWs) to
help them to understand their job better and work with the CHW, the SG and the community.
Also, it was felt that countries should consider each of the following topics:
financing of CHW activities
supervision
coverage.
Participants agreed to discuss the 5 topics mentioned above as well as other follow-up
studies and activities with their colleagues. Within three months, they will each submit a
plan to implement these activities - including, if necessary, requests for technical or
other assistance from WHO.
Participants agreed that WHO should convene a follow-up meeting in approximately two
years' time to report on the studies they will have conducted and improvements made in their
CHW activities.
SHS/HMD/84.1
page 37
CHAPTER 4
RECOMMENDATIONS AND FOLLOW-UP ACTIONS
1.
When deciding on a model for the involvement of the community in solving their own
health needs and related problems, several options should be provided, and through the
participatory approach and social preparation of the community, assistance should be
given in choosing the most suitable solution given their situation, needs and
resources. Support from established and well organized systems (e.g. training,
supervision, communication, technology) should be readily available.
2.
The Worldwide economic crisis is affecting the financing of Primary Health Care and is
ultimately weakening the structure in which the CHW has to function. In order to remedy
this situation, countries should be innovative and examine realistic and appropriate
ways, within their own political, cultural and legal contexts, to generate the support
and commitment needed for the continued promotion of health and welfare, particularly in
aid of the rural population, the underserved and poor communities.
3.
Countries should examine critically the issues related to training and supervision;
review their own programmes and devise strategies which will inform and convince of the
value of the CHW and the system within which he/she operates, These strategies should
also aim at involving the community in order to provide the necessary support for the
CHW to function at a highly motivated level. This level would be an indication of the
competence of his/her supervisor/trainer and therefore of the effectiveness of the
system as a whole.
4.
The CHW job-description includes a number of tasks to be performed as part of the
primary health care approach; however, this job description should be limited to the
strict necessities of the PHC programme and should serve as the basis of training given
to the CHW.
5.
Countries should adopt an approach which would allow an efficient and effective
management by mobilizing community-based resources, external agencies, and by resorting
to the technical assistance offered by the World Health Organization.
In addition to the above recommendations participants identified areas which they
believed required follow-up in their respective countries. These are;
BENIN:
Financing of Primary Health Care
Community involvement and social preparation
BOTSWANA:
Community participation
Training and review of job description
Supervision
COLOMBIA;
Management of Primary Health Care
Re-direction of job description to reflect the needs of urban
sector as well.
Community organization
JAMAICA:
Community participation
Supervision
LIBERIA;
Primary Health Care to be dealt with at national level.
PAPUA NEW GUINEA:
Extending Community Health Worker coverage to rural population
Training of trainers
Supervision
SHS/HMD/84.1
page 36
Other health support services such as dental care, maternal and child health, sexually
transmitted diseases prevention units are located within the health centres with lying-in
facilities. This infrastructure was seen as an interesting option for solving many of the
problems of Primary Health Care.
It was extremely encouraging to observe the team spirit, goodwill and cohesiveness
animating the various members implementing the project, from the Medical Director down to
the volunteer community health worker. This was seen as the main reason for the community’s
successful involvement and leadership for the fulfilment of the targets of PHC.
SHS/HMD/84.1
page 35
CHAPTER 3
URBAN PRIMARY HEALTH CARE
The Manila Field Trip
Participants from the 11 participating countries were given the opportunity of going on
a field trip to the urban Manila Health Programme project at present being implemented in
three ’Barangays' (villages) No. 865, 844 and 839.
The main purpose of the visit was to meet with the team of health managers and community
leaders in order to discuss the programme, and observe the procedure of community
organization, its response to the health needs of the community, the response of the
community to the programme, and the ways of encouraging or improving community participation.
The various health centres are responsible for the ’Barangays’ which are sub-divided
into ’Puroks’(. There is a very good communication and referral system manned by
well-trained and well-motivated community leaders.
’Barangay1 865 has a population of 2,528; ’Barangay’ 844 counts 2,818 individuals and
’Barangay’ 839, 2,956. These barangays come under the supervision of 3 health centres
responsible for 21 such ’puroks’ between them, in the 4th Health District of Manila alone.
This programme was started as a pilot project to identify the causes of the only slight
reduction in the morbidity and mortality rates despite an ever-growing number of health
centres, greater manpower and extension of health services, and despite the variety of
health delivery services and the concentration of medical practitioners and medical
institutions in the city.
The project was started in 1981 and will continue to be implemented until their PHC
objectives are reached. In 1982, the Health Department celebrated its 42nd anniversary with
the theme; "Health for all Manilans through Primary Health Care".
The participants took great interest in the various activities in the Barangays such as
the fund-raising projects and health-related activities (weighing and charting processes for
a nutrition surveillance scheme carried out independently in each village). They noted the
pride and confidence of the community in itself and its leaders. The proposals related to
fund raising were being considered to increase the number of blood pressure instruments and
to train some leaders to perform this skill so that they may later monitor such activities
in the community under professional guidance.
The majority of leaders seen were women, and these seemed to be very influential in
mobilizing the community. They knew how to evaluate correctly the problems and needs of
their communities, and were able to provide the information required by the visiting
participants. They were also able to explain the prevalence and incidence of diseases. Not
only did they have the necessary data at hand, but they were also capable of interpreting
and using it to relate figures to reality.
Social problems, such as large families, over-population, low income and poor
environmental conditions were evident; but the highly commendable efforts displayed by the
health staff backed by strong and effective community leadership and participation have kept
this project viable dispite the existing social problems.
(Dpurok; zone - lowest political/administrative division of a village (barangay).
SHS/HMD/84.1
page 34
Control of Diarrhoeal Diseases
The activities relative to the monitoring of diarrhoeal cases are included in the job
description of various countries. The newly introduced management schedule of oral
rehydration salts (ORS) also assigns this task to the community health worker.
For this new task, the community health worker is expected to:
evaluate the level of dehydration
treat diarrhoea by ORS
educate mothers/community on how to prevent dehydration and how to treat diarrhoeal
diseases at home
educate mothers on how to prepare ORS when necessary
keep simple records regarding these actions
encourage breast-feeding
recognize the signs and symptoms of dehydration, that is:
reduced urine
sunken eyes
sunken fontanelle
loss of skin elasticity.
It was noted that cultural practises influenced the management of diarrhoeal diseases
such as in India where mothers delayed breastfeeding during diarrhoeal bouts, and in other
countries, (e.g. Colombia) where other cultural beliefs stop mothers from breastfeeding
during the diarrhoeal periods.
Intersectoral collaboration and actions are needed in order to cope with the
environmental problems but the community health worker can wield a positive influence by
mobilizing the community to action and promoting health education regarding health practices
such as refuse disposal, food hygiene and water sanitation systems.
Participants felt that several of the solutions are within the competence of the
community health worker and that the community’s response is crucial to the issue of control
of diarrhoeal diseases.
FOLLOW-UP ACTION;
1.
In the control of diarrhoeal diseases, the administration of oral rehydration salt
against a salt and sugar solution needs to be reviewed, depending on supplies available.
2.
WHO should be contacted through the regional offices when technical support is necessary
and unavailable locally.
SHS/HMD/84.1
page 33
The problems of malnutrition are very complex. Although the CHW can participate
actively in solving the problems arising from within the community itself (stemming from
cultural practises, e.g. husbands get the best part of a meal, traditional/religious
beliefs, ignorance, etc.), he/she would need another type of training to educate and inform
the community of problems arising in areas such as adequate food production, employment,
child diseases, etc.
Expanded Programme of Immunization
This programme is in progress in most countries participating in this study, and
activities are at various stages, managed by the available human resources at country
level.
In some countries the responsibility of the community health worker for immunization
was a single and/or participatory activity under the guidance of supervisors, in order to
provide a balanced coverage throughout the country.
Participants expressed the desire to expand the immunization programme beyond the s ix
diseases (Measles, Diphtheria, Tetanus, Poliomyelitis, Pertussis, Tuberculosis).
The decision was left to each country to see how many more diseases could be included in
the programme according to existing means. However, it was vital that they use the same
techniques when dealing with the additional diseases as with the initial six: they need to
maintain effectively the "cold chain", adequate sterilization and supervision activities,
the potency of drugs and learn about the side-effects of the additional diseases.
Malnourished children were one of the vulnerable groups who should be fully immunized to
improve their
improve
their chances
chances of
of survival.
survival. This fact needs to be taken into account by professional
staff as well as by mothers and families of malnourished children.
It is an accepted fact that for best results and effectiveness all children should be
immunized within the first year of their life. One task of the community health worker in
Colombia, Papua New Guinea and in Sudan is to give immunizations and other injections,
In one
regardless of their level of education and the stage of training they have reached.
participating country, the community health worker operates from her own home when
necessary, and this presents difficulties, as this
t-- worker is expected to perform duties out
of working hours, consequently overloading her schedule.
Although practical experience in immunization techniques and uses makes up for 704 of
the 12-hour training programme, (with supervision by professional hospital staff), the
the
support for this activity during the actual implementation in the field is inadequate,
'cold chain' cannot be maintained because of lack of transport and poor supervision.
The establishment and maintenance of the "cold chain" mechanism in the EPI programme is
amongst the most critical issues to be reviewed by countries presently conducting programmes
and or proposing to do so. Botswana has started a pilot project in which the Community
Health Worker is taught to use immunization techniques, maintain the "cold chain," and care
for the catchment population to make up for the infrequent visits of the mobile clinic.
In another instance, one participating country utilized the community health worker to
give immunizations in the rural areas. In addition, veterinary officers entrusted the
community health worker with some medications, and nomadic chiefs expressed the desire for
their animals to be vaccinated against the common diseases in the district by the community
health worker. Papua New Guinea reported that CHWs were supported by appropriate equipment
and adequate drugs.
It was concluded that if the community health worker was adequately trained and
competent in this skill, it is appropriate to assign CHWs competent in that task to remote
areas where there is a lack of transportation, few or no health facilities or personnel.
This is a way of utilizing available human resources with training to make up for the
urban/rural imbalances in the provision of health care.
In order to have a more equitable
coverage, and given the acceptability of the community health worker, Sudan, is proposing to
recruit and train more workers to serve the rural population in particular.
SHS/HMD/84.1
page 32
In the light of this discussion, the following facts emerged;
the causes and effects of disease incidence are closely related, therefore the
indicators for intervention and problem solving are similar.
Decisions concerning policies, political influences and cultural manifestations
determine the CHW's performance of these tasks in technical areas.
The community should be mobilized to play an active role in the management of these
technical schemes.
The greater the CHW's competence in performing multiple tasks, the greater the number of
links established between supervisors and CHWs, between CHWs with supervising
capabilities and other CHWs, and CHWs and their community.
The logistics of oral rehydration treatment were discussed.
The methods of population coverage depend on the CHW and the number of tasks he/she can
perform competently and effectively within a given context. The use of CHWs leads to a
diversity of pre-training periods and nomenclatures; CHWs need to be incorporated into
health systems and their various infrastructures.
The "cold chain" should be established and maintained.
A more detailed summary about what has been said on the subject of technical aspects is
given below;
Nutrition;
Most countries depend on the CHW for the presentation of health promotion and food
demonstration activities. The CHW also demonstrates the varied uses and methods of
charting, weighing and distribution of food supplements.
In some of the countries, the
3
different methods are used simultaneously, in others a single method is followed,
countries report a deficiency in the monitoring system.
The opportunity was given, during the workshop, to share the ’Thailand Experience' on
nutrition, where the food supplement skimmed milk was not accepted by the community, As a
result, an alternative activity was adopted with great success, The community was mobilized
to provide food for a twice-a-week supplementary feeding programme for 3rd degree
malnourished children, Village health communicators volunteered as health workers, and
these workers were each responsible for ten households.
This limited coverage for each worker was a practical option in the problem solving
approach by the community for the community and was undoubtedly the major reason for the
success of this activity.
On the other hand, countries reported that weighing and distribution of food supplements
were not tasks performed by the community health worker, and this aspect of the maternal and
child health programme needed strengthening.
The use of the arm circumference measuring tape was not considered sufficiently
sensitive as a method of identifying severe malnourishment within an overall monitoring
system. However, it could still be used by the CHW in remote areas where it was difficult
to use a scale.
In Yemen, the arm circumference measuring tape was used to monitor
malnourished children whose condition was precipitated by measles. Nevertheless, it was
found that weighing was the most accurate method.
SHS/HMD/84.1
page 31
CHAPTER 2
TECHNICAL ASPECTS OF THE CHW.
There is a tendency among decision makers in primary health care to expand programmes
without either preparing the community or the worker for the new tasks included or
modified. Whenever this is the case, programmes are badly implemented. Sometimes, when
CHWs are in fact trained to perform these new/modified tasks, then the training and other
support systems are inadequate; in some cases, these systems are of such poor quality that
the programmes themselves lose their viability. Successful programmes reflect good social
preparation and acceptability of health workers and community alike.
It is vital to ensure that support systems are soundly established before assigning CHWs
to primary health care programmes, especially in the technical fields such as Nutrition,
Expanded Programme on Immunization (EPI) and Control of Diarrhoeal Diseases. Because of the
fact that support systems and implementation of the technical aspects of programmes are so
closely related, the CHW needs adequate support systems to be able to perform his duties
efficiently. He/she should also acquire a basic knowledge of these technical aspects which
are part of the curative/preventive approach of Primary Health Care. To illustrate this the
following issues were discussed in relation to the role of the CHW in the implementation of
three technical programmes:
1.
Nutrition:
Monitoring of growth performance with 2 major purposes:
(a)
increasing the awareness of mothers to health problems before children reach a
critical stage of illness;
(b)
detecting special risk families and groups of families;
Mobilization of the community to provide food for severe cases of infantile
malnourishment.
2.
Expanded Programme on Immunization:
Identification of target groups in the community, e.g. high risk pregnant women and
children under one year of age.
Education and motivation of families in order to complete the immunization scheme which
includes coverage for 2nd and 3rd immunization rounds.
(1) Knowledge of the names given locally to
Recognizing the six EPI diseases.
diseases, information and referral system, definition of the role of the CHW as a
support to the family when problems arise.
3.
Control of Diarrhoeal Diseases:
Four strategies were adopted for a medium-term objective to reduce the mortality rate of
children under five years old:
case management, including oral rehydration;
maternal and child health practices;
epidemic control by rapid diagnosis of disease and prompt intervention; encouraging
breast-feed ing;
developping environmental health conditions to include water supplLe<^
(1) Measles, Diphtheria, Tetanus, Poliomyelitis, Pertussis J/Tutte rculoals
TM*UO^
s(
Ao k
SHS/HMD/84.1
page 30
CONCLUSIONS AND RECOMMENDATIONS REGARDING THE COMMUNITY HEALTH WORKER
AND HIS/HER COMMUNITY
In view of the discussions held during the Manila workshop on CHW s and if the target of
primary health care, "Health for all by the year 2000” is to be achieved, several facts and
in poor and under-served
propositions need to be explored in order to accomplish such a goal
g
countries and communities.
Among other measures, it was suggested that governmental resources be re-allocated
1.
to overcome local and regional imbalances. These measures would include free health care
(government) schemes, and health insurance schemes. Thus a redistribution of the health
budget to accommodate primary health care and implement health service delivery, would
improve the CHW activities and increase support.
A detailed budget, allocated to primary health care, should be separate from the
2.
general one to enable adequate backing for the CHWs and for other essential support systems
of the programme.
The community
3.
L.._
..
. support groups should be provided with the necessary managerial tools
to understand and utilize the principles of budgeting, accounting, planning, organizing,
implementing and controlling, in order to establish practical and workable systems for an
efficient utilization of funds. Those who will train CHWs and SG members should receive
adequate training themselves for that purpose.
Community financing will increase community involvement and thus, increase their
4.
sense of "ownership” of the programme, provided that there is adequate social acceptability
and preparation of the community, as well as strong support.
The community's transition from the status of recipient to provider poses many
5.
problems and the various attitudes of community members need to be taken into account.
However, the learning experiences debated during the workshop served to encourage countries
to carry out in-depth evaluation of their situation, and to help them adopt the established
decisions concerning their
"guiding principles” iin view of enabling them to make appropriate
...
welfare.
6.
Some governments can no longer afford to finance the present CHW workers, or expand
the programmes and give adequate support, because of economic difficulties. The
implications of a change in the existing social order is also causing great problems.
Therefore, options to suit their own policies and cultural situation need to be investigated.
7.
In countries with economic problems, a new system was accepted considering the cost
factor and the fact that primary health care reduces the workload to a minimum number of
specialist cases for hospital-referral. This system is based on the withholding of the
secondary care budget for 5 years (for example) and using the interest from that sum to
finance primary health care.
These suggestions have to be carefully considered and would need confirmation at the
political level of policy making in the various countries.
SHS/HMD/84.1
page 29
The method used to finance health care should be carefully selected, as it affects the
social acceptability and economic effectiveness of the measures implemented. It should take
into account the existing social structure.
Participant countries were encouraged to
benefit from the 'Chinese Experience' which showed that work and reward were respectively
compatible with and proportionate to levels of production.
It also suggested the
establishment of a financial mechanism which would, among other things, "reward communities
that are able to achieve better health care at lower cost"^ and help the government "to
promote a wider acceptance of what it considers to be in the best interests of the nation by
subsidizing services that otherwise might not be demanded (e.g. immunization and family
planning).D
However, as it is impossible to define health care and financing in internationally
applicable terms, there is no single expenditure system which would solve the problems of
financial health care viability.
It is crucial for the countries to review, modify and/or
improve their programmes in order to increase the efficiency of the primary care approach
and to further community involvement: this is the objective of this exchange of learning
experiences, especially since countries report that the different communities are willing
and able to assume the responsibility for their own health care. To this end, health
behaviour needs to be modified, potential developed, and initiative encouraged towards
productive ways of promoting health care.
care. The participants stressed the importance of
utilizing a uniform approach to financing PHC. This was especially the case for the
difference in demands for payment made from rural and urban populations.
populations,
It was observed
that some countries, for instance, requested the rural community to contribute to the
payment of certain aspects of their programme, whereas this was not the case for urban
populations who by and large have greater access to health services, Whatever the decision
taken, it should be applied nationally so that no special demands are made from certain
population groups and not others.
The example of countries where the government contributes to drug costs should be
emulated by countries where this expenditure is eroding an already minimal primary health
care budget.
In Botswana the cost is nominal; in the Philippines certain drugs are supplied
free of charge, others are paid for by the community.
In the Sudan, this type of community
financing is being experimented with on a small scale.
(1) Primary Health Care - The Chinese Experience, Report on an Inter-regional Seminar,
Yexian County, Shandong Province, China, 13-16 June 1982, WHO Publication 1983, p. 81
SHS/HMD/84.1
page 28
In most countries, the CHWs were paid from government funds. In Benin, the system of
payment is based on both government and community funding. In Thailand, governmental salary
is complemented by the profit from drug sales; in the Philippines it is increased by funding
from external agencies.
The discussion of these systems raised critical issues concerning the loyalty of the CHW
to the agency who pays his/her salary, the baseline of salary scale, and the implications
and consequences of any system of payment (see table 8).
The salary scale does not seem to depend on any one constant: the full-time or
part-time status of the CHW does not affect the size of the population covered, between 50
and a thousand individuals divided into households.
In this manner, CHWs cover 15-150
households: these figures are indicators of payment. There are cases of very well paid CHWs
(by the government) and CHWs who receive a salary much lower than average. No general
answer could be given in relation to the salary scale as this is established according to
the drug-sales possibilities and level dictates of each country.
As regards the loyalty of the CHW to its financing agency, two major reactions were
discussed; that of the community, and that of the CHW him/herself.
Any system that prescribes community financing will have to provide options from which a
scheme can be selected, e.g. Philippines and Thailand, and examine ways of helping
communities to become financially self-sufficient for various health related activities,
rather than depend so greatly on drug sales, as is the case in most countries. This
decision would be taken according to certain priorities.
In some of the countries funds
were used not only for remuneration and drug supply, but also for the transfer of patients
to health centre or hospitals, for the purchase of food supplements for malnourished
children, and for the construction of wells and health facilities among other projects.
A community financing scheme which is introduced without adequate social preparation can
diminish the interest of health workers and community alike. An example of this situation
was reported in India. The participating countries felt that this was due to a deficiency
in the infra-structure of the health system rather than in the payment scheme.
If
remuneration of CHWs were channelled through the Support Groups, the workers would have more
loyalty to the group. In Liberia, it was reported that communities were willing to
contribute towards a one'-time-cost , but unwilling to share recurrent expenses such as CHW
remuneration and drug supply.
The workshop provided a baseline for countries in order to strengthen a vital component
of primary health care strategy: community participation.
Experience shows that any system of financing will have repercussions, be they on the
government, the voluntary and/or external agencies and on the community itself. An analysis
of country programmes indicated that among the reasons for deterioration or ineffectiveness
of a programme were the following: lack of social preparation, lack of understanding and
acceptance of the programme, lack of response to health measures as regards appropriate
steps to be taken in consideration to health needs and community attitude towards such
efforts, and lack of support from decision makers in order to implement such measures
effectively. Since the socio-economic system plays such an important role in the financial
viability of improving services, appropriate mechanisms must be established in order to deal
successfully with social problems.
After considerable discussion and analysis of various country experiences, the
participants agreed on a list of guidelines which they felt were important in view of social
preparation. This preparation depends on: a) a "sensitization" to problems in general; b) a
knowledge and understanding of the decision-making process; c) community diagnosis,
community motivation and education; d) community awareness and knowledge of overall
programmes, resources and implications; e) performance-check of the health system at
national level; f) political preparation; and g) importance of governmental response to
health needs, and attitude of communities towards health measures taken.
TABLE 8.
BENIN
COMMUNITY FINANCING
BOTSWANA
COLOMBIA
INDIA
JAMAICA
no
no
no
no
Does the CHW
receive a salary
or other payment
from the community?
some yes
some no
Does the community
pay for drugs?
yes
yes, but
nominal
amount
yes, but
minimal
Metliod(s) of
raising funds from
the community
drug
purchase
drug
purchase
drug
purchase
raffle
cultural
event
LIBERIA
PNG
no
no
no
no
no
no
agro
nutri
tion
fair
local tax
for deve
lopment
activities
PHILIPPINES
SUDAN
THAILAND
no
no, but can
keep drug
sale profit
some drugs
free; others
paid by
community
no, but
being
tried on
small
scale
yes, except
drug cost
can be
reimbursed
for low
income
people
income from
village drug
store: dance,
lottery,raffle
donations
from local
organizations
drug
purchase
donat ion
(both cash
and com
modities)
drug purchase
drug co
operative
no
YEMEN
no
only when
not avail
able from
CHW or health
centre
ns cn
00 cn
Q
ro
§
oo
SHS/HMD/84.1
page 26
1 1 can
__ i be either too abundant or insufficient. Both extremes are
The information collected
of little use. To remedy this situation, the participants discussed at length the various
forms used for data collection and information (questionnaires, tally sheets, registers,
cards, report books, etc.). The CHW finds himself swamped by the numerous, duplicate forms,
some of which fill up with too much information, some of which are irrelevant and some
Countries were encouraged to review these forms, to check on their validity, their
useless.
relevance and usefulness to the current health system.
Sudan is at present developing a Health Information System for primary health care and
strengthening the support system, e.g. providing an acknowledged list of essential drugs.
In Jamaica, the Health Information System (HIS) is already developed, and is being
reviewed and strengthened by the Health Management Information Programme (HMIP). Aspects ot
this system include computerizing health records, providing training in system management,
supplying drugs and essential lists for each type of health centre, running transport and
emergency services, and establishing referral systems between the primary health care
centres at village, intermediate and national level.
The community health worker will accede to this information through adequate training
and reports will be available when information is relayed back to the health centres,
particularly the maternal and child health records (MCHR); however, interpretation,
comprehension and relevance as monitoring tools need strengthening.
The community involvement component is weak, and is presently being tightened; however,
formal relationships have to be developed at all levels to ensure participation of the
community in order to fulfil the aim of primary health care.
The Manila Urban PHC project was given as an example of an informational approach
closely involving the community to assist the CHW in monitoring the community-oriented
activities. The Community Council evaluates the problems faced and then is responsible for
the records, maps and other aspects of the country profile reflecting health conditions,
problems, population, available resources and referral systems.
The types of records to be kept by the community health worker were not generalized nor
standardized as these were dictated by individual countries in response to the various
systems, taking into account the socio-cultural implications. This response provided a
useful opportunity for retrospection and for monitoring situations. The information in
record form is then available to community health workers and community for discussion and
thus allows prompt and appropriate intervention.
PATTERNS OF FINANCING:
In all
variety of
government
government
of the countries represented, financing of the CHW activities was based on a
systems, ranging from responsibility for financing by the local or central
or both, and payment by the community in cash or kind, tto a joint funding by
and an external agency.
Several countries, in which the communities did not play a major financing role,
nevertheless listed numerous important advantages of community financing. Two major
arguments were presented in relation to community financing (for CHWs and drugs), one in
favour, the
the other
other against:
against; ccommunity financing will increase community involvement and the
feeling of "ownership" of the programme; on the other hand, governments can no longer afford
to pay for an increasing number of CHWs who distribute drugs subject to great price rises.
Others indicated that their current programme is directed towards community-action for
fund-raising for various purposes. However, existing constraints were difficult to
overcome, such as lack of understanding of the role of the CHW, inadequate social
preparation of the community, a strong belief that the poor should not pay for health
services, and a history of paternalism according to which the government should be the sole
provider.
SHS/HMD/84.1
page 25
Several suggestions for the improvement of supervision and coverage were discussed. The
first of these was that, since the countries themselves were responsible for the training of
supervisory personnel, a budget should be allocated for that purpose. The curriculum of the
medical and para-medical schools should be revised to include basic social skills and
effective supervision. A re-orientation of health personnel was also suggested, as a means
of relieving them from responsibilities which can be entrusted to other competent staff,
thus allowing for a supervision system which would be adaptable to local realities and
change.
The question of incentives gave rise to an interesting discussion. These can be either
moral or economic incentives. However, it was felt that job-satisfaction, moral support and
acceptance by the community were greater incentives than short-lived, economic reward.
Finally, the participants felt that if the supervisors had adequate training in
management, in the use of schedules and check-lists, they would be able to improve their
performance for a better implementation of national policy programmes.
In several countries, it was reported that the Support Group would refer matters to the
supervisors, especially when problems arose. No formal links were mentioned as existing in
the community which acted as supervisor to the CHWs, but this was implied to a certain
extent in those countries where the community participates in the assessment of the CHWs.
INFORMATION SYSTEMS;
Several issues on this subject were discussed, namely the use of information; the
different systems used in the various countries; information as a tool for epidemiological
charting, CHWs and village council records; and the differenciation between information and
data.
Different systems were in operation in the various countries based on child health
records kept by the mothers for nutrition surveillance; and monthly records from the
community health workers; simple survey sheets for community diagnosis (Sudan);
identification of maternal and child health and high risk curative cases (Jamaica); and
feedback of information of crucial value to the Planning and Evaluation Unit at central
level.
In Thailand, voluntary community health workers are not required to report
information, but to collect it. Supervisors compile reports directly from the community
health workers records for use within the system. The importance of understanding,
correlating, utilizing the epidemiological approach and feed-back was considered vital to
the management of primary health care delivery.
The difference between data and information lies in the different forms in which the
evidence is presented.
If the data collected is not presented in a form that can be readily
understood, analyzed and disseminated, then compilation of data is a futile exercise. Once
date is presented informatively, then it can be used with effect, for example, to predict
disease incidence and patterns. The CHW should be trained to understand and interpret this
type of information in order to monitor curative and preventive activities, and thus control
the disease. Before planning strategies for community mobilization, referring to
intermediate and national level, and relating to other agencies, the CHW's first step is to
consult this information. Various countries reported the need to further this methodology,
while others decided to adopt it for the first time.
The information collected and made available should be credible.
It is the
responsibility of the supervisor to emphasize this aspect during the pre-service training
and field activities. The CHW and other workers should be aware of the personal and job
implications of relaying distorted information. Two countries in particular reported that
records were often falsified to obtain a greater supply of drugs. This was harmful to the
CHW's reputation.
T3
Cb
00
tfi
X
cn
4> U
TABLE 7.
BENIN
BOTSWANA*
COLOMBIA
oo
CHW SUPERVISION IN THE COMMUNITY
INDIA
JAMAICA*
PNG
LIBERIA
PHILIPPINES
SUDAN
THAILAND
YEMEN
Is supervision done
by Health Centre
personnel?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Should be
but is
not
Yes
No, but was
recently
added to
their res
ponsibilities
Is there anyone who
only does supervis ion?
No
Yes
No
No
Yes
Yes
No
No
Yes
No
Yes, plus
t raining
How often is each
CHW scheduled to
receive a supervisory
visit?
2-4 per
month
monthly
1/month
2/month
about 1/
month
1/month
8/month
How often do they
actually receive a
supervisory visit?
1-2 per
month
irregularly 1/month
(80%)
2/month
Do supervisors
regularly visit
jSG members?
Yes
II
Do supervisors have
training in methods
of supervision?
1/month
First year 1/month
Thereafter 1/2 months
(from teams
of 3 super
visors )
2-3/year '
1/2 months
same as
above
Yes
Yes
Yes
Yes
Yes
Some
yes
Yes
Yes
fortnightly
monthly
fortnightly
Yes
Yes
Yes
(basic
principles)
1/month
2/month
44%;
1/month 16%;
1/month 41%
Yes
No
Yes
No
Yes
No
No
Is lack of interest
in supervision by
supervisors a
major problem?
Yes
Yes
Yes
Yes
Yes
Yes-
Yes
Yes
Yes, but not
a major one
Is lack of adequate
transport a major
problem?
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
*In Jamaica, the CHWs function in Health Centres; in Botswana, many of them work in Health Centres, despite the fact that they are not
supposed to do so. This factor confounds many of the questions concerning supervision.
SHS/HMD/84.1
page 23
Country experiences show that one of the major weaknesses of most CHW training
programmes is the omission of management topics. The CHW’s job is a complex one which could
be organized and conducted far more efficiently if the CHW knew how to use a few simple
management tools.
Precisely which tools to include in CHW training will vary from country
to country, but those suggested as possibilities were; mapping, scheduling, problem-solving
techniques and a reliable two-way information system.(D
The only technical discipline specifically discussed in relation to training was drugs,
It was noted that it is preferable to train CHWs to distribute drugs on the basis of
symptoms rather than disease diagnosis (the implication of this is that the curriculum
should include sections on cough, fever, diarrhoea, etc. rather than on leprosy,
tuberculosis, cholera, etc.).
In countries where CHWs are to be trained to administer a
large number of drugs, this skill should be taught over a period of time rather than
concentrated in one training session.
SUPERVISION;
This topic was discussed in terms of the type of supervision, the training and attitude
of supervisors, the frequency of supervision, and the support system for that programme.
The majority of countries reported that supervision was done by Health Centre personnel
except in Yemen, where this was recently added to their list of responsibilities.
In Sudan,
the supervisors who participated in training courses are responsible as trainer-supervisors
for the Community Health Worker but very few are assuming this responsibility. This
ineffectuality is due to their distance from the workers, the heavy work load, the lack of
transport and expectation. This is a situation where a good programme is planned for an
in-service Education, but, because of poor management, it is ineffective.
There is a general lack of interest in supervision by those designated for the job and
this is a major problem. Supervisors expect special remuneration; the work-load is too
heavy; they seem to under- or over-estimate their role; all these are constraining factors
undermining the health and CHW programs. The lack of adequate preparation needed for their
job causes them to become poorly oriented, unproductive and unmotivated workers, incapable
of promoting and implementing health care and community development.
The effectiveness of supervisory visits seems to suffer from inadequate planning. A
practical schedule should be established to be used as a means of monitoring activities and
providing the necessary support for good performance, both of the supervisors and the
trainees.
It was felt that the issue of social preparation within the community is directly
related to the performance of the supervisor. A barrier created by hostile human
relationships frustrates the efforts of the worker and discourages him/her. The
participating countries felt that this issue ought to be reviewed.
Participants also thought that the experienced CHWs could be further trained to assume
supervisory roles and perform their duties independently, thus enhancing their status and
providing opportunities for career up-grading. This had proven successful in some
countries.
In other countries this system may not be accepted for cultural reasons,
therefore research into alternative methods of supervision needs to be carried out in case
CHW's have to be supervised and supported in isolated rural areas. Considering the needs
and the system, a dual supervision programme is worth investigating.
(1) To that effect see "ON BEING IN CHARGE, a guide for middle-level management in PHC"
WHO Geneva, pp.261-342.
SHS/HMD/84.1
page 22
allow the trainee to deal with his various tasks one by one as he/she keeps learning to
In India and in one of the Philippines projects, this approach is currently
perform them.
being used. Colombia has experimented with both types of training and has reported that
spaced-out training is more effective, but also more costly.
Community involvement during training was considered highly desirable, but it is not
clear how this is best implemented. Spacing out the training programme is one approach, as
it brings the trainees back to their communities and allows them to discuss problems during
subsequent training sessions, Using sites within the proximity of the community to hold the
training is another approach, Training at a health centre, for example, may include
community-based activities. Another suggestion to elicit community involvement was to
encourage financial support for training, especially if the training is conducted in a
health centre or other site which is not equipped as a training centre.
The number of trainees per programme will depend upon many factors, some of which are
unrelated to optimizing the quality of training. Participatory methods, such as small group
activities and skill practice, are much more difficult to use in a very large training
group; but these methods are usually felt to be more effective than others? Most countries
viewed a maximum size of 20-30 per group of trainees as appropriate. Colombia recommended a
maximum of 20, preferably even less. Liberia suggested a maximum of about 10 trainees.
Training methods
In general terms, the process of preparing a curriculum, developing training aids and
lesson plans, teaching and evaluating CHW training is essentially similar to the process
used for other health and non-health projects. In some countries (e.g. Benin), some of the
trainees may be either illiterate or barely literate - a factor which would affect the
teaching methods. But, with this exception, training of CHWs should only differ in content
and not in form, from other training programmes.
Only certain elements should therefore be discussed. The approach of learning by
objectives was emphasized, that is, that the whole process be geared towards teaching the
CHW the tasks ultimately to be performed. These task-oriented objectives should also be
used as a basis for developing assessment tools.
The most common teaching method in many training programmes is lecturing; it is also
probably the worst, since it is ineffective at training people to perform practical tasks or
to influence attitudes - the two main aspects of any CHW's job. Alternative methods were
suggested: dialogue, demonstration, skill development, field trips, self-learning
exercises, small group discussion, role-playing. A variety of teaching methods should be
encouraged.
In the majority of the countries participating in this study, CHW training is conducted
by people who are not full-time trainers - mostly health centre and district health staff.
Training them how to teach was considered an essential first step. Beyond that, general
opinion was that the Ministry of Health (or the central project unit) should be as generous
as possible in the provision of the various written materials required to conduct a training
programme: curriculum, training aids and evaluation tools; these should be provided to the
trainers with as much informative detail as possible. However, this suggestion was not
intended to imply that the trainers would not be free to make modifications where
appropriate. The Philippines rejected this approach, maintaining that health centre
trainers are sufficiently capable of developing their own training aids and other material,
and that they did not need assistance in that area.
Content
The content of CHW training should, of course, derive from the job description. One
major weakness (as reported by Liberia, but more broadly applicable) is the "lack of social
preparation and clearly defined role of communities" as regards the content of many training
programmes.
SHS/HMD/84.1
page 21
paraprofessional health training institution by the staff of these schools.
In India and
Thailand, they are trained by health centre personnel.
In Colombia and Jamaica, CHWs are
trained primarily by district-level health staff. In Benin and the Phlippines, CHWs are
trained by both health centre and district health staff. Finally, Yemen has adopted yet
another model: its CHWs are trained by units who deal only with Training and Supervision.
Clearly, there are advantages and disadvantages to each approach. In countries such as
Papua New Guinea, where the duration of training is very long, it is virtually impossible to
do anything but hold the training sessions in a separate training institution. But where
the training is only a few weeks long, any of these approaches is feasible. The general
opinion was that - if at all possible - CHWs should be trained by the same individuals who
will later have the primary responsibility of supervising them. By such an involvement in
training, the future supervisors will be aware of each individual's strengths and
weaknesses. Thus, person-to-person relationships develop, which will help in an effective
long-term supervision. In Botswana, where trainer and supervisor are two positions held by
two different people, it was felt that this differentiation should be reconsidered in favour
of one person responsible for both aspects of the Training and Supervision Programme.
It is
Training staff might also consist of experienced, seasoned and efficient CHWs.
clear that these are the people who are best placed to know what a CHW truly does, Thailand
and Papua New Guinea both currently employ experienced CHWs as part of their training units
and most of the other countries thought that this was worth emulating. Colombia noted,
however, that removal of a CHW from his/her community to assist in the training of others
would leave that CHW’s area uncovered.
It was suggested that a way of avoiding this problem
was to use experienced CHWs as role models during field training; thus, the CHW would still
be able both, to serve his/her own community, instead of going away to another health centre
or training institution, and contribute to the training of other CHWs.
To optimize collaboration with other sectors, it was suggested that qualified staff from
other fields, such as Agriculture, Administration, Social Welfare, etc. also be invited to
participate in the training project..
Very often, people knowledgeable in technical disciplines included in
i the CHW curriculum
are invited as guest speakers during the training programme. This approach is generally
found to be non-productive, especially when the speakers have an inadequate understanding of
the trainees' abilities and of the job expected of them, Very often, they try to cover too
many topics during a brief presentation, thus confusing rather than teaching the CHW
trainees. JIt was felt that the assistance of such people should be minimized and that they
should be prepared to limit their talks to what the CHW trainees really need.
Duration of Training:
The duration of the training which CHWs receive in the countries ranges from five days
to one year.d) On average, part-time CHWs receive less training than full-time CHWs (6
weeks compared to 10 weeks, exclluding the Sudan which has a much longer training period) but the duration of the programme varies considerably from country to country.
It was noted
that the decision on training duration rarely derives from an estimation of the time
required to train CHWs adequately to perform their job; rather, it is made on the basis of
financial or personnel availability, or (perhaps most commonly) in a somewhat random
manner. Participants thought it would be useful to conduct operational research on this
topic, to compare the skills learned by CHWs who have experienced different durations of
initial training.
Another aspect of the duration of pre-service training whichi was discussed was whether
the total period is to be structured as a single training programme, or divided into a
series of courses spread over a longer period of time. The latter form of training would
(1) PNG is excluded:
see footnote Table 1 for explanation.
wo
ubu00
X5 co
00
rt)
X
cn
to
O
TABLE 6.
Pre-service training
BENIN
BOTSWANA
COLOMBIA
4 weeks
11 weeks
urban,
rura 1
13-14 wks.,
ind igenous
8 weeks
In-service training
duration and
f requency
1 week
every b
months
usua1 ly
1 week
per year
irregular
carried out
through
supervision
INDIA
200 hours
in 3
months
00
CHW TRAINING
JAMAICA
LIBERIA
PNG
PHILIPPINES
SUDAN
THAILAND
YEMEN
8 weeks
6 weeks
2 years
a) 1 month
b) 2 weeks
c) once per
1 year
a) 5 days
(VHC)
b) 15 days
(VHV)
3 months
week for
15 months
supposed
to be 1
day per
month but has
not
succeeded
durat ion1 day
monthly
and as
needed
monthly
1/2 - 1
day
every 6
months
for 1
week
once a week
for 4 hours
10 days,
6 months
after
pre
service
training,
then
period
ically
thereafter
a) 1 day
(VHC)
b) 2 days
(VHV)
Also self
teaching
modules
motivated/
supervised
by HC staff
with super
vision
visits usually
monthly
(by Train
ing Super
vision
Teams)
Pre-service Trainers:
Health Centre Staff
(HC), Training
Institution Staff
(TI), others
HC +
district
health
staff
TI
-district
health
staff
-nursing
school
-heads of
programme
HC
district
health
staff
TI
TI
- some HC;
- some HC+
project
staff +
people
from
health,
other
sectors
TI
HC
separate
supervision
training
team
Do trainers also
supervise CHWs?
Yes
No
occasion
ally
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
TABLE 5.
PHILIPPINES
PNG
Acriflavine Emulsion
Antibiotic Compound powder
Application for Treatment
of Scabies
Benzoin Compound Tincture
(Friars Sa Ison)
Crystal Violet 1%,
solution (Gentian violet)
"Tincture of Iodine"
Salicylic Acid Paid 10%
(Grille Lotion)
Ammoniated Mercury ointment
(H.D.A.)
Cod Liver Oil Ointment
No standard list, but
usually cough mixtures,
anti-pyretics, vitamins
anti-parasitics and 1 NH
Oral Drugs
Amodiaquine tablets lOOmg
Aspirin tablets, 300mg
Chloroquine tablets, 150mg
Cod Liver Oil Ointment
Cough Mixture
Local Anaesthetics
Procaine Hydrochloride
Injection (Plain) 1%, 2ml
Injection Drugs
Penicillin Aqueous Procain
Injection (Plain) 1%, 2ml
Quinine Injection 600mg ml amp
Ergometrine Maleate Injection
I
Ghlorhexidine, Comp.Antiseptic
Iodine solution 2.5%
Ointments
Sulphadetamide Eye Ointment,
10% 5mg tube
Liniment of Turpentine
Water for injection 10ml
SUDAN
Standard list of drugs
but not specified in
report
(continued)
YEMEN
THAILAND
Household Medicines
1. _________________
1.1 Stomachic mixture
1.2 Compound Magnesium
Trisilicate tablets
1.3 Alumina and magnesia
tablets
1.4 Alumina and magnesia
oral suspension
1.5 Sodamint tablets
1.6 Peppermint spirit
1.7 Tincture Asafetida
1.8 Compound Cardamum
1.9 Sodium Bicarbonate
1.10 Salol and Menthol
Mixture
1.11 Sulfaguanidine tablets
1.12 Phythalylsulfathiazole
1.13 Camphorated Opium
1.14 Kaolin Mixture
1.15 Kaolin Mixture with
Pectin
1.16 Kaolin and Campho
rated Opiutim Mixture
1.17 Castor Oil
Cough Mixture for Infants
Pyrantel tablets 125mg
"Kaolin Sedative Mixture"
Sulphadimidine tablets 0.5mg
Oral Rehydration
Antiseptic Drugs
DRUGS PERSCRIBED BY CUWs
1.46i
1.47
1.48i
1.49I
1.50i
1.51
1.52
1.53I
1.54
1. 55>
Sulpha ORS
Sulfacelamide eye drops
Tetracycline eye ointment Aspirin
Nitrofurazone ear drops
MV & FS
capsules
Ephedrine nasal drops
Tetracycline
Mandi's Paint
eye ointment
Sulphur ointment
Chloroquine
Salicylic acid & sulphur
Penicillin V
Salicylic acid & sulphur
tabs
Analgesic balm
Compound Methyl Salicy
Diperazine tab
Tet racycline
late Liniment
(Caps symp)
Methyl Salicylate Ointment
Coal Tar Ointment
Whitfield Ointment
Calamine Lotion
Scabicide Emulsion
Burns and scalds Mixture
Thimerosal Tincture
Iodine Tincture
Thimersal Solution
Merbromin Solution
Gentian Violet Solution
Acriflavine Solution
1.56>
1.57
1.581
1.59'
1.60I
1.61
1.62!
1.63I
1.64>
1.65>
1.66>
1.67’
1.68i Tooth-ache drops
announced by the
2. Drugs
I
Ministry of Public Health
2.1 Chlorpheniramine
2.2 Baralgin
2.3 Di-iodoquino1ine group
2.4 Ethyl alcohol
2.5 Ma-kleao and ma-had
2.6 O.R. S.
1.18 Aromatic Castor oil
1.19 Liquid Paraffin
1.20 Milk of Magnesia
1.21 Magnesium Sulfate
1.22 Piperazine Citrate
1.23 Aspirin tablets
1.24 Paracetamol tablets
1.25 A.P.C. Tablets
Groups of drugs which can be used by VHV;
1.26 Paracetamol Syrup,
1.27 Cough Syrup
Gr. 1 Antibiotic
1.28 Brown mixture
Gr. 2 Analgesic
Gr. 3 Antae id
1.29 Compound Ammonium
1.30 Eucalyptus oil
Gr. 4 Antitussis
1.31 Cold Inhalant
Gr. 5 Antihistamine
1.32 Aromatic Ammonia Spirit Gr. 6 Antispasmodic
Gr. 7 Antidiarrhoea
1.33 Sulfadiazine tablets
Gr. 8 Antirheumatic
1.34 Trisulfapyrimidine
Gr. 9 Vitamin
1.35 Trisulfa Suspension
Gr. 10 Anthelminthian
1.36 Sulfadoxine and
Pyrimethamine tablets
Gr. 11 Miscellaneous
- First Aid
1.37 Quinine Sulfate tablets
- ENT
1.38 Sulfadxone tablets
- Skin
1.39 Vitamin Bl tablets
1.40 Vitamin B Complex tabs
1.41 Multivitamin tablets
1.42 Multivitamin capsules
1.43 Vitamin C tablets
1.44 Cod Liver Oil Capsules
1.45 Compound Ferrous Sulfate Tabs
A) EC
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