SEA-HSD-309 _A-4 - WHO | World Health Organization

SEA-HSD-309 Distribution: General

Revisiting Community-Based Health Workers and Community

Health Volunteers

Report of the Regional Meeting Chiang Mai, Thailand, 3–5 October 2007

Regi onal Office for South-East Asia

© World Health Organization

This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes.

The views expressed in documents by named authors are solely the responsibility of those authors.

New Delhi, February 2008

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Contents Page

Executive summary.................................................................................................v

1. Introduction .................................................................................................. 1

2. Inaugural session ........................................................................................... 2

2.1 Significance of the role of community-based health workforce in health ................................................................................ 2

2.2 Social justice, equity and primary health care........................................... 3

3. Objectives..................................................................................................... 5

3.1 General objective ................................................................................... 5

3.2 Specific objectives .................................................................................. 5

4. Technical sessions ......................................................................................... 5

4.1 Community-based health workers and community health volunteers in countries of the South-East Asia Region................................ 5

4.2 Experience in primary health care ......................................................... 10

4.3 Voices from the field ............................................................................ 11

4.4 Global and regional policies and activities .............................................. 12

4.5 Regional strategic directions for strengthening CBHWs and CHVs........... 13

4.6 Country way forward............................................................................ 14

5. Conclusions and recommendations............................................................. 17

5.1 Conclusions ......................................................................................... 17

5.2 Recommendations ............................................................................... 18

Annexes

Meeting programme............................................................................................ 20

List of participants................................................................................................ 24

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Executive summary

Regional Office for South-East Asia (SEARO) of the World Health Organization (WHO) organized the Regional Meeting on Revisiting Community-Based Health Workers and Community Health Volunteers from 3-5 October 2007 in Chiang Mai, Thailand. The broad objective was to revisit and strengthen the Community-Based Health Workers (CBHWs) and Community Health Volunteers (CHVs) in countries of the South-East Asia (SEA) Region. The specific objectives were to review the experiences of countries in South-East Asia on community-based health action for CBHWs and CHVs; identify crucial strategies that contribute to a more integrated approach and sustainable actions in supporting CBHWs and CHVs; initiate a national network of key actors for actions on CBHWs and CHVs; develop Regional Strategic Directions for Strengthening CBHWs and CHVs in the SEA Region, and to facilitate the way ahead for Member Countries on CBHWs and CHVs. There were 120 participants from various sectors from across 10 countries in the South-East Asia Region. Dr Samlee Plianbangchang, Regional Director, WHO SEA Region, and Dr Halfdan Mahler, WHO Director-General Emeritus, addressed the inaugural session. The meeting was inaugurated by His Excellency Dr Mongkol Na Songkhla, Minister of Public Health, Royal Government of Thailand.

Dissemination techniques adopted at the meeting included presentations, panel discussions, field trips and group work, and group presentations. At the meeting, the policy and experiences of WHO at the global and regional levels on CBHWS and CHVs, experiences of people who are CHVs, expert opinion on country experiences with the evolution and development of CBHWs and CHVs, and the way ahead for countries were presented and discussed. The Regional Strategic Directions for strengthening CBHWs and CHVs in countries of SEA Region were adopted with some suggestions for revision. Recommendations for further action were finalized for implementation by Member countries and WHO.

Through the discussions at the meeting, it became possible to raise the levels of awareness among participants on the need to revisit the CBHWs and CHVs. Main points of the discussions can be concluded as follows:

(1) Various types of CBHWs and CHVs have long been involved with the community on health aspects in all countries of the SEA Region. Their contributions to the health of the people, especially towards the

Report of the Regional Meeting

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reduction of the disease burden through primary prevention interventions, and through the reduction of health risks and health determinants, were clearly highlighted and recognized. However, these have not received much attention and support from the Government.

(2) Due to the change in population structure, epidemiology, disease patterns and socioeconomic and political factors and a revisit of primary health care, this is an opportune time to revisit and study the type and scope of work and identify mechanisms to promote and sustain CBHWs and CHVs for better health services, particularly to the poor, unreached and underprivileged. The definition, type, scope of work and mechanisms to develop and maintain CBHWs and CHVs should be both country- and cultural-specific.

(3) The draft Regional Strategic Directions for Strengthening CBHWs and CHVs was adopted with some suggestions and recommendations for revision.

(4) The Strategic Directions are based on three pillars: (1) The need for CBHWs and CHVs in a changing environment; (2) The development of CBHWs and CHVs; and (3) The supporting environment, including legal and administrative framework, local administration involvement and support from the health systems, NGOs and partners.

(5) There is a need for capacity building, research and linking of CBHWs and CHVs to the formal health system for their better utilization.

(6) Multisectoral and multidisciplinary approaches are the key for the development and sustenance of these CBHWs and CHVs.

(7) Proposed country actions varied from developing a of plan for strengthening CBHWs and CHVS, organizing a meeting to revisit CBHWs and CHVs, continuance of training, and district mapping of CBHWs and CHVs, to amendments in government policy.

Recommendations

For member states

(1) Revisit the categories, roles, functions and mechanisms to promote, develop and sustain Community-Based Health Workers (CBHWs) and Community Health Volunteers (CHVs) in the community.

Revisiting Community-Based Health Workers and Community Health Volunteers

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(2) Review the proposed country actions for strengthening CBHWs and CHVs and take priority actions forward.

(3) Adapt the Regional Strategic Directions for Strengthening Community-Based Health Workers and Community Health Volunteers in countries of the South-East Asia Region.

(4) Support the development of a public health workforce, including CBHWs and CHVs at the grassroot level to tackle public health problems.

For WHO

(1) Advocate the significant role of CBHWs and CHVs in ensuring good health at the community level to the governments of the Member States to elicit their commitment towards the development and sustainability of this workforce at the community level.

(2) Support Member States in the use or adaptation of the Regional Strategic Directions for Strengthening Community-based Health Workers and Community Health Volunteers in countries of the SEA Region.

(3) Develop evidence-based best practices, tools and guidelines for the development of CBHWs and CHVs.

(4) Provide technical and financial support for the development of CBHWs and CHVs in countries of the South-East Asia Region. These include organizing training courses, workshops and meetings on CBHWs and CHVs, supporting study tours and establishing training centres at the national and regional levels.

1. Introduction

The Alma Alta Declaration on Health for All through Primary Health Care has been implemented for 30 years but equity in health has not been achieved globally, especially among the poor, underserved and underprivileged. Countries of the SEA Region have faced a high burden of disease, some of which could have been prevented if people are aware of their responsibility in health and are able to take care of their health. There are various categories of the community-based health workforce working in the community in all SEA Region countries. In order to ensure that the volunteers are not excluded, this workforce includes the CBHWs and CHVs who can be of considerable service in health promotion and disease prevention. However, the development of CBHWs and CHVs do not receive much attention and support from the national or local governments.

The development of a community-based health workforce is one of the strategic areas in the Regional Strategic Plan for Health Workforce Development in the South-East Asia Region adopted at the Fifty-ninth Regional Committee Session (SEA/RC 59/R6) in Dhaka. The Regional Office was scheduled to carry out advocacy to develop CBHWs while Member Countries were to take action on CBHWs.

At a time when that WHO is due to cerebrate thirtieth anniversary of the Alma Alta Declaration on Primary Health Care in 2008, it is an appropriate moment for countries in the SEA Region to reassess the role of CBHWs and CHVs who have been the cornerstone of the primary health care movement since its inception. They have also contributed considerably to the improvement of the health of their population, especially the poor, underserved, underprivileged, marginalized and the vulnerable. In this context, the meeting on “Revisiting Community-Based Health Workers and Community Health Volunteers” was organized from 3 to 5 October 2007 in Chiang Mai, Thailand. It was the first meeting of its kind and the deliberations there were to serve as the inputs for revitalizing the primary health care approach.


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2. Inaugural session

At the inaugural session, participants were welcomed by Dr Wattana Kanchanakamol, Chief Medical Provincial Officer, Chiang Mai. Dr Samlee Plianbangchang, Regional Director, WHO Regional Office for South-East Asia, delivered his address focusing on the role of CBHWs and CHVs and the need to revisit them. Dr Halfdan Mahler, WHO Director-General Emeritus, presented his reflections on primary health care. The meeting was formally inaugurated by His Excellency Dr Mongkol Na Songkhla, Minister of Public Health, Royal Government of Thailand.

2.1 Significance of the role of community-based health workforce in health

The Regional Director indicated the significance of roles that CBHWs and CHVs play in ensuring the health of the people and identified some strategies for development of this workforce.

Roles of CBHWs:

Ø CBHWs and CHVs have contributed considerably to ensuring equity in health at the grassroot level.

Ø They contribute very substantially to the efforts of their governments towards the realization of health care for all, particularly the poor, underserved and underprivileged.

Ø As an integral part of the community, CBHWs and CHVs can render health care to a degree acceptable to all people. They are effective agents of change to help ensure the involvement of people in health matters, have better understanding of the health needs of the people in the community, and empathize with and respect the needs of the people in the community better.

Ø CBHWs can help in reducing the disease burden through disease prevention focusing on health risks and health determinants.


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Suggested strategies for development of CBHWs

Ø There is the need to provide CHWs and CHVs with proper development and training, proper referral system for sending sick people from the community to a higher level of care, institutional support throughout their career, professional backing in planning, implementing and monitoring their activities to ensure efficiency and effectiveness, and clear Government policy and operational back-up for their effective development and deployment.

Ø The keys to sustain the community-based health action and CHWs and CHVs include diverse models of community participation and involvement, different forms of teamwork for community action to address local health challenges, equity and social justice in health, capacity building through interactive learning processes with built-in systematic research and development procedures, leadership of health personnel and health professionals at all levels, adequate financial support and multidisciplinary and multisectoral partnerships.

Ø This strategy must lead to a perceptible change in social values to create self-responsibility, self-reliance, self-discipline and partnerships for health for all at the community level.

2.2 Social justice, equity and primary health care

Dr Halfdan T. Mahler, WHO Director-General Emeritus, presented his thoughts and reflections on PHC experiences by reminding participants about the intrinsic relevance and pertinence of WHO’s definition of health that is enshrined in its Constitution and the objective of the Organization which focuses on the attainment by all people of the highest possible level of health. The highlights of his presentations were:


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Ø Health for All and Primary Health Care strategies provide significant starting force and added impetus for health development all over the world.

Ø Adequate level of health is a basic ingredient that fuels the transmission of social apathy to social and economic productivity. Development is about the creation and expansion of opportunities for human beings to realize what they consider to be their positive destiny.

Ø It is important for leadership to be linked to the collective process of society. The effectiveness of the leaders must be gauged by the actual social change they create, measured by satisfaction of human needs and expectations.

Ø Social equity takes time to happen. It must be incorporated in the political system and supported through the strategic and decision-making process. It must be reinforced continuously through the diligent pursuit of facts and fearless exposure of the actual prevailing situation for social justice.

Ø The binding contract for Health for All was the basis for the primary health care strategy which implied not only a commitment of conventional health care system but also people’s own control over their health and well being to the extent that they would be willing to handle profound social reforms in health.

Ø This implies a continuous empowerment process whereby people acquire the skill and will to become the social carriers of their own health and well-being. When people are socially productive there is much hope for economic productivity.

Ø The fundamental values of social justice and equity are firmly embedded in the vision of Health for All and the strategy of primary health care. This can be a strong force for achieving social justice and equity. This requires sensitive political understanding emanating from relevant epidemiological, sociological and operational research.

Ø Therefore more leadership potential must be generated as a collective force from all levels of society, locally and globally, towards accelerating the abatement of the gross health inequity evident in society today.


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3. Objectives

3.1 General objective

The general objective of the meeting was to revisit and strengthen the Community-Based Health Workers and Community Health Volunteers in countries of the South-East Asia Region.

3.2 Specific objectives

The specific objectives of the meeting were to:

(1) Review experiences of countries in South-East Asia on community-based actions for Community-Based Health Workers (CBHWs) and Community Health Volunteers (CHVs) ;

(2) Identify crucial strategies that contribute to a more integrated approach and sustainable actions in supporting CBHWs and CHVs;

(3) Initiate a national network of key actors for actions on CBHWs and CHVs;

(4) Develop Regional Strategic Directions for strengthening CBHWs and CHVs in the SEA Region, and

(5) Facilitate the road ahead for Member Countries on CBHWs and CHVs.

4. Technical sessions

4.1 Community-based health workers and community health volunteers in countries of the South-East Asia Region

Information on the situation, evolution and development of CBHWs and CHVs in countries of the South-East Asia Region were retrieved from papers and panel discussions and can be synopsized as follows:


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Definition

The community-based health workforce refers to people who perform community-based health actions. They may be volunteers or trained and paid workers who work for the health of the people in the community. The Alma Ata Declaration spurred a movement in countries of the SEA Region to accelerate community health workers to carry out or assist in the work guided according to the principles of primary health care. WHO defines “Community Health Workers” as “Men and women chosen by the community and trained to deal with the health problems of individuals and the community and to work in close relationship with the health services”. They should have a level of primary education that enables them to read, write and execute simple mathematical calculations. They should be members of the communities wherein they work, should be selected by the communities themselves and answerable to the same communities for their activities, should be supported by the health system though not necessarily be a part of its organization, and have a shorter span of training than that of professional workers.

With the rapid changes in the socioeconomic and political situation, epidemiological patterns and health-care system, there are several community-based health actions performed by a wide gamut of people. For this meeting, the terms Community-Based Health Workers (CHWs) and Community Health Volunteers (CHVs) were used to ensure the inclusion of volunteers who are the pioneer workers in the community.

CHVs are be defined on the lines of the WHO definition in 1978 and 1989. In the meanwhile, for the purpose of this meeting, CBHWs are referred to as those “who provide health services or perform community-based health actions to people in the community, especially those who are poor, underserved or underprivileged”. It refers to a broader range of people who

Ø have formal training to carry out a series of specified roles and functions;

Ø are health professionals as part of health system or from other disciplines;

Ø work independently or under public, private or nongovernmental organizations (NGOs);


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Ø spend substantial part of their working time actively reaching the community; and those who

Ø deliver their services at the health care facilities, community or home.

Categories

There are many categories of CBHWs and CHVs in countries of SEA Region. Based on reports from countries, CBHWs and CHVs can be categorized into two main categories: (1) volunteers and (2) health-related personnel. Religious readers and monks, NGOs and, community leaders are also found to play a significant role in empowering people, building partnerships, mobilizing community resources and in other health activities.

Categories BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS

Village Health Volunteer/Worker

X X X X

Accredited Social Health Activist (Anganwari/Posyandu)

X X

Maternal and Child Worker, Female Community Health Volunteers

X

Community Health Worker, Ten Household Worker, Community Support Group, Reproductive Health Promoter, Community Own Resource Person

X

Health/Family Health Inspector

X

Trained Traditional Birth Attendant

X X

Family Welfare Assistant /Visitors

X X

Health Assistant X X X


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Categories BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS

Assistant Clinical Officer

Assistant Health Worker/inspector

X

X X

Basic Health Worker, Care taker, Multi-purpose worker

X X

Auxiliary Nurse Midwife, Auxiliary Nurse

X X X

Midwives, Public Health Midwives

X X X X X X

Nurse, Nurse Midwives

X X X X X X

Public Health Officer X

Doctors X X X X

Roles and responsibilities

Roles of the each category of CBHWs and CHVs in each country are varied. In general, they include:

(1) Health promotion and disease prevention through health education.

(2) Screening, surveillance.

(3) Basic treatment and care.

(4) Monitoring and evaluation.

(5) Rehabilitation.

(6) Referral to health-care facilities.

(7) Coordination with people, community, health-care facilities and other organizations.

(8) Change agents.

Areas of responsibility vary according to national policy, and the number and categories of workers available. Most of CHVs are mainly


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responsible for the health of mothers, children and chronic illness patients. Trained health personnel are responsible for all groups of clients in every health status. They may perform their roles through education or health education, empowerment, community participation, home visits, counselling, advocating, data collection and record, measurement, and through assisting in or providing direct clinical services.

Education and training

Almost all volunteers have had very short periods of training ranging from days to weeks that focus on their work and some diseases commonly found in the village. The health professionals receive training during their study but have limited opportunity for continuing education to update their knowledge and skills. It was suggested that CBHWs and CHVs should be trained on a regular basis to understand the change in health problems and work to be done.

Incentives

All volunteers are not paid but some may receive incentives in terms of free health-care service and uniforms. Apart from one or two days of orientation to the work or briefing on the new policy and task, most CHVs do not receive any training. Paid workers rarely have the opportunity to attend to the trainings.

Linkages

Most of the volunteers do not have formal linkages with the health system and some of them even do not receive recognition and respect from health personnel. Meanwhile, those CHWs who are trained and hired by health organizations are part of the health system. NGOs in Bangladesh play a significant role in strengthening CBHWs. Local governments and other organizations still have a limited role in working with CBHWs.

Based on the panel discussion on country experiences, it emerged that:

Ø Member countries can boast of a proud history of community-based health action.


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Ø In some countries such action was initiated as early as more than five decades before the PHC approach was introduced.

Ø Following the Alma Ata Declaration, Member countries intensified their community-based health action, aligning their programmes to suit national health challenges.

Ø Irrespective of the size of the country or its population, the health issues, challenges and system complexities are numerous.

Ø There is no “one-size-fits-all” solution. There is no single strategic approach. The approaches are multiple and undergoing dynamic changes and may vary from country to country and region to region.

Ø There is a necessity to use multiple CBHWs and CHVs, with a range of competencies to address the existing challenges.

Ø Health challenges in today's context remain numerous and vary from country to country with a varying degree of magnitude.

Ø CBHWs and CHVs continue to have an important role to play in health development activities in the countries.

Ø Selection, development, work responsibilities, incentive mechanisms of CBHWs and CHVs may need to be reassessed keeping in mind the current challenges.

4.2 Experience in primary health care

Dr Amorn Nondasuta re-examined the role of village health volunteers (VHVs) in Thailand and made certain proposals about what should be done and not done regarding VHVs or CHVs. It was suggested that CHVs be identified from those who are willing or already assuming the functions expected in PHC, that salary be substituted with other incentives, a critical number of CHVs be decided upon, and direct communication lines be established. It was also recommended to identify clear type and functions of CHVs, identify work expectations with the emphasis on process rather than output, and provide educational support to CHVs. CHVs should not be treated as subordinates, and burdened with records and reports or work for the health staff.


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4.3 Voices from the field

Two Anganwadi workers from India, one Posyandu from Indonesia and one Health Volunteer from Thailand shared their work experiences and thoughts on being CHVs/CBHWs. They said they were all proud to work for the health of the people who reposed their trust and support in them. They also reiterated that no constraint would deter their commitment to their work.

Anganwadi workers are a group of volunteers and paid female workers under the Integrated Child Development Services Scheme (ICDS) in India, which is one of the world’s largest programmes for early childhood development launched countrywide in 1975. There were 748 229 Anganwadi workers covering 24.4 million children in India in 2006. The services include supplementary nutrition, non-formal pre-school education, immunization, health check-up and referral services for children aged between 0 and 6 years and pregnant and lactating women.

Recollection of an anganwadi worker

“We do not want any incentives but would like to be recognized. Sometimes we have to do more than what we are supposed to do to save lives. I had once delivered a baby in a public vehicle. I was proud to raise money from the community to pay for the transportation of a sick boy to get treatment in the city. I could not raise a large sum but it was adequate”.

Posyandus are women volunteers who care for women and children aged under five. The services that they provide for women include family planning, nutrition and immunization for pregnant women, and an array of health services for children including nutrition, immunization and the use of ORS for diarrhoea management. There is at least one Posyandu deployed in every village and they execute their work under the guidance of the local health centre.

Recollection of a Posyandu

“We raise some money to support Posyandu activities. I enjoy what I do. I am 78 years old but will continue to work….work hard and put my heart to it.”


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The Village Health Volunteers (VHVs) scheme in Thailand was established in 1978 as an instrument to realize the goal of health for all. There are more than 800 000 VHVs or at least one VHV per 15-20 households. They are given a 15-day initial training and onsite training for certain specific diseases. They take standard care of the eight PHC elements and also provide guidance and assistance in health care on mental health, dental health, consumer protection, AIDS, accidents and rehabilitation. They also work with other sectors on issues that may affect health, such as to provide community-based surveillance for avian influenza in animals and human beings and providing service to affected people from emergencies and disasters.

Views of a Village Health Volunteer

“The government provides training courses in many areas to strengthen technical knowledge and management skills. The attitude of health officials and the local administration displays a certain lack of confidence in us. There are too many rules and regulations imposed on us. We aim to have access to the political establishment to influence public policy in health.”

4.4 Global and regional policies and activities

Dr Sultana Khanum, Director, Health Systems Development, Regional Office for South-East Asia, Dr Mohammad Assai Ardakani, Regional Adviser, Community-based Initiatives, Regional Office for Eastern Mediterranean, and Dr Manuel Dayrit, Director, Department of Human Resources for Health, WHO/HQ, reflected on the increasing community-based health actions, CBHWs and CHVs after the Alma Ata Declaration, the link between the number of health workers and health outcomes and the need to have CBHWs for the poor and the unreached.

Countries in the South-East Asia Region have been using CBHWs for a long time and SEARO has a strong commitment to strengthening CBHWs by including it as a strategic area in the Regional Strategic Plan for Health Workforce Development. Evidence from the implementation of the community-based initiatives (CBI) by trained CHWs in countries of the


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Eastern Mediterranean Region showed a marked improvement in inequity and potential toward poverty reduction and health improvement. Sustainability of CBHWs was one of the common concerns. Ways forward to make the CHWs programme work better include appropriate selection, continuing education, involvement and reorientation of health service staff, improvement of supervision and support, political leadership and provision of substantial and consistent resources.

4.5 Regional strategic directions for strengthening CBHWs and CHVs

The Regional Strategic Directions for Strengthen Community-based Health Workers and Community Health Volunteers were endorsed in principle with some suggestions. The Strategic Directions come under five guiding principles, as follows:

(1) Evidence-based decision-making and policy development

(2) Equity and recognition of the community-based health workforce;

(3) Participation and partnership in community health development;

(4) Community empowerment and the ability for people to think and act for themselves; and

(5) Equality in gender.

The process development of CBHWs and CHVs is based on three important pillars:

(1) Identification of the need for CBHWs and CHVs to meet the country context in a changing environment,

(2) The development of CBHW and CHV movement, and

(3) The supportive environmental factors for effective functioning of CBHW.

Under each pillar, key strategic areas are developed for a total of nine strategic actions:


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Nine Key Strategic Actions

(1) Identify the needs for community-based health actions.

(2) Map out the health workforce requirement for delivery of community health actions.

(3) Train and retrain CBHWs and CHVs based on health needs and demands.

(4) Develop effective incentives schemes/motivation mechanisms.

(5) Create local ownership and partnerships.

(6) Maximize support from district/sub-national health systems.

(7) Ensure adequate legal and administrative framework.

(8) Fine-tune local/district administrative structures to harness synergies of CBHW/CHV action.

(9) Develop favourable values and opinions in societies for community health action.

The details of the strategic directions, with proposed actions for Member countries and WHO, are provided in a separate WHO publication.

4.6 Country way forward

Participants from the countries proposed the following activities that should be implemented or that they could implement to take the meeting recommendations ahead:

County Proposed activities

Bangladesh (BAN) Ø Organize a national consensus workshop on roles and functions of CBHWs and CHVs in Bangladesh.

Ø Conduct a rapid assessment of current community-based services and workforce of the government and NGO sectors.

Ø Develop/revise curricula for training and refresher training of different categories of CBHW s and CHVs.


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Bhutan (BHU) Ø Develop the capacity of district health offices in the development of need-based volunteer health workers’ programmes at district levels.

Ø Encourage the Royal Institute of Health Sciences to provide trainings for CBHWs.

Ø Review/enhance the career development of the community-based health workforce.

India (IND) Ø Ensure that all components of design of CBHWs are local-sensitive.

Ø Strengthen linkage of training of ASHA with job profile; outline clear actions for ASHA .

Ø Identify and involve NGOs and State functionaries in building/strengthening mentoring mechanisms.

Ø Create an environment of convergence through team -building.

Ø Increased involvement of NGOs under the National Rural Health Mission.

Ø Operationalise Village Health and Sanitation Committees so as to enhance inter-sectoral coverage.

Ø Facilitate the functioning of CBHWs through:

Radio programmes targeted at CBHWs.

BCC activities.

Increased mobility (cycles).

More effective telecommunications (mobile phones).

Indonesia (INO) Ø Strengthen the existing policy of community-based activities.

Ø Socialization and advocacy.

Ø Development of a district model by integration of community-based health action.


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Maldives (MAV) Ø Organize a national consultation to redefine roles and responsibilities of health workers in the community and introduce the concept of volunteerism .

Ø Organize a study tour of community leaders to study VHVs in Thailand.

Ø Accelerate training of Skilled Birth Attendants.

Ø Organize a national meeting to promote NGO s and Community-based Organizations’ (CBOs) involvement in health.

Myanmar (MMR) Ø Redefine the roles and responsibilities of CBHW s and CHVs based on the current need.

Ø Develop the training and retaining facilities of CBHWs and CHVs.

Ø Design incentive schemes and motivation mechanisms.

Nepal (NEP) Ø Organize a dissemination m eeting with policy-makers and other stakeholders to advocate on the need to develop CBHWs/CHVs.

Ø Organize a consultative meeting to review existing policies and strategies on CBHWs/ CHVs.

Ø Develop comprehensive guidelines and code of ethics for CHVs and all categories of CBHWs.

Ø Review the logistic supplies and make proper strategies.

Sri Lanka (SRL) Ø Organize a national consultative meeting on development of CBHWs.

Ø Identify new challenges that need to be addressed by CBHWs/CHVs.

Ø Examine possibilities to ensure career development for CBHWs.

Ø Technical assistance to design career development paths for CBHWs.


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Thailand (THA) Ø Apply strategy map to be implemented at local the level:

Forums among partners at the national level.

Roles and functions.

Ø Review training capacity for all partners at all levels:

Universities and educational institutes.

Ø Review financial and administrative framework to facilitate implementation of strategy map.

Timor-Leste (TLS) Ø Conduct an advocacy meeting on development of CBHWs and CHVs among nine to fourteen districts.

Ø Launch a national campaign on CHVs and FHP .

Ø Carry out a field study on the need, roles and responsibilities of CHVs in the local context.

5. Conclusions and recommendations

5.1 Conclusions

(1) CBHWs and CHVs of various categories have long been working with the community on health aspects in all countries of the SEA Region. Their contributions to the health of the people, especially on reduction of the disease burden through primary preventi ve interventions, and through the reduction of health risks and health determinants were clearly highlighted and recognized. However, they have not received much attention and support from the Government.

(2) Due to the change in the population structure, epidemiology, disease patterns and socio-economic-political factors and a revisit of primary health care, this is an opportune time to revisit the type and scope of work and identify mechanisms to promote and sustain CBHWs and CHVs for better health services particularly to the poor, unreached and underprivileged.

(3) The definition, type, scope of work and mechanisms to develop and maintain CBHWs and CHVs should be country- and culture-specific.


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(4) Draft Regional Strategic Directions for Strengthening CBHWs and CHVs was adopted with some suggestions for revision.

(5) The Strategic Directions consist of three pillars: (1) the need for CBHWs and CHVs in a changing environment, (2) the development of CBHWs and CHVs; and (3) the supportive environment including the legal and administrative framework, involvement of the local administration involvement and support from the health system, NGOs and partners.

(6) There is a need for capacity building, research and linking of CBHWs and CHVs to the formal health system for better utilization.

(7) Multisectoral and multidisciplinary approaches are the key for the development and sustenance of these CBHWs and CHVs.

(8) Proposed country actions varied from the development of a plan to strengthen CBHWs and CHVS to organizing a meeting to revisit CBHWs and CHVs, continue trainings, conduct a district level mapping of CBHWs and CHVs and revision of government policy.

5.2 Recommendations

For member states

(1) Revisit the categories, roles, functions and mechanisms to promote, develop and sustain community-based health workers and community health volunteers in the community.

(2) Review the proposed country actions for strengthening community-based health workers and community health volunteers and take priority actions ahead.

(3) Adapt the Regional Strategic Directions for Strengthening Community-Based Health Workers and Community Health Volunteers in countries of the South-East Asia Region.

(4) Support the development of the public health workforce including Community-Based Health Workers and Community Health Volunteers at the grassroot level to tackle public health problems.


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For WHO

(1) Advocate the significance of the role of CBHWS and CHVs in health at the community level to the Governments of the Member States for their commitment, and the development and sustainability of this workforce at the community level.

(2) Support Member States in the use or adaptation of the Regional Strategic Directions for Strengthening Community-Based Health Workers and Community Health Volunteers in countries of the South-East Asia Region.

(3) Develop evidence-based best practices, tools and guidelines for the development of CBHWs and CHVs.

(4) Provide technical and financial support for the development of CBHWs and CHVs in countries of the South-East Asia Region by organizing training courses, workshops and consultations on CBHWs and CHVs, support study tours, and the establishment of training centres at the national and regional levels.


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Annex 1

Meeting programme

DAY 1, Wednesday, 3 Oct 2007

08:30 – 09:15 Inaugural session

Ø Welcome address by Dr Watana Kanchanakamol, Provincial Medical Chief Officer, Chiang Mai

Ø Address by Dr Samlee Plianbangchang, Regional Director, WHO/SEARO

Ø Address by Dr Halfdan T. Mahler, WHO Director-General Emeritus, on “A few reflections on community-based health care”

Ø Inaugural address by H.E. Dr Mongkol Na Songkla, Minister of Public Health, Royal Government of Thailand

Ø Group photograph

09:45 – 09:55 Plenary Session

Moderator: Dr Sultana Khanum, Director, Health Systems Development, WHO/SEARO

Ø A brief on meeting objectives and structure

Dr Prakin Suchaxaya, Regional Adviser (Nursing and Midwifery), WHO/SEARO

09:55 – 10:05 Voices from the field

Ø Primary Health Care Strategy and Lessons Learnt

Dr Amorn Nondasuta, President of the Foundation for Quality of Life, Thailand

10:05 – 11:40 Ø Experiences from the field

Speakers:

(1) Ms Ranjana Mehra, India

(2) Ms Jyoti Martin, India

(3) Ms Harini Bambang, Indonesia

(4) Sub Lt Sontaya Mahotan, Thailand


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11:40 – 12:30 A round-table Presentation

Moderator: Dr Suwit Wiboolpolpratsert, Senior Adviser on Disease Control, MoPH, Thailand

(1) Involvement of Community-Based Health Workers and Volunteers in Public Health Programme: Issues in the South-East Asia

Dr Sultana Khanum, HSD, WHO/SEARO

Community-based Initiatives for Poverty Reduction and Health Development in the Eastern Mediterranean Region

Dr Mohammad Assai Ardakani, Regional Adviser (Community-based Initiatives), WHO/EMRO

WHO policy on Community-Based Health Workers and Volunteers

Dr Manuel Dayrit, Director, Human Resources for Health, WHO/HQ

12:30 – 12:45 Discussion on the round-table presentations

13:45 Panel I: Evolution and situation of community-based action for health, Community-Based Health Workers and Volunteers

Moderator: H.E. Dr Abdul Azeez Yoosuf, Deputy Minister of Health, Maldives

Speakers:

(1) Dr San Shway Wynn, Myanmar

Dr (Mrs) Chandrani Jayasekara, Sri Lanka

Dr Nonglak Pagaiya, Thailand

Panel II: Strategic Approach towards the development of community-based health action, community-based health workers and volunteers

Moderator: Dr Supachai Kunaratanapruk, Director-General, Department of Health Service Support, MoPH, Thailand

Speakers:

(1) Dr Gyembo Dorji, Bhutan

Dr Tarun Seem, India

Dr Shiba Kumar Rai, Nepal


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16:00 – 17:00 Panel III: Issues, Challenges, and Future Prospects for Community-Based Health Workers and Volunteers

Moderator: Shri Amarjeet Sinha, Joint Secretary (NRHM), Ministry of Health and Family Welfare, India

Speakers:

(1) Dr Azaher Ali Molla, Bangladesh

Dr Yaslis Ilyas, Indonesia

Ms Aishath Ahmed Didi, Maldives

Day 2, Thursday, 4 Oct 2007

08:30 – 08:45 Summary of Day 1

Ms Laksami Suebsueng, Technical Officer (AIDS), WHO/SEARO

08:45 – 10:00 Presentation of a Draft on Framework and Strategic Directions for Strengthening Community-Based Health Workers and Volunteers in Countries of South-East Asia Region

Moderator: Mr Kapil Dev Ghimire, Joint Secretary, Ministry of Health and Population, Nepal

Speakers:

(1) Dr Somsak Chunharas, Secretary-General, Thailand National Health Foundation, Thailand

Dr Sultana Khanum, Di rector, Health Systems Development, WHO/SEARO

10:00 – 10:30 Video presentation on “Community Health Volunteers in the context of Thailand”

10:30 – 10:45 Briefing on Group Work-I and Field Visits

Dr Sudhansh Malhotra, Regional Adviser (Child Health and Development), WHO/SEARO

11:00 – 13:30 Group Work I: Reflections on the Regional Strategic Directions on Strengthening Community-Based Health Workers and Volunteers

1330 – 1730 Field trips


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Day 3, Friday, 5 Oct 2007

08:30 – 10:15 Moderator: Mr Dr Edi Suranto, Director of Community Health, Ministry of Health, Indonesia

Presentation of Group Work I

Ø Rapporteur

10:15 – 10:25 Briefing on Group Work II

Ø Dr Thushara Fernando, GAVI/HSS, WHO/SEARO

10:45 – 12:30 Group Work II: Country way forward in Strengthening Community-based Health Workers and Volunteers

13:45 – 15:15 Presentation of Group Work II

Moderator: Mr Mohammed Golam Quddus, Joint Secretary (Hospital & Nursing), Ministry of Health and Family Welfare, Dhaka

15:35 – 16:00 Recommendations and way forward

Ø Dr San Shway Wynn, Deputy Director-General, Public Health, Department of Health, Myanmar

16:00 – 16:15 Closing session

(1) Dr Halfdan T. Mahler, WHO Director-General Emeritus

Dr Sultana Khanum, HSD, WHO/SEARO


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Annex 2

List of participants

Country participants

Bangladesh

Mr Mohammed Golam Quddus Joint Secretary (Hospital & Nursing) Ministry of Health and Family Welfare Dhaka.

Mr Muhammad Abdullah Deputy Secretary (Administration) Ministry of Health and Family Welfare Dhaka.

Dr Saleh Md Rafique Director (PHC) Directorate General of Health Services Dhaka.

Prof Dr Khondaker Md Shefayetullah Director Medical Education and HMPD Dhaka.

Dr Md Akhter Hossain Director (Training) NIPORT Dhaka.

Dr Mr. Salah Uddin Civil Surgeon Jessore.

Mrs Syeda Muhbub Ara Begum Family Welfare Visitor MCH Training Institute Azimpur, Dhaka.

Mr Tushar Mohon Shadhu Khan Executive Engineer DPHE Ministry of LDRD Dhaka.

Dr Md. Ariful Alam Programme Manager (Training) BRAC Health Programme Dhaka.

Dr Syed Moshfiqur Rahman Deputy Project Coordinator Projahnmo Child Health Unit Public Health Sciences Division ICDDR,B: Knowledge for Global Lifesaving Solutions Mohakhali, Dhaka1212.

Bhutan

Mr Gyembo Dorji Programme Manager Environmental Health and Village Health Workers PHD, Ministry of Health Thimphu.

Mr Sangay Phuntsho Lecturer Royal Institute of Health Sciences Thimphu.

Mr Dorji Wangchuk Health Assistant Basic Health Unit Haa Bali.

India

Shri Amarjeet Sinha Joint Secretary (National Rural Health Mission) Ministry of Health and Family Welfare New Delhi.

Mr VLVSS Subba Rao Director (SGSY) Ministry of Rural Development New Delhi.

Dr Namshum Deputy Commissioner (Training) Ministry of Health and Family Welfare New Delhi.


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Smt Archana Verma Deputy Secretary (NRHM) Ministry of Health and Family Welfare New Delhi.

Dr John Ekka Mission Director (NRHM) House No. 16 Khanatara Guwahati 781 022 Assam.

Dr Dinesh Arora Mission Director (NRHM) Directorate of Health Services General Hospital Junction Thiruvanthapuram, Kerala.

Smt Sushma Rath Under Secretary (Infrastructure Development) Ministry of Health and Family Welfare New Delhi.

Ms Jyoti Martin Gali No.5 Mahatma Gandhi Colony Kota, Rajasthan.

Indonesia

Dr Edi Suranto Director of Community Health Directorate-General Community Health Ministry of Health Jakarta.

Dr Siti Zainar Rosihan Chief of Sub-Directorate of Basic Health Institution and Community-based Health Programme Directorate-General of Community Health Ministry of Health Jakarta.

Ms Muhani Mualip Staff of Community Participation and Partnership Center for Health Promotion Secretariat General Ministry of Health Jakarta.

Mr Windasnofil Chief of Section of Community Participation Programme Sub-Provincial Health Office of Health Promotion and Human Resources for Health West Sumatera Province.

Ms Susilawati Soebakti Team Leader of Working Group-IV of the Central Family Welfare Movement Jakarta.

Ms Eppy Lugiarti Chief of Section of Family Welfare Directorate of Social Cultural Empowerment Directorate General Village Community Empowerment Ministry of Home Affairs Jakarta.

Ms Rina Budhy Ariani Team Leader of Family Welfare Movement of Kudus District Central Java Province.

Dr Koeswando Chief of District Health Office of Lumajang the East Java Province.

Dr Haridana Indah Setiawati Mahdi Chief of Kudus District Health Office Central Java Pronvince.

Ms Mulyanah Abdulhaq Chief of Section of Supervision and Evaluation.

Ms Lusi Afriani Staff Bureau of Planning and Budgeting Ministry of Health Jakarta.

Maldives

Mr Ahmed Khaleel Assistant Director-General Department of Public Health Male.

Ms Najma Abdul Rahmaan Community Health Worker B Hithaadhoo Health Centre.


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Ms Muneera Ibrahim Community Health Supervisor F. Atoll Hospital.

Ms Aminath Mohamed Didi Community Health Supervisor S. Hulhudhoo-meedhoo Health Centre.

Mr Hussain Moosa Community Health Supervisor HDh. Nolhivaram Health Centre.

Myanmar

Dr Nyo Nyo Kyaing Deputy Director (Planning) Department of Health Ministry of Health Myanmar

Dr Than Lwin Deputy Director (Basic Health) Department of Health Ministry of Health Myanmar

Dr Tin Win Kyaw State Health Director Shan State (South) Taunggyi District.

Dr Moe Swe Divisional Health Director Tanintharyi Division Dawei District.

Dr Thuzar Chit Tin Assistant Director (Basic Health Service) Department of Health Ministry of Health Myanmar.

Nepal

Mr Kapil Dev Ghimire Joint Secretary Ministry of Health and Population Kathmandu.

Mr Ghan Shyam Pokhrel Public Health Administrator Management Division, DHS Kathmandu.

Dr Ramesh Man Singh Senior Medical Officer Lumbini Zonal Hospital Butawal.

Mr Dhir Jang Shah Public Health Inspector District Health Office Dailekh.

Mr Babu Ram Acharya Public Health Inspector District Health Office Kapilvastu.

Mr Dina Nath Lamichhane Health Volunteer, Teku Hospital.

Mr Subash Kaji Shrestha Youth Health Volunteers Dhulikhel.

Ms Beema Bishwakarma Female Community Health Volunteer (FCHV) Chitawan.

Ms Shanti Devi Chaudhari FCHV Siraha.

Ms Pushpa Lata Ghimire FCHV Udayapur.

Dr Mahesh Kumar Maskey Chairman Nepal Health Research Council Kathmandu.

Sri Lanka

Mrs B Kodithuwakku Director Nursing (PHS) Ministry of Health Colombo.

Mr V Akalanka Training Manager St. John’s Ambulance Services.

Dr G Jayakody Consultant, Community Physician Central Province.


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Mr Anura Bandara Public Health Inspector MoH Office Maharagama.

Mrs BPCR Malkanthi Public Health Midwife Morawaka.

Dr NT Cooray Former Director National Institute of Health Sciences Kalutara.

Thailand

Dr Boonchai Somboonsook Deputy Director-General Department of Health Service Support Bangkok.

Mr Tongchai Sarakul Director of Northern Regional Training Center for Primary Health Care Development Nakhonsawan Province.

Dr Supattra Srivanichakorn Director Institute of Community Based Health Care Research and Development Bangkok.

Prof (Emeritus) Dr Wichit Srisupan President Thailand Nursing Council Bangkok.

Associate Professor Dr Choomnoom Promkatkew Naresuan University Pitsanulok.

Associate Professor Dr. Khanitta Nontaboot Department of Community Nursing Faculty of Nursing Khon Kaen University Khon Kaen.

Ms Duangporn Hengboonyaphan Planning, Evaluation and Capacity Development Section Thai Health Promotion Foundation Phayathai Bangkok.

Ms Orajitt Bumrungskulswat Director Bureau of Public and Private Participation National Health Security Office Changwattana Road Nonthaburi.

Dr Orapin Singhadej Secretary-General Network for WHO Collaborating Centers and Centers for Expertise in Thailand Bangkok.

Assistant Professor Dr Songkramchai Leethongdee Faculty of Public Health Mahasarakham University Mahasarakham.

Associate Professor. Anamai Thetkathuek Department of Industrial Hygiene and Safety Faculty of Public Health Burapha University Chonburi.

Associate Professor Dr Koolarb Rudtanasudjatum Chairman MPH Programme, Faculty of Public Health Burapha University Chonburi.

Associate Professor Vasuton Tanvatanakul Associate Dean for Academic Affairs Faculty of Public Health Burapha University Chonburi.

Timor-Leste

Mr Jose dos Reis Magno Head of Aileu District Health Service Ministry of Health Aileu District.


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Mr Carlitos Freitas School Health Officer Ministry of Health Dili.

Mrs Lucinda Soares dos Santos Representative PSF of Liquica Ministry of Health Dili.

Mr Jeremias Gusmao Guterres Ximenes District Public Health Officer – Health Promotion Viqueque District Ministry of Health Dili.

Advisers

Dr Halfdan T. Mahler WHO Director General Emeritus Geneva.

H.E. Dr Abdul Azeez Yoosuf Deputy Minister of Health Government of Republic of Maldives Male.

Dr Amorn Nondasuta President of the Foundation for Quality of Life (S. Sithigarn) Chiang Mai.

Dr Paichit Pawabutr Dean Faculty of Public Health Naresuan University Pitsanulok and a former Permanent Secretary Ministry of Public Health Thailand.

Dr Prat Boonyawongvirot Permanent Secretary Ministry of Public Health Thailand.

Dr Supachai Kunaratanapruk Director-General Department of Health Service Support Ministry of Public Health Thailand.

Dr Suwit Wiboolpolpratsert Senior Adviser on Disease Control Ministry of Public Health Thailand.

Resource persons

Dr Zafarullah Chowdhury Projects Coordinator Gonoshasthaya Kendra (GK) Dhanmondi Dhaka, Bangladesh.

Dr Azaher Ali Molla Assistant Professor Institute of Health Economics University of Dhaka Bangladesh.

Dr Jumroon Mekanorn Adviser Asian Institute of Health Development Mahidol University Bangkok Thailand.

Dr Tarun Seem Director National Rural Health Mission Ministry of Health and Family Welfare New Delhi, India.

Dr Yaslis Ilyas Senior Lecturer Department of Health Administration and Policy School of Public Health University of Indonesia Jakarta Indonesia.

Ms Aishath Ahmed Didi Faculty of Health Sciences Maldives College of Higher Education Male Maldives.

Mr San Shway Wynn Deputy Director-General (Public Health) Department of Health Naypyitaw Myanmar.


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Dr Shiba Kumar Rai Department of Microbiology Nepal Medical College Attarkhel, Jorpati Nepal.

Dr (Mrs) Chandrani Jayasekara Director (Training) National Institute of Health Sciences Kalutara Sri Lanka.

Dr Nonglak Pagaiya Sirindhorn College of Public Health Khon Kaen Thailand.

Ms Ranjana Mehra Anganwadi Worker New Delhi, India.

Ms Harini Bambang Resource Person from Cilandak Community Health Post South Jakarta Indonesia.

Sub Lt. Sontaya Mahotan President of the Association of Health Volunteers Central Region Chiang Mai Thailand.

Partners

South-East Asia Public Health Education Institutes Network (SEAPHEIN)

Associate Professor Dr Orawan Kaewboonchoo (SEAPHEIN Secretariat) Deputy Dean for International Relations and Training Faculty of Public Health Mahidol University Bangkok, Thailand.

South-East Asia Nursing and Midwifery Educational Institutions Network (SEANMEIN)

Dr (Mrs) Indarjit Walia (Chair, SEANMEIN) Principal National Institute of Nursing Education PGIMER Chandigarh, India.

Asia-Pacific Action Alliance on HRH (AAAH)

Ms Chawewan Yenjitr Asia-Pacific Action Alliance on Human Resources for Health Bangkok.

Dr Piya Hanvoravongchai Coordinator Asia-Pacific Action Alliance on Human Resources on Health Bangkok.

UNAIDS Thailand

Mr Sompong Chareonsuk Social Mobilization and Policy Advisor Joint UN Programme on HIV/AIDS in Thailand Bangkok, Thailand.

Asian Disaster Preparedness Centre

Dr Luis Jorge Perez Calderon Deputy Executive Director Office of the Executive Director Asian Disaster Preparedness Centre Pathumthani Thailand.

CARE India

Mrs Biraj Laxmi Sarangi State Programme Representative INHP Programme CARE India.


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Secretariat

WHO

Dr Myint Htwe Director Programme Management SEARO.

Dr Sultana Khanum Director Health Systems Development SEARO.

Dr P.T. Jayawickramarajah WHO Representative to Thailand Bangkok.

Dr Manuel Dayrit Director Human Resources for Health WHO/HQ.

Dr Prakin Suchaxaya Regional Adviser for Nursing and Midwifery SEARO.

Dr Sudhansh Malhotra Regional Adviser for Child Health and Development SEARO.

Ms Laksami Suebsaeng Technical Officer – HIV/AIDS SEARO.

Dr Thushara Fernando GAV/HSS SEARO.

Dr Mohammad Assai Ardakani Regional Adviser (Community-based Initiatives) WHO/EMRO.

Dr Khaled Hassan MO-HRH WCO Bangladesh Dhaka.

Ms Rinji Om HRH Focal Point WCO Bhutan Thimphu.

Ms Anagha Khot National Consultant (HSD) WCO India New Delhi.

Ms Amelia Kurniati Special Assistant WCO Indonesia, Jakarta.

Prof Muzaherul Huq MO/HRH WCO Nepal Kathmandu.

Dr R. Kesavan National Consultan WCO Sri Lanka Colombo.

Dr Somchai Peerapakorn HRH Focal Point WCO Thailand Bangkok.

Ms Nathaporn Wanijjapiwong Administrative Assistant WCO Thailand Bangkok.

Mr Chander Shekhar Sharma Administrative Assistant (HRH) SEARO.

Others

Dr Somsak Chunharas Secretary-General Thailand National Health Foundation Bangkok.

Dr Chaisiri Angkurawaranon Department of Family Medicine Faculty of Medicine Chiang Mai University Chiang Mai.

SEA-HSD-309 _A-4 - WHO | World Health Organization

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