1. Page 1 The Role of Community Health Workers The Key to Progress in Delivering Care to the Poorest of the Poor Eric Swedberg Child Health & Nutrition Advisor The PepsiCo Foundation Meeting March 31, 2008 The PepsiCo Foundation

2. Page 2 Discussion Outline Why Community Health Workers (CHWs)? Roles Operational Considerations Results in Selected Countries: Mali, India, Ethiopia Costs Progress-to-Date and Future Plans Ethiopia Video of CHW

3. Page 3 Rationale Shortage of health-care professionals throughout the developing world Some countries have 1 doctor for every 50,000 people compared to US ratio of 1/391 Inability of health care delivery systems to meet needs Worldwide 200 million children under age 5 do not get basic health care when they need it Inaccessibility within rural communities Reaching the nearest health facility requires a journey on foot of several hours or even a day

4. Page 4 Low Access: Nicaragua 1. Blurred photo due to a tropical downpour. 2. 24 mile trip to clinic for baby’s (in plastic) pneumonia. 3. Better off than her neighbors, she’s on “cusp of inaccessibility.”

5. Page 5 Community Health Workers Characteristics Volunteer health workers who live in communities with the parents and children who need help most Community members carefully selected, trained, and equipped to be health workers Serve as first line of defense against the most common killers of children

6. Page 6 Diverse CHW Roles Preventive Health Education –Health education to their neighbors –Referral to health facilities for illness Reproductive Health –Trained birth attendants to ensure safe childbirth and proper newborn care –Family planning counseling and contraceptives

7. Page 7 Diverse CHW Roles…Cont’d Child Health –Immunization, growth monitoring and promotion –Individual and group counseling on exclusive breastfeeding and complementary feeding practice –Referring severe acute malnutrition to facilities Treatment Provision—Save the Children is expanding the CHW role to include –Management of child illness: diarrhea, pneumonia, malaria, newborn sepsis –Treatment for severe acute malnutrition

8. Page 8 Key Operational Considerations

9. Page 9 Critical CHW Program Components Establish the roles and responsibilities Establish criteria and methods of recruitment Carry out competency-based training Provide tools to enhance performance, e.g. job aids Take action to maintain performance Measure performance after training Identify problem areas and provide feedback

10. Page 10 Performance of CHWs One of the foremost concerns of CHW programs Critical success factors (driving higher quality services) –Increased supervision –Less population to cover –More experience SC approach –Build MOH capacity –Engage local village leadership –Increase coverage e.g.. 2 CHWs per village, regular refresher trainings

11. Page 11 Retention Significant challenge: Starts with close attention to the operational components—particularly selection Monetary and In-kind / other incentives –Profit from medicine sales –Assistance with farming –Basic equipment such as bicycles –Refresher training SC approach –Health impact valued by communities –Local recognition (badges, certificates, t-shirts, caps)

12. Page 12 Drug Supply Essential part of CHW effectiveness Restock—through closest Ministry of Health facilities or purchase separately Financing—by national government/outside donors or community cost-recovery

13. Page 13 Community Case Management Equip and train Community Health Workers –Treat and sometimes refer common, serious, community-acquired childhood infections (pneumonia, malaria, diarrhea, newborn sepsis) –Manage small drug boxes Train Families –Recognize and promptly seek treatment for childhood danger signs –Complete the treatment or accept referral Equip and train Ministry of Health partners at clinics –Support, supply, supervise CHWs

14. Page 14 Results

15. Page 15 5 Districts with a total population of nearly 1 million Mali

16. Page 16 Health Zones of Sikasso Region, Mali Health center Village drug kits 5 to 15 km from health center 79 health zones with 478 drug kits in Sikasso Region

17. Page 17 The Village Drug Kit System Two Community Health Workers –Main CHW –Assistant to CHW in case CHW is away CHWs selected by community and trained by MOH and Save the Children Print materials in each kit –Counseling materials –Notebooks to record sales and track stock –Notebook for births and deaths –Notebook to record behavior change activities –Register of referrals to health center

18. Page 18 Products in the Drug Kits Oral rehydration salts and zinc Paracetamol pills and syrup Aureomycin ointment 1% Contraceptives: Pills & Condoms Insecticide for treating mosquito nets and long lasting mosquito nets Chloroquine tablets and syrup Withdrawn according to government policy in June 2007 and replaced with new malaria treatment

19. Page 19 CHW and Village Oversight Committee

20. Page 20 Drug Kits and Health Center Referral of ARI and severe cases, restocking, monthly meetings Formation/refresher training and supervision for CHWs

21. Page 21 Results in Mali: Malaria Treated = Lives Saved Health Districts Episodes Of Fever Treated Drug KitsHealth Centers Number Treated Bougouni57%43%15,854 Kolondièba72%28%6,511 Yanfolila71%29%3,977 Sélingué47%53%3,680 Yorosso49%51%30,778 Total55%45%60,800 Period: July 2006 – June 2007

22. Page 22 Results in India: Saving Newborn Lives Funded by Gates Foundation CHWs… –Delivered key messages Clean delivery, immediate breastfeeding, skin-to-skin care, etc. Home visits: 2 antenatal, postnatal day 0/1, 3 –Trained community volunteers Results: 50% reduction in NMR (after only 1 year’s implementation)

23. Page 23 Results in Ethiopia: Pneumonia Case Management % * * = 200,000 untreated cases of childhood pneumonia, malaria, and diarrhea every year 17%58%84% Community Case Management (CCM) of pneumonia and malaria. Clinic-based treatment of pneumonia and malaria.

24. Page 24 Costs One CHW can assist 50 -100 children. It only costs about $100 to train a CHW each year and $25 to equip her. It costs about $1000 to train a medical professional who will supervise 10 CHWs. One community health worker can save one to 3 children’s lives in high mortality settings every year.