REGIONAL COMMITTEE Sixty-fourth Session Jaipur, Rajasthan, India 6-9 September 2011
Provisional Agenda item 5.1 SEA/RC64/6 14 July 2011
Consideration of the recommendations arising out of the Technical Discussions on “Strengthening of the community-based health workforce in the context of revitalization of primary health care” (Working Paper for the Technical Discussions) The Regional Director convened the Technical Discussions on “Strengthening of the community-based health workforce in the context of revitalization of primary health care” from 1 to 3 June 2011 at the National Institute of Health Sciences, Kalutara, Sri Lanka, as per decision of the Sixty-third Session of WHO Regional Committee for South-East Asia. The working paper was used for the Technical Discussions is submitted to the Sixtyfourth Session of the Regional Committee for its information.
Contents Page Introduction ................................................................................................................................1 The context: health improvement and challenges in South-East Asia Region .......................1 Community-based health workforce – the foundation of a PHC-based health system .........2 The Community-Based Health Workforce in South-East Asia .......................................................3 Issues and Challenges in Strengthening CHWs and CHVs.............................................................4 Demographic and epidemiological transition: need for revisiting roles and functions ..........4 National health policy and plans.........................................................................................4 Capacity building................................................................................................................5 Skills for community education and empowerment ............................................................6 Motivation and enthusiasm.................................................................................................6 Health system support ........................................................................................................6 Information and research....................................................................................................7 Strategic Actions for Strengthening Community Health Workers and Community Health Volunteers.....................................................................................................7 Review and revise national health policies and plans to strengthen the role of community health workers and community health volunteers.............................................8 Redefine the roles of the community health workers and community health volunteers to meet emerging epidemiological and demographic imperatives ......................9 Redesign education and training to strengthen capacity building.........................................9 Reinforce health workforce management..........................................................................10 Invest in human resource for health Information system and Innovative research and development .............................................................................................................11 Conclusions ...............................................................................................................................11 References.................................................................................................................................13
SEA/RC64/6
Introduction The context: health improvement and challenges in South-East Asia Region 1. During the past three decades the health status of people in South-East Asia has witnessed impressive improvements. Life expectancy has increased from 41 years during 1950-1955 to 66 years during 1995-2000, infant and child mortality as well as the maternal mortality ratio has decreased. The average annual rates of decline in mortality in children under five years were 2.5% and 3.8% during 1990-1999 and 2000-2008 respectively. People live longer and as a result, the numbers of the elderly population in most countries in the Region is increasing. The percentage of people aged 65 and above will continue to increase in all WHO-SEAR Member States1,2,3,4. In 2005, out of a population of 1.64 billion, 5.25% were 65 years and above. By 2015, the proportion of this population will range from 3.0% in Timor-Leste to 10.4% in DPR Korea5. At the same time, due to socioeconomic development and successful family planning programmes, the percentage of young people in the overall population will gradually decline. 2. It is predicted that during the next 25 years the world will experience dramatic shifts in the distribution of deaths from younger to older ages and from communicable diseases to noncommunicable diseases. The proportion of all deaths due to communicable, maternal, perinatal and nutritional causes is expected to decrease from 30% in 2005 to 22% in 2030, while the share of noncommunicable diseases is likely to increase from 61% to 68%. Injuries are estimated to account for 9% of all deaths during this period6. Since most developing countries are yet to control infectious and communicable diseases, Member States will be faced with a double burden of communicable and noncommunicable disease. 3. An additional challenge that the Region faces is emergencies and disasters, both natural and manmade. Countries have experienced major disease outbreaks such as SARS and pandemic influenza and disasters such as tsunamis, earthquakes and flooding. The health effects of global warming and climate change are emerging challenges. 4. The rapid pace of the often unplanned and unregulated urbanization in the Region poses additional challenges to health care delivery. Currently the urban population in the Region is estimated to be about 600 million, of which 150 million are poor. In the absence of a strong primary health care infrastructure in the urban areas in many countries addressing health of the urban poor is an emerging priority7. 5. Health systems in the Region have evolved with a focus on provision of medical care. Relatively less emphasis has been accorded to prevention of disease and health promotion; little attention has been given to education and empowerment of individuals, families and communities to take care of their own health or participate in health programmes8. Sociocultural factors are rarely factored in provision of health care. 6. It is generally acknowledged that health budgets are disproportionately skewed towards secondary and tertiary curative care at the expense of preventive and promotive care. This has contributed to the very high out-of-pocket expenditure on health. Over 60 % of health expenditure in the Region is out-of-pocket and is recognized as a significant contributor to poverty9,10,11.
SEA/RC64/6 Page 2
7. Several countries have decentralized health care systems or are embarking upon decentralization. This has implications on management of the community-based health workforce. Further, in addition to the community-based health workforce, there exists a large number of community-based workers of other sectors/ministries. There is an urgent need to coordinate and synergize the work of the community-based workforce of various sectors to achieve maximum efficiency. 8. Many countries are falling short of achieving the health MDG targets set for 201512. It is highly likely that equity in health and health outcomes will not be attainable in the near future for many Member States. It has been suggested in several forums that revitalization of primary health care is a means to narrow the health equity gaps among and within countries. 9. This requires a sufficient number of motivated and competent health care providers, with appropriate knowledge, skills and attitudes to address new health problems and challenges, especially at the primary level. According to the World Health Report 2006, 57 countries, six of which are in the South-East Asia Region, are considered having a critical shortage of health care workers13.
Community-based health workforce – the foundation of a PHC-based health system 10. The community-based health workforce, adequately supported and backed by an appropriate referral system, forms an important component of the public health system. Their numbers, skills, distribution, and morale largely determine the performance of health systems and serve as a vehicle to improve public health14. 11. There is evidence from systematic reviews on the effects of lay health workers’ interventions in primary and community health care showing that public health interventions and treatment of basic illness could be effectively delivered by community health workers (CHWs)15. 12. Currently, the accessibility to quality health care services in many Member States, especially in the unreached or hard-to-reach areas, is still far from ideal. Health care services at primary level in many countries have been considered as low quality and often remain underutilized13. On the contrary, secondary and tertiary care facilities are over-crowed with patients, a large proportion of whom do not need medical attention from medical doctors. This contributes to escalating the existing health system inefficiencies and high out-of-pocket expenditures. These patients could be equally well treated at a primary care facility or even at the community level. Further, their conditions may be prevented through proper self-care16. 13. Hence, it can be stated that a well trained, well equipped, well supported and well distributed community-based health workforce is necessary for ensuring universal access to and coverage of health care, effecting health system efficiencies and improving health services utilization. This category of health workers is uniquely placed to cater to the socio-cultural dimensions of health and for working towards improving health literacy of individuals, families and communities17,18.
SEA/RC64/6 Page 3
The Community-Based Health Workforce in South-East Asia 14. The community-based health workforce refers to individuals who perform communitybased health actions. They are a key component of a health system who can effectively contribute to health equity and social justice. They can reach the unreached, vulnerable and marginalized. They provide a bridge between the community and health service system at the primary care level18. 15. The strategic directions for strengthening community-based health workers and community health volunteers in the South-East Asia Region categorize the community-based health workforce into two broad categories: community-based health workers and community health volunteers19. 16. Community-based health workers (CBHW): All health care workers who are part of the formal health organization, and have undergone formal training to carry out a series of specified roles and functions, and spend a substantial part of their working time actively reaching out to the community, discharging their services at the individual, family or community level. These may include doctors, nurses, midwives who fulfill the above criteria, public health inspector health attendants, health supervisors and family health visitors, etc. who spend a substantial part of their working time actively reaching out to the community. 17. Community health volunteers (CHV): Members from communities often selected by the communities themselves and answerable to them, and who have undergone shorter training than professional workers. They are not salaried but may receive financial and other incentives. They are predominantly involved in health promotion and prevention of health problems, and are supported by the community and health system but are not necessarily a part of the formal organization. 18. As per the conventional WHO definition, community health workers (CHWs) should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers”. It is evident that the term community-based health workforce is broader than the community health worker20. The community health workers, however, are a vital component of the community-based health workforce. 19. The Region witnessed rapid expansion of the community-based health workforce, particularly the community health workers, in the 1980s in the wake of the Alma Ata Declaration on Primary Health Care. Their roles and function and scope of work are varied depending on the country health systems context. 20. There is a wide heterogeneity in the nomenclature and type of responsibilities entrusted to the community-based health workforce in countries of South-East Asia. These include, but are not limited to, for example, household doctor (DPR Korea), nurse-midwife/public health nurse (Thailand, Myanmar), public health midwife/community midwife (Sri Lanka, Indonesia), public health officer (Thailand), auxiliary nurse midwife (India), health assistant (Bangladesh, Bhutan, India), lady health visitor (India), family welfare assistant (Bangladesh), family welfare visitor (Bangladesh), primary health care worker (Maldives), Accredited Social Health Activist
SEA/RC64/6 Page 4
popularly called ASHA (India), female community health volunteer (Nepal), village health volunteer (Thailand, Timor-Leste), traditional health practitioner/healer (India, Bhutan) and several others. 21. Even though there are many categories of CBHW working in countries of South-East Asia Region, in this paper, the focus will be on the community health workers(CHWs) and community health volunteers (CHVs) who provide health services or perform communitybased health actions in the community, especially those who are poor, underserved or underprivileged. 22. In general the community health workers and community health volunteers share the following characteristics:
They are generally not regarded as professionals but have been trained to carry out a series of roles and functions. They are usually a part of the health system. In addition to being functionaries of the government, they may be functionaries of private or nongovernmental organizations. They spend a substantial part of their working time actively in the community; and deliver their services at homes, in communities or in community-based health care facilities.
Issues and Challenges in Strengthening CHWs and CHVs Demographic and epidemiological transition: need for revisiting roles and functions 23. Traditionally, the community health workers and community health volunteers focused mainly on provision of maternal and child health care and control of selected communicable diseases. Due to epidemiological, demographic, environmental, and socio-cultural changes, developing countries, including those in the South-East Asia Region, are facing a double burden of disease (communicable diseases, noncommunicable diseases, and mental health and injuries). In addition health systems have to be strengthened to meet challenges posed by disasters, climate change and health needs of the increasing numbers of the elderly. 24. The need to empower the community for health promotion and disease prevention and self-care cannot be overemphasized21,22. This is especially relevant in the context of the increasing burden of noncommunicable diseases and ageing of the population. Further, the community health workers are the first tier of the health system that can mobilize communities to respond to health emergencies and disasters. The community health workers are also uniquely placed to recognize, take initial measures and report unusual health events (disease outbreaks).
National health policy and plans 25. It is important that national health policies emphasize and provide allocations for primary health care. Within this context, a renewed emphasis is needed to recognize the importance of
SEA/RC64/6 Page 5
disease prevention and health promotion and community education as well as empowerment. Polices and plans for human resource for health development need to recognize the community health workers and community health volunteers, both in urban and rural areas, as an important component of the health system. The roles and functions of the community health workers and community health volunteers in delivering public health interventions needs to be reviewed, revised and redefined accordingly. There is also an urgent need for health policies to recognize that they cannot operate in isolation. They are an integral part of the health system and need to be organically linked and supported by the referral system23. They need to work in collaboration with community-based workers of other sectors to make health development sustainable. 26. Depending upon the country context, effective policies need to be developed/ strengthened for the development, placement, career progression and retention of CHWs and CHVs to meet the current and emerging health needs.
Capacity building 27. In the context of strengthening health care systems based on primary health care, education and training programmes that effectively provide community health workers and community health volunteers with knowledge, skills, and attitudes appropriate for working in the community, with the community and for the community are indispensible24. 28. The curriculum and teaching/learning methods for community health workers and community health volunteers need to be aligned to build their capacity for their expected roles and responsibilities. Innovative training tools and methodology are needed to cater to the varied educational backgrounds of the newly-recruited workers and volunteers. Pre-service education 29. Current teaching/learning methods focus more on developing technical skills for treatment. Conceptual, human and social skills such as problem solving, communication, education and empowerment, networking, social mobilization, and behavioural changes are not well cultivated and nurtured during the course of study. 30. Training programmes are often institution-based and opportunities for students to be exposed to and work with the community are limited. This prevents development of appreciation of socio-cultural dimensions and desirable attitudes13,25. 31. The recruitment of students and trainees for pre-service education/training is also important. The current method of recruitment gives high priority to candidates’ academic performance rather than attitudinal and socio-cultural aspects. In addition, the community and local bodies are rarely involved in the recruitment and employment of community health workers13,25. Continuing education and in-service training 32. Relevant continuing education and training are necessary to ensure that capacity to meet current and emerging challenges is up to date with current policies and practice. It is observed that health workforce practicing in the community or remote areas often lack opportunities for continuing education and career development; accessibility to sources of knowledge and information is also limited. The lack of opportunities for continuing education and training in
SEA/RC64/6 Page 6
remote and isolated areas results in a negative attitude towards these locations, consequently affecting job-related decisions26. Opportunities for career progression need to be inbuilt in HRD policies.
Skills for community education and empowerment 33. Conventionally community health workers have been relied upon mainly for health service delivery. Current imperatives necessitate expansion of the role of community health workers to become “change-agents” in order to empower individuals and communities to adopt behaviours conducive to health. To be effective in educating and empowering people for health literacy and proper self-care, in addition to technical skills, they need to have skills in leadership, communication, facilitation, negotiation, advocacy, socio-cultural, community organization and mobilization, and networking. In dealing with people, they must also take into account the socio-cultural, economic, psychological, mental, and spiritual aspects of health. 34. It is a common observation that these skills are not well-developed among CHWs during pre-service training. To address the rising trend of diseases caused by unhealthy lifestyles and unhealthy behaviours, the health workforce needs to have skills in negotiating for behaviour change.
Motivation and enthusiasm 35. In some settings the turnover rates among community health workers are substantial. In part this could be attributed to lack of access to social, economic, educational and professional opportunities24,26. This could also be attributed to the fact that they are not adequately prepared to work in the community. Absentee rates are among CHWs particularly if the worker lives far away from the area of posting24. 36. Workers at the peripheral level of the health care system often are disadvantaged in career and professional development, income (opportunity for private practice), workplace security and safety. The remoteness adversely affects their timely access to information and many times puts them at risk of crime and violence.
Health system support 37. In many countries, community health workers and community health volunteers who work in rural or remote areas face many difficulties with no/little support from the health system. These include:
Lack of or inadequate supportive supervision and on-the-job training. Inadequate or inappropriate infrastructure for their living as well as to perform their duties. Inadequate legal framework to support their practices. Lack of recognition as a part of the referral chain. Absence of incentives and recognition for working in difficult conditions to name a few.
SEA/RC64/6 Page 7
Geographical distribution of the community health workers is an issue. It is observed that difficult, hard-to-reach and remote areas generally have too few CHWs. The relative absence of the community-based health workforce in general and community health workers in particular, in urban areas needs attention particularly to address the health issues of the urban poor.
38. These factors need urgent attention to improve the effectiveness of this important human resource for health.
Information and research 39. A major barrier/constraint to assuring a sufficient and competent workforce is the lack of systematic data/information on the community health workers and volunteers: the categories, capacity, tasks, workplaces, career advancement, and support systems including supervision and evaluation. Such information will facilitate the capacity up-dating, and supporting and retaining community-based health workers accordingly14. 40. Operational research is needed on issues such as the cost-effectiveness of different categories of the community health workers and volunteers; optimal utilization of these health workers and volunteers, for instance, can task-shifting be utilized to make more efficient use of doctors and nurses; developing innovative tools for their training and so on25. 41. Both information and results of operational research are indispensable in the formulation of policy and strategy to strengthen community health workers and community health volunteers.
Strategic Actions for Strengthening Community Health Workers and Community Health Volunteers 42. Efforts have been made to strengthen community health workers. For example, a Regional Meeting on Revisiting Community-Based Health Workers and Community Health Volunteers was held in Chiang Mai, Thailand in 200727 which resulted in developing Strategic Directions for Strengthening Community-based Health Workers and Community Health Volunteers in the South-East Asia Region28. The regional conference on Revitalizing Primary Health Care (Jakarta, Indonesia 2008) reiterated the role of the community-based health workforce in revitalizing primary health care29. Apparently, implementation at the country level has been diverse and more needs to be done to focus on non-professional health workforce: community health workers and community health volunteers. Their roles, capacities and education/training, and supportive systems need to be revisited and clearly redefined to enable them to effectively manage emerging and re-emerging diseases, disasters and health challenges. 43. To effectively strengthen community health workers and community health volunteers, the following strategic actions are proposed:
SEA/RC64/6 Page 8
Conceptual framework for strengthening CHWs and CHVs The Challenges Strategic actions Expected output and outcomes
Revisit roles and functions of CHWs/CHVs in light of epidemiological and demographic transition Strengthen National Health Policy and Plan to redefine role of CHWs/ CHVs Develop innovative and effective capacity building Reinforce supportive health system and mechanisms Generate evidence for policy formulation and decision making
Re-define roles and responsibilities Strengthened Community-based Health Workforce
Review & Revise Policy, strategy to strengthen CHW/CHV
Re-design and strengthen education and training
Reinforce HRH management system: Enabling working environment Career development Salary & incentives Legal and administrative support Coordination with community workforce of other sectors
REVITALIZATION OF PHC
Improved Equity in Health
Operational Research
Review and revise national health policies and plans to strengthen the role of community health workers and community health volunteers 44. Health policies need to be informed to recognize the importance of the principles of primary health care and health promotion and disease prevention in achieving equity in health; and to recognize and reiterate that the community health worker and volunteer is the backbone of PHC-based health systems .They should be recognized as an integral part of the health system as a means for universal coverage and equity and as an important medium to reach the unreached, difficult to reach and vulnerable populations. 45. They must be recognized as an essential component of the health workforce in their own right with well defined roles and functions and not as a substitute for other categories of health workers. 46. Policies should recognize the community health worker and volunteer as important components of the continuum of health care to be organically linked with the referral chain and supported by the health system. It is also important to recognize that they need policy support to work in collaboration with community-based workers of other sectors to make health development effective and sustainable.
SEA/RC64/6 Page 9
47. Investments in primary health care, including strengthening of the community health worker and volunteer, are necessary for a more healthy population and for reducing the burden on the health system. A well functioning community health worker and volunteer can significantly contribute to reducing health costs and for improving the efficiency and effectiveness of the health system. 48. The PHC-based health service system in urban areas should also be strengthened. In most countries the community health worker and community health volunteer is either weak or absent in urban areas. Urban health policies need to recognize and define their roles in urban settings. Additionally, this category of the health workforce can be instrumental in reducing the equity-gap in hard-to-reach and vulnerable populations.
Redefine the roles of the community health workers and community health volunteers to meet emerging epidemiological and demographic imperatives 49. In most settings community health workers and community health volunteers are the frontline workers and the inter-phase between the community and the health system, respectively. They are uniquely placed to play the crucial role of becoming change-agents for better health. For this they need to be equipped to educate and empower the community in matters related to their health. It must be reiterated that they must facilitate the adoption of healthy lifestyles by individuals and communities to promote health and prevent disease30. Their role in prevention and control of communicable and noncommunicable diseases, healthy ageing and ambulatory care can contribute immensely to reducing the burden on the already overstretched health care services15,18. 50. Experience suggests that the community health workers and community health volunteers play an important role in disasters and emergencies. Further, they can play the role of frontline sentinels for recognition, notification and early measures for disease outbreak control18. 51. The community health workers and community health volunteers can improve coverage and quality of primary care. In many settings community health workers already provide basic medical care. There is a need to clearly articulate and define what conditions they can recognize and treat. Clear guidelines for appropriate referral will ensure that this category of health workers become an effective component of the referral chain18.
Redesign education and training to strengthen capacity building 52. There is an urgent need to revisit training (both pre-service and in-service) of the community health workers and community health volunteers. In addition to aligning the curricula with the new roles and functions that they can play (NCD control, ambulatory care, care of the aged, role in disasters and outbreaks), there is a need to focus on communications skills building. This would be essential to equip them to work with communities for behavioural change31,32. 53. Teaching/learning methods need to be reviewed and redesigned to ensure that it is competency-based, community-oriented and includes a problem-based approach. Innovative use of ICT in training could be an effective means to train and re-train at low cost expeditiously.
SEA/RC64/6 Page 10
Customized and user-friendly training tools are needed to meet the profiles and jobresponsibilities of the community health worker and community health volunteer. Education/training programmes and certification for community health workers should be standardized. This will provide them an opportunity for a career path. 54. Capacity building of educational/training institutes (faculty and appropriate infrastructure) is a component of the national HRH policy. In many countries the HRH policy needs urgent attention and review.
Reinforce health workforce management 55. Improve selection criteria: Selection of people who can become community health workers and volunteers needs attention. Ideally, they should be from the local community and the community should have a role in the selection process. Further, mechanisms are needed wherein the community plays a role in their monitoring and evaluation. These measures have the potential of enhancing community participation in health programmes18. 56. Strengthen supportive supervision and on-the-job training: Supportive supervision and on-the-job training of community health workers and community health volunteers in most countries needs strengthening. Innovative methods (including community supervision and evaluation and use of ICT) needs to be explored for this purpose. 57. Strengthen Career progression: A common observation across the Region is the lack of career-progression opportunities for the community-based health worker. This becomes a factor in their low motivation. Countries need to examine how best career progression can be ensured. In addition, depending upon the country context, incentives (monetary and non-monetary) for good work done by the community based workers and volunteers need to be institutionalized. This could include performance-linked incentives. 58. Develop/reinforce policy and strategy for the retention of community health workers and community health volunteers: Retention of the community health worker and volunteer is an issue in some areas. Innovative policies like for instance, time limited postings in hardship areas, incentives, opportunities for in-service training and others are needed to ensure retention. 59. Develop legal and administrative support: A strong legal and administrative framework will go a long way in supporting the work of the community health worker and volunteer in a rapidly evolving socio-cultural environment. Development of protocols and regulations to enforce them will assist in developing a protective environment for their effective functioning. 60. Develop policy and mechanism for coordination: Community workers of ministries/ departments other than health play a significant role in public health. Examples of such workers include nutrition workers, sanitarians, and extension workers of agriculture and animal husbandry departments, child development workers and so on. Co-ordination of the work of these persons with that of the community health worker and volunteer will assist in mounting a synergistic inter-sectoral approach and contribute to effecting efficiencies in social sector programmes. There is an urgent need to establish mechanisms that can strengthen inter-sectoral collaboration in community-based initiatives of various ministries and departments.
SEA/RC64/6 Page 11
61. Strengthen health workforce management capacity: In several countries, the management of various categories of health workers is fragmented. To improve effective management of human resources for health, integrated policies and management structures are necessary. Depending upon the country context, managerial structures and capacity for human resources for health including the community health worker and volunteer needs to be strengthened. This will contribute to efficient utilization of the workforce.
Invest in human resource for health Information system and Innovative research and development 62. There is a paucity of research and evidence regarding effectiveness and ways to improve efficiency of the community health worker and volunteer. Health systems research is needed to generate evidence for informed policy making. Some of the areas that could be explored in the near-to medium-term include18,30,33:
Mapping of types and numbers of community health worker and volunteer and their job profiles. Evidence for cost-effectiveness of community health workers and volunteers vis-à-vis other categories of health care providers. Development of innovative training methodology and tools including use of ICT for training of the community health worker and volunteer. Development of job-aids and tools. Generate evidence for development of protocols for effective functioning of the community health workers and volunteer as members of the referral chain for continuum of care. Operational research for task-shifting/task-sharing to explore interventions that can be safely and effectively implemented by community health workers and volunteers.
Conclusions 63. The community health worker and community health volunteer can make a valuable contribution to health of the community and improve access to and coverage of communities with basic health services. They can make significant contributions to achieving national and global health goals. 64. This category of health workers and volunteers should not be considered as a cheap alternative to provide access to health care for underserved populations. They should be viewed as an integral component of the continuum of care within the health system with well-defined roles and functions. 65. Health policies should clearly re-examine and articulate the role of the community health worker and volunteer in the light of current and emerging health needs. Innovative interventions for their capacity building are required to address current and emerging health needs.
SEA/RC64/6 Page 12
66. In order to be able to make an effective contribution, they need to be carefully selected, appropriately trained and adequately and continuously supported with training, management, supervision, and logistics. 67. Contextual factors such as supportive legal and administrative framework for their functioning, attention to career progression and strategies to improve motivation and retention will facilitate effective utilization of this human resource. 68. Operational research within the context of South-East Asia is necessary to mount evidence based interventions for improving the effectiveness and efficiency of the community health worker and volunteer.
SEA/RC64/6 Page 13
References (1) (2) (3) (4) World Health Organization, Regional Office for South-East Asia. Health situation in the South-East Asia Region 2001 – 2007. New Delhi: WHO/SEARO, 2008. World Health Organization. World health statistics 2010. Geneva: WHO, 2010. Yaukey D, Anderton DL. Demography: the study of human population. Prospect Heights, IL: Waveland Press, 2001. WHO/UNICEF Joint monitoring programme for water supply and sanitation. Progress on sanitation and drinking-water: 2010 update. Geneva: World Health Organization, 2010. United Nations. World population prospects: the 2006 revision. New York: United Nations, Department of Economic and Social Affairs: Population Division, 2007. Social and Cultural Planning Office. Social and cultural report 2000. The Hague: Social and Cultural Planning Office, 2000. Aggarwal S, Yoosuf AS. Urbanization dynamics and WHO’s “healthy city” initiatives in the South-East Asia Region. Regional Health Forum. 2010; 14(1): 25-34. World Health Organization, Regional Office for South-East Asia. Innovations in primary health care: report of regional consultation, Chiang Mai, Thailand. 17 – 19 August 2010. New Delhi: WHO-SEARO, 2011. Singh A. Health financing and PHC. Health in South-East Asia: a SEARO Newsletter. 2008; 1(2): 4-6. Garg CC, Karan AK. Reducing out of pocket expenditures to reduce poverty: a disaggregated analysis at rural-urban and state level in India. Health Policy and Planning. 2009; 24: 116-128. van Doorslaer E, O'Donnell O, Rannan-Eliya RP, Somanathan A, Adhikari SR, Garg CC, Harbianto D, Herrin AN, Huq MN, Ibragimova S, Karan A, Lee TJ, Leung GM, Lu JF, Ng CW, Pande BR, Racelis R, Tao S, Tin K, Tisayaticom K, Trisnantoro L, Vasavid C, Zhao Y. Catastrophic payments for health care in Asia. Health Economics. 2007; 16(11): 1159-84. World Health Organization, Regional Office for South-East Asia. Health inequities in the South-East Asia Region, magnitude and trends and what contributes to health inequities. New Delhi: WHO-SEARO, 2007. World Health Organization. The world health report 2006: working together for health. Geneva: WHO, 2006. World Health Organization, Regional Office for South-East Asia. Profiling public health workforce in countries of the South-East Asia Region. New Delhi: WHOSEARO, 2006. Zulfiqar A B, Zohra S, Lassi GP, Luis H. Global experience of community health workers for delivery of health related millennium development goals: a systematic review, country case studies, and recommendations for integration into national health systems. Geneva: WHO, 2010.
(5) (6) (7) (8)
(9) (10)
(11)
(12)
(13) (14)
(15)
SEA/RC64/6 Page 14
(16) Anand K, Shah B, Yadav K, Singh R, Mathur P, Paul E, Kapoor S. Are the urban poor vulnerable to non-communicable diseases? A survey of risk factors for noncommunicable diseases in urban slums of Faridabad. National Medical Journal of India. 2007 May-Jun; 20(3):115-20. (17) Chowdhary S. Health shocks and the urban poor: a case study of slums in Delhi. New Delhi: National Institute of Public Finance and Policy, 2009. http://www.isid.ac.in/~pu/conference/dec_09_conf/Papers/SamikChowdhury.pdf accessed 15 June 2011. (18) Lehmann U, Sanders D. Community health workers: what do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: WHO, 2007. (19) World Health Organization, Regional Office for South-East Asia. Strategic directions for strengthening CBHWs and CHVs in the South-East Asia Region. New Delhi: WHO-SEARO, 2008. (20) World Health Organization. Declaration of alma-ata: international conference on primary health care, Alma-Ata, USSR, 6-12 September 1978. Geneva: WHO. http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf - accessed on 9 May 2010. (21) Ruth C. The role of the health professional in supporting self care. Quality in Primary Care. 2006; 14: 129 – 31. (22) World Health Organization, Regional Office for South-East Asia. Self-care in the context of primary health care. Report of the regional consultation, Bangkok, Thailand, 7-9 January 2009. New Delhi: WHO-SEARO, 2009. (23) Beaglehole R, Dal Poz MR. Public health workforce: challenges and policy issues. Human Resources for Health. 2003; 1: 4. (24) Bryant J. Education and training of health professionals for the emerging challenges of Africa. Report for the consultative meeting on improving collaboration between health professions and governments in policy formulation and implementation of health sector. Addis Ababa, Ethiopia, January 28 – February 1, 2002. (25) Shrikant I, Bangdiwala MS, Fonn S, Okoye O, Tollman S. Workforce resources for health in developing countries. Public Health Reviews. 2010; 32(1): 296-318. (26) Dovlo D. Retention and deployment of health workers and professionals in Africa: report to WHO-AFRO. Geneva: World Health Organization, 2001. (27) World Health Organization, Regional Office for South-East Asia. Revisiting community-based health workers and community health volunteers: report of the regional meeting, Chiang Mai, Thailand. 3-5 October 2007. New Delhi: WHOSEARO, 2008. (28) World Health Organization, Regional Office for South-East Asia. Strategic directions for strengthening CBHWs and CHVs in the South-East Asia Region. New Delhi: WHO-SEARO, 2008. (29) World Health Organization, Regional Office for South-East Asia. The regional conference on revitalizing primary health care, Jakarta, Indonesia, 6-8 August 2008. New Delhi: WHO-SEARO, 2009. (30) World Health Organization. Health promotion. Geneva: WHO, 2010.
SEA/RC64/6 Page 15
(31) Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. American Journal of Health Promotion. 1992 Jan-Feb; 6(3): 1970-1205. (32) World Health Organization, Regional Office for South East Asia. Health of the urban poor: report of regional consultation, Mumbai, India, 13 – 15 October 2010. New Delhi: WHO-SEARO, 2011. (33) Bluestone J. Task shifting for a strategic skill mix: capacity project knowledge sharing. JHPIEGO. June 2006.
REGIONAL COMMITTEE Sixty-fourth Session Jaipur, Rajasthan, India 6-9 September 2011
Provisional Agenda item 5.1 SEA/RC64/6 Inf. Doc. 15 July 2011
Consideration of the recommendations arising out of the Technical Discussions on “Strengthening of the community-based health workforce in the context of revitalization of primary health care” (Report of the Technical Discussions) The Regional Director convened the Technical Discussions on “Strengthening of the community-based health workforce in the context of revitalization of primary health care” from 1 to 3 June 2011 at the National Institute of Health Sciences, Kalutara, Sri Lanka, as per decision of the Sixty-third Session of WHO Regional Committee for South-East Asia. The report of the Technical Discussions is submitted to the Sixty-fourth Session of the Regional Committee for its information and consideration.
Contents Page Introduction...................................................................................................................1 Technical presentation ...................................................................................................1 Conclusions and Recommendations ...............................................................................4 Recommendations for Member States ............................................................................5 Recommendations for WHO..........................................................................................5 Draft resolution ..............................................................................................................6 Annexes 1. 2. List of participants ...............................................................................................7 Draft Resolution ..................................................................................................9
SEA/RC64/6 Inf. Doc.
Introduction 1. As per the decision of the Sixty-third Session of the WHO Regional Committee for SouthEast Asia, Technical Discussions on the subject “Strengthening of the community-based health workforce in the context of revitalization of primary health care” was organized from 1 to 3 June 2011 at the National Institute of Health Sciences, Kalutara, Sri Lanka. The recommendations arising out of the Technical Discussions will be submitted to the Sixty-fourth Session of the Regional Committee, to be held in Jaipur, India, from 7 to 9 September 2011. 2. The Technical Discussions were inaugurated by Mr Lalith Dissanayake, Hon’ble Deputy Minister for Health, Sri Lanka. The message from Dr Samlee Pliangbangchang, WHO Regional Director for South-East Asia was delivered by Dr Firdousi R. Mehta, WHO Representative to Sri Lanka. Twenty representatives from ten Member States of the South-East Asia (SEA) Region and five staff from WHO-SEARO and two from WHO Sri Lanka Office attended the Technical Discussions. The list of participants is at Annex 1. Mr Abdul Bari Abdulla, Hon’ble State Minister for Health and Family, Ministry of Health, Maldives was nominated as Chairperson, Dr (Mrs) H.S.R. Perera, Director (Policy Analysis), Ministry of Health, Sri Lanka, was nominated as Co-Chairperson and Dr Chencho Dorji, Director, Royal Institute of Health Sciences, Thimphu, Bhutan was nominated as Rapporteur. 3. In his message, Dr Samlee Pliangbangchang stated that the South-East Asia Region is in the midst of a rapid demographic and epidemiological transition. There is a need to address the health inequities within and among countries. The community-based health workforce can play an effective role in addressing contemporary health issues in an efficient manner and being a part of the multi-disciplinary workforce it can serve as a “change-agent” to empower individuals, families and communities to promote health and prevent disease, contributing to community development. A well-functioning community-based health workforce can significantly contain health costs by providing ambulatory care and by serving as frontline health workers during disease outbreaks, emergencies and disasters. Dr Samlee was confident that the Technical Discussions would cover various dimensions related to the subject and develop actionable recommendations for consideration of the Regional Committee. 4. In his inaugural address Mr Lalith Dissanayake recounted the long history and experience of a primary health care-based health system in Sri Lanka which is responsible for the good health status of the population. Sri Lanka also has a very long experience with training of the community-based health workforce. He stated that it is opportune that the venue of the Technical Discussions was the National Institute of Health Sciences, Kalutara, Sri Lanka, as this institute is over a century old and has the potential of serving as a regional training centre for the community-based heath workforce. He invited all Member States of the WHO South-East Asia Region and development partners to utilize the excellent training facilities in the National Institute of Health Sciences.
Technical presentation 5. The working paper on the subject, was presented by Dr Athula Kahandaliyanage, Director, Department of Health System Development, WHO-SEARO. He stated that there is overwhelming consensus in Member States of the Region that primary health care-based health
SEA/RC64/6 Inf. Doc. Page 2
system strengthening is perhaps the most effective way to address existing and emerging health challenges. This consensus has been reiterated in several forums including the Regional Conference on Revitalizing PHC, Regional Seminar on Decentralization of Health Care Services, Regional Meeting on Health-Care Reform for the 21st Century and at other forums. 6. The community-based health workforce is the backbone of a PHC-based health system and there is a great degree of heterogeneity in the nomenclature, duties and responsibilities entrusted to the community-based health workforce in Member States. He reminded the audience that the community-based health workforce comprises a wide variety of workers who are part of the formal health system, and have undergone formal training to undertake a series of specified roles and functions, and spend a substantial part of their working time actively reaching out to the community, discharging their services at the individual, family or community levels. The working paper focused on the community health workers (CHWs) and community health volunteers (CHVs). The CHWs and CHVs provide health services or perform community-based health actions in the community, especially covering those who are poor, underserved or underprivileged. 7. Traditionally, the focus of work of CHWs and CHVs is mainly on the provision of maternal and child health care and control of selected communicable diseases. Due to the double burden of disease (communicable diseases and noncommunicable diseases), disasters, climate change and health needs of the increasing numbers of the elderly population that the Region is faced with, the need to empower the community for health promotion, disease prevention and selfcare cannot be overemphasized. The roles and functions of the community health workers and community health volunteers in delivering public health interventions needs to be reviewed, revised and redefined accordingly. 8. Policies and plans for human resource for health development need to recognize the community health workers and community health volunteers, both in urban and rural areas, as an important component of the health system. There is also an urgent need for health policies to recognize that they cannot operate in isolation. They are an integral part of the health system and need to be organizationally linked and supported by the referral system so as to work in collaboration with community-based workers of other sectors to make health development sustainable. 9. Education and training programmes that effectively provide community health workers and community health volunteers with knowledge, skills, and attitudes appropriate for working in the community, with the community and for the community is indispensible. The curriculum and teaching/learning methods for community health workers and community health volunteers needs to be aligned to build their capacity for their expected roles and responsibilities. Innovative training tools and methodology are needed as training programmes are often institution-based and opportunities for students to be exposed to and work with the community are limited. This prevents appreciation of socio-cultural dimensions and desirable attitudes. The recruitment of students and trainees also needs attention. The current method of recruitment gives high priority to candidates’ academic performance rather than attitudinal and sociocultural aspects. In addition, community and local bodies are rarely involved in the recruitment and employment of community health workers.
SEA/RC64/6 Inf. Doc. Page 3
10. In many countries, community health workers and community health volunteers face many difficulties with little support from the health system. These include lack of or inadequate supportive supervision and on-the-job training; inadequate or inappropriate infrastructure for their living as well as to perform their duties; inadequate legal framework to support their practices; lack of recognition as a part of the referral chain; absence of incentives and recognition for working in difficult conditions, to name a few. Geographical distribution of the community health workers is also an issue. It is observed that difficult and hard-to-reach terrains and remote areas generally have very few CHWs. The relative absence of the community-based health workforce in general and community health workers in particular, in urban areas needs attention particularly to address the health issues of the urban poor. 11. A major constraint to ensuring a sufficient and competent workforce is lack of systematic data/information on the community health workers and volunteers: the categories, capacity, tasks, workplaces, career advancement, and support systems including supervision and evaluation. Operational research is needed on issues such as the cost-effectiveness of different categories of community health workers and volunteers; optimal utilization of these health workers and volunteers; task-shifting to make more efficient use of doctors and nurses; developing innovative tools for their training and so on. 12. A proposed conceptual framework to address this issue is depicted in Figure below. Figure: Conceptual framework for strengthening CHWs and CHVs The Challenges Strategic actions Expected output and outcomes
Revisit roles and functions of CHWs/CHVs in light of epidemiological and demographic transition Strengthen National Health Policy and Plan to redefine role of CHWs/ CHVs Develop innovative and effective capacity building Reinforce supportive health system and mechanisms Generate evidence for policy formulation and decision making
Re-define roles and responsibilities Strengthened Community-based Health Workforce
Review & Revise Policy, strategy to strengthen CHW/CHV
Re-design and strengthen education and training
Reinforce HRH management system: Enabling working environment Career development Salary & incentives Legal and administrative support Coordination with community workforce of other sectors
REVITALIZATION OF PHC
Improved Equity in Health
Operational Research
SEA/RC64/6 Inf. Doc. Page 4
13. The working paper was discussed in detail in plenary and in group work sessions that focused on issues related to (i) National health policy and strategy for strengthening the community health workers and volunteers; (ii) Capacity building – upgrading skills; and (iii) Community-based health workforce as a part of the community-based workforce. 14. The deliberations were enriched by sharing contemporary experiences from Member States. These included: Future role of community health workers in Sri Lanka; Challenges in scaling up Accredited Social Health Activists (ASHAs) in India; Expanding role of the Female Community Health Volunteers in Nepal; Upgrading skills of health assistants – the Bachelors in Public Health programme in Bhutan; and development of community health workforce for Community Health Clinics in Bangladesh. The challenges faced by the countries and how opportunities were seized to overcome these challenges were discussed. This provided a backdrop for the development of the recommendations.
Conclusions and Recommendations Conclusions 15. After extensive deliberations, the following conclusions were arrived at by the participants. These were presented in the concluding session by Dr Chencho Dorjee, the Rapporteaur of the Technical Discussions. (1) (2) All countries in the SEA Region have community-based health workforce. However, there is a wide heterogeneity in the types of workers and their roles and functions. Community Health Workers (CHWs) and Community Health Volunteers (CHVs) are an important component of the community-based health workforce and backbone of the PHC-based health system. The CHWs and CHVs have a great potential in becoming change-agents for promoting healthy behaviours, reducing health inequities and contributing to community health development. The CHWs and CHVs can play an effective role in addressing emerging epidemiological, demographic and socio-cultural imperatives including prevention, primary care and control of noncommunicable diseases and ambulatory care of the aged. National health policies, strategies and plans need to clearly define the role(s) of the CHWs and CHVs as an integral component of the referral chain to ensure effective and efficient continuity of care. Long-term planning is needed to cater to future health needs. While countries have taken initiatives to improve the technical capacity of CHWs, more effort is needed to strengthen the pre- and in-service training to meet emerging health needs, to equip them to function effectively and for career development. In many countries the urban primary health care infrastructure is not as developed as in rural areas. There is an urgent need to address this issue. Community health workers and volunteers can contribute to meet the health needs of the urban population.
(3)
(4)
(5)
(6)
(7)
SEA/RC64/6 Inf. Doc. Page 5
(8)
In many countries nongovernmental organizations play a significant role in training CHWs and CHVs and in the provision of primary care. Depending upon the country context, NGOs could be involved in capacity building of these workers. More research is needed to develop innovative approaches to improve the competencies, effectiveness and efficiency of the CHWs and CHVs.
(9)
(10) As far as possible, the community should be involved in selecting and monitoring the work of CHWs and CHVs. (11) In many countries several sectors deploy community-based workers. There is an urgent need to effect coordination and synergies in the work of community-based workers of other relevant sectors with the CHWs and CHVs.
Recommendations for Member States 16. It was recommended that Member States should: (1) Review their national health policy and human resources for health policy and explicitly define the role and placement of the CHWs and CHVs in the health system to ensure continuity of care to address existing and emerging health problems within their socio-cultural and political context. Establish mechanisms to effect synergy and coordination in the work of community health workers and volunteers with other community-based workers of other sectors by establishing an inter-sectoral task force. Establish a national mechanism to standardize the training and education programmes for CHW and CHVs. Increase support for building capacity of trainers and improving facilities for effective planning and implementation of community-based training programmes. Generate evidence through routine information systems, analyze secondary data, conduct research for policy development and advocacy for the effective and efficient utilization of CHWs and CHVs for community health development. Continue building technical capacity of CHWs and CHVs for providing preventive, promotive, curative and rehabilitative care and strengthen their communication and negotiation skills to enable them to become change-agents for community health development.
(2)
(3) (4) (5)
(6)
Recommendations for WHO 17. It was recommended that WHO should: (1) Continue advocacy for revitalization of primary health care and strengthening of the community-based health workforce to enable Member States to achieve national and international health goals and a healthy community. Provide technical support to countries to strengthen national health policies for effective utilization of the CHWs and CHVs and in monitoring the implementation of these policies.
(2)
SEA/RC64/6 Inf. Doc. Page 6
(3) (4) (5)
Assist countries in sharing best-practices and networking of institutions to strengthen the CHWs and CHVs. Provide technical assistance to develop and implement regional programmes for training of trainers of CHWs and CHVs. Assist countries in generating evidence to guide and improve policies and strategies to increase effectiveness of CHWs and CHVs.
Draft resolution 18. The participants finalized a draft resolution on the subject “Strengthening of the community-based health workforce in the context of revitalization of primary health care” for consideration of the Regional Committee. The draft Resolution is at Annex 2.
SEA/RC64/6 Inf. Doc. Page 7
Annex 1
List of participants Bangladesh Dr Mohammad Ariful Alam Programme Coordinator BRAC Health Programme 16 Floor, BRAC Centre 75 Mohakhali Dhaka Bhutan Dr Chencho Dorjee Director The Royal Institute of Health Sciences Thimphu Mr Sangay Phuntsho Lecturer The Royal Institute of Health Sciences Thimphu India Prof. Deoki Nandan Director National Institute of Health and Family Welfare Baba Gang Nath Marg Munirka New Delhi Indonesia Dr Adang Bachtiar President Indonesian Public Health Association Chairman, Department of Health Administration and Policy Studies Faculty of Public Health University of Indonesia Jakarta Mr P.A. Kodrat Pramudho Head, Division of Community Empowerment and Participation Center for Health Promotion Ministry of Health Jakarta Maldives Mr Abdul Bari Abdulla State Minister for Health and Family Ministry of Health Government Maldives Male Ms Geela Ali Permanent Secretary Ministry of Health and Family Male Mr Maizan Ali Manik Councillor Male City Council, Male Mr Abdullah Thayyib Councillor Addu City Council, Male Ms Aishath Ahmed Didi Faculty of Health Sciences Head of the Curriculum Department Male Myanmar Dr (Ms) Thuzar Chit Tin Deputy Director (Basic Health) Department of Health Naypiytaw, Myanmar Nepal Dr B.S. Tinkari Director, PHC Revitalization Division Ministry of Health and Population Government of Federal Democratic Republic of Nepal, Kathmandu Dr Suniti Acharya Executive Director Center for Health Policy Research and Dialogue House No.40, Kapanmarga, Maharajgung, Basbari, Kathmandu Sri Lanka Dr (Mrs) H.S.R. Perera Director (Policy Analysis) Ministry of Health Colombo Mrs R.M.W.M. Rathnayake Director (Nursing) Public Health Services Ministry of Health Colombo Dr L. Gamlath Director National Institute of Health Sciences Kalutara
SEA/RC64/6 Inf. Doc. Page 8
Thailand Dr Supattra Srivanichakorn Director ASEAN Institute for Health Development Mahidol University 25/5 Phutthamnothon 4 Rd Salaya, Phutthamonthon District Nakhon Pathom, Bangkok Dr Jariya Wittayasooporn Director, School of Nursing and WHO CC for Nursing and Midwifery Development Faculty of Medicine Ramathibodi Hospital Mahidol University, Bangkok Timor-Leste Mr Domingos Soares Director National Institute of Health (NIH) Ministry of Health Comero, Dili, WHO Secretariat WHO Sri Lanka Dr Firdousi Rustom Mehta WHO Representative to Sri Lanka Dr R. Kesavan National Professional Officer Health Systems Development Social Determinants of Health
Mrs Kumudini Henrietta Ragel Secretary to Technical Officer Programme and Management WHO-SEARO, New Delhi Dr Athula Kahandaliyanage Director Department of Health Systems Development Dr Prakin Suchaxaya Regional Adviser Nursing and Midwifery Dr Duangvadee Sungkhobol Temporary International Professional Human Resources for Health Dr Sudhansh Malhotra Regional Adviser Primary and Community Health Care Dr Boosaba Sanguanprasit Temporary International Professional Primary Health Care Mr N. Mitroo Senior Administrative Secretary Primary and Community Health Care
SEA/RC64/6 Inf. Doc. Page 9
Annex 2
Draft Resolution Strengthening of the Community-Based Health Workforce in the Context of Revitalizing Primary Health Care The Regional Committee, Recalling World Health Assembly resolution WHA62.12 on primary health care, including health system strengthening and its own resolution SEA/RC61/R3 on revitalizing primary health care, Reaffirming the commitment for revitalizing primary health care (PHC) to address the emerging epidemiologic and demographic transition within the socio-cultural context of Member States and the challenges faced by climate change and rapid urbanization, Concerned that the Region confronts an increasing burden of noncommunicable diseases, mental health problems, accidents and injuries while the agenda of communicable disease control and addressing maternal and child health demands continued attention, Acknowledging that the community-based health workforce (particularly the community health workers and volunteers) is the backbone of a PHC-based health system, Recognizing that a well-trained, well-equipped and well-supported communitybased health workforce will assist in achieving universal coverage, health equity, multisectoral collaboration, community participation and has the potential for improving efficiency and effectiveness of the health system and contributing towards the achievement of health MDGs and other national and international health goals, Noting the country initiatives in implementing the recommendations of the “Strategic Directions for Strengthening Community-based Health Workers and Community Health Volunteers in the South-East Asia Region” (SEA/HSD/311) and the opportunities and challenges for further strengthening the community-based health workforce, Recognizing further that additional policy support is required for strengthening the community-based health workforce, and Having considered the report and recommendations of the Technical Discussions on “Strengthening of the community-based health workforce in the context of revitalizing primary health care”, 1. ENDORSES the recommendations contained in the report; and 2. URGES Member States:
SEA/RC64/6 Inf. Doc. Page 10
(1)
to review and further strengthen national health policies, including human resources for health policies on the community-based health workforce (with specific reference to community health workers and volunteers) and redefine their roles to effectively address the epidemiologic and demographic challenge within the socio-cultural context of the countries; to further strengthen the skills of CHWs and CHVs as front line health workers for providing comprehensive (preventive, promotive, curative and rehabilitative) health care to the community for existing and emerging health problems; and to give additional focus on building capacity to enable them to effectively perform the role as “change agents” with emphasis on skills building for empowering the community for self-care, health promotion and disease prevention; to institute urgent policy measures to address issues related to the management of the community health workers and volunteers including adoption of appropriate selection criteria; strengthening supportive supervision; rationalization of their distribution in remote as well as urban areas; incentives for retention of workers especially in remote and difficult areas; administrative and legal support; career progression and strengthening co-ordination with community-based workers of other sectors; to generate evidence and conduct operational research to formulate and strengthen evidence-based policy to further enhance the efficiency and effectiveness of CHWs and CHVs; and to advocate strengthening of national health policies, including human resources for health policies for strengthening CHWs and CHVs; and support the Member States to develop appropriate mechanisms for monitoring and implementation of policies for strengthening CHWs and CHVs; to facilitate exchange of information, experiences and best practices for strengthening CHWs and CHVs and support collaboration and networking among countries and institutions; to support evidence generation, operational research and development of appropriate models to inform policy for strengthening of the community-based health workforce in the context of revitalization of PHC.
(2)
(3)
(4)
3. REQUESTS the Regional Director: (1)
(2)
(3)