Future Applications
The experience so far in CHNPs can be applied more broadly, especially where community organizations can sustain support for CHNWs. CHNPs have worked best so far in Asia and Latin America. However, with the HIV/AIDS epidemic in Sub-Saharan Africa needing high-priority attention, application of CHNP experience to the HIV/AIDS crisis should be explored.
Extending CHNPs' Coverage and Intensity
In a project sponsored by the Asian Development Bank (ADB) and UNICEF that was aimed at identifying ways of investing in improved child nutrition, Mason and others (1999, 2001 have reviewed the extent of CHNPs in Asian countries. Resources were estimated in terms of annual expenditures per child and of ratios of population to community workers ("mobilizers"). The project addressed the needs of eight countries (Bangladesh, Cambodia, China, India, Pakistan, the Philippines, Sri Lanka, and Vietnam), and previous experience in Indonesia and Thailand provided additional guidance.
The population coverage of CHNPs was estimated as about 5 to 20 percent, except for India with the ICDS, which reports about 70 percent coverage. The next indicators refer to estimates within programs. The calculated intensity was commonly 200 children to 1 community worker (for example, Bangladesh, India, Sri Lanka); ratios of up to 100:1 were reported in Pakistan and Vietnam and up to 60:1 in the Philippines. Further research has stressed the variation in time commitment of CHNWs in different places—hence the need to convert to FTEs. The ratio used as the norm, derived from experience in Thailand and Indonesia, of about 1:20 is probably equivalent to 1:200 in FTEs. In India, opinion has been that about a doubling of the ANW numbers in the ratios is needed to get more effect (Measham and Chatterjee 1999). From this perspective, these estimates indicate that both coverage and intensity are low, although intensity may be half that needed, whereas coverage (except in India) is far too small. Supervision ratios are estimated as about 1:20 and higher. Expanding the numbers of CHNWs also means increasing the number of supervisors (usually from the health system), with associated costs.
Calculations from scarce financial resource data show that most government programs cost about US$1 per participant child per year or less, whereas Bangladesh (BINP, with donor support and in line with other donor-supported programs) reached costs of US$15 to US$20 per child per year. By this calculation, too, the resources per head, as well as the coverage, were in most cases too low for widespread effect.
The estimates of coverage and intensity can be combined to calculate the extent of current programs in relation to that needed for full coverage at adequate intensity. The results based on a 1:20 ratio of CHNW to children suggest that less than 1 percent of the need was currently available; at 1:200 (which would cost more, because the CHNW would work full time) perhaps 10 percent of the need would be covered. Either way, a massive expansion would be called for if CHNPs were to be used as a means for widely improving health (but still calling for only about 20 percent of the public budget for health).
Expansion requires major resources, and not only financial ones. Thailand trained 1 percent of the population as community health workers (part time) and established an extensive supervision and support structure, including retraining. The estimates for the ADB-UNICEF project in financial terms were, for Bangladesh, Cambodia, Pakistan, Sri Lanka, and Vietnam, some US$190 million to US$280 million per year for improvement of underweight by an additional 1.5 ppts per year (Mason and others 2001, 64-68).
The Potential Role of CHNPs in Combating HIV and AIDS in Sub-Saharan Africa
Controlling the epidemic of HIV and AIDS in Sub-Saharan Africa will take an unprecedented effort. As antiretroviral therapy becomes available there will be new opportunities to turn the tide. Supply of antiretroviral therapy drugs, although essential and the cutting edge of new programs, is only part of the need. Food and income support, care for children (orphans and others affected), counseling, support to promote and sustain behavior change, and rehabilitation of people and communities are needed (see chapter 18). Many of these activities have precedents in the types of CHNPs run by community health workers that are discussed here. What lessons are transferable?
One concern is that CHNPs have a greater history of success in developing countries outside Africa. Those within Africa seem to have been sustained for limited periods, often linked to donor interests. Reasons may have to do with lower levels of administrative infrastructure, different existing community organization, and varying political commitment (see table 56.4). These factors may now be weakened as the AIDS epidemic reduces the numbers of qualified people and undermines community organizations. It will be urgent to work on such contextual factors to create conditions in which community organizations can be refurbished and built on.
Community organizations can work in Africa, as elsewhere, when they have a real function with activities perceived as useful to pursue and some resources (including mobilizing their own) to use. Some transferable lessons are that such local organizations are crucial; that in regard to supervision and access to certain resources, they need to work with the government structure—often through health system employees; and that they need sustained resource support, much of which must come from donors.
Treatment and rehabilitation of people with AIDS will be home based in most cases and will depend substantially on community support. Nutrition is an important component; improved food intake is likely to enhance the effect of anti-retroviral therapy, and when treatment progresses, nutrition will help get sick people back on their feet and returned to a productive life. A village health worker could play a key role in this process. In much of Africa, HIV and AIDS affect many communities, and in southern Africa, where HIV prevalences reach 30 to 40 percent, almost all communities have chronically sick adults. This fact means that most communities need programs: the problem is not highly concentrated. On the positive side, the more developed and accessible communities are those most affected by AIDS (Mason and others forthcoming; UNICEF 2004), where establishing programs may be easier. HIV and AIDS are affecting children both directly, as pediatric AIDS, and indirectly, through the impoverishment and destitution of affected households. This effect is seen in worsening child malnutrition. Here, too, support through CHNPs could play a useful role.
The characteristics of CHNPs elsewhere—in terms of intensity, training, supervision, and so forth—may provide some guidance for establishing or extending them in Africa. Mechanisms for identifying, supporting, and training village or community health workers in this context can draw on experience with CHNPs; such issues as their identification in the community and links with community and facility programs will arise. A key issue will be the remuneration and incentives for community workers, and this issue may need some research and testing of different approaches. The activities of community workers in dealing with treatment (and prevention) of HIV and AIDS have parallels to malnutrition and would probably include the following items:
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social support and facilitating access to resources (possibly including food aid)
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counseling
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treatment and referral for opportunistic infections
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promoting rehabilitation to productive life (which may benefit from improved nutrition) as antiretroviral therapy progresses.
Schools too have an extremely important role in the fight against HIV and AIDS and should be linked to, or part of, CHNPs. Schools provide a refuge and a means of providing help for orphans and vulnerable children, and they also provide a crucial opportunity for preempting and combating high-risk behavior.
