Programmatic Factors
Programmatic factors are considered first in terms of the characteristics of the activities—their population coverage and targeting, how much resources are applied per head (intensity), and the technologies used. Then the needs for initiating and sustaining these activities are discussed—the training needs, supervision methods, and (importantly) incentives and remuneration for field workers.
Coverage, Targeting, Resource Intensity, and Technology
Even effective programs improve the health and nutrition only of those they reach, so achieving as complete coverage as possible of those at risk is a major determinant of the effect. Although variations in the content of programs are seen in different circumstances, most activities are common to most programs. Variations in effect stem from factors such as coverage and adequacy of resources. How have CHNPs fared in reaching large sections of the population with adequate resources—and, indeed, what is the gap that would need to be filled? The achievements of the 14 programs drawn on here as case studies are summarized in table 56.3.
[Table .]
The programs expanded to include most of the communities within the areas targeted. The common evolution was to target select areas and specific biological groups within those areas—generally women and children—but not to give priority to any great extent to poorer or less healthy communities. Screening is sometimes done of individuals for admittance into the programs (a form of targeting), based on nutritional status, as in growth monitoring and promotion, as well as on a onetime basis (for example, thin children in Zimbabwe). Recent thinking suggests that because mortality risk, growth failure, and morbidity are concentrated in children less than two or three years of age, in contrast to an earlier focus on children under five, these younger children should increasingly be a focus of CHNPs. A common policy observed in practice, therefore, is to aim for complete coverage within the areas participating, adding new sites until the entire region is covered. Relatively untargeted expansion to universal coverage may have been at the expense of establishing adequate resources and quality in the areas initially covered. In at least one case (Thailand), having achieved broad coverage and reduced malnutrition, the program became more targeted to areas in which progress was lagging. The coverage figures in table 56.3, although approximate, demonstrate considerable success in initiating and implementing CHNPs on a large scale—usually enough to have a substantial effect if the other factors needed for success were met.
How complete a coverage of the population should one recommend? This factor relates to targeting, to the additional resource requirements to reach the nonparticipants, and to their level of risk. Usually risk is spread throughout the population, although the extent varies considerably—at least a doubling of indicators of risk is usually seen between better-and worse-off areas or groups (for example, see Mason and others 2001, figures 1.4-1.7). The remoter areas—or groups that are hard to include for other reasons—may be more expensive to reach. Clearly the calculations depend on conditions and have to be made on a case-by-case basis. The principle is obvious: only those areas and people included in CHNPs are going to benefit; so wherever need exists, programs are indicated. The implementation strategy, in theory, may need to begin with the most urgent needs, although in practice, programs may expand from the easier, more accessible areas; this practice seems reasonable, provided that the expansion really occurs and leads to equitable use of resources.
The program content is a mix of the components described earlier, varying with local priorities. The most crucial difference is whether extensive supplementary feeding is included. In middle-income countries, supplementary feeding was less prominent, often considered unnecessary, and because expensive, perhaps counterproductive (for example, in Costa Rica; Mata 1991). At the other extreme, such as for the Integrated Child Development Services (ICDS) in India, food distribution became the raison d'etre of the program but, alone, was again probably not worthwhile. For some of the intermediate cases, supplementary food played a supporting role, with varying results. Except in the very poorest societies, supplementary feeding seems unlikely to be cost-effective.
The resources used for the programs found in table 56.3 can be expressed per participant (referred to as intensity), as total expenditures, and in terms of personnel; the latter figures may be more generalizable. (The outcomes associated with these resources are shown in table 56.5.) Data such as these have been the basis for estimating that US$5 to US$10 per child per year may be needed for effective programs. The dollar figures vary from less than US$1 to more than US$20. Probably the low end of this range (say, less than US$1 per child per year) does explain low or doubtful effect. Both low coverage and low intensity may explain the unchanged underweight prevalences in the Philippines until 2000. Fund levels in Indonesia are unsure; Rohde (1993) gave a figure of less than US$1, but others gave higher estimates. Most would reckon the intensity in India too low (Measham and Chatterjee 1999) at about US$2 per child per year. Looked at otherwise, the intensity planned for external funding (even if part of such funding is international costs) is in the US$10 to US$20 range (Bangladesh, India—Tamil Nadu, and Tanzania) and is the same as the estimate for Thailand. A level of US$10 to US$20 per participant per year is probably advisable for planning and sustaining effective programs.
[Table .]
The intensity measures of workers per mother-child and the supervision ratios are relevant in assessing needs. The suggested norms, originating from the Thai experience are 1:10-20 for both. Since then, it has emerged that the full-time equivalence of community workers must be taken into account; the Thai workers are local volunteers, probably devoting 10 to 20 percent of their time. In Honduras, Fiedler (2003) in a careful cost study estimated that each volunteer spent 3.5 hours per week (less than 10 percent of full-time equivalent, or FTE), with a ratio of 1 volunteer to 8 children. The ratio of community health and nutrition workers (CHNWs) to children may, therefore, be as low as 1:200 for FTEs and as high as 1:8 or 1:10 for part-time volunteers. In Jamaica, where the community health aides work full time, the ratio is 1:500 households; in the BRAC program in Bangladesh, it is 1:300, about half-time work (afternoons) (Chowdhury 2003). (An indication of the status of community workers is shown in brackets in the last column of table 56.3.) In any event, these ratios provide some basis for gauging the adequacy of personnel, and it seems that an effective ratio may be about 1:500 for community workers employed full time and 1:10 or 1:20 for local volunteers working part time.
In reality, the ratios of community workers to children are probably—not surprisingly—on the low side. Thailand, which trained 600,000 village workers (1 percent of the population), operated at about 1:20 for part-time volunteers, with similar supervision ratios. The Indonesian program was similar (or better) but had much less supervision. In contrast, the low resourcing of the ICDS in India shows up in a ratio of 1:200 (for part-time anganwadi workers, or ANWs), and in the Philippines, the ratio has until recently been 1:300 (for essentially voluntary workers).
Increased application of technology can contribute to the organization and running of community-based programs. Technology can be applied easily to methods of assessment and monitoring of children's progress; improved weighing scales (or in some circumstances, where rapid assessment in remote areas is important, using arm circumference) can simplify anthropometry. Modern computer technology for recordkeeping could be much more widely used, freeing staff time for home visits (for example, in Jamaica); e-mail, which is being rapidly adopted, has great potential for transferring information, troubleshooting, and consultation. Cell phone use is beginning to transform communications even in the poorest countries, where it is leapfrogging landline installation and use; as coverage expands, it will facilitate referral, for example, for emergency obstetric care, the need for which may first be identified by community workers. Coupled with improved transportation and procedures to allow the use of such transportation in cases of urgent need, modern communications can link communities to centers with advanced knowledge for information exchange and, by facilitating transportation when time is crucial, for referral. Modern communications may also provide more efficient ways of providing training, retraining, and supervision.
Application of current research and resulting technologies can improve many of the other interventions discussed earlier. In the micronutrient field, periodic supplementation (with vitamin A in high doses) can be extended through community programs, and fortified foods and micronutrient "sprinkles" can be promoted (see chapter 28). The prospect of enabling communities to test their salt for iodine content with simple and cheap test kits is intriguing and has often been recommended but has not yet been widely applied. Improved immunization technology should continue to protect health, for which CHNPs' main role is to provide information and to ensure that children are taken for immunization (either to regular clinics or for National Immmunization Days and the like). Periodic deworming can be conducted by community programs (and hookworm vaccines currently under development may soon contribute). Supporting the use of insecticide-treated bednets could be fostered through CHNPs. By far the most potentially important application of technology, certainly in Sub-Saharan Africa, will be the unprecedented effort to provide millions of people with antiretroviral therapy and associated care and support, as discussed later.
Training, Supervision, Incentives, and Remuneration
Community-based health and nutrition programs typically involve community workers, who may be entirely part-time volunteers (for example, in Honduras and Thailand) or may receive some remuneration financially or in kind (for example, in India). Community workers may be part of the health system, earning a wage and based in a local clinic (for example, in Jamaica) or in the community itself (for example, in Costa Rica); or they may be selected by and report to the community (for example, in Tanzania and Thailand). Table 56.3 indicates the status of community workers in the programs examined here. The training, supervision, and incentives for community workers are critical aspects of successful programs.
Inadequate training and supervisory support of community workers are common weaknesses. Considerable attention was given to training for the Iringa project (Tanzania), with village health workers trained for up to six months. In the Tamil Nadu Integrated Nutrition Program in India, community workers received three months of training and participated in annual refresher trainings. ICDS (India) initially trained the ANWs for three months, with two annual refresher courses, but this process declined. In Thailand, volunteers had two to five days of initial training, with annual refresher courses; Indonesian practice was similar. In Jamaica, where the community workers are employees of the health system, two months of initial training is provided to recruits with significant prior educational requirements. In Bangladesh, the BRAC community health volunteers have four weeks of training. The quality of the training has varied, poor training having been blamed for inadequate implementation in cases such as ICDS in India (Measham and Chatterjee 1999). Sanders (1985, 176-93) describes experiences in the 1980s of village health workers (and barefoot doctors) and their relation to the community.
Supervision of community workers is generally done by employees who are commonly in the sector. Training of supervisors (who often take on the role in addition to many other tasks) for these purposes is highly variable and not always adequate. Providing resources for visits to provide supervision to community workers is a further constraint. Supervision ratios in effective programs are about 1:20 (table 56.3, last column, when reported). Supervision and training of community workers are closely linked; indeed, supervision (which must be supportive rather than disciplinary) should include a substantial element of on-the-job training.
Remuneration and incentives for sustaining motivation are key issues in replicating the successful features of these programs, and the options vary with the culture. In Thailand, it is argued that village volunteers consider the prestige associated with the role of health worker preferable to getting a low wage. In many cases, some right of access to health care is part of the incentive. For the ICDS in India, in contrast, the ANW receives a small financial remuneration, but the government (as elsewhere) will not grant formal employment status (and attempts to form unions have been strongly discouraged). Direct comparisons of the options of paid remuneration and voluntary work are rare. One opportunity to study options for remuneration is in the Philippines, where under a World Bank Early Child Development project, the child development worker receives a wage, which could be compared to near-volunteers at the barangay (village) level.
When CHNWs are primarily voluntary, they are selected by the community and report to community committees in some form. CHNWs on government payrolls may come from the communities and thus may be known to and identify with the communities, but they may report to supervisors higher up in the system. Both models can work, depending on the culture. What probably works least well is when the community worker is paid little and receives inadequate support and recognition from the community or even comes from elsewhere. Furthermore, as development progresses, reliance on volunteerism may become less useful.
For planning CHNPs in terms of community workers, the total numbers and resource implications can be estimated as follows. A full-time equivalent CHNW might visit 5 to 10 households per day, averaging a visit to each household roughly every two months; a ratio of 1 CHNW to 200 households, therefore, seems to be in the range within which an effect in terms of improving child health and nutrition is expected. Calculations from salaries of community health aides (CHAs) in Jamaica work out to US$7 per household per year, within the usual range for expected effect. An important factor in regard to financial resources, however, concerns the substantial cadre of personnel who have training and job descriptions for community work, are based in health centers, and for administrative and financial reasons seldom leave the health facility. Moreover, funds may not be released to allow travel to nearby villages. An example is from Jamaica, where, because of clinic workloads, CHAs spend time helping in clinics rather than on home visits; in fact, technology could free staff time for community work by automating tasks, such as record keeping, that detain the CHAs. More effective deployment of existing personnel may frequently be an option. Hiring additional personnel as community health workers would consume a significant proportion of typical health budgets (at 1:200 households for FTEs, this would amount to US$1 to US$2 per person per year, or about 20 percent of public health budgets in low-income countries). A mix of redeployment of existing staff and new hiring from budget reallocations should, nonetheless, be cost-effective.
Organization
Effective, respected, and socially inclusive organization at the community level seems to have been a key feature of the success in launching, expanding, and sustaining CHNPs. Most of the successful CHNPs drew and built on established community procedures; where they did not, effect and sustainability were in doubt. In Thailand, the health services and the religious organization at village level were important. The health services themselves play a key role in Costa Rica, Honduras, and Jamaica. In Indonesia, it was the community organizations (and women's groups) together with (initially) the family-planning services. In Iringa, Tanzania, it was the local political party structure, with substantial input from UNICEF. In Zimbabwe, immediately after independence, it was the village organizations that had fought the war, later helped by a consortium of national and international nongovernmental organizations (NGOs). The major part of the still-expanding program in Bangladesh is run by BRAC, an NGO, and has built on its links to the community for development, food security, and educational activities, as well as for health. In contrast, CHNPs that either failed to launch a wide program (for example, in the Philippines) or had limited effect (in India, ICDS) probably lacked some of these features. Inclusiveness is probably hard to achieve if not inherent.
Support from the central government is also crucial: CHNPs need this support for training, supervision, wages, supplies, facilities, and the like. Where such support becomes a regular government budget item, activities tend to become embedded and are sustained, in contrast to where the support is from donors.
A further issue concerns maintaining the community program's preventive orientation. In Indonesia, for example, according to Rohde (1993), the health services co-opted (and medicalized) the posyandu (weighing post, or community health and nutrition center) system by adding a diagnostic and treatment module (in fact, a table in the meeting place). This module attracted most of the attention, to the disadvantage of the preventive aspects of the program. Thus, if the extension of IMCI into the community means treatment (by trained but not medically qualified people) in the community rather than referral to facilities, treatment could become the main or even sole focus, shifting attention from prevention. Some parallels exist to the experience of ICDS in India, where, as noted earlier, food became the raison d'etre.
