Community health volunteers as mediators of accessible and responsive community health systems: lessons from the Health Development Army in Ethiopia

Many low (and some middle) income countries face critical shortages of health workers. Governments have sought to compensate by mobilising community health workers (CHW), who can often be trained and deployed quicker than traditional health workers and can take over some of their roles. Their presumed advantages include a good understanding of their communities (particularly of remote, marginalised, and hard to reach populations) and greater community involvement and accountability. While there is some evidence that their introduction can be successful, less is known of how they are perceived, the challenges they face, how the health system can maximise their potential and, if shown to be effective, how they can be scaled up and linked most effectively to formal primary health care (PHC) structures.

Ethiopia offers a unique opportunity to understand the role of the CHWs and their potential to both fill skills gaps and develop a model of accessible and responsive PHC. The needs are huge, reflecting historical under-investment in training, exacerbated by migration of health professionals. The problem is compounded by the need to reach out to remote areas in a large, complex, and multiethnic society with urban and rural, settled and nomadic populations, all with low service utilisation. However, what makes Ethiopia different from many similar countries is its commitment to community-led PHC, with a high priority placed on improved access to essential services, and the creation of two distinct but, at least in theory, complementary types of community health workers. The first comprise the Health Extension Workers (HEW), a flagship national programme initiated in 2003, comprising individuals who have been given basic training to work in their own communities providing basic health services. The programme has attracted international interest but its success in facilitating access to PHC has been moderate. The second group, initiated in 2010-11, comprises volunteers in the Health Development Army (HDA), who act as agents and mobilisers to bridge the gaps between front line services (often perceived as inaccessible) and communities, cultivating trust and supporting participatory health systems. The HDA works across sectors reflecting a paradigm of PHC that addresses the broader social determinants of health.

We seek to know whether, when faced with scarce resources, community health volunteers can make a meaningful contribution to better health and, if so, under what conditions, and how can their contribution be optimised. Our objectives include exploring what the different types of community health workers actually do, their relationship (in terms of trust, power and knowledge) with their local communities, the barriers to them doing more, both in terms of scope and quality of practice, and what they might do with appropriate support. To answer these questions, we will first develop an analytical framework in which access is seen as a social process, and then fill it in as far as possible with data and information from policy documents. This will be used to refine the study design and develop appropriate tools to collect qualitative data. The research will give voice (including via video diaries) to the different types of CHWs, the communities they serve, and the policy makers on whose decisions they depend.

The project will generate timely, policy-relevant information, identifying bottlenecks to improving access to key services and promoting partnerships with communities, as well as developing plans for a subsequent evaluation of the HDA, working in partnership with health authorities at all levels. Although focused on Ethiopia, the findings will be relevant to those planning CHWs initiatives in resource-poor settings elsewhere.

Faced with chronic health worker shortage, many LMICs have invested in community health workers to extend and enhance health care in low-resource settings. This project examines the role of the Health Development Army (HDA), a large multi-purpose cadre comprising locally-recruited and trained community volunteers in Ethiopia, intended to mobilise communities, that complements the existing cadre of more highly trained Health Extension Workers (HEW), with the HDA acting as intermediaries between formal PHC services and the communities they serve.

A better understanding the HDA experience offers a means to gain important insights into ways to use community volunteers, working across sectors, to support participatory models of grassroots PHC that both enhance access to care and address the social determinants of health.

The project asks first: what role does the HDA play (who are they? what roles do they assume in their communities? How are they perceived by their communities and the health care providers with whom they interact, including the HEW (examining trust, power and knowledge imbalances)? What factors - within and beyond -health systems facilitate or obstruct their activities)? Second, what are the conditions that may increase their potential to improve access to care and address health determinants, including those that lie within the purview of other sectors? Based solidly on theory, it employs a mix of qualitative research methods and is set in one of the Ethiopian regions that pioneered the HDA concept.

Evidence generated by the project will exploit a window of opportunity to inform policy in Ethiopia, addressing a recognised need to understand the contributions of the HDA and their relation with the HEW and PHC structures, as well as the scope for expansion to support hard-to-reach populations. It also addresses a growing international interest in the role of community health workers as part of a package of low cost, responsive PHC models.

The project offers a potential for significant impact both in terms of generating new evidence and influencing policy and practice in Ethiopia and beyond. Project impact will be maximised by employing an appropriate Theory of Change model, based on collaboration and engagement with a broad range of stakeholders, paying attention to their concerns.

Impact will be sought, initially, at regional and national level, where decisions are being made about the Health Sector Development Programme despite the scarcity of available evidence. Prospects for success are enhanced by the ability to elicit the challenges facing the HDA programme, capturing the perspectives of frontline staff and their communities and giving them voice (via video diaries) that maximise audience impact. The findings will be framed in ways that speak to the concerns of policy makers, elicited from our close interactions with them at all stages of the project, from problem definition to choice of settings and format of results. Our familiarity with the complex policy environment in Ethiopia, as well as established links to policy makers based on mutual respect and trust, will enable us to ensure that our findings are salient to their needs.

The research will take place in Oromia region. Although Jimma University already has excellent existing partnerships with regional authorities, engagement in this project will further strengthen their links with the Regional Health Bureau, whose collaboration on study design, interpretation and dissemination of the results with strengthen their understanding of research and how they can maximise its value to them. Practically, an advisory board including managers and planners at regional level and key policy actors at federal level will support shared understanding between the centre and the periphery. These processes will be facilitated by the extensive experience that team members from both LSHTM and Jimma University have in policy engagement and knowledge brokering at national and international level, as well as their in-depth understanding of the Ethiopian policy context and knowledge of key stakeholders.

Impact is also envisaged regionally (in Africa) and globally. The issues are of significant interest to many LMICs countries seeking to cover poor, rural and hard to reach populations with essential front line services as they progress toward universal coverage. Given that the HDA programme is backed by the government, rolled out nationally, and seeks to operationalise the political commitment to extending access to key services in poor settings, the project offers a unique learning opportunity. Understanding the role and potential of the HDA workers alongside other PHC cadre, is likely to motivate further work on developing people-centred health systems.

Academic audiences will also be engaged through journal and policy papers, with an emphasis on open-access formats including conference presentations, policy briefs and infographics, videos, social media. This will link to existing networks and communities of practice such as Health Systems Global and its Thematic Working Group on community health workers) which includes practitioners and policy makers interested in sharing experience. All team members have extensive networks: the PI Balabanova is Board Member of Health Systems Global and McKee chairs the Global Health Advisory Committee of the Open Societies Foundations.

Project impact will be further catalysed through teaching programmes in Jimma University and LSHTM on health systems and other capacity building opportunities including training and sensitising of community volunteers from other African countries in Ethiopia; an idea championed by the MoH. For all these reasons, we are confident that the proposed research and further evaluation (under a subsequent call) will be of great value to decision makers as well as to community workers and volunteers in Ethiopia.