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

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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.