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

许多低收入国家(和一些中等收入国家)面临卫生工作者严重短缺的问题。各国政府寻求通过动员社区卫生工作者(CHW)进行补偿，他们往往比传统卫生工作者接受培训和部署得更快，并可以接管他们的一些角色。他们假定的优势包括对他们的社区有很好的了解(特别是对偏远、边缘化和难以接触到的人口)，以及更多的社区参与和责任。虽然有一些证据表明它们的引入可以取得成功，但人们对它们的看法、它们面临的挑战、卫生系统如何最大限度地发挥它们的潜力，以及如果被证明是有效的，如何扩大它们并将其最有效地与正式的初级卫生保健(PHC)结构联系在一起，知之甚少。埃塞俄比亚提供了一个独特的机会，让人们了解社区卫生组织的作用及其在填补技能差距和发展可及和反应灵敏的初级保健服务模式方面的潜力。需求是巨大的，反映出历史上对培训的投资不足，卫生专业人员的移民加剧了这一问题。在一个庞大、复杂和多民族的社会中，需要接触偏远地区，城市和农村人口、定居人口和游牧人口，所有这些人的服务利用率都很低，这让问题变得更加复杂。然而，埃塞俄比亚与许多类似国家的不同之处在于，它致力于社区主导的初级卫生保健，高度重视改善获得基本服务的机会，并创建了两种截然不同但至少在理论上互补的社区卫生工作者。第一个由保健推广工作者组成，这是2003年启动的一项旗舰国家方案，由接受过基本培训的个人组成，他们将在自己的社区工作，提供基本的保健服务。该方案吸引了国际上的兴趣，但它在便利进入初级保健中心方面取得的成功不大。第二个小组成立于2010-2011年，由卫生发展军(HDA)的志愿者组成，他们充当代理人和动员者，弥合一线服务(通常被认为难以获得)与社区之间的差距，培养信任并支持参与式卫生系统。人类发展评估跨部门开展工作，反映了PHC的范式，解决了更广泛的健康社会决定因素。我们试图了解，在面临稀缺资源的情况下，社区卫生志愿者是否可以为改善健康做出有意义的贡献，如果可以，在什么条件下，以及如何优化他们的贡献。我们的目标包括探索不同类型的社区卫生工作者的实际工作，他们与当地社区的关系(在信任、权力和知识方面)，在执业范围和质量方面阻碍他们做更多工作的障碍，以及他们在适当的支持下可以做什么。为了回答这些问题，我们将首先建立一个分析框架，在这个框架中，获取被视为一个社会过程，然后尽可能地用政策文件中的数据和信息来填写。这将被用来改进研究设计和开发适当的工具来收集定性数据。这项研究将(包括通过视频日记)向不同类型的社区卫生工作者、他们所服务的社区以及他们所依赖的决策制定者发出声音。该项目将产生及时的、与政策相关的信息，查明改善获得关键服务的瓶颈，促进与社区的伙伴关系，并与各级卫生当局合作，为随后的人类发展评估制定计划。虽然重点是埃塞俄比亚，但这些发现将与那些在其他资源匮乏的环境中规划社区卫生服务倡议的人相关。

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.