Community health-workers: scaling up programmes

Abstract

In todays Lancet Andy Haines and colleagues re view the changing fortunes of community health-worker (CHW) programmes and the current favouring of large-scale interventions by CHWs. They present adequate evidence that CHWs are necessary and effective but caution that success depends on specific contexts and that effectiveness in large-scale programmes is far from settled. Their discussion is especially timely for India where state-wide CHW programmes are under way as part of the National Rural Health Mission. The Mitanin programme of Chhattisgarh state in India highlights the many dilemmas and possibilities in the scaling-up of such programmes. Created in 2000 by division of the large central state of Madhya Pradesh Chhattisgarh inherited a public-health system that had an inadequate number of facilities and human resources. In the context of high illiteracy and poverty and with a third of the population consisting of indigenous people the 3818 health subcentres (staffed by one auxiliary nurse in every centre) were unable to provide outreach services to the 18 million rural population dispersed over 54 000 habitations. In 2000 Chhattisgarh had a rural infant mortality rate of 95 deaths per 1000 livebirths -the second highest in Indian states. (excerpt)