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[afro-nets] Lay or community health workers can improve health (16)
- From: "Mohammad Ali Barzgar" <firstname.lastname@example.org>
- Date: Thu, 15 Apr 2010 01:07:53 -0400
The community health workers of Iran (BEHVARZ).
The Behvarz is a girl or a boy with primary school education (5-6 grades), with special Block System (theory and practice)training of one year in which only four months of it is in class room in a health center, and eight months practical training&delivery of services under close supervision. She will be graduated after one more year delivery of services under supervision and periodically evidence based training. One of the very restricted criteria for the recruitment of the Behvarz was that she/he must be from the community and reside in where she is supposed to serve (being a part of the community and supported by the community).
I should mention here that not only they could improve the health situation of the community especifically women and children the most vulnerable group, the health services set-up has been reorganized based on the data and services which they provide. As Sara mentioned in her comment, the use of community health worker was initiated more than 30 years ago in 1973. I had the honor to be the initiator of the Health Services System Development Research (HSDR) project of West-Azerbaijan , Iran at the field level. In 1972 prior to the use of community health workers, a health situation analysis was made which showed that the IMR was 131/1000 live birth, MMR 140/100,000 and Birth Rate was 42/1000 populatin. In 1973, the first batch of Behvarz were trained and posted in 10 Health Houses which overall were covering 30,000 population. After 3 years of services delivered by the Behvarz the IMR was reduced from 131 to 76/1000, Birth Rate from 42 to 27/1000 population. It should be mentioned that in neighbouring community without benefiting from the services of community health workers IMR was 122/1000 and Birth rate was 41/1000. Severely malnurished children were managed in the meeting of the mothers with sharing the practical experience of successful mothers in the community with well nourished healthy children (through promotion of Breast Feeding and use of available food in family). Also, 80% of the common illness were managed and treated by Behvarz and the 20% complicated cases were referred to the physician in the near by health center in which if required they would have been sent to the district hospital. Even in 1976 with assisstant of Behvarz we carried out for the first time the Research on the Effectiveness of Oral Rehydration Salt (ORS) in acute diarrhoea of children under 3 years. Even they as grass root workers contibuted to a lot of priority researchs like malnutrition, tuberculosis, diarrhoea...etc. In 1976 we initiated TB control program in a Kurdish village where TB was a big problem. By that time we could implement DOT Programm without naming it as DOT. The Behvarz in Kahriz village twice daily was observing to make sure that the TB patients swallow the numerous pills of PASS, Rifampicin and Isoniazide for a long time until the patient received a 'Healthy' card from the District TB center.
In the year 2000 , I had the opportunity to visit the same area that, I had initiated the experiences in 1973 after about 15 years. Interestingly, some of the Behvarz who had been recruited and trained by me and the other members of our research center still were in service. They very proudly were saying that the people follow what they were advising them about their and their family members health . 'Even they consider us as the community leader of the community, because we were serving them for several years with dedication and sincerity'. Incidentally, while I was visiting the area, students of the School of Medicine were in the field training for their public health course. The Behvarz confidently played the role of an instructor for the students of medical school especially in practical interventions, like measurement of blood pressure, immunization, and drawing the growth chart for the children. She was very proud of being able to teach the students of the medical school confidently.
I am pleased to learn that Sara mentioned that some study is going on to assess the impact of the primary health care of Iran. I am sure a lots of things could be learned from such an important countrywide program which is the corner stone of the health services of a country with a population of 70 million for more than 30 years. As we have learned during the 15 years of the process of its development and implementation as follows:
When we introduced the community health worker at the grass root level of the health services system of the country, we realized that our medical education is not relevant to the country health needs. Then efforts were made to change the classic medical education to the community oriented medical education. After some successful experimental community oriented medical school, we realized that in order to change medical education we needed more training sites at different levels for the medical students. For the above mentioned purpose the National Assembly approved the Integration of the University of the Medical& Health sciences into the Ministry of Health. The Ministry of Health was renamed as The Ministry of Health& Medical Education. The Chancellors of the 29 Universities became responsible for the medical education and health services of their catchment areas as Deputy to the Minister of Health of the country. It meant that the medical education that the university delivered should be relevant to the needs of the country and 29 provinces concerned. At the same time, a primary health Network of three levels of primary, secondary and tertiary levels of health services for the referral and supervisory function were developed in each province. (I should mention that in regard to referrals the system was not successful at secondary and specially at tertiary level). Also, the Medical Association went through some changes in order to be responsible for the health situation of the country as an advisory body to the ministry of health and take part in continuing education of the health manpower. As a result of all of this reorganization, reoriontation and innovations, the health indicators improved dramatically since before introduction of the Comprehensive primary health care(CPHC). For example IMR reduced from 131 to 26/1000 live birth (10-36 in rich and poor provinces respectively), MMR from 140/100,000 live birth to 28 and Birth Rate from 42/1000 population to 26/1000 population (17-to29 in different provinces) since 1972 to 2010. This improvement is additional to the lots of socio-economic changes that happened due to the introduction of CPHC. In fact, it was the real approach of comprehensiveness of the Promotive, preventive, curative and rehabilitative services of the Primary health care and not only the other meaning of primary health care as the first level of the health services.
I am pleased to mentioned here that about 28000 of the community health workers (Behvarz) are based at the frontline level of the health services system of Iran and serving about 30 million people at the most remote and periphery levele of the country.
I should mention here that the intersectoral development was almost nil in the Iranian experiment and therefore it was more health and health services oriented. Also, because of the political situation, the community involvement was weak. A big lesson learned from the program is :
Any program to be relevant to the needs of the people will be accepted by the successor government even after Revolution or a coup. The presence of the lay primary health care worker will guarantee the relevance of the program to the priority needs of the community.
Mohammad Ali Barzgar