PHM-Exch> Lay or community health workers can improve health (11)

[Claudio Schuftan]

From: Mohammad Ali Barzgar barzgar89 at yahoo.com

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 (teory 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 childeren 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 birtb, 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
benefitting 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 nurished 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 recieved 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 presure, immunization,and drawing
the growth chart for the children. She was very proud of being able to teach
the students of the medical  school confidetly.
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 diferent levels for the medical students. For
the above mentioned porpose 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 fonction were developed in each
province. (I should mention that in regard to referrals the system was not
successful at secondary and specially at tetiary 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 thart
happenned due to the introduction of CPHC. In fact, it was the real approach
of comorehensiveness 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 therfore 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 Revoulution or a coup. The presence of
the lay primary health care worker will gaurantee the relevance of the
program to the priority needs of the community.
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