"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.
Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time.
Currently, 90% of health services in Iran are provided by the public sector, and a large portion of basic health services are provided by the over 30,000 village health workers (VHWs), called behvarzs, who focus on the health needs of the rural population and specifically on MCH.1
Following health care reforms in the early 1980s, Iran built Health Houses, each of which was meant to serve approximately 1,500 people living within a 1-hour walking distance. Each Health House (Khaneh Behdasht) is staffed by one man and one or more women who provide preventive and basic care.2 Today 17,000 Health Houses serve 23 million rural Iranians.2
The Behvarz Training Centers provide pre-service as well as in-service training programs that consist of coursework divided into three grades over a 2-year period.
Behvarzs’ responsibilities include MCH care, communicable and non-communicable disease management and detection, care of the elderly, oral health care, health care in schools, environmental and occupational health, annual population census, completion of reports and forms, attendance at in-service training sessions, and membership on the Behvarz Council.
Because the CHW program is an integral component of Iran’s PHC system, financing of these workers is regulated into national health planning. The behvarz workers are paid a fixed salary approximately one-sixth that of physicians.
Regular supervisory visits to Health Houses are planned and performed by rural health centers. Provincial and national teams also evaluate program effectiveness and quality of care.
Iran has built a strong PHC system, and the behvarz CHW program has been a fundamental element of it. The strong progress that Iran has made in improving the health of its population and in narrowing the rural-urban gap in health status since the 1970s is due in large part to the performance of its community-friendly health workers and the PHC system more broadly.
What is the historical context of Iran’s Community Health Worker Program?
The Behdar (healer) Training Project in 1942, the West Azerbaijan Project in 1972, and the Village Behdar Training Scheme of Shiraz University are all earlier examples in Iran of utilizing local health workers to address health concerns of the rural poor.3,4 Following the Alma Ata Declaration of 1978, Iran established a network for PHC with a new CHW program that refined and expanded on projects such as the Behdar Training Project.5 The West Azerbaijan Project, developed in one province in Iran, aimed to expand medical and health services by establishing a comprehensive health delivery system and training auxiliary health personnel, which was the translation of a PHC approach into practice. In the same years as the West Azerbaijan Project, similar experiments in the use of auxiliary health personnel to deliver health services were also conducted in other parts of Iran. The PHC program in Iran has expanded beyond MCH services and now also provides services pertaining to elder health, youth health, and non-communicable diseases.
What are Iran’s health needs?
CHW programs in Iran are focused on the health needs of the rural population, specifically in terms of infant mortality, maternal mortality, and childhood illnesses such as diarrhea. The content of CHW training is adapted according to changing rural health care needs. For example, midwifery programs in rural areas have been added relatively recently. Needs addressed beyond maternal health include non-communicable diseases, immunization, personal hygiene issues, acute respiratory infection, and FP.5
What is the existing health infrastructure?
There are four levels of health workers: the family, informal and traditional workers, CHWs, and professionals. Health system reform, focusing more on primary care, coincided with the Iranian revolution in 1979. The new health system also integrated medical education and health care services. A goal of the new health system has been the reduction of urban-rural disparities in health outcomes.
What type of program has been implemented?
The Health House is the first contact between the rural population and health providers in the PHC network. Each Health House provides MCH care, FP services, health education, environmental and occupational health services, and disease control activities. CHWs conduct home visits. The Health House facilitates referrals to higher levels of care. An annual census of the population is also conducted.5
Specific CHW roles and responsibilities include vaccination, growth monitoring, IMCI, breastfeeding promotion, and nutrition support for infants and children. ANC and PNC are provided along with FP services, treatment of minor illnesses, and first aid. CHWs provide care for the elderly, oral health care, care of young people at school, and occupational health. CHWs receive a salary that is approximately one-sixth of a physician’s salary.6
What about the community’s role?
Community engagement in health promotion activities became part of the policy agenda in 2004.5 Promotion of community participation and promotion of collaboration at the local level of other social sector programs with health programs is part of the role of CHWs.
How does Iran select, train, and retain its Community Health Workers?
Selection and recruitment of CHWs (behvarzs) in Iran strongly reflects the WHO definition of CHWs as “members of the communities where they work [who] are selected by their communities.”7 Local people, including religious leaders and families, are involved in the selection of behvarzs. By 2004, a more formal process involving behvarz recruitment committees had been established in each district to assess vacancies and to find the most appropriate candidates using local media. A written examination and interview with the candidates are the final steps of behvarz recruitment.
Qualifications for behvarz candidates include a high school degree. Since 2005, more and more are being selected who have undergraduate university degrees in a health-related field. Both men and women are eligible. Behvarz candidates have to be resident in the rural area for at least 1 year. If there is no applicant from the main village, applicants from neighboring villages can be recruited.5 Moreover, to promote long-term retention of behvarzs in rural areas, priority is given to the local candidates or to female candidates whose husbands have a permanent job in the village. The appointment of behvarzs should be confirmed by a committee consisting of representatives of the Behvarz Training Center, the district PHC division, and the local rural council.
District Behvarz Training Centers, which are part of the district health system, provide pre- service as well as in-service training to behvarzs.8 The behvarz training program consists of theoretical and practical coursework over a 2-year period as well as clinical placements in Health Houses and rural health centers. Behvarz trainers have university degrees in family health, disease management, environmental health, midwifery, and nursing. Training courses are held twice a year for 7–15 behvarzs. Students receive free training and financial support (free accommodation, meals, transport) throughout the 2-year period of their training. In return, they are formally obliged to remain in and serve at the village for a minimum of 4 years after the completion of their study.
An important policy change has been the inclusion of behvarz training at the university level. The rationales for this change were the following:
- Provision of behvarz training at the university level will encourage a larger number of rural high school graduates to choose behvarz as their future job.
- A better-educated behvarz is more accepted by the community and can provide higher-quality health care to rural families.
The course is still 2 years long and leads to an undergraduate degree. Course topics are constantly under review. In 2006, several new topics—including health education, oral health, elderly health, research methods and problem solving, introduction to statistics, intersectoral collaboration, and natural disasters—were added to the training material. Other new topics include the health system and rural communities, social determinants of health and well-being, communication skills, human rights, and cultural beliefs. These new topics demonstrate a policy shift toward a more comprehensive notion of PHC in Iran.
How does Iran supervise its behvarzs?
Regular supervisory visits to Health Houses are planned and performed by staff from rural primary health centers. In addition, provincial and national teams evaluate program effectiveness and quality of care. A number of checklists which are designed by provincial and national health deputies are used to check
- Data recording,
- The behvarz’s knowledge,
- Drug supplies and equipment, and
- Work-related problems and suggestions identified by the behvarzs themselves.
A recent approach to CHW collaboration in Iran is the behvarz council, established in 2006 with the aim of engaging behvarzs in problem identification, problem solving, knowledge transfer, and policymaking. Behvarz councils have been established at different levels of the health system, from the local health center to the district, provincial, and national levels.
Behvarz council meetings are held on a regular basis to discuss a broad range of issues concerning the behvarzs’ work, such as recent policies, behvarzs’ viewpoints about in-service trainings, work-related problems, and recommendations to overcome problems. Meeting minutes and the final report are submitted to the higher-level council for further follow-up. Behvarzs’ representatives are responsible for transferring ideas and solutions to other team members and for following up on issues raised in the meeting.
How is the program financed?
Because the CHW program is an integral component of Iran’s PHC system, financing of these workers is stipulated by national health planning regulations.5
What are the program’s demonstrated impact and continuing challenges?
After almost 3 decades, the behvarz program in Iran has contributed to significant progress for many health indicators. In particular, the gap between rural and urban areas in terms of various morbidity and mortality indicators has narrowed considerably. IMR per 1,000 live births in 1976 was at 60.4 in urban Iran and 123.7 in rural Iran. Since the development of PHC and the behvarz program, the IMR per 1,000 live births in 2000 was at 27.7 in urban Iran and 30.2 in rural Iran, showing a distinct improvement.9
Studies have examined the job satisfaction of behvarzs and the contribution of behvarzs to rural health outcomes.10-14 It has been suggested that the significant improvement in rural health outcomes is strongly related to the performance of community-friendly health workers, although these improvements are unlikely to have been achieved through PHC alone; the period also saw economic growth, a rise in literacy rate, and improvement in environmental services such as access to safe water and sanitation.11 Common challenges cited by behvarzs included insufficient support systems; inadequate infrastructural support such as Health House facilities, physical space, and maintenance; lack of recognition by higher authorities; and the level of incentives.5 Despite formal supervisory mechanisms being in place, as revealed in policy documents, poor-quality supervision was one of the barriers reported by behvarzs. In most cases, supervisory teams do not provide sufficient technical and emotional support and give too much attention to deficiencies.
- NSSO. National Sample Survey 60th Round. Delhi, India: Ministry of Statistics and Programme Implementation, Government of India, National Sample Survey Organization (NSSO); 2006.
- WHO. Selected National Health Accounts Indicators: Measured Levels of Expenditure on Health 2003-2007. 2007. Available at: http://www.who.int/nha/country/nha_ratios_and_percapita_levels_2003-2007....
- Amini F, Barzgar M, Khosroshahi A, Leyliabadi G. An Iranian Experience in Primary Health Care: The West Azerbaijan Project. New York, NY: Oxford University Press; 1983.
- Ronaghy HA, Mehrabanpour J, Zeighami B, et al. The Middle Level Auxiliary Health Worker School: the Behdar Project. J Trop Pediatr. 1983;29(5):260-264.
- Javanparast S, Baum F, Labonte R, Sanders D, Heidari G, Rezaie S. A policy review of the community health worker programme in Iran. J Public Health Policy. 2011;32(2):263-276.
- Farzadfar F, Murray CJ, Gakidou E, et al. Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study. Lancet. 2012;379(9810):47-54.
- WHO. Strengthening the Performance of Community Health Workers in Primary Health Care. Geneva, Switzerland: World Health Organization; 1989.
- Javanparast S, Baum F, Labonte R, Sanders D, Rajabi Z, Heidari G. The experience of community health workers training in Iran: a qualitative study. BMC Health Serv Res. 2012;12:291.
- Aghajanian A, Mehryar AH, Ahmadnia S, Kazemipour S. Impact of rural health development programme in the Islamic Republic of Iran on rural-urban disparities in health indicators. East Mediterr Health J. 2007;13(6):1466-1475.
- Asadi-Lari M, Sayyari AA, Akbari ME, Gray D. Public health improvement in Iran—lessons from the last 20 years. Public Health. 2004;118(6):395-402.
- Mehryar AH, Aghajanian A, Ahmad-Nia S, Mirzae M, Naghavi M. Primary health care system, narrowing of rural-urban gap in health indicators, and rural poverty reduction: the experience of Iran. XXV General Population Conference of the International Union for the Scientific Study of Population; 2005; Tours, France.
- Mehryar A. Primary health care and the rural poor in the Islamic Republic of Iran. Scaling Up Poverty Reduction: A Global Learning Process and Conference; 2004; Shanghai, China.
- Movahedi M, Hajarizadeh B, Rahimi AD, et al. Trend and geographical inequality pattern of main health indicators in rural population of Iran. Hakim Research Journal. 2008;10(4):1- 10.
- Arab M, Pourreza A, Akbari F, Ramesh N, Aghlmand S. Job satisfaction on primary health care providers in the rural settings. Iran J Public Health. 2000;36(3):64-70.
m This case study was written by Zayna Chowdhury and Dena Javadi, students at the Johns Hopkins Bloomberg School of Public Health.