An interview with Dr. Ram Shrestha:Supporting Community Health Workers- Where do we stand?

Rhea Bright

Quality Improvement & Human Resources for Health Advisor, USAID Bureau for Global Health Office of Health Systems

In this post, Rhea Bright interviews Dr. Ram Shrestha.

As a health professional, whenever I visit a rural village in a low-or middle-income country, several thoughts come to mind. Knowing that the formal health system usually ends at a health center, dispensary, or health post in these rural communities, does everyone in this village have access to health services? How can we ensure that there are enough health workers in nearby facilities to provide needed services? Are there community health workers (CHWs) in this village, and are they well supported? I started thinking more and more about these questions as World Health Worker Week (April 7-11, 2014) approached…consequently even more questions came to mind.

As I thought through these questions, I decided to interview my colleague, Dr. Ram Shrestha, a community health expert. Dr. Shrestha is known across the globe for his vitamin A work in Nepal. Don’t believe me? Google, “Vitamin Sherpa.” Here’s what he and I discussed:

In our efforts to achieve universal health coverage (UHC), how are we doing when it comes to making sure that everyone has access to affordable health care services that meet their needs?

Dr. Shrestha: In order to ensure access to health services, many governments are using CHWs as a means to achieving UHC. Even though CHWs have been successful in creating awareness, physically one or two CHWs cannot provide all households with the necessary primary health care services. We need to look at ways to support CHWs in meeting the health needs of people in their community.

I know that your Vitamin A work in Nepal was very successful in supporting Female Community Health Volunteers (FCHVs) to reach all children throughout the country with Vitamin A capsules. What lessons can you share from your experience that may help other countries in supporting CHWs to extend health services to all households?   

Dr. Shrestha: From my previous work experience in Nepal, I found that support from family members, community groups, local leaders, and schools were a main contributor for FCHVs to reach more than 90% of the children with Vitamin A capsules. Similarly, in other countries, I found that community support has helped CHWs to not only create awareness, but to deliver simple health services to all households. 

Can you explain how community groups and family members are able to support CHWs?  

Dr. Shrestha: From my work, I noticed that CHWs require support from the community, specifically, from patients and their family members. Observing the way that people in rural villages support each other during social events (e.g. weddings, ritual ceremonies, etc.), disasters (e.g. fires, floods, etc.), and everyday communication, I saw that there is a system which we may not notice as an outsider. This system is an informal community system that villagers use to address issues in their community.

I found that almost everyone in a village belongs to a group (i.e. savings & credit; religious; teachers; women’s groups), where they seek help and share information. These groups function as a component of the community system, which can be leveraged to support CHWs to reach all households with health messages.

How does the informal community system help CHWs?

Dr. Shrestha: In these rural communities there are usually village committees. These committees provide operational management of the community system. I found that these committees are made up of members from various community groups in their respective villages. I thought that community committees would be useful in supporting CHWs to reach all households because of the representation from the various community groups.  

The way that this informal community system helps CHWs is that it creates a channel of information flow from the health center to the households. During the village committee meeting, CHWs share health information with representatives of various community groups. The group members go back to their homes and share the information with members of their households. Similarly, group members can gather information from their households and bring it back to the village committee, where CHWs compile those data to bring to the health facility.

Can you give me an example of a program where community groups have supported CHWs to increase service coverage?

Dr. Shrestha: In Muheza, Tanzania, we found that after community groups supported CHWs to spread health messages to their households about the importance of testing for HIV, there was a significant increase in the number of men and women tested at the health facility (See image below).

Client HIV Testing in Mkuzi and Kilulu Communities in Tanzania

Has support from community groups improved the motivation and performance of CHWs?  

Dr. Shrestha: In Ethiopia, after community groups began supporting Health Extension Workers (HEWs) to identify and refer pregnant women for antenatal care (ANC) services, HEWs expressed to me that now they feel that there is not a member of a household who cannot be reached. Each community group member knows who is pregnant in their household and who they referred to ANC services. A client even told me that the HEW is like a friend, and that she does not find it difficult to share every problem that she has with the HEW because the HEW either helps her or takes her to the health facility.   

The lesson for all of us is to move away from individual and ad hoc group support to CHWs.  In order to achieve universal health coverage, we should use the existing community system to support CHWs in extending health services to all people in need of health care. 

To learn more about the Rx for Survival Project and PBS television broadcast, click here

Related Countries: 


I agree with Dr Shrestha because since January 2014 we began a community PMTCT demonstration Project in Burundi by improving performance of ASC (CHW) by strengthening Community System to improve PMTCT services and now we can see that for example the number of pregnant women identified in the community is significantly increasing because of the support of the community group members ; the number of pregnant women receiving ANC services at the health facility is also increasing. The informal community system is also a reality in Burundi.

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