Primary Health Care Program: Global Context
   
As far back as 1978, the Alma Ata Declaration highlighted the need for attention to the health workforce, noting that primary health care “relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.” It is widely recognized (1-4) that Community Health Workers (CHWs) (referred to here as broad range of community based health workers and volunteers) have high value as trusted providers, communicators, facilitators and enablers who are permanent members of the health team. This has been the basis for renewed interest and targeted investment in scaling up CHW programs. Governments, multilateral agencies, donors, and NGOs have seen the potential of CHWs in reducing the gap between the local communities on the one side and the facility-based health services on the other. What has received less attention is how to develop and manage CHW teams in a systematic and collaborative approach that will create synergies and will contribute to sustainable scale-up rather than fragmentation and duplication between different short-term initiatives.

Primary Health Care Program: Tanzania Context

Tanzania has been committed to fighting poverty and disease since its independence in 1961. The Arusha Declaration in 1967 strengthened that commitment, making health care services free for all, emphasizing self-reliance and self-determination. In 1978, following the Alma Ata declaration, Tanzania was among the first few countries to embark on the development and implementation of the Primary Health Care (PHC) strategy (5). Tanzania spearheaded the ‘Health for All’ approach by massively expanding first line health services. According to the Primary Health Services Development Programme (2007-2017), the goal was to expand health services by adding at least one health center to every ward and at least one dispensary to every village by 2017. Access and equity in health care have, therefore, been a driving principle in the implementation of the national health policy (5), with particular emphasis on self-reliance through community mobilization.
In 1983, PHC was adopted by the Government of Tanzania as its main strategy for improving access to, and, equity of, health services. The strategy emphasized community participation and overall community development with Village Health Workers (VHWs), the key service providers at the community level. These health workers were intended to provide a link between community-based health care and formal health services. After five years of implementation, the village health worker program was evaluated and a number of gaps were identified. This evaluation resulted in the formulation of the first Community Based Health Care (CBHC) guidelines in 1992. During that year the PHC strategy document was also produced, advocating for political commitment and involvement of all sectors, beyond health. Implementation of the CBHC approach, however, remained fragmented and mostly donor-dependent; limiting the potential to optimize access and effective linkages.

Momentum Towards a Nationally Integrated CHW Cadre

Given the existing presence of uncoordinated CHW programs in different regions, there is wide consensus among stakeholders that its health sector develop and implement a general, multi-purpose CHW cadre. One of the major benefits of a general CHW cadre would be the institutionalization and integration of this cadre into the health system in an effort to standardize practice throughout the country and strengthen policies for remuneration of services. While many government officials and development partners have supported this vision, the exact pathway to get there has been rather nebulous. A critical question for the Tanzanian health sector has been whether one CHW would be able to address all the needs of an integrated maternal neonatal child health (MNCH), HIV/AIDS, and nutrition program. To date, the majority of CHWs working throughout the country have been engaged in multiple community programs. However, their capacity (i.e., education level) and motivation to provide a broader range of services is unknown.

Development of the CHW Task Force

Over the past 3 years, the MOHSW, development partners, and donors have been engaged in discussions on how to determine and develop an optimal CHW model for Tanzania. In August 2012, the MOHSW organized a stakeholders’ workshop on CHW initiatives to explore sustainable ways to promote community health in Tanzania. Based on recommendations emergent from the workshop, the MOHSW established a CHW Task Force to advise the Ministry on matters related to community-based heath services in line with the health sector policy, strategies, plans, and guidelines. The goal of the National CHW Task Force since has been to administratively and technically guide the development of a national program for CHWs that accounts for a variety of needs and experiences on the part of health providers. Membership has included MOHSW officials, donors, development partners, academics, and consultants with expertise in this field. Task Force members were nominated and approved and they convened for the first meeting on April 4, 2013. Under the leadership of Ms. Helen, Semu (Health Promotion and Education Section, Department of Preventive Services, MOHSW), the group has met continuously since its inception to strategize the scope of CHW curriculum, training, and practice, and how best to transition from the existing system of varied CHW initiatives to a coherent multi-purpose CHW program. As scale-up plans are developed for community-based programs, establishing appropriate supervision and support systems, incentive structures, and linkages with health facilities and health management information systems (HMIS) will be critical components of such a program.