Rural Community health workers (Behvarzes): a strategy to ensure access to equitable primary health care services in rural areas of Iran
The Alma-Ata Declaration of 1978, which was endorsed by the WHO and its member state, emerged as a major milestone of the twentieth century in the field of public health. The declaration marked a global recognition that health and access to primary health care (PHC) are fundamental human rights and it identified PHC as the key to the attainment of the goal of "Health for All by the year 2000".
Report from: Zahedan University of Medical Sciences, Vice Chancellery for Health
Published on: 3 September 2020
The Alma-Ata Declaration of 1978, which was endorsed by the WHO and its member state, emerged as a major milestone of the twentieth century in the field of public health. The declaration marked a global recognition that health and access to primary health care (PHC) are fundamental human rights and it identified PHC as the key to the attainment of the goal of "Health for All by the year 2000".
Declaration of Alma-Ata (1978) defines the concept of primary health care (PHC) with focus on four principles of social justice, social participation, interdisciplinary participation and appropriate technology. The Primary Health Care (PHC) approach, identified in the Alma Ata conference in 1978, stressed the role of Community Health Workers (CHWs) in addressing community health needs. Training of CHWs is one of the key aspects that generally seek to develop new knowledge and skills related to specific tasks and to increase CHWs" capacity to communicate with and serve local people.
In line with fulfilling the Alma-Ata vision, Islamic Republic of Iran has showed remarkable achievements toward this goal. In 1981, a PHC development program was piloted in the Western Azerbaijan province, and expanded to all other provinces in 1983, that had focused strongly on PHC. The plan emphasized on community participation and inter-sectoral cooperation in offering PHC services.
Recognition of the CHW program and their training in the national health planning and financing facilitates the implementation and sustainability of the program. The existence of specialized training centers managed by district health network provides an appropriate training environment that delivers comprehensive training and increases CHWs" knowledge, skills and motivation to serve local communities.
WHO in its World Report 2008, has stated that Iran is one of the successful example in the world for implementation of PHC. In 2016, Bloomberg News ranked Iran 30th most efficient healthcare system ahead of United States and Brazil. The significant primary healthcare advances in Iran has taken place through a multi-tiered network of health centers, starting form health houses in rural areas and health posts in urban areas, to health centers and district teaching hospitals. The Iranian public sector has provided PHC services to even its most rural populations via health houses staffed with Rural community health workers (Behvarz). The wide range of PHC services in Iran has been complemented with impeccably recorded data. The universities of medical sciences, of which one exists in each province, play an important role in medical education and in the provision of health services.
Locally sourced community health workers (behvarz) from the Farsi words beh (good) and varz (skill) were originally trained to meet the basic health-care needs of people living in rural areas. A female behvarz was responsible for, among other things, child and maternal health; a male behvarz for sanitation and environmental projects (1).
Working in pairs out of modest, village-based facilities, the Islamic Republic of Iran"s trained community health workers, the behvarz, provide basic health care to most of the country"s rural population. The Iranian health houses, conceived and introduced during the 1980-1988 war with Iraq, have been at the center of a so-called master plan to bring health care to every district. People enjoy primary health care services free of charge. The health workers are well familiar with the culture and traditions and that is a big advantage (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. Today 17,000 Health Houses serve 23 million rural Iranians. 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 (2).
Iranian CHWs have an in-depth understanding of health, including its social determinants, and are responsible for a wide range of activities. Trust-based relationships with rural communities, an altruistic motivation to serve rural people, and sound health knowledge and skills are the most important factors facilitating successful implementation of the CHW program in Iran (3).
Behvarzes are trained in areas such as maternal and child health, communicable diseases, and environmental health. More recently, CHW curricula have begun to emphasize subjects like non-communicable diseases, school health, and oral health, amongst others. This shift shows how the behvarz are responding to the changing needs of the communities they serve. Perhaps the most important characteristic of Iran"s behvarz is the way in which they are successfully integrated into Iran"s primary health care (PHC) system. CHW programs are planned, implemented, and supervised by provincial and national teams. This means that the programs are recognized in national health planning, policymaking, and financing (4).
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 (2). The health status of Iranians has improved over the last 40 years. For instance, maternal and child mortality rates have fallen significantly, and life expectancy at birth has risen remarkably to a regionally high level of 74 years.
Iran"s CHW program is notable for three main reasons: strong pre- and in-service training, a changing catalog of services that reflects the needs of the communities they serve, and thorough integration into the country"s PHC system. Community health programs everywhere should take a leaf out of Iran"s book. Although CHW programs vary by country and context, the CHW training program in Iran offers transferable lessons for countries intending to improve training as one of the key elements in their CHW program.
References:
1. World Health Organization. Iranian health houses open the door to primary care: World Health Organization,; 2008 [Available from: https://www.who.int/bulletin/volumes/86/8/08-030808/en/.
2. Chowdhury Z, Javadi D. IRAN"S COMMUNITY HEALTH WORKER PROGRAM 2020 [Available from: https://chwcentral.org/irans-community-health-worker-program/.
3. Javanparast S, Baum F, Labonte R, Sanders D. Community health workers" perspectives on their contribution to rural health and well-being in Iran. American journal of public health. 2011;101(12):2287-92.
4.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 services research. 2012;12:291.
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