Community health volunteers as mediators of accessible and responsive community health systems: lessons from the Health Development Army in Ethiopia (360G-Wellcome-110322_Z_15_Z)

Faced with chronic health worker shortage, many LMICs have invested in community health workers to extend and enhance health care in low-resource settings. This project examines the role of the Health Development Army (HDA), a large multi-purpose cadre comprising locally-recruited and trained community volunteers in Ethiopia, intended to mobilise communities, that complements the existing cadre of more highly trained Health Extension Workers (HEW), with the HDA acting as intermediaries between formal PHC services and the communities they serve. A better understanding the HDA experience offers a means to gain important insights into ways to use community volunteers, working across sectors, to support participatory models of grassroots PHC that both enhance access to care and address the social determinants of health. The project asks first: what role does the HDA play (who are they? what roles do they assume in their communities? How are they perceived by their communities and the health care providers with whom they interact, including the HEW (examining trust, power and knowledge imbalances)? What factors - within and beyond -health systems facilitate or obstruct their activities)? Second, what are the conditions that may increase their potential to improve access to care and address health determinants, including those that lie within the purview of other sectors? Based solidly on theory, it employs a mix of qualitative research methods and is set in one of the Ethiopian regions that pioneered the HDA concept. Evidence generated by the project will exploit a window of opportunity to inform policy in Ethiopia, addressing a recognised need to understand the contributions of the HDA and their relation with the HEW and PHC structures, as well as the scope for expansion to support hard-to-reach populations. It also addresses a growing international interest in the role of community health workers as part of a package of low cost, responsive PHC models.