Bringing Primary Care to the Village

China formalized this program nationwide from 1968, training farmers and other rural residents in basic preventive and curative medicine, immunization, first aid and family planning so they could serve part-time as health workers in their own villages. Many kept farming and were paid partly through their home agricultural collective. The program is credited with helping inspire the World Health Organization's 1978 Alma-Ata Declaration on primary health care.

In the early 1980s the Bangladeshi organization BRAC shifted away from paramedics modeled on China's barefoot doctor approach and began training local women as Shasthya Shebikas. These volunteers earn no salary, instead making small profits from health products and receiving incentive payments tied to specific services. Their numbers grew from 1,080 in 1990 to roughly 43,000 in the source's later count.

Cuba's family doctor and nurse program began as a pilot on January 4, 1984, at a polyclinic in Havana's Lawton neighborhood. Here the community worker is a trained physician and nurse team, with each family doctor-and-nurse office caring for 20 to 40 families and reporting to a community polyclinic. The program was extended across the country before the end of 1984.

Indonesia's Posyandu, short for Integrated Service Post, was formally recognized by the Ministry of Health in the mid-1980s. Volunteer community workers called kaders staff village posts that each serve about 100 children under five, or about 700 residents. Its stated goals were to lower infant and child mortality, improve family planning acceptance and nutrition, and empower the community.

Developed by the World Health Organization and UNICEF beginning in 1992, this strategy gives first-level health workers one protocol to assess a sick child, classify severity, and treat or refer. It shows the community worker model moving from single villages to an international standard, adopted in some form by more than 100 countries. Evaluations found real gains in care quality but effects on child mortality that were harder to isolate.

Brazil created the Family Health Program in 1994 and renamed it the Family Health Strategy in 2006, when it became the organizing structure of primary care in the public Unified Health System. Each team, typically a physician, a nurse and several community health agents, is responsible for a defined geographic population, and the agents visit every household in their area on a regular schedule.

Ethiopia's Health Extension Program, launched by the Federal Ministry of Health in 2004, assigns two salaried Health Extension Workers to each kebele, the lowest administrative unit, to provide education, immunizations and curative services. By 2010 the program had trained 33,819 workers, who were deployed to reach an estimated 89 percent of Ethiopian communities.

India launched the National Rural Health Mission in 2005 with a nationwide cadre of village-level Accredited Social Health Activists, known as ASHAs, who link villagers to government services and promote institutional delivery and immunization. It was folded into the broader National Health Mission from 2013, and reviews have also documented continuing gaps in staffing, infrastructure and medicine availability.