Village health workers in Java, Indonesia: Coverage and equity

Village health workers are often the main vehicle for promoting the primary health care approach in developing countries. Services provided by these workers are expected to be more appropriate to the health needs of populations than those of clinic-based services, to be less expensive and to foster self-reliance and local participation. Because village workers are more accessible and acceptable to clients in their communities, they are expected to improve the overall coverage of services as well as equity--increased service use by poorer individuals and households. This paper presents research on coverage and equity from village health worker programs in Java, Indonesia. Rural health and nutrition projects in Java using village-level volunteers with limited training have grown since the early 1970s to include large national programs managed by the government's rural health system. Volunteer village workers are now the most extensive link between the rural population and the formal health service structure. Previous research on coverage and equity of these village worker activities is reviewed and results from the author's own study are presented. Services provided by village health workers achieve significantly higher levels of population coverage than similar clinic-based services. In most cases, village workers show no bias towards better-off clients and they may favor poorer beneficiaries. These findings show that village workers are meeting the coverage and equity objectives of the primary health care approach. However, some of the research reviewed raises questions about the ability of village worker activities to maintain these results over a longer period. The rapid expansion of these programs requires continued research, not only on coverage and equity, but also on health outcomes, costs, and participation.