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Kate Hawkins, 23 June 214

We're really looking forward to the Health Systems Global Symposium, it's been in our calendars for some time. The conference is an excellent way to communicate the findings of our initial research and to create a demand for future research outputs, to network with other attendees, and to learn from new research which will be presented there. We have organised a panel session, Close-to-community providers and health systems: What are the implementation challenges and how can we overcome them? and we will be attending an event being run by the Thematic Working Group on Community Health Workers, which Lilian Otiso will chair.

Oral and poster presentations

We've recently heard that a number of abstracts that we submitted to the conference have been accepted. So we will be giving a range of oral and poster presentations. Details are below.

Oral presentations

Community Health Workers programs: Opportunities to contribute to broader social change

Sumit Kane, Hermen Ormel, Maryse Kok, Miriam Taegtmeyer, Sally Theobald, Lilian Otiso, and Korrie de Koning

Background: Community Health Workers (CHW) and other close to the community providers are increasingly a part of public health programs in low and middle income countries (LMIC). Central to most CHW program designs is a commitment to ‘Empowerment of CHWs’ and ‘Promotion of Social Equity’. We present here a critique of how these notions are operationalized in practice and reflect upon opportunities for improving CHW programs from different perspectives.

Methods: We present an analysis of the discourse encountered during a systematic review of literature on the design and functioning of CHW programs in LMICs (143 studies were included, double-read and analyzed), and 6 country case studies (Indonesia, Ethiopia, Malawi, Mozambique, Kenya, Bangladesh).

Results: ‘Empowerment of CHWs’ and ‘Promotion of Social Equity’ are discursive formations that are well entrenched in CHW program designs in LMICs but not systematically operationalized. CHW programs often fall short in empowering CHWs and challenging existing social and gender inequities. For instance, contrary to expectations, CHWs are sometimes selected by local elites andremain beholden to them. Gender roles, social expectations and relations, and incentive arrangements intersect to shape experiences of CHWs in different contexts. We found that CHW positions are often insecure and lack professional development opportunities. While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, inadequate attention is given to the experiences of CHWs themselves, both as health providers and as social beings.

Discussion: There is need to firmly move beyond a narrow and instrumentalist approach to CHWs. CHW programs must make explicit efforts to take a developmental and empowerment perspective when engaging with CHWs in order to empower and support this vital cadre and maximize their opportunities to contribute to social change, gender equity and people centered health systems.

Sharing learning on close-to-community health programmes across different contexts: A south-south technical assistance capacity building model

Yamin Tauseef Jahangir, Malabika Sarker, Ilias Mahmud, Sabina Faiz Rashid, Sally Theobald

Focus: There is increasing interest in the role of close-to-community (CTC) programmes in supporting people centred health systems. We need to better understand which approaches work best at-scale in different country contexts and are potentially transferable. The REACHOUT consortium (working in Bangladesh, Ethiopia, Kenya, Malawi, Indonesia, and Mozambique) aims to build capacity for research and delivery on CTC programmes through implementing and evaluating of two cycles of quality improvement (QICs) to strengthen CTC services in each context. Within REACHOUT country contexts there are diverse approaches to retention, motivation and supervision of CTC providers, mechanisms to support service quality and referral.

Purpose and significance for field building dimension: REACHOUT’s capacity development strategy includes South-south technical assistance to ensure that we build on the strengths and context embedded experiences of all partners in designing, implementing and evaluating the QICs. Here we report on the purpose of developing this novel south-south capacity building approach, the process of matching (following identification of strengths and weaknesses) carried out across and between partners and the learning and capacity development generated through immersion in diverse CTC programmes. For example, BRAC in Bangladesh can offer expertise in supervising, retaining and motivating community health workers through their extensive programmes of 97,000 shasthyashebika who have impacted on maternal mortality. Whilst Kenyan based LVCT can offer experience in community referral, and peer supervision with positive impacts on community based approaches to addressing HIV. REACHOUT partners (researchers, policy makers and practitioners) can visit and ‘immerse’ themselves in CTC programmes in other contexts to inform their own QICs. Following each south-south exchange, visitors and hosts will be asked to reflect on what they learnt through the process and implications for quality, effective and equitable CTC programmes within their own contexts. The target audience is people interested in capacity building models and/or CTC programmes.

Community based health systems in the urban slums in Bangladesh: What are the challenges, opportunities and links between formal and informal close-to-community providers?

Ilias Mahmud, Sally Theobald, Hermen Ormel, Bulbul Ashraf Siddiqi, Salauddin Biswas, YaminTauseef Jahangir, Malabika Sarker, Sabina Faiz Rashid

Background: Different types of formal and informal close-to-community (CTC) health service providers operate in Bangladesh. However, gaps remain in the evidence-base on the roles, responsibilities and performance of CTC providers. For ensuring quality of care understanding the inter-relationships between formal and informal CTC providers and their linkages in the context of community-based health systems is crucial, particularly in the context of urbanisation in Bangladesh.

Methods: We aimed to understand the context in which CTC providers operate in urban slums in Bangladesh with respect to sexual and reproductive health. We conducted a qualitative study including 12 focus group discussions with community (married) men and women, 32 semi-structured interviews with formal and informal CTC providers and 24 in-depth interviews with clients of menstrual regulation services (manual vacuum aspiration to safely establish non-pregnancy up to 8-10 weeks after a missed menstruation period).

Results: We found that informal CTC providers are well accepted in urban slums for all types of health problems. They are more acceptable to the community in terms of their availability, accessibility and affordability, for health seeking behaviour and treatment support while formal CTC providers remain as the second choice. Consequently, formal CTC providers have to work very hard to build rapport and gain the trust of community members; they face challenges of workload and limited incentives. In addition, limited training and supervision and absence of effective referral links between various health providers are the key areas that affect (formal and informal) CTC providers’ performance in the field of sexual and reproductive health.

Conclusion: The unsystematic nature of the Bangladeshi health system creates segregation between formal and informal providers. Establishing closer communication, coordination and appropriate referral between formal and informal CTC providers is required to build more effective and equitable community health systems in urban slums in Bangladesh.

Poster presentations

Community, provider and policymaker perceptions of community health policy in Kenya: implications for policy change

Rosalind McCollum, Lilian Otiso, Maryline Mireku, Sally Theobald, Korrie de Koning, Miriam Taegtmeyer

Background: Global interest and investment in close-to-community health services is increasing and Kenya are presently revising their Community Health Strategy (CHS) alongside political devolution, which will result in re-visioning of responsibility for local services at County level. This paper aims to explore drivers of policy change from key informant perspectives and to study perceptions of current community health services from community and district level, highlighting implications to inform unfolding discussions for managing policy change.

Methods: We conducted forty in-depth interviews and ten focus group discussions with a range of participants to capture plural perspectives, including those who will influence or be influenced by CHS policy change in Kenya (policy makers, district health management teams, facility managers, Community Health Extension Worker (CHEW), Community Health Workers (CHW) and community members) in two purposively selected counties: Nairobi and Kitui. Data was digitally recorded, transcribed, translated, and coded prior to framework analysis.

Results: There is widespread community appreciation for the existing strategy. High attrition, lack of accountability for voluntary CHWs and lack of funds to pay CHW salaries, combined with high CHEW workload are seen as main drivers for strategy change. Areas for improvement identified include: lack of clear supervisory structure including provision of adequate travel resources, current uneven coverage of community health services, limited community knowledge about the strategy revision and demand for home based HIV testing and counselling (HBTC).

Conclusion: Recommendations are provided to raise awareness of strategy revision, strengthen supervisory systems, monitor and address equity concerns including coverage, pilot HBTC and build the engagement of communities with the revised strategy to increase social accountability. These recommendations seek to inform the process of policy management to contribute towards a more people-centred health system for improved equity, effectiveness and success of policy change through the roll-out of the revised strategy.

Barriers to acceptance and utilisation of skilled birth attendants in 16 villages in South West Sumba and Cianjur districts, Indonesia

Sudirman Nasir^,Rukhsana Ahmed, Ralalicia Limato, Miladi Kurniasih,Korrie de Konning, Olivia Tulloch, Din Syafruddin

Background: Indonesia has developed a strategy to ensure skilled birth attendance by the Village Midwifery programme implemented in 1987. Yet the utilisation of skilled birth attendants in SW Sumba and Cianjur is moderate (46% and 60% in each province) with deliveries by traditional birth attendants (TBA) persisting. We explored the reasons for TBA utilisation.

Methods: We conducted a total of 110 semi-structured interviews and 7 FGDs amongst informants in 8 villages in South West Sumba, a predominantly Christian rural Island and 8 villages in Cianjur, a predominantly Muslim, peri-urban district in East Java. The informants included village midwives/nurses, ‘Posyandu kaders’ (village health volunteers), TBAs, mothers and husbands, village heads and district health officials.

Findings: TBAs are preferred because of convenience, close proximity and ease of contact and their adherence to traditional practices. The lack of responsiveness to local traditions, distance, cost of travel and perceived indirect costs were reported as barriers to attend health facilities for childbirth. Most informants appreciated improved quality of birth care provided by the midwives. The limited presence of midwives in their assigned village, and difficulties contacting them during labour were reported by many community informants as what hindered midwife use at childbirth. Some differences exist between the two districts which affected the midwives and TBA service delivery: in Cianjur TBAs receive greater incentive and are more empowered, whereas in SW Sumba TBA practice is not formally permitted under the recent maternal health revolution initiative and incentives provided to midwives through the new health insurance schemes are not consistently applied.

Conclusion: Strategies to get midwives to reside in villages, easier contact and community health education strategies to address cultural practices could increase midwife use and health facility attendance for childbirth. Formulating ways to improve collaboration between TBAs and midwives could benefit pregnancy outcome in rural Indonesia.

Which intervention design factors influence performance of Community Health Workers in low and middle income countries? A systematic review

Maryse Kok, Marjolein Dieleman, Miriam Teagtmeyer, Jacqueline Broerse, Sumit Kane, Hermen Ormel, Mandy Tijm and Korrie de Koning

Background: Community Health Workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle income countries (LMIC). Many factors influence CHW performance; particularly the design of community-based health programs and interventions. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs.

Methods: We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMIC. 140 studies were included, double-read and analysed. An initial framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the search and the review. This framework was finally refined based on review findings.

Results: Intervention designs which involved remuneration, frequent supervision and continuous training led to better CHW performance in certain settings; however, performance-based incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which included non-financial incentives, community involvement and strong links with health professionals improved CHW’s motivation and positively affected their performance. Training and supervision were frequently mentioned but few studies tested which approach worked best.

Discussion and Conclusion: When designing community-based health programs, factors that increased CHW performance in comparable settings should be taken into account. A for the CHW predictable mix of financial and non-financial incentives is an effective strategy to enhance performance of CHWs, especially those with multiple tasks. Embedment of CHWs in community and health systems diminishes workload and increases credibility. Clarity on roles and introduction of clear processes for communication between different levels can strengthen CHW performance. Additional intervention research to develop a greater evidence base for the most effective training and supervision mechanisms and qualitative research to inform conditions for scaling up interventions are needed.

Factors Influencing Maternal Health-Seeking Behaviour in Rural Ethiopia: What are the opportunities for strengthening community-based health systems?

Aschenaki Zerihun, Olivia Tulloch,Daniel Gemechu, Maryse Kok,

Introduction: Many countries are investing in community-based health systems and community health workers. Ethiopia has high maternal mortality and low maternal health service utilization. In 2004 Ethiopia launched a Health Extension Program (HEP) which focuses on providing promotive, preventive and some basic curative health services to the community, including maternal and child health. In order to increase maternal health service uptake, we need to understand factors influencing health-seeking behaviour. This study aimed to identify community-related factors which affect maternal health-seeking behaviour in order to develop a quality improvement cycle to strengthen community-based approaches in Southern Ethiopia.

Methods: The study comprised a desk review and qualitative research. Primary data were collected at community level in 8 Focus Groups Discussions (FGDs) with women or men, 21 interviews with women, Kebele administrators and traditional birth attendants; provider level in 6 FGDs and 12 semi-structured interviews with health extension workers; 11 key informant interviews were conducted with health extension program coordinators, health centre heads and delivery case team leaders.

Results: Multiple factors affected low uptake of maternal health services. Individual factors: prioritization of domestic or agricultural activities, desire to have more children, low perception of risks during pregnancy and delivery; family factors: lack of support from husbands, conflating advice from influential relatives; cultural practices: non-disclosure of early pregnancy, burying the placenta at home. Other barriers related to the health system/sector: lack of privacy, unwillingness to be seen by unacquainted health-workers, use of a delivery couch, worry about unfamiliar health facilities.

Conclusion: Attempts to strengthen community-based maternal health services should be responsive to factors influencing health-seeking behaviour. Targeted awareness creation and community mobilization, specific training and support of HEWs to help women and their families to better negotiate the multiple barriers to care may improve service utilization as part of a quality improvement package.

Integration of vertical programmes in response to community need: Integrating HIV testing into Kenyan community health systems

Otiso, Lilian, Mireku, Maryline^, McCollum, Rosalind, Kiruki, Millicent, Karuga, Robinson, de Koning, Korrie, Taegtmeyer, Miriam

Introduction: The call for integration of HIV into other health services is strengthened by the current context of scale-up, sustainability and reduced donor funding. HIV programs in Kenya, an HIV endemic country, with 53% HIV positive individuals untested, are vertical, often run by non-governmental organizations. The Kenya community health strategy (CHS) defines service provision at household level and offers potential for such integration. We sought to identify opportunities and constraints for the integration of home-based HIV testing and counselling (HBTC) within the broader CHS to improve acceptability and performance of community based services.

Methods: We conducted a context analysis using qualitative research in peri-urban Nairobi and rural Kitui, exploring community and provider perceptions of integration. We carried out 40 in-depth interviews with policymakers, district and facility managers, and 10 focus group discussions with community health extension workers (CHEWs), community health workers (CHWs), HBTC providers and community members. We specifically asked about current practice and the need, willingness and concerns around HBTC service integration. Data was digitally recorded, translated, transcribed and coded in Nvivo10 prior to framework analysis.

Results: HBTC is offered in the community by NGO-employed HBTC lay counsellors as a vertical program that is not part of the current CHS. Policymakers expressed a strong desire to have CHWs trained to offer HBTC in households. There was enthusiasm and willingness among community members who stated that this would increase access to testing of men. Some concerns about stigma and confidentiality remained among all respondents who stated that training on confidentiality was required.

Discussion/Conclusion: Our findings reveal community demand for integrated HBTC at household level that is endorsed by providers and policymakers and practical suggestions on how to overcome challenges in implementation, give potential for leveraging existing funding and expertise to meet community needs and national health priorities.

An assessment of Health Extension Workers’ linkages with community and health system: opportunities for strengthening community-based health systems in Ethiopia

Maryse Kok, Aschenaki Zerihun, Daniel Gemechuand Olivia Tulloch

Background: Health Extension Workers (HEWs) in Ethiopia have a unique position, as they connect the community to the health system. Qualitative research was conducted in southern Ethiopia to understand linkages between HEWs, the community and health system, in order to inform policy on optimizing HEW performance, specifically in maternal health.

Methods: We conducted six Focus Groups Discussions (FGDs) and 12 semi-structured interviews with HEWs and 14 interviews with key informants working in administration, curative services and supervision of HEWs. At the community level, we conducted eight FGDs with women or men, 12 interviews with women and six with traditional birth attendants. Interviews were recorded, transcribed, translated, coded and thematically analysed.

Results: HEWs had two-directional linkages with the community and health system. The most important linkages were related to referral, supervision, monitoring and support. The Health Development Army (HDA), a community-based structure supporting HEWs, identified pregnant women. HEWs referred high-risk cases to a health facility, with generally appropriate responses, although procedures were not standardized and there was no referral tracking mechanism. Supervisory structures of HEWs recently changed, leading to lack of clarity regarding roles in some settings. Supervision was found to focus on record checking and little on problem solving and learning. Involvement of the HDA in HEWs’ activities was not established everywhere. Health professionals, administrators, HEWs and community members occasionally met in special meetings to monitor HEW performance and program needs.

Discussion and Conclusion: HEWs’ intermediary position between the community and health system improves access to health services, but could be challenging for HEWs with regard to responsibilities and accountability towards both levels. Clearly defined roles and responsibilities at all levels and standardized support and communication mechanisms could facilitate HEWs in maximizing the value of their unique position, in order to improve their performance.

Role of village health volunteers (Posyandu kaders) in maternal and child health program as a link between health systems and community in Indonesia

Ralalicia Limato,Rukhsana Ahmed, Miladi Kurniasari, Sudirman Nasir, Olivia Tulloch, Korrie de Koning, Din Syafruddin

Background: Integrated health service post (posyandu) is a community-driven health effort to facilitate the community to access basic health services. Efforts to improve the function of posyandu is the responsibility of both government and community, including village health volunteers (kaders). Kaders were trained to engage in Posyandu activities: antenatal and postnatal care, child growth monitoring and immunization. We examined their role to deliver health promotion and preventive services to the community with a focus on maternal and child health.

Methods: Using a qualitative study we obtained information on kader selection, training and their tasks in Posyandu. Trained staff visited 8 villages in SW Sumba and Cianjur district and interviewed kaders, village midwives, mothers, Traditional Birth Attendances, and heads of village using semi-structured interviews and focus group discussions in September and December 2013.

Findings: The main role of the kaders is to organize Posyandu, weigh children, assist with registration and provide health education. They also encourage pregnant women to attend health facility for deliveries, do postnatal care visits, and advise on family planning. Overtime their role has expanded and in Cianjur some kaders are trained to assist midwives during delivery and in neonatal care. Kaders are mostly chosen by the village elite. This practice is changing by the village midwives who increasingly chose kaders to assist them. Although kaders are volunteers provided with modest financial incentive, most expressed recognition of their work and appreciation by the community as the most important motivational factor.

Discussion: We found that the kaders are the main agents of health promotion and prevention services in the community and are responsible for community mobilization and Posyandu activities. However, more attention needs to be given to their role as agent of change that could be used as the prime link between the health system and the community.

Challenges of Supervising Community Health Service Providers: A Context Analysis of the Kenyan Community Health Strategy

Maryline Mireku, Millicent Kiruki, Lilian Otiso, Robinson Karuga, Rosalind McCollum, Miriam Taegtmeyer, Korrie de Koning

Background: Supervision is widely presented in policies and literature as an important factor for ensuring quality of providers output. The Kenyan Community Health Strategy (CHS) is a program through which the government provides guidelines for provision and supervision of community health services. It states that Community Health Committees (CHC) and Community Health Extension Workers (CHEWs) are designated supervisors of volunteer community health workers (CHWs) while District Health Management Teams (DHMTs) are CHEWs’ supervisors. We present findings of challenges faced in supervision of community health providers in the current Kenyan CHS.

Methods: We collected data through a qualitative study in an urban slum and a rural district of Kenya. We purposefully selected 179 participants and conducted 10 FGDs and 40 IDIs. Digitally recorded data was transcribed and translated where applicable. Data was coded and analyzed using Nvivo10.

Results: Supervision emerged as a factor motivating CHWs and CHEWS in addition to the positive health changes brought about by the CHS. Health system challenges hindering effective and consistent supervision were: lack of clear guidelines; inadequate transportation mechanisms and high workload especially for CHEWs who had dual roles as health facility and community based providers. There was emphasis on reporting tools in CHS program but providers’ performance measurement tools were generally lacking except in programs with NGOs involvement. It was unclear who directly supervised CHWs between the CHEWs and CHCs. CHEWs did not adequately supervise community engagement especially in relation to HIV and sexual health services provided by CHWs.

Discussion/ Conclusion: Our findings underscore the need for development and operationalization of supervision guidelines and performance appraisal tools to ensure adequate and standardized supervision in CHS. The supervisors in turn need support from CHS coordinators through continuous capacity building and adequate planning for resources which should also aim at relieving CHEWs of the dual roles.

Voices and experiences of front line health workers in Malawi: Strategies and opportunities to better support community based health systems

Lot Jata Nyirenda, Kingsley Chikaphupha, Sally Theobald, Maryse Kok, Ireen Namakhoma

Background:Malawian Health Surveillance Assistants (HSAs) play a key role in delivering health services at the front line in communities in a broader national context of acute shortages of human resources for health. This study aimed at understanding and analysing the perspectives and challenges faced by HSAs, bring their voices into the debate on health systems and into the design of ongoing quality improvement cycles in order to strengthen community-based health systems.

Methods: Qualitative research using focus Group Discussions and semi-structured in-depth interviews was conducted in two districts in the central region of Malawi: Mchinji and Salima. Study respondents included: mothers with children under five years of age, health workers including HSAs officials working for the District Council and non-governmental organisations. A stakeholder analysis was also conducted and fed into the qualitative analysis process.

Results: HSAs play a pivotal role as a bridge between health systems and communities. Challenges faced by HSAs include: the role of allowances and the need for coordination, support and supervision. Incentives were motivating; HSAs who felt side-lined by those in charge of allowances opted not to dedicate themselves to the tasks at hand but seemed more devoted to activities that promised more allowances. Supervision structures for HSAs were in place;howeversupervision was mostly not done due to inadequate financial and human resources. Most HSAs reported getting feedback only when something went wrong with their work. Supervision was uncoordinated, was mostly one-way and unsupportive.

Conclusion: HSAs are embedded at community level play a vital role in linking health systems and marginalised communities. Their voices and experiences need to be considered and acted upon to build equitable and sustainable community based health systems. There is a need to address the multiple concerns of HSAs through coordination,transparent and accountable approaches to incentives and supportive supervision.

We will provide more information on the scheduling and location of these sessions when the conference organisers make them available.

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