APE in mozambiqueBy Maryse Kok and Korrie de Koning, 18 April 2014

One of the main tasks that REACHOUT has been working on over the last year is the context analysis. Comprised of an international literature review, six country desk studies and six country qualitative studies, the context analysis has enabled us to identify what factors facilitate and undermine effective, efficient and equitable close-to-community (CTC) health services. This blog is an attempt to pull together some of the findings which are emerging so far. Our work is preliminary as further analysis is currently underway and we will be formally publishing the report later this year.

Policy and governance issues

In all countries a policy on close-to-community providers is available, apart from Bangladesh. In Ethiopia, Malawi and Indonesia there is a lack of policies for Traditional Birth Attendants (TBAs) (they are officially banned), which is problematic given their still existing role in supporting women through pregnancy and childbirth.

In terms of governance, in many cases structures and systems to support close-to-community providers are not in place or are not operational: for example, there is weak coordination (particularly in Kenya, and Malawi); in Kenya and Indonesia health system devolution or decentralisation of decision making and funding is an issue, as there is uncertainty about how this will effect CTC programmes. In many settings there is a drive to professionalize CTC programmes and to embed them in the health system; this could have implications for equity and the role of communities.

In countries such as Kenya and Malawi, a lack of coordination across different projects, for example between programmes run by various NGOs, has implications for workload and may create competition across different programmes and health issues, as some CTC providers are paid and some are not. Mozambique faced the same problem but the government has taken more control to address this. Coordination and communication across different CTC providers and between CTC providers and professional health staff can lead to improved performance. For example, in Indonesia coordination between midwives, kaders and TBAs facilitates referral and utilisation and the same is true in Ethiopia, where regular meetings between Health Extension Workers (HEWs) and Kebele and Woreda level staff facilitates the performance of CTC providers.

The role of community

Community engagement can facilitate support and increase respect for CTC providers and programmes. It can facilitate strong feelings of community ownership of a programme, such as in Mozambique where the community plays an active role in choosing the Agent Polivalente Elementar

(APEs). However, related to selection of CTC providers, in some cases it is either community leaders or health systems actors who make the decisions and comprehensive community involvement is not forthcoming.

When the community is resistant to CTC programmes this can be a barrier to good work. For example, in Kenya there was some community resentment about the assumed or actual incentives that the CTC providers were receiving. If CTC providers are selected by health system actors rather than the community this could lead to less community involvement and community expectations that are not in line with the CTC provider’s tasks and responsibilities. From the context analysis, we found that communities tend to appreciate the equipment, attitudes, supplies and curative services that form part of CTC programmes.

In terms of the characteristics of CTC providers, the ideal characteristics of CTC providers as reported by community members differed across contexts – there was a general preference for women, for married people and sometimes for older males, for example in Kenya.

Community acceptance and meeting the needs of the communities that they serve are important intrinsic motivators to CTC providers. When community expectations cannot be met this can lead to frustrations and demotivation.


In all of the REACHOUT countries, stakeholders report that training is often insufficient to foster the skills and competencies necessary for CTC providers to do their job. Understanding of what appropriate training might look like differed depending on context. It was felt that more complex tasks require longer training, that training should encompass a mix of theory and practice (with the practical elements being particularly important in facilitating their work) and that refresher training was required to keep skills and competencies live. Importantly, CTC providers felt that training should be offered in the interpersonal aspects of their job, for example communication and negotiation skills.


When there are lines of supervision and supervision guidelines in place and used, CTC providers are able to perform well. Supervisors need adequate time for the job. This is often not the case, as supervision is not seen as priority. The nature of the type of supervision makes a difference too, in almost all countries CTC providers reported the directive (rather than supportive) supervisory style as a problem.

Focus, workload, remuneration and incentives

Unsurprisingly we found that the performance of CTC providers suffers if roles are not clear or keep on changing.

High workload is found almost everywhere, with sometimes unrealistic targets which can undermine motivation and performance. If there is an increase in demands and responsibilities placed upon CTC providers and a formalisation of roles, this can lead to an increase in CTC providers’ demand for salaries and formal incentives. Within existing programmes there are inequities in the ways that CTC providers are rewarded within and across countries. Salaries were sometimes perceived too low, irregular or not standard or conversely not differentiating for different roles. This could lead to demotivation. In some contexts, variations in allowances across different CTC programmes led to selective commitments.

Non-financial incentives that were reported by CTC providers include: being a civil servant; non material rewards such as the recognition of the community; being seen as a “mini doctor” in offering curative services; and material rewards (such as cell phones, t shirts and uniforms).

Poor transport links, no fuel or maintenance of vehicles were felt to be a barriers to the work of CTC providers. When CTC providers hail from outside the community, lack of accommodation or opportunity to transfer were reported as demotivating factors.

Referral processes

In some contexts, the referral process was clear, well documented and including a feedback system. In these contexts, the referral system was a facilitating factor of CTC provider performance. But often, referral is hindered by a lack of transport, poor feedback, the absence of formal referral processes, poor quality of care within the services CTC providers refer to, high costs of care in health services and a lack of responsiveness of staff in the next level.  These factors could hinder CTC provider performance.

Monitoring and evaluation

Feedback loops in the monitoring and evaluation system are important, but across the six countries, this was less than optimal due to logistical problems, inadequate transport, lack of training and lack of capacity in the system.


Supplies of essential materials which CTC providers require to do their job affected performance and a lack of budget for travel costs was problematic in many contexts as well.

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