C. Baker, R. Limato, P. Tumbelaka, B. B. Rewari, S. Nasir, R. Ahmed and M. Taegtmeyer

BMC Pregnancy and Childbirth 

Open access: https://doi.org/10.1186/s12884-020-02993-x 

Abstract: 

Quality Improvement (QI)

To empower community and facility health workers to work together and collect, analyse and use their own data to improve quality of antenatal care provision and enhance pregnant women’s experiences.

Integrated Point of Care testing (iPOC)

To improve the availability of testing for four common conditions (HIV, syphilis, anaemia and malaria) in ANC facilities.

Community Pregnancy Tests and Referral (CPT)

To increase early detection and referral to ANC care, particularly younger women and those in rural areas.

Research methods

This 18-month pilot aims to develop and assess the acceptability, feasibility and effectiveness of the 4byFour model at three facilities in Migori, Western Kenya

It is an observational study which uses process evaluation for complex interventions. The research objectives are summarised below.

To explore acceptability & feasibility

To assess effectiveness

To develop robust follow up tool

To document the process 

Beyond a pilot

The 4byFour model is designed to work within the existing health system to improve quality antenatal care and pregnancy outcomes. Its success will depend on QI approaches that link communities and facilities, being done within available resources and on the sustainable provision of integrated point of care testing. Our partnership brings together the key people and skills and puts us in a strong position to move beyond a pilot to a sustainable county led model.

Roy*, a male participant at a gender workshop tweets on gender discussions ongoing in the meeting. Roy* immediately receives a call from a fellow man: “What are you doing at a gender workshop?” Roy* shares this with fellow participants at the workshop to everyone’s utmost shock and sarcastic laughter followed by heated conversations with a mixture of grunts from one side of the audience, rolling eyes from another and nods from the corner section.  

Gender norms and power plays demonstrated above are not only at this high level but also influence the work community health workers (CHWs) do at the household level, community level and societal level. Harmful gender norms shape vulnerability to ill health and impact on health seeking behavior and access to health services in negative ways.

During a recent meeting in Nairobi on Building Health Systems that transform gender norms, participants concurred that with support, CHWs are well positioned to challenge gender norms as they are the interface between communities and the health system and are intimately aware of how they play out.

Despite the very essential role that they perform, CHWs continue to experience perennial challenges like under- or lack of remuneration as well as the lack of motivation.

In the course of the meeting in Nairobi, findings from diverse contexts revealed that In Uganda just like in other countries, CHWs are selected by their communities and are required to have some level of education. Many of the CHWs are women because of the voluntary nature of the job. More men were recruited in Sierra Leone because they have easier access to education hence more are educated. In Kenya, most CHVs are women, with a few men.

CHWs are subject to gender norms that play out in their communities.  In many contexts, roles are divided between men and women for reasons such as people in the community prefer getting help and services from a CHW of a similar gender.  The different genders are also sometimes expected to perform different roles; for example, in Uganda community mobilization and responding to emergencies is heavily dependent on male CHWs because they have access to transport. Activities that require manual labor are also usually for the male CHWs. Female CHWs played more active roles in maternal and child health, handling sick children/people as most are already mothers. Women CHWs are tasked with more roles as they are considered more available than men because most men work longer distances away from home. All the aforementioned reasons reinforce the importance of having both genders as they all play different roles and it has policy implications.

Charity Tauta from Kenya said, “It is vital to have gender mainstreaming in policy.” In order to do this, deliberate strategies need to be undertaken to encourage gender equity. Gender sensitive indicators and tools need to be incorporated into projects and programmes that are implemented with the help of CHWs.

There is also need to empower representation of marginalized groups like women and encourage them to speak out. At the end of the meeting, Prof. Sarah Ssali powerfully wrapped up the meeting by reminding all present participants that as we strategize and plan forward, there is need to remember that culture and other factors that influence gender norms are dynamic and there is need for people to constantly be alert and cognizant of this.

This convening was funded by Advancing Learning and Innovation on Gender Norms (ALIGN), an initiative led by the Overseas Development Institute (ODI). For further information, visit www.alignplatform.org and follow @ALIGN_Project. It was organised by Kui Muraya, Kate Hawkins and Rosemary Morgan on behalf of RinGs and KEMRI Wellcome Trust.

Recent news

• REACHOUT at the Global Symposium on Health Systems Research, 1 October 2018
• Webinar - Mobile community health data systems: Experience from India, Ethiopia and Madagascar, 10 July 2018
• LSTM Seminar: Community Health Systems for achieving universal health coverage: panacea or poison?, 6 March 2018

DISCUSSING CULTRURAL BARRIERS TO HEALTH FACILITY DELIVERY IN INDONESIA AND ETHIOPIA

Sudirman Nasir

Cultural barriers to health facility delivery are a common experience worldwide despite wide variations in context. Close-to-community (CTC) health providers play an important role in bridging communities and health systems and their role in maternal health is particularly key.

Sudirman Nasir, senior research associate of REACHOUT Indonesia as well as a senior lecturer in the Faculty of Public Health, Hasanuddin University (Indonesia) delivered a public lecture on the above topic in Liverpool School of Tropical Medicine on 13 December 2018. Dr. Nasir came to Liverpool as a visiting fellow supported by a fellowship funded by the Indonesian Ministry of Higher education to write and submit a paper in an academic journal. Dr. Nasir along with several REACHOUT colleagues i.e. Aschenaki Zerihun Kea (Reachout Consortium, Ethiopia),  Rosalind Steege (Liverpool School of Tropical Medicine, UK),Ralalicia Limato (Eijkman Institute of Molecular Biology, Indonesia),  Patricia Tumbelaka (Eijkman Institute of Molecular Biology, Indonesia), Daniel Gemechu Datiko (Reachout Consortium, Ethiopia),  Syafruddin (Eijkman Institute of Molecular Biology, Indonesia), Maryse Kok (Royal Tropical Institute, The Netherlands) Rukhsana Ahmed (Eijkman Insititute of Molecular Biology, Indonesia and Liverpool School of Tropical Medicine, UK) and  Miriam Taegtmeyer (Liverpool School of Tropical Medicine, UK) completed and submitted a paper on the above topic in a journal.

During the lecture, Dr. Nasir presented the paper's  findings and recommendations. The paper explored the views of CTC maternal health providers and other community members on the cultural barriers to health facility delivery in two districts in Indonesia and six districts of Sidama Zone, southern Ethiopia. Employing a qualitative approach, we conducted 110 semi-structured interviews (SSIs) and 7 focus group discussions (FGDs) in Indonesia and 44 SSIs and 14 FGDs in Ethiopia. Participants in both contexts included mothers, husbands, male community members, traditional birth attendants (TBAs), village heads, local administrators and district health officials as well as health care workers and CTC health providers. Despite significant geographical and cultural differences, the main findings were similar in the two countries’ study areas. These included: strong cultural-religious beliefs; culture of shyness and privacy around pregnancy; highly gendered decision making related to pregnancy and delivery; as well as preference of the TBA care. TBAs’ close proximity at the time of childbirth and their adherence to traditional practices were important factors influencing preference for TBAs. These cultural barriers interplay with geographical, transportation and financial factors hindering pregnant women from delivering at a health facility. Intensifying health promotion on health facility delivery, increasing collaboration among CTC health workers such as community midwives, health extension workers and TBAs, and enhancing responsiveness to traditional practices may overcome cultural barriersto facility delivery in both countries.

The lecture's audience responded with several interesting comments. One of the audience who participated in a study in maternal health related issues in Uganda mentioned several  similar findings, particularly preference for TBA care.

The global scale-up of community health workers (CHWs) depends on supportive management and supervision of this expanding cadre. Existing tools fail to incorporate the perspective of the CHW (i.e. perceived supervision) in terms of supportive experiences with their supervisor. Aligned to the WHO’s strategy on human resources for health, we developed and validated a simple tool to measure perceived supervision across seven low and middle-income countries.

Phase 1 was carried out with 327 CHWs in Sierra Leone. Twelve questions, informed by the extant literature on health worker supervision, were reduced to six questions using confirmatory factor analysis. Phase 2 employed structural equation modelling with 741 CHWs in six countries (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique), to assess the factorial validity, predictive validity, and internal reliability of the questions at three time-points, over 8-months.

We developed a robust, 6-item measure of perceived supervision (PSS), capturing regular contact, two-way communication, and joint problem-solving elements as being critical from the perspective of CHWs. When assessed across the six countries, over time, the PSS was also found to have good validity and internal reliability. PSS scores at baseline positively and significantly predicted a range of performance-related outcomes at follow-up.

The PSS is the first validated tool that measures supervisory experience from the perspective of CHWs and is applicable across multiple, culturally-distinct global health contexts with a wide range of CHW typologies. Simple, quick to administer, and freely available in 11 languages, the PSS could assist practitioners in the management of community health programmes.

Wednesday 10 October

12:45 - Measuring Quality in Malawi’s Community Health System: Barriers and Challenges, Poster, ACC Hall 2M, Galleria and Level 3

16:00 – 17:30 - Putting quality at the heart of community health services for maternal, newborn and child health, Panel, ACC Room 1B

Thursday 11 October

13:15 - When and how do incentives help improve Community Health Workers’ performance? A qualitative multi-county study, Poster, ACC Hall 2M, Galleria and Level 3

14:00 – 15:30 - CHWs provide “second class care” and are a temporary fix to the human resources crisis and health systems constraints, Participatory session, ACC Hall 2E

16:00 – 17:30 - Ethiopia’s Health Extension Programme: Implications of mobile technology for strengthening community health systems, Oral presentation, ACC room 11C   

Friday 12 October

09:00 – 10:30 - Improving the health workforce quality in Indonesia through collaborative approaches between higher education and health system: A proposal of multisectoral actions, Oral presentation, ACC room 12   

10.30 - Quality improvement in community health: A novel approach to improve efficiency and outcomes of Community Health Worker programs in Kenya, Poster, ACC Hall 2M, Galleria and Level 3

10.30 - “Do you trust that data?” – A mixed-methods study assessing the quality of data reported by Community Health Workers in Kenya and Malawi, Poster, ACC Hall 2M, Galleria and Level 3

12.45 - Measuring quality from a community perspective: Using a community follow up tool to measure the quality of community health services at household level in Kenya, Poster, ACC Hall 2M, Galleria and Level 3

13.15 - Strengthening the community health system in Mozambique: a gender analysis of the Agentes Polivalentes Elementares programme, Poster, ACC Hall 2M, Galleria and Level 3

13.15 - Creating a forum for shared learning and advocacy in strengthening community health systems: Lessons from community-based quality improvement teams in Kenya, Poster, ACC Hall 2M, Galleria and Level 3

Recent news

• Webinar - Mobile community health data systems: Experience from India, Ethiopia and Madagascar, 10 July 2018
• LSTM Seminar: Community Health Systems for achieving universal health coverage: panacea or poison?, 6 March 2018
• In Shebedino REACHOUT’s Quality Improvement approach is here to stay, 6 February 2018

Join our discussions on twitter

Follow: @REACHOUT_TWEET
Hashtag: #CHW
              #HSR2018

Community health workers (CHWs) improve access to quality health services at the community level. Despite the critical role that CHWs play, governments often have limited insight into their activities, the quality of their services, the conditions of the communities that they serve, and how best to link these CHWs and their beneficiaries to the larger health system. To effectively monitor CHW services and improve public health management at the community level, practical, effective and integrated systems for data collection, analysis and monitoring are needed. Mobile technologies show great promise, but how do we ensure they are integrated with national HMIS systems and how do we scale them to meet the need? 

Highlighting case examples from three countries, this webinar presents the successes and challenges of linking a CHW workforce to larger national health systems with mobile technologies. Presenters will explore the technical process of integrating various mobile platforms; best practices and lessons learned building reports to facilitate data-based decision making at the government level; and how to design for scale within existing systems and considering the processes needed to integrate with those systems.

Panelists will share lessons learned from the following initiatives:

Ethiopia – JSI Research & Training Institute, Inc (JSI) and the Government of Ethiopia are working to equip 10,000 CHWs with an innovative mobile solution to improve Post Natal Care (PNC) in the first 48 hours after birth.

Madagascar – The Ministry of Health in Madagascar is working with USAID, MSH and Dimagi to build a comprehensive mHealth application for use by community health volunteers (CHVs) to improve the health of women of reproductive age, children under five, and infants by enhancing the quality of primary health care services at the community level.

India - Dimagi is working with the Ministry of Women and Child Development to launch a maternal and child health (MCH) application to over 100,000 community health workers across eight states of India. Data collected through the system is made visible in a robust reporting dashboard at the Central, State and District levels.

Join the Webinar on Wednesday August 1 at 9:30 AM EST/US

At: Join from PC, Mac, Linux, iOS or Android: https://zoom.us/j/340622344

Or iPhone:

US: +16465588656,,340622344# or +16699006833,,340622344# 
Or Telephone:
Dial (for higher quality, dial a number based on your current location): 
US: +1 646 558 8656 or +1 669 900 6833 
Meeting ID: 340 622 344

International numbers available: https://zoom.us/u/dUsNAd2vn

Recent news

• LSTM Seminar: Community Health Systems for achieving universal health coverage: panacea or poison?, 6 March 2018
• In Shebedino REACHOUT’s Quality Improvement approach is here to stay, 6 February 2018
• BRAC JPG School of Public Health celebrates five years of REACHOUT research in Bangladesh!, 18 January 2018

By Rosalind McCollum

Universal Health Coverage (UHC) is one of the four pillars of the Kenyan president Uhuru Kenyatta's current term in office (2017 – 2022). This has attracted the attention of several international development organisations that are keen to support Kenya to achieve health for its most vulnerable and poorest populations, through community-based primary health care.

Decentralisation, including devolution, is increasingly being adopted by countries seeking to address health inequities. In Kenya, pre-existing historical inequities between regions, with wide variations in power, resources and levels of access to and use of essential health services were felt to have contributed to the demand for devolution.  This contributed to the devolution of administrative, political and fiscal responsibility for health care from the national level to 47 entirely new sub-national (county) levels in 2013. 

What were we trying to find out?

Given the short timeframe since devolution was introduced, little is known about how and why priorities for health are set and how this influences effective and equitable coverage of community-based primary health care at county level.  We carried out the first large-scale qualitative study of post-devolution priority-setting for community-based health services.  We sought opinions and experiences from 269 health workers, policy makers and politicians from across the health system in ten counties, and perspectives from 146 community members through focus group discussions.

What did we find?  

We found that devolution has great potential for increasing health equity and UHC.  Our study revealed a general perception of improving equity between counties, with health equity felt to have improved in some previously neglected counties.  The potential for deepening inequities within counties has not yet been adequately addressed, since any rapid transition in power carries with it a certain degree of risk that local elites may capture priority-setting processes.   

Devolution is transforming the balance of power in Kenya by reducing the role of national bureaucrats and sub-county health implementers and increasing the degree of decision-making power at the (new) county level.  Here multiple political, technical and community actors, each with their own values and motivations, must compete to influence the priority-setting process.  This changing balance of power has wide-reaching implications for community-based primary health care and for achieving UHC.  Politicians’ have greater influence and may be motivated to provide services which appeal to their electorate, consolidate political support and maximise their voter base in pursuit of re-election.   Given such political processes, lower profile community-based health services risk being neglected, in favour of more visible curative services.

Our own and others’ research has shown that the rapidity of devolution can be a threat to its success:  with limited time to build up technical expertise and processes at county level this can lead to further unintended consequences. This can be compounded by insufficient clarity surrounding roles and responsibilities for actors within priority-setting; limited understanding by technical actors about how to engage meaningfully with politicians; insufficient knowledge and understanding of holistic health care; limited scope for meaningful participation of marginalised groups; reduced opportunity for involvement of health workers and insufficient guidance and capacity building for priority-setting before the roll-out of devolution. 

What can we learn from this study?

Several counties in Kenya have stated UHC and community health services for all as priorities, but with different interpretations or adaptations of both. In contrast other counties do not yet have adequate focus or capacities to ensure vulnerable groups are not left behind, risking failure to realise UHC.  The tumultuous electoral events of 2017 and recurring health worker strikes have created uncertainty, further threatening progress towards UHC.  There is therefore a need to learn from current best practices (see box 2 in study) and to lay down institutional structures, processes and norms which promote health equity for all Kenyans. As the president and interested international development organisations discuss UHC with related media attention, there is a critical window of opportunity to build political backing at sub-national (county) levels for planning and investing in community-based primary health services. 

Recent news

• LSTM Seminar: Community Health Systems for achieving universal health coverage: panacea or poison?, 6 March 2018
• In Shebedino REACHOUT’s Quality Improvement approach is here to stay, 6 February 2018
• BRAC JPG School of Public Health celebrates five years of REACHOUT research in Bangladesh!, 18 January 2018

By Rosalind Steege

The European Commission funding of the REACHOUT project may have officially come to an end, but the impact of the work and its legacy will surely live on. This became apparent to me when I was fortunate enough to visit the REACH team in Ethiopia for the project’s final dissemination meeting. REACHOUT has been working for the past five years in Shebedino district just outside of Hawassa.

It had been a year since my last visit and the road from Hawassa to Shebedino (where the project was implemented) is still being worked on, it makes for a strenuous journey as stretches of new tarmac are interspersed with patches of rubble that would challenge even the best suspension mechanisms. Over time of course, piece by piece, the rubble will be filled in until inevitably one 25km swathe of smooth tarmac will connect the two and greatly improve the efficiency (not to mention comfort) of the journey. Travelling this bumpy road on the way to visit the health centres in Shebedino, I couldn’t help but reflect on how the incremental step by step approach they have taken to building the road, is not dissimilar to the approach REACHOUT has taken with its Quality Improvement (QI) cycles, where QI teams use a PDSA (plan, do study, act) approach resulting in continuous incremental improvements that expands the overall quality of health service provision. 

Reflections from the meeting

The final dissemination meeting was held in a hotel in Hawassa and was well attended by delegates from the Zonal Health Department, Regional Health Bureau, health centre staff, Health Extension Workers and of course, REACHOUT project staff.

Aschenaki Kea opened the day by outlining the findings from the context analysis completed at the start of the project which revealed some of the strong cultural beliefs upheld by communities with regards to maternal health. For example, the practice of burying the placenta beneath the house believed to ‘root’ the child, which can be a barrier to delivery within facilities. He also highlighted that there had been a level of mistrust of health workers and misconceptions around payment for ambulance services. This was compounded by poor supervision structures and a lack of referral systems. REACHOUT’s approach was therefore across three core areas: community engagement, referral linkage and supportive supervision. Initially, 45 health centre staff were trained in Shebedino, which was then expanded to a total of 81.  He then handed over to the nine health centres who had done the hard work to present their achievements. 

I was struck by the dedication the health centre QI teams had, they spoke of how integral the PDSA approach has become to their work - and they have the health benefits to show for this dedication. The comprehensive problem-solving approach that they adopted has gone beyond maternal health, impacting across health services from HIV to TB. The teams now also have a dedicated budget for QI activities which they plan and implement on a regular basis.

The presentation from Abela health centre not only spoke to the decrease in drop-out rates for ANC attendance – which are now up to 81% - but have other aspirations: not content with just ‘model households’ the team have set their sights on creating a ‘model village’. Woinadega health centre spoke of their pro-equity approach; identifying patients with special requirements implementing three-step programme to better serve them. This includes waiving payment for services, establishing an outreach programme and implementing a microfinance initiative to improve their socio-economic position. The head of Dulecha health centre also spoke of the importance of teamwork “Many threads together are strong enough to tie a lion”. Whereas another health centre staff member reported on the capacity building side of the project, “This REACHOUT project was like a school to me, I learned about presentation skills on top of QI and everything.”

New initiatives at Telamo health centre

Prior to the meeting I also had a chance to visit some of the health centres to see the impacts first hand and get a more comprehensive overview their individual achievements. Telamo health centre is a well performing and impressive health centre. It has a laboratory as well as delivery room that surround a well-manicured garden with bright pink flowers. I spoke with the head of the centre, Solomon Daniel, about their experiences with the REACHOUT project. In his opinion, the biggest changes they have seen relate to the establishment of a referral system for pregnant mothers (there was none before), and guidelines for the pregnant women forum (PWF).

“REACHOUT is a kind of spice to add flavour to the dish, but we are the cooks, it’s our own work, so we will continue to do it,” Solomon Daniel

He highlighted that the impact for the community of the QI teams is that the health development army is functioning well, which leads to improved information dissemination within the community. As a result of this well-established link between health centre and community, health seeking behaviour has improved.  

One of the wonderful initiatives that has been up and running for six months at Telamo health centre is the mothers’ waiting room. The waiting room was built in the traditional Sidama cultural style of a round hut with a thatched roof, in accordance with community wishes. It serves as a place for up to four mothers (and their family members) to stay whilst they wait to deliver for up to a week before their due date. This is especially useful for women who live far from the health centre but want to give birth in the facility. The room is kitted out with electricity and even a TV. The expectant, and new, mothers are also well looked after; the health centre staff contribute ten Birr from their salary every month (about 0.37 USD) to provide tea, coffee, flour, butter, sugar etc. They celebrate each newborn arrival with a porridge ceremony. On my visit I met a young mother who had given birth the day before. She lay comfortably on the bed breastfeeding her new son Chance. She lived 28k away and had stayed for two days before her birth accompanied by her mother and sister and without this waiting room, may not have had the chance to deliver in a facility.

Improved health services at Abela health centre

I also visited Abela health centre and spoke with their head, Gebre Tunga.  Gebre highlighted the main impacts of REACHOUT at Abela to be the improvement in coverage, and the improvement in the quality of services. Before REACHOUT they did not provide a syphilis and HIV tests for pregnant mothers, but now this is part of their routine care. This is important for the health outcomes of the community as testing is provided alongside information and counselling services. Information to expectant mothers on the syphilis testing is provided during the Pregnant Women's Forum and they are counselled on the importance of knowing their status. If they test positive for HIV they will be counselled and linked to antiretroviral treatment. If they test positive for syphilis they will be treated, protecting the baby. The test is given at the first antenatal care visit and with a negative HIV result, the test is given repeatedly at three month intervals in case the viral load is undetectable at first.

But in answer to the all-important question…Will it be sustained?

“Without a doubt, no question. It is our routine task. Our knowledge and practice is due to REACHOUT training. Quality is one component of health centre reform, which is also part of the government initiative, so REACHOUT’s focus on quality is aligned with the government initiatives of health centre reform,” Gebre Tunga

Recent news

• BRAC JPG School of Public Health celebrates five years of REACHOUT research in Bangladesh!, 18 January 2018
• New maternal health promotion resources from Indonesia, 03 January 2018
• Now I know how to do my job…”: how community health services in a Kenyan urban slum improved, 20 December 2017

Lakeshore Hotel, Road # 41, House # 46, Gulshan- 2, Dhaka on 28^th January 2018, 09.30-12.30

Since 2013 the BRAC JPG School of Public Health have been working to understand and improve close-to-community programmes for menstrual regulation in Bangladesh. Working closely with colleagues at RH STEPS and Marie Stopes Bangladesh they have implemented a series of quality improvement cycles aimed at improving the referral services offered by community level workers.

A package of interventions was provided including supportive supervision training, facilitative referral training, and the creation of a revised referral card through a participatory process. Simultaneously mixed method research was conducted to monitor the effects and impacts of the intervention.

In this dissemination event, the key findings from the five-year project will be shared; and a panel discussion on menstrual regulation services in Bangladesh and its challenges will be facilitated. There will also be a chance to see our new video documentary about the project and celebrate excellence through our awards ceremony.

The event will be an opportunity to interact and share insights for the professionals/organizations involved and interested in working healthcare sector; gender and women rights; operational/implementation research; and community based services using a range of health cadres.

If you want to find out more about the event or the research please contact farzana.islam@brac.ac.bd

Recent news

• New maternal health promotion resources from Indonesia, 03 January 2018
• “Now I know how to do my job…”: how community health services in a Kenyan urban slum improved, 20 December 2017
• The journey of a referral card: Implementation, embedment and challenges, 18 December 2017

By Licia Limato

Health promotion is a major component of the primary health programme in Indonesia. Most of the health promotion is done in the Posyandu, the monthly community integrated activities held in the villages. It is in the Posyandu that antenatal care is provided to the women in the villages and maternal health promotion is a vital activity for making them aware of healthy pregnancy and safe childbirth. Therefore, having staff knowledgeable in maternal health issues is important for quality assured delivery of maternal health promotion.

The staff working in the Posyandu are the village midwives and the Posyandukader (community health volunteers). Well trained staff in the Posyandu is pivotal for effective health promotion and for pregnant women to value the advice given by Posyandu staff.

The training manual with title “Pedoman pelatihan promosi kesehatan ibu untuk kader Posyandu” was developed to meet the needs of the Posyandu staff, particularly the Posyandu kader. The guidelines for trainers was designed for those who are planning to conduct health promotion training with emphasis given to participatory training with role play and acting out sessions. An introduction to the use of pictorial counselling cards is provided in this guideline. The guidelines for trainees is provided for the participants of the training and can be used during and after the training.

Following the positive response received to the trainings we conducted under our REACHOUT project, we felt that by making the manual electronically available we could reach a larger number of trainers In Indonesia working in maternal health programmes. 

Recent news

• “Now I know how to do my job…”: how community health services in a Kenyan urban slum improved, 20 December 2017
• The journey of a referral card: Implementation, embedment and challenges, 18 December 2017
• Challenges and barriers in accessing Menstrual Regulation services in Bangladesh, 11 December 2017

By Robinson Karuga, Judy Warioko and Maryline Mireku

Bangladesh. Curious name for an urban slum that is sandwiched between Nairobi’s sprawling national park and middle class residential estates in Langata sub-county. Bangladesh slum is home to about 640,000 people who mainly provide casual labour to nearby stone quarries, as touts and as drivers of matatus (public service vehicles) in a nearby peri-urban town called Ongata Rongai. In total, there are about 370 houses made from assorted materials such as mud, wood, and iron sheets.

Despite the lack of social amenities such as piped water, sewerage system and garbage management, Bangladesh slum is impressively clean, compared to other slums in Nairobi. As one walks through the alleys in Bangladesh, they can’t fail to spot healthy and leafy kale growing in black-polythene door step gardens in most of the households. Another interesting observation is the number of water filled “leaky-tins” that are hung on majority of the pit latrines as hand-washing facilities. This place is different from many other slums.

 “This is all the work of Community Health Volunteers (CHVs)” said Maryline Mireku. Maryline is a Research Officer in the 5-year multi-country REACHOUT project that has been involved in embedding quality improvement in community health services in Nairobi County. One of the interventions involved building capacity in supportive supervision of CHVs in Bangladesh slum. Bangladesh slum is served by 14 CHVs who make up a cadre of lay health workers that are nominated by fellow community members to provide health education and basic health services (Vitamin A supplementation, growth monitoring, follow up for maternal and child health services) at household level. They are also crucial for referring community members for primary health care services.

What follows is a story that started when I enquired on the effects of this intervention from the Officer in Charge of community health services in Langata sub-county. Her name is Judy Warioko.

“By the way, REACHOUT really contributed to bringing community health in Bangladesh to life”, stated Judy. This response triggered our discussion on how REACHOUT’s had influenced community health services in Bangladesh. According to Judy, Bangladesh slum consistently performed poorly in all the community health indicators before the REACHOUT intervention in 2015, such as community health reporting rates, maternal, newborn and child health (MNCH) indicators, referral and sanitation. This poor performance had been going on since the Ministry of Health established Bangladesh slum as a community unit in 2012. “Things are better now since you people trained on supportive supervision”, she continued. “CHVs now report on time and we have noticed an improvement in the quality of reporting”. According to Judy, CHVs in Bangladesh slum had started submitting their well completed monthly community health reports and were more active in refering community members for primary health care since supervisors were trained on supportive supervision. The 6-day training on supportive supervision focused on the educative, supportive and administrative roles of supervision, different approaches in supervision, problem solving and advocacy. Training was done using a workshop approach and monthly coaching after the workshops.

Being a skeptic, I decided to find out a little more from other sources in Bangladesh slum. My first stop was a conversation with Fredrick Onyango; a CHV who had been nominated as a peer supervisor by CHVs in Bangladesh slum. Fredrick was one of the peer supervisors who participated in the training in supportive supervision.

He confidently started our conversation by saying “Before I did not know anything about group supervision and one-to-one supervision”. The skills in supportive supervision learned during the workshops, subsequent coaching sessions by REACHOUT staff helped him, and other supervisors understand what supervision is and how important it is while delivering health services in the community

According to Fredrick, most of the CHVs could not comprehend the instructions and indicators in the community health reporting tools, which they were required to complete on a regular basis (household service registers and referral forms) before the training. Moreover, CHVs completed these tools incorrectly without supervision. They also constantly ran out of these community health-reporting tools and had to make copies with their own money. This affected the timeliness and quality of reports that they submitted to the health information systems officer at sub-county level.

In addition to training supervisors on supportive supervision, REACHOUT supported Langata sub-county officers to train peer CHV supervisors on how to correctly fill-in the reporting tools. REACHOUT also supported the supervisors by printing and distributing the community health reporting tools. After the training, CHV peer supervisors started using group supervision approaches to coach and support CHVs as they prepare their monthly reports for submission to their supervisor (Community Health Extension Worker -CHEW). CHEWs are primary health worker who supervise CHVs

Accompanied household visits by peer supervisors and CHEWs has improved health services to the community members. Through these approaches in supportive supervision, CHVs are now more rigorous in checking for health services that community members have not received and refer them for primary care such as immunization, antenatal and post-natal care, growth monitoring, among others. Improvement in supervision of CHVs has improved their performance in referral and follow up of community members to take up primary health services.

“Before, CHVs only used to refer community members who came to them. Now they are more keen to look out for health services that a household does not have”, added the CHEW in charge of Bangladesh. They also work with households to ensure that the “leaky-tins” are functional for hand washing purposes and community members are using them.

As I travelled back to the city center, a statement made by Fredrick “After the training, now I know how to do my job” kept ringing in my mind. This effect in Bangladesh slum is a contribution to the bigger universal health coverage picture. I started this series of informal conversations a skeptic. I’m now convinced and proud to say that REACHOUT will be long remembered for starting off places like Bangladesh slum on an exciting journey in improving the quality of community health services. Improvements in referral and reporting in Bangladesh are quick wins to celebrate and share widely.

At the beginning of our conversations, Judy mentioned, “I recommended Bangladesh because it was a low performing unit. Looking back, I think it was a good idea”. I agree with her! REACHOUT’s work in Bangladesh slum was a great place to demonstrate the effect of supportive supervision in improving the quality of community health services.      

Robinson Karuga is a Research Fellow at LVCT Health and is part of the REACHOUT team in Kenya. Judy Warioko is now the Community Health Services Coordinators in charge Nairobi County.  Special thanks to Neville and Fredrick who work tirelessly to improve the quality of community health services in Bangladesh.The photo is of the Link Facility Nurse (middle) and Peer CHV supervisor (Fredrick in blue shirt) conducting one-on-one supervision on a CHV (in yellow shirt) in Bangladesh slum.

Recent news

• The journey of a referral card: Implementation, embedment and challenges, 18 December 2017
• Challenges and barriers in accessing Menstrual Regulation services in Bangladesh, 11 December 2017
• Problem solving on maternal health: Experience of Shebedino Quality Improvement Team in Ethiopia. 5 December 2017

By Irin Akhter, Farzana Islam, Sumona Siddiqua, Sushama Kanan, Malabika Sarker and Sabina Faiz Rashid

In Bangladesh, there are two types of close-to-community (CTC) providers: formal and informal. Formal CTC providers are the staff of the non-government organizations (NGOs) and government, whereas the informal CTC providers are drug sellers, homeopaths, traditional birth attendants (TBA), and other traditional practitioners. Both types of CTC providers play a key role as negotiators between communities and health systems to provide sexual and reproductive health services to women of Bangladesh and often act as a bridge between them in various contexts. Informal providers often maintain an informal personal link to the formal health sector and make referrals, when required. It is usually based on personal relationships with formal CTC providers in the organizations, rather than a formal structured process.

Reaching out and linking in

In Bangladesh, REACHOUT aims to understand and strengthen the role of CTC providers involve in menstrual regulation (MR) services in two implementing partner organizations, Marie Stopes Bangladesh (MSB) and Reproductive Health Services Training & Education Programme (RHSTEP). MR is a procedure to safely remove risk of pregnancy up to 10 weeks by paramedic or nurse and up to 12 weeks by doctor after a missed menstrual period. MSB is a large international organization and organization RHSTEP is a locally renowned NGO working closely with the government. Both the organizations provide MR services to the poor women; and largely depend on their CTC providers to promote their services in the community and increase service uptake through referrals.

Through the initial context analysis REACHOUT Bangladesh identified that there are no formal links between formal and informal providers and the client referral process faces many challenges. Poor instruction on the referral process, limited referral and interaction between formal and informal providers have negative impact on the health of poor people, especially MR clients.

To minimize the gap between formal and informal providers the following interventions were carried out through two quality improvement cycles (QICs):

• Facilitative referral training for both formal and informal CTC providers to strengthen their capacity of referral. Facilitative referral is a process where a CTC provider provides continuous assistance and all necessary information of the service to the client
• A revised referral card for both organizations to implement effective referral 

Why revise the referral card?

The existing referral card was a one page paper printed on both sides. One side has address and the service hours of the clinic. The other side has the available health services of the respective clinic. It had no provision to document the information of the client and the referrer and had no way to track the referrer.

To revise the referral card REACHOUT Bangladesh applied a participatory approach and discussion with different level of staff from the partner organizations.

• CTC providers were asked to list out the information they would want to see in a referral card and to draw a draft referral card during their first facilitative referral training
• The draft including the information was shared with CTC providers’ supervisors and they gave feedback on the draft
• Researchers designed a referral card addressing all the suggestions and feedbacks from the CTC providers and their supervisors
• The research team met the higher authority of both partner organisations separately and shared the newly designed referral card mentioning how they have addressed CTC providers’ and their supervisors’ feedback
• The higher authority of the partner organisations approved the design and the concept of the revised referral card
• Final proof reading and editing was done involving the clinic managers of the intervention areas
• REACHOUT Bangladesh financially supported the printing of the revised card and distributed it among the partner organisations
• CTC providers were trained on how to use the referral card in the facilitative referral training

What is the difference? 

The revised referral card has two parts with the same serial number printed on both. One part is for the referrer to keep with himself/herself and another part is handed over to the client to carry it to the clinic while accessing services.

The referral card has referrer’s name, referrer’s cell number, date of the referral, due date by which the client has to visit the clinic for the service considering her last menstrual period (LMP), the address of the clinic, and the service hours of the clinic. The client’s name and client’s cell number is printed only in the referrer’s part to track the client and to maintain client’s confidentiality.

Appreciation from providers and supervisors

“This referral card is like an ID card…it is good, if client show this card she gets the benefit and she is satisfied. This referral card is better than the previous slip. It is a document that I can send with the patient to the clinic. If the patient takes the service or not I will know that... If I give this referral card to the patient, she will be happy because I told her if you show this card you will have the treatment quickly and you don't have to face any problem.”

34-year-old pharmacist in an in-depth interview

The formal and informal CTC providers and supervisors of formal CTC providers appreciated the revised referral card as it helps them:

• To keep records and to track the referred clients and the referrer
• To ensure that the referral fee is paid to the referrer as they also keep a part which is a proof of their work
• The referral card is itself documentary evidence of the referral system
• The address printed on the referral card helps the client to get to the appropriate clinic

Challenges

Processing of the referral card has taken a long time to get off the ground (seven months) and still the intervention clinics are not able to cover their catchment area due to drop out and shortage of CTC providers. Some CTC providers and clinic managers shared that sometimes the clients have the tendency not to take the referral card with them or not to show it to the service center due to misconception that if the client brings or shows the card, the CTC provider would disclose her secret to her community or would get extra monetary benefit.

Recommendations and next steps

CTC providers recommended that the cover page of the referral book should be colorful with the address and logo of the clinic; and the name of referrer should be placed on the top of the referral book.

Continuing referral training, availability of the referral card and its regular distribution to CTC providers, documenting the information of the referral card in the organisations’ health information system, and ongoing monitoring of the information received in the referral card are important requirements for this restructured referral card.

Conclusion

The revised referral card has brought changes in the intervention areas of both the implementing partners. If the intervention will be scaled up to the other clinics of the partner organizations, it will be more feasible. 

Recent news

• Challenges and barriers in accessing Menstrual Regulation services in Bangladesh, 11 December 2017
• Problem solving on maternal health: Experience of Shebedino Quality Improvement Team in Ethiopia. 5 December 2017
• A Community Health Worker gender action framework: Implications for decent work, rights, and responsibilities, 27 November 2017

By Raafat Hassan, Farzana Islam, Mohammad Riaz Hossain, Sushama Kanan, Malabika Sarker, Sabina Faiz Rashid

Being pregnant is a happy and welcome experience for many women. Yet some women may have to decide to discontinue their pregnancy at some point because of economic factors, health issues, or the need to maintain one’s dignity in within our gendered society.

Terminating a pregnancy is a critical process and an essential maternal health issue as well as a sexual and reproductive right. This process requires trained health professionals and facilities with appropriate equipment for providing a quality service. Lack of these facilities can lead to a woman encountering health related complications which can turn to life threatening hazards.

The REACHOUT Bangladesh team is working towards strengthening the capacity of close-to-community (CTC) providers to enable a strong referral network to ensure women have easy access to safe Menstrual Regulation (MR) services at local health facilities.

MR has been a fundamental part of the family planning programme in Bangladesh since 1979.  A range of MR service providers co-exist in Bangladesh. Government and NGOs have made the services available even at the union level facilities and in urban slums; still there are several barriers to building a strong referral network for women so they can access safe MR services.  

In 2014, almost half of all pregnancies were unplanned and almost three-fifths of those pregnancies ended through MR and unsafe abortion. Unsafe MR services from clandestine operators can create complications such as hemorrhage, incomplete abortion, shock, uterine perforation, and sepsis.  

MR is still stigmatized as a matter of shame and sin, and frowned upon in society. Some even consider it an act against god. A CTC provider who used to refer MR clients to a nearby local facility had stopped referring clients because of her religious beliefs. She said:

“…I do not refer MR clients anymore, because it is a sin and I don’t want to be associated with any of it.”

This kind of belief in society is one of the major reasons behind maintaining secrecy. Women who visit a facility for MR raise a lot of questions within her family and community. Visiting a clandestine provider is seen to safeguard confidentiality.

Older women can be stigmatized for being sexually active. A 43-year-old client who had taken MR services mentioned:

“…I got pregnant in this age. I was very ashamed and could not tell anyone. My elder daughter scolded me for being so careless.”

Women in Bangladesh do not always have the authority to make decisions regarding getting pregnant and pregnancy continuation or termination, because many women in Bangladesh are not socially, culturally, or economically empowered. Women have to depend on their husbands and families for the permission about the decision to seek MR services; and are usually forced to act according to the wishes of others. One 17-year-old client who had taken MR services mentioned:

“…I had to terminate the pregnancy because my mother-in-law told me that it might get suspicious if I get pregnant so early after the wedding.”

In fact, some of the clients did not even tell their husbands about using MR services; because they might be forced to continue with the pregnancy. One client said:

“…My husband lied to me about having vasectomy and told me not to take any precautions as he wanted me to get pregnant. He wants me to get pregnant only because I go outside for work and he suspects men can be interested about me. That is why when I was pregnant I did not tell him and had the pregnancy terminated.”

Clients are also being persuaded by brokers/dalals to use untrained clandestine providers. These brokers/dalals disregard the risks and consequences of their client’s health; they only serve their own financial interests.

In 2014 the government made some policy changes to improve the quality of MR services and to make the access easier. In addition, the government approved ‘mifepristone’ and ‘misoprostol’ known as MRM (MR with medicine). The recent availability of over the counter MR medication in local pharmacies has made it easier for women to access MR services and creates an opportunity for women to maintain secrecy and allow them to take the pregnancy termination decision on their own. Therefore, women prefer having MRM at home rather than visiting facilities to have MR services. However, due to information gaps and lack of proper instructions for administration of the medicines, sometimes women face further health complications such as hemorrhage, incomplete abortion, shock, uterine perforation and sepsis. One of the Clinic Managers mentioned:

“…Nowadays, we receive Post Abortion Care (PAC) clients more than regular MR clients. Because nowadays women tend to perform MR at home using medicines. As most of the time, they do not follow the proper instructions, they face complications like hemorrhage and terrible stomach pains because of incomplete pregnancy termination. Therefore, they come to us for PAC.”

The drug sellers who sell these medicines cannot always provide proper guidance/instructions.  There have been several cases where clients were taken to hospitals/clinics because of  complications. A local drug seller who had stopped selling MR medicines for this reason explained:

“…I have stopped selling MR medicines. Because one of my customers had a massive hemorrhage. Afterwards, her husband came and blamed me for it. Finally, she had to be taken to Sohorwardi Hospital (A public hospital in Bangladesh).”

Besides these, there are also other barriers in access to MR services, such as the high cost, a general lack of information regarding available services, and distances to facilities. Moreover, there are provider-related constraints as well; such as inadequate training of providers, staff turnover and logistical insufficiency.

In Bangladesh, both the public and private sectors should take necessary steps to address these barriers. Extensive awareness building outreach activities on safe MR services at the community level will help to reduce the social stigma and sensitivity around it gradually. Regular follow up with the clients as part of the outreach programs by the CTC providers can also make clients more aware of the role and impact of clandestine operators and their brokers/dalals. Moreover, focused and informative outreach activities about the complications of improper administration of ‘over the counter MRM’ medicines are necessary to reduce complications. Building a strong referral network and dissemination of proper information will gradually allow women to have their own voice in the decision making process regarding pregnancy termination and access safe MR services. 

Recent news

• Problem solving on maternal health: Experience of Shebedino Quality Improvement Team in Ethiopia. 5 December 2017
• A Community Health Worker gender action framework: Implications for decent work, rights, and responsibilities, 27 November 2017
• Reflections on the Salima Quality Improvement team experience, 20 November 2017

By Aschenaki Z. Kea, Kate Hawkins, and Daniel G. Datiko

Though improvements have been achieved in maternal and child health related indicators, Ethiopia still experiences high maternal mortality due to challenges related to utilization of antenatal care, skilled delivery and postnatal care.

REACHOUT has been working to improve the performance of health extension workers (HEWs) in maternal health by strengthening services provided in primary health care units. Through the intervention we have seen remarkable improvements in the uptake of maternal health services.

What did we do?

The life cycle of the REACHOUT project can be broadly divided in three phases: a context analysis and two quality improvement cycles. The context analysis was carried out to understand the barriers to and facilitators of maternal health. This informed the introduction of the first quality improvement cycle in Shebedino woreda/district in Sidama zone. The key interventions of the first quality improvement cycle included group supervision of HEWs, community engagement and strengthening referral linkage, it was led by the research team.

The second quality improvement cycle, primarily led by the woreda health system, was started by establishing a Quality Improvement Team and a technical working group (TWG) at nine health centers and woreda health offices and scaled up to six districts of Sidama zone. The intervention has transitioned from being project led to district led as a result of embedment in the health system. The health center Quality Improvement Teams are made up of five members: the head of the health center (chair), the person responsible for the Health Management Information System, the maternal and child health coordinators, a HEWs’ supervisor and the Woreda Health Office focal person for that particular health centre.

A three-day training was provided to the Quality Improvement Teams in our first workshop, which included how to identify and prioritize quality problems in maternal health, how to develop a change plan, and how to measure and document changes. They identified the root cause of the problems using problem tree and fish bone analysis exercises based on service standards, from their practice and routine reports. Some of quality problems identified and being addressed include: inadequate routine lab services for pregnant mothers including testing for HIV and syphilis; poor data quality; low coverage of fourth ANC visit and facility delivery; lack of logistics; and shortages of supplies.

Priority problems were selected by the Quality Improvement Teams based on a prioritization matrix and developed detail change plan including monitoring and evaluation mechanisms.  The TWG provided technical support and oversaw the Quality Improvement Team to ensure functionality and sustainability.

The Quality Improvement Teams held regular meeting on a monthly basis to discuss the progress of the implementation of the selected quality improvement indicators and develop the next action plans based on the identified gaps. The findings were shared with the HEWs and their supervisors during group supervision meetings.  

Besides the Quality Improvement Team monthly meetings, three joint workshops were held including the initial training. The two subsequent workshops addressed the problems identified in previous workshops, and reviewed the change plans developed for the identified problems, activities undertaken, successes achieved, challenges encountered, and lessons learned.

What have we achieved?

Implementation of the multidisciplinary Quality Improvement Team team has improved the efficiency of the team, quality of group supervision, and the exchange of feedback within primary health care unit.

A focal person from the woreda health office shares information about the work of the Quality Improvement Team with the woreda health office to ensure district led sustained support and learning across the health centers. The tools developed by the project have been successfully decentralized and used in health facilities, contributing to the successful provision of maternal health services. The shift from project led to district led implementation has improved the coverage of facility delivery in Shebedino woreda from 28% in 2013 at the baseline to 78% by July 2017. 

Recent news

• A Community Health Worker gender action framework: Implications for decent work, rights, and responsibilities, 27 November 2017
• Reflections on the Salima Quality Improvement team experience, 20 November 2017
• Towards a Community Health Worker Gender Action Framework, 9 November 2017

By Rosie Steege, Sally Theobald, Kate Hawkins

The health system is a growing employer of women and can help to contribute towards gender equality. Yet gender biases and discrimination are sadly alive and well within this sector. The need to promote gender transformational processes and decent work for health workers of all cadres was discussed at the WHO Human Resources for Health (HRH) Forum held in Dublin earlier this month.

A gender lens is often missing from analysis of the Community Health Worker (CHW) cadre of health workers who operate within communities serving as a vital link between them and the health sector. Although it varies by context, CHWs are predominantly women, often of lower socio-economic status, who have limited career opportunities. The HRH Forum provided an opportunity to highlight some of the gendered aspects of this cadre and showcase experiences and inspiring stories of action for CHW programmes. A panel chaired by Sally Theobald covered India, Brazil, South Africa and Malawi. She opened the session by highlighting the importance of gender and equity in human resources for health and “decent work” agendas, stressing that this lens needs to extend to CHWs who both experience gender inequities and also negotiate the ways in which gender and power play out within the households and communities they serve.

Gender dimensions of the ASHA programme

The first panellist was Kerry Scott (on behalf of Rejani Ved and Asha George) presenting work on the ASHA programme from India. The all-female cadre of staff was developed order to meet the country’s maternal and child health goals. The programme is now made up of 850,000 ASHAs (one per village). In order to better meet the needs of ASHAs a number of policy changes have been made. ASHA’s training has become residential with a crèche facility to ensure the women can participate and also fulfil childcare duties. ASHAs are included as member secretaries of village health committees. This enables them to move beyond the all-female maternal health space and encourages their active leadership in traditionally male dominated realms. Although ASHAs are not formally employed by the government, there are increasing monthly economic incentives for ASHAs to help them meet their need for regular income and encourage the uptake of banking services. The creation of more government scholarships for higher education for ASHAs creates more opportunities for women to access a career pathway. Newly introduced social security measures help support ASHAs via life and accident insurance and pension opportunities. Finally, the creation of rest accommodation in health facilities helps to increase ASHA safety and comfort (as one of their main duties is to escort expectant mothers to facilities to deliver, often at night). 

These policy changes demonstrate positive active steps towards securing the safety and wellbeing of the ASHA as a mobiliser, facilitator and as a care provider. However, there are still challenges. There have been shocking examples of ASHAs being sexually harassed and even raped by community members and other health service providers in the course of their work. The government response has been to ensure that all service providers undergo sensitisation training, but there is still work to be done to ensure ASHAs’ safety and rights are protected at the community level. Kerry concluded with the call for constant adaptation of policies to ensure appropriate response to the ASHAs gendered needs. She posed the question, how do we balance policy progress against social norms which are slower to change? 

Power, gender relations and heteronormativity in Brazil

João Nunes presented on Brazil and highlighted that there is a need for a political economy in analysis of human resources for health and the ways in which international political economies intersect with gender. Since its inception in 1987, the Brazilian CHW programme has been shaped by gender norms. The programme developed against a backdrop of neo-liberalisation, privatisation and an increasing feminisation of labour, where women were seen as precarious workers to fulfil permanent job needs. The programme was initially conceptualised as a way to reduce infant mortality whilst at the same time provide employment opportunities for poor vulnerable women and a make-shift solution for the health of poor communities. Perceived as natural carers and providers for their communities, these women are often required to go beyond their job specification and working hours, providing informal work which is not remunerated such as support for single mothers, victims of domestic violence, and sexual health. 

As is often seen CHW programmes that require CHWs to come from the communities they serve, CHWs work in systems that enable and reproduce gendered vulnerabilities. Informal care work is seen as a women’s domain - this work is downgraded and informalised within the socio-economic system. Similarly, primary health clinics are understood to be a feminine space and often men do not visit. This is compounded by the cultural understanding that men must play a bread-winning role, working during the hours that the primary health care clinic is open. An example of how CHWs internalise and reproduce the norms that they work within was given with regards to the family health strategy – which assumes a binary heteronormative family of man, women and child. In recent years there has been change to make this strategy more diverse and reflective of current households and communities but there has been conservative push back with many CHWs themselves sharing these views. 

Finally, João described how there are many obstacles to the discussion about women’s sexuality which has an impact on what CHWs can do in their formal conversations and advice. Women are seen as mothers and daughters and activities to support women’s sexual health is perceived to be limited to vulnerable groups such as sex workers or trans women. Due to religious and cultural norms discussion about sexuality can be very difficult. For example, the use of condoms is not acceptable for married couples. In the same way that heteronormative gender norms limit women’s capacity to provide sexual and reproductive care, they also constrain men in becoming CHWs. Due to sexual politics men are unable to enter homes which prevents them from providing adequate care. This suspicion of men and reluctance for them to enter the household space, is not unique to Brazil and similar dynamics have been seen in Kenya and many other countries. 

Gender roles and CHWs in Malawi

Kingsley Chikaphupha from REACH Trust (and co-chair of the Thematic Working Group) gave us examples from Malawi, where there are both male and female Health Surveillance Assistants (HSAs). He highlighted how recruitment of CHWs, is not considered from a gender perspective and because of this there is a large imbalance between the numbers of men and women performing the role. Across all districts there are 30% male HSAs to 70% female HSAs. However, when you look specifically at hard to reach areas within these districts, the numbers are flipped, with 70% male, 30% female. 

In hard to reach areas the 30% that are female also appears to be diminishing – this may be due to pressure from husbands to leave the role, or often it is reported that female HSAs leave if they are married to men in who are posted to work in urban settings due to their jobs. In some cases, male HSAs had wives who were posted to urban settings however, they chose to remain in rural areas due to cultural norms that make it shameful for men to be seen to follow their wives. 

We heard how this imbalance affects the health of the community as, although both male and female HSAs have the same responsibilities on paper, in reality the division of labour is quite gendered.  In most settings male CHWs are more privileged than women with greater access to supervisory roles and equipment such as motorcycles. 

King called for: 1) More gender disaggregated data on CHWs; 2) Greater support for skills development; 3) Gender transformative approaches in CHW policy; 4) Work with broader coalitions to prompt societal transformation, a review of current gender strategies, and the creation of a gender frameworks for CHWs.

Working with CHWs to engage fathers in health, wellbeing, and care

Andre Lewaks of Sonke Gender Justice South Africa, talked us through the MenCare Project,  gender transformative training by CHWs to promote father’s involvement in Early Child Development (ECD). 

In South Africa 64% of children don’t live with their biological fathers following patterns that reflect strong cultural and patriarchal norms that promote women as the natural caregiver for children. For every hour of unpaid care given by a man, a woman gives eight. The MenCare Project trained child and youth care workers (CYCWs), provided home visitation programmes and complimented this with onsite mentorship and support of CYCWs. 

A mixed methods evaluation of 544 fathers who took part in the project found a positive transformative change in attitudes towards heteronormative care roles and women’s labour. For example, when asked whether they agree with the statement “a women’s most important role is to take care of her home and cook for her family” before the intervention 79% of men and 60% of women agreed. After the intervention, this dropped to 31% of men and 33% of women. Participants also realised father’s roles went beyond provision of financial support and some women also reported that they realised their own role in the entrenched patriarchal mind set of the community. 

The project reported that CYCWs had an improved capacity to understand and engage men. Men had an improved ability to express themselves which in turn improved communication between partners and lead to improved sharing of household responsibilities. Importantly, in a context of a high prevalence of intimate partner violence, there was a reduction in men’s abusive behaviour. 

Instilling a gender transformative approach to National CHW programmes

Sarah Crass (on behalf of Polly Walker) discussed the gender transformative approaches that World Vision International (WVI) are undertaking through their CHW programmes in Lesotho, Ghana, Sudan and Mauritania. This includes the Timed and Targeted Counselling (TTC) model. 

Fathers’ have a huge impact on children’s cognitive outcomes and even the relationships that they will go on to have in later life. Negative father figures can result in early sexual debut and increased childhood pregnancies. WVI’s evaluations found that a key limitation of CHW programmes, is lack of male partner engagement. Through their TTC model men are included by default and indicators for their involvement are included. It uses positive role modelling and healthy family models to engage men in family activities including time to play with their children and take part in other household activities traditionally viewed as women’s work. The model also makes use of male and female CHW pairs in household visits which is beneficial to circumvent norms that may inhibit cross gender discussions. 

Through this intervention WVI found that TTC counselling is more productive and results in a greater number of concrete decisions being made if male partner is present. They also found that at the policy level male involvement is inadequately addressed and there is dearth of evidence here. They report that policy makers are aware of this gap and are keen to explore new methods for male involvement in community health as the non-participation of men inhibits early childhood development. Through a qualitative evaluation of the TTC model, they were able to report that male involvement leads to improved sharing of household chores with male partners. Male partners were also reported as more likely to take an interest in mothers’ nutrition during pregnancy and accompany mothers to give birth. 

This panel helped to illuminate some of the issues facing CHWs and the communities they serve around gender. It was part of a larger call for greater gender analysis of challenges facing human resources for health which was heard throughout the conference.  For more information on gender and CHWs see our previous webinar on this topic and the REACHOUT blog. If you are interested in community health workers – join our thematic working group by emailing Faye.moody@lstmed.ac.uk.

Recent news

• Reflections on the Salima Quality Improvement team experience, 20 November 2017
• Towards a Community Health Worker Gender Action Framework, 9 November 2017
• Ava’s story: How do gender norms effect close-to-community provider retention in Bangladesh?, 8 November 2017

In Malawi the REACHOUT project works in two districts within the central region - Mchinji and Salima - to promote the work of Health Surveillance Assistants (HSAs), a close-to-community (CTC) cadre employed by the Ministry of Health.

REACHOUT has implemented two quality improvement cycles. In the first, REACHOUT Malawi worked on improving the supervision of HSAs. New challenges were identified which included poor quality of services and data, which are addressed in the second cycle which focuses on quality improvement and management.

The REACHOUT Malawi team trained health workers in Salima in quality improvement processes. With facilitation from REACHOUT, health workers from the districts formed a multidisciplinary quality improvement team, consisting of representatives from the clinical, nursing, environmental health, management and administration departments (including the health management information system and district health management team); and representatives from three health centers (Khombedza, Lifuwu and Baptist) that were pilot sites for the quality improvement initiative. Data quality improvement was the priority problem identified. The quality improvement team agreed to focus on this after discussing a range of problems including poor data storage; lack of data analysis culture to support decision making; multiple and duplicative data collection tools; and limited data collation and reporting.

The problem identification process was done in a participatory manner and involved all members of the team who developed a problem tree which helped them identify the root causes of poor quality data and the effects of poor quality data. To improve data collection the team started by developing one integrated data quality assessment tool to replace the multiple forms that were being filled out but rarely collated. The tool focuses on all heath programmes at the health centre level including maternity services, HIV Testing and Counselling, family planning (FP), Out-patient department (OPD), sexually transmitted infections (STI), Antenatal care (ANC), Anti-retroviral Treatment (ART), postnatal services, and the Expanded Program on Immunization (EPI).

The tool is comprehensive and includes a focus on registers, reports, data collectors, data supervision, presence of guidelines or protocols to measure data consistency and reliability, presence of tables, graphs and charts that would indicate data is analyzed and the results used for decision making, and presence of meeting minutes with data quality on the agenda.

The tool was then piloted and the QI team presented the results to the District Health Management Team (DHMT) for guidance and approval. The DHMT approved the tool and allowed the QI members to use it in assessing the facilities. Several data quality supervisions have so far been conducted at the three pilot facilities and results show improvement in some areas.

At the district level the success story of the QI team initiative has been the acceptance and adoption of the data quality initiative by the District Health Management Team and including it in the district implementation plan. This means QI activities will be funded from district funds and hopefully be sustained.

At the facility level there are also successes:

• Establishment of safe data storage rooms that are lockable so that all data can be stored with easy access to those who need it and to minimize data loss.  All the three participating facilities have such rooms now
• Data reporting has improved for these facilities and they are now able to report in a timely fashion

Locally led multidisciplinary QI initiatives can contribute to the improvement of community data quality at facility level.  A key lesson is that where the team is allowed to identify their own priority problems and find their own ways of solving them, there is greater success and impact. The approach also ensures sustainability of the initiative unlike when problems are identified elsewhere and solutions imposed on locals by those outside the system.

The newly established data storage room at Khombedza - one of the facilities in the intervention led by the Salima quality improvement team.

Recent news

• Towards a Community Health Worker Gender Action Framework, 9 November 2017
• Ava’s story: How do gender norms effect close-to-community provider retention in Bangladesh?, 8 November 2017
• Ensuring data quality? Let’s walk in the shoes of Community Health Workers in Kenya and Malawi, 27 September 2017

We’re delighted that REACHOUT members Sally Theobald and King Chikaphupha will be taking part in an innovative session at the Global Forum on Human Resources for Health in Dublin next week which will highlight the impact of gender on community health worker (CHW) programmes.

When: Thursday 16 November, 10.30-12.00

Where: Minerva

Why?

CHWs are a key workforce cadre encompassing millions of people around the world, yet we have paid limited attention to the gender dynamics of their role, and the impact of this on their own experience and their work with communities and families. Few policies address this issue directly; yet implementation on the ground is deeply gendered. This panel highlights the ways in which gender shapes CHWs’ experiences of decent work, rights and responsibilities across different geographical contexts and sectors and provides a forum for dialogue on the evidence to build and sustain gender transformative and equitable health systems and opportunities for action to support this pivotal cadre.

What will we do?

This panel will share practical challenges and experiences on the ways gender and power shape the recruitment, day-to-day work, retention, promotion and training of CHWs and ways to use gender analysis to transform gender norms within communities and families and build better people-centred, resilient and gender responsive health systems

We will hear from panellists from India who will present gendered experiences from the ASHA programme and implications for roles, designation, power and authority, incentives, career pathway, monitoring and supervision and programme implementation. Next, we move to Brazil for a critical analysis of how gender relations simultaneously empower female CHWs, and leave them vulnerable. In Malawi, where CHWs are both male and female, we will hear how gender power relationships shape this cadre’s interactions at multiple levels and how this is addressed in new approaches to supportive supervision. Next, we hear from the work of Sonke Gender Justice implementing the MenCare Global Fatherhood campaign in South Africa, on strategies to support CHWs to challenge the structural barriers underpinning limited male engagement in child care and health and well-being within households and communities. Finally, we hear from World Visions’ experience of instilling gender inclusive involvement in CHW programmes to address gender and structural barriers shaping early child development and female genital mutilation in different African contexts and supporting gender aware advocacy processes.

Who’s talking?

• Gender Dimensions of the ASHA Programme: Programme Design, Evolution, and Implementation Truths, Asha George, University of the Western Cape, Cape Town, South Africa
• Power, Gender Relations and Heteronormative Norms in the Brazilian Community Health Worker Programme, João Nunes, Department of Politics, University of York, UK
• Gender Roles and Community Health Workers in Malawi: Power and Partnership in Supervision Processes, King Chikaphupha, REACH Trust, Malawi
• Working with CHWs to Engage Fathers Better in Health, Well-Being and Caring, Andre Lewaks, MenCare, Sonke Gender Justice, South Africa
• Instilling a Gender Transformative Approach to National CHW Programmes: Addressing Male Involvement, Gender-Based Violence and Caregiving – Experiences from Lesotho, Ghana, Mauritania and Sudan, Polly Walker, World Vision, UK

Do come along and join us!

Photo credit: Mehret Lamiso At Her Health Post Becha Kabele, Ethiopia. Photo taken by Rosie Steege.

Recent news

• Ava’s story: How do gender norms effect close-to-community provider retention in Bangladesh?, 9 November 2017
• Ensuring data quality? Let’s walk in the shoes of Community Health Workers in Kenya and Malawi, 27 September 2017
• The first step in saving life: Community health workers of Bangladesh and menstrual regulation, 20 September 2017

By Sumona Siddiqua, Farzana Islam, Malabika Sarker, Sabina Faiz Rashid

Bangladesh, like many other developing countries of Asia and Africa, is going through a tremendous crisis of health workforce where estimated ratio of doctors and nurses are 3.05 and 1.07 for per 10,000 population respectively. To combat the shortage of health workforce the Bangladesh government along with the private sectors and non-government organizations (NGOs) involve close-to-community (CTC) providers, including formal and informal providers.

CTC providers are low paid or volunteer front line workers and responsible for regular field visits to households to disseminate information on sexual and reproductive health (SRH) issues; menstrual regulation (MR) services; family planning; antenatal care (ANC) and post-natal care (PNC) services. They counsel the clients, promote clinic services and referral activities, and carry out data collection. They also visit homes, identify clients who wants to do MR, refer them to a clinic, and if needed they accompany them to their appointment. This cadre serves as a bridge between professional health staff and the community and assists communities to identify and address their own reproductive health needs related to family planning, MR services, sexually transmitted infections, and pregnancies. But as in many countries, Bangladesh faces challenges in retaining CTC providers, especially volunteers.

Ava’s experience

Ava (not her real name), one of the CTC providers who took part in the REACHOUT facilitative training programme, has been working to help women in the community with their reproductive health needs as an informal CTC provider for over ten years and referred clients to the Marie Stopes Bangladesh clinic. She is a 31-year-old married woman who has two school-going children. Her husband is an informal traffic control worker. He did not earn much and wasn’t able to fulfil the family’s basic needs.

From the very beginning of her family life, Ava wanted to contribute to the family income and provide monetary support to her children’s education. She tried to find a job, however, she was not successful as she has no formal education or any technical training. She did not give up and tried to talk with the neighbourhood women to find out whether there are any opportunities to have a job. Finally, she got to know from a Marie Stopes Bangladesh staff member about cash benefits by referring female clients in the clinic for child delivery, family planning, and MR related services. Without delay, she made the decision to start work as an informal CTC provider and to be volunteer of Marie Stopes Bangladesh. Her activities were not limited to only referring the clients to Marie Stopes Bangladesh, she also accompanied clients to the clinic, provided support to the clients while they were using the clinic’s services, communicated with clients by mobile phone to follow up, and provided moral support whenever needed. She was very hardworking and passionate to her job and her neighbourhood women clients were welcomed by her and sought her support even at midnight. Ava dedicated herself to support vulnerable women so that they could have easy access to quality SRH services, especially MR services.

But after 10 years, unexpectedly her husband started mistrusting her activities. He showed disrespect and made negative comments, such as “you are going for bad work with other men”.  Ava’s husband prohibited her from discussing MR and SRH-related issues with other men. He was motivated by people around him. He felt that women of good character should not work in the community and conduct door-to door visits and talk about these issues. He started to scold Ava and humiliated her both mentally and physically for her job. He even attended Ava’s mobile calls and addressed her clients disrespectfully. He used to call her to find out about the locations she was working and then followed her to see exactly where she was. 

Ava became upset with this kind of attitude of her husband. She is a dignified woman with self-respect. She left her husband twice to avoid the embarrassing situation, however, every time she came back because of her children.  “I know how bad he is, but I cannot leave because of my two children,” is what she said about the situation. Although she loved her job and believed that she has responsibilities to her neighbourhood women in terms of providing a quality service for the sake of children’s wellbeing she decided to leave the job. Women from her community came to her for several times and repeatedly requested her to continue her job and get rid of the brokers who used to confuse them and forced them to receive SRH related services especially MR services from providers who were not professional.

Ava felt that she had saved many women from complications after MR through timely referral to clinical services. She was very happy with the REACHOUT training, but felt bad because afterwards she was not able to apply her updated knowledge in the field. She said, “If anyone will train me in the future, I will appeal to them to please train my husband along with me.” She remains hopeful that her husband will be able to understand her and allow her to start work again as a community health care provider.

Implications

Ava’s story helps us to understand the challenges faced by female CTC providers, and some of the reasons for the high level of dropout. Female CTC providers experience more difficulties than male CTC providers to continue their work due to lack of family members’ support, social insecurity, teasing from both male and female community members, and social taboos. Many women in our society often sacrifice their jobs because of their husbands’ dominant character and family pressure, and reasons linked to gender relations and women’s disadvantaged status in society. Sometimes husbands feel inferior when their wives work outside and bring a steady income home, sometimes social pressure (insinuating comments from family, neighbours and other community members) become too much. This problem of female CTC providers who feel they cannot continue their work must be addressed in the organisations by conducting counselling sessions involving the family members of the CTC providers and sensitize the family members about the nature of community health workers’ job-related responsibilities and activities in the community.  This could help to empower female CTC providers, both formal and informal and reduce the number of dropouts. 

Recent news

• Ensuring data quality? Let’s walk in the shoes of Community Health Workers in Kenya and Malawi, 27 September 2017
• The first step in saving life: Community health workers of Bangladesh and menstrual regulation, 20 September 2017
• Is my job worthwhile? A story of an Indonesian village midwife, 20 September 2017

By Kingsley Chikaphupha, Regeru Njoroge Regeru and Kate Hawkins

Data from community health programmes is essential in understanding their contribution to healthy lives and promotion of well-being of all. Unfortunately, the quality of data reported by Community Health Workers is often poor meaning - like community health programmes themselves – this information remains on the periphery of health systems and is not used by decision- and policy-makers at district and national levels.

Let us put ourselves in the shoes of a Community Health Volunteer (CHV) in urban Kenya:

Why should I worry about the quality of the data that I report to the Community Health Extension Worker (CHEW), a.k.a. my supervisor? Us CHVs are meant to meet with the CHEW monthly but she never calls us. I am still holding on to reports for the past two months because I don’t know where to take them. 

And wait – what does data quality even mean? No one has ever told me. When I was recruited as a CHV two years ago, I was replacing another volunteer from my area who had suddenly dropped out from the programme. He had to go make money to feed his family. I was recruited after one of my friends who is also a CHV introduced me to the CHEW for our community unit. She told me that I was lucky because a non-governmental organisation would be conducting a training on water, sanitation and hygiene (WASH) in a few days and that I could join that training and then start working. The CHEW took me to our Chief and he gave his approval and that was that. I attended training on WASH the next week and the CHEW gave me photocopies of a form she said I should use to collect data when I make household visits. I began visiting households in our community unit with my friend and then eventually by myself. When I first started using that form I noticed there was so much we are meant to write about mother and child health. No one has ever taught me about mother and child health! My friend told me I should record data using ticks and crosses but this confused me so I just use 1s and 0s. Some of the terms also confuse me - what exactly does skilled delivery mean?

Anyway – I’ll just keep doing what I’m doing because whenever we meet the CHEW she just picks up our forms and we never get any feedback.

Now let us put ourselves of the shoes of a Community Health Volunteer in rural Malawi:

My Health Surveillance Assistant (HSA), a.k.a. my supervisor, has just called for me to come and help him with data collection about how many children under five in my catchment area are up to date with immunization. Now what am I going to write on? I just bought a new notebook for school for my child last week – I guess I must tear out some pages so I have data to give to my supervisor. I wish we had a tool from the government – after all we are collecting data that goes into government forms used by our supervisors.

Community health workers have the potential to be the ‘eyes and ears’ of the health system. They are our first point of contact with communities, collecting data that should be an essential underpinning to decisions about health service provision. Yet as these vignettes illustrate, the ways which they are treated run counter to the frequently repeated claim that decision making should be evidence based.

And we can do so much better. It is time that all community health programmes took steps to demonstrate how much they appreciate community-level data, and the people who collect it.

We put forward the following six recommendations for community health programmes:

1. Inform Community Health Workers why the data they collect and report is important.
2. Provide Community Health Workers with the tools that they need to do the job and ensure these are designed with their input.
3. Teach Community Health Workers how to complete their data collection and reporting tools and provide regular feedback and guidance on data management especially when new tools or processes are introduced.
4. Support supervisors of Community Health Workers in analysis of community-level data for identification of gaps and increased responsiveness to the challenges facing their communities.
5. Provide written guidelines and procedures for data management in community health information systems.
6. Inform Community Health Workers how the data they have reported has been used in decision- and policy-making so that they can see the impact of their labour.

Recent news

• The first step in saving life: Community health workers of Bangladesh and menstrual regulation, 20 September 2017
• Is my job worthwhile? A story of an Indonesian village midwife, 20 September 2017
• Community Health Volunteer backpacks: The heavy burden of community health worker responsibilities, 19 September 2017

By Tamanna Majid, Sushama Kanan, Farzana Islam, Malabika Sarker and Sabina Faiz Rashid

In Bangladesh, poor women often lack access to the necessary information about sexual and reproductive health services like menstrual regulation (MR)^[1] and menstrual regulation with medication (MRM)^[2] because it is a sensitive issue.  Though MR must be done in a limited time period, women frequently exceed the safe period of MR because they lack proper information about the time window and the quality services that are available. They resort to low-quality but cheap services from informal providers as they are easily accessible in urban communities.  In most instances, these informal providers do not have enough qualifications or basic training to provide these services safely. Every year a huge number of unintended pregnancies occur in Bangladesh.

Here is one woman’s story:

Rashida, a 16 year old girl, wanted to do Menstrual Regulation (MR) because her husband did not acknowledge her baby and was not willing to live with her. She lived with her father, who is a poor day labourer, and faced difficulties in providing her food and medical expenses.  Despite having a kidney problem she desperately wanted to do MR because her husband would not bear her expenses and she did not want to become a burden for her family. As she was pregnant, nobody wanted to give her employment…But she did not have the necessary information on how to obtain MR so she had tried to collect information from different informal providers like drug sellers and dai (traditional birth attendants). She got conflicting information from many different people. Some of them told her that doing MR is easy and some told her she cannot do MR because of her young age and health problem and that she might die.  She could not get the right information or proper counselling about MR or quality services for Antenatal Care (ANC). While she was searching for information, one of her relatives took her to a clinic where an MR service is provided. However, it was revealed after having an ultrasound that she had already passed the safe time period for having MR because of the delay. She was told to take ANC care but she was willing to terminate her pregnancy at any cost. So, she went to a drug seller and bought medicines which can induce abortion. After taking the medicine she had severe bleeding and had to be taken to hospital for a blood transfusion and post abortion care which cost a lot of money and put her in debt.

Community health workers (CHWs) work as a bridge between the community and health care facility. A range of CHWs, both formal and informal, are available in Bangladesh. Formal providers are the health workers are affiliated to NGOs and government and informal providers are those who do not have any institutional affiliation. Usually formal CHWs are trained and play an important role in child, maternal, and sexual and reproductive health (SRH). They are the first point of contact at community level, and do promotional and preventive health services in urban communities. CHWs disseminate health related information like clinic addresses of nearby health facilities to make the community aware of available health services and related cost. This information helps clients to take decisions about health care services especially sensitive issues such as MR. Poor women can avoid unnecessary hassles, save time and money, and protect themselves from clandestine operators and brokers by getting the right information from trained CHWs.

As part of REACHOUT, efforts are being made to build the capacity of these CHWs. In Bangladesh, the project focuses on the improvement of CHW’s effectiveness on MR. This project provided training to the CHWs on facilitative referral so that they can understand the referral system and how to provide information dissemination, networking, counselling, and efficient and timely referral. The aim is to provide accurate information to the client, provide a referral card, and lower the rate of unsafe MR. Training of CHWs can enhance their motivation and commitment levels. 

Facilitative referral training has strengthened capacity of CHWs in the intervention area. CHWs showed improved counselling techniques, greater confidence regarding field work, rapport building skills, and prioritized the clients’ perspective which has resulted in better quality services by CHWs and increased service uptake by clients. As the next case study shows, by utilizing their new skills CHWs can support poor women to get quality health services especially on sensitive issues like MR where they may face problems in telling others or seeking help.

When Amina, a 24 year old women, became pregnant again, she already had three children and could not afford to feed, clothe, and educate another child. She wanted to do MR but she did not know where to go. A CHW from Marie Stopes Bangladesh, partner organization of REACHOUT, visited her house for their service promotion. The CHW had received facilitative referral training. Amina shared her problem with the CHW who explained the process for obtaining a quality service within the safe time period. The CHW also mentioned that if a client took the MR service from the health care centre they will provide her family planning counselling and suitable methods for family planning. The CHW gave her all the information she needed about the clinic and the cost of MR and MRM services, maintaining confidentiality, and quality of service. After that the CHW gave Amina a referral card where the address and time of the service was clearly written. The client got all the information she wanted, she took consent from her husband, and went to the clinic with the CHW. She was very satisfied with the service and now she can share this information with her neighbours who need it.

In 2014, an estimated 1,194,000 MR and abortions were performed and many of these were done in unsafe conditions or by untrained providers.   Currently, 53% of government facilities are permitted to provide MR services.  Some NGOs and private sector also provide MR Services though they are not sufficient for the whole population. So there is a huge unmet need for safe MR services. The results from the REACHOUT project training intervention come from two intervention areas in Dhaka city. Scaling up the intervention in other areas will allow more CHWs to strengthen their capacity and help poor and vulnerable adolescents and women to get quality and safe MR services. Access to accurate information and quality services will make a big contribution to better reproductive health outcomes in Bangladesh.

By Patricia Tumbelaka

Cianjur is one of the districts in West Java, Indonesia with high maternal death cases and one of the contributing factors is the service quality delivered by the CTC (close-to-community) providers. REACHOUT, a five-year research project involving six countries focusing on the equity, effectiveness and efficiency of CTC services in rural area, collaborated with the District Health Office to address this issue. In 2015, REACHOUT conducted the first Quality Improvement (QI) cycle in four villages which targeted the village midwives and kader (volunteer community health workers) who worked closely with the community in providing health services, specifically maternal and child health services. Two interventions were conducted, health promotion training and supportive supervision training, which aimed to improve the communication skills in providing information on maternal issues and to enable supportive supervision amongst the CTC providers.

Seven village midwives and 188 kader were involved in this training and this story of one village midwife captures her experiences in improving her skills.  

“My name is Rose (not her real name) and I would like to share my story on how REACHOUT has influenced my career. I am a village midwife in one of the villages in Cianjur district in Indonesia. I have been working as village midwife for more than 20 years and my main task is to provide service in maternal and child health, family planning, and nutrition. Being a round-the-clock village midwife is not an easy profession. I faced several challenges, such as waking up in the middle of the night to attend delivery and during rainy season, the road becomes muddy and difficult to access. The community also demand that I provide general health care, specifically care for the elderly which is beyond my job description.

As the only health care provider in the village, not all of the community members accept and respect me. Some of the mothers rarely shared their problems with me, probably because they think I am not friendly. On top of that, I also need to deal with the issue of high maternal death cases in the village, which the community blame on me. Having these many responsibilities, tasks, and demands from the community made me feel unhappy, tired, and unmotivated to work.

When REACHOUT came to the village and introduced quality improvement programme, I was reluctant to take part because I thought the training was not suitable for me as a village midwife. However, after the aim of the training was explained, I agreed to be involved. I made the right decision to participate in the training. There are many benefits that useful for me. I learned better communication skills to talk with the mothers. I learned how to supervise and give feedback to the kader. Before, I never evaluated their work, but now I gathered all the kader at the end of Posyandu (health integrated post at the village) and talk to them. I feel my workload lessened and my motivation increase to give a better health service to the community.”

The impact of REACHOUT was truly beneficial to the CTC providers, particularly the village midwives. Changes in their attitude and motivation were clearly seen across the seven village midwives who participated in the training. They are motivated to perform a better health service in the community. One of the success factors was the participatory approach of the training which allowed the participants to interact actively during the process. It also provided the opportunity to be directly involved in the learning process.

Based on the experience of Rose and her fellow midwives the REACHOUT team recommends the Puskesmas (community health centres) adapt the training approach and implement it on a larger scale with different participants from other villages. Furthermore, constant monitoring from the health managers in the Puskesmas level is needed to ensure that the supervision processes in the Posyandu are sustainable. 

Recent news

• Community Health Volunteer backpacks: The heavy burden of community health worker responsibilities, 19 September 2017
• Village Health Volunteers in Indonesia: Negotiating changes in health seeking behavior with pregnant women, 18 September 2017
• Measuring quality in Malawi’s community health system: Barriers and challenges, 31 August  2017

By Nelly Muturi

The eighth REACHOUT Consortium meeting was held in Malawi from 11^th to 16^th September 2017. The meeting started on a high note with a Knowledge Café that provided an opportunity for all country teams to showcase their Quality Improvement (QI) work and learn from the Malawi teams from Salima and Mchinji districts. Part of the day’s activities was to display the contents of a standard community health worker backpack from each of our countries. I had the privilege of presenting the contents of the backpack from Kenya based on what I had observed during the course of our field work.

What is in the bag?

A standard Community Health Volunteer (CHV) backpack contains both work-related and personal items used in the day-to-day life of a CHV. Work related articles include; the Middle Upper Arm Circumference (MUAC) tape, standard Ministry of Health reporting tools (service delivery logbook and the referral booklet), a notebook and a pen, de-worming tablets, water purifying tablets, condoms, pain killers (Paracetamol) and Information, Education and Communication (IEC) materials that mainly focus on Maternal, Newborn and Child Health (MNCH), and Water Sanitation and Hygiene (WASH), Sexual and Gender-Based Violence messages (SGBV).

Women’s backpacks often differ significantly to men’s. Women can carry personal effects such as a khanga[1], body lotion, a mirror, or sanitary pads. In this way the backpack replaces her handbag. Not all CHV backpacks are the same. All CHVs should be provided with a bag for work. But in reality many are not and so they have to improvise. A lot of CHVs use polythene bags (which are now banned in Kenya) or personal handbags (for woman CHVs) as their backpack. The ones with branded backpacks consider them a motivating factor.

What do the contents of the bag tell us?

Looking at the bags helped me to reflect on the multiplicity of tasks that they have to perform and how that impacts on what they carry while executing their day-to-day responsibilities. A CHV has multiple roles and does not only serve their community as a health worker. They may be a parent, and are certainly a community leader in one way or another, and as such have to balance this with serving the community.

In Kenya, CHVs are volunteers and do not receive monthly pay for services. Their key responsibilities include; health promotion and education, growth monitoring for children under five years of age and referral of community members to link health facilities. In other settings, CHVs have more responsibilities for example in Malawi Health Surveillance Assistants (equivalent of CHVs) have up to 500 roles which they support to implement as part of health service delivery at community level.

CHVs have standard reporting tools developed and approved by the Ministry of Health (MoH) which include the Service Delivery Log Book (MoH 514) and the referral form (MoH 100). The standard MoH 514 is a large book that is in the words of CHVs, “very bulky and difficult to carry around.” Consequently, this contributes to a huge load on a standard CHV backpack because a CHV has to carry the reporting tools every time they are conducting a household visit.

Vertical CHV programmes have negatively impacted on backpack contents. Projects in different areas such as HIV, malaria, maternal health etc. introduce new tools for CHVs resulting in additional responsibilities which they are expected to deliver and report on. In some instances, a CHV may be required to fill up to four different tools in a single household in order to report on different programme areas. Reflecting on this, I appreciated the dilemma CHVs face on which roles to prioritize over others. As a result, most of the time CHVs prioritize working on what is easiest, what is paid for, or what they feel is important to them as opposed to trying to do and document everything.

The Knowledge Café provided us a great experience to walk in the shoes of a CHV and to appreciate the relevance of each of the contents by taking the visitors through each component of the backpack. Of particular interest was the referral form and participants were wanted to hear how the CHVs used it and how it supported referral follow up to monitor uptake of health services by community members at facility level. In addition, it provided an opportunity to appreciate the multiple roles of CHVs in communities. It allowed researchers to understand the complexities of the health systems which CHVs work in and possibly understand why or how CHVs make choices when faced with multiple responsibilities.

As a researcher, this experience highlighted the need for community health worker programmes to integrate reporting into tools that are already in use by CHVs and to seek their input when developing new ones. It also demonstrated some of the ways governments, policy makers, and programmes can keep CHVs motivated. Motivation approaches should be both financial and non-financial incentives like branded CHV backpacks. On a positive note, the exhibition experience provided an opportunity to show how the CHVs have adapted to the different settings and despite the challenges that they face - especially the lack of adequate commodities to do their work. It also showed that CHVs are willing to go out of their way to use their own personal effects to facilitate their service provision at community level.

By Rukhsana Ahmed, Sudirman Nasir, Licia Limato and Korrie de Koning

Cianjur is one of the nine districts in West-Java Indonesia, and it is one of the districts with the highest maternal mortality rates in the country, despite close proximity to the capital city. To support the district health system in improving maternal health services, REACHOUT research identified the need to improve birth preparedness and to work with Posyandukader (one type of close-to-community health workers in Indonesia) in counselling pregnant mothers and communities about maternal health issues.

Health promotion and supportive supervision training

REACHOUT Indonesia developed a health promotion and supportive supervision training and follow up programme to improve the communication skills of the Posyandukader and village midwives.  The aim of the programme was to inform women about dangers in pregnancy and childbirth, negotiate the common goal of a healthy pregnancy and delivery, and promote the supportive supervision of village midwives and Posyandu kader in a structured manner.

An evaluation of this intervention was conducted through individual interviews, group discussions and a most significant change (MSC) methodology with women, key informants, village midwives, kaders and supervisors. It demonstrated encouraging results. Pregnant women appreciated that Posyandukaders were better able to answer questions and that women and pregnant women are receiving more information than previously, as one mother in the study confirmed:

“After the kader received training, I observed kaders are showing more care to Posyandu visitors. Now, kader give information that pregnant women with labour signs should seek help immediately. I used to ask something to kader but only Mrs E could answer it and other kaders were unable to answer. Now they are able to provide comprehensive information with examples and what are the things that pregnant women must do if the labour signs happen.”

This viewpoint was echoed by the kader:

“[This is] the first time pregnant women are aware of the signs of labor, breastfeeding, and postnatal care…Bbefore the REACHOUT training, the knowledge then was likely to be only known by mothers who are pregnant with their third child. I also observed that as the pregnant women became aware of health [issues]; it encourages their husband to participate in supporting their wife to give birth in a health facility by providing them the delivery budget.”

Most kader were enthusiastic about their new knowledge and expanded skills, and felt motivated by the ability to answer questions:

“Back then, I was easy to become furious, emotional, and upset because I didn’t know how to answer those questions. Now I feel happy because, with my limited educational background (elementary school), limited knowledge and experience, I can still help people in my area.”

The following quote from one of the midwives illustrates how village midwives improved the interaction with clients:

“Training gave me knowledge about how to face the community and negotiate their issues with them... earlier I thought that the patient must agree with my decision but now as a village midwife, I am not allowed to force the patient. I just have responsibility to give suggestions and let the patient make their own decision.”

Village midwives also shared how the improved knowledge of kaders assisted in timely referral:

“Kaders became more pro-active. I was called to the house by the kader…it turned out that the opening (of the cervix) was already complete while the mother was apnoea. I directly referred her to the hospital. Fortunately, I have kaders who inform me about that.”  

In summary, results show that the health promotion and supportive supervision training improved the ability of kaders to share knowledge with mothers and changed the approach to communication with pregnant mothers by some of the village midwives and the Posyandu kaders. This positively affected the appreciation of the mothers and increased the motivation of kaders to conduct counselling.

What worked well were interactive learning approaches in small groups, feedback during follow up observations, the use of appropriate, newly developed counselling cards and the support and supportive supervision by midwives. At the same time, improved management of the Posyandu created a more conducive environment for conducting the counselling.

Recent news

• Measuring quality in Malawi’s community health system: Barriers and challenges, 31 August  2017
• Do devolved Kenyan county governments prioritise universal health coverage?, 10 August 2017
• Improving maternal health in Shebedino district, Ethiopia: Positive stories need to be told, 1 August 2017

By Kate Hawkins, Maryse Kok, Kingsley Chikaphupha and Meghan Bruce Kumar

“There is significant data collection through various methods and implementers of community health. HSA’s are technically assigned to complete over 40 M&E forms and processes while there are currently 15 different types of data used in community health. The amount of data collection creates a burden for implementers around consistency and quality of data that is weakened by insufficient quality assessments and training for data collection… Multiple processes for data collection also raises questions around data quality given the amount of time needed to devote to multiple M&E processes as well as limited trainings and supervision.”

Malawi National Community Health Strategy 2017 - 2022

As the drive for Universal Health Coverage and the Sustainable Development Goals (SDGs) has led to a push for greater health service access, the issue of sustaining and embedding quality in the ways in which these services are delivered has gained prominence.

Measurement of quality and attribution of its effects in health is challenging at any level. But little is known about how quality is assessed within community health programmes, who are on the frontline of health service delivery in many low- and middle-income settings. The degree to which new initiatives like the Lancet Commission on Quality in Health Systems will include community health programming and the role of close-to-community health providers is currently unclear.

Health systems are shaped around well analysed power asymmetries. Relatively less powerful staff who labour at the interface of the community and health sector are rarely canvassed on their opinions of quality nor are their voices prominent in the decision-making processes that effect their daily labour. At the more local level differences in the personal characteristics of community health workers and their supervisors (such as sex, educational level, class, experience of poverty etc.) also act to reinforce power asymmetries.

This brief explores how close-to-community health providers in Malawi perceive quality as an aspect of their work and highlights some key challenges which may hinder the definition, measurement, and achievement of quality at the community level. It is based on research conducted by REACH Trust.

We found that Health Surveillance Assistants, the community health workers that operate in Malawi, experienced many challenges which hindered the provision of what they would consider a ‘quality’ service, these included:

• Inadequate training on quality improvement/assurance and a lack of incentives for peers to learn from each other on this issue
• Supervision which was not supportive and which rarely focused on quality of care. Where progress was measured against quality indicators this tended to be partial and limited to a handful of programmes
• That guidelines on topics like task shifting had not reached the district level and below and when they are received they are not always used
• Erratic monitoring visits
• Multiple quality measures that were related to the plethora of vertical interventions which are managed by NGOs in addition to those required by the government
• A lack of standard Ministry tools to enable HSAs to measure progress which leads HSAs to create their own informal summary activity reports which are often supplemented by a multitude of programme-specific reporting forms (e.g. for nutrition, iCCM, family planning).
• A lack of pre-testing of new tools which means that they are not always fit for purpose
• Poor data quality at community level which is reported on an ad hoc basis if/when requested by NGOs or HSAs. When this data is collected it is not always analysed or interpreted. Collated data is not consistently fed back to communities so that they can make changes

Read the brief to find out more.

Latest news

• Do devolved Kenyan county governments prioritise universal health coverage?, 10 August 2017
• Improving maternal health in Shebedino district, Ethiopia: Positive stories need to be told, 1 August 2017
• Universal Health Coverage: The economists’ perspective, 26 July 2017

By Rosalind McCollum,

Kenya went to the polls this week in the first general election since devolution reforms began in 2013.  As citizens select their new political leaders, including at the devolved county level, we reflect on findings from our recent study which explores priority-setting for health at the new county level, across ten of Kenya’s 47 counties.  

Devolution in Kenya occurred largely in response to growing frustrations caused by the wide inequities and inefficiencies of the former centralised government and growing local and international pressure following the post-election violence of 2007-2008.  These inequities have led to differing levels of access and use of essential health services, health facilities, and health workers between the 47 counties, influenced by a persons’ geographic location, wealth, education level, gender and age.  In response to these unfair differences, the allocation of funds from national to county governments, according to the commission for revenue allocation formula, takes into account each county’s poverty level, with the addition of an equalisation fund for the 14 most marginalised counties to promote development of formerly disadvantaged areas.  Once funds reach the county government, how priorities are set and how budgets are allocated falls within the responsibility of county authorities.  Since different health services promote equity to varying extents, we carried out qualitative research with a range of respondents, including typically unheard voices, from community to national level.  We studied how county decision-makers identify health priorities and the implications of this for health equity and community health services - the first tier of the Kenyan health system and a recognised platform for achieving universal health coverage. 

Our findings (summarised in a policy brief) suggest devolution is improving equity between counties, bringing positive ramifications for health equity in previously neglected counties.  However, equity within counties remains unclear. Participants described wide variation in the distribution of funds between areas, with some counties attempting to adopt pro-poor distribution and others providing equal distribution regardless of underlying needs.  The rapidity of devolution and accompanying funding responsibilities (which went to scale across the country within a matter of months), combined with limited guidance and varied technical capacity has meant that decision-making and prioritisation for health have at times been captured for political and power interests.  More powerful politicians were found to influence the distribution of investment, typically leading to more infrastructure within their home areas, compared with those of less powerful politicians.  Unless championed by a powerful decision-maker within the county, less visible community health services, including health promotion, disease prevention and referral, risk being neglected in the prioritisation process. 

“The decisions might be subjected to a lot of political interference by the county (politicians)….  Many of them see the importance of curative services but they do not see the strength or the importance of the health promotion, public health activities, and therefore getting financial allocation to that department has been a challenge.  Because …they make decisions based on votes, will this get me more votes? So, they do not tend to see that when we prevent malaria or prevent diarrhoea that you are going to get votes.”  County Level Health Respondent

As Kenya moves forward, we hope these lessons will be beneficial to decision-makers at county level in the new government as they take up the opportunity of the immediate post-election period to address the community health gap and lay down positive institutional structures, practices and norms which promote health equity for all Kenyans.  

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By Maryse Kok

Shebedino has a lot to offer. Especially the tastiest Ethiopian coffee, if you believe the locals. Indeed, the coffee ceremony in the Woreda Health Office not only provided a nice opportunity for a catch up between the REACHOUT team and the head of the office, Buriso Bulasho, but also brought us warmth and comfort on this cold and rainy day.

Although Shebedino is only 25km from Hawassa, where REACH Ethiopia – partner in the REACHOUT consortium – is located, the bad shape of the road made the trip to the final quality improvement evaluation workshop uncomfortable and time consuming. Arriving at the venue of the meeting, nine health centre level quality improvement teams were all ready to present their progress over the past year.

The quality improvement process

The health centre quality improvement teams comprise of five members: the head of the health centre (chair), the health management information system and maternal and child health coordinators, a health extension workers’ (HEWs’) supervisor and the Woreda Health Office focal person for that particular health centre.

As such, the diversity of workshop participants was wide and therefore I was impressed by the fact that all had the same understanding about what quality in primary health services entails. In line with the national healthcare quality strategy, quality care was defined as:

"Comprehensive care that is measurably safe, effective, patient-centered, and uniformly delivered in a timely way that is affordable to the Ethiopian population and appropriately utilizes resources and services efficiently"

The process of quality improvement, the plan-do-study-act (PDSA) cycle, was explained by several presenters. Earlier the quality improvement teams selected ten problems related to quality, of which they prioritized three. The problem was assessed, targets were set and activities were planned for, presented in a clear table including recourses needed, timing, evidence for completion of activities and who was responsible. This was the time for evaluation and refection.

Outcomes of the quality improvement interventions

Dulecha health centre (25km from the Woreda Health Office, four health posts, serving 38,214 population in a poor area), focused on antenatal care (ANC), postnatal care (PNC) and skilled birth attendance. HEWs with their health development armies (HDAs, women from each household assisting the HEW in health promotion) were tasked with early identification of pregnant women. In addition, health education was intensified through pregnant women fora and home visits by HEWs. Performance was evaluated every month; and the zonal level visited the quality improvement team once, to discuss the project. Attendance at the first antenatal visit increased from 63% to 73%, at the fourth from 53% to 68%. Challenges remained: skilled birth attendance (currently at 63%) is to be improved by reducing the drop-out of pregnant women from ANC4 to facility delivery. Furthermore, HDAs need further strengthening and HEW home visits still need to take place more often.

Dobe Toga health centre (catchment population of 34,089) brought about change in ANC1 and 4 (56% to 74%; 49% to 68%) by improving registration of pregnant women, improving feedback to HEWs from the side of the facility and continuous monitoring of pregnant women by HEWs and HDAs.

Abela Lida health centre (serving 28,391 people) reported on the grading of HDAs. A committee with different officials, including HEWs, perform quarterly assessments of households. Based on this, households receive a grade (A, B or C; with A being well performing and C being less well performing). Progress was made with more households deserving an A. This system made me wonder: the publicly announced grade can motivate, but also demotivate community members. The quality improvement team explained that very poor households are helped by the neighbourhood, for example by the provision of materials for pit latrines. Therefore, no one can have an “excuse” not to perform.

Over the past year, Telamo health centre (catchment population of 24,507) focused on improving the acceptance of long term family planning methods and increased service delivery to community members in need of special support. Identification of blind, deaf and elderly people was conducted together with the kebele chairmen, HDAs and HEWs. The poorest people were selected and provided with special support or health services via outreach. The presenter discussed a slide on “quality” versus “equity”, after which a good debate took place on how to achieve equity in all nine health centres that Shebedino has.

Mechanisms for success

Not sure if you have the same feeling from reading the summary above, but I was impressed with the progress made in the nine health centres. What were the mechanisms for success? Based on what transpired during the meetings, I identified the following:

1. The Government of Ethiopia is currently focusing on quality improvement in health. In some health centres, the quality improvement team had more than four members (to six), as per recent training and guideline of the Ministry of Health. This reinforced the importance of the quality improvement team and its work, and provides an excellent opportunity for sustainability of the teams initiated by REACHOUT.
   
   
2. The head of the Woreda Health Office, who attended the REACHOUT quality improvement workshop in Indonesia in 2015, has a strong interest and provides leadership in quality improvement through applying the PDSA cycle. With the decentralization of the health system, health centres receive a budget allocation from the government on an annual basis and on top of that, they have their own income from fees related to some of the services they provide. Therefore, after prioritizing quality problems, they are able to allocate budget for trainings or other activities. The joint enthusiasm for the quality improvement intervention even led to health posts making their priority lists and going through the same cycle.
   
   
3. Many of the activities that were implemented by the health centres, following the action plan of the PDSA cycle, needed the work of HEWs and HDAs. Communication with HEWs was enhanced through HEW focal persons (lately re-named as kebele supporters): they are the linkage between health centres and health posts. They have monthly meetings with HEWs, in which performance is jointly assessed. HEWs are motivated by the possibility of upgrading, which is working well in Shebedino – again because of leadership at the level of the Woreda Health Office. HEWs do joint planning with HDAs. Although there is no reward system for HDAs, they get recognition in public meetings, because good performers are mentioned by name.
   
   
4. Efforts from non-governmental organisations such as Reach Ethiopia never stand alone: the district has made progress as a result of the strong leadership at the Woreda Health Office, as well as (limited) efforts of other partners. To improve maternal health, maternity waiting homes were built at all health centres in 2014. In addition, a free ambulance has been running for two years, with 24/7 midwife attendance in the ambulance. I met the two midwives who are dedicated to making a difference for poor pregnant women living in hard to reach areas: it is not easy to be on the road at night. These are examples of interventions, launched by the Woreda Health Office, that contribute tremendously to the goal of REACHOUT in Shebedino: improving maternal health.

Positive stories need to be told

In health systems programming and research, there is a general complaint that positive stories outnumber the negative ones. We should learn more from things that did not work. I definitely agree with this. However, it is also important to write about the positive. Not only we can learn from the mechanisms of success in Shedebino for other districts in Ethiopia and beyond, but stressing the positive also keeps us going.

At the end of the day, heading back to Hawassa on the same bad road, the diversity of people walking, talking, selling and buying – but also struggling, exhausted because of hard working, in pain or feeling too cold – again stressed the idea that improving community health serves even a wider goal than health for all, it is a basis for sustainable economic development.

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I spent several days last week attending the International Health Economics Association’s biennial congress in Boston, USA.  Aside from being a great place to enjoy the company of my delightful brother and his family, who live there, it was also a chance for me to reflect on other perspectives that sometimes get lost in the disciplinary bubble in which I find myself.

Much of the time during this meeting, I was reminded of my MSc course on Health Policy, Planning and Financing. By design, the course is spread between two institutions, the London School of Hygiene and Tropical Medicine and the London School of Economics. Ostensibly, this gives the student the benefit of these two institutions: diverse areas of expertise, networks of alumni, and of course perspectives on global health issues.  In reality, it often felt like being in the middle of a great debate about whether equity and epidemiology or financing and utilization were more important considerations in shaping health systems.  More broadly, this reflects fundamental beliefs about whether individuals combine to shape the system (bottom-up) or whether the system will determine the outcomes (top-down).

That feeling aside, a few things that stood out for me from the conference:

1. Defining Universal Health Coverage (UHC) is a question that is dealt with on a national level:

In my day-to-day work, we emphasize increased equity of access to care as the key aspect that would be a change from current systems under UHC.  In the conference, there was a lot of focus on the WHO Cube, which talks about three dimensions: for whom (equity), what (services), and how (financing) UHC would work.  This was a good reminder to me that each of these elements need to be defined.  Sometimes we take a naïve view that UHC means free healthcare for all.  But really, it’s some services for some people paid in some part. Defining that package is still in progress in most countries and greatly shapes whether UHC is claimed as an achievement.

2. Quality continues to be a neglected piece of UHC debates:

All this talk about UHC is great, but it’s amazing that in a group of people (read: economists) who talk so much about benefits and value, we are still struggling with defining quality of care.  Dr. Kruk, Chair of the Lancet Commission on High Quality Health Systems, was the only person I heard describe this problem in detail.  However, repeatedly I heard people saying something to the effect of, “We keep confusing the fact of whether we want more healthcare or more health – they aren’t synonymous”.  So there is clearly a need for more work on improving quality measurement and the reliability of data as well as quality improvement work at all levels of the health system.

3. But really, who decides?:

The top-down, system and finance heavy approach to UHC leaves the mixed methods researcher in me a little queasy.  An increased focused on complexity and low- and middle-income countries was welcomed in the conference agenda. However, these conversations were often absent in the session debates. I’d like to see more space in the UHC world for innovation and policy experimentation rather than blanket policy norms. This would require active elicitation of narrative and qualitative reporting exploring what different approaches mean for the people involved, whether positive or negative (e.g. increased workload, more satisfied customers, improved skills), as well as questions about money.

At the end of this meeting, I was left with a strong feeling that I’m working in the right place.  The issues that we deal with in REACHOUT at the community level are very relevant within the national and global debate on UHC. Individuals shape systems and systems shape individuals and we need to bear this in mind as we move toward evidence-based decision-making alongside donor-driven priorities and domestic politics.

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Community health workers are increasingly recognized as an integral component of the health workforce needed to achieve universal health coverage in low- and middle-income countries. They have a unique intermediary position between communities and professionals in the health sector. Their performance is shaped by transactional processes between these different actors.

In her talk Maryse will analyse the multiple factors that influence community health worker performance and develop a framework on their performance. This is based on evidence from a systematic review that included 140 studies related to community health workers working in promotional, preventive or curative primary health services. Empirical data came from a multi-country study on community health worker performance in Ethiopia, Kenya, Malawi and Mozambique, in which focus group discussions and interviews were undertaken with community health workers, their supervisors, managers and community members.

The framework on performance demonstrates that programme design, health system and broader context are most important to performance. Influencing factors can be divided into ‘hardware’ and ‘software’. Hardware elements, such as supervision systems and accountability structures, continuously influence software elements: the ideas and interest, relationships and power, values and norms of the actors involved.

The framework touches upon interesting considerations for policy, practice and research. The realization that hardware and software elements are both needed and need to strengthen each other, calls for the incorporation of programme or intervention elements facilitating this process. For example, the introduction of a supervision system should reflect and take into account power relations and values and norms of the people involved, including those in the community. Health systems research should take into account the software elements, as effective systems thrive on these elements, and performance, in particular community health worker performance, correlates with the strength and nature of relationships between all actors. 

If you are at the conference please do come along and say hello.

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By Amin Soebandrio, Rukhsana Ahmed (both Eijkman Institute, Indonesia) and Hermen Ormel (KIT, the Netherlands)

The Eijkman Institute for Molecular Biology in Jakarta, Indonesia, one of the REACHOUT partners, was founded during the Dutch colonial era in 1888. Its first director was Dutch scientist Dr Christiaan Eijkman, who in 1929 received the Nobel prize for his ground-breaking research linking vitamins, nutrition and health. The institute, which was closed during much of the post-independence 60s, 70s and 80s, was reopened in 1992 and in August of 2017 will celebrate its 25^th anniversary.

For these historic reasons and the current collaboration between the Eijkman Institute and KIT, through REACHOUT, the current Director of the Eijkman Institute, Prof Dr Amin Soebandrio was recently invited to the Netherlands to attend the 110^th anniversary congress of the Netherlands Society for Tropical Medicine and International Health, held at KIT on 9 June 2017. Rukhsana Ahmed, who coordinates the REACHOUT Indonesia work, accompanied him. Prof Soebandrio used the opportunity to share historical highlights of the Eijkman Institute as well as key REACHOUT findings from the Indonesia chapter of our research consortium. KIT staff and REACHOUT principal investigator Hermen Ormel, in collaboration with REACHOUT overall coordinator Dr Miriam Taegtmeyer of LSTM Liverpool, offered the overall background information on REACHOUT and some of the inter-country results to date.

Interestingly, the congress’ opening plenary presentation by Leo van Bergen, a medical historian, convincingly showed that ‘tropical medicine’ in the Dutch colonial era was in fact ‘colonial medicine’. Focus was on “fighting disease that threatened Dutch colonial rule or economic gains”, with “medical thinking dominated by Western supremacy”.

During his presentation Prof Soebandrio took the audience on a tour to Indonesia and the Eijkman Institute history, leading to the current-day Institute’s recognition as the National Center of Excellence in Molecular Biology and Genomics. While much of the Institute’s work deals with genetic biodiversity, human genetics and infectious diseases, through REACHOUT an important component was added focusing on social science research on maternal health and community health workers (CHWs). Prof Soebandrio emphasized the importance of the REACHOUT research among community integrated health posts (Posyandu) volunteers (kader), to support reducing Indonesia’s maternal mortality ratio (359/100,000 live births; 2012 data). Kader are the first point of contact of the communities (suburban and rural) to access maternal and child health services.

The Eijkman Institute’s REACHOUT research brought attention to several challenges faced by Indonesian CHWs. At community level, the patriarchal cultural norm hinders referral by the kader of pregnant women for facility delivery.

“My challenge is that the communities can’t accept what I told them. The pregnant woman wanted to deliver at home because her husband didn’t permit her to deliver in the health facility.” (Interview with female CHW)

At CHW level, findings highlight the limited training opportunities for kader, leading to suboptimal service quality.

“There are some kader that haven’t got training yet… The new ones who haven’t got any trainings, they don’t understand their work.” (Interview with community midwife)

Lastly, at health system level, the REACHOUT research points to ‘favouritism’ in kader recruitment and retention, which hindered the continuity of their work in the Posyandu.

"Kader recruitment and dismissal are based on the favour of the community leader and not on their performance." (Interview with community midwife)

In sum, Indonesian CHW performance is challenged by gender-based decision making at household and community-level, favouritism in recruitment and training limitations. Greater involvement of local leaders to recognize kader’s voluntary work and quality services is crucial to help sustaining maternal and child health programs.

The dedicated Dutch audience thus received a glimpse of the rich menu of findings that Eijkman Institute as REACHOUT Indonesia partner offers.

Photo captions and credits:

Prof Dr Soebandrio, Chair of the Jakarta Eijkman Institute, doing his presentation at the congress – linking colonial medical research to global REACHOUT research (KIT Amsterdam, 9 June 2017; photo Hermen Ormel).

Posyandu volunteers in action (photo Eijkman Institute)

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On the 12 June 2017 the University of York’s Department of Politics and Centre for Global Health Histories held a fascinating meeting which explored the impetus towards the mobilization of communities in the definition of health policies and the delivery of care; and the role played by community health workers (CHWs) in this process. It was a chance to look backwards and get a historical view of the formation and adaptation of CHW programmes in different settings as well as looking at some of the more contemporary challenges and how these two things might relate. Three elements of the discussion stood out for me: religion, gender, and community and participation.

Religion

Recently I have been working with colleagues on a literature review on gender and CHW programming which is part of a larger paper. One of the things that struck me is the only papers that we found that made an explicit link between gender and religion were those from Muslim-majority countries. One can only speculate at the reasons for this. These papers tended to focus on how becoming a CHW increased women’s mobility in settings where they have traditionally stayed in the home and how this can be an empowering experience. They also point to the potential dangers of women breaking social norms and their vulnerability to attack and sexual assault by men when out and about in the course of their work. It may be due to our search terms, or the journals we are limited to, but I was surprised at the lack of papers where Christianity was at the forefront of analysis. As an atheist, I have had time to contemplate faith while at meetings on CHW programming that begin (and often end) with a prayer. The workshop was refreshing in that we heard new perspectives on how Christianity has influenced the conception and function of CHW programmes in different settings.

What became clear from our discussions is that Catholic and Protestant organisations have different models of mobilising communities, and attitudes towards them, which plays out in the design and functioning of CHW programmes. Ben Walker presented on Medical missionaries, Community Health Workers and NGOs competing and creating universal health care in Ghana between 1967-1983. Ben challenged the perception that the implementation of Community Health Workers was an entirely secular venture by describing the way in which missionaries and Churches in Ghana were involved in their formation. He tracked the changing attitudes amongst the Presbyterian and Catholic churches in Ghana across the 1950s to the 1970s in order to show how, whilst initially mission doctors and Ghanaian Christian health work prioritised a hierarchical relationship with local communities, reformations in mission theology in the 1960s shifted their practices. Particularly he emphasised how Vatican II, medical missionaries connection to local anthropologists and Christians studying at U.S. public health schools all encouraged community-oriented perspectives on how to incorporate Ghanaians into medical work. 

We heard how Liberation Theology (of the type found mostly in Latin American countries) purposefully centred on the agency of communities and their active participation in overcoming socio-economic inequity. This essay by Paul Farmer describes how this approach underpins community health interventions in Partners in Health. We heard how in the Brazilian health system Catholic and African religions are integrated and this was central to the development of their model of health care. Community conceptions of what constitutes good health and wellness were what shaped the interventions provided, which is why homeopaths/herbalists are licenced providers of care. Polly Walker described how World Vision’s faith-based approach to development has evolved over the past 60 years, moving away from a provider-beneficiary relationship towards a model of transformational development and partnership (which reflects local ownership and definition).

Gender

REACHOUT was represented by Rosie Steege who reflected on some of the gender issues that have been raised as part of the work of the consortium and in her PhD research. She concluded that gender impacts upon CHWs in a multitude of ways and current CHW policies do not acknowledge the complexity gender plays ‘supply side’. This is a missed opportunity to promote gender transformative approaches at all levels of the health system. Her overall argument was that approaches on the ground are often governed by gender but not gender transformatory policies as a result they are sub-optimal.

Gender was also a focus in the presentation by João Nunes (Department of Politics, University of York) on CHWs in Brazil. He described CHWs as simultaneously vulnerable and empowered and in part this is because a big percentage of them are women (98% in some states). CHWs are often precariously employed with short term contracts, underpaid, and seen as disposable members of the health teams. They experience occupational health problems, such as trauma, stress, and physical injuries. João described how the community health programme is deeply heteronormative. Women are chosen as CHWs as men are not allowed to go into people’s homes unaccompanied, reflecting dominant conceptions of what is ‘appropriate’ for men and women. He relayed an anecdote where a member of staff recounted, ‘we have one male CHW but he is a homosexual so that is alright’. Heteronormative structures are very much present in many of the CHW programmes that I have seen – in anything from the way that households are defined, to assumptions about women’s caring responsibilities and natures, to CHW attitudes towards clients who break norms related to sexuality such as having children as teenagers - but they are rarely remarked upon. It would be great to see further analysis of this area.

Group discussion focused on whose ends are served by pushing women into positions where they are vulnerable to community violence and other forms of harm. I have long wondered why there is not more discussion about workplace health and safety in relation to CHW programmes. Employers have a responsibility to those who labour for them whether their workplace is an operating theatre or a doorstep.

Community and participation

In the CHW world there can be a tendency to posit communities as benign and all community participation as positive. Yet conversations at the workshop pointed to some of the limits of CHW programmes and how good intentions within drives for community health could have negative unanticipated consequences.

An excellent presentation by Karina Kielmann (Institute of Global Health & Development, Queen Margaret University) described how relationships and provider/client interactions are key to the delivery of HIV interventions through CHW programmes. She talked of how pre-existing social bonds can be instrumentalised by community health programmes and these can have negative consequences. For example, the creation of ‘expert patients’ to support adherence to ARV treatment in Malawi weakened horizontal links between peers and therapeutic solidarity as their positions were professionalised. In Zambia, the professionalisation of home based care practices meant that CHWs were less involved in physical care and did not support households through the provision of food. As their traditional role transformed people felt surveilled and policed by CHWs who were thought to adopt a berating attitude and meddle in household affairs through their treatment adherence practices.

Emma-Louise Anderson (University of Leeds) presented a paper on dependent agency and the limits of community mobilisation for democratisation and equity. Based on work in Malawi and Zambia (both countries which are extremely aid dependent in terms of their HIV programmes) she described how networks of people living with HIV and the support groups that followed from them are considered potential mechanisms to foster equity. However, in these settings aid recipients are ‘dependent agents’ who are constrained by exclusionary informal networks, donor recipient relationships and patronage politics. This is not to say that they were powerless and there were many ways in which structures were subverted, for example, through 1) the outward performance of compliance, such as using human rights language without a commitment to their realisation for all; 2) extraversion, or making dependency obvious so that it is advantageous in terms of additional resources; and 3) resistance below the line such as using euphemisms, stretching rules, and dragging feet. Nevertheless, community health in this environment has undermined the solidarity, accountability, transparency and the trust needed for democracy. It has led to the exclusion of certain groups and the pitching of different communities against each other. CHW interventions need to better understand the behind the scenes ways local people are enmeshed in unequal power hierarchies and social obligations if their programmes are to be successful.

In other conversations, we discussed how regimes of expertise and practice take up and then discard community members as the popularity of CHW programmes ebb and wane. One participant described CHWs as the ‘handmaidens’ for opening up markets for Western drugs as part of a global trend that is moving away from community care towards biomedical interventions.

The workshop was an excellent opportunity for academics from different backgrounds and disciplines to come together and share. I am hopeful that it will lead to fruitful collaborations in the future.

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In a panel discussion on 'Economic evaluation of complex service delivery interventions in low- and middle-income countries', Meghan Kumar will be presenting early PhD research on methods, challenges, and findings from REACHOUT related to the costs of quality improvement for community health.  Following this, Jason Madan will be presenting musings on applied approaches to cost-effectiveness looking at the REACHOUT case study and building on sessions in April 2016 and March 2017 with the REACHOUT country teams.

Stay tuned for a blog on the meeting and how it is shaping REACHOUT’s participation in the Economics of close-to-community providers network.

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The workshop focuses on two interlinked features: the impetus towards the mobilization of communities in the definition of health policies and the delivery of care; and the role played by community health workers (CHWs) in this process. The rationale underpinning this is that:

“On the one hand, communities were heralded as the natural site for the mobilization of health initiatives aimed at the democratization of access – indeed, community responses were seen by many as a privileged strategy to avoid top-down, ‘one size fits all’ approaches. On the other hand, from the outset CHWs functioned as a rallying point for the improvement and democratisation of healthcare, with more equitable and affordable coverage being combined with the promotion of healthy lifestyles and environments. Since then, whilst lip-service continues to be paid to community-centred approaches, their fate has often been subject to the vagaries of donor agendas. Likewise, CHWs have fallen victim to cost-cutting and to a global shift towards the control and eradication of specific diseases. This interdisciplinary workshop sets out to explore the efforts to inspire and mobilize community participation throughout the twentieth and twenty-first centuries, and the role played by CHWs as a unique mechanism for the improvement of health systems with the potential for enhancing equity by bringing services to the previously excluded, while also enhancing democracy by mediating marginalised groups’ perspectives through to decision-making processes.”

Rosie Steege will be presenting on the importance of gender transformative policies for CHW programmes and Miriam Taegtmeyer will provide a paper on a systems-thinking approach to improving community health and the interface role of close-to-community providers in Africa and Asia.

The workshop is being organized by Dr João Nunes (Department of Politics, University of York) and Dr Alexander Medcalf (WHO Collaborating Centre for Global Health Histories, University of York). To find out more please contact João (joao.nunes@york.ac.uk).

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In March, the REACHOUT consortium gathered in Nairobi, Kenya for our seventh consortium meeting, bringing together health systems researchers, implementers, and policymakers working on community health in six countries.  As the world celebrated International Women’s Day, we gathered to discuss the role of gender in the work of Community Health Workers (CHWs) in these diverse contexts. Presentations from the various countries highlighted the fact that the problems were largely common yet solutions were local, demanding a deep understanding of the complexity of the context and individuals involved to be effective over time.

Broadly, our work is mixed-methods implementation research.  In qualitative work, we have spoken with communities, health workers, health system managers, and decision-makers at all levels - and of course, with the CHWs who serve at the interface of communities and health systems.  Even as we as researchers aggregate these voices into findings relevant to the health system, we feel the power of the individual stories.  In the words of Miriam Taegtmeyer, what continues to bubble to the surface is the “moral obligation to ensure the voices of the community health workers are heard in the halls of power”.

What emerges strongly in all countries where we are working is the role of power and politics in achieving local change and system-wide change.  Despite the overwhelming prevalence of researchers at the Health Systems Research meeting in Vancouver last November, the key message I came away with was the fact that in many cases, evidence was not the gap.  Sometimes, evidence is indeed the foundation of policy, but the policies are not implemented.  As Penina Ocholla of Great Lakes University, Kisumu stated: “…all these wonderful policies are gathering dust!”

In “How Change Happens”, Duncan Green emphasizes the importance of “dancing with the system”, embracing complexity and moving away from logical frameworks.  This resonated with me on a very deep level.  In simple words, REACHOUT supports district health management teams to improve documentation and measurement, bringing data to the forefront of community health systems management. Despite this seemingly straightforward task, we are left with questions that have answers difficult to quantify:

• How do you identify the institutions and norms that need to adapt for change to persist? 
• How do you harness and strengthen capacity of individuals even as natural turnover moves that capacity outside our geographic area of intervention?
• Is it possible for institutions to develop and sustain capacity that is primarily built through investment in individuals? Is this ‘resilience’?
• Can resilience be planned or must it emerge?

As REACHOUT moves toward the end of its funding period, we actively observe and embrace non-linear pathways to change. These changes come largely through ‘software’ elements of the system like relationships, trust, leadership and mentorship – as well as the fundamental ideas, institutions, and interests that define the system.

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• Emerging issues related to gender and community health workers, 27 March 2017

By Camille Coyle

As community health worker (CHW) programmes expand throughout the world, it is crucial that we learn from the experiences of CHWs themselves. By giving voice to these frontline health workers, CHW programme design can be informed by and responsive to their unique needs. In 2014, I conducted a qualitative study that explored the perceptions and experiences of health extension workers in Ethiopia.

With a workforce of over 38,000 female health extension workers (HEWs), Ethiopia is at the vanguard of global efforts to expand community health worker programmes. Just as Ethiopia’s health extension programme was inspired by Pakistan’s lady health worker programme, many countries are striving to replicate Ethiopia’s success. As this takes place, the voices of HEWs must be heard. 

Uncovering agency

As part of my study, in-depth interviews took place with ten HEWs in southern Ethiopia, and the research uncovered a powerful sense of agency among them. These HEWs reported feeling proud of their work and of their role in the community. Moreover, they felt motivated by engaging with and serving their communities, and they described this as the most satisfying aspect of their job:

We are happy with our service by looking at the changes in the community and the fruits of our performance. I am so satisfied because of my good performance for my community.

Participants gave particularly rich descriptions of the satisfaction they experienced when working with mothers and children, and they highlighted the fact that knowing these women and children personally heightened their sense of gratification:

I am proud to support and serve the mothers in my community, who taught me when I was young. I felt so much pleasure one time when I supported a mother I know. She gave birth to a healthy child after being assisted by me. When she looked at her baby for the first time and said “my child,” I felt joy.

HEWs also conveyed a deep sense of commitment to their communities, which they described as having strongly influenced their commitment to the job:

I was offered a different position in another district regarding women’s affairs politically. I refused that position because I love to serve the mothers in my community. I do this job with great pleasure. I always remember my mother, she gave birth to 11 children. If there had been such privileges previously like there are now with the health extension programme, our mothers would not have suffered.

However, alongside their commitment to the community, many HEWs expressed deep frustration with work overload, lack of career development opportunities, and low levels of financial reward relative to their hard work:

The tasks we are performing are too many and do not match the salary we are being paid. There is such a big difference. We are neither satisfied by our salary, nor are we getting the opportunity to advance ourselves in our jobs. But still I am performing this job with great pleasure because I have fallen in love with this HEW job.

How can other countries learn from this?

This study has important implications for the global expansion of CHW programmes. The findings suggest that HEWs in southern Ethiopia feel a strong sense of agency, marked by commitment and motivation, based on satisfaction derived from supporting their own communities. However, it is unclear if this is sustainable without addressing their underlying frustrations. Furthermore, addressing these issues could potentially increase their sense of agency.

Policy makers could operationalise these findings and address HEWs’ frustrations in a variety of ways. Salary scales for HEWs could include incremental annual increases – even small annual increases might allow HEWs to feel that their hard work is valued, not only by the community, but by the health system as a whole. Regarding career development opportunities, policy makers ought to design career pathways for HEWs that facilitate merit-based upward mobility. These career pathways, along with specific promotion criteria, should be shared with HEWs during initial training and during annual career performance evaluations.

Health extension workers have become the bedrock of Ethiopia’s health system. These women are the human foundation upon whom expanded access to health services is almost entirely dependent. Their satisfaction, motivation, and commitment to their work is paramount. Serving them and addressing their unique needs, indeed the needs of all community health workers, is key to unlocking our potential to achieve health for all.

Peer-reviewed articles resulting from this study are forthcoming. For further information, please contact Camille Coyle at camillejcoyle@gmail.com

The photo is of Fantu and her daughter in Ethiopia by Rosie Steege

Recent news

• Research uptake: Learning from policy makers in Kenya, 5 April 2017
• Emerging issues related to gender and community health workers, 27 March 2017
• Women in the changing world of community health work, 17 March 2017

Lynda Keeru, Kate Hawkins and Robinson Karuga

Since our inception, we have placed a great deal of emphasis on communications and research uptake. Our initial project planning included a stakeholder mapping and policy and practice analysis which led us to prioritise this area as an integral part of our research on community health workers. It was underpinned by a number of principles that guided our interventions: 1) that the research uptake process is complex and non-linear; 2) researchers are more likely to have an impact if there is early and ongoing engagement with stakeholders; 3) embeddedness in the context and with policy makers and processes is crucial; 4) outputs and processes need to be tailored to audiences; 5) identifying allies and champions supports the research uptake process; 6) using existing channels of communication rather than creating new ones provides value for money; and 7) monitoring progress and remaining adaptable is important.

We took advantage of our annual meeting in Nairobi to engage with health policy makers from the national and county level to better understand how they use evidence in policy and the weaknesses and strengths of current systems of researcher-decision maker interactions. We will use this knowledge to shape our communications work as we move forward.

What evidence is used for decision making?

We heard from national and county level government officials that that a range of data sources are used by decision makers including: desk reviews; online databases; evidence from development partner projects; and routine data from the community (for example from dialogue days and meeting plans), facilities and hospitals. A great deal of routine data is collected by Community Health Volunteers and analysed by their supervisors, Community Health Extension Workers.

Despite a wide array of data sources this evidence is not put into use most of the times. There is a weakness in the culture of using data and data analysis needs to be built into management meetings. Analysis and use of data can happen on different levels. However, some levels of staff do not have the skills or the means to do this.  The quality of data is sometimes very compromised, which leads to wishy washy reports. 

How can evidence be aligned with policy needs?

Although not all evidence generated through research leads to policy change, there is a need for operational research to generate ready to use data. This research should be guided by the Ministry of Health’s research agenda rather than being imposed from the outside. We heard that too often partners come to counties with their own ideas about what they want to research – there is no ‘partnership’ in this approach. It was agreed that decision makers at all levels need to be involved in the research process from the outset. It increases the likelihood of use and that the research itself is fit for purpose.

There are also weaknesses in the mechanisms for sharing data. Universities often fail to engage policy makers. Data needs to be made accessible – not just in a format understood by academics or presented in a conference in ‘Copenhagen’ – but demonstrating local solutions in a manner that local stakeholders can understand. Research should not just be disseminated but the communication of data should also be tailored to the politics and context of the where academics are working. The policy makers told us that timing matters in terms of research uptake, there is a need to take advantage of windows of opportunity for change, and spotting and engaging with these chances is easier if you are based locally. 

How is policy made and implemented?

Research can inform policy and policy can inform research. Most policies are set by Presidential or Ministerial Directive which are guided by research. One challenge is the gap between written policies and their implementation. Research institutions should make in effort to better understand these challenges and offer concrete suggestions for how they can be overcome. In Kenya this will need to take into account the process of devolution and how this is playing out in the health system.

We heard that researcher and policy maker incentives aren’t always aligned and so researchers are rewarded for peer review publications which are not so useful for decision making. This is a weakness in the system of knowledge generation. Forums like government Technical Working Groups can be a place where researchers can share knowledge. But they also need to include government workers from the sub-national level. If this doesn’t happen then there is a danger that the work will be rejected.

We thank all the policy makers who shared their time and knowledge with us and look forward to many more fruitful collaborations in the future.

Recent news

• Emerging issues related to gender and community health workers, 27 March 2017
• Women in the changing world of community health work, 17 March 2017
• What does trust have to do with Community Health Workers and the Sustainable Development Goals?, 6 March 2017

By Kate Hawkins, Sally Theobald, Rosie Steege, Maryse Kok, Mohsin Sidat, Kingsley Chikaphupha, Ralalicia Limato, Hermen Ormel, Daniel Gemechu Datiko, Robinson Karuga

To celebrate International Women’s Day the REACHOUT Consortium held a symposium in Nairobi on “women in the changing world of work”. This symposium grew out of a recognition that the sex of the Community Health Worker (CHW) influences their interaction with the health system.

Gender norms also shape CHWs’ different experiences in the course of their work both with households and the health sector. We have argued that CHWs play a critical interface role – connecting the health sector with the community – and although an analysis of the ways that gender influences this was not explicitly built into our research design from the outset, it emerged as an important issue in our REACHOUT context analysis. To investigate further, a Liverpool based Masters student, Woedem Gomez, undertook a literature review on gender and close-to-community (CTC) providers.  REACHOUT PhD student, Rosie Steege is exploring this topic in international policy discourse, as well as conducting empirical case studies in Ethiopia and Mozambique investigating how the health system can best support both male and female CHWs, recognising their differing needs.  We also worked with the Health Systems Global Thematic Working Group on CHWs to hold a webinar to share learning on gender and CHWs in different settings, including Democratic Republic of Congo and Palestine; which triggered further debate and questions.

Based on this learning and the premise that we still have time in the last months of our research programme to further educate ourselves on this area (and at least encourage others to consider from our lessons learned, positive and negative) we decided to spark off the process with a dialogue that enabled our team to engage with other stakeholders in Kenya.

Gender norms and related attitudes and behaviours are not fixed

We heard that gender norms are contextually specific and subject to flux and change through time. Mohsin Sidat (Mozambique) pointed out that many years ago women were not allowed to learn and practice medicine and about 100 years ago female physicians were still exceptional in the medical world. Today the scenario is different and, for example, in Faculty of Medicine of University Eduardo Mondlane where he is Dean they have about 60% female students. This clearly indicates gender roles in medical study and practice have changed.  Nevertheless, for centuries, the role of midwifery has been reserved for women and it continues to be so in recruitment and training of midwives. The midwifery role attributed to women is acceptable in most countries and few men take it up (in Sub-Saharan Africa). However, men and women are trained as Gyneco-Obstetricians and both perform deliveries and the role of men at this level is not questioned. These gender ascribed roles within health sector are certainly historical and perhaps also consolidated by social and cultural norms.

Miriam Taegtmeyer (UK) made a strong case that it is the responsibility of health systems researchers to challenge gender inequities – it is an ethical issue – and one that enables us to contribute to tackling the social determinants of health, as well as harmful practices such as gender-based violence and female genital mutilation.

CHWs are leaders

There is increasing focus on women and leadership in the global community, although this often focuses on leadership within the UN, WHO, donors, national parliaments and universities and is not extended to the community level. Sally Theobald (UK) led us through the global literature in which it has been argued that women may make up 70% of the CHW cadre.

They are arguably leaders at the community level. Unfortunately, although training and salary differ across contexts, female CHWs are more likely to be unpaid than their male counterparts – which is a unacceptable example of gender inequity, with higher level positions often reserved for men. Drawing on research on leadership in the Kenyan system more generally Kui Muraya (Kemri, Kenya) explained that there are social and cultural factors which are a hindrance to women’s leadership. Women’s domestic responsibilities often mean that they do not have the same amount of time for this work which means that these barriers need to be tackled if quotas are to be met.

Kingsley Chikaphupha (Malawi) reflected on how at the recent Kampala conference a community health volunteer (CHV) articulated these issues very clearly. Framing his thinking via the Sustainable Development Goals (SDGs) and in particular SDG 8 relating to decent work, he posed the question: Are we providing enough decent work for women?  He felt that if one were talking about gender and CHWs and all of the unpaid volunteers were women and most of the paid positions were filled by men, then this is a serious problem. If the health system provides decent work to women, there will be no excuse for excluding women from decision making. However, others argued that women having paid jobs doesn’t automatically mean they are heard when it comes to decision-making; in many organizational setting men’s voices are more often heard (they are in higher positions etc.).

Daniel Gemechu Datiko (Ethiopia) explained how (all-female) Health Extension Workers (HEWs) in his setting are paid and that this is a deliberate move to recognise the work of women as part of the health system and empower them by expanding the role that they were already doing for free in the community. Wages cover the opportunity cost of the time that they spend doing this work. HEWs leadership is positioned and explicitly recognised through their role as the secretary for the village committee/leadership, this positon allows them to call meetings, share health related information and to influence their peers. Some HEWs have moved up the career ladder and obtained their diploma and Bachelors degree, and in some cases they have been assigned to health centres and district health programmes. In three years’ time all of the HEWs will complete their training diploma as a matter of national policy. However, there are still very few female supervisors – so although we are paying this cadre of women, there is still a ceiling for them to become leaders among HEWs and until we address wider issues of female education/ gender and culture norms then this will remain a barrier.

In a story from Kenya, Penina Ochollo, explained how she had observed female CHWs taking leadership when it was not offered. A group of female CHWs who had been working for ten years got tired of retired men from the big city dominating in the community councils and pocketing expenses. Through their lobbying one of the local women got elected to the council anddespite being in the minority, it changed the dynamic. She argued that initiatives like this need support and that gender mainstreaming needs to come from county leaders in line with the Kenyan gender mainstreaming strategy which was written in 2006 but has sadly yet to be fully implemented at County or community level. In her reflections, Penina stated that women took up leadership in delivering community health services whilst delivering on pressing household and societal duties – with no financial incentives.

Being a CHW can be empowering but there are gender-related challenges

Penina shared many insights about the trajectory of CHW programmes in Kenya. She explained how the trainings that CHWs receive create changes in their personal and family life. Becoming a CHW enables them to participate in exchange visits around Kenya, to network and attend training seminars which inspire them. They are no longer ‘poor ladies’. Whilst some husbands agreed that there had been positive changes in the home due to this, they were suspicious about home visits, that their wives might be involved in mpangowakando (having extra-marital sexual relationships). This led, in some cases, to gender based violence. The likelihood of suspicion and violence increased proportionately to the CHWs popularity in the community and influence with local leaders. She explained that male CHWs have the potential to influence other men in the community however they were not always received favourably by husbands who were suspicious of their presence in the house - another trigger for gender based violence. Penina argued that there was a need to work with the male partners of female CHWs to ‘sensitise’ them to what the job involves and include them in things like workshops so that they better understand the CHW role and its impact. Other countries, such as Ghana, have chosen for an explicit combination of male and female CHWs at the village level, which also needs special attention on how to address gender and optimize programme outcomes.

Rifat Mafuza explained how in Bangladesh the concept of women’s empowerment is explicitly linked to economic empowerment within the CHW policy. For this reason, CHWs are linked to micro-credit schemes to expand their economic potential and that their interactions with women in the home also cover access to education, legal services etc. 

Gender-sensitive policy making and implementation is a gap that needs to be filled

Penina reminded us about the 1978 Alma Ata Declaration and the policy trajectory of primary health care and community health care. As the community health strategy was developed in Kenya they called upon the assistance of women, “they were the rock to move this mountain!” Women were the first choice of CHWs as they were directly affected by issues like nutrition and family planning. Initially women volunteered; it was not a paying job and had no career path. Men were not interested. There was too little attention to gender in the implementation of the strategy and its development over the years. She explained that male involvement has become more and more critical – particularly in terms of support for maternal, newborn and child health. Greater numbers of men are becoming CHVs but the ratio today is still around an 80/20 female to male.

We heard from Sally that CHWs can support change in the community– in terms of the social determinants of health and harmful gender norms - but we don’t always give them the tools or support to do this. This requires the support of the health system through policies related to supervision and community oversight bodies who need to be sensitised to gender-related. Summarising discussions, Maryse Kok (the Netherlands) explained how in community health committees in Kenya there are more males than females but that this is sometimes at odds with the constitutional requirement that no more than two-thirds of elected or appointed public bodies consist of one sex. Even when policies like this exist, their implementation may be slow. Kingsley suggested that when it comes to the selection criteria for CHWs we take our own biases into the process. If we say that women have more caring qualities, we influence the way that clients see male workers which makes it difficult for them to be employed as CHWs and carry out the role.

Salim Hussein (Kenya) returned to this point arguing that we need to mainstream gender inclusivity throughout the community health programme and that CHWs need to be trained in how they can improve gender equity and given messages that they can disseminate to the community. For this to be successful we need to sensitise formal health workers and to motivate and incentivise the leaders so that they have the capacity to advocate for gender equity. Simultaneously we need to assist communities in holding leaders to account. There was a strong plea for more leadership at all levels: from international to national and communities. Carol Ngunu (Kenya) explained that in Nairobi County they are ensuring that traditional birth attendants (TBAs) become CHVs because their experience in these roles means that they understand the challenges and norms in the community – and are an accepted support system that men feel comfortable with. She also outlined that Nairobi county is the first Kenyan county to roll out the gender mainstreaming guidelines in health facilities and the importance of these reaching the community level, including community leaders. She also stressed that there is a need for gender specific targets in health programmes.

The international literature outlined by Sally shows how the CHW role can bring personal harm and risk of sexual and gender based violence. This concern about safety was echoed by Penina and other participants, particularly the risk of sexual and gender based violence as they do this work, which needs to be a priority area to be addressed by the health system.

The contribution of CHWs to sexual and reproductive health and rights

We heard many examples of frontline, cutting edge sexual and reproductive health work by CHWs in diverse settings. For example, Licia Limato (Indonesia) explained how kader (community health volunteers) play a role to support unmarried, pregnant, teenage girls who are highly stigmatised and shamed. Usually, because of social disapproval and laws that prohibit service provision to unmarried women, the family hides the daughter in the house for the full pregnancy, with no ANC checks. Then at the time of delivery they are more likely to use the services of a TBA than the formal system. Because they are ‘of the community and for the community’ kader are more aware of when a young woman is pregnant and isolated. They often counsel parents about the importance of health checks with persistence. Sometimes they take the girls to formal services, mostly to the village midwife for delivery under the cover of darkness.

Rifat (Bangladesh) spoke about the ways in which maternal mortality has been reduced through the provision of safe abortion, or menstrual regulation (MR), services. There is a government regularised system of MR with trained providers. CHWs play a key role in referral of clients to MR services and REACHOUT has been supporting quality improvement to these systems and the supervision of CHWs.

Christine Sammy (Kenya) spoke about the improvements that have been made to family planning, HIV and maternal health services through the involvement of CHWs in Kitui county. The CHVs have been trained in recognising the danger signs and other elements of maternal health. They are becoming referral champions and are monitoring expectant mothers through house visits. By encouraging male involvement more households are saving money for transport costs so that women can go to the health facilities for birth. She emphasized the importance of collaborating with non-state actors, such as LVCT Health, in building the capacity of CHVs in maternal health.   

Continuing the conversations

At the recent Kampala Conference we heard from CHWs in India and Uganda that some of their concerns relate to gender. In REACHOUT we believe that as researchers we have a moral obligation to let the voices of CHWs be heard ‘up there’ in national governments and in organisations like WHO. Given the increasing policy attention being given to this cadre of health worker, the coming years bring opportunities to gather and disseminate more information.

We will consider how we can communicate with a larger body of CHWs, policy makers, researchers and practitioners to keep conversations alive. In particular, the SDGs have a focus on unpaid care and there is more that we can do to make the links between this and volunteer labour in the health sector. We also need to look at the working conditions of CHWs as it relates to the concept of ‘decent work’.

Photo: The image is of Mehret Lamiso at her health post in Becha Kabele, Ethiopia. It was taken by Rosie Steege.

Recent news

• Women in the changing world of community health work, 17 March 2017
• What does trust have to do with Community Health Workers and the Sustainable Development Goals?, 6 March 2017
• Community health workers – optimizing the benefits of their position between communities and the health sector, 23 February 2017

By Lynda Keeru

During US President Obama’s visit to Kenya in July 2015, he warned that nations would not succeed if they continued treating women as “second class” citizens.

Around the world, there is a tradition of repressing women, and treating them differently and not giving them the same opportunities, husbands beating their wives and girl children not being sent to school. Progressive development policies demand that girls get an education. Evidence shows that societies that give daughters similar opportunities as their sons are more likely to progress faster, and when they become mothers are more likely to bring up educated children, Obama said.

We marked the International Women’s Day last week with the theme: “Women in the changing world of work” Many organizations used the day as a launching pad to speak about their initiatives especially around the work they do to ‘empower’ women. The question though is whether women are actually getting empowered and supported to live to their fullest potential? As a participant at REACHOUT’s 7^th consortium meeting in Nairobi, celebrating and acknowledging the day alongside fellow women, evidence showed that perhaps, there is very little empowerment that has occurred, especially for female Community Health Workers (CHWs).

Roles within the health workforce are highly gendered and health systems rely on a foundation of health workers that are often female, informal, poorly remunerated and poorly supported. Globally, it is estimated around 70% of CHWs are female and those unpaid are most likely to be female. In many contexts, the job is on a voluntary basis. According to the World Bank, there is a significant gender gap in earnings and wages, even after controlling for industry and occupation. UNHLP Report on Women’s Economic Empowerment reports that the unexplained gender pay gap reveals gender discrimination.

The women continue to volunteer and persevere amidst these harrowing challenges because they best ‘know where the shoe pinches’. Of particular interest is the fact that, much as the majority of CHWs are women and know exactly what happens on the ground, they are rarely incorporated into decision making committees at village and community levels.  As aforementioned, the female CHWs face a myriad of challenges as they execute their duties. In the course of their home visits, they are accused by their husbands of extramarital affairs that sometimes culminate in gender based violence. On occasion, they are accused of disregarding their household chores as they carry out their CHW roles. There are other barriers including poor terrain and transport barriers, insecurity including rape cases in some instances, among others that they have to deal with and overcome in their daily service.

Women are the chief caretakers of their families and are natural researchers. CHWs have untapped insights around gender, equity, power struggles and this should be tapped to build more responsive health systems. When any of their family members are unwell, they suffer incredibly. Not all get remuneration in their roles as CHWs, some are motivated by the fact that healthier children and families mean a burden less off their shoulders.

Strong gender mainstreaming is required where both men and women share in the execution of CHW tasks. We need to create awareness among the CHWs of their rights, and how inequity affects health. This will tackle harmful gender norms and behaviours in their communities. Women should be given a seat at the table to identify their issues, get solutions to them, and get involved in decision making.  We need to include this vital interface cadre in debates and efforts to support women’s leadership in health.

Women’s career progress needs to be fostered and gender parity in leadership positions addressed. The voice of the woman needs to be strengthened and heard collectively. When women are given greater opportunities to participate in the economy, the benefits extend far beyond individual girls and women but also to societies and economies as a whole.

Recent news

• What does trust have to do with Community Health Workers and the Sustainable Development Goals?, 6 March 2017
• Community health workers – optimizing the benefits of their position between communities and the health sector, 23 February 2017
• Achieving Equity: Women at the interface of community health systems, 15 February 2017

By Kate Hawkins, Kingsley Chikaphupha, Rosalind Steege, Sushama Kanan, Aschenaki  Z. Kea. Robinson Karuga, Ralalicia Limato, Nelly Muturi, Daniel Datiko, Maryse Kok

Trust: “The optimistic acceptance of a vulnerable situation in which the trustor believes the trustee will care for the trustor’s interest” (Hall et al. 2001)

Trusting relationships:“Respectful, fair and cooperative interactions between individuals” (Gilson 2003; Okello and Gilson 2015)

The work of Dr Maryse Kok has brought to the attention that health systems are social institutions and community health worker programmes are part of this complex map. Besides the ‘hardware’ elements of health systems (often referred to as the WHO’s building blocks) we need to take account of the 1) ideas and interests, 2) relationships and power, and 3) values and norms that effect these programmes (the software elements of health systems). Looking at this ‘software’, every health worker is part of social interactions and environments, which, together with available resources, shape their performance.

Performance is a transactional social process and trust plays a part of this. Trust can be built by personal behaviours and organizational practices that provide space for engagement and open dialogue (Gilson 2006). Other factors that have been found to influence trust of health workers are: perceived organisational support, communication, procedural justice and feedback from upper levels (Albrecht and Travaglione 2003; Nyhan 2000). Understanding the factors that influence trust and CHWs interpersonal relationships with different actors in the community and health sector (such as supervisors and managers) is important in order to analyse and improve CHW performance.

In a refreshing fish bowl session at the first symposium on the Contribution of Community Health Workers (CHWs) in attainment of the Sustainable Development Goals (SDGs) we heard from colleagues from around the world about how CHWs can build trust, how we can strengthen the software components of the system and how to improve data quality and feedback loops. As well as hearing some warnings on how mistrust can negatively impact CHW programmes. We thank the participants whose interventions have helped us write this blog.

Building trust is an evolving process

Several participants pointed out that the process of building trust does not happen overnight.

We heard that trust starts with how CHWs are selected, their training, and the quality of their work. In Ethiopia, the community is part of the selection process for hiring CHWs. They choose community members that they trust to play the role of CHW and the CHW cements and builds this trust through their ongoing work. The more useful they are the more it grows. This can create demand for more services – which is evidence of their impact. From Uganda, we heard that CHWs’ integrity has at its foundation a clear terms of reference right from their first engagement with the community. One colleague pointed out that having adequate time to spend with the community can make the community feel trust in the CHW. Building rapport can be a long-term process.

Policy making and implementation to build trust

Policy making and implementation that favours CHWs can improve CHWs motivation. Suspicion from communities of CHWs’ involvement in politics also influence their trust of the CHWs.

In Ethiopia policy makers demonstrate their trust in CHWs when they construct policies, structures, and budgets (including monitoring and evaluation systems) that support and celebrate their work.

CHWs told us that whether or not the district level management is aware of them and is sensitised to their work motivates the CHWs. It is important that the health units know who the people are in the community.

We heard that policy makers need to take account of the plurality of health care providers within communities. In Bangladesh, informal for-profit providers such as pharmacists are more integrated into the community and accepted as almost family members. Because they are more trusted the community find them more credible than other health care providers and they are often the first point of call in the case of ill-health. So, good communication and rapport with informal providers helps CHWs in Bangladesh to build trust with community and refer clients to proper health facility. How can CHW programmes work with them and learn from them? In Uganda, we heard that Traditional Birth Attendants (TBAs) are part of the Village Health Teams (VHTs) and the communities trust them.  However, policy makers do not trust them despite training them in the past. In Ethiopia, TBAs used to be very important in providing family health. But now they have been integrated into the CHW programme as health development army leaders working towards ensuring model household families.

From South Africa, we heard what happens when the trust breaks down. In this highly-politicised environment - which has moved from Apartheid to democracy - people may be reluctant to trust CHWs who they see as agents of the state as they think that they are visiting the home to try and canvas for votes or act as surveillance force. Fear of surveillance is heightened because of very real fears about HIV-related stigma. To counteract this there is a need to involve the communities in designing the intervention itself. Top down approaches to programme design often fail to take into accounts beliefs and norms and local context which is important to success. For example in South Africa, there is a belief in some communities that you should not allow visitors into your home 100 days after the birth of a child, which is at odds with the CHW policy. By ignoring cultural values, the relationship between the CHW and the community is at risk of further deterioration.   

From Kenya, we heard how CHW programmes can be effected by political events and crises in the health system that go beyond the community sector. For example, the Kenyan doctors and nurses strikes can undermine trust in the health system which effects CHWs. However, CHWs may have an important role in re-establishing trust in systems that have been battered by instability and it would be good to understand better how this process can be supported. 

CHW practices that maintain trust

To gain trust from the community, CHWs are expected to keep confidentiality and act in a responsble manner during interactions with the community, they should have a good knowledge on the health topics they deliver and be available whenever the community needs them.

A colleague from Kenya pointed out that when CHWs maintain confidentiality this supports the process of trust building. CHWs are in the unique position of not just handling sometimes stigmatising health issues but seeing vulnerabilities within the private space of the household. If they are successful communities have to believe that they will handle this information responsibly and sensitively. Commenting on Ethiopia a colleague pointed out that this becomes even more important when it comes to mhealth and new communication technologies. Communities may not fully understand who will see the information that is being entered into electronic devices and what it might be used for. So, they need to place a great deal of trust in the hands of the person that they are giving this data to. Conversely, just having access to an electronic device, like a phone or tablet, may make CHWs more trustworthy as it may make them seem more professional, or at least better equipped. The use of text messaging helps them to make prompt follow up of clients and improved adherence to care.

A colleague from Uganda felt that when CHWs treat themselves as professions for example, they don’t turn up to the household visits drunk, this can increase the respect and therefore trust that their clients have for them. However, another VHT colleague argued that you need to ‘live the professionalism’. A corporate manner when speaking with bad boys does not work. If you have a little drink with the alcoholics as it gains their trust. In addition, speaking the language of the community helps you to relate. You need to put yourself in the shoes of the people you are talking to – CHWs need to advise not supervise.

Colleagues from TASO in Uganda related that being experts in the subject that you are talking about, in this case HIV, helps build trust. This expert knowledge may mean you are living with HIV or have relatives or friends affected by HIV. In this way clients know that you are coming with a knowledge of the issues that are relevant to them.

We heard that trust is linked to availability. When the community knows the CHW is there for them they can trust then and in Zambia this has been shown to increase health service delivery. Availability isn’t just about the amount of time spent with the community. Particularly in emergency care settings it is about being there when a crisis occurs.

Data handling and trust

Trust between CHWs and the community can affect data collection and handling in terms of the aim of data collection, the existence of community dialogue/participation, and the availability of quality tools. 

From Kenya, a participant felt that data quality was part of the process of trust building – in terms of what is collected and what is relayed to the community. Relationships effect the quality of data. If communities don’t trust that household visits are authentic and if they think the CHW got paid for collecting data it can affect the quality of the data provided and this is particularly true for vertical programmes. The reasons for collecting data need to be transparent. In addition, if CHWs are expected to ask the same questions of the same households month after month then households can fail to see the importance of answering them correctly. This effects the reliability of the information we are working with. A colleague pointed out that falsification of data sometimes occurs because of pressure to perform. To overcome this all CHWs need to meet together and frankly discuss the challenges that they have in data collection. From a disability organisation in Uganda we heard that an app for diagnosis and prescription improved the quality of the data collected by CHWs as they knew there were ramifications of not filing information correctly.

In Kenya, the governance of community health programmes can effect trust. CHWs collect data and submit it upwards but if they don’t know what happens to it they can stop feeling incentivised. In this case why not make it up – after all they do not know what they are contributing to. We heard that in Cote D’Ivoire the Ministry of Health wanted data accountability. To facilitate this data was made available at the clinic and CHWs and community members could talk directly to the nurses about it. In this way they could verify that they were being heard and that the community and the health system were connected. In Kenya, community dialogue days enable people to view the data collected by CHWs on a chalk boards and prioritise community action days. However, for these to be successful more support from development partners is required. A colleague in Uganda suggested that parallel systems of data collection for CHW data are being created and this can erode trust.

A participant from Uganda pointed out that to get quality data CHWs need quality tools. Whilst in Kenya it was argued that there are too many tools, as NGO working with specific community units and programmes often introduce their own tools creating parallel reporting systems with the standard Ministry of Health system thus leaving  CHWs over-burdened and as a result cannot clearly see the impact of their work. In addition, we heard from South Africa that tools tend to measure how much work a CHW has done but whether or not this work was appropriate is not captured. This calls for a focus on quality not just coverage. In Malawi, We learnt that conducting regular and supportive supervision was key to getting quality data. Irregular supervision or lack of it led to CHWs testing the system in search of being supervised by submitting poor data that led to serious effects on decision making and interventions.

Other health system practices to build trust

Feedback to the community, approaches from CHWs’ supervisors, and financial incentives also can influence trust between CHWs and the health system.

We heard that in Malawi feedback loops for information help to build trust. For example, being able to tell communities what has happened to the information that has been collected is helpful for the relationship with the CHW.

Another participant felt that it was important that CHWs provide correct and accurate information in their messages, but also that they accept when they are defeated and don’t know. They pointed out that if community members suspect a CHW is pretending to know something that they don’t their clients may provoke them to see how much they know, with potentially negative results.

We heard that in terms of the supervision of CHWs trust is important. The approach and aim of supervision affect the relationship between supervisor and the CHWs. Fault finding can cause mistrust in the CHW relationships with their supervisors which can have knock on effects in the service that they provide. We heard from Ethiopia that the language of supervision is important. CHWs feel sense of belongingness and freely share their ideas when the supervisors able to speak local languages spoken by the CHWs. Using phrases like, ‘Let’s do this together’ and ‘We both want to achieve this’, can be motivating. From Uganda, we heard that the delegation of responsibility to CHWs – as long as it is manageable - can build trust, and it boosts confidence.

From Malawi, we heard that financial incentives can be motivating and build trust between the health system and CHWs. However, they can also have a negative effect. They can move CHWs to the programmes that pay the most, cause attrition, particularly allowances linked to training and workshops. This can affect trust across a range of other stakeholders, and the community. In many cases, community members expect basic care from CHWs. When the CHW supply kits are not sufficiently stocked over prolonged periods of time, apathy develops towards CHWs and this affects the trust that community members have in CHWs.

Gendered elements of trust

We heard that in Kenya the sex of the CHW matters as young men coming to visit the house is seen as a security concern by many. In addition, women do not want to have personal conversations with male CHWs about family planning as they fear that confidential information may be relayed to their husbands or others.  Conversely, the trust built between a CHW and the community can also help women to overcome harmful gender norms. In Bangladesh, female CHWs are more able to freely move around the community and are less at risk from provocation by local thugs as they have earnt a position of respect within the community. In Ethiopia, all CHWs are women and are better positioned to make household visits and address maternal and child health issues.

Conclusion

From the above experiences and literature it is evident that most challenges affecting health systems are behaviour and relationships related. Trust has a lot to offer in health care delivery and policy analysis and by exploring it further, we are able to capture its relevance to health systems and the need to harness it. Trust plays a very important role for both health care providers and institutions and is a fundamental human norm. As such, it demands consideration as a key ‘software’ element of the health system. Further, the implications of ‘hardware’ interventions on trust, and how these play out in the community provide important lessons for CHW programmes across contexts.

Key note speech CHW symposium Kampala, 23 February 2017

Maryse Kok

Good morning to you all. I feel honored to be invited to speak at this symposium on the contribution of community health workers in attainment of the sustainable development goals. The 2030 agenda for sustainable development reassures a focus on universal health coverage and access to quality health care. It is clear that in many societies, community health workers directly contribute towards attaining the SDGs. Their role in ensuring healthy lives and promoting well-being for all is widely recognized. Although sometimes less visible, community health workers also contribute towards other goals, such as achieving gender equality and empowering of communities, including women and girls.

Over the past years, community health workers have received considerable attention of policy makers, practitioners and researchers. The realization that community health workers are needed to achieve universal health coverage is there, in many corners of the world. We know that since Alma Ata, community health worker programmes have been on the rise and in decline. The recent renewed and strategic interest in the role of community health workers stresses the importance of learning from the past (and the present). What works and in which context? Which elements of community health worker programmes make them work, which issues can result in inefficiency or ineffectiveness? Despite the fact that community health workers have so many different positions and roles within health systems; and are working in different contexts, even within countries, I do see cross-cutting issues that should be taken in consideration when we aim to optimize community health workers’ performance and increase programme effectiveness.

Hard- and software and their influence on community health worker performance

The unique intermediary position of community health workers – between communities and the health sector – has a profound influence on their performance. On the one hand, community health workers are well positioned to increase access of communities to health services; and facilitate interactions between communities and the health sector. On the other hand, their intermediary position can result in a double burden with regard to accountability and expectations.

Community health workers have an interface role in health systems, and health systems are complex, social institutions. In these complex systems, performance is very much influenced by the ideas, interests, relationships, power, norms and values of all people that make up the system. This is what is called the systems “software”. Performance can be seen as a transactional social process. Every health worker is part of social interactions and environments, which, together with available resources, related to systems “hardware”, shape their performance. I argue that the intermediary position makes the influence of software on performance even more profound in the case of community health workers. They need to understand and deal with interests from both communities and the health sector. They are part of both, and they cannot “hide” for the other at one of both sides.

An example

Let me introduce you to Damitao Asharn, a health surveillance assistant with whom I worked between 2009 and 2011 in Mwanza, Malawi. Asharn was one of the best performing community health workers. While many villages were facing health challenges in this poor and rural district, the villages that Asharn was responsible for were doing better compared to others on several health indicators: there were more pit latrines at the household level, and more women were delivering in the health facility instead of at home. What made, besides his personal dedication, the difference with the rest of the district?

Health surveillance assistants are not selected with involvement of communities: they are recruited at central level. Therefore, Asharn was not from the community he served, but made sure he lived in the village. He established trusting relationships with the head teacher, traditional leader and village elders. He made sure he was present and participating in community activities, such as molding bricks for the church. People came to know him. He organized the village health committee, consisting of ten volunteers, chosen by the community. Together, they mapped the village; a situation assessment was done. Asharn linked with the district health office, obtaining small funds for realizing local pit latrines built by the community. District officials heard about this success and visited the area. This boosted a feeling of recognition of the volunteers in the village, resulting in active participation during child health days and other campaigns. The idea of an inter-household competition on hygiene was born within one of the monthly village health committee meetings. A local team of volunteers, led by Asharn, prepared small prices for winning households and set criteria for assessment. An awarding ceremony was held, with active participation of the village headman. The initiative spread to other parts of the district, and small scale awarding ceremonies turned out to be well attended health education events (as you can see from this picture).

What is standing out in this example? That relationships are the glue that supports community health workers in their interface role. The strength of community health workers’ relationships influences their motivation and performance, which affects the access to and the quality of the services they provide.

Trusting relationships

While we need to keep on improving the hardware elements of community health worker programmes, such as the availability of supervision structures and training, it is equally important to look at how these structures could be set up, so that they trigger mechanisms that generate trusting relationships. Trusting relationships – between community health workers and community members (here we see the interaction between community health workers and a community member at the household level), but also between community health workers and professionals in the health system, such as supervisors. Programme design can influence software elements, such as relationships, trust and power, which are essential for optimal performance.

Evidence from the REACHOUT consortium, which has been studying community health worker programmes in six countries, identified several mechanisms related to trusting relationships.

Let’s first focus on the mechanisms that we identified regarding relationships between community health workers and communities, which were leading to better performance:

• For both community health workers and community members, feelings of connectedness, familiarity, serving the same goals, and free discussion lead to trusting relationships and better performance.
• For community members, the perception that community health workers serve in the community’s interest enhances recognition and respect; and notions of credibility (for example through visible supervision or expanded curative tasks of community health workers) lead to trusting relationships and better performance.
• For community health workers themselves, feelings of self-fulfilment lead to trusting relationships with their communities and better performance.

Between community health workers and their supervisors and other health professionals, trusting relationships also relate to feelings of connectedness and serving the same goals. When community health workers believe that they are supported by health sector staff, relationships tend to be stronger. When health professionals value the role of community health workers and believe that their work assists them, relationships appear to get strengthened and performance improves.

What does this mean, what can we do to improve community health worker programming?

How can we trigger those mechanisms that facilitate trusting relationships? We know, from various examples in the international literature, that it helps when the programme design ensures that community health workers are recruited from the place that they work in, with the involvement of communities in decision making. The involvement of volunteers as an official element of the programme, as well as the involvement of traditional leaders, is also proven to facilitate trusting relationships between different actors, especially in contexts where community participation and volunteerism are generally valued in society. An example is the Ethiopian health extension programme, where the government made the health development army explicitly part of the programme. This mix of volunteers and paid community health workers is seen, more often, in other countries as well, but implications on trusting relationships and performance still need further research.

Trusting relationships could also be enhanced if curative tasks are shifted to community health workers: it gives them credibility. However, all actors in the health system should agree and be clear about which tasks are supposed to be conducted by community health workers (and which not), to avoid expectations that cannot be met. In addition, when inadequate training and supplies hinder community health workers from conducting their new tasks, credibility can come into danger, and relationships could deteriorate.

In contexts where gender roles in health care are separated, having female community health workers is important. However, we know examples of female community health workers in Afghanistan being constrained in conducting certain tasks, as male involvement is no option in a society where females cannot speak to males outside their own households. In this way, programme design could hinder the ability to establish relationships and negatively influence performance. Other countries therefore chose for a mix of female and male community health workers. It shows that we need to think critically about gender in the deployment and valuing of health workers.

Furthermore, relationships can be strengthened through joint trainings of community health workers and health professionals. It can increase team work, and clarify roles and expectations. Visible supervision of community health workers can not only improve quality of their services, but can also enhance recognition of the community health worker in his or her community. There is a need for improved, supportive supervision, rather than administrative or fault-finding supervision.

When training supervisors, there should be a focus on technical skills, people management and the implications of community health workers’ intermediate position for relationship building with communities. As supervision is a form of human interaction, strategies that reduce social distance between supervisor and supervisee (such as team building events) could improve relationships and performance.

Learning from things that do not go well yet: listening to the voices of community health workers

In the same district in Malawi which I referred to earlier, I came across situations of mistrust between volunteers, health surveillance assistants and supervisors. This mistrust was a result of perceptions of dishonesty towards the “upper level” about financial incentives that were expected to come, but were felt to be not distributed properly. This situation was caused by multiple programmes that worked separately from each other, each with their own incentive structure. It shows that programme design, in this case the way incentives are handled, can – quite easily – knock down existing, but fragile, trusting relationships. Community health workers can end up being “caught” between different forces.

Too often, in the past and in the present, community health workers have to juggle between the health sector and the community. They are in a continuous balancing act to meet the interests of their surroundings. They work in a complex environment, where power relations and societal values and norms influence their ability to act. We need to hear from them what helps in the balancing act, how to optimize the benefits of their unique position.

Over the past weeks, Healthcare Information For All hosted an online discussion on community health workers. Accredited social health activists (ASHAs) in India reacted, through a What’s App group, on the question what are the triggers of stress in their lives. Also for them, issues regarding being denied incentives that they are entitled to result in problematic relationships with both health professionals and their own families. Their undefined position in the health system make some of them feel vulnerable. One ASHA said: "Neither does the health services system hold our hand, nor do they leave our hand". And a village health team member from Uganda stated: “We would like it very much if officials from the ministry of health visit us and listen to our concerns as some problems cannot be solved by our coordinators.”

By listening to the voices of community health workers, we would be able to understand communities better as well. Community health workers are not only part of the health workforce supporting the achievement of – often – disease related targets. They also have the potential to facilitate relationships between different actors in the health system, and act as social change agents by raising the voices of communities. In other words, community health workers play an important role in bonding, bridging and linking – the pillars of social capital.

Some people argue that this function of community health workers has been unjustly pushed away from the forefront. Indeed, often, the task composition, but also the way in which performance is measured, focus a lot on reaching the targets set on health indicators. With the arguments that I am presenting in this speech, I want to stress that these targets, of course related to the sustainable development goals, cannot be reached without acknowledging the importance of the software elements within health systems. Community health workers can act as agents of social change, when they feel empowered and supported. They need to be trained in soft skills such as communication, problem-solving, and assuring confidentiality at community level.

We need to look beyond human resource management interventions to improve community health worker retention and productivity, and incorporate lessons learned from community health workers’ realities as intermediaries within health systems, embedded in specific social, political and economic contexts. Only with these insights from community health workers themselves; policy makers, practitioners and researchers can draw conclusions on what can be done, together with community health workers, to improve trusting relationships and address power between all actors involved.

If we have an eye for both the hardware and software, I believe community health workers would gain the support they need, to be able to make substantial contributions to achieving the sustainable development goals.  

Recent news

• Achieving Equity: Women at the interface of community health systems, 15 February 2017
• REACHOUT at the Kampala Community Health Worker conference, 11 February 2017
• Building a resilient and responsive health system needs strong community support 10 February 2017

The theme of this year’s International Women’s Day is “Women in the Changing World of Work”. A topic that will resonate with many working on community health. Although women make up the majority of people working on health in many countries they are woefully under-represented in leadership positions meaning that our policy and practice is not shaped by their particular experiences and expertise.

Women and girls act as the foundation of most health systems – providing unpaid care to family members and neighbours with little recognition. Community Health Workers are also crucial to the health and wellbeing of many citizens, a role that in many contexts falls disproportionately on women. Yet often their contribution is unpaid and they labour as volunteers.

Community Health Workers – of all genders – can transform gendered roles and relations because of their unique position. They are community leaders whose advice and guidance is trusted by the people that they work for. They interact with people in their homes, tackling the social determinants of ill health. They deliver essential sexual and reproductive health services, which contribute to women’s well-being and enable them to succeed in other areas of their lives. Their ability to interact with government services through their supervisors allows them to collect, interpret, and communicate essential data for better decision making.

National governments and the international community are beginning to appreciate the actual and future potential contribution of Community Health Workers to health and development. To help decision makers develop policies and programmes with the potential to create deep and enduring gender transformation our half-day symposium on community health workers brings together an international panel of speakers to interact with their Kenyan counterparts.

Our aim is to capture lessons about how community health workers are supporting gender equity and what more we can do to support them in their efforts. The symposium will enable dialogue that furthers our shared efforts towards Sustainable Development Goal 5 and universal health coverage. The event will be structured around two question time panels – where a moderator will ask our experts a series of questions and the audience will be asked to raise their voices too. 

We welcome you to participate in this symposium which will take place on Friday March 10 2017, 8:00 – 13.00 at the Silver Springs Hotel, Nairobi. Please contact RKaruga@lvcthealth.org for more information.

Symposium Agenda

Photo courtesy of Ericsson

Recent news

• REACHOUT at the Kampala Community Health Worker conference, 11 February 2017
• Building a resilient and responsive health system needs strong community support 10 February 2017
• Recognition of best performance of community health workers: experiences from Malawi, 7 February 2017

There are just 10 days to go until an international crowd with an interest in community health workers convene in Kampala. REACHOUT are delighted to be a co-sponsor of the event and we have a busy schedule of presentations and sessions. We hope that you will come along and meet with us. It is a great opportunity for sharing, learning, and networking!

Keynote presentation

Maryse Kok (KIT) will give the keynote presentation on Thursday 23 February where she will speak on, “Community health workers – optimizing the benefits of their unique position between communities and the health sector.”

Panel

Wednesday 22 February, in the Nile Hall, from 09.00-10.30 we will hold a panel on trust and the Sustainable Development Goals where we will explore the multiple relationships shaping Community Health Workers’ experiences and performance. The session is a chance to learn more about how the software components of the health systems (including ideas and interests, relationships and power, values and norms) shape the relationships between community health workers and their respective communities and other actors in the health sector. Feelings of connectedness, familiarity, serving the same goals - have effects on community health worker performance, influencing self-esteem, attitudes, and agency, in addition to motivation and satisfaction. We have speakers from Indonesia, Malawi, Kenya, Bangladesh, and Ethiopia!

Papers

REACHOUT staff will be delivering papers in a range of sessions throughout the conference. You can find a comprehensive list of our presentations here!

Meet the Thematic Working Group

On Tuesday 21 February from 17:30 - 18:00 in Sezibwa Hall there will also be a chance to meet members of the Health Systems Global Thematic Working Group on Supporting and Strengthening the Role of Community Health Workers in Health Systems Development. We are all members and we hope to see you there!

Recent news

• Building a resilient and responsive health system needs strong community support 10 February 2017
• Recognition of best performance of community health workers: experiences from Malawi, 7 February 2017
• Online discussion on community health workers: Join in, 4 January 2017

“Forget about these people in the national office,” said Maria (not her real name). “They are not in touch with reality!” Maria is a district health manager in Kenya. This was her response when I asked how closely she works with the national Ministry of Health in delivering community health services.

In 2013, the governance system in Kenya changed from a centralized system to one in which decision making and the delivery of services such as healthcare was transferred to county governments. The national Ministry of Health however retains responsibility for policy formulation, development of standards and guidelines, and technical support to the counties.

Most of the counties lacked the capacity to cope with the sudden increase of responsibility, and were unable to respond to the priority health needs of their constituents. Devolution of healthcare has therefore been characterized by confusion, collapse of some health programmes, drug stock, poor information management, demoralized health workers due to a lack of finances for salaries and basic services, and an uncoordinated reshuffling of health workers. These disruptions dealt severe shocks to the health systems in all 47 counties of the nation. In some instances, these shocks paralyzed the delivery of health services, especially community health services.

Despite the upheaval, Maria’s district has been able to deliver community health services to residents of an informal settlement—people who are typically marginalized in terms of access to government services. “So how have you managed to successfully run community health services,” I asked. This is her story:

As soon as she was posted to her new role, Maria invested effort in building a strong team of community health volunteers who actively collect health related household data, refer people to the primary health care facilities and monitor epidemics. Lack of sustained engagement with community members over time and weak supervision from the Nairobi county health department before Maria took over, had led to low morale of the volunteers, and high rate of attrition, and poor performance.

Maria appointed community health volunteer team leaders from among the volunteers to extend supervision to community level. Sensitive to the power dynamics in the informal settlement, she appointed land-owners to serve as the team leaders. Working with this tight team of volunteers ensured the delivery of health services despite the disruptions caused by the devolution of healthcare. When there  was a cholera outbreak in some settlements in her district a rapid response could be mounted to stop the outbreak before it could spread to other parts of the district due to the efforts of the community health workers who quickly identified and alerted the district health management team about the outbreak. “You cannot make any progress here without having strong community support”, continued Maria.

Maria also forged close partnerships and collaborations with NGOs working in her district. Fruits of this partnerships were witnessed during the cholera outbreak. Due to the bureaucracies involved in releasing rapid response funds from the county treasury, there was a lag in responding to curb the cholera outbreak. Maria turned to her NGO partners in her district and they responded immediately to stop the epidemic by providing household water treatment products, mobile toilets, disinfectants, and clean water to arrest the spread of the outbreak.

Building responsive and resilient health systems calls for the sort of innovation and working relationships that Maria brought to her work as district health manager. As I walked out of her office, it struck me that she was building a “resilient and responsive” health system and I was inspired by her story. We need to understand and recognise frontline health workers, like Maria, who innovate to build resilient health systems that can withstand disruptions within the health system.

This blog was first posted on BMJ Opinion.

Recent news

• Recognition of best performance of community health workers: experiences from Malawi, 7 February 2017
• Online discussion on community health workers: Join in, 4 January 2017
• Four tips for embedding quality improvement in community health worker programmes, 9 December 2016

By Kingsley Chikaphupha and Maryse Kok

Supervision is one of the most challenging elements of close-to-community programmes yet it is considered one of the most important elements. In Malawi a lack of recognition is a demotivating factor for health surveillance assistants (HSAs) which has a knock on effect on their performance. Our intervention trialed a number of new ways of supporting HSAs – and these were met with a variety of outcomes. In this blog, we explore some of the unanticipated negative consequences of introducing awards for well performing community health workers and suggest ways that they can be overcome.

Community health worker supervision – prompting improvements

During our research we found that, if they were performed at all, performance assessments of HSAs in Malawi focused on checking registers or attendance and did not include evaluation of the quality of services that were delivered. The community was not asked to provide feedback, and limited feedback was provided to HSAs on how they were performing according to programme indicators and targets. To overcome this, we planned an intervention to strengthen supervisory systems.

Firstly, a training of 60 supervisors was conducted in Mchinji and Salima districts. The monthly group and peer supervision meetings that were introduced at the “block” level permitted supervisors and supervisees the opportunity to work as a team to meet common goals and objectives. Along this supervision intervention, we started a performance appraisal system for HSAs. The intervention introduced rewards to recognize best performance of HSAs. We learnt that the supervision training itself was motivating. A manager reported:

“Before the coming of REACHOUT, there was this other HSA who was so rude and uncooperative despite the fact that he was very good at his job. But today I thank REACH Trust for coming with the training of supervisors. When this project came we selected this troublesome HSA to undergo the training and today this HSA has completely transformed, his attitude is changed as well as his working ethics. He is the best block leader (supervisor) surpassing those who have been supervisors over the years and we actually recommend others to go and learn from him”.

Performance appraisal

As a result of the awards it is likely that the winners will be highly motivated to work. However, it is also possible, going by the outbursts of HSAs who were not awarded in Salima, that HSAs’ disgruntlement may put them off the project. On the other hand, the attitude displayed by the HSAs in Mchinji gives us encouragement that the awards achieved their purpose i.e. to motivate all HSAs to work as hard and be dedicated, so they could emerge the winners next time.

The intervention was a good step in the direction of performance management, but improvements are needed with respect to assessment of performance of HSAs during household visits (actual observations) and possibly developing mechanisms to include the views of community members on HSAs’ performance. In this way, the system might be viewed as fairer, and decisions on who is awarded might be more accepted. Bottom line is these approaches are producing the fruits and they are worthwhile to implement. But it is important to acknowledge that despite good intentions the appraisal system and awarding of best performers had unintended consequences. In the future we hope that performance appraisal will be carried out  taking into consideration suggested inclusions herein and that the intervention will be adjusted where needed. At the same time, we should realize that in some cases HSAs could stay demotivated, because human beings by nature have dissenting views to almost anything and everything. 

Recent news

• Online discussion on community health workers: Join in, 4 January 2017
• Four tips for embedding quality improvement in community health worker programmes, 9 December 2016
• Community health workers: great potential for resilient and responsive health systems, 28 November 2016

Community Health Workers (CHWs) are widely recognised as critical to meeting the health needs of people in low- and middle-income countries. 

Healthcare Information For All (HIFA) and the HSG Thematic Working Group on Supporting and Strengthening the Role of Community Health Workers in Health System Development invite you to a dynamic online discussion on CHWs centred around six key questions, which will take place on the HIFA discussion forum from January 16th - February 24th, 2017.

This  discussion is for anyone with an interest in the work of CHWs and the promotion of health in low- and middle-income countries. Input from CHWs, CHW trainers and programme managers, and people responsible for developing policy on CHWs is especially welcome.

The discussion will build on the learning from the recent Health Systems Research Symposium in Vancouver (November 2016) and current initiatives including the new WHO guideline on CHWs (in development). And it will lead into the Symposium on Community Health workers and their contribution towards the Sustainable Development Goals, 21-23 February 2017, Kampala, Uganda. Key points of the discussion will be presented at the Symposium, thereby providing an opportunity for people to input their experience even if they are not able to attend in person.

The discussion is organised by the HIFA Project on Community Health Workers, one of eight HIFA Projects led by HIFA volunteers, and they invite your suggestions on what themes/questions you would like the discussion to address. 

For further information and to join the online thematic discussion, Join HIFA.

We are happy to co-sponsor the online discussion aong with The Lancet, World Vision International and the USAID Assist Project.

Recent news

• Four tips for embedding quality improvement in community health worker programmes, 9 December 2016
• Community health workers: great potential for resilient and responsive health systems, 28 November 2016
• Close-to-community providers and menstrual regulation, 25 November 2016

By Kate Hawkins

There were many community health worker (CHW) sessions at the recent Global Symposium on Health Systems Research in Vancouver. The need to support CHWs, and to better evidence our policy and interventions, appears to be an issue that is gaining greater traction internationally.

I enjoyed the REACHOUT session on how we can embed quality improvement interventions into community health programming. It is an important issue because, as Miriam Taegtmeyer eloquently argues, as the potential contribution of CHW programmes is increasingly recognised the people that work within them are being asked to take on ever-more tasks and responsibilities. Often, they are expected to take on new areas without adequate thought to how this additional burden will be offset through remuneration, better supervision and support, and improved coordination and contact with communities and the broader health system. So, quality – not just quantity – matters.

Here are the four things I took away from the session about embedding quality improvement:

1. It’s political!

Olivia Tulloch helped us reflect on learning on sustainability for health interventions from the broader development sector – problems and their solutions should be defined by local people, we should take small steps and small bets to tackle them. We also need to look at the political economy questions behind what how development happens.  Essentially, people who should benefit from development often lack power and are not engaged in the design and implementation of the interventions that are meant to help them. Initiatives can fail if we don’t analyse power within our interventions.

2. Money matters

Malabika Sarker gave a great presentation about work with NGO providers, informal providers, and the formal private sector (hospitals and so on) and the provision of Menstrual Regulation services in Bangladesh. The introduction of a referral card system – so that the efforts of close-to-community providers could be tracked by their supervisors and clinics - meant women could avoid middle-men and providers understood the impact of their work. Embedding this intervention was challenging (in part) because of financing constraints – funding was needed to print the card and turnover of close-to-community providers was high. In her words, “We glorify the contribution of the CHW but we pay them as little as we can.”

3. We need to change cultures

Kassim Kwalamasa explained how embedding quality improvement is a journey and not a destination. That it is an ongoing process of building relationships and institutions. He reflected on efforts to improve CHW supervision in Malawi – to train, plan, monitor success and failure, and encourage the routine collection of data and then make decisions based on this. He felt that there is a need to constantly engage all partners (NGO, national government, district level decision makers) to keep the work going. If all partners bring their own particular standards then chaos and confusion will continue. People need to be encouraged to work together and to let local (community and district level) stakeholders set the agenda.

4. Action, alignment and appropriateness at all levels of the health system

Decentralisation of decision making in the health systems is occurring in many countries. Focussing on the Kenyan experience Robinson Karuga explained how the backdrop of decentralisation has forced their research to engage with all levels of the system. In Kenya power and resources are devolved, so counties are responsible for implementing programmes, managing human resources for health, and making financing decisions about health care. This autonomy means CHW programmes can be viewed differently in different counties -  for example, some officials in the health departments do not view preventive/promotive health services at community level as a priority. This area is therefore largely left for NGOs to support. National government is still very important – particularly when it comes to standard setting, capacity building, and technical support. To embed quality improvement in a decentralised setting there is a need to continually engage all actors recognising that they all have different interests. For sustainability, it’s key to formally institutionalize acceptable structures for quality improvement that are aligned to the health system to ensure continuity. The tools that we use to do this need to be simple and understood by all – recognizing different information needs and literacy levels.

As the REACHOUT programme continues we will be generating more learning on embedding quality in community health worker programmes. We look forward to sharing it with you in the future.

Recent news

• Community health workers: great potential for resilient and responsive health systems, 28 November 2016
• Close-to-community providers and menstrual regulation, 25 November 2016
• Indigenous knowledge and intersectionality: “Incremental radicalism” and front line health workers, 23 November 2016

Over the past years, attention to the role of community health workers (CHWs) has been growing, so it was no surprise to me that the Global Symposium on Health Systems Research 2016 offered a considerable number of organized sessions, panels, presentations and posters around this subject in Vancouver last week.

UNICEF organized a session on “community health systems”, with a focus on CHWs. Evidence was shown on how several “hardware” elements of these systems (such as financing, monitoring and training and supervision) could be improved. For example, the Malaria Consortium developed m-health tools to support CHWs’ skills in prevention and diagnosis of diseases and provide a vehicle for data collection and supervision. The project shows good results in Uganda and Mozambique. World Vision has extensive experience in CHW programming and takes the lead in harmonizing CHW programmes in various countries, by developing clear job descriptions, tools for competency-based supportive supervision and training curricula. Management Sciences for Health has developed a tool for costing of CHW programmes, which can provide insight into needed resources to reach several specific health targets over time at national or district level. UNICEF will publish a study showing how CHWs are distributed at national and district level in Sierra Leone, Liberia, Niger and Malawi, and how close to their communities they are (in terms of distance). The evidence from these initiatives and studies provides important insights for policy makers, programme managers and implementers on what can be done to improve CHW and programme performance.

The realization that besides hardware, “software” elements (such as trust, values and relationships) are needed to reach optimal performance, was supported by various speakers during the symposium. Health systems are complex and social institutions, in which health worker performance is shaped by transactional processes between different actors. The intermediary position of CHWs makes this even more profound, as addressed in various presentations from the REACHOUT Consortium: CHWs continuously need to serve and link to communities and the health sector. Why do I refer to the “health sector” here, and not the “health system”? Because CHWs – and communities – are part of health systems. I think we should question ourselves when we talk about “community health systems”. We can keep it simple: we are talking about health systems.

The notion of health systems as complex, adaptive and social institutions affirms the attention to the role of CHWs. They are not only part of the health workforce supporting the achievement of disease related targets, but they also have the potential to facilitate relationships between different actors in the health system, and act as social change agents by triggering the raising of voices of communities. In other words, CHWs play an important role in bonding, bridging and linking – the pillars of social capital. We need to look at how hard- and software elements in health systems and in community health programmes interact with each other. For example, how can training or supervision interventions for CHWs be shaped in such a way that they trigger feelings of connectedness and serving the same goals, and create a sense of trust between various actors?

This is related to the call, in one of the plenary sessions, for intersectionality when analyzing and improving health systems. People are at the center of health systems, and the system’s functionality depends upon health workers, clients and communities. People can experience health status, phenomena affecting health and health care differently. If we had a better understanding about this in particular contexts, programmes could be optimized and health systems could become more equitable.

CHWs, as members of the communities they serve, have access to much needed context specific knowledge. They are said to have the ability to reach and include minority groups in health programmes. However, CHWs themselves, as every other health worker, share norms and values existing in communities; and their performance could be constrained by this. For example, female CHWs in Afghanistan are constrained in conducting certain tasks, as male involvement is no option in a society where females cannot speak to males outside their own households. It is important to reflect upon these issues, including reflexivity of how we as researchers are part of and influenced by the ideas and interest and norms and values of the communities we are part of.

We have seen that over the past decades and even now, CHW programmes do sometimes not perform in an optimal way, because of demotivation, mistrust, constrained communication and diverging expectations. Research on CHW programmes has much focused on hardware, but less on the software elements in health systems. The complex connection between the broader context and (the hard- and software elements of) health systems is recognized, but research related to this is scarce and translation of research findings to policy and programming options is even more challenging.

We need to look beyond researching how human resource management interventions can improve CHW performance, and expand on researching CHWs’ realities as intermediaries within health systems, embedded in specific social, political and economic contexts; and draw conclusions on what can be done to improve trusting relationships and address power between all actors involved. I believe if we do so, CHW programmes could be one step closer in contributing to resilient and response health systems, and therefore to health for all.

Recent news

• Close-to-community providers and menstrual regulation, 25 November 2016
• Indigenous knowledge and intersectionality: “Incremental radicalism” and front line health workers, 23 November 2016
• REACHOUT at the Flinders University Indonesian Alumni Symposium, 2 November 2016

The liberation war in Bangladesh ended in December 1971. It has left many legacies, one of which is the provision of Menstrual Regulation services. Some health systems researchers have described the post-conflict moment as a ‘window of opportunity’ when policy makers and practitioners have space within the flux of change to do things differently. In the aftermath of war in Bangladesh many women were pregnant due to rape by war perpetrators. Menstrual Regulation was a medically reliable, politically expedient, culturally acceptable, morally correct, and humane response to this. Menstrual Regulation is essentially the termination of pregnancy of up to 12 weeks gestation sometimes through Menstrual Regulation Medication (misoprostol) or manual vacuum aspiration.

Menstrual Regulation services continue in Bangladesh, providing legal pregnancy termination services, while abortion continues to remain illegal.Nowadays many different women access Menstrual Regulation services. However, younger, married women are more visible because of stigma related to non-normative sexualities (e.g. women who have extra-marital sex; sexually active single women, young working women, divorcees and widows; and older women who continue to have sex past an age deemed appropriate by mainstream society). While access to services is available, the care pathway to these services is by no means straightforward and is mediated by a number of formal and informal health systems actors. Within REACHOUT we have been exploring the role or close-to-community health service providers in improving access to Menstrual Regulation services and using quality improvement methods to see how they could be better supported in this role.

Accessing Menstrual Regulation services: Opportunities and challenges

Bangladesh has a famously complex and plural health system with a range of paid, unpaid, public, private, formal and informal providers – many of whom cross these categories from time to time. As in many other low- and middle-income countries there is also growing urbanisation in Bangladesh. Through acontext analysis in Sylhet and Dhaka and quality improvement process with Marie Stopes and RHSTEP clinics in Dhaka we have gathered useful insights into how access services could be improved.

Women’s choice of health provider is mediated by: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect, privacy and familiarity. In our study informal providers are usually the first point of contact even for those clients who subsequently access sexual and reproductive health services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding sexual and reproductive health services.

Motivating close-to-community providers, most of whom work for low or no pay, is a perennial problem in many settings. In our study close-to-community providers related that they were motivated by acknowledgement from the community and appreciation from within their organization, their supervisors and bosses. Of course, salary was also a motivating factor. Some said that they felt like ‘invisible men and women’ and there is a perception that if they weren’t there the client would still come to the clinic. This is very hurtful. One of the interventions that we are trialing on our quality improvement cycle is a referral card which ensures that there is documentary proof that someone has been referred and supervisors can see the effort that has been expended on encouraging take up. We are currently analyzing the impact of this.

Close-to-community providers also benefit from supportive supervision in the workplace – as most of us do. We have been working through our quality improvement approach to improve this management relationship and build the skills of supervisors.

So what?

The research that we have done so far has shown that training informal close-to-community providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality sexual and reproductive health (and other) care at the community level.

Building these links and better coordination requires evidence – which health systems researchers are ideally placed to gather. We are working with neglected health workers within the system who are laboring on an issue which is profit based, blurred between private and public, contested and tricky. These close-to-community providers require your support. So, as we head towards International Women’s Day we would like to invite further enquiry into this area and that sexual and reproductive health experts and their counterparts in health systems better collaborate for women’s health.

Recent news

• Indigenous knowledge and intersectionality: “Incremental radicalism” and front line health workers, 23 November 2016
• REACHOUT at the Flinders University Indonesian Alumni Symposium, 2 November 2016
• Community health worker symposium: Kampala, February 2017, 24 October 2016

By Sally Theobald

Health Systems Global 2016 was opened by leaders of the Canadian First Nation community through song and dance and a discussion of how health has four components: physical, mental, emotional, and spiritual. The First Nations Perspective on Health and Wellness stress the need for a balance between these aspects of wellness and that they are all nurtured together to create a holistic level of well-being. 

It struck me that this conceptualisation, together with intersectionality, is a good way to think creatively about ways forward in health systems, and in particular the experiences of frontline health workers.

Physical health:

In the conference opening plenary Karsor Kollie, head of the Liberian NTD programme, discussed the impact of Ebola on front line health workers: death, injury and morbidity. Later in the conference video extracts of him interviewing community based drug distributors demonstrated the risks they faced as their roles expanded to include community action on Ebola and the burial of the deceased. Zara Trafford from University of Cape Town, also brought video insights from community health workers (CHW) in South Africa. One exhausted female CHW had an accidental needle stick injury; unlike formal paid cadres, such as nurses, she was not entitled to post exposure prophylaxis. This led to physical risk of infection, extreme stress, and a strong sense of being undervalued. The physical health impacts on front line health workers on CHWs working in contexts affected by conflict and epidemics is acute. Clearly CHWs deserve the same levels of protection as health workers in other cadres.

Mental Health:

Work on promoting a resilient health workforce in conflict affected areas highlighted the many mental health impacts on front-line health workers including post-traumatic stress disorder, insecurity and fear, and the risk and reality of abduction. Haja Wurie from ReBUILD explained how health workers were a specific target for abductions during the northern Ugandan conflict, and had to disguise themselves in order to get to work. A skills building session on life histories, used participatory approaches to understand health workers’ experiences during and post-conflict to explore how individual experiences are shaped by broader contextual changes with many mental health implications stemming from violence, trauma and fear. Close-to-community providers deal with a wide range of issues with implications for their own mental health: domestic and sexual and gender based violence, abuse, alcoholism. Polly Walker, explained how World Vision incorporated Psychological First Aid training in their core CHW model in response to increasing need. Observation of implementation in over ten countries shows immense need here on the importance of skills-building for both mental health and psychosocial support of CHWs working in a wide range of circumstances not only to serve their client better, but also to better cope with their own experiences. World Vision are currently working on a more in-depth model for support.

Emotional Health:

Despite the multiple challenges for mental and physical health, front line health workers, demonstrate “reservoirs of resilience”. New technologies can also play a role here: in Sierra Leone, in the face of Ebola, health workers used WhatsApp groups to support each other, and share vital safety information. Sophie Witter shared how coping strategies for conflict were gendered and shaped by poverty and household structure. Families, sense of nationhood and patriotism were all strategies deployed by health workers to build emotional health in these contexts. REACHOUT research within complex adaptive systems brought insights by highlighting the importance of the software of health systems (relationships, reciprocity, and trust) alongside the hardware (training, supervision and policy). When strong, respectful and trusting relationships are in place for CHWs – both with supervisors and communities – emotional health is likely to be enhanced. 

Spiritual Health:

The First nations community explained that “​Nurturing spirit is the aspect in your life that makes you smile! This is about what makes you feel good and connected. This builds your self-esteem, self-confidence and allows you to be connected to others, mother nature and yourself.” With strong links to emotional health and social capital, religious faith can help build the spiritual health of frontline health workers. Studies on health workers’ experience in Sierra Leone, N.Uganda, Zimbabwe and Cambodia showed that religion is a key motivator to join the profession and also a strong factor supporting staying in service during tough times.

So where do we go from here?

The brilliant plenary on intersectionality, showed how we need to consider multiple axes of inequity (race/poverty/gender/(dis)ability/sexuality etc.) to address power and privilege. These play out in different ways at different moments in time and in different contexts. Social justice is key, as is reflexivity and critically thinking through our own roles as researchers within health systems. There are parallels here too with the First Nations’ concept of “cultural humility” as a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Olena Havinsky, from Simon Fraser University in Vancouver, referred to the idea of “incremental radicalism”, small steps to build mutual understanding and alliances for change and to promote social justice. We need to draw on these concepts and put in place strategies to further support the holistic health and well-being of front line health workers who are the key to both responsive and resilient health systems and universal health coverage. 

Recent news

• REACHOUT at the Flinders University Indonesian Alumni Symposium, 2 November 2016
• Community health worker symposium: Kampala, February 2017, 24 October 2016
• Meet REACHOUT at the Global Symposium #HSR2016, 17 October 2016

Growing hope – building sustainable futures in Indonesia will take place on the 5-6th November 2016 in Yogyakarta. It brings together Flinders alumni and staff to share approaches to effecting positive change in Indonesia. REACHOUT will be represented by Ralalicia Limato and Patricia Junio Veronica Tumbelaka, members of our Indonesia team.

Licia will be presenting a paper on, "Power and politics at the decentralised level: Lessons from Cianjur district, Indonesia on how local governance effects the provision of maternal health services."

Good governance is one of the determinants of a well-functioning health system and effective health service delivery. Under the decentralised government in Indonesia, health system management shifted from national to district level in 2001. It was believed that decentralisation would make the provision of health services responsive to the needs of the community. However, reports from national and district level have indicated continued failure to deliver services that satisfy community expectations.

This study explored the impact of decentralisation on maternal health service delivery. Data were collected using semi-structured interviews, focus group discussions and field notes in four villages in Cianjur district, West Java province, Indonesia. Forty-six informants included health stakeholders, village heads, community leaders, maternal health service providers and community members. All interviews were recorded, transcribed, translated into English, coded and analysed using NVivo10.

The findings show that the decentralisation to district-led governance impeded maternal health service delivery in four ways: 1) delayed disbursements of staff entitlements (delivery fees) decreased the motivation; 2) greater focus on tax and revenue generation compared with maternal health programmes; 3) prioritisation of the incumbent political party agenda over the community health needs which led health officials to support politic interests for fear of transfer to less attractive postings; 4) inappropriate use of earmarked health funds for political lobbying.

Our study provides lessons on governance in decentralised systems which resonate with other settings where this process is underway. Under the decentralised system, the political agenda took precedence over serving the health needs of the community. This affected staff motivation, funding for services and the quality of health services. Potential strategies to mitigate this include stronger oversight by the central government and/or by independent bodies to monitor the local government actions.

We hope to see you at the Symposium and learn more about your work.

Recent news

• Community health worker symposium: Kampala, February 2017, 24 October 2016
• Meet REACHOUT at the Global Symposium #HSR2016, 17 October 2016
• E-health in Sidama Zone: Improving the social currency of health extension workers?, 19 September 2016

This symposium is being organised by the School of Social Sciences Public Health team at Nottingham Trent University (NTU), Makerere University School of Public Health (MakSPH) and the Ugandan Ministry of Health (MOH). 

The event will be interdisciplinary and inclusive to those working in the health and development fields in order to maximise the themes and discussions about the value, importance and contribution of CHWs to the SDG agenda in Uganda, Africa and the global health and development community. Participation is invited from researchers, community health workers, policy makers, funders, implementers, civil society and other stakeholders from  international, national and regional associations and professional organisations. You can download the symposium poster and we would be very happy if you would circulate it to your contacts.

Sub-themes

CHWs programmes (past, present and future)

• History and current state of CHWs programmes
• Recruitment, retention and attrition of CHWs
• Training models for CHWs programmes
• Performance, motivation and satisfaction of CHWs
• Coordination and supervision of CHWs
• Gender and ethics in CHWs work
• Community Health Extension Workers (CHEWs)
• CHWs programmes across the world (Africa, Asia, America, Europe and Australia)
• Challenges, lessons learnt and opportunities

CHWs and health systems

• Leadership, governance and accountability
• Human resources for health
• Financing of CHWs programmes and sustainability
• Medicines and health supplies
• Health Management Information System (HMIS) and mobile health
• Community health innovations
• Delivery of health services
• Research priorities and gaps

Role of CHWs in the SDGs era

• Communicable diseases (malaria, pneumonia, diarrhoea, HIV/AIDS, TB and others)
• Non-communicable diseases
• Maternal, newborn and child health
• Alcohol, drug and substance abuse
• Sexual and reproductive health
• Universal health coverage (UHC)
• Water, sanitation and hygiene (WASH)
• Early warning and management of national and global health risks
• Multisectoral collaboration

Please submit an abstract. Deadline 30 November 2016.

Registration now open

Fees

Ugandan students

• Early bird registration – UGX 50,000
• Late registration – UGX 80,000 –

Ugandan non students

• Early bird registration – UGX 100,000
• Late registration – UGX 150,000

International participants

• Early bird registration – GBP (£) 125
• Late registration – GBP (£) 175

This page provides details of how to register.

Recent news

• Meet REACHOUT at the Global Symposium #HSR2016, 17 October 2016
• E-health in Sidama Zone: Improving the social currency of health extension workers?, 19 September 2016
• REACHOUT at the 2016 Global Symposium on Health Systems Research, 23 August 2016

This year we are involved in a range of panels and poster presentations. If you want to learn more about our work on quality improvement in Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, and Mozambique come along and meet the team. You can also find us in the market place.

Recent news

• E-health in Sidama Zone: Improving the social currency of health extension workers?, 19 September 2016
• REACHOUT at the 2016 Global Symposium on Health Systems Research, 23 August 2016
• The challenges of implementing research in the context of health system devolution in Kenya, 18 July 2016

Mehret Lamiso at her health post, Becha Kebele (Photo: R. Steege)

By Rosalind Steege, Daniel G. Datiko and Sally Theobald

“It's easy to use, I enter data on the spot, including client location and save the data. It's much easier and quicker than the paper based system which takes longer" Mehret Lamiso

We’re sat in the small health post of Becha kebele, listening to Mehret Lamiso, a health extension worker (HEW) in this kebele for the past 9 years, share her experience of the new e-health platform that is operating Sidama Zone, Southern Ethiopia. During our discussion, community members whose curiosity has been piqued, gaze through the window casting shadows on the paper reports that adorn the walls. These walls tell the story of tuberculosis (TB) REACH success project in this region, which by bringing services to the community, increased TB case notification – as a result annual TB detection rates increased from 60% to >100% and treatment success improved. In particular the programme was able to increase detection among previously underrepresented groups, such as women, children and the elderly, and brought the ratio of TB positive men to women from 3:1 to 1:1. As a consequence of the programme, TB and HIV co-infection have reduced and the success of this programme means it is set to be rolled out nationwide.

How the E-health platform works

The e-health platform, which is being implemented across six districts in Sidama zone (population of about 3.5 million), is linked to TB REACH, and builds on successes in this programme in TB case finding and management. Within TB REACH, HEWs used mobile phones to contact field supervisors and report that they prepared smears to collect the slides; field supervisors then collect the slides to the laboratory for examination. This and other examples suggest that rapidly changing technological contexts are an opportunity for health services at local level to improve data transmission and strengthen equitable health systems in rural areas and improve quality of care.

The e-health system will initially focus on TB and maternal and child health – both priority health areas for Ethiopia but the approach has potential to be scaled up to other national health priorities. In Ethiopia almost all HEWs are women, as social norms make this an appropriate choice for improving maternal health. However, women are often underrepresented in higher levels of the health system. HEWs will use the technology in Sidama zone with the aim of building a more gender equitable health response embedded within local context. This can be done by more effectively linking HEWs with the wider health system, strengthening the reach of services and thereby their equity. In this way, the project is well aligned with SDG 5 target to ‘enhance the use of enabling technology, in particular information and communications technology, to promote the empowerment of women.’

Success and challenges

So far, a total of 57 HEWs and 68 health professionals have been trained on using the e-health platform. Two female HEWs per kebele receive training on using the phone, data input and how to send the data to the server, where it is checked. The technology makes reporting easier for the HEWs who can enter the data for ANC visits, delivery, postnatal care, identification and registration of pregnant women and TB in real time. HEWs can then access a woman’s profile to determine all the services she has previously had. This data is then accessible by the health centre to be used the same day; health centre staff now have access to timely, complete and accurate data via a simple management system.

In Bona Zuriya district the system has seen an increase in numbers of skilled deliveries, which is now at 98% and has also helped to reduce drop out rates for ANC visits. Since the introduction of the mobile phones the number of those lost to follow up has reduced 39%, and is now as low as 11%. The Head of the District attributes this reduction to the follow-up SMS service, which is helpful in reminding HEWs to visit expectant mothers in the weeks leading up to their due date. Importantly, all levels of the health system may receive an SMS, helping to improve accountability throughout the health system. However, challenges remain electricity outages and limited Internet connection. To circumvent this data can be input without connectivity and is stored until the phone reaches Internet connection at which point the data is automatically sent to the server.  

The future for HEWs

The role of HEWs as agents of change is long established in Ethiopia, with HEWs remit extending beyond health to ‘social change’ agents also educating community members on agriculture, education and improving overall village development. The female HEWs also have opportunity for improved social mobility by having a paid job, contributing to better health outcomes in the community and potentially saving lives. However, recent research found that despite the potential for the HEP to contribute to strategic advances in women’s position, unfavourable terms and conditions mean that improvements in status are minimal. Listening to Mehret’s experience suggests that this technology may be one way to move this agenda forward and improve social currency of the female HEWs in this region.

“People admire us having the phone… the government recognises the work we are doing... It’s changed our relationship with the community. Now people see us for our good achievements.  In pregnant women forums we bring solutions and achievements and can filter voices up to the health system”

We also heard about women’s groups that have been set up off the back of the pregnant women’s forum (which was facilitated by the e-health platform) where women contribute money into a kitty to host a traditional coffee ceremony to mark the new arrivals once a mother has given birth. This creation of a safe space for women in the community to come together can be seen to be gender transformative as research has shown strong relationships between women in communities to be a critical factor for women’s economic empowerment. 

We will be watching this space to see how the programme impacts on the HEWs and the community they serve in the future. When asking Mehret her hopes for the future she answered simply: “that [the programme] will still be used as it’s accurate and timely and could be rolled out beyond maternal health”

The e-health platform is being piloted by researchers at Sidama Zone Health Department (REACH Ethiopia) in collaboration with colleagues at the Liverpool School of Tropical Medicine (LSTM) under a grant from the IDRC.

Recent news

• REACHOUT at the 2016 Global Symposium on Health Systems Research, 23 August 2016
• The challenges of implementing research in the context of health system devolution in Kenya, 18 July 2016
• Announcing our new USAID SQALE project: Strengthening community health in Kenya, 8 July 2016

By Kate Hawkins

We’re big fans of Health Systems Global and the symposium that they hold every couple of years. Their next conference is coming up in November in Vancouver and we hope you will join us there to find out more about the work we are doing on community health workers. Details of our poster presentations will be released shortly, but you can put the dates of our panel sessions in your diary right now!

Adaption and innovation in the health system: Embedding quality improvement in community health in Africa and Asia

16/11/2016, 11.30-13.00, Meeting Room 14 

We all want to improve the quality of health services – but how can we do it in practice? This session will explore the challenges to embedding quality improvement in close-to-community programmes in Bangladesh, Kenya, and Malawi and suggest some way they can be overcome.

Recent investments and support to community health workers (CHWs) and other close-to-community services are to be welcomed, not least because these programmes provide a valuable link between communities and the health system and can foster a more effective approach to the social determinants of health and universal health coverage. However, scale up of services without a simultaneous focus on addressing quality will have limited impact on population health and has the potential to further entrench inequality.

Multiple project-led quality improvement initiatives in community health programmes have been shown to be effective in temporarily increasing CHW performance and effectiveness. This is particularly the case for programmes that describe tasks in a single disease area, where proven effectiveness of narrowly focused interventions is not sustained after the end of donor or research funding.

The challenge now it is to transition knowledge from these individual quality improvement efforts to a district-led health systems approach to embedding quality that ensures the local ownership of data collection, analysis and use for quality efforts at community level and is able to negotiate and sustain this in a complex system.  

Some health programmes which are technically sound fail to deliver the expected change or results; a lack of institutional and political capacity to deliver reform can help explain some of these problems. Understanding how political structures, power relations and historic legacies shape the motivations of different stakeholders and the behaviours within systems is therefore an important piece of the puzzle, alongside considering the financing gaps or technical understanding of what works for health reforms. This means looking at the incentives and norms that explain why and how heath systems operate as they do – in other words, the political economy of those systems.

The purpose of this session is to use case studies to explore the complexities of embedding quality improvement efforts in community health programmes in Africa and Asia and discuss how these efforts can be designed to ensure sustainability.

Increasing the voice of community health workers in building resilient and responsive health systems

18/11/2016, 14:00-15:30, Meeting Room 11

Community health workers (CHWs) play a central role in linking communities to health systems and thereby making health systems more people-centered. This panel session focuses on the need and strategies for strengthening the voices of CHWs, which are essential in building resilient and responsive health systems.  

Over the last decade, the role of CHWs within health systems in low- and middle-income countries has gained interest. CHWs can connect communities to health facilities, increase access to health services for underserved populations and improve population health outcomes related to HIV/AIDS, maternal and child health. CHWs often work in a context of poor infrastructure and constrained resources. Even in highly fragile settings or during disasters, CHWs have demonstrated to be invaluable frontline health workers, playing a role in emergency response, health promotion, social mobilization and referral. The Ebola epidemic in West Africa has proven once again the important role that CHWs have for building resilient and responsive health systems. To be able to maintain and expand this role, there is a need to identify strategies for strengthening the voice and engagement of CHWs.  

The purpose of this session is to explore what research, policy and practice can do to enhance the voice of community health workers in building resilient and responsive health systems. The session will highlight personal stories from CHWs in the field in various health system settings and experience of active engagement of CHWs in health system research.

The session falls under the thematic area of new partnerships and collaborations for health systems research and development. Recently, research has increasingly included voices of CHWs, to gain in-depth knowledge on how policies, programmes and interventions could be shaped to optimize CHW performance and enhance their role in building resilient and responsive health systems. Still, CHWs’ voices are often unheard. The session will discuss to what extent CHWs’ voices are taken on board in policy making, programme development and overall learning, and issues to take into account to ensure meaningful participation that supports the role of CHWs. The session will present various case studies in which CHWs take the floor, after which learning points will be discussed on strategies for strengthening the voices of CHWs in building resilient and responsive health systems.

Recent news

• The challenges of implementing research in the context of health system devolution in Kenya, 18 July 2016
• Announcing our new USAID SQALE project: Strengthening community health in Kenya, 8 July 2016
• REACHOUT partners from Asia, Africa and Europe converge for their annual meeting in Bangladesh, 4 July 2016

By Maryline Mireku and Lilian Otiso, LVCT Health

Conducting implementation research means adapting to, and coping with, changes in the external operating environment. In Kenya the REACHOUT team has had to conduct their research on improving the quality of close-to-community health programmes whilst the country implements the process of devolution. This has created new challenges and opportunities that we have needed to respond to. Our experiences provide lessons for other countries undergoing similar changes.

Devolution refers to the process of decentralization of government that Kenya underwent in 2014 from one centralized government to 47 counties with responsibility for hiring, budget and decision making leaving the national government with capacity building, standards and policy making

In 2013, LVCT Health conducted a context analysis on community health services in Kenya which identified lack of supportive supervision as a factor influencing performance of community health workers. The second phase of the study involved implementing a supportive supervision intervention in four community health units in Nairobi and Kitui counties, Kenya.

The early days

When we disseminated the findings of the first phase of our REACHOUT study in early 2014, health had not been fully devolved and there was still reliance on decision making at the Ministry of Health in central government.

After gaining ethical approval for the second phase of our study from the national Kenya Medical Research Institute (KEMRI) Ethical Review Committee (ERC) devolution meant that we had to proceed to County and Sub-County health offices to seek further approval before embarking on the implementation. As the study coordinator I was sure this process was not going to be difficult since these were offices we had worked with in other endeavours but also specifically during the first phase of the study. All I needed to do was send letters and the proposals to the offices and wait for feedback.

Changes in county health planning and priorities

In the pre-devolution era most Counties priorities echoed those of central government. However, as we moved into the second phase of REACHOUT, we came to realize that County priorities had changed. Counties were now responsible for prioritizing and managing budgets in the face of major reduction in funds from the central government and donors. In addition, the central government appears to no longer have the resources to enforce implementation of national policies by the counties. The result of this was major changes to community health services implementation including changes in practice and in some cases the decision to not implement changes which had been recommended by the central government before devolution. For example, the Community Health Strategy (revised in 2014) called for changes in roles of community health providers such as the community health volunteers (CHVs) only being involved in mobilization of community members as opposed to the initial plan where they not only conducted mobilization but also collected data on household health status and in some cases provided basic curative services. But this has only kicked off in less than half of the Counties with the non-implementing ones sighting issues such as budgetary constraints and need for additional changes to the model to suit their needs as hindrances to adoption.

New positions and titles and vacant offices

County Health Management Teams (CHMTs) are composed of heads of various divisions in the health department at county level headed by the county director of health (a new position). The constitution of CHMTs and the persons heading them (sometimes the County Executive Committee Member for Health) varied across the counties. New positions and functional groups such as County Research Technical Working Groups (TWGs) were created and formed a new layer we had to work with to conduct the study.

Due to the process of setting up, some of the offices created by the CHMT lacked an individual to head them due to lack of adequate staff or staff with the right qualifications or ongoing consultations. During the course of our work we noticed either prolonged vacancies in some of these positions or frequent changes in the people heading these positions. For example, in one of our study sites we had two offices headed by three different people in a span of six months.

This has had impacts on the research. We did not anticipate creation of new offices in the CHMTs with a responsibility of ethical appraisal of research studies. Before devolution the Ministry of Health structures (Provinces and Districts) accepted approvals from the existing ERCs and studies not need to undergo additional ethical approval. One of the Counties where we are implementing our study developed a County Research Office which was tasked with appraising all studies. Taking our study through another approval process meant we had to wait to begin the study and caused a delay that we had not planned for.

Frequent transfers

Unfortunately, even when new offices were created, there were several transfers with staff filling the positions for very short periods of time. In one of the offices we were working with we experienced three different people occupying an office in a span of three months. Upon raising my concern of the frequent changes one county official explained to me how these were some challenges with devolution. He concluded ‘at least the office still exists, we have had situations where posts were created only to be disbanded later’.

Similar changes were taking place at sub-county level. Some transferred staff would take some time off before reporting to their new posts. Expectations of transfers also made some sub county officials reluctant to be involved in activities especially because some of the transfers were happening sporadically. Often we would begin working with somebody only for them to be transferred midway. In one instance we were ‘accused’ of running activities at the Sub County level without the Sub County approval because the Medical Officer of Health who gave the approval and a good number of the Sub County Health Management Team (SCHMT) were transferred. We had to put our activities on hold and go back and re-sensitize the SCHMT.

Senior managers closer to implementers

Devolution has resulted in leaders being closer to the implementers. For researchers this has resulted in Key Informant Interviews with senior managers at County levels being more productive compared to pre-devolution where the provincial level managers would not know much about the implementers they were making key decisions for. Decision making by leaders has also taken a more practical approach and implementers have been able to successfully influence plans made by managers. In addition, issues which would take longer to be resolved due to the many bureaucratic levels that existed pre-devolution can now be managed faster. This is an advantage to researchers who hope to influence practice by giving decision makers feedback of good practices from interventions.   

Implications for research

The experiences laid down here were from a time when Kenya had just devolved its health system. Researchers should anticipate similar issues where government systems and structures are undergoing change such as what we anticipate in the upcoming Kenyan general election or the recentBrexit vote for UK to exit from the EU.  This has implications for research:

• County buy-in

Devolution has increased interest in research by counties which may result in more buy in especially if the research is aligned to the county priorities. Delays may however occur due to longer approval processes. 

• Development of adaptable research plans

Because our intervention focused on supervision we were interested in working with supervisors at the sub county level. However due to transfers we were forced to wait for individuals to report to their posts and sensitize them. These changes were necessary but in as much as they were anticipated on the ground the specifics were not known such as the timing and the regions/posts which would be affected. Researchers implementing in the Counties need to have plans which can be adapted to changes in the context they are working and avoid linear approaches and commonly held assumptions. We have had to be flexible and align our study to fit into these changing contexts although there is still uncertainty of what other changes will come up in the life of the study.

• Reporting findings across sites

In such different and fluid contexts a researcher has to be ready to accept that at the end of your study, especially if long term, one may face difficulties in carrying out comparisons across sites, tracking changes and even making attributions. There is need therefore to embrace active observation to record possible confounders and their effect on the studies we are carrying out.

• Way forward for advocacy

According to the new constitution, the role of the central government is development of policies and standards. From our experience, the central government has no mandate to enforce these policies. County governments are now amending or developing new policies contextualized to the local priorities.  However, this process is affected by lack of structures and experience in utilization of evidence to make decisions to inform policies. For researchers in Kenya this means new players in the policy environment who have to be involved from the beginning to the end of the research for it to inform policy. Researchers will not only have to involve the Counties in advocacy but also work with some Counties to build capacity of some heads of department in this area.

Implementing research in uncertain contexts calls for researchers who not only anticipate change but also have the ability to adapt to the change at any time of the implementation. Our experiences from the Kenyan context offers lessons for others experiencing similar, rapid change.

Photo courtesy of Mkimemia

Recent news

• Announcing our new USAID SQALE project: Strengthening community health in Kenya, 8 July 2016
• REACHOUT partners from Asia, Africa and Europe converge for their annual meeting in Bangladesh, 4 July 2016
• Exploring lessons learnt from Close-to-Community Health Worker Programmes: A symposium, 20 June 2016

By Kate Hawkins

We are delighted to announce the launch of the USAID SQALE project: an initiative to embed and study quality improvement interventions in eight counties in Kenya. This project brings together REACHOUT partners LVCT Health and the Liverpool School of Tropical Medicine with a new partner, URC, and will run for three years.

“The community health strategy provides a great opportunity to achieve significant reductions in maternal and child deaths. With USAID SQALE, we get an opportunity to enhance efficiency and effectiveness of the community health services based on research findings to achieve greater results with minimal additional investments by focusing on continuous quality improvement.”

Lilian Otiso, LVCT Health

Why we need USAID SQALE

The 2014 Demographic and Health Survey shows that under-five child mortality in Kenya is 52 per 1000 live births and that 68% of children have received complete vaccination. Only 58% of pregnant women attend four antenatal care visits and 61% deliver in a facility. Hard-to-reach areas are particularly poorly served, and skilled delivery attendance varies significantly across counties. Women and children make up the majority of users of the public healthcare system and community health services. However, because women often do not manage household finances for travel and illness, they may not be able to access services for themselves and for their children when they need them. These challenges are compounded by delays in seeking care due to cost, distance, poor ambulance services and roads, and delays in receiving care due to poor facilities, lack of supplies, inadequately trained or poorly motivated staff and lack of functioning referral systems.

The organization of Kenya’s health services is changing as it undergoes full decentralization to county level. Alongside devolution the revised Community Health Strategy places more emphasis on the equity of services. In this time of rapid change there is a potential risk to both service quality and equity as new funding mechanisms, lines of accountability and supervision are implemented as power is devolved.

Our goal is to contribute to the reduction of maternal and child deaths by increasing the quality of services at community level and the use of services at facility level.

What exactly will we do?

USAID SQALE will embed quality improvement methods into the community health system in four counties in Kenya and disseminate current national standards to an additional four (control) counties. The project will:

• Strengthen national coordination of community health programmes;
• Build the capacity of county decision makers to prioritize and budget for community health programmes using an equity approach; and
• Improve community health programme quality and performance and generating demand through ongoing provider and community engagement.

Our legacy

Through project monitoring and evaluation and a focus on capturing learning through a robust research agenda we hope not only to contribute to maternal, newborn and child health, but also to create new knowledge which we can share at sub-national, national and international levels. Our close links with the Kenyan Government have helped us to define an agenda that responds to very real challenges that are being faced at the frontline of the health system and we look forward to supporting them with the evolution of the Community Health Strategy over the coming years.

Recent news

• REACHOUT partners from Asia, Africa and Europe converge for their annual meeting in Bangladesh, 4 July 2016
• Exploring lessons learnt from Close-to-Community Health Worker Programmes: A symposium, 20 June 2016
• How equitable are Community Health Worker programmes?, 31 May 2016

By Daniel Kavoo, Kingsley Chikaphupha, Maryline Mireku, and Patricia Tumbelaka

REACHOUT is a five-year European Commission (EC) research project with the aim of maximising the equity, efficiency and effectiveness of community health service delivery. The eight countries include six implementing countries; two in Asia (Indonesia and Bangladesh) and four in Africa (Kenya, Malawi, Ethiopia, and Mozambique) with the remaining two (UK and Netherlands) providing technical support through the Liverpool School of Tropical Medicine and KIT .

REACHOUT consortium partners,policy makers and practitioners from implementing countries (e.g. Ministries of Health) meet annually in each member country. The broad aims of these meetings are: capacity strengthening, sharing experiences and lessons learnt from each site to improve programme implementation, to review research communication and dissemination plans and outputs and to discuss how these can be best used to impact the community health worker (CHW) landscape.

The James P. Grant (JPG) School of Public Health (of BRAC University) is the implementing partner in Bangladesh. In Bangladesh there is a strong partnership between government and the NGO BRAC due to its national coverage and the wide range of services provided by the NGO such as provision of health and education services, capacity building and micro-finance activities. As part of sharing experiences and lessons participants at our annual meeting undertook a field visit to gain experience of BRAC initiatives and approaches, success and challenges with a specific focus on close-to-community (CTC) providers.

Consequently, we reflected on the differences and similarities between the BRAC programme and those in our own countries:

• Similarities between countries:

CTC providers across the consortium countries conduct home visits to provide services and collect health information. Services include the provision of health promotion messages, treatment of minor ailments, mobilization for uptake of health services, and referral to health facilities. CTC providers also conduct regular meetings with community members to conduct dialogues and discussions according to need and with their supervisors to submit reports. CTC providers are availed with basic health care service provision kits. Health promotion messages in the countries are delivered through visual aids such as flip charts.

• Differences between countries:

While CTC providers generally volunteer without pay, some countries provide them with incentives which recognise their performance which vary in regularity. For instance, in Kenya not all CTC providers receive incentives while in Ethiopia they are salaried workers. Delivery of health education is also different across countries. Some countries deliver need-based health education while others such as Bangladesh have specific modules which guide CTC providers on areas of focus. Participants observed that it was only Bangladesh which has CTC providers involved in primary eye care services. Unlike the other countries tests for bilirubin, blood glucose, and albumin are conducted by CTC providers in Bangladesh. Blood pressure checking is also done by the providers in Bangladesh and Indonesia.

Most of the countries have a well-defined career path for CTC providers where they can progress up the health system hierarchy from one level to the other depending on their performance and education. In some of countries changes in careers entailed on-job training such as six-months training to become skilled birth attendants for the Shasthya Kormis of Bangladesh.

In some contexts CTC providers charge a small fee for service provision, such as in Bangladesh for tests and medicines.

In Bangladesh CTC providers have one register for recording services provided and household information in the community while other countries have different registers for different services and also cadres.

Lessons for REACHOUT

Consortium meetings provide rich opportunities and a conducive environment for member countries to learn and share their experiences and appreciate the similarities and differences across the REACHOUT contexts. The similarities across the countries is an opportunity for the REACHOUT members to influence each other through learning from best practices and contribute to the improvement of community health programme implementation. On the other hand, the differences can be adopted and adapted to the local contexts to ensure practices are in line with country guidelines, standards, and policies.

Watch this space for the next consortium meeting to take place in Kenya, the land of champions, March 2017!!!

Recent news

• Exploring lessons learnt from Close-to-Community Health Worker Programmes: A symposium, 20 June 2016
• How equitable are Community Health Worker programmes?, 31 May 2016
• How relationships shape community health workers’ performance in Ethiopia, Kenya, Malawi and Mozambique, 13 May 2016 

By Anushka Zafar

On 12 June 2016, REACHOUT team members from all six of its working countries came under one roof for a symposium on ‘Strategies for Optimizing Close To Community (CTC) Worker Programmes to Create more Resilient and Responsive Health Systems’. As part of a larger consortium of eight partners, the sixth consortium meeting was held in Bangladesh from 6-15 June, hosted by the REACHOUT Bangladesh team, at Brac University’s James P Grant School of Public Health (JPGSPH).

Panel presentations highlighted lessons learnt from CTC programmes in Bangladesh, Ethiopia, Indonesia, Kenya, Malawi and Mozambique. From each country, we see that CTC health providers stand at the intersection of several forces – such as the community, the health system and the market. They are not only deliverers of programmes, but often also health activists, engaging the community. They are also increasingly subjected to the forces the evolving health market, and must navigate this with very little guidance.

As a result, these health workers face a range of challenges. In Kenya, for instance, the programme is confronted with high dropout rates due to financial constraints. In Malawi, a lack of senior officers makes supervision of CTC workers more difficult. Meanwhile in Bangladesh, where CTC health workers mainly tend to hard-to-reach populations and rural villages, the programme now has to adapt to provide access to healthcare in urban slums, a dynamic space with pluralistic health services.  

Overall, across each country, the findings show the need to provide support on both the supply and demand side; this includes retaining staff, sustaining CTC worker motivation, addressing lack of governance, and the overall sustainability of these programmes. There also needs to be greater investment in training and tools.

Looking at the obstacles and what the future holds for these programmes is particularly crucial as we go on to address more complex health targets. However there is a lot of scope to develop and assess interventions with the potential to make improvements to CTC services. Speakers from Malawi and Kenya discussed the opportunity to incorporate the use of mobile phones to strengthen and increase accuracy in data management. In Kenya, mobile applications for training CTC workers have also been established to reinforce their capacity development efforts. These are some examples of solutions to issues that seem to similarly challenge programmes in all six countries.

REACHOUT examines the big picture across each country and across time – this will not only reveal the larger story but also help each country learn from one another and implement improvements according to their context. Bringing REACHOUT team members together to examine the findings thus far continues to help generate informed, evidence-based and context-appropriate policies for future CTC services.

As we transition from Millennium Development Goals to the next set of Sustainable Development Goals, countries striving to achieve universal health coverage are increasingly depending on CTC health services. Now more than ever, there is a need for health systems to understand the context and conditions in which these services operate in order to realise their potential.

Anushka Zafar is a communications and knowledge manager at JPGSPH, Brac University

The photo should be credited to Istiak Tonu

Recent news

• How equitable are Community Health Worker programmes?, 31 May 2016
• How relationships shape community health workers’ performance in Ethiopia, Kenya, Malawi and Mozambique, 13 May 2016 
• Co-constructing knowledge about health with the young people of Korogocho informal settlement, 28 April 2016

By Rosalind McCollum,

There are dramatic differences in mortality and life expectancy between and within countries. Disadvantaged groups have poorer survival chances and use facility-based services less than other groups.  Community health services are an opportunity to improve this situation and create a pathway to Universal Health Coverage (UHC). 

Community Health Workers (CHWs) can improve equitable child survival, health, and nutrition by bringing services closer to the homes of hard-to-reach and underserved people.  However, new health interventions typically reach richer groups first, only benefiting the poor later. So we shouldn’t assume that introducing CHWs within a health system will automatically result in equitable coverage of health services.  We carried out a systematic review which describes how equity plays out within CHW programmes and identifies ways in which we can design CHW programmes that influence equity.

What were we trying to find out?

In this study we wanted to understand:

1. What evidence there is of (in)equity in CHW programmes?
2. What influences how equitable CHW programmes are in terms of access, utilisation, quality and community empowerment?

What did we find?

There were few studies which assessed levels of equity in CHW programmes (34 papers included, from 32 studies).  There was a difference in the package of services provided between continents.  CHW programmes in the Americas had a comprehensive bundle of services which provided care for all the family, in Asia CHW programmes were often focused on a single group within the population, such as mothers and newborns.  While in Africa CHW programmes studied had a disease specific focus, for example home based diagnosis and treatment of malaria.  Given the limited package of services observed in studies conducted in Africa this raises equity concerns around access to comprehensive community health services. 

CHW programmes were found to promote equity in terms of access and utilisation of community health services by reducing inequities relating to place of residence, gender, education and socio-economic position.  CHWs can also contribute towards more equitable uptake of referrals at health facility level.  There was no clear evidence for equitable quality of services provided by CHWs, with no studies having assessed technical quality, although client satisfaction with services (as a proxy for quality) indicated lower quality for poorer clients in some studies.  There was limited information regarding the role of the CHWs in generating community empowerment to respond to social determinants of health. 

How to improve CHW programme design

Recruitment of the poorest community members as CHWs, close proximity of services to households, pre-existing family relationship or social ties with CHW, home-based services, free service delivery, targeting of poor households, strengthened referral to facilities, sensitisation and mobilisation of community members were all things that promoted greater equity within CHW services.  There were also programme design features that appeared to hinder equity in programmes. These include low numbers of CHWs and a lack of consideration for the terrain or population density that they have to cover, long distances between CHWs’ homes and health posts, costs of services, lack of information about services and failure to mobilise community. Policy makers should take these factors into account when planning programmes. 

What can we learn from this study?

CHWs are able to address both supply side barriers (aspects of the health system that may hinder use of services) and demand side barriers (things that influence ability to use health services at individual, household or community level) to uptake of health services to promote more equitable access and use of health services.  However, care must be taken by policymakers and programme designers and managers to take into account factors which can influence the equity of services during planning and implementation of CHW programmes.

Photo credit: CHW Diana carrying out a household visit in her community in rural Turkana County, Kenya. Taken by Rosalind McCollum.

Recent news

• How relationships shape community health workers’ performance in Ethiopia, Kenya, Malawi and Mozambique, 13 May 2016 
• Co-constructing knowledge about health with the young people of Korogocho informal settlement, 28 April 2016
• Embedding Group supervision to ensure quality maternal health services in Shebedino District, Ethiopia, 15 April 2016

By Maryse Kok, KIT

Community health workers (CHWs) have a unique position between communities and the health sector. Relationships are the glue that support CHWs in their interface role. The strength of CHWs’ relationships influences their motivation and performance, which can affect the quality of the services they provide. This is an area that policy makers and programme managers need to take seriously if they aim to improve service coverage and quality.

To understand the importance of relationships to the work of CHWs, REACHOUT conducted a qualitative comparative study in Ethiopia, Kenya, Malawi and Mozambique. This work offers important lessons for countries that are reliant upon CHWs to improve citizen’s health and wellbeing.

What did we do?

We conducted focus group discussions and interviews with CHWs, their supervisors, managers, and community members. We collected interviewees’ perspectives on factors that influenced the performance of CHWs and relationships between CHWs, communities and the health sector (supervisors, managers and health professionals). A comparative analysis with a “realist lens” was conducted, identifying which mechanisms, in which contexts, led to either trusting or weak CHW relationships. These are called context-mechanism-outcome (CMO) configurations.

Relationships between CHWs and communities

Trusting relationships between CHWs and their communities were a result of:

• Feelings of connectedness, familiarity, serving the same goals, and free discussion;
• The perception that CHWs serve in the community’s interest and enhanced recognition, respect and credibility from the community; and
• Feelings of CHW self-fulfilment.

The way in which programmes are designed can support trusting relationships. For example, it helped if CHWs were recruited from the place that they would be working in, with the involvement of communities in decision making. The involvement of volunteers as an official element of the programme was perceived to be helpful, as was the involvement of traditional leaders. Trusting relationships could be enhanced if curative tasks were shifted to CHWs. In contexts where gender roles in (reproductive) health care were separated having female CHWs was important.

Other broader contextual elements that were considered important included: valuing and promoting community participation; a history and value of volunteerism, and the importance of and respect for traditional leadership at the community level.

Relationships between CHWs and the health sector

Trusting relationships between CHWs and the health sector were related to feelings of connectedness and serving the same goals (from both sides) and CHWs’ belief that they were supported. Other studies have identified additional mechanisms, for example, related to health professionals reporting that CHWs assist them in reducing their workload. For the mechanisms to take place, the following programme-related contextual factors were found to be important:

• Professional support structures to be available;
• Curative tasks to have been shifted to CHWs; and
• Regular and visible supervision to take place.

We found that weak relationships between CHWs and their supervisors and managers were a result of disrespect and doubts from the health sector about CHWs’ competencies; CHWs feeling disconnected, unfamiliar and unsupported, or having a lack of confidence or perceptions of dishonesty and unfairness in supervisors and management; and misunderstandings related to lack of communication (from both sides). In some cases, weak relationships between CHWs and their supervisors or managers had a negative knock-on effect on the strength of CHWs’ relationships with their communities.

Some CMO configurations were more specific to particular settings. For example, in Ethiopia communities could perceive CHWs as dishonest if they were (forced to be) involved in politics. In Malawi, communities perceived CHWs as not trustworthy if volunteers received different and irregular incentives, as a result of multiple vertical programmes.

What next?

The study demonstrated a complex interplay of factors influencing trust, and thereby the strength of relationships, between CHWs, their communities and actors in the health sector. Trusting relationships are instrumental to improve CHW performance and should not be overlooked in programme design. Policy makers and programme managers should take into account the broader context and could adjust CHW programmes so that they trigger mechanisms that generate trusting relationships between CHWs, communities and other actors in the health system. Hereby, lessons learnt on what worked in comparable contexts should be taken into account.

Read the full paper...

Photo credit: The image is of Hope who works for a UK aid supported family planning clinic, Banja La Mtsogolo which means "Future Families." She was originally a client at the clinic and then became a Community Health Worker. It was taken by Lindsay Mgbor/Department for International Development

Recent news

• Embedding Group supervision to ensure quality maternal health services in Shebedino District, Ethiopia, 15 April 2015
• Community engagement in Ethiopia: Efforts towards improved maternal health, 29 March 2015
• Practical training on e-health delivered by REACH Ethiopia, 23 March 2015

In our discussions about community health we rarely capture and explore the experiences and concerns of young people. But if we are serious about ‘people centred health systems’ their views and engagement are crucial.

To overcome this knowledge gap we have been working with youth in an informal settlement in Nairobi, Kenya. Korogocho is the fourth largest informal settlement in Nairobi, with an estimated population of 100,000 to 120,000 people living within 1.5 square kilometres of land owned by the government.

Our project used PhotoVoice - a participatory photography research method which seeks to bring about positive social change in communities by providing photographic training through which project participants can advocate and improve the quality of their lives.

Nine young people, aged 16 – 18 years who had dropped out of school (5 girls and 4 boys) were selected and trained on how to use digital cameras and getting people’s consent, before capturing aspects of life and health in their community.  Regular meetings were held where they discussed their photos and identified potential solutions with the rest of the research team.

Negative issues that were highlighted by the PhotoVoice team include unsafe communal toilets where young people feared sexual assault, rubbish sites where children without parents would scavenge for food, unclean water, long waiting times and disrespectful staff at the local government health centre, lack of medicines at the health centre which meant that people went to pharmacies instead, and unsafe electricity supplies. But they also highlighted how vegetable sellers make a livelihood but also provide nutritious food to the community, how the private health centre provided services without long queues, and the way that community health workers empower pregnant women to attend medical services and support community health.

The film was screened as part of a photo exhibition held with community leaders and influential stakeholders in order to generate discussion and identify community led actions to address issues identified.  We will continue to raise the concerns of the young people of Korogocho at national and international levels.

To find out more about the project and how you can support the young people of Korogocho by disseminating their book or showing their film contact Rosalind McCollum (Rosalind.McCollum@liverpool.ac.uk).

Recent news

• Embedding Group supervision to ensure quality maternal health services in Shebedino District, Ethiopia, 15 April 2015
• Community engagement in Ethiopia: Efforts towards improved maternal health, 29 March 2015
• Practical training on e-health delivered by REACH Ethiopia, 23 March 2015

By Nega Teyikie

Access to quality health services is greatly influenced by the performance of health workers. Consequently, quality improvement of health services requires continuous supportive supervision. In the context of strengthening community health worker (CHW) programmes, various studies showed that supervision systems are essential to increase productivity and performance. Supervision is one of the most relevant tasks in health systems management, yet health managers commonly neglect supervision, and many supervisors lack the knowledge, skills and tools for effective and supportive supervision.

Group supervision is a form of supervision where CHWs come together to meet with their supervisor either at a health facility or in a village. The monthly meetings usually include discussion of collected data, discussion of problems encountered, sharing suggestions of local solutions and continuing education.

It is often the time when health workers realize how they can help and support each other. Group supervision provides a rich forum for CHWs to share their unique experiences and challenges, and could be a mechanism for mitigating burnout among CHWs as a result of interacting with clients in the course of their community work. It is recognized as a key approach for strengthening the quality of all aspects of community health service delivery.

REACHOUT has been implementing group supervision as part of a quality improvement intervention, to enhance equality of maternal health service delivery by health extension workers (HEWs) in Shebedino District, Sidama Zone, South Ethiopia.

The monthly health centre based supervision meeting sessions are conducted with the help of a guide for supervisors, adapted from a supervision curriculum developed in collaboration with LVCT Health (Kenya) and the Liverpool School of Tropical Medicine.

HEW supervisors were trained on group supervision by REACH Ethiopia, using an adult learning approach. The training focused on how to facilitate group supervision meetings and how to use the guide to support in structuring the sessions.

We visited Telamo Health centre during one of the group supervision sessions, while they were discussing activities during December 2015.  One of the HEWs, pointed out “…It is Group Supervision that brought such a remarkable achievements on maternal health activity in our catchment and contributed for the best performance of our district in a year of Sidama zone…”

Similarly, Primary Health Care Unit director mentioned that that the good things achieved in group supervision: to easily monitor the success and gaps of facilities, improves the inter and intra facility referral linkage of pregnant women, and clearly define the role and responsibility of HEWs and their supervisors while executing services.

It is inspiring to see the ownership of the teams (supervisors with HEWs) and their drive to promote maternal health. The positive evaluation will be used to further strengthen and upscale the supervision system, so that it can truly contribute towards realizing increased coverage and quality of health services in general.

Photo credit: Monthly group supervision discussion session of Dec/2015 of at Telamo HC, Shebedino district, Sidama zone, South Ethiopia.   

Recent news

• Community engagement in Ethiopia: Efforts towards improved maternal health, 29 March 2015
• Practical training on e-health delivered by REACH Ethiopia, 23 March 2015
• Junior doctors in the UK are striking: How to motivate the health workforce, 25 February 2016

By Elias Michael

REACH Ethiopia works on improving the performance of health extension workers (HEWs) on maternal health in Sidama Zone of the South Nation Nationalities and Peoples Region. This work is part of the REACHOUT consortium, an ambitious 5-year international research consortium funded by the European Commission. REACHOUT helps to understand and develop the role of close-to-community (CTC) providers working on improving the health status of communities in Africa and Asia. The aim of REACHOUT is to maximize the equity, effectiveness and efficiency of CTC services in rural areas and urban slums in six countries: Bangladesh, Ethiopia, Indonesia, Kenya, Malawi and Mozambique.

In 2013, a context analysis, consisting of a document review and a qualitative study in six districts of Sidama revealed that supervision of HEWs, referral and coordination and community engagement were the main areas for improvement of performance of HEWs. Therefore, a quality improvement (QI) intervention focusing on these areas was introduced in 2014. This marked the start of a QI cycle, in which the outcomes of the interventions were followed over the course of one year in one district, using observations, tracking registers and interviews with HEWs and women in the community. 

The community engagement intervention

The community engagement part of the intervention was based on existing strategies and programmes in Ethiopia. As such, no new structures were introduced. Existing community engagement activities, related to pregnant women forums (PWFs) and health development army (HDA) leaders’ meetings were reviewed, adapted and included in an integrated refresher training of the HEWs. A PWF and a HDA leaders’ meeting guide were developed, in order to assist HEWs during these meetings. Sixty-five HEWs received the training and guides and were responsible for facilitating the intervention in the community. The intervention was supervised by health centre staff (the official supervisors of the HEWs) and REACH Ethiopia staff, and feedback about the implementation of the intervention was provided to HEWs.

What is the pregnant women forum?

Each health post, staffed by two HEWs, is supposed to hold one PWF per month. Pregnant women living in the community are expected to attend the PWF regularly. During the meeting, danger signs of pregnancy, advantages of antenatal care (ANC), institutional delivery, postnatal care (PNC) and cultural and other factors influencing mothers to access maternal health services are discussed and addressed as per the queries raised in the group. Every pregnant mother develops an individual birth plan with the ultimate goal of giving birth at the health facility. The PWF is led by a HEW, often in cooperation with a health professional, such as a midwife.

What is the health development army?

The HDA is an organized movement of the community, introduced nationwide in 2012.Through participatory learning and action meetings led by HEWs, communities are capacitated to take ownership of their own health. A Development Group is a community structure composed of 30 women representing their families. The women in each Development Group are clustered in one-to-five networks. The one-to-five networks develop their own health improvement plan which is further cascaded to each individual woman in the network. These plans contain individual targets in line with the Health Extension Programme. Members of the network implement and continuously monitor their performance with close follow-up and technical support from HEWs, during monthly HDAleaders’ meetings at the health post level.

Key findings

The participation for both types of meetings increased over time as a result of the intervention. The proportion of pregnant mothers who attended the PWF in the 1st, 2nd and 3rd quarters was 47.9%, 88% and 119% respectively. (The percentage above 100% shows that there is still a gap in information on the number of pregnant women in the community.) The proportion of HDA leaders who attended the HDA leaders’ meeting in the same period was 11%, 28% and 44%. In both community meetings, the level of participation shows a promising trend.

The HDA leaders also contributed to an increase in the identification of new pregnancies, thereby linking referral between the community and the HEWs. The percentage of pregnant women who came for care and were identified by the HDA increased from 43% to 85%. Generally, the ANC utilization figures went up, from 73% to77%. The institutional delivery increased from 79% to 83.3%. The community engagement activities could have contributed to this change, as illustrated by the following quotes:

"Health development army are always identifying pregnant women and report every week. When there were referral cases, they give a call to HEWs, and then we go to their home with ambulance. Whereas, when there is new pregnancy they inform to the leader of the team, then the leader would bring her to HEWs..." (Interview with HEW)

"The one-to-five leader encourages us a lot to deliver at the health facility. When our abdomen increases in size, she comes to us and asks us whether we are pregnant or not. If she gets a woman who is pregnant, she advices a lot so as to go to the health facility. She teaches us a lot." (Interview with woman in the community)

Of course, other parts of the REACH intervention, related to supervision and referral, could also have contributed towards the above mentioned improvements.

Besides the increase in identification of pregnancies and utilization of maternal health services, HEWs and community members felt there was increased knowledge and awareness about maternal health issues in the community. Some of the constraints as indicated by HEWs were absentees and the unfulfilled request for financial incentives by HDA leaders.

"These HDA leaders were previously voluntary community health workers. These guys previously got incentives one a three month or six months and have such habit. But now nothing at all; these people rumour such things saying health extension workers getting for themselves letting us to work for free. As this programme is a government concern some are working and some are not because of explained reasons" (Interview with HEW)

The issue of incentives was not posed as a problem for the PWF: women were willing to come and eager to discuss maternal health issues with each other. In some areas, HEWs and health centre staff provided the women tea and coffee, paid for with their own money. Support from the Kebele (the lowest administrative unit) administrator was mentioned as a facilitating factor for HDA leaders’ meetings, as it provided recognition for HDA leaders. However, this support was not available in all areas.

In 2016, REACH Ethiopia will implement a second QI cycle, with intensified community engagement elements, scaled up to five other districts.

Photo credit: Pregnant Women Forum held in Shebedino woreda, Nure Dulecha health post, by REACH Ethiopia

Recent news

• Practical training on e-health delivered by REACH Ethiopia, 23 March 2015
• Junior doctors in the UK are striking: How to motivate the health workforce, 25 February 2016
• Working with what we’ve got – an(other) reflection on human resources for health

REACH Ethiopia operates in southern Ethiopia and implements projects on public health priorities in line with the health sector transformation plan. In collaboration with LSTM REACH Ethiopia implements maternal and child health (MCH) programmes in partnership with close-to-community services through the REACHOUT consortium  and TB prevention and control efforts. REACH Ethiopia is implementing an e-health project, funded by IDRC, in Sidama zone, southern Ethiopia. This exciting project works with all female Health Extension Workers, supporting them to use mobile technology (e-health) to improve health management information systems (HMIS) and contribute to more responsive TB and maternal and child health progammes.

As part of this programme, following a multi-method baseline analysis on HMIS and understandings of e-health, integrated MCH and TB training was conducted in Furra Institute of Development Studies, Yirga Alem. The training was provided to all Health Extension workers based in six woredas of Sidama Zone and six selected health centers. The training was officially opened by the representative of Sidama Zone Health Department, Mr. Emala Lamacha. In his key note address Mr. Lamacha stated that this collaborative project aims to improve our data management and use for timely action on major public health priorities. He underscored his commitment and requested the participants to support successful implementation in order to contribute towards improved health service delivery. 57 female health extension workers and 17 health workers, including the district and zone program coordinators of MCH and TB programme participated in the training.

The training was organized by REACH Ethiopia office teams as part the orientation and training necessary for the implementation of the e-health project. The training was interactive and included both practical and theoretical sessions; although the priority was practical as most participants had limited experience of using smart phones. Participants worked in six groups (one for each woreda) which supported practical learning, support and relationships building between health extension workers and their colleagues and supervisors. The group worked through exercises on how to use smart phones and on procedures to be applied when using the specific e-health platform that has been developed. In the feedback at the end of the sessions, participants stated that the training was well organised and that they have acquired appropriate skill and knowledge for project implementation.

Stay tuned for further updates on this project!

Photo credit: This image is featured courtesy of UNICEF Ethiopia/2014/Nesbitt under Creative Commons license

Recent news

• Junior doctors in the UK are striking: How to motivate the health workforce, 25 February 2016
• Working with what we’ve got – an(other) reflection on human resources for health
• Webinar: Community health workers - the gender agenda #HSGGENDER, 8 February 2016

By Miriam Taegtmeyer,

This week junior doctors in Britain’s National Health Service (NHS) have announced a further series of strike action – an unprecedented action among a dedicated group of professionals. The NHS was established in the wake of World War II amid a broad consensus that health care should be made available to all and since then has provided care that is free at the point of delivery and based on need. At least so far.  The irony is that  while the rest of the world is debating and embracing universal health coverage (UHC), and has put it as target 3.8 of the Sustainable Development Goals, Britain is systematically dismantling its excellent NHS and leaving in its place a fragmented system where health care is a business and patients are a market.  Efficiency is a key driver as funding decreases while expectations and patient numbers continue to increase. It is this that junior doctors are rallying against – their strike is first and foremost an action to save our NHS.

I had the privilege of providing consultant cover on our infectious disease wards –on the last day of strike action (Feb 10^th 2016). As an academic with clinical commitments I have grown used to relying on the team of juniors to guide me patiently and cheerfully through the new protocols, requirements, NHS pressures and expectations, allowing me to focus on listening to people, examining them, diagnosing and looking things up. Things I have been doing since I was a junior doctor myself, that I find immensely rewarding and that I am prepared to go the extra mile for. Because I believe in the NHS and what it stands for.  

As house officers we did long hours. Ridiculously long hours. We expected to, and I loved it. I loved it because I was learning to be a better doctor, because I got positive feedback from patients and families, because we supported each other. My motivations were intrinsic: I knew my patients; I was part of a team; my seniors invested in teaching and supporting me; I spent more time with patients than with paperwork; we provided continuity of care and we learned from it. It was nice to earn a salary but for me it wasn’t a huge driver. As I muddled through clumsily on strike day I couldn’t help thinking how these basic intrinsic motivations have been eroded systemically over time.  Junior doctors now work shift patterns, hand over cases without being able to follow up the outcomes and spend close to 50% of the average working day on paperwork. No wonder that imposing a new contract which further erodes motivation is a step too far.

So what has all this got to do with REACHOUT and research on community health workers and UHC in low- and middle-income countries? Community health workers in Bangladesh, Indonesia, Malawi, Kenya, Ethiopia and Mozambique point to the intrinsic motivations which drive them such as the support they get from supervisors, the appreciation communities give them and the satisfaction of learning collaboratively as a respected member of a team. They are dedicated individuals working for UHC because they too believe in it and they deserve to be recognised, supported and paid for their work, just like our junior doctors.  We cannot expect excellence in health care when we have a demoralised and demotivated workforce. As these new strikes are announced it seems to me that the UK’s Department of Health stands to learn a lot from REACHOUT as well as from its junior doctors at home, if the politicians and Jeremy Hunt can muster sufficient humility to listen. 

Photo credit: Rohin Francis https://www.flickr.com/photos/rohinfrancis/22079392868 

Recent news

• Working with what we’ve got – an(other) reflection on human resources for health
• Webinar: Community health workers - the gender agenda #HSGGENDER, 8 February 2016
• Panel on community health workers at the Prince Mahidol Award Conference, 7 January 2016

By Stephanie Topp,

As the Reachout Consortium reminded us in a series of well tweeted-about presentations at Prince Mahidol Award Conference (PMAC) 10 days ago, community health workers (CHW) need to be a centerpiece of human resource for health (HRH) policies targeting health equity, effectiveness and efficiency via universal health coverage (UHC).  Their work is a timely reminder of a point I made in my last IHP blog  which is that the expansion of CHWs or cadres of ‘close-to-community’ health workers will be critical for overcoming the chronic insufficiency and maldistribution of human resources for health in many low- and middle-income, as well as a number of high-income, countries.

Why have I returned to this issue? In part to draw attention (again) to the need for deep engagement by global health advocates, practitioners, researchers, and policy makers (i.e. us), with the complexity of designing and making operational HRH and CHW policies.  I look at the extraordinarily high level and the sustained nature of engagement by international and national policy makers on the issue of national health insurance design & implementation, and I find it curious that the same level debate has not emerged in relation to enhancing HRH or scaling-up CHWs schemes.  These health workers, will, after all, be the mainstay of actually delivering services that any national health insurance scheme pays for.  And the service coverage and quality components of UHC will be directly associated with the sophistication and contextual fit of the HRH policies in play.

Perhaps we need a Lancet Commission with Horton-style advocacy to make this issue sexier and drive the sort of ‘glamour-engagement’ that ensures a spot on the mainstream (rather than semi-peripheral) global health agenda.

I wanted to take a moment to draw out the comparison between the ‘dialogue’ on national health financing versus HRH and CHWs, spurred in part by Michael Reich and colleagues’ analysis of 11 countries’ progress towards UHC.  In re-reading this article, it struck me how across a raft of countries, progress towards UHC-oriented national insurance schemes was typically achieved via incremental steps in a kind of a ‘work-with-what we’ve-got’ approach.  That is, national health insurance schemes evolved (either via expansion, or consolidation of more targeted schemes) from existing, less comprehensive health insurance policies.  The article also neatly summarises the deep and broad analysis (predominantly domestically-led) that has underpinned this progress –  as countries grapple with the questions of who should be covered, where the money will come from, how it will be collected and re-distributed and the implications that different combinations of each of these have for the goal of UHC.

Sounds sensible?  It is.  This process also speaks to a key feature of policy design in complex systems – namely the need to understand, and work with, historical decisions and processes while accounting for various dynamic interactions between current political, social and economic features that influence the efficacy of any given reform.  Moreover, in the cut-and-thrust of such analysis and debate we see facilitation between potentially conflicting interest groups and the adjustment and reform of appropriate governance mechanisms to boot.

We in global health need to up our game when it comes to the chronic emergency of HRH.  And while far from flawless, the simultaneously high-level and broad and deep nature of the UHC-inspired national health financing dialogue does provide one example.  It is no longer sufficient or even helpful to consider HRH policies in terms of their ‘recruitment’ or ‘retention’ siloes.  Nor, as the health financing example shows us, does it seem particularly useful to rely on well-meaning but ultimately high-flown global strategies  in the absence of more robust and contextualized domestic debates that will account for the reality on the ground.  We do need a broad-ranging conversation – and one with sustained high-level sponsorship such as that provided by Global Health Workforce Alliance – but that conversation must welcome, not avoid, the messy and heterogeneous reality of existing policies, structures, institutions and norms that frame different countries’ approach to health worker recruitment and retention, organizational culture and quality improvement, and formal and informal regulatory and incentive mechanisms.  Like the health financing dialogue, moreover, these elements must be considered concurrently in order to design (country-by-country) HRH policies that not only work with what we’ve got but that also make the best of it.

About Stephanie

Stephanie is a Senior Lecturer in Global Health and Development, James Cook University, QLD, Australia – Twitter: @globalstopp 

Recent news

• Panel on community health workers at the Prince Mahidol Award Conference, 7 January 2016
• Putting the politics into international public health, 5 January 2016

Close-to-community (CTC) providers include community health workers, village midwives and community-based drug distributors, who deliver a wide range of services at the community level and are often female. Gender affects, and is affected by, close-to-community health programmes in a number of ways. 

On February 10th, 2016 at 1pm GMT Health Systems Global invites you to the new webinar: 'Community health workers - The gender agenda.' This webinar showcases a panel of researchers from around the world who have been exploring the issues.

Tune in and learn more about how:

• Human resources, deployment, and motivation are gendered and this in turn shapes the ways in which community health workers undertake boundary work and develop trusting relationships with individuals, household and communities.

• Community health workers are normally members of the communities they serve, and are likely to have internalised the very social and gender influences that are important to address at individual and community levels.

• Community health workers have tacit knowledge and are strategically placed to understand and address the ways in which social and gender relations shape understanding of illnesses, bargaining positions, vulnerability and access to health care.

• Community health workers can negotiate gender and power relationships within households and communities in their routine work, are often familiar with the environment and understand how social determinants of health, including food insecurity, and intimate partner violence and limit people’s ability to access care.

The webinar will be chaired by Asha George of Johns Hopkins School of Public Health and the RinGs project. The webinar is organised and sponsored by Health Systems Global and CHW Central as part of their ongoing work on community health workers.

Panel:

Sally Theobald, REACHOUT Consortium, Liverpool School of Tropical Medicine, UK

Amuda Baba, IPASC, Democratic Republic of Congo

Stelio Dimande, Ministry of Health, Mozambique

Hana Rabadi, World Vision, Jerusalem - West Bank - Gaza

You can register for the webinar here. 

To learn more about community health workers please take a look at our article collection in Human Resources for Health

Follow us on Twitter: #HSGgender

Recent news

• Panel on community health workers at the Prince Mahidol Award Conference, 7 January 2016
• Putting the politics into international public health, 5 January 2016

The Prince Mahidol Award Conference will take place in Thailand from the 26-31 January and is organized around the theme of decision making for Universal Health Coverage (UHC). They note:

“Universal health coverage (UHC) is high on the global agenda as a means to ensure population health, equity and social development. In most countries where current access to essential health care is limited, introducing UHC prompts serious concerns among government leaders on the growing expenditures and demands for public resources. As such, priority setting is indispensable and has been applied at various levels, to ensure that finite health resources can be used in the most cost-effective ways, to provide a high quality and appropriate package of healthcare for the population.” 

A focus on community health workers

We are delighted that the Thematic Working Group, in partnership with USAID and the World Health Organization’s Global Health Workforce Alliance, will be running a session at the conference devoted to community health workers (CHWs) on 27 January 14.00 – 17.30.

The importance of Community Health Workers (CHWs), and their contribution to health care and health promotion have garnered increasing attention from governments, donors, health systems researchers and planners within post-2015 and UHC agenda setting, and also as related to increasing focus on global health security. CHWs often work in the most underserved areas and serve as frontline health workers key for advancing services for maternal and child health and HIV/AIDS and in support of the control of other infectious diseases.  In recent years, emphasis has been placed on addressing identified evidence gaps for CHWs, implementing national programmes and strengthening the fragmented CHW programme landscape within countries. Simultaneously, across the globe, many country governments’ increased focus on CHWs has led to increased stakeholder engagement. Yet the extent to which evidence for CHWs has been used within this dialogue and the effectiveness of the participation and processes utilized by these decision making entities (e.g. national steering commitments, working groups) is unclear and have not been a focus to date.

The session will examine the extent of which evidence has been used to inform decision-making and the impact of diverse stakeholder participation in the dialogue around strengthening CHW programming for UHC and health goals in countries.

Panel

• Dr. Jan-Walter De Neve, Harvard School of Public Health, USA. PEPFAR/USAID supported case studies conduct to inform decision-making to harmonize CHW investments for HIV programs in Swaziland, Mozambique, Lesotho, and South Africa
• Lillian Otisio, LVCT Health, Kenya. Experience from the REACHOUT Consortium, a project working across six countries in Africa and Asia to strengthen the role of close-to-community providers of health care
• Dr. Emma Sacks, Johns Hopkins University, USA. Experience in using the C3 Tool, an analytic decision-making tool, in Tanzania and Rwanda to help governments prioritize technical content for CHWs and refine strategies for investment, training and coverage
• Department of Health Workforce, World Health Organization. The purpose and process of the development of WHO Guidelines on Community Based Practitioners for UHC

Find out more

The session is open to all conference participants and we hope that you will come along. If you would like to find out more please contact Diana Frymus, Health Science Specialist, USAID Washington, DC and Co-Chair Health Systems Global TWG on CHWs, (dfrymus@usaid.gov)

Follow updates from the session on Twitter: #CHWs4UHC

Recent News

• Putting the politics into international public health, 5 January 2016
• Most Significant Change:  Community evaluation of programme implementation through stories, 16 December 2015
• Quality improvement cycles to strengthen close-to-community services: REACHOUT reflections, 10 December 2015

We are delighted that Lilian Otiso and Miriam Taegtmeyer will represent us at this event that will take place at the Overseas Development Institute (ODI) in the UK on the 20 January 2016 14:00 - 16:00 (GMT+00). Those of you tuning in from elsewhere in the world can watch as it is livestreamed.

There has been a surge of interest from donors and the international development community in the concept of adaptive development and what it may look like in different sectors, including health.  Adaptive types of programming from the health sector are relatively advanced. As we work towards the Sustainable Development Goals (SDGs), experiences in health can provide useful lessons for other areas of development.  The international health community may not use the label ‘adaptive development’, but many are already conducting adaptive work. 

This event brings together experts from the international health and international development communities to present and discuss work on adaptive programming in the health sector, and in particular the tried and tested approach of ‘quality improvement’.

What is quality improvement?

• Quality improvement (QI) is problem-driven, iterative and flexible. The methodology and principles can be used to identify, test and implement changes in any context or part of a health system.
• QI is being used successfully, but there is still limited experience and evidence of how to apply its values and philosophy beyond the project level and embed it within national structures and systems.
• Systems thinking and analysis of the political economy environment may help embed complex interventions like quality improvement and sustain their achievements.

The discussion will aim to stimulate stimulate debate in the following areas:

1. Is QI politically savvy enough to really be considered adaptive development?

2. Working politically – an uncomfortable position for health professionals?

3. How can adaptive programming – such as QI – be embedded in national health systems?

4. QI is often instigated by donor projects, does locally-led adaptive programming really exist in the health sector?

Contributing Chair:

Tim Kelsall - ODI

Speakers:

Olivia Tulloch – ODI

Lilian Otiso - LVCT Health, Kenya

Miriam Taegtmeyer - Liverpool School of Tropical Medicine

Vicki Doyle - Capacity Development International

Recent news

• Most Significant Change:  Community evaluation of programme implementation through stories, 16 December 2015
• Quality improvement cycles to strengthen close-to-community services: REACHOUT reflections, 10 December 2015
• Kenya develops guidelines to strengthen Community Health Dialogue, 7 December 2015

By Ralalicia Limato and Rukhsana Ahmed

Most Significant Change (MSC) is one of several methods used by the REACHOUT Indonesia team to monitor and evaluate the first quality improvement cycle. The quality improvement cycle took place from January to August 2015 in Ciranjang sub-district in Cianjur district and focused on health promotion, supportive supervision and community engagement. The four villages selected for the study interventions were Ciranjang, Mekargalih, Karangwangi, and Sindangsari.

MSC is a participatory M&E process in which beneficiaries evaluate the success of a programme through stories. This approach creates better opportunities for communication between programme implementers, stakeholders and beneficiaries to feedback and to plan programme revisions. In addition, offers the opportunity for the programme implementers and stakeholders to understand why changes happen or do not happen after a programme is implemented. Furthermore, it can identify and strengthen the capacity of programme implementers and stakeholders.

The MSC process includes eight main activities: clarification of the aim of MSC approach, determining the domain (indicator), collecting and writing stories, selecting the most significant story, feeding back of the result, result verification, monitoring and secondary analysis and programme revision. 

Preparation: Before conducting the MSC series, we held discussions with the stakeholders from the District Health Office, Cianjur and Puskesmas, Ciranjang and: raised their interest; developed instruments; determined the beneficiaries for the interviews; planned the panel discussion, data analysis, how to feedback and verify the results, and programme revision.

Collecting and writing stories: Three village midwives, eight kaders (village health volunteers) and four mothers participated in the interviews. The village midwives and kaders had participated in REACHOUT health promotion and/or supervision trainings. The mothers were those who routinely attended the Posyandu services before, during and after we conducted the trainings for the village midwives and kaders. Prior to the interviews, consent was obtained from the beneficiaries to record the interview and for the panel to select as the most significant story and to publish the story using the name of the beneficiary. The questions used to prompt the beneficiaries during the interview were “Have you observed or experienced any changes in the services and activities in the Posyandu in the last six months/after health promotion and/or supervision training?” “What are the changes?” “Amongst all the changes you observed, which one do you consider is the most significant change?” “What are the reasons for selecting it?” “Why has this change happen?” The interviews lasted between 15 to 30 minutes and the stories were written by the researchers according to how the story was related by the beneficiary, transcribed into Indonesian and translated into English.     

Selecting the most significant story: The panel meeting to select the most significant story was held on 6 October 2015. The panelists consisted of those who are responsible for programme revisions in the future and included stakeholders from different levels of health system: Puskesmas (community health center), the District Health Office and programme implementers. The panel included the Head of Maternal and Child Health division and the Programmer of Maternal Health at the District Health Office, Cianjur, the Head of Puskesmas, the Midwife Coordinator and the Health Promotion Officer of the Puskesmas Ciranjang. The country coordinator and senior research associate from REACHOUT Indonesia represented the intervention implementers. Panelists were divided into two groups (A and B), each group consisted of one or two representative from the Puskesmas, DHO and REACHOUT Indonesia: four members in group A and three in group B. The facilitators divided the 15 stories between the two groups. The members of group A read seven stories and group B read eight stories. Each group panelist selected the story he/she considered  the most significant and shared it with the rest of the group. After discussions on “for and against” each group selected the one most significant story. Thereafter, the two groups presented and discussed their selected stories to select one most significant story. This story was from Ms. Santi from Ciranjang village.                    

Ms. Santi is a mother who routinely visited Posyandu Kamboja for antenatal care during her pregnancy. The story of Ms Santi highlighted the success of the intervention from the client or mother’s view which was one important reason considered for the selection of the most significant story. She clearly stated the changes she had observed and experienced about the Posyandu services before and after the kaders had the health promotion training. As an example she stated that there was better Posyandu management, kaders were more knowledgeable and became more attentive after the training. In addition, she mentioned  support from the head of neighbourhood association and community association. The most significant change that Ms. Santi experienced was that the health information the kaders delivered was more comprehensive and the kaders showed more attention to the Posyandu visitors. This story was verified by the Health Promotion Officer from the Puskemas, who mentioned that the kaders in Posyandu Kamboja had become more skillful in delivering health counseling.    

Feedback and verification: The story was fed back to Ms. Santi, and she had no objection regarding the content of the story and how it was written. The truth of the story was also verified by village midwives and kaders after the panel discussion. The story will be submitted to the DHO, Puskesmas Ciranjang and village stakeholder for advocacy material.

Action plan: Several suggestions relating to the quality improvement cycle surfaced after the panel discussions and included the training of trainers of health promotion and supervision, advocacy with the district government to pay more attention to maternal health problems in Cianjur, monitoring and evaluation of village midwives and kaders and financing of the follow-up interventions in the next cycle. We will discuss this further in a series of small meeting to be held in the future.

Most Significant Story selected by the panelists: “Changes in Posyandu Kamboja”

Area: Puskesmas Ciranjang

Village: Ciranjang

Type of participant: Mother

Name: Santi

“I think Posyandu Kamboja has become more comfortable and organized since kaders attended training. Back then, the service schedule between pregnant women and toddlers were not divided and it resulted in long queue and chaotic services because Posyandu visitors did not want to queue and everyone wanted to be served immediately. Now, after the service schedule between pregnant women and toddlers is divided, Posyandu becomes more organized and pregnant women feel more comfortable to tell kaders their problems because there is no distraction of the babies crying. Moreover, I see that kaders are more frequent in doing counseling, while previously only kader Enok, was doing the counseling. This situation is different from current situation where all kaders are more confident in delivering health counseling.       

In my opinion, the most significant change happened in Posyandu is kaders deliver more comprehensive information after participation in the training. The way kaders communicate the information is better and it makes us understand more about the message. Previously, kaders were less knowledgeable, and when mothers shared problems to a kader, they day dreamed before answering the questions. Now, kaders give complete and detail information to us, and also directly practice it. Back then, only Ms. Enok who had good knowledge, the other kaders were only helping her. Now, kaders tasks are well distributed including writing KMS (healthy book), doing the weighing and recording data in the registration book. Previously, all tasks were done by Ms. Enok alone. Now, everything is organized because all kaders are capable to carry out their tasks.  

Furthermore, after the kaders received training, I observed kaders were showing more attention to Posyandu visitors. For example, previously, the information about delivery was only delivered as a short notice from kaders. Now, kaders also give information that pregnant women with labour signs should seek helps immediately. I used to ask something to kader, but only Ms. Enok could answer it and other kaders were unable to answer. This is maybe because of their limited knowledge. Now, they are able to provide comprehensive information with some examples, and what the pregnant women must do if something happens. When I asked kader about nutrition for my child, kader explained me about the food that can be consumed by my child so I can prepare it at home. I think all the changes happen because of the willingness of the kaders to improve their knowledge, and also because the support from the head of neighborhood association and community association. The new head of community association is more attentive, displayed in their support to provide venue for Posyandu and it resulted in more organized Posyandu services. Previously, we used simple wooden baby weight scale and there was no private room for examination. Now, the head of community association provides space for Posyandu services.     

I observed, after training, kaders are more prepared in responding our complaints. If someone is sick, kaders are ready to escort him/her to Puskesmas. The kaders also told us to immediately call them if we need help. I feel that the way kaders giving the information is very helpful because the community knowledge about health is still low. If I go for consultation with private doctor or private midwife, then I have to pay. Meanwhile I can obtain this information in Posyandu for free”.  

Recent news

• Quality improvement cycles to strengthen close-to-community services: REACHOUT reflections, 10 December 2015
• Kenya develops guidelines to strengthen Community Health Dialogue, 7 December 2015
• Capacity building for better health: policy, research and practice, 27 November 2015

The range of close-to-community (CTC) providers within the six REACHOUT countries (Ethiopia, Kenya, Malawi, Mozambique, Bangladesh & Indonesia) are diverse and changing. For example, in Ethiopia, the key CTC providers are female Health Extension Workers who have been selected and recruited at community level, work on 16 health packages and are salaried employees of the health system. They interact and are supported by a structured community participation process.  This contrasts with urban Bangladesh where there is a complex plurality of both formal and informal health care providers. Here informal providers (such as traditional healers) have a density that is 12 times higher than their formal CTC provider counterparts and they are the first point of call for many poor women, men, boys and girls, as well as being an obvious resource for government and NGOs. Indonesia’s unique geography: a population of 250 million spread over more than 17,000 islands, means there are particular challenges in ensuring remote populations receive quality health services. Indonesia and Kenya are also both currently undergoing processes of devolution which brings both challenges and opportunities for strengthening CTC providers. As Charity Tauta, from the Kenyan Ministry of Health explained:

“Devolution to 47 counties, has made work a little bit tricky here and there – at national and county level – and we are still learning. When formerly we had districts we knew our link persons – now we are still trying to understand how to work together”.

Despite contextual differences, approaches to strengthen CTC services are similar

In the first phase of REACHOUT we conducted a situational analysis of the current challenges and opportunities for positively impacting on the equity, efficiency and effectiveness of CTC services and developed areas for action for our first set of quality improvement cycles. Four key problem areas for action emerged from the joint analysis:

• Supervision of CTC providers is either non-functional or irregular and if it did exist it focuses on fault finding rather than supportive approaches
• Referral pathways are not always clear
• Community engagement strategies, materials and processes better need to reflect community experiences and realities
• Coordination amongst CTC providers and the different stakeholders supporting these processes is poor

All six REACHOUT country partners have taken forward quality improvement cycles that focus on addressing two or more of these problems.

Lessons and reflections from the first round of REACHOUT quality improvement cycles

• Cementing partnerships through a participatory approach was a key approach in many country contexts. For example, the Ethiopia team has successfully worked in partnership with key players in the health systems at zonal and district levels, jointly developed guides manuals and tools and formed close mentorship and mentoring approaches. In Malawi, participatory approaches enhanced reception and buy in amongst different stakeholders, with the District Environmental Health Officer from Salima saying,  “They have given us the mandate to decide how best we can improve supervision”. In Bangladesh, the team are working in collaboration with Marie Stopes and RH Steps to support uptake of quality menstrual regulation services, by developing structures for supportive supervision: the decision was taken to use trainers from these two institutions rather than from the REACHOUT partner – James Grant School of Public Health - in order to maximise the sustainability and ownership of the process.
• Developing new tools/approaches has been enabled through partnership. For example, in Indonesia, where the focus is on maternal health, the quality improvement cycle has involved the introduction of a pictorial aid to support CTC providers’ counselling role, which previously was the most avoided task. Now, qualitative analysis has shown that with aide and training, CTC providers are undertaking the counselling role. Other changes include the embedding of a referral card (Bangladesh) and checklists for supervision (all countries).
• Developing new trusting partnerships has been important.In Ethiopia, where the quality improvement cycle focus is also on maternal health, one of the interventions has been the establishment of a pregnant women forum. Here pregnant women are supported to meet on a monthly basis to discuss, liaise and plan for services and ANC and importantly, are encouraged to deliver in health facilities. This has served to develop and cement further trusting relationships between CTC providers and pregnant women. The Bangladeshi team are also working on cementing trusting relationships between formal and informal providers for sexual and reproductive health and both sets of providers come to regular meetings at Marie Stopes, which in turn builds trust and exposes informal providers to the types of services provided within Marie Stopes.
• A paradigm shift in supervision was identified through ongoing analysis by the Malawi team. Quality improvement data analysis revealed that the approach to supervision is moving away from a checking/controlling approach to a more supportive, enabling approach at the local level. The situational analysis in many contexts also revealed that supervisors themselves felt un-supported and approaches to improve and expand supervision support are taken forward at many levels. The Bangladeshi team explained that it’s sometimes hard to know where layers of supervisory processes start and finish. In Kenya, it was felt that supervision should be embedded as part of moitoring and evaluation.
• Common challenges include expectations of per diems and other incentives (Ethiopia, Mozambique); competing priorities and workload of CTC providers and their supervisors (Mozambique, Ethiopia, Bangladesh, Kenya); changeover of key stakeholders at district and/or national level (Malawi, Indonesia); political unrest (Bangladesh); and challenges in sustaining changes in supervision (Ethiopia, Indonesia).

Taking forward a learning agenda: implications for the second round of quality improvement cycles

There is renewed emphasis and excitement about the potential of CTC providers in contributing to realising universal health coverage and supporting the Sustainable Development Goals. The REACHOUT perspective is that promoting universal health coverage means expanding both the equity and quality of CTC services. We are now planning the second round of quality improvement cycles where we will innovate and test new approaches. However, to address the issues of sustainability, the focus of the second quality improvement cycle is to move from a researcher-led project to a country led approach in order to embed positive changes for the longer-term. As such we are encouraging capacity strengthening through South-South technical assistance as well as the need for increased advocacy in light of the changing political climates. In our 5^th consortium meeting in Cianjur, Indonesia we have been joined by strategic policy makers from each country context in a training of trainer’s process to develop systematic, robust, simple and regularly applied processes to quality improvement. Watch this space! 

Recent news

• Kenya develops guidelines to strengthen Community Health Dialogue, 7 December 2015
• Capacity building for better health: policy, research and practice, 27 November 2015
• A learning agenda and “NICE guys”: reflections on capacity, 16 November 2015

By Robinson Karuga,

Kenya’s Community Health Strategy (CHS) emphasizes the role of community partnership and participation in health and development. One of the processes to empower communities to improve their health and lives is community health dialogue.

However, since the launch of CHS in 2006, no clear community health dialogue guidelines have been developed. In response to this gap, the Community Health Unit of the Ministry of Health convened a 3 day workshop in Nakuru County - in November 2015 - to develop these guidelines. The workshop included participants involved in community health research, policy makers in National and County government, and non-state actors.

Enriching discussions during the plenary sessions revealed that as much as all the partners in the workshop were invested in enhancing community participation, each partner had their own approach to community dialogue and each had different tools for documenting dialogue at community level. The approaches varied from community conversations, chiefs barazas, community score cards, to community based education. This demonstrated a clear need for harmonization of community health dialogue.

At the end of the three day workshop, participants had developed a draft guideline that aimed at creating a common understanding of how to conduct community health dialogue among all stakeholders. The draft guideline also provides a clear and informed road map for planning, implementation and monitoring and evaluation. At the moment, Counties and non-state actors do not have a standardized and structured approach to conducting community health dialogue but this draft guideline will be available in early-2016. This will be a useful resource for all who are implementing community health dialogue in Kenya and potentially beyond.

The second REACHOUT Quality Improvement (QI) Cycle will largely focus on embedding QI in Kitui and Nairobi County and enhancing community participation.  This research was welcomed by all participants and was lauded as a platform for providing evidence on the most efficient way of strengthening community participation in health matters at community level.

Recent news

• Capacity building for better health: policy, research and practice, 27 November 2015
• A learning agenda and “NICE guys”: reflections on capacity, 16 November 2015
• The Netherlands: Symposium on community health workers, 11 November 2015

From 5 – 7 of November 2015 I participated in the 22^nd Canadian Conference on Global Health held in Montreal which focused on capacity building for global health.  This conference was an opportunity to build on work we are doing in the SEARCH project - applied research on Health Extension Workers using e-health to strengthen equitable health systems in Southern Ethiopia - and in REACHOUT.

At the conference I presented the baseline findings of an e-Health project and raised issues to consider when implementing such projects in the community. The Ethiopian Health Extension Programme - which is the flag ship of community interventions in the country and the backbone of the health service - is an opportunity to use mHealth as stipulated under the health sector transformation plan to ensure an information revolution. 

What do we mean by capacity building?

The Conference focused on capacity building for global health: in communities, institutions and countries. Capacity building is an ongoing integral process of strengthening the capacity of individuals so that future communities and institutions benefit.

Capacity building at the individual level: The future of global health is in the hands of the next generation of global health researchers created within countries and institutions. Therefore, creating learning opportunities and pathways to support the careers of emerging researchers in global health was a big part of the conference.  

Capacity building at the institutional level: Community led participation in generating health and individual capacity building is shaped by institutional visions. Engagement, partnership and networking among global health researchers is necessary so that we design pragmatic interventions and shape institutions to move forward to global health agenda. Exemplary practices were shared from sub-Saharan Africa about how community based learning, local led capacity building, and training of future researchers has improved. This process is underpinned by: capacity building with institutions; the retention of global health researchers; and interdisciplinary partnership which includes flexible collaboration.

Capacity building at the community level or society: There are a wealth of resources and knowledge in communities that remain untapped and require support to be used effectively. Participatory action research has demonstrated a breakthrough in improving the role of the community in its own health related decision-making. The Ethiopian health sector transformation plan underscores that the community has the capacity and the right to produce its own health, given the right opportunities. This includes transforming the community from passive health service user to active user. Community learning models were described from the experiences of South Africa indicating the importance of interdisciplinary partnership to make effective use of the available meagre resources

Preparedness and responsiveness

The Ebola epidemic has demonstrated that health systems need pre-emergency capacity building to ensure that there is a rapid response when there is a crisis. This requires us to learn lessons from the epidemic to make sure that such disease outbreaks are tackled quickly and do not lead to such huge and tragic losses of resources and lives.

Global health is crucially important in our century and improving it requires concerted multidisciplinary approaches, partnership and networking and building the capacity of young researchers and programme implementers to lead and shape the future.  

About SEARCH

SEARCH assess the feasibility and effectiveness of using information and communication technology (e-Health) to strengthen equitable health systems and related governance processes through inter-package linking and integration into the existing health management information system in Southern Ethiopia. It initially focuses initially on tuberculosis and maternal and child health – both priority health areas in Ethiopia – through HEWs using e-Health technology within their core duties. Process evaluation and mixed methods approaches are being applied to assess the effectiveness of the e-health data collection system.

Acknowledgements

We would like to thank Canadian International Health for facilitating participation, sharing and learning during the conference and  IDRC funding the project. The SEARCH project is led by Daniel G. Datiko from REACH Ethiopia in collaboration with Liverpool School of Tropical Medicine and has strategic links with REACHOUT in Ethiopia.

Recent news

• A learning agenda and “NICE guys”: reflections on capacity, 16 November 2015
• The Netherlands: Symposium on community health workers, 11 November 2015
• Close to community providers and community action to address maternal health in Cianjur, Indonesia, 9 November 2015

“If you have capacity built to support quality close-to-community service provision you will encourage the community to maximally access service care and ensure healthy outcomes” Allone Ganizani, Ministry of Health Malawi.

Capacity strengthening is a critical strand throughout REACHOUT and one third of our budget is dedicated to taking forward capacity from a holistic perspective: strengthening the capacity of researchers, institutions, policy makers and practitioners. At the midway point of our REACHOUT journey and at our fifth consortium meeting in beautiful mountainous Cianjur (Indonesia), we thought it was an opportune moment to reflect and share experiences about some of our capacity strengthening strategies.

Building a legacy for close-to-community research: Strengthening researchers’ skill sets

REACHOUT has a ‘young researchers’ group. The group meets regularly to share experiences, resources and networks and came to Cianjur a week earlier than the rest of the consortium for research skills training led by Vicki Doyle, Malabika Sarker and Miriam Taegtmeyer. The sessions focused on qualitative and quantitative analysis and the ‘how to’ of integrating mixed data sets. Sozinho Ndima, from University Eduardo Mondlane in Mozambique explained:  “I enjoyed the focus on mixed methods and how to integrate different qualitative and quantitative data sets.”

Vicki explained: ‘there’s no point being a great researcher unless you can share your findings – this needs both verbal and written skills’. Sessions also included personal development plans (PDP); sharing your passions through a soap box delivery and elevator pitches (what do you say about your research when you only have two minutes with a key and powerful person in a lift).  Elias Bunte from REACH Ethiopia said: “it was very nice, we talked without power points, it gave us confidence about how to speak in public” and Sadia Chowdhury from the Bangladeshi James P Grant School of Public Health shared how she “enjoyed the quantitative analysis, as I’m a qualitative researcher I fully understood the motivational questionnaire which was great, I also liked discussing the pitfalls of mixed methods and the PDP was wonderful.”

Young researchers were challenged to practice their elevator pitches on policy makers and key stakeholders the following week.

A learning agenda, experience sharing and south-south exchange

Enabling joint learning and south-south exchange is a key component of our capacity strengthening strategy. The REACHOUT partnership includes countries taking forward innovative and respected Community Health Worker/close-to-community provider approaches and this provides an excellent opportunity to share experiences across contexts about practices and innovations that could be adapted. James P Grant School of Public Health leads the REACHOUT capacity strengthening strategy and are evaluating south-south learning and exchange. Many examples of south-south learning in the experiences on our first round of quality improvement cycles were shared during our consortium meeting in Cianjur, for example:

• The district health officers from Cianjur district were interested to learn more about the process and impact of establishing the pregnant women’s forum in Ethiopia. Nega Teyikie from REACH Ethiopia explained how this meets regularly supported by female Health Extension Workers and has been one of the strategies in Ethiopia that has led to impressive increases throughout the first quality improvement cycle in uptake of both antenatal care and facility deliveries.
• Robinson Karuga shared the LVCT Kenyan processes of undertaking community score cards with Dr Gita Maya, Director of Maternal Health in the Indonesian Ministry of Health and also learnt about tailored Indonesian approaches to community engagement, feedback and partnership. In the score card process, communities visit health facilities, and then through a community dialogue process, discuss and score five key priorities areas for action to improve quality. Health providers go through a similar process followed by a joint interface (community and health worker) and joint planning meeting.
• Ershad Sumon from Marie Stopes in Bangladesh discussed with the REACHOUT team the importance of maintaining quality in the provision of menstrual regulation services in Bangladesh. Here to assess quality as seen through the eyes of clients, they have a “mood metre box” where clients can insert a token – in confidence- to rate the service they have received. The box is opened every day to get immediate feedback.  
• We also had a very informative exposure trip to visit Poysandus and Kaders in Indonesia to learn about how this works in practice and share experiences across different contexts

Being a “NICE guy”: embedding quality improvement approaches to strengthen close to community services

The legacy of REACHOUT is sustained as improved close-to-community services, during the second Quality Improvement (QI) cycle, will move from a mainly researcher led process to one that is more embedded and owned by district practitioners and policy players. And each country partner was joined by at least one key policy maker in the Cianjur meeting to jointly go through a Training of Trainers approach for embedded QI cycles. This included training sessions in the morning and ‘teach back’ sessions in the afternoon, where participants were challenged to conduct 20 minute training sessions on the morning’s content (e.g. why quality is important, indicators and methods for quality) to colleagues who pretended to be participants from the various countries e.g. District officials and supervisors from Mozambique. The sessions were interactive and trainers used a lot of engaging adult learning approaches, such as role plays and group exercises. QI processes use a systematic approach and are simple, robust and regularly applied through a cyclical action learning approach. Vicki explained there is little research on the processes of embedding QI cycles in community health services and we will be both pioneers and “NICE guys” who Nurture, Inspire, (provide) Continuity and Embed. In a nutshell we need to inspire others and be creative facilitators and advocates for QI within our countries and programmes.

Charity Tatua, Lilian Otiso and Nelly Muturi role play quality in community health service provision in the teach back session. 

Recent news

• The Netherlands: Symposium on community health workers, 11 November 2015
• Close to community providers and community action to address maternal health in Cianjur, Indonesia, 9 November 2015
• REACHOUT at the Canadian Conference on Global Health, 3 November 2015

Community health workers (CHWs) play an unique role in connecting local communities with the health sector, especially in low- and middle income countries. Access to quality health care is a prerequisite for development and it is important to know how this can be improved. KIT advisor, and our dear REACHOUT colleague, Maryse Kok, conducted her PhD research to gain insight into how performance of CHWs in low- and middle-income countries can be improved.

On Monday 23 November she defends her thesis at the VU University in Amsterdam. The defense will be preceded by a symposium on community health workers.

Renewed interest in community health workers

Community Health Workers form an essential part of the health system in low- and middle-income countries, connecting communities with the health sector. The continuing shortage of human resources for health combined with evidence that these local health workers effectively bring health care closer to communities has led to a renewed interest in CHW programmes.

Maryse Kok: “Community health workers have a great potential to increase access to health care. More tasks are shifted from higher level health workers towards local health workers, and thus responsibilities grow while community health workers receive limited training and work in poor and challenging settings . More insight is needed in how to optimize their work. That’s why I focused my research on factors influencing performance of community health workers.”

The research conducted

The thesis presents research from a systematic review of the international literature, two single case studies and a qualitative comparative multiple case study about the CHW programmes of Ethiopia, Kenya, Malawi and Mozambique. The work was undertaken within REACHOUT.

Community health worker performance: a complex interaction of “software” and “hardware”

It was found that a complex mix of factors, which are highly context dependent, continuously shape and change performance. Maryse Kok:

“Despite the contextual differences, we found that trust, relationships and expectations between different actors in the health system are important drivers of community health worker performance in all settings. These “software” elements interact with the programme “hardware”, such as the supervision system and communication structure. Both software and hardware elements are necessary to yield optimal CHW performance and ultimately improve the health status of poor and rural communities”.

The insights gained are relevant for policy makers, programme managers and researchers in the field of human resources for health and CHW programmes. One community health worker in Malawi nicely summarized the potential of these workers:

“We are like the messengers between the health workers and the people in the community, connecting them regarding the problems they face concerning health.”

The research presented in Maryse Kok’s thesis gives directions on how to optimize community health performance workers performance in resource-constrained settings, so that the benefit of CHWs’ unique position between communities and the health sector and their role in achieving universal health coverage can be enhanced.

Symposium Community Health Workers

The Athena Institute of the VU University and the Royal Tropical Institute are pleased to invite their Master students, staff members and others interested to attend the symposium on CHWs. The symposium aims to provide insight into the (expanding) role of CHWs in health systems in low- and middle-income countries.

Date and Time: 23 Nov 2015, 9am
Venue: VU University, Auditorium (de Boelelaan 1105, Amsterdam)
Please register at: secretariaat.athena.falw@vu.nl

The symposium includes a presentation by Dr. Miriam Taegtmeyer, Department of International Public Health, Liverpool School of Tropical Medicine – also part of the REACHOUT team. She will talk on Quality Improvement and CHW performance.

Download the invitation

Recent news

• Close to community providers and community action to address maternal health in Cianjur, Indonesia, 9 November 2015
• REACHOUT at the Canadian Conference on Global Health, 3 November 2015
• Alignment, engagement and collaboration: approaches to ensuring Quality Improvement is embedded, 2 November 2015

By Allone Ganizani (Ministry of Health, Malawi), Shashamo Bulasho (Head of Shebidino District, Sidama, Ethiopia), Sudirman Nasir (REACHOUT Indonesia) and Sally Theobald (Liverpool School of Tropical Medicine, UK)

We were welcomed into the home of Papat Patonah (leader of the voluntary community health workers) and her husband Ratim, head of the neighbourhood in Karangwangi village, Cianjur. This was the occasion of the Posyandu, a once monthly community based check-up for pregnant women and mums with new babies.  Papat’s house was full of beautiful babies, proud mums and pregnant women. One father was also present in the Posyandu and encouraging male involvement is critical and is an important aspect to drive forward. Participants were taken through a health promotion session on health care seeking in pregnancy, danger signs and nutrition during and after pregnancy.

The session was conducted with the help of an interactive pictorial guide designed following baseline research by the REACHOUT Indonesia team. Village volunteers were trained by REACHOUT Indonesia through participatory workshops in adult learning approaches to use the pictorial card to discuss maternal health issues with pregnant mothers.

The Posyandu approach has been in existence since the 1980s and is a key strategy in bringing lifesaving maternal and new-born health services closer to communities across Indonesia’s 17,000 islands. There is much diversity across these islands and some Posyandu’s are more active than others. We visited an active one, Ratim, head of the neighbourhood, is an ex-soldier and had previously served in Papua where he had learnt about women giving birth alone, and facing challenges and death in some cases. He was motivated to help as is his wife Papat leader of the kaders (voluntary Community Health Workers) and together with inputs from a community midwife they welcome women into their house for a range of services including: health promotion, blood pressure, vitamin A, iron tablets, checking foetal movement and baby checks – including weighing. Posyandus are either held in the home of a kader, in a school or a community building. Their construction is a joint venture between the government and communities: sometimes the communities donate the land and the government supports the provision of materials for construction. The Posyandus are held in the first three weeks of each month and the final week of the month is dedicated to processing and sharing data on uptake of services with the local health centre (Puskesmas).

We asked about the presence of traditional birth attendants (TBAs) and were told they are also present; and a collaborative relationship has been forged between the kaders and the TBAs to support and promote women’s health. Many women prefer TBAs because of the cultural familiarity, the use of massage and special bathing ceremonies for the new born. In the new collaborative relationship, TBAs support pregnant women to avail of the services at the Posyandu and facility birth but can still provide post-partum massage and support in line with cultural preferences and norms.

Like in many contexts, poverty and gender play out in rural Indonesia to limit poor women’s access to health care. Previously there was a special scheme to support pregnant women to access care, this has now been integrated into a broader national insurance scheme. Kaders and the neighbourhood association play in key role in supporting poorer women to access health services through liaison with the village head who can issue a letter that can be used to be included in the insurance scheme. Village members also donate to an Islamic charity fund which can be used to pay for transport to the health centre when required as the community insurance dos not cover indirect costs

We were inspired by the community ownership and drive to promote women’s health we witnessed in Karangwangi village. Close-to-community providers are a vital interface between communities and health systems, and can play a critical role in realising universal health coverage and improving community health and well-being.

Shashamo Bulasho from Shebdino, Ethiopia visiting women using the Posyandu services in Cianjur, Indonesia

Recent news

• REACHOUT at the Canadian Conference on Global Health, 3 November 2015
• Alignment, engagement and collaboration: approaches to ensuring Quality Improvement is embedded, 2 November 2015
• Participation, perspectives and possibilities: Mobiles, Development and Global Health, 29 October 2015

By Kate Hawkins

The 22nd Canadian Conference on Global Health will provide a forum for practitioners, researchers, educators, students, policy makers and community mobilizers interested in primary health care to share knowledge, experience and promote innovation and collaborative action. It will take place from the 5-7 November.

The theme of the conference is 'Capacity Building for Global Health: Research and Practice' and we are delighted that we have been chosen to give a poster presentation.

Our poster describes the process that we used to determine existing close-to-community (CTC) health service research capacity at the individual and institutional level, and develop bespoke capacity strengthening action plans. The research capacity strengthening goal of REACHOUT is ‘to build a community of researchers, who are able to design, conduct and use health systems research to improve CTC services.’ We conducted a literature review to design an optimal capacity checklist, with indicators at the individual and institutional level. Specific themes included: research skills, equity and fairness, human resources, and administrative capacity. We developed both qualitative and quantitative data collection tools to determine the existing research capacity of all participating institutions.

You can read the full poster here...

Recent news

• Alignment, engagement and collaboration: approaches to ensuring Quality Improvement is embedded, 2 November 2015
• Participation, perspectives and possibilities: Mobiles, Development and Global Health, 29 October 2015
• REACHOUT holds Consortium meeting in Indonesia, 26 October 2015

By Rosalind Steege

Panellists: Allone Ganizani, Chief Environmental Health Officer, Ministry of Health, Malawi; Buriso Shasamo, Head of Shebedino district, Sidama (REACHOUT implementing district), Ethiopia; Charity Tauta, Head of Operations Research in the community health and development unit, Ministry of Health, Kenya; Ershad Hoque (Bangladesh); Bedilu Badego Director of the Zonal Health Bureau, Ethiopia; Stelio Dimande Ministry of Health, Mozambique

Engagement with policy makers is key to research uptake. That’s why at the 5^th REACHOUT consortium meeting in Cianjur, Indonesia, our six country teams were joined by policy makers, practitioners and NGO lead implementers from each country context.

On the last day of the meeting, not wanting to miss an opportunity to hear from key decision makers, we held a panel to explore perspectives on embedment of quality improvement cycles. The panel included Ministry of Health staff from national, zonal and district levels and was chaired by Professor Sally Theobald of Liverpool School of Tropical Medicine. We wanted to find out what really makes policy players sit up and take note of research, and find out their advice to strategies and approaches to embed quality improvement (QI) - the focus for the second REACHOUT QI cycle.

What messages research methods and communication types influence you the most – what do you like to hear from researchers and partners? What’s the most influential and positive for you?

Our panellists highlighted that the voice of the community is the most influential. From Kenya, Charity Tauta noted: “Not through research as such, but through our interactions when we are with them [the community]. You listen, and you hear that they are saying things that point to us as health workers not really delivering. That would make me think we need to do things differently.” Similarly, in Bangladesh, Ershad explained that visits to the Pushtans are a way to hear the voice of the community, while in Ethiopia a more structured approach is taken, with quarterly meetings with the community and the staff who serve the community, to hear their ideas and experiences.

Close-to-community (CTC) providers were cited as an important part of linking communities with the health system as they often bring forward issues from the community. “At health post level the Health Extension Workers also raise interesting ideas since they are engaged with the community. So I want research that is done at the community level.” (Bedilu Badego)

You see a lot of projects come and go; what makes some stick and others not? What are your experiences of sustaining programmes into government health systems?

Experience from Malawi, Mozambique and Ethiopia suggests that failures in resource mobilisation and fragmentation of donors is a key reason for projects failing to be sustained. Stelio Dimande from the Ministry of Health, Mozambique, advised that coordinated approaches and a unified strategic objective for CTC providers in Mozambique is key:

“I can see that when we talk about CTC providers we are not always speaking the same language… Every NGO and partner has their own agenda at the end of the period and I think that something that’s missed is to develop a national strategy to CTC providers” (Stelio Dimande)

Allone Ganizani, Malawi, and Buriso Shasamo, Ethiopia, also stated that in addition to resource constraints, without effective exit strategies the sustainability of projects can be affected; implementers need to look at the resources of the community to ensure that they not only have the resources to be able to continue with the projects, but the capacity to use those resources to continue.

What does it take for something to make it into a budgeting cycle? Taking into account that financial incentives and allowances often drive participation in projects how best can REACHOUT embed without compromising the QI cycle?

Alignment with national priorities was seen to be key in ensuring that innovations make it into the budgeting cycle. Our colleague from Kenya also spoke to the need for clear, thought through concepts from partners and the importance of developing concept notes in partnership.

Budgeting is a complicated process and the panel emphasised the need for a transparent and collaborative approach and pointed to thematic working groups and advisory groups of being a key way to achieve this.

“If we have a specific plan for each project we will go back to fragmentation at the end of the day. To have sustainability in all actions we have to integrate the plans and have a clear vision of the total project resources… transparency here is important.” (Stelio Dimande)

How would you embed QI? What challenges do you anticipate and what pitfalls can we avoid?

Panellists from Malawi and Ethiopia, where QI is already part of the approach, fielded this question and spoke of the importance of ownership across different levels, from community through to government level. Highlighting the need for community members, who are using the services, to have access to the guidelines and become familiar with QI issues so that they can judge the quality of services and recognise the value themselves. From Malawi, Allone Ganizani discussed ownership at the government level: “It doesn’t have to be a REACHOUT activity. We have to feel that ownership. We do that by participating and taking lead in the whole process. Let us come up with the quality indicators ourselves that we want to monitor.” Buriso Shasamo also commented that professional commitment and energy is needed to ensure that the QI already in place becomes embedded: “In our districts we have started but the challenge is a lot of energy is needed to mobilise… Mobilise and work together.”

At the end of the lively and engaging discussion the key messages for researchers that consistently came through were:

• The need for inclusive plans and budgets that all donors collaborate on, in order to avoid fragmentation
• Alignment of research and interventions with national priorities to ensure uptake and embedment, “That’s why we are excited about REACHOUT, maternal health is a priority for the country” (Bedilu Badego)
• Engagement with government to bring evidence to the fore, collaborate on policy briefs and bring different perspectives to the table is also vital as researchers. “Dialogue with us…work with us. We don’t always see it the way you see it. We don’t interpret it as you do. So we need you to be close to us. What you [REACHOUT] are bringing on board is important”(Charity Tauta)
• Finally, researchers should also be aware of timeliness of engagement with government for embedding QI. Engaging policymakers during the development of country’s five-year strategic plans is crucial in influencing budgets and agendas

We look forward to continuing to learn from and work in partnership with policy players as we continue our REACHOUT journey. 

Recent news

• Participation, perspectives and possibilities: Mobiles, Development and Global Health, 29 October 2015
• REACHOUT holds Consortium meeting in Indonesia, 26 October 2015
• We must move beyond the ‘pay vs. no pay’ debate for community health workers, 6 October 2015

By Hayley Teshome Tesfaye and Jarso Tulu

On the 29^th and 30^th September 2015 Hayley Teshome Tesfaye, Speciality Registrar in Public Health at Liverpool School of Tropical Medicine and Jarso Tulu, SEARCH Associate Researcher, Reach Ethiopia, Sidama Zone Health Department contributed to a two day symposium “Mobiles, Development & Global Health; A way forward” hosted by Dr. Niall Winters Associate Professor of Learning and New Technologies at University of Oxford, Department of Education.

In this blog, Hayley and Jarso reflect on the symposium and the issues for consideration for the SEARCH project.

Background

Reach Ethiopia and Liverpool School of Tropical Medicine are currently implementing SEARCH – “Applied research on Health Extension Workers using e-health to strengthen equitable health systems in Southern Ethiopia” – funded by International Development Research Centre.

SEARCH will assess the feasibility and effectiveness of using information and communication technology (e-Health) to strengthen equitable health systems and related governance processes through inter-package linking and integration into the existing health management information system in Southern Ethiopia. The e-Health system focuses initially on tuberculosis and maternal and child health – both priority health areas in Ethiopia – through health extension workers using e-Health and mobile technology within their core duties. Process evaluation and mixed methods approaches are being applied to assess the effectiveness of the e-health data collection system. SEARCH is in an early implementation phase, following the completion of baseline data collection and preparation for training and implementation.

Symposium

International specialists in the fields of technology, training and global health gathered in autumnal Oxford, the “city of dreaming spires”, enabling the exploration of mHealth projects, aims, challenges, impacts, pedagogy and collaboration. Through inter-disciplinary participation, perspectives were articulated and future possibilities for utilising mobile technology for health objectives (mHealth) envisaged.

The symposium highlighted key issues for SEARCH to consider as implementation of the intervention moves forward.

Information Governance

Symposium participants identified that information governance is a potential and important issue within the design and delivery of mHealth and e-Health projects. Technology can be empowering, enabling increased networking and communities of practice. However, this may also result in unprotected sharing of Client/Patient information and images through social media to access peer/supervisor advice and support. This has ethical issues regarding confidentiality and information can to be disclosed within small communities. SEARCH needs to review and ensure that Client/Patient identifiable information and clinical details are protected through an information governance framework, built into the intervention training including ethical considerations.

Sustainability

Alice Lakati AMREF Health Africa clearly emphasised the need to consider sustainability of mHealth research projects. Alice encouraged the engagement of relevant stakeholders connected to planning and delivery of the intervention, plus ownership of country health system for ongoing implementation and development at the end research project funding. SEARCH from the outset have consulted with relevant stakeholders and the national health system, developing the e-Health intervention tool to mirror existing health management information and ensure interoperability of the community-based e-health with the existing health management information system. However, further engagement by SEARCH with the national health system will be necessary to ensure long term financial commitment and future development of e-Health within Southern Ethiopia.

Outcomes

Emerging from the symposium, it was apparent that mHealth outcomes were perceived differently by specialists within technology, training and global health.  An intervention could be evaluated and have impact at multiple levels, intended and unintended. For the SEARCH team due to start implementation of the intervention, we have reflected on the need to ensure the training element designed, delivered and evaluated to maximise learning and inform future rollout.

NB: We would like to thank Dr. Niall Winters @nwin and @m_CHW team for the opportunity to participate in an excellent opportunity to share ideas and network across global and inter-disciplinary boundaries. The SEARCH project is led by Daniel Gemechu Datiko from REACH Ethiopia in collaboration with Liverpool School of Tropical Medicine and has strategic links with REACHOUT in Ethiopia.

mCHW: a mobile learning intervention for community health workers http://www.mchw.org/

Recent news

• REACHOUT holds Consortium meeting in Indonesia, 26 October 2015
• We must move beyond the ‘pay vs. no pay’ debate for community health workers, 6 October 2015
• Why we use a group supervision approach in REACHOUT, 22 September 2015

By Rosie Steege

The REACHOUT consortium meeting was held from 7th-16th October and was hosted by the Eijkman Institute in Cianjur, Indonesia. REACHOUT colleagues joined from LSTM, UK; KIT, the Netherlands; LVCT Health, an NGO based in Kenya; REACH Trust, Malawi; REACH Ethiopia, Ethiopia; University Eduardo Mondlane, Mozambique and the James P. Grant School of Public Health in Bangladesh.

REACHOUT, which is now in its third year, is an ambitious five-year project, which aims to increase the equity, efficiency and effectiveness of close to community providers. The first quality improvement (QI) cycle is being completed and planning is taking place for QI cycle two.

With an emphasis on capacity building, the first week of the meeting was focused on young-researchers development. Activities included public speaking workshops, mixed methods analysis training and creating personal development plans. Ralalicia Limato, Research Operations Manager, REACHOUT Indonesia said:

“REACHOUT Consortium meetings are always exciting for me. Meeting colleagues from the REACHOUT family and sharing knowledge and experience with them are both enjoyable and valuable. Moreover, being able to learn in a safe environment is a unique opportunity provided by REACHOUT, including this meeting."

For the second week, partners from each country context joined the REACHOUT country teams. Our partners included policy makers, practitioners and NGO lead implementers, and the focus for the week was on embedding quality. We opened with presentations from the country teams on the findings from the first QI cycle and engaged with Indonesian politicians and local press who attended the event to build advocacy for the work we are doing. We were also fortunate enough to be joined by Dr. Gita Maya, Indonesian Director of Maternal Health, who discussed the issues in Indonesia relating to the high maternal mortality ratio and shared with us the country’s plans to address this.

The engaging and interactive programme for the week included training of trainers in quality improvement approaches for close to community providers, developing SWOT analysis for embedding quality and panel discussions with the country partners. The participants also visited volunteer-led village health centres or ‘Posyandus’ on the monthly vaccination day to observe the community health workers ‘kaders’ in action and visited the Community Health Centre ‘Puskesmas’. The meeting generated much exciting and insightful discussion around community health services in different contexts, with a focus on maternal and child health.

Recent news

• We must move beyond the ‘pay vs. no pay’ debate for community health workers, 6 October 2015
• Why we use a group supervision approach in REACHOUT, 22 September 2015
• Global Strategy on Human Resources for Health: How can it support close-to-community providers?, 10 September 2015

By Stephanie Topp, James Cook University, Australia

After several years of consultation, the SDG agenda was launched last week with much fanfare in New York.  Amongst the various health-related targets established by the forthcoming Sustainable Development Goals (SDGs) target 3.c aims to:substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in the least-developed countries and developing small-island states. This target speaks to the ‘chronic emergency’ many low- and middle-income countries (LMIC) face both in terms of the quantity and performance of human resources for health.  Importantly, meeting this target will be a prerequisite to attaining SDG target, 3.8 which aims (amongst other things) to: achieve universal health coverage [via] financial risk protection and access to quality essential health care services […]. 

The financing and sustainability of a strengthened health workforce is one of, if not the key component(s) underpinning our ability to achieve universal health coverage (UHC).  But the wording of Target 3.c, with its reference to the need for recruitment and development and training and retention, hints at the complexity of an issue that must be central to global health and health systems debates in the coming months and years.  Increasingly, the human resource crises in LMIC are being recognized as not simply a crisis of numbers but also a crisis of human resource management.  Although strengthening local training capacity and increasing the output of health professionals is desirable, the experiences of various countries have demonstrated that it is not possible to ‘train’ our way out of this problem.  Even assuming they stay in the system, having more doctors, nurses or even stipendiary or volunteer community health workers available is simply no guarantee of universal access to good quality and essential health care services – as issues of distribution, motivation and retention all come into play.

While more doctors and nurses are undoubtedly needed, experiences from across different regions and countries have repeatedly demonstrated the challenges of retaining clinical health workers in service of the most vulnerable populations – including both rural and urban poor.  Meanwhile, health systems and global health programs continue to rely on lay or community health workers to deliver various primary-level services in various permutations of community- or clinic-based care.

Clearly, given the scope of the human resource short-fall and the issues of distribution in many LMICs, it is time to place community health workers (or lay health workers or auxiliary workers) at the centre of discussions around how UHC can be achieved.  And as part of that debate, the thorny – even ideological – issue of volunteerism versus formal employment of these lower cadres must be tackled.  On one side of this debate it has been argued that there is an economic imperative to maintain non-paid health workers as the only way to ensure basic service coverage in geographically remote or otherwise marginalized communities.  The potential for formal payments and/or employment to pervert intrinsic pro-social motivations among such workers has been raised along with the need for non-monetary incentives.  Problematically, however, a number of studies have also demonstrated that along with genuine ‘help-giving’ motivations, health volunteers often experience severe economic need that contributes to high levels of physical and mental stress that undermine performance and retention. Some have even suggested that our widespread reliance on volunteerism to provide health services to marginalized people is reflective of societies habituated to inequality.

Where does that leave us? As we think about how to gain traction for increased funding or negotiate complex policy reform targeting the HRH-oriented SDG target, we must move beyond the dichotomy of ‘pay vs. no pay’ in relation to community health workers.  A more helpful starting point is the desired outcome – UHC – and a better more thoughtful assessment of the way inconsistencies in recruitment, posting and retention policies impact on (both professional and community) health workers’ motivation and capacity to deliver on that outcome.  Assessment and reform of health systems to ensure congruence between the system-wide goal (UHC encompassing financial protection and service coverage) and health workers’ goals (both intrinsic and economic) is required.  This is a more nuanced lens through which to discuss the central role that CHWs will have to play if we are to achieve ‘universal’ care.  It is an approach that allows for different meanings and significance attributed to “volunteerism” in different settings. But it also moves us away from the pervasive and dangerous assumption that the most vulnerable members of our health workforce should, and are able to provide, continuous service with only minimal or no support.

This article was first posted on the International Health Policies blog and we are sharing it with their permission. You can subscribe to their newsletter here.

Photo courtesy of Direct Relief.

Latest news

• Why we use a group supervision approach in REACHOUT, 22 September 2015
• Global Strategy on Human Resources for Health: How can it support close-to-community providers?, 10 September 2015
• Announcing a new research collection on community health workers, 8 September 2015

By Kingsley Chikaphupha, Ireen Namakhoma and Miriam Taegtmeyer

In REACHOUT we developed group supervision in response to findings from research with community health workers in six countries. They told us that they really needed and appreciated the supervisors but they all too often supervision was infrequent irregular and of a fault-finding approach. Supervisors told us they were rarely trained in how to do supervision, lacked funds for site visits and felt they lacked skills on how to support Community Health Workers (CHWs). When we looked at the literature we found that many studies report supervision to be an important factor to increase CHW performance, although details of how supervisors were trained and supported and how supervision was done were scarce.

How we use group supervision

We use group supervision to bring together a group of peer CHWs on a regular basis. Trained supervisors facilitate meetings that cover the three main functions of supervision: administration and reporting, refresher training and support. A typical session might include a round of feedback and reports based on the CHW work plans; a short topic of training and a facilitated group discussions on challenges and possible solutions. A supportive environment allows genuine issues to be discussed openly and peers to offer solutions. This cross learning strengths the whole group and improves relationships and motivation through building the team.

What research is being conducted?

The next step for REACHOUT is to conduct research on the effectiveness, costs and impacts of group supervision. We have designed tools that track attendance at supervision and also follow up on referrals and other routine programme data. Through the development of an eleven point perceived supervision scale we are able to track how supported the CHWs feel by supervision and the approach that supervisors take in listening to their views and helping them to solve problems. This scale was developed and validated in conjunction with partners at the University of Dublin and we are excited to work more with them in REACHOUT as we move forward. We are also tracking the impact of supervision on the overall functioning of the CHW programme at district level and through engaging key district people are working to embed approaches to quality improvement in community health care.

The potential learning for other projects

We have developed a generic group supervision curriculum that can be adapted to other projects and we are aiming to publish the perceived supervision scale. We have also tried and tested a range of tools to track supervision. The key learning so far is that a supportive approach to supervision is as important as (or more important than) its frequency. 

Recent news

• Global Strategy on Human Resources for Health: How can it support close-to-community providers?, 10 September 2015
• Announcing a new research collection on community health workers, 8 September 2015
• Twitter chat: People-centred research methods for health system development, 28 July 2015

By Kate Hawkins

Are close-to-community providers and community health workers (CHW) part of the health workforce? If so, what can governments and international agencies like the World Health Organization do to support them and ensure that their work is integrated into and supported by the wider health system? What does a human resources for health strategy that includes CHWs actually look like? These are some of the questions that we have been grappling with in REACHOUT as we read and responded to the recent World Health Organisation consultation on this issue.

A focus on community

One of the many positive elements of the draft strategy that is under consideration is that one of the principles explicitly mentions the role of communities in realising the right to health and states that communities should be empowered in order to work on the social determinants of illness.

“Support governments to build optimal health workforce models for the provision of people-centred integrated health services, responsive to patients’ sociocultural expectations, and empowering and engaging communities to be active participants in the health care production process.”

We believe that various types of close-to-community health care workers are vital human resources for health and that these cadres provide a critical interface between the community and the formal health system. We are concerned that this cadre of staff are not explicitly mentioned in the Global Strategy and that as a result they will not be factored into this holistic approach.

While there are certainly challenges in scaling up, and making the most of, close-to-community health programmes CHWs should be valued and nurtured in a similar manner to their formally employed peers who they work alongside often at considerable material and emotional cost to themselves.

We have gathered together some of the evidence in strengthening these programmes in our recent special supplement on the topic, “Supporting and strengthening the role of close-to-community (CTC) providers for health system development”. Further information on the costing of close-to-community programmes can be found in our WHO Bulletin article and this editorial “Maximizing the impact of community-based practitioners in the quest for universal health coverage”.

We would like to stress that we call for a greater emphasis in this area not to create special vertical programmes for CHWs, but rather to support the overall effectiveness and equity of national and sub-national health systems.

Political will 

We note the focus in the draft strategy of the importance of political will in the scale up of well-functioning, appropriately supported health workforces. In recent months there has been a surge of support for close-to-community programmes. For example they have been being heralded as a ‘good buy’ for development in a high-level report released at the Financing for Development Conference. But how do we ensure that these programmes are effective and are run efficiently and equitably in ways that are owned by health care staff, CHWs and communities? From our REACHOUT analysis key areas of concern have emerged that have potential to undermine CHW programme effectiveness and equity: 1. supervision; 2. community engagement; 3. referrals; and 4. coordination between stakeholders. Scale-up of CHW programmes is seen as a way of reaching universal health coverage, but rapid scale-up that does not address these concerns poses a potential risk to service quality and equity.

Migration and health worker shortage

The overview of the draft strategy suggests that the out-migration of health workers from low- and middle-income countries and under-investment by governments in this area places a strain on the health system. We would also argue that it places more responsibility on under-supported close-to-community providers who are being expected to add new areas of work to their existing portfolios, despite limited capacity, barely any support and no complete picture of the quality of the services that are delivered. There is a danger that they are seen as a “magic bullet” which will ameliorate weaknesses in other areas of the system.

Improving the evidence base

We note that the draft strategy calls for stakeholders to draw on “evidence on what works in health workforce development across different aspects, ranging from assessment, planning and education, across management, retention, incentives and productivity, and refers to the tools and guidelines that can support policy development, implementation and evaluation in these various areas.” We feel that there should be mention of the local and community level in this paragraph. In REACHOUT we have been exploring quality improvement cycles in close-to-community programmes. We define quality improvement as a systematic approach to planning defining, monitoring, improving and evaluating community health programmes. Through our work we are embedding into CHW scale-up, tried and tested quality improvement methods that are easy to use, simple to do and where data are collected, analysed and used by communities and CHWs to improve things in their own contexts.

This is not without its challenges. Government standards and guidelines are not widely known or disseminated and few people in the health system and in the community are clear on what their roles in quality improvement for community health might be. There are far too many tools and documents that are not owned by communities and CHWs.

Furthermore, we note that there are few studies that capture or explicitly discuss the context in which CHW interventions take place. In our work contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were also prominent. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All these contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. Future health policy and systems research should better address the complexity of contextual influences on programmes.

Focus below the national level

Whilst increasing national and institutional capacity to govern programmes is a laudable aim we believe that attention should also be paid to the sub-national and community levels and management capacity. Our research has argued that a mix of financial and non-financial incentives, predictable for the CHWs, is an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.

We also feel that capacity for conducting community health research deserves special attention as the voices and perspectives of communities are not adequately represented and this requires developing strategic partnerships and using innovative methods.

We look forward to the next steps in the policy development process and hope that some of our desires and concerns are reflected in the document moving forwards.

Recent news

• Announcing a new research collection on community health workers, 8 September 2015
• Twitter chat: People-centred research methods for health system development, 28 July 2015
• Research can be a challenge: Reflections on ethical and practical dilemmas faced by our team in Bangladesh, 25 June 2015

By Kate Hawkins

One of the main purposes of the Thematic Working Group on Community Health Workers is to support the generation of evidence to inform the scale up of Community Health Worker programmes which is pragmatic and contextually embedded. To try and publish and promote good work in this area we partnered with Human Resources for Health on a thematic series. We are delighted to announce that the first papers from the article collection are out now!

What are people saying?

There are papers from a range countries about people working in quite different contexts and we also have articles which take an international or overarching approach. What seems clear is that CHW programme scale up is challenging in the face of health systems constraints and that there is no blue print approach. However, systematic and systemic interventions, for example related to human resource management or the governance of programmes is needed. Another key message is that it is important to, “put the human into human resources”, and that people-centred health systems need to understand community health workers as people with their own challenges, strengths and motivations. These can relate to incentives in the health system as well as the ways that they relate to community members and institutions. We also have a lot to learn about the costs of CHW programmes and how best to asses these.

Summary of the available papers

• Costs and cost-effectiveness of community health workers: evidence from a literature review

• Supervision of community health workers in Mozambique: a qualitative study of factors influencing motivation and programme implementation

• Snap shots from a photo competition: what does it reveal about close-to-community providers, gender and power in health systems?

• Exploring competing experiences and expectations of the revitalized community health worker programme in Mozambique: an equity analysis

• Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach

• Using a human resource management approach to support community health workers: experiences from five African countries

• Exploring the context in which different close-to-community sexual and reproductive health service providers operate in Bangladesh: a qualitative study

• Supporting close-to-community providers through a community health system approach: case examples from Ethiopia and Tanzania

What next?

The thematic series is not finished yet and will run for some time to come. So look out for new papers and the editorial which brings together learning on what has been published so far. We have also asked some of the authors to tell us a bit more about their work. So expect blogs and other communications from the Group over the coming months.

Recent news

• Twitter chat: People-centred research methods for health system development, 28 July 2015
• Research can be a challenge: Reflections on ethical and practical dilemmas faced by our team in Bangladesh, 25 June 2015
• Innovation alive and well in Bangladesh and embodied in REACHOUT, 18 June 2015

By Kate Hawkins

We are delighted that Miriam Taegtmeyer and Kingsley Chikaphupha will take part in the Health Systems Global Twitter chat on people-centred research methods. It is a great chance for us to share some learning from our experience of quality improvement cycles.

The Cape Town statement on People-Centred Health Systems suggests that as researchers we should: “Allow the experience of communities and health workers to be heard, through use of innovative research methods that engage and empower communities including participatory action research, photo-voice, simulations and games." In the chat a panel of researchers working on health systems will explain what novel approaches they have taken, challenges and un-anticipated consequences in the research process and the gains that they think these methods have brought. 

How to join in

The chat will take place on Thursday August 20th at 14.00 BST.

If you are not able to attend the live discussion, please feel free to tweet your comments to @H_S_Global or @REACHOUT_Tweet using the hashtag #HSR2015. An edited summary of the tweet chat will be published in a Storify post shortly after the session.

Other useful events

If action research and operational research are your thing you might like to join series of webinars by the Harmonization for Health in Africa (HHA) Community of Practice on health systems planning and budgeting.

This Community of Practice is organising a series of capacity building webinars on action research and operational research in health, in an attempt to enhance members' capacities to promote evidence-based health decision making. Guest speakers at these webinars will be Professor Valéry Ridde from the University of Montreal for the webinar on action research (in French) and Dr Geoff Royston (webinar in English), currently an independent analyst and researcher on operational research in health.  Valéry Ridde is scheduled for Wednesday 29th August at 13.00 GMT.  For more information on this speaker, see here.  Dr Geoff has worked as a senior health analyst for the World Health Organization, among others, and is a long standing member of the Euro working group on operational research applied to health services. The webinar with him will take place on Wednesday August 12th at 15.00 GMT. For more information on Dr Geoff, see here. 

To register for these webinars, send an email to ade_nadege@hotmail.com copying in jarkien@gmail.com and noelnahounou@gmail.com with the subject line: capacity building webinars-action research and operational research in health. They will give you the practical details of how to join the webinars.

Recent news

• Research can be a challenge: Reflections on ethical and practical dilemmas faced by our team in Bangladesh, 25 June 2015
• Innovation alive and well in Bangladesh and embodied in REACHOUT, 18 June 2015
• Why do health inequities persist in Kenya? What difference can community health workers make?, 9 June 2015

By Salauddin Biswas, Noor Kutubul Alam Siddiquee, Sumona Siddiqua, Tamanna Majid, Muhammad Riaz Hossain and Sally Theobald

Menstrual regulation (MR) is a way to safely establish non-pregnancy up to 8-10 weeks after a missed period. MR is legal in Bangladesh and many women have undergone this procedure. Despite this, MR remains a very sensitive and stigmatized issue. Women’s experiences are shaped by the gender and power relations they experience within households and communities.  Differing levels of stigma exist with various communities.

The team in Bangladesh have been conducting research on sexual reproductive health (and in particular MR) in collaboration with Marie Stopes and RHSTEP at a time of political upheaval. During the process we have had to deal with a number of challenges and remain flexible and responsive in our approach. In this blog we provide some learning which we hope will be useful to others working on health systems.

Careful interviewing

During our research we found that women who had undergone MR were reluctant to have their experiences recorded. Religious, social and family pressure can bring stress to potential interviewees; for example in-laws may pressure young women into keeping a pregnancy when they do not feel ready to do so. We therefore made the decision to not record the interviews and focus group discussions but instead take detailed notes. So that we did not lose the depth and detail of the information we:

1. Ensured we had an experienced team - all of the research assistants had a masters degree (mainly in Anthropology); rigorous and thorough training was undertaken with them.
2. Interviewed in pairs - one note taker and one interviewer swopped roles on a regular basis. We interviewed a maximum of two people a day to ensure that researchers did not become fatigued.
3. Paused and clarified at key points during the interview - which also served as a form of participant checking.
4. Wrote up notes immediately while minds were fresh after the interview or focus group discussion - with inputs from both recorder and interviewer.

We paid attention to the choice of interviewer, women researchers interviewed MR clients to help build up rapport. We also thought carefully about the terminologies deployed. In discussing MR, the Bengali terms (baccha nosto kora, baccha wash kora, baccha falay deoa) literally translate as ‘dropping a baby’ and so it was thought best to avoid them. The terminology of MR is common and this was used or instead interviewers asked, “what do you do if you/person X doesn’t want to keep a baby?” Initially some MR clients were not comfortable talking about themselves and were nervous. They often talked in the third person about other women’s experiences, followed by their own only when they felt comfortable.

Confidentiality and anonymity

Sensitive approaches are critical when dealing with an issue like MR and confidentiality needs to be maintained at all times. Anonymity is absolutely key in the provision of MR services at Marie Stopes; for example client names and details are not requested. This brought challenges in terms of interviewing clients who had been referred for MR. Where possible trusted providers/referrers made links to women to discuss this further only if they were happy to be interviewed.

MR clients did not want to be interviewed in their homes or communities, and there was no private space at the clinic. The where, when, and process of negotiating informed consent in these contexts needed careful consideration: we let the clients decided the where and when of the interview.

Challenges of working with time–poor participants                                                            

Both close-to-community (CTC) providers and women living in Dhaka’s urban slums are time poor and juggling multiple demands. CTC providers are busy with their work and meeting targets for visiting clients and referral. Urban slum women are negotiating the challenges of paid work (for example as cleaners and cooks) and unpaid family responsibilities (such as the household, child care and domestic work). Both have to cope with the demands of Dhaka’s notoriously terrible traffic.

Ensuring interviews were conducted at a time and a place that was convenient to participants was paramount, and required great patience from research assistants who sometimes had to wait 12 hours for one interview. Sometimes CTC providers were impatient with detailed probing interviews, complaining that they had targets to reach. As a result decisions on the order of the topic guide and the depth of probing had to be made.  Urban women also needed to rush back to their household chores or they would be in a position where they needed to explain to their family members why they were so late at the clinic. Sometimes clients’ husbands came with them to the clinic and did not permit their wives to participate in the study, or if they did, it was not for long.

Writing up transcripts

Transcripts were first written up by hand in Bengali and then translated into English and typed up. There were dilemmas related to transcription: does it make more sense to employ professional transcription specialists with excellent English, or should research assistants who may not have excellent English but collected the data undertake the transcription? In this case it was decided that the research assistants should do it: they undertook the interviews and knew the depth and detail of the interaction, the nuance and the unspoken body language – which can provide critical clues to meaning.  The translation process from Bengali to English was overseen by senior researchers to double check meaning and transcripts were returned with queries if there were inconsistencies, omissions or didn’t seem to add up/make sense. Working as a team and bringing different perspective to the analytical process strengthened its quality and robustness. We debriefed on a daily basis to bring in different perspectives, to triangulate across different methods, sites and participant groups and to understand and interrogate inconsistencies if and when they emerged.

The realities of political unrest: researching in unpredictable contexts

Bangladesh has faced periods of political upheaval, strikes and unrest during the period that we have been undertaking this research. In response to the political environment, James P Grant School of Public Health has at times had to inform its staff that it is their choice whether to come to work or not. REACHOUT staff have shown fantastic commitment and continued with their work, and under the excellent management of Ilias Mahmud, who asked all research assistants to keep their timetables on google file and update any changes so all could be accounted for. The political situation has also brought challenges to the processes in the Quality Improvement cycle - sometimes special transport (ambulances) had to be arranged for people to come to trainings and feel safe to travel.

Ensuring quality and trustworthiness across the qualitative research cycle is challenging. We look forward to further discussion and exchange on the experiences of data collection within the realities of research in different contexts and on a variety of topic areas.

Recent news

• Innovation alive and well in Bangladesh and embodied in REACHOUT, 18 June 2015
• Why do health inequities persist in Kenya? What difference can community health workers make?, 9 June 2015
• Kartini and women's lives, 11 May 2015

Sally Theobald and Miriam Taegtmeyer

“Innovation means: 1. thinking creatively for solutions while learning from setback and mistakes; 2. being courageous to try something new and 3. adapting well to changes in the work environment”, declares a poster in the reception of BRAC, the largest Non-Governmental Organisation in the World. BRAC’s innovative outlook is clear even from the reception area where we read in the BRAC bulletin how an all-girls cricket tournament was launched on International women’s day 2015 and how BRAC Chicken (Healthy Choice) is the proud sponsor of the first ever national surfing tournament at Laboni Beach in Cox’s bazaar (find out more on facebook/BRAC.chicken); meanwhile the video screen in the corner highlights BRAC’s programme training women drivers to tackle the realities and challenges of Dhaka’s congested streets. The signage to what happens on each of the 21 floors of the BRAC building (which coordinates its action in all 64 districts of Bangladesh) also highlights innovation and includes teams working on the social innovation lab; disaster, environment and climate change; and gender, justice and diversity.

Bangladesh has also demonstrated innovation in the provision of services for sexual reproductive health. Menstrual regulation – to safely establish non-pregnancy up to 8-10 weeks after a missed period- has been available and legal since 1972. The horrendous mass rape of many women during the liberation war in 1971 created a clear demand for menstrual regulation and a political will with the creation of a new country. The political space to continue this much needed service has been maintained and menstrual regulation is currently available through both government and non-governmental service providers (such as Marie Stopes and RH Steps). The focus of REACHOUT in Bangladesh is on sexual and reproductive health and menstrual regulation in collaboration with these partners. We visited Marie Stopes programme in the urban slums of Keraniganj and met women, men, girls and boys living in the slums. Marie Stopes volunteers, CTC providers and supervisors each shared a snapshot of their experiences and invited us into their homes and working environments. We experienced the joys of Bangladeshi hospitality first hand, including the most delicious in season alphonso mangos!

Saluddin Biswas, REACHOUT senior research associate, discussed the question of who is the close-to-community provider, and who is the supervisor? There is a clear hierarchy from Marie Stopes volunteers, to a range of formal close-to-community providers including outreach workers, service promoters, health educators and field coordinators. Boundaries are blurred and multiple players are involved to ensure that women from urban slums receive quality confidential services. REACHOUT uses quality improvements (QI) cycles to support innovation to strengthen close-to-community services. In Bangladesh this includes supportive supervision and referral. The supervision approach recognises that people have dual roles at every level i.e.an outreach worker supervises volunteers but is herself supervised by a field coordinator. The supportive supervision model incudes learning by doing and role play with the aim of supportive (rather than fault finding) approaches cascading throughout the hierarchy through training, role modelling (individual and group) and feedback. This supportive supervision process will also support feedback on referral. Developing robust structures for supervision allows for space to innovate, create and adapt to change and brings a platform for the voices and experiences of close-to-community providers to be heard.

Recent news

• Why do health inequities persist in Kenya? What difference can community health workers make?, 9 June 2015
• Kartini and women's lives, 11 May 2015
• REACHOUT contributes to Ebola enquiry, 27 April 2015

By Rosalind McCollum,

Kenya has made excellent progress towards reducing child mortality, with under-five mortality rates having reduced from 111 deaths per 1000 live births in 2003 to 52 deaths per 1000 live births in 2014.  However, these improvements mask an increasing relative inequity, with urban child survival gaps between the richest and poorest children having doubled in recent years.  In fact Kenya is reported to have some of the most inequitable cities globally for health.  These gaps between rich and poor are not isolated to urban areas, but exist between and within counties. 

What is health equity?

Health equity means that all people have equal access to health services according to their needs.  They have equal use of services according to their needs and they receive equal quality of care regardless of where they live, their gender, age, occupation, race, religion, level of education, social connections, income level, (dis)ability or sexual orientation.

What are the reasons?

Health inequities in Kenya, as all over the world, occur as a consequence of a multitude of inter-related reasons.  However, in the most recent Kenyan DHS (2014) differences in the use of health services are described based on a person’s location, poverty level, education level, gender and age.  For example there are considerable differences for delivery rates with a skilled provider among live births in the previous five years.  Mothers over 35 years (53.9%) are less likely to deliver with a skilled provider compared with younger mothers (63.1% for mothers aged 20-34 years), as are mothers living in rural area (50.4%) compared with mothers in urban area (82.4%), mothers with no education (26.4%) compared with mothers with secondary education (85.1%) and the poorest mothers (31.1%) compared with the richest mothers (92.7%). 

Moving towards equity for health is a complex process and one which most high income countries are yet to achieve.  However, there are features of Kenya’s health system which contribute towards lack of progress in this vital area. 

Kenya continues to under-invest in health.  Despite having signed up to the Abuja declaration (2001) and committed to allocate 15% of the national GDP on health, spending for health in Kenya is consistently below 5%.  As a consequence of low government investment in health, people are forced to pay for health care.  This is sometimes termed out of pocket (OOP) payments for health services, with OOP payments accounting for almost a quarter of all health expenditure in 2010.  This regressive form of financing for health means the poorest and most vulnerable end up bearing the greatest burden, pushing many into impoverishment as they pay for healthcare.  The recent elimination of user fees at dispensaries and health centres and free maternity for all in 2013 will go some way towards reducing this burden. 

Where are inequities found?

Inequities exist across levels in the health system.  There are marked differences between the 47 counties in the availability of the essential health package, health facilities and health workers, resulting in inequities in service use. For example, there is less than one health facility per 10,000 population in Bungoma County, compared with over 3.5 health facilities per 10,000 population in Mombasa County.  This trend continues within counties, with those living in the most remote areas often having lower access and use of health services compared with those living closer to a facility.  Even within a single community there are some who are underserved by health services compared with their neighbours. 

What can be done?

Primary and community health care have been shown to improve health equity, for example when Community Health Workers (CHWs) were introduced in Malindi and Lamu districts in Kenya, use of their services for malaria treatment was highest among the poor and most poor.  Community health services are promoted as a means to improve equity of access and use of health services by those in hard-to-reach areas and among traditionally underserved groups.  Not only this but CHWs are uniquely placed to enter their neighbour’s homes and observe the social determinants of health, allowing them to provide targeted health promotion and disease prevention education which can potentially help to address some of these underlying factors. 

Kenya describes the need for a shift from curative to preventive care and has pronounced the benefits of a primary and community health care approach, although secondary and tertiary facilities have historically been allocated 70% of the budget.   In recent years however, there has been a degree of increased investment in primary health care with per capita outpatient visits subsequently increasing.   Kenya also introduced a Community Health Strategy, however there has been limited financial backing or commitment of funds for community health from within the Government. Even vertical programmes like HIV have shifted resources away from community interventions to facility based interventions.

As a result, within certain counties those living in the most remote areas do not have access to community health services, which have been developed primarily for their benefit.  This occurs as a consequence of heavy partner involvement, which permits partners to select their operational areas, with some deciding to establish community services in more readily accessible communities. 

What next for Kenya?

Kenya’s decision to vote for devolution has the potential to transform longstanding inequities.  In order to tackle some of these the Government has introduced an equalisation fund, equivalent to 0.5% of funds which is distributed among 14 priority counties.  Analysis of key health indicators for these 14 counties reveals that in general they have higher mortality rates and lower service utilisation rates than the 33 remaining counties and so have the most to gain through these additional funds. 

Furthermore, each county government now has the power to determine which services are prioritised within their county.  This is a fantastic opportunity for investment and change in community and primary health care.  A potentially exciting and transformative period for health equity in Kenya as funds are no longer allocated based upon national decisions but on county decisions, informed directly by community participation and county priorities. 

However, there is the possibility that funds will not be used for the benefit of the whole population, as some politicians may want to demonstrate to their constituents the ‘good use’ of county funds and so may decide to prioritise tangible, visible services such as ambulances and upgrading of hospitals over less visible, but more equitable community health services.  This will result in tough decisions to be made in each and every county, as county health management teams must advocate and demonstrate the benefit of community and primary health care for improving health equity and demonstrating health care results.  

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By Sudirman Nasir

This article was first published in the Jakarta Post.

Four days before the commemoration of Kartini Day on April 21, as a researcher I attended a village health community (Posyandu) session in a village in Cianjur, West Java. A village midwife and four volunteers were busy organizing activities such as providing iron tablets and health information for pregnant women, as well as weighing and giving additional nutritious food for infants. 

Kartini, our heroine of women’s rights in Indonesia, would be surely proud of such unsung heroes, the highly motivated health workers. Without them our maternal and child deaths would be much higher. 

Kartini herself died before she turned 25 years old, after giving birth to her first son in 1904. Over a century later, despite great advances in medical and public health sciences, many young Indonesian women still face a similar fate.

According to the World Health Organization (WHO) maternal mortality is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

 Our maternal mortality rate is still the highest in Southeast Asia, at 359 maternal deaths per 100,000 live births. Our efforts to materialize the Millennium Development Goals’ target of a maternal mortality rate of 102 per 100,000 live births by 2015 seem very distant. 

Several studies in Indonesia and other developing countries have shown numerous biomedical issues contributing to the high rate of maternal deaths such as post-delivery bleeding, infection, high blood pressure and obstructed labor, made worse by the poor quality of emergency obstetric services, poorly organized referral systems and human resource distribution particularly in rural areas. 

Further, maternal deaths in Indonesia mostly occur among mothers who give birth at home without skilled birth attendants. Though more women have deliveries in health facilities, it is not as high as expected. 

Our current study in the regencies of Cianjur, West Java, and Southwest Sumban East Nusa Tenggara, confirm numerous social, economic and cultural barriers that may hinder pregnant mothers from delivering at health facilities. 

These barriers include distance, poor road conditions, lack of availability of transportation (including transportation costs), as well as cost of accommodation and food for family members accompanying the patient to health facilities.

Furthermore, many may lack access to a midwife. Many midwives do not reside in their assigned village, due to limited supporting facilities and family reasons, or difficulties in contacting the midwife due to distance and lack of communication tools.

Our findings also revealed that women and families tended not to have deliveries at health facilities owing to poor perception of benefits of delivery at health facilities and preference for home delivery and traditional birth attendants. 

Further, the traditional attendants rarely referred pregnant women to midwives, with whom they had little communication. The traditional attendants mostly live near to the pregnant women compared to the midwives.

The traditional attendants also provide psychological and cultural support such as massages, herbal medicine and recitation of specific prayers that are perceived as valuable services by the families and communities. 

Our study also found that compared to other villages in Cianjur and Southwest Sumba, several villages in both regencies had higher attendance of antenatal care to check pregnancy progress, as well as higher levels of delivery at health facilities. The better performance and enthusiasm of village midwives and Posyandu volunteers, and support from important stakeholders such as the heads of the villages, hamlets, neighborhoods and other leaders including those from the local Family Welfare Movement (PKK) is crucial in achieving better maternal health indicators.

Unfortunately, the support of these important stakeholders is not systematically created. These villages are merely lucky to have these proactive stakeholders, with no guarantee of sustainable support when their tenure ends. 

Therefore we should remember another pioneer of women’s rights and women’s health — the late Kardinah Soepardjo Roestam who died in 2012. Kardinah, the wife of the late Soepardjo Roestam, a home minister in the 1980s, played a key role in developing Posyandu and encouraging its volunteers to support pregnant mothers and women’s health programs in villages across the archipelago. 

She was also tireless in encouraging regents, village heads and the wives of such officials to support the community health centers and maternal health programs. Because of her role, she received the prestigious Sasakawa health prize from the WHO in 1989. 

We hope to have a new prominent maternal health advocate such as Kardinah. We also hope the First Lady, First Lady Iriana, Coordinating Human Development and Culture Minister Puan Maharani or Social Affairs Minister Khofifah Indar Parawansa will jump to this strategic role. 

Photograph by Olivia Tulloch.

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By Kate Hawkins

The recent call for more of a focus on people centred health systems and the devastating effects of Ebola in West Africa have brought communities to the forefront of the attention of decision makers. REACHOUT, along with our sister consortia ReBUILD and COUNTDOWN, are part of a growing group of health systems researchers who are trying to provide guidance to those grappling with health systems strengthening in Ebola-affected countries. Most recently we have provided written evidence to the UK All Party Parliamentary Group on Africa under their call for inputs on community-led health systems and Ebola.

Why focus on communities?

Communities play a largely unrecognised, unrewarded and unsupported role in health systems around the world. There are many families and community structures (such as local governments and schools) which perform tasks which are central to good health. Yet they are rarely factored into health system planning and their views tend not to influence policy and practice in this area.

Close-to-community providers of health care (such as community health workers (CHWs)) live and work within their communities, visiting people in their homes and workplaces every day, they can have a vital role in informing realistic healthcare policies that deliver results at community level. However even when their health promotion and delivery activities are recognised, for example in some CHW initiatives, they are often working in sub-optimal circumstances and are poorly linked to, and managed by formal health programmes. This has led to a disconnect between healthcare policy and the workers delivering healthcare services directly to individuals, families, and communities. This disconnect has resulted in loss of motivation and problems with health worker retention and ultimately an additional disconnect between service users in the community and health facilities resulting in a decrease in service utilisation. In Ebola-affected countries this is exacerbated by poor infrastructure, inadequate skilled health workforce which was further depleted by loss of health care workers to the illness, health systems which were already struggling and unresponsive in a post-conflict context, and Ebola-stigma against front-line workers.

Our submission to the enquiry in a nutshell

• Community structures and close-to-community providers of health care have the potential to improve health system functioning and health outcomes in Ebola-affected countries and beyond. They are vital to rebuilding trust between communities and health systems. Yet their (potential) role and responsibilities are poorly understood and supported. There is an urgent need to gather more information which can better integrate their work into the larger health system. This is a body of research that the UK Government should support.
• There is much that we can learn from the response to Ebola. Yet platforms and information sharing mechanisms are inadequate. The UK Government could play a key role in financing multi-stakeholder platforms to this end.
• Community-level health work is reliant on the robustness of the overall health system. In Ebola-effected countries (which were also post-conflict settings) the overall system had critical weaknesses. Efforts to strengthen the whole system under the leadership of national government are sorely needed.
• The lack of appropriately trained, remunerated, and incentivised health workers is of particular concern to Ebola-affected countries.
• Improving health needs to be a multi-sectoral endeavour. Infrastructure, telecommunications networks, and roads as well as urban regeneration are also important to the response.
• A body of evidence on both community action on health and system strengthening post-conflict and crisis already exist and should not be overlooked as we rebuild in the post-Ebola era.
• The UK Government develop a strategy that specifically addresses the role of communities and CHWs in supporting better health.

Latest news

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• REACHOUT quality improvement cycle in Indonesia: Our work in pictures, 9 April 2015
• Communicating better about community health workers: Reflections on #ResUpMeetUp, 30 March 2015

By Rosalind McCollum,

Kenya’s community health strategy (2006) expounds the country’s plan to expand access to community health care for the whole population, through two close-to-community providers:  community health workers (CHWs) (community selected community members who carry out a range of activities at household level) and community health extension workers (CHEWs) (government selected workers who supervise CHWs among other community health tasks).

Kenya is currently revising the strategy for community health, which will result in a proposed increased number and role of county government salaried CHEWs working at community level.  These changes are occurring alongside the process of political devolution, which results in shifting responsibilities for health from national to county level and changing health priorities and health service implementation between counties. 

New community health study conducted in Kenya

Recent qualitative research conducted by REACHOUT in Kenya revealed that communities greatly appreciate and value the work of their local CHW.  However, lack of funds to pay salaries for CHWs was identified as a threat to the sustainability of the community health strategy in Kenya, due to high CHW attrition and lack of accountability, leading to the need to revise the strategy.  Policymakers describe a desire for evidence based revision of the strategy

“I think that it is very important that the lessons and the challenges should inform the decision to revise the community strategy ... so that we can come up with something that can work well for us and we can remove what we feel did not work well for us.” (Policymaker)

This research highlighted a number of key limitations associated with the current strategy, including: poor distribution of community units; uncertain level of community engagement with CHEWs (who will have a greater community role according to the revised strategy); expectations for greater service integration (including home based HIV testing and counselling); irregular and poorly structured supervision; demand for incentives and current heavy workload for CHEWs.

What are the implications of world health worker week for policy change in Kenya?

World health worker week provides a fantastic opportunity to support health workers, including CHWs and CHEWs, by recognising and celebrating the amazing work which they do.  However, world health worker week also presents us with a challenge to call on those in power to ensure that these health workers are equipped to do their jobs safely and effectively.

With the shifting power dynamics associated with devolution, the 47 Kenyan county governments now have increased autonomy and power in decision making for health.  Devolution brings with it unique opportunities and challenges for each county to influence equity of health service provision, since decision making is brought closer to communities. Counties can now prioritize services for more equitable coverage, addressing county specific health burdens and allowing for greater coordination between actors and opportunity for stronger community participation at county level. However, devolved county authorities also have authority to prioritize services and resources which may result in greater rather than reduced inequities.

Advocacy is needed at county government level to demonstrate the potential benefits of the revised strategy, to promote financial investment in community health and to tackle the exposed challenges experienced by close-to-community providers such as supervision, incentives and workload.  In this way ensuring that close-to-community providers are more effectively supported and equipped to do their work through implementation of the revised strategy.

Recent news

• REACHOUT quality improvement cycle in Indonesia: Our work in pictures, 9 April 2015
• Communicating better about community health workers: Reflections on #ResUpMeetUp, 30 March 2015
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Recent news

• Communicating better about community health workers: Reflections on #ResUpMeetUp, 30 March 2015
• Gender Equity Analysis: A necessary prerequisite for addressing gender related outcomes, 24 March 2015
• Kenya and Sierra Leone:  A wake up call in light of Ebola, 14 March 2015

By Faye Moody

It was fantastic to have the opportunity to go to the ResUpMeetUp Conference in Nairobi. It was a busy week but a great opportunity to discuss research uptake with others from a wide variety of backgrounds. Communications and research uptake has been a part of my role working on multiple research projects at Liverpool School of Tropical Medicine. I have a particular interest in online communication and the part it plays in getting research into policy and practice.

It was clear that it is very important to create a research uptake strategy at the very start of the project and adapt as necessary as the project progresses. Beyond this there are four main areas that came through strongly at the meeting.

1. Repackage for different audiences

At ResUpMeetUp there was a lot of discussion about how different stakeholders and audiences require research to be repackaged in different ways and that communication and engagement methods will vary dependant on the project’s context and objectives. At the meeting there was plenty of discussion about policy makers and how they have their own agenda to follow and so technical reports and journal publications are unlikely to attract attention without a clear link to what stakeholders or policymakers are trying to achieve. As secretary to the Health Systems Global Community Health Worker Thematic Working Group I can see how multi-stakeholder platforms that bring together experts in the field are an effective channel of communication to disseminate research directly to key stakeholders who then can circulate to their wider networks. But they also allow discussion on how people like to receive information and the types of formats that work best.

2. The role of social media

Sharing new publications, briefs, press releases, and blogs through social media networks like Twitter, Facebook or LinkedIn is something all researchers and project administrators or managers can easily do to increase an online following of the research. This can create a bigger impact which can all be tracked over the internet through the various performance metrics that these platforms capture.  In addition to this there are many innovative tools to communicate research in different ways such as data visualisation tools to make it easier to see the data findings. Digital stories can also be put together just using a tablet.

3. Building capacity

Research uptake is not just about the supply of knowledge, it is also about demand. At ResUpMeetUp we talked a lot about building the capacity of stakeholders/policy makers to help them understand how to use research. This can also be done in many innovative ways such as mobile apps, online videos, webinars, workshops etc. Monitoring and evaluation tools can then be used to understand the impact of the research.

4. Continuous learning

Research uptake is a continuous cycle of stakeholder engagement using various communication methods and tools; with continuous monitoring and evaluation, building capacity where necessary by engaging with stakeholders using various communication tools and methods. This is important as we need to learn as we take this work forward. I created the diagram blow as a reminder of how all of these elements fit together.

I’m looking forward to putting some of this learning into action as we move forward with the REACHOUT project.

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By Ireen Namakhoma

Earlier this month the Global Health Action produced a special issue on Gender and Health. One of the articles which I co-authored together with colleagues from Liverpool School of Tropical Medicine, Eleanor MacPherson, Sally Theobald and Esther Richards, highlights critical issues regarding sexual and reproductive health (SRH) in East and Southern Africa. We conducted a literature review on gender and health with the aim of identifying important issues for action.

The review found gender inequalities to be common across a range of health issues relating to SRH with women being particularly disadvantaged. Gender inequality is a critical structural constraint to development and improved health outcomes. Gendered social norms undermine women’s position in society leaving women with limited access to social and economic resources and impacting negatively on women and girls’ health and well-being.  The ability of women to realise their sexual and reproductive rights is vital to achieving gender equity in health as well as the empowerment of women. SRH relates to the health and well-being of people in matters related to sexual relations, pregnancy, and birth. The ability of women to realize their sexual and reproductive rights is vital to achieving gender equity in health as well as the empowerment of women.

Eastern and Southern Africa has the highest burden of infectious diseases including HIV and AIDS. The high HIV prevalence could be a significant contributor to high mortality rates within this region.

This region also has high maternal mortality rates. Comparison of data from the 16 countries in the region between 1980 and 2008, actually showed worsening maternal mortality rates in Bostwana, DRC, Lesotho, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. Almost half of all maternal deaths occur during labour, delivery, or the immediate postpartum period. There is also a high unmet need of contraceptives which can lead to higher likelihood of unsafe abortions. Gender based violence is common and takes multiple forms - physical, sexual, psychological and economic. The data on gender based violence is shocking, for example in a study in South Africa, 27.6% of the men interviewed admitted to raping a woman; while estimates by the United Nation’s Children Fund reveal that 13-49% of women having been physically assorted by an intimate male partner.

Gender equity analysis is important

Recently on Sunday March 8, we commemorated the Women’s International Day, which reinforced for me the importance of gender equity analysis. It is critical that the focus on gender analysis is not lost in health research in order to have better understanding of how gender impacts on health inequities and related health outcomes. The Research for Equity and Community Health Trust has been central to debates and research that is close to policy to put forward gender and equity perspectives. Studies have shown gender to be an important determinant in access to health services. Analysis of pathways to care seeking in Malawi shows that women take longer to report to health facilities than men. The delay period amongst TB patients showed that women took longer to be diagnosed with TB than men and had more repeated visits. An exploration of desire to give birth among people living with HIV showed that women often against their wishes, were under pressure from their partners and spouses to fulfil community expectations in having children. Access to family planning was hindered by as some men perceived that the use of modern contraceptives negatively affected marital sexual relations. Gender also has impact on men living with HIV as often perceptions of masculinity affect access and retention to HIV services resulting in poor treatment outcomes.

Opportunities for advancing gender equity in health

Many researchers, like the ones in RinGs, are exploring ways to make health systems more gender-responsive and more gender-equitable. An issue that is important to me is the role of close-to-community providers, as I am the principle investigator for the REACHOUT consortium in Malawi. Effective community health worker (CHW) programmes have shown to have potential to better meet the needs of women, tend to be easily accessible, and minimize costs of care seeking. In a study which investigated the impact of using CHWs to promote early diagnosis and referral for HIV, showed a 37% increase in new patients initiating antiretroviral therapy and 61% increase in uptake of HIV testing within a 12 month period. CHWs are strategically placed to understand the challenges women face in accessing care and how this relates to broader societal and infrastructural challenges including gender norms. However for CHWs to be effective, there is need for mechanisms that sufficiently support and motivate them such as a responsive referral systems, adequate training, supportive supervision, community engagement and good coordination among the different stakeholders working at community level and we hope to learn more about this as our REACHOUT work progresses.

Recent news

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• Experiência como primeiro autor de um artigo – Lições aprendidas e desafios, 14 January 2015

By Rosalind McCollum

Last week, Save the Children launched ‘A wake up call’, drawing lessons from the Ebola Virus Disease epidemic for health systems strengthening on a global scale. 

One of the key messages of this report is that Guinea, Liberia and Sierra Leone are not unique in their vulnerability to Ebola.  Save the Children identify 28 countries with health systems as fragile as, or weaker than Liberia’s, emphasising that weakened health systems which contributed to the extent of the current outbreak are not a one off.  There is widespread need for drastic health systems strengthening and resilience building on a global level.  Guinea, Liberia and Sierra Leone’s under-resourced, under-funded and poorly equipped health systems were quickly overwhelmed by Ebola.  The case for universal health coverage (UHC) has never been stronger. 

Comparing rankings on health access in Sierra Leone and Kenya left me feeling shocked!

Having worked in Sierra Leone both before and during the Ebola crisis and now living in Kenya I decided to compare their rankings in the report’s health access index.  I was shocked to discover that Kenya ranks lower (47/72) than Sierra Leone (46/72) for health access.  How could this be the case? Kenya has a gross domestic product (GDP) of $1245.50 per capita, while Sierra Leone’s is just $679 per capita, meanwhile Kenya has 9.7 doctors, nurses and midwives per 10,000 population compared with 1.9 per 10,000 population in  Sierra Leone.  Yet there is remarkably little difference in per capita government expenditure on health, with $15.9 per capita in Sierra Leone and $17.0 in Kenya. Both skilled birth attendant and immunisation rates are higher in Sierra Leone than Kenya.  Not only this, but the ratio between the richest and poorest for skilled birth attendant at birth shows remarkable differences, with a ratio of 1.6 in Sierra Leone and 4.0 in Kenya.  Perhaps their rankings are not as outlandish as I had first considered?

Equity gaps persist

Sierra Leone has slowly been recovering from the aftermath of its civil war with recent recognition of the need for universal health coverage and initial steps taken towards investing in primary health care through introduction of the free health care initiative in 2010.  This resulted in free health care for all pregnant and lactating women and children under five years, prior to the onset of the Ebola outbreak. Kenya too describes the need for equity and access to health care for the whole population within its policies and yet drastic equity gaps persist.  As a signatory to the 2001 Abuja declaration Kenya has committed to allocate at least 15% of national GDP to health care, yet allocation has remained below 5%, with secondary and tertiary facilities historically allocated 70% of the budget.  However, Kenya has increased its investment in primary health care and per capita outpatient visits are thought to have almost doubled in the 2003 – 2013 period based on household healthcare utilisation and expenditure data (2013).  Free maternity was introduced in all public health facilities in 2013 to address challenges with access to skilled deliveries but it has also suffered from challenges with the health system. There has also been renewed interest in community health services.

Devolution in Kenya brings opportunities for equity

As recently highlighted by RESYST researchers, Kenya is undergoing meaningful change through devolution, which is driven from the public rather than the centre.  Responsibility for health coordination and management of healthcare now lies at county level.   The introduction of equalization funds for marginalised counties demonstrates commitment to reducing inequalities between counties.  County decision makers have the opportunity to identify context specific health priorities, giving them the freedom to provide more context appropriate and equitable services, thereby allowing them to increase health coverage and build a more resilient health system.  Not only this, but there is potentially greater opportunity for collaboration with other ministries at county level, enabling not only provision of health services but engagement and empowerment of communities in tacking underlying social determinants.  In light of Ebola’s impact in Guinea, Liberia and Sierra Leone there is a need to explore and understand priority setting processes within counties following devolution in Kenya, to measure and track equity indicators and health coverage and to understand strategies for strengthening the six WHO components for health systems at county level, as highlighted in ‘A wake up call’ report.  

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By John Dusabe, Daniel G. Datiko, Jarso Tulu and Sally Theobald

Every year we celebrate International Women’s Day (IWD) on 8^th March. IWD draws our attention to women’s challenges and contributions in our society in past times, today and in the future. Women’s contribution to health includes basic science and discovery, management and treatment of diseases as well as promotion and improvement of health care internationally, nationally and within communities and households. Recognition only is not enough. There’s still work to be done - such as institutional gender mainstreaming to ensure health programmes are responsive to the needs of women, men, boys and girls; that information is used appropriately to meet this goal and that the gendered needs and requirements of all health workers are met.  In 2012, the World Development Report prioritised Gender Equality and Development and highlighted progress made in different countries; taking stock and reflecting on progress and evaluating the impact of gender-focused initiatives. For example the report highlighted success in initiatives that promote productive resources for women, such as giving land titles to women in Ethiopia.

Ethiopia has also spearheaded recognition of women’s contribution to the health system through innovative community approaches. The government launched the Health Extension Programme (HEP) aimed at the provision of primary healthcare. The HEP engages health extension workers (HEWs) who are exclusively women. These women are trained, certified and employed through government systems to provide health services including maternal and child health, TB, HIV, malaria, immunization, nutrition hygiene and sanitation as well as health education. Within 5 years of the HEP launch there were more than 30,000 HEWs providing health services nationwide, and provision is in place for additional support if HEWs go on maternity leave. HEWs devote 70% of their time to making house-to-house visits providing a range of services. For example in tuberculosis their roles include early identification of TB cases, provision of DOT, linkage to facility-based services and referral while in maternal and child health (MCH) they provide ANC, and support women to give birth in health facilities. Women HEWs come from, and are committed to, improving the health of the communities they serve. Under the health centre and health post links, their contribution has expanded and functions beyond the primary health care unit as the lowest tier of the health system. REACH Ethiopia have been working with LSTM to take forward research in partnership with the HEP and HEWs to promote vulnerable and rural women (and men) to access health care. For example the TB REACH project worked with HEWs to bring TB diagnosis to the community level, significantly increasing the number of women diagnosed with TB (see Yassin et al 2013). REACHOUT in Ethiopia uses quality improvement cycles to work with women HEWs and others to improve access to a high quality service for pregnant women.

The existing health information management system (HMIS) that support the HEP depends on paper based reports, transported from health posts to health centers, districts, zones and finally to the region. This system can lead to delays, incompleteness or inconsistency of data,  inadequate data collection tools and monitoring can lead to poor documentation and under-utilization of existing data hindering prompt and responsive action. Through IDRC’s Governance for Equity Health Systems (GEHS) funding, an e-Health project is being implemented in Southern Ethiopia to support female HEWs, their supervisors and zonal health department to improve this HMIS system for HEP through mHealth resources. Back in 2010 the Ethiopian Federal Ministry of Health (FMOH) designed an m-Health strategic framework to improve health management information system to provide better health service. This IDRC-funded e-Health system is embedded within that strategic framework, to provide an important facilitative policy-backed innovation with electronic data systems. The project involves a 7-step process including baseline evaluation, e-Health system design, HEW training, e-Health system implementation, TB and MCH indicator review, revision of the e-Health system and final evaluation.

HEWs, their supervisors, district and zonal health officials have been involved in the design of research tools and development of the e-Health system. Local developers have specifically been involved in the design of the e-Health system to boost HMIS linkages and interoperability as well as capacity building. Indicators from that system will serve to improve HEWs’ TB and MCH reporting from village to health post, district, zonal, regional and FMOH levels.

What we want to achieve for gender equality is “to end discrimination against women in all forms” as adopted by the Convention on Elimination of All Forms of Discrimination against Women (CEDAW) in 1979. Our mHealth project will contribute to this by supporting vulnerable individual’s and household’s access to services; and empowering women HEW with the information and support they need to better provide integrated services to their communities and feed information and priorities from their communities into decision making processes. Our focus on introducing a robust and responsive e-health process for individuals will support HEWs with the robust usable local health data to better meet the different dimensions of health needs of women and men laid out in the Women and Gender Equity Knowledge Network Report. The official UN theme for this year’s International Women’s Day is “Empowering Women – Empowering Humanity: Picture it!”. Working with an all-women HEW team supports this theme and provides important driver for the transformative post-2015 agenda. The Ethiopia Federal Ministry of Health echoes this: in the recent mHealth Conference at University College London, Dr. Kesetebirhan Admasu the Minister of Health said that the Ministry is committed to supporting HEWs to reach communities and demographics never reached before. Reaching the previously unreached is one of the general goals of mHealth. Recently, in a blog hosted by Research in Gender and Ethics (RinGS), Linda Waldman and Marion Stevens argued that mhealth could overcome barriers of patient privacy and confidentiality, limited availability of medical equipment and challenges of health information sharing and dissemination. These are key factors for reaching health services in the underserved communities.

Lastly women are not the only individuals needed to promote empowerment of women and societies. We need men to get on board too! Indeed, for us to attain full human potential it is important that men work alongside women to ensure access to sexual and reproductive health services and protection against gender-based violence. On this International Women’s Day men’s engagement in gender equality is needed now more than ever.

Photo of Fetlework Gezahgn, Health Extension Worker at Remeda Health Post, Sidama Health Zone Ethiopia

Recent news

• Experiência como primeiro autor de um artigo – Lições aprendidas e desafios, 14 January 2015
• What I learned through the process of being a first author on a REACHOUT paper, 9 January 2015

By Sozinho Ndima

Foi uma experiência incrível e positiva escrever um artigo no qual sou o primeiro autor. Me fez pensar que seja qual for o nível não é fácil escrever um artigo do princípio até ao fim sem o apoio de outras pessoas. Foi muito interessante a forma como interagi com os co-autores, o seu cometimento e feedback sempre a tempo tornaram uma realidade este artigo, desde o início até a sua submissão. Estes aspectos eu considero pontos positivos deste processo, especialmente o apoio directo que tive durante o encontro do consórcio em Awassa, Etiópia. Tive a oportunidade de repensar o artigo passo a passo.

Sendo a primeira vez que escrevo como primeiro autor é difícil indicar pontos negativos mas sim pensar em alguns desafios:

• Conciliar vários comentários de modo a ter um artigo que espelha muito bem os meus objectivos e que incorpore melhor as ideias dos diferentes autores;
• Pensar em uma forma específica de escrever para uma determinada revista/jornal (seguimento de requisitos de um jornal;
• Pensar e escrever em Inglês não é um processo simples para quem é fluente em uma outra língua;
• Dar maior atenção ao artigo tendo em consideração que existem outras actividades também prioritárias.
• Fazer uma boa discussão e uma boa metodologia (penso que continuarei precisando de apoio, sobretudo no que diz respeito a fazer uma metodologia relacionada à Saúde Pública ou pesquisa em Saúde).

Como me referi antes, o mais importante foi o apoio dedicado é que deu este resultado e espero (como todos) que tenhamos sucessos nos passos subsequentes e que este processo tenha sido uma experiência na área de escrita científica.

Recent news

• What I learned through the process of being a first author on a REACHOUT paper, 9 January 2015
• A REACHOUT update from Ethiopia, 8 December 2014
• A REACHOUT update from Indonesia, 4 December 2014

By Kingsley Rex Chikaphupha

I am not entirely new to the process of writing articles for publication - this was my second time as a first author and the fourth time as a co-author. However, the mentorship that I have undergone through the approach taken by the REACHOUT has left a memorable mark on how I think about writing.

During the scientific writing workshops at the REACHOUT Consortium meetings in Maputo and paper surgery sessions in Ethiopia I learned tips like "make every sentence count". Colleagues supported the process by peer reviewing my work and asking critical questions as the paper evolved.

Harnessing reviewers’ comments

There's that silent debate on how an issue, paragraph or chapter should be presented. One paragraph of my paper was changed more than once by three different reviewers/co-authors. Each time a draft was revised each reviewer had a different perspective with regards to how it should read.

At one point it occurred to me - should I just ignore all this and maintain my original presentation on this issue? That's when I learnt the biggest lesson of the whole process! As the first author you are at liberty to agree or disagree with what reviewers are suggesting. However that shouldn't be done under the influence of selfishness rather should be guided by evidence from either your data or literature.

Scientific writing should contribute to building up of a body of knowledge.So as a first author I learnt that this writing was not about me and what I feel, rather it was all about the target audience. This was where I look back and say peer reviews are really motivating and they help shape and sharpen your piece of writing that makes it rigorous and authentic in terms of the acceptability of the conceptual underpinning of your paper.

Positive feedback is motivating!

It was so inspiring to know that reviewers simply wanted the best out of me so that I may be just as good as they are! So juggling multiple reviewer comments and reaching a consensus of a best piece of writing or presentation was a huge learning point for me.

At my level, getting feedback like, "This is excellent work King" on my very first draft by almost all my co-authors and colleagues was also a huge motivation to keep the momentum. Their comments and inputs were so refreshing. Feedback gave me the sense of being welcomed and accepted in the academia as I wrote to, and with, people of high calibre, and that I respect. It was a ‘wow moment’ for me!

An opportunity for reflection

Although am yet to address reviewer comments from the journal that I have submitted to, the reviews that I got from my co-authors and few external reviewers sharpened my writing skills. They also helped me understand my dataset in a different light. As a first author, the peer review process connected me more to the data and the learning from that is just huge. I am motivated to write more papers as the interactions I had with the dataset showed me that there are other perspectives that the data presents. I have learnt that scientific writing exposes the writer to more learning, critical thinking and analysis that is just so exciting and interesting to share.

I am thrilled and motivated that I can contribute to the body of knowledge in the scientific world and be accepted as one of the social sciences authors of this generation. Of course the learning process continues! 

Recent news

• A REACHOUT update from Ethiopia, 8 December 2014
• A REACHOUT update from Indonesia, 4 December 2014
• A REACHOUT update from Kenya, 2 December 2014

By Kate Hawkins, 8 December 2014

Main messages:

• The Quality improvement cycle will focus on community engagement, supervision and referral
• This builds on the strengths of the existing system at multiple levels
• REACHOUT research provide strategies to monitor and improve supervision policy and practice

REACH Ethiopia are working to improve the performance of close-to-community health programmes in Ethiopia (Health Extension Workers, or HEWs) through their first quality improvement (QI) cycle. Their overall focus is on improving supervision structures for HEWs and the community members engaged in work on health that they oversee, the Health Development Army (HDA).

There are a number of existing community engagement structures within the Ethiopian health system which the QI cycle will build on and seek to strengthen.

The Health Development Army facilitate a Pregnant Women’s Forum which all pregnant women in a Kebele should attend, as per government guidelines. In the Forum the family health card and Information, Education and Communications (IEC) materials are used to prompt discussion on safety and health during pregnancy and childbirth. These stress the importance of facility delivery and the danger signs to look out for during pregnancy and birth. This discussion is led by the HEWs and midwives and every woman has to prepare a birth and complication readiness plan.

The HDA leaders meet once a month. At these meetings religious leaders and other influential people in the community feedback on any health service issues or barriers that have arisen. They also play a role in identifying new pregnancies in their area and linking newly pregnant women to the HEWs. The HDA report to their HEWs – sometimes orally and sometimes in a written document if literacy is not an issue.

All HEWs are trained on Focussed ANC and on referral to the health centre (e.g. for HIV testing). Every woman should know the danger signs and the expected date of delivery. They use a standard checklist while providing ANC to pregnant mothers.

HEWs supervisors (the health centre focal people) and HEWs have been trained on supervision curriculum, maternal health, community engagement and coordination. Existing training materials have been adapted and used for further training. Trainers were drawn from Regional Health Bureaus, the Zonal Health Department, and the Woreda Health Office. Catchment Health Centre group supervision will be implemented and a group supervision guide will be provided for this. Individual supervision will be carried out every month using the checklist by the HEWs supervisors.

As part of group supervision referral sheets have been adapted and referral registers have been developed to support future tracking. A coordination meeting will be held with maternal health staff in hospitals and health centres to assess progress. Participant observation of the use of the ANC checklist has already occurred. This helped the team to understand how the ANC care was being provided before the training. They will do in-depth referral interviews and observation of community meetings as the QI cycle rolls out. The project is coordinated with the District Health Office.

Recent news

• A REACHOUT update from Indonesia, 4 December 2014
• A REACHOUT update from Kenya, 2 December 2014
• Three positive outcomes in one: The REACHOUT external review, 01 December 2014

By Kate Hawkins, 4 December 2014

Main messages

• The first Quality Improvement (QI) cycle will focus on strengthening the partnership between Village Midwives, Kaders, and Traditional Birth Attendants (TBAs)
• The intended outcome of this work is increased referrals to health facility for delivery
• Through the health promotion intervention the communication and advocacy skills of Village Midwives, Kaders and TBAs will be strengthened
• There will be a focus on community engagement including male involvement
• Interdisciplinary and multi-methods research will be applied to measure the outcomes of the QI cycle

The QI cycle in Indonesia is focussed on health promotion, partnership, and community engagement. This will be supported by interventions to strengthen the supervision of community health workers. Village Midwives in four villages in Cianjur (more than 200 community health workers) will be trained in health promotion and provided with counselling cards that help them explain the danger signs in pregnancy and childbirth and importance of childbirth in health facilities. In health promotion we will train village midwives and kaders in 4 villages in Cianjur. This is more than 200 CHWs. The Village Midwives and kaders will use home visits and appointments in the community intergrated health posts (Posyandu) to talk about this information. This also explains when referral should happen.

The second intervention is focused on partnership and community intervention. Close-to-community providers will be encouraged to stimulate broader stakeholder engagement on the topic of maternal health. Community forums only happen about once a year in some of the settings REACHOUT are working in. This means the barriers and the issues don’t get discussed. The team will encourage stakeholders to come together more often in partnership with village leaders.

The midwife coordinators – who oversee the village midwives – will be provided training related to supportive supervision.

Various methods will be employed to measure the impact of the intervention. Village Midwives will be observed at the Posyandu. The team will also conduct exit interviews with mothers who attended sessions to get a sense of their knowledge the delivery of information. To measure the partnership and community engagement element of the work the team will track the number of women who go to the facility for delivery as a result of advice from the Village Midwives, Kaders and TBAs and women’s perceptions of the importance of institutional delivery. They will track the number of home deliveries to see whether the TBA or Village Midwives are in attendance. For the community engagement strand of work we will monitor the number of meetings in community. To measure the effects of supportive supervision training the close-to-community providers will be asked to complete a motivation questionnaire. For health promotion the team will use numbers of people who deliver in a facility and will track the perceptions of women on the importance of delivering in a health facility. Whilst there is a policy on the relationship between the TBA and Village Midwife REACHOUT are innovating by bringing the Kaders in to this engagement. To stimulate support at the community level they will encourage more frequent community forums which are currently lacking. The team hope to improve the Village Midwife and Kader negotiation and advocacy skills.

One challenge is that there is still a great deal of trust in TBAs and preference for them even though they are forbidden from conducting deliveries at home by government policy. The REACHOUT team also believe that it is important to engage male partners as they are not very involved in decision making around delivery. This will require support from health and non-health stakeholders.

Recent news

• A REACHOUT update from Kenya, 2 December 2014
• Three positive outcomes in one: The REACHOUT external review, 01 December 2014
• Community dialogues to support maternal health: lessons from the world’s newest nation, 26 November 2014

Kate Hawkins, 2 December 2014

Main messages

• There is an urgent need for enhanced supervision among community-level staff in Kenya
• Formal policies for supervision of CHWs and CHEWS don’t currently exist
• By testing group supervision, peer supervision, and other tools LVCT Health hope to support the Government in strengthening the Community Health Strategy
• LVCT Health will work with NGO partners to adapt best practice
• They may face challenges due to health system devolution and the withdrawal of funding for community health worker programmes from some donors

The REACHOUT team will be looking at supervision and the role of the Community Health Committees in monitoring. They are going to be giving supportive supervision training to the Community Health Workers (CHWs) peer supervisors, the Community Health Extension Workers (CHEWs) and the people who manage the CHEWs in the County and sub-County Health Management Teams. The CHWs work in a Health Unit but there are no supervisory tools in the government programme. LVCT Health are planning to map the tools used by other non-governmental, vertical programmes and adapt them and hope the government will take them up.

To monitor the intervention they will collect the referral reports from facilities on service utilisation. They will look at data collected by CHWs in the Community Based Health Information System. Notes from supervisory meetings will be analysed. They have a programme assessment tool and will use a motivation questionnaire that will also support data collection.

Stakeholder engagement has been key to the process. The team have involved the Government from the very beginning of the research process and have provided them with the findings from the context analysis. They have linked with monitoring and evaluation and standards staff in Government too and will ask them to review the tools that will be used in the study. A staff member from the Community Health Service is part of the research team.

The team have an opportunity to influence change in Kenya. There is a demand for supervision tools as none exist in Government programmes at present. However, challenges remain, funders appear to be pulling out of community health services as a lack of documentation means that they cannot see the impact of them. 

Recent news

• Three positive outcomes in one: The REACHOUT external review, 01 December 2014
• Community dialogues to support maternal health: lessons from the world’s newest nation, 26 November 2014
• A REACHOUT update from Malawi, 25 November 2014

By Miriam Taegtmeyer, 1 December 2014

I am feeling good about the recent REACHOUT external review undertaken by the European Commission so I thought I would share some reflections on what went well and what more needs to happen. 

When we first heard that we would have an external review we were very uncertain exactly what this would involve and it was a bit nerve racking preparing for it. This review came after our first annual report and was intended to be a more in-depth exploration of our research, management and progress

External reviews by the European Commission are rare events, reserved for complex projects and generally led by senior experts in the field.  We really didn’t know what to expect so asked around only to discover that there has never been one within a Liverpool School of Tropical Medicine EC-funded project. 

The review was an opportunity to share some of the hard work we have been doing and to get feedback. We prepared proactively and set up a pre-review meeting to share a brief presentation to take the reviewer through our project aims and objectives, our partners, our work, and our successes and challenges to date. The pre-review Skype was helpful in guiding us on what the reviewer was thinking and what the focus of the face to face meeting in Brussels would be, as well as discussing the actual process the reviewer would go through. We also discovered that external reviewers have a standard template to fill out and this was in fact a publically available document on the European Commission website. You can find it here if you ever need it.

The reviewer only had access to the European Commission reports and deliverables and publically available documents. So we decided to make our intranet fully available to the reviewer and created a folder for him where we uploaded copies of key documents that provided evidence for us meeting each project milestone.  

The process itself was of exceptional rigour and we were held to high standards. Our documents were checked and cross referenced in detail, our progress examined and big picture questions asked. It was a privilege to have someone with so much interest and experience in community health workers going through our work and making helpful suggestions.

The review results were ultimately very positive, with some encouraging comments made about our progress to date and our likely outcomes as a consortium. It also threw up some big questions for us and has led to reflection in the team and with our Expert Review Group. What is the legacy of REACHOUT’s capacity development approach going to be and how will progress be measured? Are we engaging an appropriate level of policy maker and how will we know what impact our research uptake activities will have? Above all it has led us as a team to review our theory of change and associated indicators as well as instigating a more integrated approach to our monitoring and evaluation.

We were given an opportunity to formally respond to the reviewer’s comments, which we did with a one-pager, designed to update the European Commission on the steps we were taking to address any issues. The only response we then had from the European Commission was a request for copies of updated strategy documents once they were finalised, and payment of our first period’s financial claims.

In hindsight, while very time consuming and anxiety inducing, we feel the process was a positive one for REACHOUT. It allowed us to bask a little in our early success, to reflect on areas in which we could improve our approach, and to educate our donors on the intricacies of our project design and implementation – three positive outcomes in one!

Recent news

• Community dialogues to support maternal health: lessons from the world’s newest nation, 26 November 2014
• A REACHOUT update from Malawi, 25 November 2014
• Reflections on a visit to the Pregnant Women's Forum in Howoleso Kebele, Southern Ethiopia, 21 November 2014

By Sally Theobald, 26 November 2014

We have recently been in Hawassa, Southern Ethiopia. The visit was brilliantly hosted by our REACHOUT partner REACH Ethiopia.

Two of our colleagues, Korrie de Koning from the Royal Tropical Institute  (KIT), The Netherlands and Kingsley Chikaphupha from REACH Trust Malawi, came straight to Hawassa from South Sudan, where they have been working on the community participation component of the ‘SHARP’ programme in northern  Bahr el Ghalzal.

The SHARP programme is funded by the Dutch Government and is a collaboration of the South Sudanese Ministry of Health, the Royal Tropical Institute, IMC, Healthnet TPO and Cordaid. Community engagement is an area of action in our REACHOUT Quality Improvement Cycles which aim to improve close to community services.

As part of our capacity development activities Korrie and Kingsley shared their experiences on community engagement in maternal health in the world’s newest country, South Sudan. 

The context

At 2,054 maternal deaths per 100,000 live births South Sudan has the highest maternal mortality in the world.

At marriage, women’s families are paid a bride price, which in Northern Bahr el Ghazal (NBeG), is paid in cows. Girls are seen as an investment and looked after well until they are married off - often in early adolescence. South Sudan is in transition. With years of conflict and the construction of a new nation, existing gender norms which expect women to bear many children have been intensified in order ‘to replace the ones that were lost’. Gender and societal norms are also in transition. Elders complain that the young no longer listen to and respect their elders, couples do not keep to the traditional three years birth spacing, and marry younger and younger. Parents worry that their girl may get pregnant before marriage so they marry her off early, especially if she is not in school. Girls and boys have very limited access to sex education or contraceptives. These factors can lead to early pregnancy.

Using community dialogue to enable reflection

KIT developed a curriculum for the training of community facilitators to support dialogue and reflection on norms and values shaping maternal mortality and health service access and use. The curriculum was shaped by various sources, but drew substantially on the GTZ developed generational dialogue. The curriculum was further adapted with input from the Community District Health Department in Wau, WBeG and Aweil North in NBeG, REACH Trust, International Medical Corps, and Healthnet TPO. Training of facilitators focussed on dialogue between older and younger women and men, comparing social and gender norms and practices between present and past, sharing knowledge on maternal health and discussing what needs to be changed for maternal health to improve.

Groups used drawings, statements and proverbs to explore the relationships between communities by gender and generation. For some women, this was their first experience of holding a pen or pencil but they were skilled in drawing images of maternal health decisions, dilemmas and outcomes throughout their life cycle. The ‘but why’ technique was used to probe and understand the rationale behind different cultural norms, their meanings and whether they were seen as fair.

Kingsley facilitated the men’s groups and explained at first there was complete refusal to even entertain the possibility of a discussion on contraception but use of the 'but why' technique enabled discussion on the impact of multiple births on (especially young) women and child survival rates. This led to some shifts in viewpoints. Drama was also used, and women acted out what it is like to have obstetric fistula, and how women with urinary or faecal incontinence were treated within their communities. Following work in women and men only groups, the community fed back their ideas and experiences to each other, and for many women (who are very powerful within their own domains) this was their first experience of speaking publicly in front of men. 

Community dialogues and commitments to change

Through the facilitated discussions between genders and generations statements for change were negotiated and agreed. Here are some examples:

• “If a man with more than one wife is not looking after one of his wives and their children, the wife has the possibility to refuse to produce any more children without having to pay back the cows/bride price and also has the right to not be beaten.”
•  “We don’t want daughters to marry or be pregnant before 18 years old and we in our family will do all we can –  we want to pledge this to our family and community.”
•  “Married women should be allowed to use contraception and have three year birth spacing.” 

This is an inspiring example of how community engagement can shift gender and societal norms and shows great facilitation skills from Korrie and Kingsley. Facilitators are being trained at local level and the approach will be rolled out and hopefully continue to challenge and change views and practices that undermine women’s maternal health. 

Recent news

• A REACHOUT update from Malawi, 25 November 2014
• Reflections on a visit to the Pregnant Women's Forum in Howoleso Kebele, Southern Ethiopia, 21 November 2014
• REACH Ethiopia win the Kochon Award for their services to TB, 29 October 2014

Kate Hawkins, 25 November 2014

Main messages

• In Malawi the Quality Improvement Cycle will focus on strengthening supervision
• The two districts we are working in currently use two different models of supervision: the cluster system and the block system
• A three-prong checklist will be used to evaluate supervision
• REACH Trust will conduct an economic evaluation based on the assumption that strengthened supervision will increase motivation, which will increase referral
• Improving supervision could lead to an increase in Senior Health Surveillance Assistants adopting the model

REACHOUT countries are beginning their Quality Improvement Cycles. This update provides a little more information on the type of issues REACH Trust in Malawi will be covering.

As agreed in a meeting with key stakeholders in Malawi, REACH Trust will be working on maternal, neonatal and child health. The focus of the Quality Improvement Cycle is on strengthening supervision in order to improve the performance of Health Surveillance Assistants.

To do this REACH Trust will adapt the supervision manual prepared by the REACHOUT Consortium and create a checklist for supervision. Training will be given to supervisors at the district, cluster and health facility levels. Each district has chosen eight health facilities for the Quality Improvement Cycles. The team have developed a 30 point supervision checklist based on community based maternal and newborn health, integrated community case management and the core functions of Health Surveillance Assistants. The Health Surveillance Assistants will have monthly group supervision meetings and senior Health Surveillance Assistants and Environmental Health Officers will have quarterly supervision meetings at district level.

Health Surveillance Assistants report to health facilities, usually health centres. The number of Health Surveillance Assistants per health facility can range from five to forty. In block supervision, practiced in Salima district, the Health Surveillance Assistants are split into groups of four and they have meetings which are documented and this is communicated to their supervisor. It is a form of peer supervision. The supervisor based at a health centre consolidates all information from the blocks and sends to the district and the individual reports are just used as back up. In cluster supervision followed in Mchinji district, the Assistant Environmental Health Officer is in charge of a cluster, which is a combination of two to three or four health centres. .

As part of the Quality Improvement Cycles, research is being conducted and several tools are in use. Besides a motivation questionnaire, a motivation topic guide has been put together in order to do in-depth interviews with at least six Health Surveillance Assistants in each of the districts. The referral topic guide will be used with Health Surveillance Assistants who run village clinics and women with children between 0 and 5 years of age who were once referred by particular Health Surveillance Assistants. REACH Trust have also developed a topic guide for focus group discussions with community members. This analysis will be augmented by data gathered through a programme assessment tool.

REACH Trust will also do an economic evaluation of their intervention. Referral will be one of the areas that they will base this on. This is underpinned by the assumption that improved supervision supports motivation, which contributes to better Health Surveillance Assistant performance which will be reflected through improved referral.

There have been a variety of meetings with stakeholders. In Mchinji District they met with the District Executive Committee’s Sub-Committee on Health – which is important in the context of devolution. At the meeting different people presented their projects and got feedback. It means that every NGO working on health in the district knows all the background to the REACHOUT project and what the research plans are. REACH Trust held another meeting in Salima District with the District Health Officer where the project was discussed further. The most recent meeting brought together stakeholders from the two intervention districts and had senior participants from the Preventive Health Department of the Ministry of Health. At this meeting they revised the supervision manual based on feedback from the stakeholders and came up with a framework for the construction of the supervision checklist.

One challenge that the team face is that the Ministry of Health have conducted interviews to appoint Senior Health Surveillance Assistants to officially be supervisors for Health Surveillance Assistants. This has implications for the Quality Improvement Cycle because the team are going to train supervisors who may not be the ones successful in the interviews. It is hoped that when the Senior Health Surveillance Assistant position gets brought in officially, there will be 50 Senior Health Surveillance Assistants per district across the country

Recent news

• Reflections on a visit to the Pregnant Women's Forum in Howoleso Kebele, Southern Ethiopia, 21 November 2014
• REACH Ethiopia win the Kochon Award for their services to TB, 29 October 2014
• REACHOUT honourable mention in photo competition, 20 October 2014

Beth Hollihead, 21 November 2014

Last week, during a somewhat intense and very busy REACHOUT consortium meeting hosted in Hawassa, Ethiopia, we were lucky enough to have the opportunity to have a field visit to a district health office, and a local health post, operating under the Ethiopia Health Extension Worker (HEW) programme. As a “non-technical” project manager, in other words primarily responsible for the administrative, regulatory and financial management of our global research consortium, this was a first for me and a trip that I found fascinating and inspiring in equal measure.

Our visit began after lunch, with me in the front seat of a minibus. I’d been unwell earlier in the week and I think the team felt I should be both comfortable and ideally at a bit of a distance! The arrangement afforded me a great view, and dominion over the radio, so I was pretty happy. We drove south, on a road which eventually leads to Kenya, much to the enjoyment of our Kenyan colleagues. After a brief stop at the district health centre where we were welcomed by the district supervisor we eventually reached our target health post (chosen by the team in Ethiopia), in Howoleso Kebele (village). Once past the crowd of over-excited school children, most proudly dressed in the Ethiopia national football kit, we entered a neat, fenced off compound and immediately saw a group of 15-20 women, in various stages of pregnancy, seated on cushions on a shady patch of grass. This was the bi-weekly Pregnant Women's Forum, and we were lucky to have chosen their meeting day for our visit. Ably assisted by REACH Ethiopia team, Miriam Taegtmeyer said a few formal words of thanks and we were then free to wander and talk to people as we liked (interpreters permitting!)

First stop was the main room of the health post (which was a single story, 3 or 4 room building set up some high concrete steps). Here is the room where Yegnanesh Teshome does her work. Yegnanesh is one of two HEWs based in this kebele. They provide a package of preventative, curative and informative healthcare for the c.8000 men, women and children of the kebele. Yegnanesh is rightly proud of the service she provides, for which she received an original 12 months training.

She told us she enjoys family planning the most among her duties, and showed us chart after chart on her walls documenting her activities and successes of the year to date. Our team now turned inquisitors, with colleagues from Malawi and Kenya in particular gleaning every ounce of information about the practicalities, responsibilities and logistics of her role. We had to almost physically drag them away to give her a moment’s peace and then they started again in the garden! It actually said more for the impressiveness of the HEW Programme than seeing the health post itself, to see how researchers from other countries were astounded at the success and smooth running of this post.

When the questioning got too technical for me, I walked outside for some air and a look around the compound. The forum had now finished, but several of the women had stayed behind: to chat, because they had ante-natal visits booked or just for a few more minutes sitting down. I took the opportunity to speak to the women (with Nega Tekiyie of REACH Ethiopia as my interpreter) and ask about the forum, and what made them come. The next 30 minutes were the highlight of my entire week as we chatted, like mums do, about the worries of pregnancy, of how to look after a newborn, of what to eat and what not to eat and what to expect when you deliver. These women were all expecting for the second, third or even fifth time, and yet they all felt they had something valuable to learn from the forum, and they unanimously agreed that they would be coming for their next baby too (except the woman who was expecting number 5 – she hopes NOT to return, as she feels that 5 is the perfect number of children). Their love of education was strongly felt, as was their enjoyment of a little time away from the family, although it was commented that this is not always easy. What a pleasure it was to chat so naturally, giggling about our kids. Eventually we sat and looked through the photo gallery of my phone, laughing at silly pictures of my son. Nega then took some pictures of us a group, which we showed to the women and promised to send some prints back – one for each woman. I don’t think I will forget Howoleso, or the women who meet there to learn about looking after themselves and their family. What a way to learn more of the Ethiopian HEW programme, and what a way connect to the region. A precious memory for me indeed.

Recent news

• REACH Ethiopia win the Kochon Award for their services to TB, 29 October 2014
• REACHOUT honourable mention in photo competition, 20 October 2014
• REACH Ethiopia nominated for the 2014 Kochon Prize, 9 October 2014

Kate Hawkins, 29 October 2014

Congratulations to our partner REACH Ethiopia on winning the Stop TB Partnership's Kochon Prize.The team are a small locally registered entity who successfully implemented a TB REACH project in the Sidama zone of Ethiopia.

Stop TB Partnership report:

REACH Ethiopia made a concerted effort to engage community members, councils, other stakeholders, TB programmes, former TB patients and religious and community leaders to increase awareness about the disease as well as expanding availability of TB services at the community level. TB case finding nearly doubled in the first nine months of the initiative. Focussing on the elderly and disabled, women and children, the project has not only brought the three million people living in Sidama Zone within the healthcare system, but the team turned TB into a disease that can be talked about out loud.

Daniel Datiko says:

Our innovative community-based approach has demonstrated that making TB diagnostics and treatment accessible at the community level increases the detection of cases, enhances treatment completion and reduces the stigma associated with the disease. We hope our experience will soon be replicated all over the country and beyond.

Read the full press release...

Recent news

• REACHOUT honourable mention in photo competition, 20 October 2014
• REACH Ethiopia nominated for the 2014 Kochon Prize, 9 October 2014
• Partnerships with community health workers key to resilient and responsive health systems, 7 October 2014 

Kate Hawkins, 20 October 2014

We are really proud that two of the REACHOUT partners (LVCT Health and The Eijkman Institute of Molecular Biology) were singled out for special praise in a recent photography competition which was organised by Research in Gender and Ethics (RinGs), a new cross-RPC partnership between Future Health Systems, ReBUILD and RESYST. The aim of the competition was to capture the everyday stories of the ways that gender plays out within health systems around the world. Our photos (above) were exhibited at the Global Symposium on Health Systems Research in Cape Town.

This was a great opportunity for us to demonstrate some of the work that close-to-community providers are doing in our respective settings. Raclicia Limato explains,

"The photograph shows Indonesian village health volunteers locally called “Kaders” in action. Kaders are non-salaried volunteers chosen by the village community to help the village midwife or nurse in organising the Posyandu. The Posyandu is a community integrated health post held monthly in the village to bring health services closer to the rural community.

The Posyandu functions mainly to provide preventive and health promotion services mainly to the mother and child. Typically a kader is expected to have basic literacy of school certification. They can be male or female. A five Kader, five table system with an activity per table is used to run a Posyandu. Their task is to register the women and children, which is what they are seen doing in the photograph. Other tasks they do are weighing under-five children, fill in the record book for growth monitoring, provide health and nutritional counselling and additional food supplementation. They also do home visits to check for pregnant women and inform of the Posyandu day."

The image from Kenya demonstrates how, in an effort to reach underserved and marginalised populations, LVCT counselors criss-cross the hilly and rocky Maasai land terrain to carry out HIV Home-Based Testing and Counselling (HBTC). Redemta Atieno documented this process and spoke to key stakeholders, 

"The HTC counsellor team leader Wilkista Nduko said her team is passionate about ensuring that this community is reached with HTC services. She at the same time noted that due to the location and terrain of the area, it is very hard to get to the villages.  “The counsellors have to leave very early on empty stomachs to start the journey to the villages because if we delay the sun becomes very hot and it becomes difficult to walk for many hours,” she noted.

Mr Risa Mbelati, a community member who was tested with his two wives said he was happy with the services offered.  “I am grateful to the team for coming this far to provide testing and counselling to us. I have received knowledge that would help me to stay negative and not put my family at risk.” 

LVCT’s Community HTC Programme Officer who is attached to the APHIAplus program Ken Omugah said the aim of this exercise was to achieve government’s pledge of ensuring that by 2013, 80 percent of Kenyans know their correct and current status.

He cited lack of information as a hindrance in penetrating the community. “Some people here had never even heard of testing. It is amazing that after continuous and persistent sensitization we have had over 91 percent of new testers and we had husbands agreeing to test with their wives,” he beamed."

To see the winning photograph and the shortlist of honourable mentions please visit the RinGs website.

Recent news stories

• REACH Ethiopia nominated for the 2014 Kochon Prize, 9 October 2014
• Partnerships with community health workers key to resilient and responsive health systems, 7 October 2014 
• Supporting engagement for close-to-community health systems in South Asia, 6 October 2014

By Kate Hawkins, 9 October 2014

We are very proud that the REACHOUT partners in Ethiopia have been nominated for the Kochon Prize. A prestigeous award in the field of lung health. The organisers, Stop TB Partnership, explain,

The Kochon Prize is awarded annually by Stop TB Partnership to individuals and/or organizations that have made a significant contribution to combating TB. The Kochon Prize, which is endowed by the Kochon Foundation, a non-profit foundation registered in the Republic of Korea, consists of a USD $65,000 award.

The Kochon Prize was established in 2006 in honour of the late Chairman Chong-Kun Lee, founder of the Chong Kun Dang Pharmaceutical Corporation and Kochon Foundation in Korea, who was committed throughout his career to improving access to low-cost lifesaving antibiotics and anti-TB drugs. "Kochon" was a pen name that he used.

The theme for this year focused on innovators working with TB communities to reach the three million people who are missed every year.

The 2014 prize winner will be announced and awarded on Tuesday, 28 October at the Global TB Symposium, an annual event at the 45th World Conference of the International Union Against Tuberculosis and Lung Disease. The Union Conference will be held in Barcelona this year.

We wish all of the team good luck!

Recent news

• Partnerships with community health workers key to resilient and responsive health systems, 7 October 2014 
• Supporting engagement for close-to-community health systems in South Asia, 6 October 2014
• What did we hear about community health workers at the Global Symposium on Health Systems Research?, 6 October 2014

Sally Theobald, 7 October 2014

The Health Systems Global Conference featured lots of discussion on close-to-community providers and REACHOUT had an excellent presence throughout the conference with the Thematic Working Group, the interactive panel and oral presentations. Our beautiful, bold and large posters also provided a cohesive overview of REACHOUT’s findings to date in multiple contexts. CHWs were featured in the final statement as follows:

“Community health workers can play an important linking role in enabling inclusive and representative community participation. We need to promote local institutional mechanisms that support inclusive and representative community participation in health, recognizing that the collective voice can drown out the needs of the most marginalized and vulnerable.”

Close-to-community providers and community based health systems are also arguably critical to another central thread of discussion throughout the Cape Town conference – Ebola. Ebola is fuelling mistrust between health services and communities and in some cases health services are being abandoned by both health workers and communities. The urgent need to rebuild trust between health systems and communities was highlighted in discussions on Ebola at Health Systems Global including at the panel co-hosted by USAID and ReBUILD.

CHWs have played a key role in stemming previous outbreaks of Ebola and in our ReBUILD meeting Sarah Ssali from the Department of Women and Gender Studies at Makerere University, highlighted how building trust and collaborative working relationships with different community groups and structures, particularly community health workers was critical to the swift response to the 2001 Ebola epidemic in conflict affected northern Uganda.

There appear to have been some missed opportunities here in current responses in West Africa and working in partnership with close-to-community providers to support health promotion and treatment seeking is arguably an important component of a robust and a resilient Ebola health systems response. Gender also matters, the roles of women as girls as carers within households and communities means they are especially vulnerable to infection. In Liberia it is estimated that 75% of Ebola cases are female and in Sierra Leone women have comprised 55 to 60 percent of the dead.  Within Sierra Leone the newly constituted Maternal Health Promoters are embedded in communities and have trusting relationships with women and could play an important and strategic role in spreading health promotion messages and support.

Photo courtesy of UNICEF Guinea https://www.flickr.com/photos/unicefguinea/14847049209

Latest news

• Supporting engagement for close-to-community health systems in South Asia, 6 October 2014
• What did we hear about community health workers at the Global Symposium on Health Systems Research?, 6 October 2014
• Our ‘emerging voice’ Rosalind McCollum provides an update, 29 September 2014

By Sally Theobald, 6 October 2014

The session on “Community-based health systems in South Asia” at the Health Systems Symposium was auspiciously held on the 2^nd of October - Mahatma Ghandi’s birthday. The Chair, K.Srinath Reddy from the Public Health Foundation of India, highlighted how ensuring all services are close-to-community and respond to community needs was central to Ghandi’s heart and philosophy. Presentations focused on community engagement and dialogue in health at multiple levels:

At the local level:

Bhupinder Aulakh demonstrated how aware and informed groups of women working as a collective can claim and demand improved and responsive health services within specific local contexts in Uttarakhand in India. Nadira Sultana used stakeholder analysis to understand the ways in which local elites and powerful others can dominate and shape power and development within urban slums in Dhaka, Bangladesh. She argued that it is important to recognise and engage which the social and structural factors that shape and influence power structures both within and outside the slums. This is important and challenging learning for REACHOUT, as in Bangladesh, quality improvement cycles will be undertaken in urban slums.

Within interactions between close-to-community (CTC) providers and communities:

Arima Mishra highlighted the importance of trust and team work in community health workers’ (CHWs) experiences of integrated health service delivery in India. Through an ethnographic approach she illustrated the importance of building trust and relationships through ongoing “sisterly engagement” both in and beyond health. Shreelata Rao Seshadi highlighted how gender and power interact to constrain the ability of young female CTC providers who are easily dominated by older male community members. She highlighted how CHWs in very rural Indian contexts come from the communities they serve and how in many cases they have internalised the ways in which gender asymmetries play out. Also from India, Bhupinder Aulakh highlighted how strengthening capacity of CHWs through supervision can improve social and health outcomes and promote equity.

Across and between institutions, practitioners and policy makers at the global level:

Ilias Mahmud from the James P Grant School of Public Health and BRAC Institute of Global Health presented REACHOUT’s capacity strengthening approach for CTC services with a particular focus on south-south technical assistance. He highlighted the process of matching (following identification of strengths and weaknesses) carried out across and between partners and the learning and capacity development that can be generated through immersion in diverse CTC programmes. REACHOUT partners (researchers, policy makers and practitioners) can visit and ‘immerse’ themselves in CTC programmes in other contexts to inform the Quality Improvement Cycles that they are cinducting. Following each south-south exchange, visitors and hosts are asked to reflect on what they learnt through the process and implications for quality, effective and equitable CTC programmes within their own contexts. 

Recent news

• What did we hear about community health workers at the Global Symposium on Health Systems Research?, 6 October 2014
• Our ‘emerging voice’ Rosalind McCollum provides an update, 29 September 2014
• UK International Development Select Committee report on health systems, 12 September 2014

Kate Hawkins, 6 October 2014

REACHOUT was well represented at the Global Symposium on Health Systems Research last week. We hosted panels, gave poster presentations and supported the Thematic Working Group on Supporting and Strengthening the Role of Community Health Workers in Health System Development. There was a real buzz around community health workers (CHWs) and they were featured in the final conference statement.

Panel

Maryse Kok wrote on the KIT website about our session Close-to-community (CTC) providers and health systems: what are the implementation challenges and how can we overcome them? Participants in the session noted:

“ In Thailand, there is much political commitment and the referral system has improved because of this. CTC providers should be recognized at the heart of the health system”.

 “We assume that supervision will happen without planning and paying for it. Supervisors have to feel that they are also accountable for the well-being of the clients, it cannot be solely the CTC provider to feel this burden..”

“Coordination is vital, otherwise CTC providers are lost by the number of supervisors, in addition to the high workload they already have. We need leadership.”

You can read more from Maryse here...

Thematic Working Group

We are delighted to be members of the Thematic Working group. Around 40 members gathered together on Tuesday for a meeting of the group. The meeting was introduced by Lilian Otiso and Diana Frymus, the chairs, who explained the background to the group and its aims and objectives. Much of the meeting was taken up with small group work where we discussed the research priorities which we feel the group should pursue and brainstormed potential activities for the next year.

Some of the (very preliminary) headlines are below:

Research:

• Integration and harmonisation. Need better guidance from documenting programmes
• The generation of evidence on scale up.  We have evidence at small scale, in particular programmes, on certain health issues under certain circumstances. But how can these programmes be expanded and sustained?
• What is the optimal or absolute workload for CHWs (in terms of patients/households as well as the packages of tasks that they could be expected to take on)?
• Rural and urban challenges
• Supervision, retention, salaries and stipends
• Equity – within the community and in the treatment of CHWs
• What elements of programmes should be monitored and shared?
• Community management systems
• What kind of performance and productivity are we looking at – social investment analysis?

Activities:

• Partnership with CHW Central
• Work with donors so that they can understand the issues and support integration and harmonisation in their funding decisions (possible webinar series)
• Support knowledge transmission from the community itself
• Forge more links with human resources for health initiatives
• Increase membership from low- and middle-income countries
• Explore collaboration with the other TWGs
• Database of who is in the group and their skill sets - so that we can perhaps run a help desk type function
• Each member to identify policy makers in their setting to potentially join the group to diversify the mix
• Partnership with HIFA
• Encourage a CHW stream or involvement at the next Symposium (where are the voices of CHWS?)
• Fact sheets or summaries of information on what is known and unknown on particular themes

To become member of the Thematic Working Group “Supporting and strengthening the role of Community Health Workers in health systems development” , please e-mail:faye.moody@lstmed.ac.uk

Diverse views

It is difficult to do justice to all of the sessions on CHWs at the conference. We have tried to capture some of the Tweets and photos of notable moments in the Storify below.

Rosalind McCollum, 29 September 2014

Joining the Emerging Voices for Global Health 2014 professional development programme over the last five months has provided me the opportunity to build skills online through discussion forums and preparation of presentations and posters.

Coming together with the other emerging voices this week means we have been able to get to know the ‘person behind the presentation’, to be able to discuss our research interests together, along with benefiting from training on a range of topics, learning about the South African health system though field visits and receiving peer and facilitator feedback to develop our presentations and posters for the Global Symposium on Health Systems Research. 

I have enjoyed being able to learn more about the similarities and differences within the different contexts where we work.  For example, during group discussions about knowledge translation we learnt how approaches differ vastly from one country to another, as accepted knowledge management approaches within one setting, such as working with advocacy groups and the media, may in fact have the reverse effect in a different setting by alienating key stakeholders or government stakeholders. 

As the face-to-face training part of the emerging voices programme draws to a close and we prepare to present our research at the pre-conference and at the Global Symposium on Health Systems Research I am looking forward to sharing some of REACHOUT’s research findings from the context analysis in Kenya and to continue to learn more from other researchers who are passionate about global health.

Should you be attending the Symposium in Cape Town this week, I would enjoy being able to share more in person during the poster session on 3^rd October 11:00 – 11:30am in the Conservatory.

Hope to see you there!

Recent news stories

• UK International Development Select Committee report on health systems, 12 September 2014
• Join us for a meeting of the Thematic Working Group on Community Health Workers, 11 September 2014
• Reaching out to the Department for International Development on Close-to-Community Providers, 25 August 2014

Kate Hawkins, 12 September 2014

The UK International Development Select Committee - a group of parliamentarians whose task is to monitor development policy - have included evidence from REACHOUT in their new report on health systems. We are delighted that they have turned their attention to the role of community health workers.

The report states:

65. The REACHOUT Consortium noted that "close-to-community" programmes "are increasingly being initiated and scaled up in response to the human resources for health crisis", but expressed concern at the lack of evidence on how best to support such programmes.[169] Dr Julian Lob-Levyt warned that CHWs "have been seen as magic bullets for under-funded and poor-performing health services", but that they required sophisticated integration with other services.[170] Oxfam stressed the importance of complementing CHWs with a system of referral to more expert care, a point reiterated by Angela Spilsbury of DFID.[171] 

Among other things the report recommends that more money be spent on research on health systems and that it is good value for money. They suggest:

12.  Community health workers can be an important part of a developing health system. They provide flexibility and enable programmes to be scaled-up very quickly. However, they should not be seen as an easy remedy for all health system problems, nor as a substitute for properly trained and specialist health professionals. As in other areas, DFID would benefit from sounder monitoring and a better evidence base in assessing the role to be played by community health workers in individual countries. (Paragraph 66)

Read the full report

Photo: Pippa Ranger, Innovation Advisor, DFID. Community health worker, Rebati, gives babies like Adilya, polio and other life saving vaccinations for at least the first year of their lives. Britain is working with the Government of Odisha, one of India's poorest states, and UNICEF, to save the lives of thousands of mums and babies.

Recent news stories

• Join us for a meeting of the Thematic Working Group on Community Health Workers, 11 September 2014
• Reaching out to the Department for International Development on Close-to-Community Providers, 25 August 2014
• Call for Papers! Supporting and strengthening the role of close-to-community providers, 13 August 2014

Please join us for an inaugural meeting of the Health Systems Global Thematic Working Group on Community Health Workers!

Where? The Global Symposium on Health Systems Research, Cape Town on the Roof Terrace

When? September 30, 2014 from 09.00 – 11.00

Are you involved in Community Health Worker research, policy or practice? New members welcome!

The Health Systems Global Thematic Working Group on ‘Supporting and Strengthening the Role of Community Health Workers in Health System Development’ (TWG) was formed in early 2014. In an environment of increased attention being put towards community health worker cadres, more evidence and shared learning from different contexts is needed to support the roll-out and functioning of community health worker programs.

The aims of the meeting are to:

• Provide an overview of the TWG’s goals and objectives
• Discuss actions and activities of the TWG
• Discuss priority items for Community Health Worker research
• Share what we know about Community Health Worker-focused content at this year’s Symposium.

Agenda and format:

Photo ©UNICEF Ethiopia\2013\Westerbeek https://www.flickr.com/photos/unicefethiopia/8527420637/ 

Kate Hawkins, 25 August 2014

This story was first published on the HEART blog.

• Community health workers in Mozambique are paid by development partners and not by the Government. How does this affect their integration into the broader health system?
• How can we incentivise supervisors in Malawi to support community health workers in a positive way?
• Sometimes donors’ desire to take action on particular health issues can mean that community health workers are overburdened with an ever growing portfolio of tasks. What guidance can you give donors on playing a more supportive role in programming?
• Can we produce generalizable evidence on close-to-community providers when there are such a wide variety of people playing this role in very particular settings?

These are just a sample of the questions that were posed when we met with the UK Department of International Development health advisers this week. Meeting with DFID was a great opportunity to update them on how the REACHOUT research is coming along but also to hear directly from them on the type of issues that they are dealing with.

About REACHOUT

REACHOUT is operating in six countries to try and improve the equity, efficiency, and effectiveness of close-to-community health projects in collaboration with a wide-range of stakeholders. The research is timely – community health workers are gaining increasing attention at international level and the push toward universal health coverage is encouraging different governments to explore different models of community health delivery in the light of the human resources for health crisis.

Close-to-community providers (which could be informal providers, community health workers, health extension workers) are embedded in communities, can see what happens in the home, and can link this learning and perspective to the broader health system. However they face challenges. There is a great deal of expectation placed upon them, they may have received little formal education or training and they are often under-supported by health system staff and structures and receive varying incentives.

The quality of the evidence on close-to-community providers varies. There are few studies that cut across different health issues and generate learning from different settings, few programmes that track progress over time and results from studies can be difficult to generalise across different contexts and countries. These are some of the issues that REACHOUT is attempting to overcome whilst building the capacity of health system actors to evaluate the benefits of improvements to close-to-community programmes.

Emerging issues

In our dialogue with DFID we all reflected on the challenges faced by community health workers in terms of expanding workload. For example in Mozambique there is talk of expanding the role of community health workers to cover new issues such as HIV and family planning, reflecting both Ministry of Health but also donor priorities. It is our experience that the desire to rationalise and harmonise vertical health programmes has sometimes seen an increased workload for close-to-community providers and as a result a cadre of people with only a couple of weeks training sometimes become the common delivery pathway for a whole host of interventions. This has implications for training, remuneration and supervision. Donor coordination may be important here also having a range of research to draw from, since no single study will give the definitive answer on the best approach in every setting and for every situation. The Thematic Working Group on Community Health Workers, in Health Systems Global, is one such useful avenue for creating dialogue between donors, researchers, policy makers and implementers in this area.

Challenges with supervision have arisen in many of the REACHOUT contexts. Close-to-community providers often complain that they have too little supervision or that it is focussed on fault finding. But supervisors need support too! Some of the ways of incentivising good practice include: group approaches to supervision; the celebration of good practice; interventions that try and spread innovative ways of working among supervisors across the health system. These needn’t be expensive – people value non-financial incentives as well as pay increases – but they do require buy-in from all actors. In settings like Malawi community health workers move between different programmes run by NGOs and this fragmentation of interventions may create challenges.

Producing research which is generalizable across, and useful for, a variety of settings is a challenge. There is a balance to be struck between conducting in-depth case studies and finding issues in common across different settings. In REACHOUT we are trying to overcome this challenge by testing interventions which respond to common health systems concerns – supportive supervision, effective community engagement, communication across different actors and building strong referral systems. We are just about to embark on the first of our quality improvement cycles in Mozambique, Ethiopia, Indonesia, Bangladesh, Malawi, and Kenya. We will be sharing lessons on what works well and some of the difficulties we encounter as we go.

Photo Credit

A newly qualified Community Health Assistant meets with Lynne Featherstone

International Development Minister Lynne Featherstone meets with a newly qualified Community Health Assistant and travels with her to a household in a rural location. The assistant shows the Minister her bike, provided by the Ministry of Health in Zambia, which she uses to visit rural families in Monze, Southern Province. UK aid is training a new cadre of 300 Community Health Assistants to deliver health services in rural areas.

Photo courtesy of Emily Travis/UK Department for International Development https://www.flickr.com/photos/dfid/8227932932

Recent news stories

• Call for Papers! Supporting and strengthening the role of close-to-community providers, 13 August 2014
• Building research relationships in Njiru and Kasarani Sub-Counties (Kenya), 8 August 2014
• Ethics and Gender: reflections from the Global Health Bioethics Network Summer School in Malawi, 18 July 2014

Kate Hawkins, 13 August 2014

Human Resources for Health in collaboration with the Thematic Working Group on Supporting and Strengthening the Role of Community Health Workers in Health System Development and REACHOUT is pleased to invite you to submit a manuscript to a new thematic series entitled “Supporting and strengthening the role of close-to-community (CTC) providers for health system development.”

CTC providers are health workers who carry out promotional, preventive and/or curative health services and who are often the first point of contact at community level in countries in the global south. CTC providers usually have at least a minimum level of training in the context of the intervention that they carry out and include a broad variety of health workers, including community health workers (CHWs) and auxiliary health workers. CTC providers are strategically placed as the interface between health systems and the communities they serve. National and international decision-makers are once again turning to (CTC) services in order to strengthen health systems in the context of the momentum generated by strategies to support universal access, delivery of the Millennium Development Goals (MDGs) and the post-MDG agenda. However there are a number of flaws in current systems that need to be better understood. We are at a critical stage in the development of CTC programming and policy which requires the creation and communication of new knowledge to ensure the safety, sustainability, quality and accessibility of services, and their links with both the broader health system and the communities that CTC’s serve.

The series invites papers on a range of topics on close to community providers for health systems development, including, but not limited to, the following:

• Conceptualising the range of CTC providers in different contexts
• Methods and tools for analysing CTC programmes
• Cost effectiveness of CTC programmes
• Challenges and opportunities CTC providers face in reaching and supporting marginalised groups
• Diverse community perspectives and ownership of CTC programmes
• Opportunities for CTC providers to act as champions for social change
• The interface between health systems and CTC programmes
• Strategies to motivate, retain and sustain CTC providers
• Integrating vertical programmes using CTC providers within national programmes

The deadline for submitting papers is 24th Nov 2014

Recent news stories

• Building research relationships in Njiru and Kasarani Sub-Counties (Kenya)
• Ethics and Gender: reflections from the Global Health Bioethics Network Summer School in Malawi, 18 July 2014
• On maternal health, future First Lady has her work cut out for her, 17 July 2014

Maryline Mireku, 08 August 2014

Conducting research is a bit like a ‘dating relationship’ between a researcher and the community. When two people are dating they get to know each other better, they share experiences, the relationship becomes two-way such that whatever either of the party does has an effect on the other party and will affect subsequent relationships. What happens when it is time to withdraw from the community? How do you avoid creating disappointment and resentment? How do you avoid being the ‘bad date’? These are some of the issues we have been dealing with in the first phase of the REACHOUT context analysis of community health work in Kenya.

Participation and stakeholder engagement has been central to the research process

In order to effectively get good feedback from participants it is advisable for a researcher to create rapport with study participants. Researchers develop field protocols which describe how they will conduct community entry and exit. Having a community entry plan is imperative for all researchers because it is the only way one will gain access to research participants is by mobilizing communities for research acceptance. LVCT Health recognizes the importance of discussing research not only with those who can influence policy but also to everyone involved and soliciting people’s inputs to shape the process. The District Health Management Team (DHMT) in our focus sub-counties (Njiru and Kasarani in Nairobi) have been a key stakeholder in the REACHOUT research process.

A lack of researcher feedback is the norm

As part of our feedback to stakeholders we were invited to attend the DHMT management meetings. The meetings were held in the DMOH’s (District Medical Officer’s) office in the District Hospitals.

We were given a time slot to present the study findings despite their long list of agenda items. In Njiru there were 17 members present while in Kasarani there were 14. Since we had limited time we only provided a brief background of the study, participants involved and key findings.

As we sat outside the DMOH’s office waiting to be invited into the Njiru DHMT meeting, one Community Health Worker (CHW) walking along the hall recognized my colleagues (Jane Thiomi, the LVCT Nairobi Regional Manager and Dorothy Njeru, Jane’s Deputy). He was involved in mobilizing the community for uptake of Home Based Testing and Counseling (HBTC). The CHW was so happy to see us he came and welcomed us. After waiting for more than two hours we were invited into the meeting. We informed the DHMT of our plan to involve their site in the next phase of the REACHOUT intervention and were given the go ahead to proceed with our plans. The Njiru DHMT members were very pleased that we had come back for dissemination of study findings. They confirmed the findings and were grateful for a hard copy of the report. We took their e–mail addresses and promised to send soft copies to their mails.

According to DHMT members a lack of feedback from researchers has become the norm. One commented, “People (researchers) come here and drop letters (of seeking authority to conduct research) and after giving them a go-ahead that’s the last time you see them.” After the meeting one of the DHMT members followed me down the hall way and reminded me in a stern manner, “make sure you send the report to our mails.” When I sent the mail I got a reply from him, “thank you for keeping your word.”

Just like the Njiru team, the Kasarani DHMT members were equally happy about the dissemination of the study findings: “This (the report) provides evidence of the work we do here.” “It is very good to know that you are actually going to provide feedback all the way down to the grass root level”.

Trouble on the horizon

However when we informed the Kasarani DHMT that their site was not going to be an intervention site they were disappointed: “You cannot tell us that we are not okay then leave us.” “Does that mean we should continue grappling with the challenges we have since you did not consider us as an intervention site?”

We explained to the Kasarani team that they were not badly off compared to the other sites which we had chosen for the intervention but that we would try and ensure that they also reaped the benefits of the research. Our experience in Kasarani brings in an important aspect of stakeholder engagement: beneficence. Research ethics calls for researchers to practice beneficence but the chances of this are low if you have an incomplete exit strategy. LVCT Health’s research exit strategy is two phased. In the first phase we inform stakeholders of the completion of data collection and when we hope to have the findings out. The second phase entails dissemination of findings and discussion with the stakeholders on the way forward and action points informed by the results of the study.  

Building good relationships

Developing rapport with study participants means researchers are engaged in a ‘relationship’ with them. Rather like the dating analogy that we used above. Unfortunately most researchers do not recognize the importance of feeding back their findings to those who were involved as participants and explaining the reasons for the decisions that they make. Researchers collect data and develop recommendations but rarely get back to the participants. It is like a bad relationship where one partner suddenly walks out on the other without feedback. This has dire consequences on the one who is walked out on (the community) and will reflect on subsequent relationships they get into e.g. lack of trust and commitment.

From our experience we urge other researchers to:

• Put in place research processes which mobilise and engage participants in a process of mutual learning
• Disseminate findings regularly
• Prioritise the community and participants as the first beneficiaries of your feedback
• Tailor dissemination to your audience type, make it understandable and don’t shy away from difficult conversations
• Work on your communication skills – during dissemination time constraints might require a planned 15 minute presentation to be given within 5 minutes. How are you going to handle this? How will you react if your audience is hostile

In the end we continue to have harmonious relationships in both sub-districts. One research participant stated, “We hope other researchers will follow your example and also come and share their findings.” And another reassured us that our results were useful, “We now have a basis from where we can refer from as we plan our work.”

Recent news stories

• Ethics and Gender: reflections from the Global Health Bioethics Network Summer School in Malawi, 18 July 2014
• On maternal health, future First Lady has her work cut out for her, 17 July 2014
• UK International Development Select Committee Hearing into Health System Strengthening, 2 July 2014

Sally Theobald, 18 July 2014

This post first appeared on the Ethics & Engagement across the Wellcome Trust Major Overseas Programmes (e-MOPS) website

What is the global health bioethics network?

The Global Health Bioethics Network is a collaboration between the five Wellcome Trust Major Overseas Programmes (MOPs) in Kenya, Thailand-Laos, South Africa, Vietnam, and Malawi and the Ethox Centre at the University of Oxford. Funded through a Wellcome Trust Strategic Award, the Network aims to: promote and support ethical reflection within MOPs; carry out ethics research across the MOPs; and improve the capacity of the MOPs to identify and address the ethical issues in their own research. To achieve these aims, the Network carries out a range of capacity-building activities which include: hosting an annual Summer School; providing annual capacity-building bursaries to researchers (Ethics Fellows) across the MOPs; providing education, training and mentorship to Ethics Fellows and other MOP staff; supporting MOP directors and other scientists in identifying and addressing the ethical aspects of their own research; supporting funding applications; and providing collaborative on-line ethics resources to promote cross-MOP discussion. In addition to its capacity building activities, the Network also conducts a number of important research projects into practical ethical issues relevant to the scientific and community engagement activities of the MOPs.

What was the focus on the summer school?

The ‘summer’ school was held in the depths of the Malawian winter in the week Malawi celebrated 50 years of independence. Among the celebrations was a space for reflection about the challenges and opportunities the next 50 years will bring the country. The summer school which brought together an impressively wide range of perspectives, professions and disciplines through a series of presentations, discussion panels and fish bowls also offered a space for reflection on the theory, practice and ethics of community engagement across the different contexts. Key questions that emerged through the discussions, included:

1. What are the goals of community engagement and whose agendas do they serve?
2. What is the interplay or overlap between approaches fostering public engagement and those aiming to take forward community engagement?
3. How can we define and deepen “appropriate” community and public participation across institutional practice and throughout research cycles?
4. How can we ensure marginalised and hard to reach groups are not excluded in community engagement activities?
5. How can promising and inspiring practices be shared across different MOPs and different contexts?

Given the recent launch of a sister network Research in Gender and Ethics in Health Systems – RinGs - I was particularly interested to learn from debates at the summer school about the interface between gender and ethics: 

The interplay of gender and generation within households and communities

Rodrick Sambakunsi’s bursary project focused on social messaging and HIV in Malawi. He aims to use social network approaches to trace the production of knowledge on HIV and explore the ways in which relationships between close and loose knit social networks shape (re)productions of knowledge. Sampling participants through science café’s, counsellor interactions and community mobilising events his initial findings highlight how gender, age and class shape who attends which events and how messages are shared. Lindsey Reynolds and Miliswa Magongo’s bursary project will use historically grounded ethnographic research to explore community perceptions of research within KwaZulu Natal and the role of gender, generation and hierarchy in shaping views points on what constitutes just ethical research.  The interplay between gender, generation and cultural perspectives will also be explored in Claudia Turner’s bursary which will examine household and community decision making processes and behaviours with respect to the care of poorly neonates in Cambodia. Claudia explained that globally neonatal mortality makes up 44% of deaths in children under 5 years but little is known about decision making processes in the first weeks of a baby’s life.

Benefits and payments through the lens of gendered household dynamics

The role of benefits in research also highlighted the role of gender and power within households. Maureen Njue’s bursary explored community perspectives on benefits and payments in coastal Kenya. She found that cash benefits were valued but had the potential to cause conflicts within families and in husband-wife dynamics, particularly when cash payments were made to the mother. Vicki Marsh also explained how in Kenya some participants felt that payments had the potential to undermine traditional gendered family values, although this was hotly contested and debated within the Kenyan community. Dorcas Kamuya explained how gender and power also shape consent processes in the household and how these are negotiated through ongoing interactions with fieldworkers.

Deconstructing communities – what are the challenges of representation?

Participants discussed the challenges and utility of trying to define fluid and dynamic communities. The complexity and fluidity of contexts and communities was beautifully illustrated by Khin Maung Lwin and Phaik Yeong Cheah who described the process of community engagement in the Shoklo Malaria Research Unit in Mae Sot on the porous Thai- Myanmar border area. Here with Decha Tangseefa they argue that the notion of community is shaped by space – whether people reside in refugee camps or border villages; subjectivities - including the role of collective and individual based memories and the realities of legal status, educational background and type of work.  Gender, generation and ethnicity overlay experiences of individual and communities making processes of community engagement and representativeness enormously challenging. Khin and colleagues have discussed the processes and challenges of establishing a community advisory board to represent community interests in Biomed ethics. CAB members speak Karen/Burmese live on either side of the border, are aged between 26-60 years old, are mainly male and include NGOs, casino workers and housewives.

Challenges and questions as we move forward…

There needs to be an ongoing critical reflection on the role of community engagement and whose interests are served and taken forward at different levels – with households, ‘communities’, research centres in the south and north, governments and donors. Given the fluidity of communities, how can different engagement activities that best represent or speak for diverse community interests be established? How can we deepen community engagement processes to include marginalised or had to reach groups? Sassy Molyneux pointed out that processes of informed consent and community engagement interact with complex power relationships within households and within communities. This poses a dilemma to the extent to which community engagement and informed consent interactions will intensify or offer opportunities to renegotiate gender and power relations, raising questions about the extent to which researchers – and front line field workers - should be attempting to engage with and/or change asymmetrical power relations?

The literature on social justice provides useful framing for some of these dilemmas. We need to think though and address ethical issues in research simultaneously at micro (e.g. informed consent and individual benefits) and macro levels (addressing structural inequalities and poverty). This means ensuring that our research and community engagement processes enhance, rather than undermine the rights and livelihoods of different women, men, girls and boys.

Recent news stories

• On maternal health, future First Lady has her work cut out for her, 17 July 2014
• UK International Development Select Committee Hearing into Health System Strengthening, 2 July 2014
• 5 key questions on close-to-community programmes as part of a broader health systems approach, 27 June 2014

Sudirman Nasir, 17 July 2014

This article first appeared in the Jakarta Globe on the 3 July 2014.

Amid the fierce presidential campaigning, not many people think and talk about the figure and the role of our next first lady. Sure, presidential hopeful Prabowo Subianto is currently unmarried but that may change and it is true that any first lady has no formal role in our government. But informally, as shown in several countries, first ladies can play important roles and contribute significantly to the people’s welfare.

Khofifah Indar Parawansa, the former women’s empowerment minister, a prominent figure within the Muslimat Nahdlatul Ulama — the women’s section of the country’s biggest Islamic organization — and spokeswomen for the Joko Widodo-Jusuf Kalla campaign, has put the crucial role of our next first lady on the agenda. According to Khofifah, who undoubtedly is eying a role for Joko’s wife Iriana, the first lady may perform a unique role in supporting village volunteer activity that is not part of any formal government policy.

Tackling maternal mortality

Programs such as the Posyandu (village health outreach) and PKK (family welfare and empowerment) play crucial roles in promoting maternal health campaigns, for instance by encouraging expectant mothers to seek antenatal care (routine checks needed during pregnancy) and give birth in a proper health facility. These activities are important to reduce the risk of maternal death.

Maternal mortality is an important public health issue in Indonesia. Our maternal mortality rate currently stands at 359 deaths per 100,000 live births. This rate is among the highest in Southeast Asia. Our progress in achieving the Millennium Development Goals target of a maternal mortality rate of 102 per 100,000 live births by 2015 remains a big challenge.

Many studies have pointed to biomedical issues contributing to the high number of maternal deaths, such as post-delivery bleeding, infection, high blood pressure and obstructed labor. These are often exacerbated by the poor quality of emergency obstetric services, poorly organized referral systems and inadequate human resource distribution, particularly in rural areas.

However, besides these biomedical and health system factors, there are several studies, including one in which I am currently involved in, in sixteen villages in Southwest Sumba (East Nusa Tenggara) and Cianjur (West Java), that have found various non-biomedical factors that also contribute to the high number of maternal deaths in the country.

It is noteworthy that most maternal deaths occur among mothers who give birth at home, unassisted by a skilled birth attendant. Though there is an increase in women who deliver in health facilities, the rate is not as high as it should be. Our current study revealed that there are numerous social and economic barriers that may prevent pregnant women from giving birth at a health facility, even though in the last few years the government has provided insurance that covers costs for such services.

The remaining barriers include distance, poor road conditions, lack of availability of transportation (including the cost of transportation) and indirect costs e.g. the cost of accommodation and food for family members who accompany the expectant mother. Furthermore, there are some factors related specifically to maternal health services, such as limited availability of a village midwife — because of many midwives do not reside their assigned village for a variety of reasons — or difficulties in contacting the midwife.

Our study also shows that poor perception of the benefits of delivery at a health facility, preference for home delivery and a preference for assistance of a traditional birth attendant (TBA) as well as limited communication and referral of pregnant mothers from TBA to midwife are also important barriers. Many women prefer to utilize TBA services because of the physical closeness of the TBA, but also because of the psychological and cultural support provided by them.

Enthusiasm and performance

Importantly, however, we found that some villages performed a lot better than others in terms of maternal health indicators such as higher attendance at antenatal care sessions and higher levels of delivery at health facilities. It turns out that better performance and enthusiasm of village midwives and volunteers like those of the Posyandu program is crucial in achieving better results. The study also suggests that these midwives and volunteers perform better and are more enthusiastic because they receive support from important stakeholders, such as the village head or the wife of the village head.

It is not hard to imagine that the enthusiasm and performance of all of these village midwives, village volunteers, village heads and wives of village heads will get a boost if our first lady — or the next president, for that matter — demonstrates a leading role in tackling this important public health issue. Moral and political support can make a big difference. Moreover, the first lady can set an important example for the spouses of leaders at all levels, like governors and district heads.

It is noteworthy that in other countries, the unique role of the first lady has long been visible. In the United States, for example, several first ladies played important roles in supporting strategic issues. Lady Bird Johnson pioneered environmental protection; Pat Nixon encouraged volunteerism; Betty Ford supported women’s rights; Rosalynn Carter promoted awareness of mental health issues; Nancy Reagan founded the “Just Say No” drug awareness campaign; Barbara Bush promoted literacy; Hillary Clinton sought to reform the US health care system; and Laura Bush supported women’s rights groups and encouraged childhood literacy. The current first lady in the US, Michelle Obama, has become identified with supporting military families and tackling childhood obesity

Indonesia’s next first lady could become a passionate advocate for maternal health — village-level health workers and volunteers will surely appreciate the support.

Sudirman Nasir is a lecturer at the Faculty of Public Health at Hasanuddin University in Makassar and a senior research fellow in the EU-funded ReachOut Project at the Eijkman Institute in Jakarta.

Recent news stories

• UK International Development Select Committee Hearing into Health System Strengthening, 2 July 2014
• 5 key questions on close-to-community programmes as part of a broader health systems approach, 27 June 2014
• Close-to-community providers and human resource management in Africa, 25 June 2014

Photo courtesy of Photo by Nena Terrell/USAID Ethiopia

Kate Hawkins, 27 June 2014

On the 26 June the UK Guardian newspaper held an online Live Question and Answer Session on health systems. Sally Theobald contributed on behalf of REACHOUT with a focus on close-to-community providers of health care. Amref set the scene by stressing that strong health systems:

‘Must reach right down to the community level as demand must exist to feed up into the formal structures...health workers, including community health workers, are a fundamental building block to promote health system strengthening in sub-Saharan Africa.’

This point was echoed by others in the discussion but they also pointed to some of the challenges in rolling out, or maximising on the opportunities afforded by close-to-community programming. Here are 5 key questions on close-to-community programmes as part of a broader health systems approach:

1. Why are community systems important?

Because they are the bedrock of the health system, argued Helen Counihan of the Malaria Consortium: 

‘the components of stronger health systems, such as sustainable funding, equitable access to care, a strong and efficient health management system and successful behaviour change communication all depend upon a greater role for communities in the delivery of services, mobilisation of demand and increasing access to those most in need.’

Community systems have the potential to make health services more inclusive and less discriminatory. Ann Noon drew on the work of the International HIV/AIDS Alliance and argued that weaknesses within health systems are, ‘felt particularly acutely by populations most at risk of HIV (or key populations), often marginalised or highly stigmatised groups including men who have sex with men, people who use drugs, sex workers, and transgender people. This underlines the importance of investing in community system strengthening’. Work with these marginalised groups is often hampered by a lack of political will on the part of Governments and therefore community-level organisations and civil society play a key role in expanding health service access and advocating for legal and policy change.  

We need to build health systems that can address the social determinants of health and the interplay between poverty and ill-health. Sally Theobald suggested that close-to-community providers – who are embedded in communities – have an important role to play here. They are: uniquely placed to understand the multiple ways in which poverty shapes vulnerability to ill health, care seeking and the impact of ill-health; strategically placed to facilitate community participation and stimulate critical thinking; and they act as a catalyst to social action to address the social and cultural determinants of poor health. However, further training, support and investment in this critical cadre is required for them to realise their full potential.

2. How should we support close-to-community programmes?

JaneCo argued that:

‘investing in health workers is central as they play a number of roles in the system; as recipients of skills and support thereby increasing the capacity in the longer term, delivering better services to patients now and in the future, plus as advocates for change, as informed voters/members of communities. The more we support health workers to fully enact their roles, the more of a 'voice' the health system has within the country and the political system.’

Neil Squires felt there was a need to go beyond the traditional health workforce and cited the thinking of a WHO working group which is building a global Human Resources for Health Strategy. Individuals, communities and non-health professionals could increasingly play a role in improving health. He explained that one of the, ‘biggest challenges to the health system will be to ensure that we think innovatively and beyond the health system, building individual and community self-reliance and resilience for improved health.’

Sara Bennett, from Future Health Systems, suggested that there was no ‘one size fits all’ approach that would be applicable in all settings:

‘Financial, geographic and cultural barriers are interconnected and often interact - compounding access problems for the poorest and most marginalized communities. I think that the entry point for addressing them varies across different contexts: sometimes it means strengthening skills for existing informal health care providers, sometimes developing effective cadres of community health workers. But there is no "magic bullet" approach that should be applied everywhere.’

3. How can we assure sustainability and accountability in close-to-community programmes?

Sarah Ssali from the ReBUILD Consortium, argued that ‘people matter but we need to accompany [community systems] with accountability mechanisms, especially social accountability to ensure that local leaders do not become a class apart and become less accountable to the local communities’. Sally Theobald explained how REACHOUT analysis in Mozambique shows that communities genuinely hold CHWs accountable and work closely with them to support them. Where these models of partnership work well this builds both the strength and responsiveness of health system as well as the resilience of communities.

Building infrastructure, longer timeframes, and exit and integration strategies were considered key to sustainability by Amref:

‘and most importantly there needs to be local ownership and leadership. If someone trains community health workers as part of a project, but doesn't empower either them or the local Government/health structures on how to work together- thereby providing ongoing support- then the community health worker will almost certainly fade away over time or when the project ends.’

This point was echoed by Helen Counihan who said that:

‘the sustainability and ownership of community-based interventions have been greatly strengthened by engaging the formal health service from the beginning. This was done by building capacity of the peripheral health facility staff as a starting point, and then placing the responsibility of training and ongoing support of community health workers with them.’

4. How do we assess the impact of close to community programmes?

Dina Balabanova (of London School of Hygiene and Tropical Medicine and Good Health at Low Cost) felt that often a ‘blueprint approach’ to health system strengthening does not ‘allow for meaningful engagement with those on the frontline, providers and users. Even where we see good governance initiatives, participation and learning from community stakeholders does not appear to be a priority.’

Much of the debate focused on the indicators that donors, in particular, use to measure the success of health system strengthening interventions in order to understand value for money and demonstrate this to tax payers. Sara Bennett described how:

‘[P]eople working on health systems strengthening do gymnastics to demonstrate how an investment in village health committees contributes, through long complex chains of causality to health impact. Making the link to service delivery outputs (coverage etc.) is easier and preferable in my view. If we really want to go this route then we also need to invest in more impact evaluations - though have to admit that I am uncertain this is always money well spent. At least let's make sure that such evaluations also provide real time evidence to strengthen implementation and aid decision making.’

Dina Balabanova made the point that:

‘We also need to raise the question of what do we mean by 'good' or 'strong' evidence? What kind of evidence is acceptable in situations of very limited data, or where no randomised design is possible (e.g. intervention is being rolled out to all)? How do we assess implementation and identify bottlenecks?’

5. How can we work together on community-level health interventions?

Panellists focused on the opportunities afforded by the upcoming Health Systems Global Symposium. Dina Balabanova explained that this year’s theme is the:

‘Science and practice of people-centred health systems, recognising the central role of people as users, creators and stakeholders in effective health systems. Recognising that health systems ultimately exist to respond to need, health seeking preferences and values. Also emphasising that those at the frontline (their views, motivation) are key to system functioning, and health systems should adapt to their needs.’ 

Sara Bennett described the growing interest in people centred health systems as an international movement and pointed to the WHO’s work putting together a new strategy on people-centred health services. She suggested that, ‘This movement…is responding in part to the growing burden of non-communicable diseases and is talking a lot about the co-production of health, meaning how can we better involve patients and communities in service delivery.’ Sally Theobald highlighted the importance of understanding and sharing knowledge about what works across different contexts. The Health Systems Global Thematic Working Groups offer excellent opportunities for dialogue and experience sharing across and between contexts.

The Health Systems Global Thematic Working Group on Supporting and Strengthening the Role of Community Health Workers in Health System Development is one such group. If you would like to join and be part of these ongoing discussions contact Faye Moody (n.f.moody@liverpool.ac.uk) to find out more.

Recent news stories

• Close-to-community providers and human resource management in Africa, 25 June 2014
• Sally Theobald is taking part in a live question and answer session on health systems for the Guardian, 24 June 2014
• Join us at the Health Systems Symposium in Cape Town, abstracts of sessions available, 23 June 2014

Photo courtsey of Dani Sardà i Lizaran

Kate Hawkins, 2 July 2014

The UK International Development Select Committee is undertaking an inquiry into Health Systems Strengthening to examine how effectively in practice DFID is implementing its objectives. It is covering the following issues:

• The impact of weak health systems on the achievement of DFID's and global health and development goals, and the extent to which poor health systems risk undermining the entire development effort
• The effectiveness of DFID's current approach to health system strengthening

The REACHOUT position

Stakeholders were given the opportunity to submit written evidence to the enquiry, a full list of papers written for the Committee are available on their website. REACHOUT's evidence made the following points:

• Close-to-community programmes are increasingly being initiated and scaled up in response to the human resources for health crisis. These programmes are providing an array of services which respond to health priorities at local level. They are often reliant on volunteer labour or employ staff who are poorly paid.
• These programmes have the potential to provide health interventions which are responsive to community level needs and close-to-community providers are uniquely situated to understand and react to gender and other equity-related issues.
• Yet close-to-community providers face challenges in relation to remuneration, sustainability and performance and workload management.
• To improve the function and the impact of close-to-community programmes investment is needed in creating an evidence base on supportive management of programmes, the equity impact of close-to-community programmes, the relationship between close-to-community programmes and the broader health system in priority setting, and the cost effectiveness of these interventions.
• Existing evidence from different settings should be translated and shared across countries and between academics, policy makers and implementers in order to improve the function of these programmes. This requires funding for multi-stakeholder learning platforms.

What happened next?

On the 24 June the Committee heard oral evidence from a range of health system experts. A video recording of the evidence session is available on the Parliament website. There was some mention of community health workers within the evidence session. Inputs mainly focussed on: the potential role of the UK in providing specialist training to close-to-community providers; the need to rationalise the responsibilities and functions of close-to-community providers so that they are not over-burdened and quality of services suffers as a result; and the caution that community health workers are not a 'magic bullet' and that these programmes need to be considered as part of a broader health system approach. It is great to see a focus on close-to-communty providers in these kinds of discussions and we look forward to the Committee's final report to see what reccomendations they have for the UK Department of International Development on how they can support these programmes.

A lively discussion took place on Twitter while evidence was given! Follow REACHOUT and be part of the debate.

Recent news stories

• 5 key questions on close-to-community programmes as part of a broader health systems approach, 27 June 2014
• Close-to-community providers and human resource management in Africa, 25 June 2014
• Sally Theobald is taking part in a live question and answer session on health systems for the Guardian, 24 June 2014

By Sally Theobald, 25 June 2014

From the 18-19 June 2014 I attended a workshop in Liverpool on the strategies for attracting, retaining and improving the performance of Community Health Workers (CHWs) in Africa. It was a chance to hear more about qualitative country case studies from: the Democratic Republic Congo (IPASC, Amuda Baba); Ghana (University of Ghana, Patricia Akweongo); Uganda (Makerere University, Sebastian Bain) Zimbabwe (BRTI, Stephen Buzuzi) and Senegal (University of Dakar, Guelaye Sall). These are all contexts where CHWs are a recognised cadre, but not contracted, employed or paid on terms and conditions of a standard paid civil service contract. The meeting was part of a project funded by the Special Programme for Research and Training in Tropical Diseases at the World Health Organization.

What is human resource management?

Drawing on the work of Armstrong, Tim Martineau explained that human resource management refers to “a strategic approach to acquiring, developing managing, motivating and gaining the commitment of …the people who work in the organisation and for it.”

With a focus on CHWs he highlighted that:

• The term CHW covers many types of workers – from community based distributors to health surveillance assistants
• There are a range of CHW roles – from community organiser to promoter of health behaviour to provider of curative health care

Key questions and challenges from a human resource management perspective include how to manage such a diverse portfolio of workers and roles? For example how do you attract people into these jobs, reduce turnover and support performance? How do you share good practice of managing and supporting CHWs?

Drawing on the PERFORM District Health Management Team methods manual, Tim highlighted strategies to support performance management, including direction (e.g. induction, appraisal, team meetings); resources (e.g. finance, infrastructure, information systems); competencies (e.g. merit based recruitment and training and development) and rewards and sanctions (e.g. team or individual incentives, additional responsibilities, issuing of verbal and written warnings, dismissal).

There is need to think through which of these strategies are most appropriate for CHWs and Claire Glenton has argued that programmes should seek to understand the expectations and motivations of local CHWs and attempt to match these expectations with appropriate incentives.  A lively discussion followed with participants, many of whom felt that given the lack of formal payment to CHWs carrots are more appropriate than sticks! Carrots may come in the form of incentives (bikes, boots and brollies); community relationships and feedback, and opportunities to interface and share experience with other CHWs. These are similar to the coping strategies of formal health workers that have emerged from research conducted in Northern Uganda for ReBUILD.  

Differences and commonalities across countries

Jo Raven talked us through some initial findings from the ongoing inter-country analysis.

In DRC, Ghana and Senegal, CHWs were attracted to the role in part because of free/reduced fee or preferential health care for the CHW and their family. In Uganda CHWs explained that the skills and supplies enabled them to take good care of their own children. With respect to recruitment and selection a range of strategies appeared to be in place; with communities often selecting CHWs, but sometimes this was the role of the chief (Ghana/Zimbabwe) or health authorities (DRC, Ghana). Some country policies stipulated that CHWs had to be married and in others being “responsible and respectable” was a prerequisite. Strategies to support retention overlapped with those related to attraction and included for example: praise and recognition from the community (Ghana, Senegal); incentives from health campaigns e.g. immunisation (DRC, Ghana, Uganda), treatment at health facilities for CHWs and families (DRC, Ghana); lunch and travel allowance for attendance at meeting (Uganda). Common strategies to enhance performance management included ad hoc refresher training related to programmes and linked to meetings (Ghana/Uganda), reporting to supervisors (Senegal, Uganda and DRC) and regular meetings with supervisors (DRC; Senegal and Uganda).

This analysis and emerging findings from REACHOUT demonstrate CHWs’ interface role showing how they act as a bridge between vulnerable and marginalised communities – and health systems; and also highlight the need for further action and innovation in different contexts to support and motivate this critical cadre. 

Recent news stories

• Storify from the Centre for Applied Health Research and Delivery Consultation, 18 June 2014
• Join us at the Health Systems Symposium in Cape Town, abstracts of sessions available, 23 June 2014
• Sally Theobald is taking part in a live question and answer session on health systems for the Guardian, 24 June 2014

Kate Hawkins, 24 June 2014

To coincide with the UK International Development Committee inquiry into health system strengthening the Guardian newspaper is running a live Q&A on the 26 June (13.00 - 15.00 BST) entitled 'Making health systems work in poor countries'. They explain,

"According to WHO, the lack of strong healthcare infrastructure in parts of the developing world is currently one of the biggest barriers to increasing essential healthcare access. Of the millennium development goals, the health-related goals are the least likely to be met, and despite a growing availability of drugs, vaccines and health-related tools, there is a disconnect between innovation and the strength of global health systems to deliver them.

So how can we help close this gap? As all health systems are context-specific, there is no single set of rules that can be put forward to improve performance. But research shows that health systems with the highest health outcomes have certain shared characteristics. To start, they have procurement and distribution systems that actually deliver interventions to those in need. Their health workers have the right skills and motivation, and they operate within financial processes that are sustainable, inclusive, and fair."

We are delighted that Sally Theobald will represent REACHOUT on their expert panel. We are sure that she will raise many crucial issues about the role of close-to-community providers. But it would be great if others working on community health worker research could join in and make this a meaningful dialogue on the future of research, policy and programming.

Details of how to join

1. Create a Guardian account

2. Leave your questions and points for discussion in the comments box

It is as simple as that!

You can also follow discussions on Twitter by searching for the #globaldev and #globaldevlive hashtags. We will also be live Tweeting.

Recent news stories

• Background paper on close-to-community providers now available!, 11 June 2014
• Building a close-to-community research agenda which is fit for the future, 18 June 2014
• Storify from the Centre for Applied Health Research and Delivery Consultation, 18 June 2014

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.

Recent news stories

• Background paper on close-to-community providers now available!, 11 June 2014
• Building a close-to-community research agenda which is fit for the future, 18 June 2014
• Storify from the Centre for Applied Health Research and Delivery Consultation, 18 June 2014

Photo courtesy of Matt Goodfellow 

Kate Hawkins, 18 June 2014

Last week many of us were busy at the CAHRD meeting in Liverpool. This was a major consultation on the future of applied health research and delivery over the next 10-20 years which attracted a large audience of academics, policy makers, and practitioners from around the world.  

Close-to-community providers featured in many of the conference sessions, where participants had a chance to reflect on some of the critical issues raised in background papers. REACHOUT was centrally involved in drafting the paper on close-to-community providers. Sally Theobald very valiantly outlined some of the key opportunities and challenges in close-to-community programming in a lightening talk of about 5 minutes! She explained how close-to-community programmes are well placed to extend health services and equity. Whilst there are evidence gaps in how far they can do this, promising practice, for example in the work of BRAC in Bangladesh, gives a sense of the possible benefits that these types of programmes could bring. Amuda Baba, from IPASC, Democratic Republic of Congo, opened the health systems stream with a discussion about human resources for health in fragile and conflict affected states, highlighting the importance of close to community provider who are embedded within communities. Close-to-community providers can play a role in translating community level knowledge for the health system and other sectors such as education and water and sanitation. However these programmes face challenges. Crucially staff need to be retained, motivated and supported to do their jobs well and systems for this are not well developed in all contexts.

The view from Bangladesh

We were fortunate to be joined at the meeting by Sadia Chowdhury, the Executive Director of the BRAC Institute of Global Health. Her presentation focussed on the way that community health workers and informal providers of health care are central to the provision of community-level care in Bangladesh. Informal providers are relatively overlooked by Government and tend not to receive the supervision or training that they require to serve their communities well. Because they charge for their services remuneration does not seem to be an issue for informal providers, but this is not the case for community health workers whose pay rises are irregular. Sadia explained how more could be done to coordinate between informal providers and community health workers and to facilitate communication between the two groups given that they are usually dealing with the same clients/patients.

Are we future focussed?

Because the conference was developing a research agenda for the next couple of decades participants were challenged to think to the future. Chris Whitty from DFID reminded us that we need to think about urban health systems, changing demographics, the rise of non-communicable diseases. He also suggested that in 20 years time it is likely that there will not be enough health care workers to meet demand and they will be drawn to the private sector serving the middle classes. A deepening human resource crisis has real implications for close-to-community programmes serving economically marginalised communities.

Lung health was one of the meeting themes. We heard some alarming statistics on the current burden of illness and projections for the future. Sundeep Salvi explained how an estimated 3.5 million patients visit a doctor for Chronic Obstructive Pulmonary Disease (COPD) or asthma in India every day. Providing the global overview, Kevin Mortimer outlined how 235 billion people have asthma, 80 million are living with COPD and there are 8.6 million new cases of TB a year. He predicted that if trends continue COPD will become the third commonest cause of death globally by 2030. Kevin suggested that there is a role for community health workers in preventing lung ill-health and also sign posting concerning symptoms to primary health care services.

The expansion to of close-to-community provider’s responsibilities to other health issues, such as supporting people with disabilities as a result of Neglected Tropical Diseases, was echoed by other plenary speakers. This prompted some debate.  Bertie Squire asked who is preparing the curricula that will equip health workers for the problems that they will face in 10 or 20 years time. Miriam Taegtmeyer agreed that close-to-community providers are both driven and motivated. But she asked with the addition of new responsibilities, who is thinking through problems related to supervision and integration with broader health systems. Finally Korrie de Koning called on governments to take up the lead in mobilising, capacitating and coordinating close-to-community providers to manage an expanded portfolio of work.

Moving forward

So the meeting left us with many questions about close-to-community providers but also a sense that an expanded range of health stakeholders are beginning to realise their potential in expanding coverage and equity. Devising a research agenda that is fit for the future and expanding multi-stakeholder platforms to bring the existing evidence base to a wider range of actors are key priorities.

Matt Goodfellow took some lovely shots of the conference which you can view here...

Recent news stories

• REACHOUT at the Centre for Applied Health Research and Delivery Consultation, 6 June 2014
• Impact of community health workers: Current evidence base and essential focus areas, 10 June 2014
• Background paper on close-to-community providers now available!, 11 June 2014

Kate Hawkins, 11 June 2014

As part of the Centre for Applied Health Research and Delivery consultation REACHOUT, with a little help from some colleagues, has prepared a background paper to help guide discussions on close-to-community health programmes.

What’s in the paper?

The paper aims to identify some key areas where there are opportunities for CTC providers to support health systems in strengthening universal health coverage, and to consider their potential from social determinants of health and gender equity perspectives.  The paper covers three themes:

1. It discusses the role of CTC providers as extenders of services;
2. It considers their potential as social change agents and;
3. It briefly reviews the need to manage CTC providers to support them in carrying out their roles.

What does the future look like?

The paper ends with a set of questions that will guide our conversations at the conference. They are a way of helping people identify the major challenges that will need to be addressed over the next 10 to 20 years and to think through future research agendas.

1. What are the best approaches to assessing the extent to which CTC providers reach and meet the needs of  different vulnerable groups, including the interplay between different axes of vulnerability – gender, ethnicity, dis/ability, caste, poverty etc. (intersectional analysis)
2. How can health system decision making processes and structures be better organised to enable CTC providers to inform priority setting? What is the potential of mobile technologies here?
3. How can the accountability of CTC providers to their communities be best understood, enabled and monitored?
4. What are the opportunities and challenges for CTC providers to support health systems and to better address the gendered social determinants of health at community level?
5. How can CTC provider’s insights feed into and support inter-sectoral collaboration with different sectors (e.g. education, transport, livelihoods)?
6. What are the best approaches to motivate, retain and support different types of female and male CTC providers in specific contexts? Does capacity development amongst CTC providers contribute towards social change?

I am sure that they will prompt lots of debate. If you have any insights that you want to share we will be Tweeting from the conference. Join in with the conversation!

You can download the paper from our publications page:

Theobald S., MacPherson E., McCollum R. and Tolhurst R. in collaboration with REACHOUT (2014) Close-to-community health providers post 2015: Realising their role in responsive health systems and addressing gendered social determinants of health, Background Paper: Centre for Applied Health Reseach and Delivery

Recent news stories

• Some emerging issues from the REACHOUT inter-country analysis, 18 April 2014
• REACHOUT at the Centre for Applied Health Research and Delivery Consultation, 6 June 2014
• Impact of community health workers: Current evidence base and essential focus areas, 10 June 2014

Kate Hawkins, 10 June 2014

We are delighted that Maryse Kok and Herman Ormel from the REACHOUT team will be participating in the first of a webinar series from Health Systems Global. The topic of the webinar is the evidence base for close-to-community health programmes and it will be held on I July at 15.00 CET.

To register for the webinar click here https://attendee.gotowebinar.com/register/2915265280083787777

Community health workers (CHW) are receiving growing attention as programmes led by governments and non-governmental organizations (NGOs) are implemented around the world. This webinar will ask: As countries scale up CHW programmes, where is a stronger evidence base needed to support policy development and programmes? How can existing evidence be better translated into action?

Join us for a lively panel discussion where you can hear more about:

• CHW commitment at the 3^rd Global HRH Forum, with an emphasis on expanding the evidence base for CHW programmes.
• The NGO community’s CHW Principles of Practice and its focus on supporting CHW research.
• Challenges faced by national CHW programmes in a range of African and Asian countries, and the alignment of research to these real world problems.
• A new reference guide on large-scale development and strengthening of CHW programmes.

 Panellists

• Diana Frymus, United States Agency for International Development (USAID)
• Maryse Kok, Royal Tropical Institute (KIT)
• Herman Ormel, REACHOUT Consortium
• Polly Walker, World Vision
• Henry Perry, Johns Hopkins School of Public Health.

This webinar is free. It is organized by the Health Systems Global Thematic Working Group on supporting and strengthening the role of community health workers in health system development. To find out more about/join this group, please contact Faye Moody (n.f.moody@liverpool.ac.uk) or visit http://bit.ly/sschwhs

To register for the webinar click here https://attendee.gotowebinar.com/register/2915265280083787777

Speaker biographies

Maryse Kok

Maryse Kok is a public health specialist, currently working as researcher on health systems at the Royal Tropical Institute in Amsterdam, the Netherlands. She started her career in policy advice at national and international level. After this, she worked for three years in Malawi at the district level in management and coordination of curative and preventive health services. She worked on improving supervision structures and performance appraisal for community health workers. She is working on a PhD at the Free University of Amsterdam, in coordination with the Liverpool School of Tropical Medicine. She is conducting research on factors influencing performance of community health workers in six countries in Asia and Africa, with a focus on Ethiopia and Malawi.

Henry Perry

Henry Perry is a Senior Associate at the Johns Hopkins Bloomberg School of Public Health. His primary research interest is in the impact of community-based primary health care programmes on health improvement, especially on the health of mothers and children. He has a broad interest in primary health care and community-oriented public health, community participation, and equity and empowerment. Recently, he has been engaged in research on summarizing the evidence regarding the effectiveness of community health worker programmes. He recently led an Evidence Review Team for the recent US Government Evidence Summit on Community Health Worker Performance.

Henry is a graduate of Duke University, where he received his BA degree. He obtained his MD, MPH and PhD degrees from the Johns Hopkins University and obtained training in general surgery at the Maine Medical Center in Portland, Maine. He is a Fellow of the American College of Surgeons. He has lived and worked in Bolivia, Bangladesh and Haiti and has worked on a short-term basis in many other countries throughout the world.

Hermen Ormel

Hermen Ormel is a social anthropologist and public health specialist with expertise in the field of sexual and reproductive health and rights. His main areas of interest are capacity development, research and evaluation, mobile health, and gender issues. Hermen has extensive experience working in Africa, Asia and Latin America.

As senior researcher, Hermen is involved in the five-year EU-supported research project REACHOUT, that addresses the performance of close-to-community services in Bangladesh, Ethiopia, Indonesia, Kenya, Malawi and Mozambique.

Polly Walker

Polly  provides  technical  oversight  to  World  Vision’s community health worker  programming  portfolio which spans over 40 countries globally. This includes  World  Vision’s  Timed  and  Targeted  Counselling (TTC) model, a behaviour  change  method  for pregnant and nursing mothers, and integrated community  case  management  (iCCM) of childhood illness. She also provides technical   guidance   on   CHW  policy,  health  workforce  strengthening, curriculum  development  and mHealth. Recent achievements include authoring World  Vision  TTC  and iCCM toolkits, CHW supportive supervision guidance, development  of  CHW  mobile  apps now deployed in nine countries, and the CHW Principles  of  Practice  for  NGOs. Polly is a post-doctoral public health researcher with 12 years experience of working in HIV and maternal, newborn and child  health.  Prior  to joining World Vision in 2011, she was a post doctoral  research  associate  at London School of Economics, and Programme Development  Manager  for  Effective  Intervention  (UK). Polly has spent eight years in  west  and  southern  Africa and Asia working in community health research  and  programming on mobile clinics, traditional birth attendants, essential newborn care and community case management and HIV. She completed her training at Oxford University and University College London.

Diana Frymuss

Diana Frymus is a Health Systems Strengthening Advisor in the Office of HIV/AIDS, USAID Washington, DC. Her work focuses on strengthening health systems to achieve and sustain national HIV responses. Her area of expertise is human resources for health and puts particular focus on better integration of CHWs into national health systems and health worker agendas. She was a member of the Steering Committee for the USG Evidence Summit on Community and Formal Health System Support to Enhance CHW Performance and co-author of the GHWA paper 'Knowledge gaps and a need based global research agenda by 2015' that was used as background to inform the 3rd Global HRH Forum commitment on Harmonized Partner Action for Community and other Frontline Health Workers. She is also a technical advisor for both the USAID CapacityPlus and ASSIST projects.  Diana has previous experience with the Clinton Global Initiative and also served as a Peace Corps Volunteer in Uganda. She received her MPH from Columbia University. 

Recent news stories

• Perspectives: The Complexity of CHW Training, 24 March 2014
• Some emerging issues from the REACHOUT inter-country analysis, 18 April 2014
• REACHOUT at the Centre for Applied Health Research and Delivery Consultation, 6 June 2014

By Kate Hawkins, 06 June 2014

Next week we will be off to Liverpool to attend a conference hosted by the Centre for Applied Health Research and Delivery (CAHRD). It is a great opportunity to feed into their longer term strategic agenda. The meeting will have a focus on lung health, maternal and newborn health, Neglected Tropical Diseases (NTDs), and health systems. CAHRD's aim is to foster dialogue and learning between these issues and across contexts and disciplines.

A focus on close-to-community providers

The health systems stream of work in the consultation has a strong focus on close-to-community (CTC) providers and some of the areas they hope to explore are:

• Identifying best approaches to motivate, maintain and support different types of female and male CTC providers as a key part of progress towards universal health coverage
• Working on opportunities for CTC providers to better address gendered social determinants of health at community level, and to promote effective multi-sectoral engagement 

But CTC health programmes also play a key role in each of the health-issue specific areas which are highlighted by the conference. You can read more about the conference and browse the agenda on their website.

Spreading the word

A number of the REACHOUT team will be attending the conference. Ireen Namakhoma (REACH Trust) will be presenting in the plenary on ‘Catastrophic care-seeking costs as an indicator for lung health’ and Sally Theobald (Liverpool School of Tropical Medicine) will present ‘Close to community health providers post 2015: Realising their role in responsive health systems and addressing the social determinants of health’. We will be live Tweeting from the event and will provide a round-up of relevant content related to CTC providers once the dust has settled.

Any enquiries about the consultation should be directed to Prof Squire who you can also follow on Twitter.

Recent news stories

• From ‘Basket Case’ to ‘One of the Great Mysteries of Global Health’: How did Bangladesh become such a success story?, 18 March 2014
• Perspectives: The Complexity of CHW Training, 24 March 2014
• Some emerging issues from the REACHOUT inter-country analysis, 18 April 2014

By 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.

Training

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.

Supervision

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.

Resources

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.

Recent news stories

• Attend our event on close-to-community providers of health care at the Cape Town Symposium, 20 February 2014
• From ‘Basket Case’ to ‘One of the Great Mysteries of Global Health’: How did Bangladesh become such a success story?, 18 March 2014
• Perspectives: The Complexity of CHW Training, 24 March 2014

By Maryse Kok and Miriam Taegtmeyer, 24 March 2014

Having resisted heavy rains and tube strikes in London, more than 30 people met in the afternoon of 6 February to discuss the possibility of developing a core set of standardized learning resources for Community Health Workers (CHWs), a meeting organized by mPowering Frontline Health Workers.

The dizzying diversity of CHW training

Given the diversity of CHWs, existing training materials are available in many forms: pre-service standardized packages that are put together by governments, modules developed by NGOs, distance learning and on the job training on multiple or specific subjects.

A literature review conducted by colleagues from the 1 Million CHW Campaign found out that there is limited information available on training for CHWs: on what works and what doesn’t work well and why? We also came across this in our REACHOUT systematic review on factors influencing performance of close-to-community providers, to be published soon.

In-country coordination of CHW trainings is much needed. In many countries, CHWs receive multiple trainings from different organizations which are sometimes not completely in line with each other. Who sets the priority for what a CHW should minimally know and what competencies a CHW should have? How do we avoid an overload of different trainings offered to the same CHWs, resulting in unmanageable workload, unclear roles and responsibilities, trainings only seen as income-generating activities and CHWs being away from the community for long times? These and other questions were part of the lively debate in the CHW forum.

Many of the issues around lack of co-ordination or standardised approaches raised by fellow participants reflect experiences we hear on the ground. For example, one of the CHWs participating in REACHOUT in Malawi said: “Nowadays there are a lot of activities and services which need volunteers hence there are so many volunteers who receive all kinds of trainings. For example, NGO A will need theirs, NGO B, Ministry of Health will also need theirs as well. However the point is the volunteers are the same people but we just change names, because the organizations have their different needs”.

Another issue with CHW training is that most of the time, content is available (information about diseases, how to diagnose), but CHWs are not taught about how to approach people in their homes, how to give feedback to communities and how to assure confidentiality, all very essential elements of a CHW’s job.

Positive change is possible

There is evidence for combining theory and practical knowledge to make improvements: using interactive methods; using technology, like mobile phones; conducting pre and post-tests to assess CHW knowledge and competencies; certification; and involving CHW in the development of training materials and evaluation.

But training alone is not enough. Training should be followed up with proper supervision and support, both from the health system and at community level. Training cannot be seen as a stand-alone intervention, it is part of a package of support that all CHWs need.

A standardised approach to learning?

Back to the question about the usefulness of a core set of learning materials. It’s obvious that there are a lot of good training materials available. But more coordination is needed to prevent people from re-inventing the wheel and inefficiently producing new content when it is already available. The main question bothering us at the end of the London meeting was: would governments and other major actors use a core set of learning resources if this were available? Sometimes they have reasons to want their own. This is not always because of political considerations; everybody acknowledges that contexts of CHW programmes are so diverse that new development of training content, curricula and pedagogy is justifiable.

A core set of learning resources should therefore be generic, adaptable and presented in modules. It should be attractive to contributors and clients (governments, NGOs), wanting to save time and money. We should give it a try and ensure that major actors, including the WHO, are willing to contribute.

This blog was first published on the mPowering Frontline Health Workers website. We want to thank them for publishing our post.This innovative partnership is designed to improve maternal and child health by accelerating the use of mobile technology by frontline health workers around the world. The founding partners are USAID, UNICEF, Qualcomm, Vodafone, Intel, MDG Health Alliance, GlaxoSmithKline, Praekelt Foundation, Frontline Health Workers Coalition, and Absolute Return for Kids. The USAID-funded MCHIP project serves as the partnership secretariat. As well as supporting financial and human resources management, MCHIP helps to identify potential points of collaboration and areas where working jointly will bring benefits to the aims of both mPowering and MCHIP.

Recent news stories

• "Remote rural" in Ethiopia, 27  November 2013
• Attend our event on close-to-community providers of health care at the Cape Town Symposium, 20 February 2014
• From ‘Basket Case’ to ‘One of the Great Mysteries of Global Health’: How did Bangladesh become such a success story?, 18 March 2014

Last week I was lucky enough to attend the UK launch of the Lancet Special Issue on Bangladesh, Innovation for Universal Health Coverage. The event was chaired by Hilary Standing, who sits on the REACHOUT Expert Review Group.

Bangladesh is a fascinating case study for this type of review because, in terms of many health and social status indicators, they outperform many of their neighbouring countries despite having a lower GDP. This is particularly surprising as their health system is weak in many respects and is pluralistic, characterised by a range of health service providers from the for-profit and not-for-profit private sectors. Per capita expenditure on health care is $27 and two thirds of payments for health care are out of pocket – meaning that government investment in the health sector is very low. There are only 0.3 doctors/nurses per 1000 population. Despite this Bangladesh is one of six countries which is on-track to achieve Millennium Development Goals 4 and 5 on child and maternal health.

Setting the scene

Dr Mushtaque Chowdhury (Vice-Chairperson and Interim Executive Director, BRAC) set the scene for the meeting, explaining that Bangladesh attained independence in 1971 after the liberation war which had caused millions of people to migrate to India and which destroyed much of the infrastructure of the country. At the time many outsiders were sceptical about the long-term future of the country and suspected that it would remain dependent on outside assistance for many years to come, hence the rather unpleasant label of ‘basket case’. However, despite this the country has turned itself around and made great strides in terms of health outcomes.

• Until the late 1980s Bangladesh was one of the few countries in the world where women lived a shorter life than men, but this has now been rectified
• There are high rates of girls’ enrolment in school at primary level
• Expanded Program on Immunization (EPI) targets are at 82% (as opposed to 44% for India)
• There is very high use of Oral Rehydration Therapy (ORT) which has been popularised by BRAC who have taught mothers how to prepare it in the home
• In terms of sanitation less than 10% defecate openly (it’s 50% in India)
• Bangladesh have already achieved WHO detection and treatment targets related to Directly Observed Therapy Shortcourse (DOTS) for TB
• Total fertility rate has reduced dramatically

Positive influences

Dr Chowdhury explained that the war of liberation changed the way that society looked at inequity and the role of women, leading to a national commitment to improve the life of the poor and marginalised. Health policies such as the 1982 Drug Policy changed the way that drugs were made available and meant that essential medicines became available at a very cheap price. New health centres and other facilities have extended the reach of the health system.  Although the population has doubled in the last 30 years, food production has trebled and there are food for education programmes and targeted programmes for the poor and girls. 80% of the poor have access to micro-finance. Women form the backbone of the front-line health worker programme providing primary health care to the people. The government has created spaces for non-governmental organisations (NGOs) to grow and flourish. Finally health research has played a large role in problem solving and there is a history of the implementation of research findings into programmes.

There is still much to do

Despite its successes there are areas of health in Bangladesh which need attention, for example:

• Skilled attendance at birth and facility delivery rates are low, impacting on maternal health
• The country is facing an onslaught of Non Communicable Diseases (NCDs)
• Malnutrition is a major problem, even among richer families

Abbas Bhuiya  (Executive Director of ICDDR,B and Director of Future Health Systems) elegantly explained some of the remaining challenges that Bangladesh faces in fixing its health system. The country has a chronic shortage of health care workers, and of the ones that they have only 5% are formally trained and they tend to gravitate to urban areas. Much of the spending on health care and medicines comes from people’s pockets rather than from the state or insurance programmes. The country has a weak and inadequate electronic records system, hindering joined up action. Finally, more needs to be done to empower the Ministry of Family Health and Welfare.

But there’s a plan

Impressively the authors of the Special Issue are keen that the information that they have shared gets followed up and they have taken proactive steps to see that it happens. The journal contains a Call to Action with the following recommendations:

1. That a national human resources policy and action plan need to be developed

2. That out of pocket spending is decreased through the establishment of a national health insurance scheme

3. That the country build an electronic health information system

4. That the capacity of the Ministry of Health and Family Welfare is strengthened so that they have the clout to appropriately influence decision making

5. That a supra-ministerial council on health is created

A learning platform is being developed to make sure that there is advocacy with non governmental organisations, the media, the government, academia and development partners to operationalise and monitor action.

Let’s hope those close-to-community providers of health care who labour at the front lines of delivery are fully and comprehensively involved in this action as it is rolled out. Given Bangladesh’s past performance in mobilising a plural and diverse set of health care actors, we have much to be hopeful for.

[Our REACHOUT colleague Sabina Rashid authored one of the papers in the Special Issue on child survival]

Recent news stories

• Attend our event on close-to-community providers of health care at the Cape Town Symposium
• Sharing and learning in Amsterdam, 25 November 2013
• REACHOUT at the Global Forum on Human Resources for Health, 25 November 2013

by Kate Hawkins, 20 February 2014

At REACHOUT we are very excited about the upcoming Global Symposium on Health Systems Research which will be held in Cape Town later in the year. The organisers explain,

“The theme of the symposium is the science and practice of people-centred health systems, chosen to enable participants to address current and critical concerns of relevance across countries in all parts of the world. Researchers, policy-makers, funders, implementers and other stakeholders, from all regions and all socio-economic levels, will work together on the challenge of how to make health systems more responsive to the needs of individuals, families and communities.”

This resonates well with our overall aims as a project and we hope there will be many discussions on the challenges to health care delivery at the community level. We will be attending as members of the new Thematic Working Group on Community Health Workers and we have just heard that we have had a panel session excepted. The panel will take place on Wednesday 1 October, 14.30 - 16.00 in Room 2.41-2.43. 

Panel session

Close-to-community providers are highly valued in some healthcare systems and community health workers are increasingly being promoted as a way of achieving universal health coverage. But challenges related to supervision (workload), referral, and community engagement and stakeholder coordination hinder the efficiency, equity and scale-up of these programmes. Drawing on learning from our research this session will use a World Café participatory format to explore the challenges being faced in Bangladesh, Ethiopia, Kenya, Malawi, Indonesia, and Mozambique. Engaging donors, policy makers, academics and practitioners in the dialogue will generate learning on how these challenges can be overcome and share experiences across different contexts.

A brief introductory plenary will outline the key lessons learnt from an international literature review on close-to-community providers and health service provision and key findings from a qualitative context analysis on community based health systems in 4 African (Ethiopia, Kenya, Malawi and Mozambique) and 2 Asian (Bangladesh and Indonesia) countries. This will capture the voices, perspectives and priorities of close to community health providers (which have not really been at the forefront of dialogue to date). An interactive café session will enable in-depth parallel discussions on three key cross cutting health systems challenges and opportunities for community based health systems: 1. Supporting close-to-community provider friendly supervision; 2. Strengthening appropriate referral and; 3. Coordination with a range of stakeholders, including the community. The concluding session (in plenary) will include reporting from each of the café groups and discuss opportunities to continue dialogue through other means (e.g. website, webinars).

This interactive session responds to the need for further experience sharing and networking (across contexts and between different stakeholders) to build capacity on key health systems challenges in community based health systems and ways to overcome them.

Watch this space

The organisers haven’t yet announced the date or the venue of the session but as soon as they do we will let you know. If you are attending the Symposium please do consider coming along and meeting the REACHOUT team. You can always get in touch in advance if you want to know more.

Recent news stories

• Sharing and learning in Amsterdam, 25 November 2013
• REACHOUT at the Global Forum on Human Resources for Health, 25 November 2013
• "Remote rural" in Ethiopia, 27  November 2013

Maryse Kok, 27 November 2013

Some months ago I was in Ethiopia, working together with my colleagues from HHA-REACH Ethiopia on qualitative research for the REACHOUT context analysis. After working hard on the protocol, the tools for interviews and Focus Group Discussions, the organisation of the field work, training the data collectors and testing and adaptating tools, it was time to go into the field. This was in mid-August! We went as a team of eight: three researchers from HHA-REACH Ethiopia, two extra hired data collectors, two drivers and me, the curious PhD researcher from Holland.

Now, I could see with my own eyes how maternal health care in rural Ethiopia is organised, what the role of the Health Extension Worker is, and what people in the community think about the services delivered. I have seen and worked in many rural areas in my life. But Chire district in Sidama zone could be labeled as “remote rural”. It’s about 200 km from Hawassa and it takes a whole day to travel there as the roads are rough (resulting in many tire punctures). Moreover, the rainy reason made some parts very difficult to pass. As a result we discovered that our team has also good skills in dragging cars out of the mud. We had a lot of fun and the whole team is still talking about the fact that we had to get out at least 10 times, to pull or push.

Health service access in pregnancy

The condition of the roads makes it even more difficult for pregnant women to access health care. Health posts, staffed by Health Extension Workers, are supposed to offer maternal health services (including antenatal care, delivery and postnatal care) close to those women that live far away. But, from many respondents in our interviews and discussions, it became clear that health posts were poorly fitted out. In many cases, there is no equipment available, not even a bed, no electricity and water. The job of the Health Extension Worker is further challenged by the fact that their training is mostly theoretical and they have limited practical experience to contribute to increased delivery. Most of the Health Extension Workers who we spoke to were, despite all the constraints, happy to do the job. They were motivated by the fact they were helping mothers and children and they were respected by the community.

Ethiopia has a low percentage of institutional deliveries (about 10%). Most women still prefer to deliver at home.  Traditional Birth Attendants are banned, but in some areas they are still working. We visited a Traditional Birth Attendant who reported us proudly that she delivered many children in the village, including the current Health Extension Worker! Our research provided some insights into why women don’t go to a health facility for delivery. Cultural practices and habits play a big role.

At the moment, we are busy analyzing all the data that was collected in 6 districts. The data set is rich and gives us a good basis for the improvement cycle that is going to be set up in 2014.

From 9-13 November 2013, the Third Global Forum on Human Resources for Health was held in Recife, Brazil. The event theme was Human Resources for Health: foundation for Universal Health Coverage and the post-2015 development agenda. The Global Health Workforce Alliance (GHWA) organised the Forum under the patronage of the Government of Brazil, the World Health Organization (WHO) and the Pan American Health Organization (PAHO). I was lucky enough to attend the meeting on behalf of REACHOUT and the Royal Tropical Institute (KIT).

The Global Forum was well attended with more than 2,000 participants. The side sessions were informative and relevant for researchers. The plenary sessions were more policy-oriented. A Political Declaration on Human Resources for Health was developed.

On Saturday November 9^th, KIT was involved in a side session organized by the GHWA, USAID, NORAD and the Frontline Health Workers Coalition.In the session, stakeholders from all levels and perspectives shared country experiences and discussed the Community Health Worker (CHW) Harmonisation and Accountability Frameworks as well as priorities for a global research agenda on CHWs developed in advance of the meeting. KIT contributed to the paper on knowledge gaps and a need based global research agenda on CHWs.

From this session, a commitment document on CHWs and other Front Line Health Workers was developed. This aims to move us from fragmentation to synergy to achieve universal health coverage. KIT is part of a core group, coordinated by the GHWA, and REACHOUT will have a role in further initiatives, by contributing new evidence on close-to-community health programmes.

On Tuesday November 12^th, KIT presented the emerging findings of a cost-effectiveness study on CHW programmes in low- and middle-income countries that was conducted together with Queen Margaret University of Edinburgh and Liverpool School of Tropical Medicine. The study is financed by the GHWA and will be published in the beginning of 2014. It consists of a literature review and the development of a generalised model to assess cost-effectiveness of CHW programmes in three REACHOUT countries (Indonesia, Ethiopia and Kenya).

The REACHOUT team came together for a Consortium meeting from the 4^th – 8^th of November in Amsterdam. Our meeting was hosted by the team at KIT who provided great facilitation, a wonderful venue and warm hospitality (despite the pouring rain). The meeting was a chance to catch up on progress over the last nine months and to strategise together about how to move forwards. It was exciting to see the volume and quality of the work that has been completed in the early stages of our project and lovely to connect with friends and colleagues, old and new.

I think it is fair to say that everyone was impressed by how far we have come. In the last nine months we have: put in place a strategy for capacity building under the leadership of James P Grant School of Public Health; created Country Advisory Groups of critical allies in each research setting and met with them to get feedback on our plans; held stakeholder meetings; formed an Expert Review Group for the Consortium as a whole; put in place systems for management of the project; secured ethical approval for our context analysis; collected lots of data from each country and analysed what we have; conducted a literature review; attended and presented at international conferences; and we are on the way to finalising our communications and research uptake plan.

A view from each country

At the meeting each country feedback learning from their context analyses, what follows is a whirlwind tour of the contexts that our research will take place in.

In Malawi REACHOUT will focus on Health Surveillance Assistants (HSAs) in Mchinji and Salima. HSAs are the lowest cadre of frontline health workers who provide Malaria, TB, HIV and child health services in hard to reach areas and are employed on a range of NGO projects and by Government. The system in which they work is often ‘dis-integrated’ from the formal health system and in need of regulation. Whilst HSAs are highlighted as a key cadre to deliver the essential health package as part of the sector wide approach they are also expected to work to deliver illness specific policies for such as those related to TB and Malaria. This can create challenges in terms of supervision and coordination and means that their roles and responsibilities often change. HSAs often complain of inadequate salaries and supplies such as pens, gum boots and registers. There are different systems of supervision and monitoring and evaluation across NGOs, Government, health centres, the district and national level which can cause confusion.

84% of the population of Ethiopia live in rural areas and in a setting with high maternal mortality which makes it a national priority.  In Sidama there is high ante natal care (ANC) but low institutional delivery which is why it is a focus area for REACHOUT. The Health Extension Programme (HEP) started about a decade ago deploying salaried Health Extension Workers (HEWs) to deliver primary health services to the community. Recently, HEWs extend the services to the community using a ‘health development army’ which works closely with households.   Health promoters, include Traditional Birth Attendants (TBAs), who used to work in the community have been integrated into the Health Development Army. HEWs are supposed to work on 16 health packages and because they have so many tasks to do their workload is high. They are also involved in other community activities which are crucial to the overall improvement of the community they are serving. The area that they have to cover, and the population size they are responsible for, influences their capacity to deliver services in the community.

In Kenya REACHOUT is concentrating on integrating HIV and community systems in Nairobi (the capital city) and Kitui (a rural area). Currently Community Health Workers (CHWs) receive basic training from the Government and cover 1000 households (5000 individuals) for whom they do health visits and referrals. They are volunteers from the community who provide preventive and promotive services and basic curative services for things like straightforward malaria. They are supervised by Community Health Extension Workers (CHEWs). The Community Health Strategy and Structures are currently in a state of flux and training curricula and a monitoring and evaluation strategy are being developed.

In Mozambique we are focussing on child health in rural areas (Moamba and Manhica). The Agente Polivalente Elementares (APE) programme was introduced in 1978 and was revitalised in 2010. It is expected to increase health service coverage from 40-60% of the population. In Mozambique health centres are mostly situated in urban areas and access to health care in rural areas is limited. The APE programme is viewed as a way providing access to basic health care to population in rural area currently with no or limited access. The role of promoting healthy lifestyles and preventing ill health due to poor sanitation, diahorrea, malaria and respiratory infections for children is mainly the responsibility of close-to-community providers who are paid a subsidy. The APE Programme went from being volunteer based to paying the workers a subsidy (not salary). APEs face challenges with regard to deficient supervision, pressure from donors to expand the APE responsibilities into other areas of ill-health, stock outs of medications and other supplies used by APEs, late payments of subsidies, large numbers of clients dispersed over wide areas and the fact that communities would like them to provide curative services too.

Indonesia is a huge and diverse country in geography, culture, ethnicity and religion and providing health care to rural and remote areas is a challenge. The maternal mortality rate is 359 per 100000 live births which is why it is a REACHOUT focus. There are a range of close-to-community providers related to maternal health in Indonesia. Village midwives provide ANC and post-natal services and attend the village integrated health post (posyandu) together with the village health volunteers (posyandu kaders) who are engaged in multiple tasks like child vaccination and growth monitoring . Alongside these Government paid midwives, there are trained and untrained TBAs who do home deliveries and accompany women to health facilities when necessary. The community can request a nurse or midwife placement in their village but they are not involved in the selection. It is difficult to recruit midwives to work in villages because of housing and education for their children. Some midwives report that they are on call 24 hours a day which is difficult to manage. Other challenges reported by close-to-community providers include a lack of clear supervisory systems, information feedback loops, and follow up on problems (such as equipment breakdown and building management). Whilst there is a universal insurance system that covers ANC visits, delivery and post-natal care, women are still not delivering in a facility because of the distance from health facilities, poor road access for ambulances and other transport means and a preference for delivering at home (sometimes with TBAs because they offer services embedded in traditional practices like massage, turning the baby and hot tamarind baths which women appreciate).

In Bangladesh we are working in Dhaka and Sylhet where there are pluralistic health systems and the market is characterised by an inappropriate skill-mix with inequitable distribution of providers including traditional healers, TBAs, and village doctors. Informal providers are providing the health services in the community and there is no systematic quality assurance or regulation. There are three categories of close-to-community providers, namely public sector providers; private community health workers who are managed by NGOs (including BRAC’s Shasthya Shebikas, Shasthya Kormis, etc.); and informal providers who are independent service providers embedded within the community. Healthcare financing is mostly out of pocket and people report that they like informal providers because they are from the community, easily accessible, provide door-steps services, provide medicines on credit and they are trusted. There is a lack of linkage between formal and informal providers and a lack of oversight creates difficulties in providing joined up and appropriate services at the community level.

Moving forward

All REACHOUT partners will have finalised their context analysis by the end of the year which will help them to prioritise which areas of the close-to-community programmes they will target for improvement. The meeting provided an opportunity to share and test out potential tools which will be used to implement the improvement cycles that we have planned for next year. Ensuring that the tools that we use and the areas we target have some common elements was one of the things that we focussed on when we met as we will synthesise learning across our different settings as well as offering recommendations for in-country stakeholders.

Participants left the meeting a little exhausted but full of ideas for how their research might roll out and with a renewed sense of solidarity about how we can work together and help each other grow as we move forward. Our next meeting will take place in Mozambique in March 2014 and we are looking forward to being hosted by our colleagues at University Eduardo Mondlane.

For those not familiar with the fastest growing mega-city in the world, Bangladesh’s capital Dhaka with 22 million inhabitants is an experience of extremes. So many people, so much traffic and such narrow Old Dhaka streets. Yes, a lot of poverty – but also a vibrancy and creativity to make the best of life that are may be best symbolized by the craziness and variation in means of transport. Cars, buses, double-deckers, lorries, manual cart pullers, ambulances, richly painted bicycle-rickshaws, ‘clean’ motor-rickshaws running on natural gas and lorry-rickshaws: they are all jostling for space and speed, and with not much consideration for each other, traffic police, beggars and pedestrians.

Although the above made the most impression on the visiting KIT researcher, all four of us have to experience the ‘creative’ traffic when finding our way to Keraniganj, a small low-income urban settlement, just across the Buriganga River. Situated on private land, a single owner left his inheritance to a number of relatives – each of whom are trying to squeeze a profit out of the tenants inhabiting the narrow dwellings in the walled, narrow alleys where we walk, children looking on us with curiosity.

Some owners apparently invest in hard-surface streets and concrete houses, sometimes two stories or higher. These parts make the area almost look  ‘developed’, and allow the charging of a monthly rent of between 1,500-2,600 Taka (USD20-35) for  single-room apartments (12x15ft or roughly 3.5x4.5m) mostly inhabited by families of two adults and several children. In comparison: a rickshaw ‘puller’ can earn up to 6,000-9,000 Taka (USD80-120) per month.  Meanwhile, other parts look like they have not been looked after in half a century and are muddy and the dwellings are mere shacks consisting of a couple of rusty, leaking corrugated sheets of metal that are in desperate need of ‘renovation’. Four toilets are used by more than thirty families.

This is the setting of one of the four sites selected for the REACHOUTresearch and intervention programme, addressing the role and performance of close-to-community (CTC) providers with a special focus on sexual and reproductive health and rights. Today we aim to talk to a couple of these providers, as well as some community members, to allow the KIT visitor to get a better idea of the context in which the research takes place.

However, several of the people we try to meet are not available. The traditional healer isn’t home as this person works elsewhere during day time. The Dai (female traditional birth attendant) is away doing her regular (non-Dai) work. And all informal pharmacies are closed, so we can’t talk to drug sellers either. The latter is due to a national strike of drug sellers, in protest against a government crackdown on counterfeit drugs, whereby (according to newspapers earlier this week) a number of drug sellers doing illegal business have been arrested and a considerable volume of counterfeit drugs confiscated.

These informal CTC providers are among the most sought after by the population, for sociocultural and health belief reasons but also out of financial considerations – private clinics, diagnostic centres, NGO  clinics or government services, all involve the need to spend cash, for transport, diagnosis or drugs. Cash that many can’t spare and this could very well make the issue of ‘access’ and ‘choice of formal versus informal service provider’ a key one for the research and intervention.

Then, finally we are able to talk to two Shasthya Shebikas – female health volunteers (and CTC providers) trained and supervised by BRAC, the Bangla partner in the 8-country REACHOUT consortium. Ideally there is one Shasthya Shebika for every 200-250 households. We talk to the two ladies in the alley outside their homes, where they offer chairs to the visitors while standing themselves. Many other neighbourhood women and some children listen in with curiosity during the conversation about their initial training, daily volunteer work visiting households, addressing child nutrition issues and referring pregnant women to the BRAC delivery centre. Their motivation “to mean something for women’s health” is impressive.  What they get in return are small incentives, based on the number of pregnant women attending ante-natal care throughout the nine months pregnancy, but also she said:

“the respect of the community, they really honour me. That makes me very proud of my work. It really makes me happy if I get a phone call at 3am to find out that my client is in the delivery centre to have her baby.”

This field trip is a good preparation for the week to come, when we will work with the rest of the BRAC University team and joined by our colleague Sally Theobald of LSTM to analyse the qualitative research data gathered, among others, in this settlement.

Coming to Nairobi feels good for me. For a start it was home for me once and for a second I always feel so welcomed by LVCT. The familiarity of people, smells, noises, traffic and the way people at LVCT laugh at my rubbish jokes just to humour me combine to make any trip here a journey I look forward to. Despite media concerns about safety after the horror of the recent terrorist attacks I felt secure, and Nairobi is going about it business.

The ease of slipping into chat with colleagues, some of whom I have known for years and see grow through many roles in the organisation makes a frantic week of work seem like a norm. We are all used to some crazy work patterns and this week is no different.  Between early morning starts, late finishes, transcript coding, writing narratives, facilitation and deep discussions about the implications of findings of the REACHOUT context analysis we manage to marvel at how people’s kids have grown and slip in gossip on who is pregnant, who is working in which department, what shuffling has gone in Ministry. We speculate on the impact of the US government closures on CDC and PEPFAR and whether this will affect community programmes in Kenya.

The energy and vibrancy at LVCT is felt from the very top and permeates the organisation.  Our workshop is full of laughter and hard work.  We have a programme manager, two research officers and 7 research assistants in the workshop.  We all fill the room with energy, laughter and hard work. Most of us are learning Nvivo software for the first time. Myself included.  Many are learning coding, analysis and narrative writing for the first time and choose to come early and stay late to complete work for the next day.  With some people making a daily commute of 3 hours each way through Nairobi’s congested streets this is truly an impressive feat.  I thought the new roads were supposed to be slowly unclogging this perennial problem but no such luck for some.

We have been bonding over the data. As we analyse we talk, think through things back and forth, work in pairs, get inputs from the group and move on.  The learning is through doing and every day we take time to reflect and have sessions where we evaluate and give feedback to each other’s work.  I can categorically state that I have had my capacity built this week. Not just in Nvivo but also in qualitative research.  Korrie through her formal teaching and informal support has allowed us all to grow and benefit from her years of experience in doing qualitative work with communities and she has learnt stuff about HIV testing programmes, the organisation of services and the workings of community health worker (CHW) programmes too.  Thanks to the amazing (and long suffering) Ginge, who provided a 24 hour Nvivo help line support system by Skype and email, we all found Nvivo user-friendly and quickly picked up basic skills including coding, merging files and querying nodes.  We also did classifications and ran some further queries, but with less confidence on these still.  Most importantly my capacity to understand the context for community health workers and community health extension workers has been built by the team and by the community and CHW voices I hear through them.

photo credit: BRAC

By Sally Theobald, 11 October 2013

Wikipedia declares BRAC to be the largest Non Governmental Organisation in the World, based on how many people it employs and the number of people it has helped. BRAC is present in all 64 districts of Bangladesh as well as in Afghanistan, Pakistan, Sri Lanka, Uganda, Tanzania, South Sudan, Sierra Leone, Liberia, Haiti and The Philippines and has offices in the UK and the USA.  The James P. Grant School of Public Health (JPGSPH) was established in 2004 and its founding members are BRAC, BRAC University and icddr,b. JPGSPH draws on these founding members – or institutional pillars – to inform and enrich its programmes and activities, which include research, education, leadership and advocacy. JPGSPH has over 200 members of staff and a vibrant MPH programme which attracts students from Bangladesh and all over the world.

Close-to-community providers and menstrual regulation

I have just spent a week at JPGSPH with Hermen Ormel from KIT, in a REACHOUT analysis workshop for looking at qualitative data on the role of - and interactions between - formal and informal close–to-community (CTC) providers. JPGSPH have focused their work on sexual and reproductive health (and in particular menstrual regulation) in 2 sites in Dhaka and 2 sites in Sylhet district. Menstrual regulation is a procedure that uses manual vacuum aspiration to safely establish nonpregnancy up to 8-10 weeks after a missed period. Research by icddr,b concluded that,

“The provision of menstrual regulation averts unsafe abortion and associated maternal morbidity and mortality, and on a per case basis, saves scarce health system resources. Increasing access to menstrual regulation would enable more women to obtain much-needed care and health system resources to be utilized more efficiently.”

Building capacity through South-South technical assistance

JPGSPH leads on REACHOUT capacity building work under the direction of Prof. Malabika Sarker –Director of Research - and Yamin Jahinger.  A key activity in REACHOUT capacity building is South-south technical assistance to ensure that we build on the strengths and experience of all partners in designing, implementing and evaluating the quality improvement cycles that we will undertake to strengthen CTC services. There are a number of work areas where JPGSPH have exciting lessons to share. These include:

• Supporting supervision, retention and motivation of CTC providers to build responsive health systems: There are 97,000 frontline community health workers - shasthya shebika in Bengali – who are linked to BRAC. Retention and motivation is supported through: community involvement in the recruitment process; continuous learning and training through refresher training; structured supervision and monitoring based on performance and continuous recognition and promotion  of shastya shebika as key pillars within BRAC. This female volunteer cadre has been crucial to health gains in Bangladesh. For example in maternal health shasthya shebika work with traditional birth attendants to support maternal and child health with an approach that aims to empower and support women. Maternal mortality has dropped sharply and steadily, from 574 maternal deaths per 100,000 live births in 1990 to just 194 in 2010, while other indicators like neonatal and under-five mortality have also fallen.

• Taking forward equity as a core component of front line service delivery and universal health coverage: JPGSPH hosts the Centre for Universal Health Coverage which aims to facilitate efforts to accelerate evidence-informed, equitable and sustainable action towards universal health coverage.  The Centre includes a Universal Health Coverage Forum for evidence informed advocacy and joint learning with local and global partners. They are also part of the Centre for Urban Equity and Health – a knowledge hub on urban health equity with a focus on human resources and service delivery. While the Bangladesh Health Watch, also hosted by JPGSPH, is a multi-stakeholder civil society advocacy and monitoring network dedicated to improve the health system in Bangladesh through critical review of policies and programmes and recommendation of appropriate actions for change. Gender equity is also an area of expertise and action through the Centre for Gender, Sexual and Reproductive Health Rights which can support analysis of the ways in which gender roles and relations shape CTC providers experiences and interactions with both communities and the rest of the health system.

A week at JPGSH and BRAC left me feeling excited about the potential of south-south technical assistance in the REACHOUT journey.

The governments of the UK and US hosted the “Millennium Development Goal Countdown 2013” during the United Nations General Assembly, in New York on 24th September.  The event aimed to showcase how girls and women are a force for change in helping the world achieve the Millennium Development Goals and to share inspiring examples of women’s leadership and innovative projects that are transforming societies. The Executive Director of UN Women Phumzile Mlambo-Ngcuka, discussed the importance of harnessing the energy and potential of women and girls in the post 2015 MDG agenda; while UK Secretary of State for International Development, Justine Greening, argued that investing in girls and women led to a virtuous cycle of development.

Female health extension workers lead the way

For Millennium Development Goal 6, “Combat HIV/AIDS, malaria and other diseases” a single case study was selected “Health heroes: Women taking the lead in health in Ethiopia”. REACHOUT’s  Sally Theobald presented the case study on behalf of the Global Fund to fight AIDS, TB and Malaria.  She highlighted the importance of frontline close-to-community providers of health care in the fight against tuberculosis and other diseases. To date, 37,000 female health extension workers (HEWs) have been recruited, trained and deployed at the local level in Ethiopia.  Through the TB REACH project in Sidama, female HEWs collect sputum and prepare smears directly from individuals during their door-to-door community visits and send them to laboratories. Bringing TB diagnostic and treatment services close to communities has increased access, particularly for women, the elderly and children. TB notification rates have doubled and there have been significant improvements in treatment outcomes. The TB REACH project has now been expanded to four additional zones and further scale-up is being planned.

Further reading: Innovative Community-Based Approaches Doubled Tuberculosis Case Notification and Improve Treatment Outcome in Southern Ethiopia

As a relative newcomer to REACHOUT, working in Maputo with the team from Universidad Eduardo Mondlane has been a great experience for me. The last two weeks have given me the chance to understand more about the role of ‘close-to-community’ (CTC) providers, known as Agente Polivalente Elementar (APE), some of the strengths of the programme and the challenges APEs face in carrying out their daily activities.

Agente Polivalente Elementar

It is estimated that only 30% to 50% of the population have access to healthcare services in Mozambique. Mozambique first introduced the community health worker programme in 1977 as a strategic attempt to reduce poor access to healthcare services in the rural population.  The APE programme was revitalised in 2010, with the intention that each APE provides health promotion and disease prevention along with curative services through household visits. This includes basic first aid for all and diagnosis and treatment for pneumonia, diarrhoea and malaria for children who are less than five years old.

Making progress on our research: Workshop on data collection and analysis

“An excellent opportunity to make the most of the research programme’s initial research data in preparation for the intervention phase of REACHOUT.” Dean of the Medical Faculty and REACHOUT Principal Investigator Dr Mohsin Sidat

During a week long workshop held from the 16^th- 20^th September, we spent time as a team discussing the process for data collection which occurred across two districts (Manhiça and Moamba in Maputo Province), reading and discussing interview and focus group discussion transcripts, and starting to analyse the data collected for the contextual analysis process.  The Programme Manager for the APE within Ministry of Health and the USAID advisor for the APE joined the team to share initial findings from the Ministry’s APE baseline study and from routine data collection by APEs. We felt privileged to hear these data, which have only just been made available, and it was encouraging to see the commitment of the staff in the Community Health Unit to the programme and exciting to see that over 2,000 APEs have been trained (2010-2013). Meanwhile, the baseline data, involving over 1,000 APEs, showed that over 3 million Mozambicans have been beneficiaries of APE services in an 18 month period.

One of the recurring themes that started to emerge during our discussions was the commitment that APEs felt to carrying out their work. One APE explained, “working for health is equal to a pastor who works for God. Working [as an APE] for people and working for God is all encompassing”. Another theme related to the difficulties faced by APEs in carrying out formal instructions to use 20% of time for curative and 80% of their time for health prevention and promotion activities. Difficulties in striking the right balance are compounded by the community, many of whom seem to prefer curative over health promotion activities. In addition, there was the continuously returning issue of the distance which APEs need to travel to carry out their work. This challenge was vividly brought to life when we visited Cesaltina, an APE in Calanga community, Manhiça district.

Notes from the field

Our trip to visit Cesaltina (see photo below) reinforced many of the issues which came up in the workshop.  To reach the community where Cesaltina lives and works was no easy task, as the sandy ‘road’ gave way beneath our sturdy 4x4 car. During our journey we saw two tractors which were stuck in the sand and making the journey on a bicycle (the only means of transport of APEs apart from walking) would be impossible.  Once we reached our destination (thanks to a superb job negotiating the sands by co-researcher turned driver Mr Sozinho Ndima), we were struck by just how geographically isolated Cesaltina is in her work and the difficulties that something as simple as collecting supplies from her nearest health facility can be.

The photo of Cesaltina demonstrates how she transports typical monthly kit supply.  It took two people to lift the box onto her head. Despite the challenges that they face, the APEs in Manhiça district appear to be very appreciated by health facility staff. One nurse we visited told us, “the APE is like a third arm for our work here.”

The week has provided plenty of further insights into the APE programme and already ideas are starting to emerge for potential interventions during the next REACHOUT quality improvement (intervention) stage.  There are some exciting opportunities to improve the working lives of  APEs like Cesaltina and I am looking forward to working together with the Mozambique team as they develop a research agenda which meets their needs.

By Sally Theobald, Liverpool School of Tropical Medicine

We held the first REACHOUT analysis workshop in Malawi (2^nd-6^th September) exploring the data collected by the REACH Trust team for the context analysis. I spent 18 months as technical adviser at REACH Trust from 2004-6, and it was excellent to return, greet old friends and see the Trust growing and consolidating under Ireen Namakhoma’s able leadership.  The Reach Trust 9 person strong  REACHOUT research team had just returned from collecting qualitative data with Health Surveillance Assistants (HSA’s, Malawi’s key ‘close-to-community’ providers), communities and key informants in Mchinji (which borders Zambia) and Salima (which is on the shores of Lake Malawi). We spent the first morning having an in-depth debrief with the research team, hearing about the process of data collection, their initial impressions of the data they collected, what was surprising, what was memorable and the cultural and contextual differences between Mchinji and Salima.

The REACHOUT research team divided up the interviews and focus group discussions depending on availability of informants and met for debriefing every evening to share experiences, discuss inconsistencies, update notes and review the purposive sampling frame.  During the debriefings, Lot Nyirenda who supervised the data collection team, challenged the team to interrogate key recurring themes from the data (sustainability of programmes, role of incentives and motivation) from multiple perspectives and through doing so better understand varying viewpoints and competing narratives that emerged. This highlighted for me how good quality qualitative research is like being a detective, unravelling and understanding the why and the how of behaviours and what motivates and sustains interactions. This is important in the REACHOUT context analysis which brings a holistic health systems analysis to understanding the multiple interactions between close-to-community providers, health systems and communities, in order to work out ways to intervene in two sets of quality improvement cycles.

We spent the next days, sitting in REACH Trust’s beautiful garden reading, coding and discussing transcripts in pairs and then in the plenary.  I read interviews with HSAs and focus group discussions with community members (such as mums with young children). These confirmed for me the central and pivotal role of HSAs as a bridge between health systems and communities, and how critical these are in hard to reach communities, such as rural Mchinji. One HSA referred to their role as being ‘the eyes’ of the Ministry of Health and ‘a shield’ to protect the community’s health. I look forward to working with the team on the unfolding analysis and with stakeholders at national and district level to identify the substance of quality improvement cycles to support the pivotal and critical work of HSAs in driving forward universal health coverage.

Korrie de Koning and Maryse Kok from the Royal Tropical Institute were there. They organised a mini-event in the Dutch booth, to introduce REACHOUT to the public. The presentation was well received by a small audience.

In one of the panel sessions, Korrie de Koning was asked by the Global Health Workforce Alliance to present about maternal health interventions involving Community Health Workers (CHWs). Some best practices from different countries were presented and evidence on effectiveness and barriers and facilitators of CHW performance were discussed. In the same session, WHO presented the task shifting guidelines for CHWs and a representative of the Indonesian Ministry of Health presented a case study.

The role of close-to-community (CTC) providers was discussed in a range of sessions at the conference. Key questions that were frequently raised included: how do you keep CTC providers motivated? Which kinds of incentives are most appropriate? How do we avoid over-work for CTC providers? What is the best way of training CTC providers? How can we assure they are embedded in the health system as well as in the community?

The discussions showed that many researchers, programme implementers and policy makers are struggling with the same kind of questions about CTC providers as REACHOUT. As context differs between settings, it’s often not possible to come up with one answer that fits all settings. But it seems that the evidence generated by REACHOUT will go some way to offering practical guidance to a range of stakeholders in different countries.

We asked Rukhsana Ahmed who is based at the Eijkman Institute for Molecular Biology in Indonesia to reflect on some of the maternal health challenges that they are experiencing in Indonesia and how REACHOUT might contribute to progress.

Q: Can you tell us a bit more about maternal health in Indonesia?

A: When thinking about health care delivery challenges in Indonesia what you need to bear in mind is that Indonesia is made up of 1000s and 1000s of islands. Although over 60% of the population live in Java there are still many people living in very rural, very sparsely populated islands. As a result accessing clinical care, in this case emergency obstetric care, when it is needed is not always straight forward. Indonesia has a fairly good number of midwives and nurses but their distribution is uneven. Numbers does not necessarily indicate outcomes or the quality of service. As a result there are just over - 200 maternal deaths per 100,000 live births; a reduction from about 400 maternal deaths per 100,00 live births in the 1990s and haemorrhage and other delivery complications are a big problem. This is something that the Government is committed to tackling to reach the MDG 5 goal in 2015.

Q: What services has the Government put in place?

A: Village midwives are the main close-to-community providers in Indonesia. They are involved with multiple health care tasks as well as obstetric work and work in village clinics (‘polindes and pustus’) or in community health centres, where they also provide outreach care and home births. Close-to-community providers encourage women to deliver in the health facilities but this does not always occur because women cannot always travel the distances necessary. A lack of strong telecommunications networks makes it difficult for women to alert health professionals when they need assistance. Cost is also a barrier to access. To support poorer people the Government has recently launched a health insurance scheme. But people in rural areas may not know about it and may not have high levels of faith in it. Even paying a small charge can put them off. A recent Government initiative, in 2011, was to create a partnership between traditional birth attendants and midwives to try and encourage the traditional birth attendants to take the women that they serve to the primary health clinics for care. A cash incentive was offered to offset losses that they might make in not looking after the women themselves. We are waiting to see what kind of impact this might have had.

Q: How will REACHOUT support maternal health interventions?

A: Research in Indonesia will focus on the village based midwives, nurses and health volunteers who have different levels of formal training but play an active role in the integrated health posts. They are working under difficult circumstances. For example, sometimes midwives posted in the villages don’t get their skills updated after their placement. We will assess the work burden of the midwives, who currently each cover three to four villages, to ascertain the extent to which human resource issues, such as high workload and the lack of regular further training and supervision, hamper the quality of service. The results of our work will be shared with Government, implementers and communities to try and inspire change.

On the 23 May LSTM hosted the launch of

The launch was opened by Professor Janet Hemingway. Welcoming participants Dr Miriam Taegtmeyer, REACHOUT coordinator explained: “REACHOUT will generate a body of experienced competent researchers and institutions with experience in generating much-needed research on close to community providers”.

Who are close-to-community providers?

A CTC provider is a health worker who carries out promotional, preventive and/or curative health services and who is first point of contact at community level. A CTC provider can be based in the community or in a basic primary facility. CTC providers are being lauded by some sections of the global health community as a significant force for good in strengthening weak and dysfunctional health systems. CTCs are often volunteers and women carrying out their role in challenging circumstances. From an equity perspective REACHOUT could provide important insights into how their jobs could be improved, in terms of better support and greater efficiency, and highlight the value of their hard work.

A partnership for change

Dr Theobald, who is one of the Principle Investigators working on REACHOUT, introduced each of the consortium partners from the Royal Tropical Institute (KIT), Netherlands; Eijkman Institute, Indonesia; BRAC School of Public Health, Bangladesh; Sidama Health Zone/TB REACH, Ethiopia; University Eduardo Mondlane, Mozambique; Liverpool VCT, Kenya and the REACH Trust, Malawi.

Dr Rukhsana Ahmed, from the Eijkman Institute, said: “maternal health is a big issue in Indonesia and our job is to identify the gaps and find the best solutions.” While Korrie De Koning from KIT commented: “The shortage of human resources in health is important and the contribution of the close-to-community providers is close to our hearts.”

The first year of the project is a key moment to consolidate the systems and tools to manage and communicate the project to health system actors who have the power to make positive changes to the position of CTCs. LSTM will lead on finding ways of working which complement the processes and priorities of partners and that encourage learning and sharing across the consortium.

To close the meeting Dr Miriam Taegtmeyer thanked the partners for coming to LSTM and presenting on their aspirations for REACHOUT. Partners and invitees then had a chance to network and learn more about the project.

From midwives, to traditional birth attendants, to informal private practitioners, community health workers, and lay counsellors; close-to-community providers are the unsung champions of primary health care. Working directly with individuals and families, often in their homes and workplaces, they are in a unique position to observe and understand the factors that influence health, gaining insights that may have been missed if the consultation had taken place in a health facility.

Since the 1970s and the Alma Ata Declaration there has been an interest in the ways in which close-to-community workers can improve health outcomes and bolster the number of available healthcare staff in settings where formally qualified personnel are in short supply. But close-to-community providers of healthcare often face challenges which prevent them from reaching their potential. It is not clear if this model can work in all settings and what support is needed to ensure quality services reach those most in need of them in poor and remote communities.

Coming together to support close-to-community providers

The REACHOUT programme is an ambitious international, 5-year research project with a budget of 5.8 million Euros which is helping to understand and develop the role of close-to-community health workers in tackling ill-health in rural and urban areas in Africa and Asia.

REACHOUT is funded by the European Commission’s Seventh Framework Programme for Research and Technological Development and is a partnership coordinated by the Liverpool School of Tropical Medicine between BRAC University, Eduardo Mondlane University,  Eijkman Institute for Molecular Biology, Koninklijk Instituut voor de Tropen (KIT), Liverpool VCT, Reach Trust, and Sidama Health Zone/TB REACH.

Together they will develop and assess interventions to improve close-to-community services. The findings of this research will be used to improve policy and the implementation of programmes from health systems and community perspectives. It will also build capacity in the focus countries to conduct health systems research.

There is a pressing need for learning in REACHOUT focus countries

To share research from the project and link with stakeholders REACHOUT have launched a new website. On the site you can find out more about the work we are doing in the 6 REACHOUT partner countries:

• How BRAC’s 80,000 community health volunteers and Bangladesh’s 62,000 unregistered pharmacies are meeting the health needs of the poor in urban areas
• Ethiopia’s acclaimed Health Extension Program and its ‘health development army’
• The potential of midwives, family planning volunteers and traditional birth attendants to improve Indonesia’s progress towards the Millennium Development Goals
• How REACHOUT will help inform a coordinated approach to Kenya’s Community Strategy
• The ways in which close-to-community providers are tackling HIV and TB in Malawi
• How researchers will be working with policy makers in Mozambique to try and improve child health

You can also learn about the challenges faced by programmes that use close-to-community providers, such as the way that workers have to juggle multiple workloads and competing priorities, poor planning and management which leads to staff attrition and poor supervision, and weak monitoring and evaluation systems which prevent programmes learning how they can realise their potential.