development

18 02 2018

6 Key Insights on Young People and SRHR in Bangladesh

“We live in a rapidly changing world where it is difficult to keep up. Sexual and reproductive health needs, desires, expectations, and pressures are part of this.” –Sabina Faiz Rashid, Dean, BRAC JPGSPH

From the 30-31 January I was lucky to attend the BRAC James P Grant School of Public Health (JPGSPH) Gender and Sexual Reproductive Health Conference for Young Adults 2018. The first day had a focus on young people (and over 700 university students participated) and on the second day the dialogue was with practitioners. This was a fantastic opportunity to not only hear about cutting-edge research for Bangladesh but also engage in a dialogue with researchers and civil society leaders from the region. It is very rare that I get to hear the views of young people, unmediated by a scholar or a journalist and I very much appreciated their inputs, and their insights into the issues that matter most in sexual and reproductive health and rights (SRHR).

It is hard to do justice to a conference with such riches of ideas. Here are six of the conference themes that stood out for me.

1. We need to better acknowledge the agency and power of young people.

Maheen Sultan, who is leading the Centre for Gender and Social Transformation at BRAC Institute of Governance and Development (BIGD), pointed out that today’s adolescents increasingly see themselves as people with agency and a voice. It is beholden on public health practitioners to accept this and listen and learn from younger people in the organisation of services and interventions. As one speaker pointed out, young people talk about desire, emotion, sexual orientation, pornography, and drugs but we don’t engage with them on this. There is no space to talk about the issues that they find pertinent, there is just silence. Luckily the conference bucked this trend.

There was a fascinating insight into young people’s agency in the presentation by Seama Mowri, project coordinator at JPGSPH, on early and child marriage in Bangladesh and how it can be addressed. Early marriage is occurring in urban slums which are in a period of transition (with Dhaka on its way to becoming the sixth largest mega-city by 2030). Young people live with insecurity in the forms of the risk of eviction, fragmented families, and criminality. It is within this environment that they navigate narrow and difficult choices. Mowri’s interviews with 130 young people and other stakeholders found that the average age of marriage was 15-16 years and that love relationships were losing their taboo status. In a context where many young people had access to a mobile device, the older generation were increasingly concerned that this form of communication was leading to clandestine relationships and elopement. We heard that sometimes adolescents blackmailed other young people or their parents into agreeing to early marriage, threatening to run away or commit suicide if their desires weren’t fulfilled. Within marriages the majority of married girls wanted to delay pregnancy and took responsibility for contraception even if their husband did not (and sometimes kept it a secret from husband and in-laws). Furthermore, remaining single and entering the world of work was not necessarily considered empowering. Young working women talked of the need for protections against assault and harassment. This evidence was refreshing as it did not rely on stereotypes about young people’s lives. It demonstrated the agency of young women living in difficult situations. Interventions to halt or reduce early marriage are unlikely to succeed unless they take these women’s views and life experiences into account.

2. Intersectionality matters.

A strong message from the conference was that we need more discussions of intersectionality and we need to purposefully integrate this analysis into our research and programming. Commenting on a session on mainstreaming sexual and reproductive health education, disability rights activist Anita Ghai lamented the ways in which people with disabilities were excluded from the narrative and the interventions that follow from it. For example, when talking about menstruation how often do educators talk about the forced hysterectomies performed on disabled girls because their menstruation is too ‘difficult to manage’? Or their sterilisation because parents don’t want their daughters to get pregnant? Sabina Faiz Rashid suggested that ‘inclusion’ is often performed in a very tokenistic way, “We cut and paste and replicate, we borrow. If we get compliant and complacent and we don’t look at the heart level about who we are leaving out and what we are uncomfortable with we will lose out.” If sexuality education truly informs young people and empowers them to take control of their lives, as Chief of Health at UNFPA Bangladesh, Sathyanarayanan Doraiswamy argued, we need to ensure that it is sensitive and responsive to all young people not just some imagined norm.

Intersectionality analysis matters when it comes to tackling harmful conceptions of masculinity too. Speaking on masculinities as a social construct, Anand Pawar, Executive Director of SAMYAK, argued that it is not enough for men to simply learn the language of gender equality without embodying these principles. He asked, “What if a gender sensitive man is Islamophobic or racist? Is this enough, if they are not working on power more generally?” There was a strong theme within the conference which stressed the need for a holistic analysis of vulnerability and privilege in sexual and reproductive health education and the way that simultaneous structural power relations shape this.

3. Race and colourism should be part of the conversation.

“When I was I in ninth grade and relatives would visit they would ask if I was actually my parents daughter because my skin is not fair like my brothers and sisters.” –Audience member

“I am dark skinned, and I am obese and our society always wants to point it out and judge. But I have a supportive family and I am really happy how I am.” –Audience member

We heard a fascinating talk by Azra Mahmood, one of Bangladesh’s top models, who experienced discrimination on the grounds of her darker skin and overcame these notions of beauty to have a successful career and found her own modelling agency.

She encouraged us all to take personal action to end bullying and discrimination based on society’s beauty standards and to use social media to spread the message.

There sometimes appears to be a reluctance among public health practitioners to talk freely about race and its impact on health and wellbeing – despite the ever-broadening evidence base that racial discrimination leads to psychological and physical ill-health the results of which can pass through generations.

4. Re-writing the masculinity script.

There were a few sessions at the conference that addressed what it is to be a man and how we define masculinity. Adnan Hossain’s presentation was a good reminder that there are many forms of masculinity, but some are hegemonic and others subaltern and there is a tendency to make a hierarchy of them. In Bangladesh, as in all other settings, notions of masculinity are historically dependent underpinned by a governing logic which stems from framings formed in colonial times, the war of liberation and in recent years related to economic growth.

We heard how normative ideas of masculinity tends to begin by constructing men in relation to their biology and social rituals such as heterosexual marriage and being an economic provider. Deviating from these norms can come with health and other costs and vulnerabilities. These issues are compounded for people who are non-binary, gay, bisexual and transgender. Adherence to these norms can also be unhealthy leading to self-neglect, poor health care seeking and underpinning gender-based violence against women, children, weaker men and non-binary people.

Drawing on his research of risky sexual behaviour and masculinity in Dhaka slums, Arifur Rahman painted a picture of a community of young men who were mostly sexually active before the age of 18 and had easy access to various types of illegal drugs. While many were having sex with girlfriends and with sex workers about half said that they were not satisfied with their sexual life. For some it went against social and religious norms and was shameful. Others felt it was unsafe. While they understood that using a condom and other forms of contraception was desirable they didn’t like buying condoms from the local pharmacy for privacy reasons, felt uncomfortable using them or had a lack of knowledge about them. A lack of privacy to have sex was also cited as a source of discomfort and vulnerability in this crowded urban space. The research uncovered tensions around their masculinity with concerns about sexual function and performance, such as premature ejaculation, about their ability to live up to financial expectations. Despite having girlfriends, they had conservative ideas about women’s dress and a victim blaming attitude towards harassment and assault. The majority said that if a woman doesn’t obey her husband then she deserves a beating, others said we should talk, others said that if it is extreme they should file for divorce.

In terms of efforts to challenge harmful masculinities, Sharful Islam Khan provided a wonderful case study from his anthropological studies with icddr,b arguing that global norms around masculinity are tied to notions of money, power and politics and privilege physical strength and toughness. These norms are reinforced by popular messaging, such as in the media. Anand Pawar argued that we need to create intervention with politicians, religious leaders and other powerful people who are creating the notion of manhood rather than only focusing on poor men. And we need to talk about market constructed norms of masculinity and the influence that they have.

Wangda Dorji, the 88^th person in Bhutan to be diagnosed HIV positive along with his wife.

5. Mental and physical health go hand-in-hand.

“When I had my diagnosis, I was more afraid people would know my HIV status than my fear of dying. At the weekend I would go into nature and close my eyes and contemplate that we all share the same universal consciousness. We all go through sadness, happiness… Now I only think about HIV when I take my medication at night. At other times, I don’t [care] about HIV.” –Wangda Dorji

“It is ok to hurt, and it is ok not to be ok.” –Onaiza Owais

Some sessions at the conference highlighted the importance of mental health to young people’s wellbeing more generally. Ms Onaiza Owais reflected on her own experiences of depression during university, seeking psychological assistance and medication and how finding a peer group who she could talk with in a safe space led her to use her experiences in assisting others facing similar challenges. Shila Rashid presented on eating disorders and how these are gendered and shaped by family, society, religion and our own perceptions. The way that mental and physical health are intertwined came through in their presentations, and that of Wangda Dorji, reminding delegates of the importance of seeing sexual and reproductive health in a complete way.

Copy of DSC_4571.JPG — Azra Mahmood (Right) and Anita Ghai (Left), who shared a book published in collaboration with BRAC JPGSPH on sexuality and disability titled “Untold Desires” during her panel session.

6. A focus on disability

“In normative society there is a conspiracy of silence about the sexuality of people with disabilities. It is thought that you are either asexual or hypersexual and not prioritised even among advocates for disability rights.” –Anita Ghai

The conference had a strong focus on disability not just in terms of exclusion (how disabled people are infantilised and their needs, desires and inputs are considered unimportant) but also on disability as a knowledge systems which can provide vital insights for those working on sexual and reproductive health. We learned how disability is heterogenous – India has 21 different categories of disability – if we were to build our sexual and reproductive health education system around catering to all students regardless of (dis)ability it would provide a more imaginative starting point for our discussions of love, sex and romance.

What next?

At the conference we heard from a range of implementing organisations about how they were responding to some of the contemporary challenges raised above.

Debarati Halder gave an overview of the subject of cyber-bullying, a more common phenomenon as rates of internet use and connectivity are rising. This has implications for regulation of online spaces but also young people’s self-image and mental health. Others spoke of the rise in young people accessing information about sexual and reproductive health online in lieu of decent sex education. Pornography is readily available in Bangladesh and is one way that young people learn about their bodies and sexuality. In this there is a challenge in distinguishing accurate from inaccurate information. One young person explicitly asked how young people can navigate ‘fake news’ online.

To provide accurate information we heard that initiatives like Digital Sister for Urban Youth are creating platforms which seek to understand how urban youth access sexual and reproductive health information and develop communication tools to meet their needs. Interestingly, the Digital Sister project had feedback from young people that they should also spread messages through offline channels. Young people were concerned that their parents had insufficient access to information and inaccurate beliefs and that online sources would not meet their needs. This speaks to the need to integrate online and offline spaces in ways which are targeted to the needs of users.

Echoing Jeroen Steeghs’s speech at the conference, it is important that implementers take these issues on board and do not leave them to parents, many of whom are ill equipped and lack information, to deal with. Adolescents have sexual needs, fall in love and feel attraction, explore and develop their sexual identity. They often have to navigate incorrect and distorted sources of information in the process, including from censored or abstinence-based sexual and reproductive health education in schools. More guidance is becoming available on sexual and reproductive health programming and sexuality education such as the recent UNESCO publication on international best practices. However, despite overwhelming evidence that comprehensive sexuality education works there are barriers to its implementation such as the embarrassment of teachers and parents in taking this forward. Similarly, existing legal frameworks can simultaneously protect young people from abuse while constraining access to information and justice, and these need to be critically considered.

Comprehensive sexuality and sexual and reproductive health education prepares and empowers young people to take control and make informed decisions. It can be transformative – and help to build a fair and equitable society by overcoming issues like colourism, sexism, homophobia, ableism, sizeism, marriage normativity and other forms of discriminatory practice. It is the responsibility of those working on policy and interventions to take the concerns of young people seriously and ensure that they are at the forefront of shaping the response.

This blog was written by Kate Hawkins, Pamoja Communications Ltd/REACHOUT Consortium.

The Gender and SRH Conference for Young Adults 2018 was funded by NUFFIC and implemented through a partnership between BRAC JPGSPH, RHSTEP and NIPORT.

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27 09 2017

Ensuring data quality? Let’s walk in the shoes of Community Health Workers in Kenya and Malawi

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:

Inform Community Health Workers why the data they collect and report is important.
Provide Community Health Workers with the tools that they need to do the job and ensure these are designed with their input.
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.
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.
Provide written guidelines and procedures for data management in community health information systems.
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.

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31 08 2017

Measuring quality in Malawi’s community health system: Barriers and challenges

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.

17 06 2017

What did we learn at the Inspiring Communities workshop?

By Kate Hawkins

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 licencedproviders 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.

read the report

05 04 2017

Research uptake: Learning from policy makers in Kenya

By 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.

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03 04 2017

Ethics in health systems research is ‘everybody’s business’

By Sassy Molyneux, Genevieve Dubois-Flynn, Kate Hawkins, Rosemary Morgan, Kate Gooding, Hayley McGregor, Dorcas Kamuya, and Bridget Pratt

Ethics is ‘everybody’s business’, and at the Fourth Global Symposium on Health Systems Research (HSR2016) in Vancouver last year, the stream on ‘Equity, rights, gender and ethics’ gave greater prominence to this topic than in previous years. We hope that ethics will be given the same prominence in Liverpool at HSR2018. With this in mind, we wanted to reflect on the on the ‘ethics’ highlights from HSR2016, and hopefully inform the themes of next symposium!

Making ‘ethics’ everybody’s business at HSR2016

Ethics featured in the titles and as core topics in many sessions and presentations at HSR2016 with several messages standing out for us:

It’s clear that health systems research ethics should address the broad justice questions that can be relatively neglected in biomedical ethics.

In all the sessions, there were many discussions about social justice, including the need to critically examine priority-setting and resource allocation, as well as understand and challenge root inequities. If health systems research is to contribute to reducing disparities in health and wellbeing, it should address broader social justice questions. Genevieve Dubois-Flynn, in her session, emphasised that the concepts of inequity and equity express a moral commitment to social justice and the need for action to eliminate underlying social disadvantage or marginalisation.

Adnan Hyder and Bridget Pratt led a session which considered how research priority setting (at global and national levels and by funders and research institutions) can be better structured to address the needs of disadvantaged and marginalised groups within countries. The session called for reliance on a deeper concept of inclusion in priority-setting; one that goes beyond achieving a range of stakeholders and incorporates consideration of equal voice (raising voice and being heard) and depth of non-elite participation (control, shared-decision-making). It also proposed using social value as a priority-setting criterion, where greater social value is defined as research that offers the greatest benefit to disadvantaged and marginalised groups.

A critical examination of more obvious or common micro-level ethics questions remains essential, such as examining how individual consent processes unfold on the ground.

Dorcas Kamuya highlighted how gender and power shape consent processes and interactions in complex ways on the ground, with important implications for household decision-making and the kinds of support that frontline research staff need (a paper on this topic is in press in BMJ Global Health). The latter requires careful attention given the essential interface role these staff play between health and research systems and communities, and the strong hierarchies and power inequities in many organisations and institutions.

In practice, all health policy and systems researchers have to consider their obligations and responsibilities in the face of multiple needs and inequities.

A critical examination of power inequities at multiple levels (local, national and global) should be central to health systems researchers. In two interactive RinGs sessions with a gender and ethics focus (led by Rosemary Morgan and Kate Hawkins), it was emphasised that this requires:

Good quality qualitative research, including careful consideration of researchers’ positionality, co-learning between a range of actors who bring different experiences and expertise to the table, and the use of specific approaches and methods (participatory, narrative and visual) aimed at flattening power relations; and
A careful and difficult balance between understanding and respecting local norms and processes, and considering if and how to respond to needs and inequities identified.

Regarding the last point, there is clearly no ‘one size’ simple solution: researchers’ responsibilities can include direct or indirect interventions, and shorter and longer term actions and strategies at different levels. In these contexts, a basic ‘do no harm’ principle needs constant revisiting; good intentions are not always enough and can bring unintended problems for those with least voice or power.

Recommendations and guidelines can be helpful in supporting ethical practice, but are not enough in themselves.

New ethics guidance for global health research were shared at the Symposium to complement existing guidance, and inform policies and priorities for global health research. The Principles were developed by the Canadian Coalition for Global Health Research (CCGHR) through a multistage, dialogue-based process with 300+ participants from diverse backgrounds and cultures, including the global South. The Principles encourage researchers and others to adopt more ethical and equitable forms of global health research. They include: humility, authentic partnering, inclusion, responsiveness to causes of inequity, shared benefits, and commitment to the future.

The Principles recognise that an ethical approach to health systems research and practice involves far more than uncritically following requirements and recommendations, it requires researchers to critically examine and challenge gender and other intersecting forms of inequity throughout the entire research process. The Principles underscore that considerations of the social, economic, and political conditions in which research is being conducted are core ethical concerns. They constitute an innovative learning tool to support researchers to question their own assumptions about the root causes of health inequities and their role in addressing them.

What next for the Ethics of Health Systems Research Thematic Working Group?

The discussions on rights, justice, inequity, gender and intersectionality, participation and voice, and resources and control were heard throughout HSR2016, and are all fundamental ethical concerns. As a Thematic Working Group (TWG) for Health Systems Global (HSG) we plan to take forward these discussions by adding a focus on power, politics, equity, and rights, and continuing to promote a recognition that ethics is everybody’s business. With HSR2018 in our sights, a key priority is to broaden the voices contributing to ethics discussion and debate.

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To join our TWG please get in touch with us through our webpage. We look forward to hearing from you!

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Image credit: Feng Yu/Shutterstock.com

06 03 2017

What does trust have to do with Community Health Workers and the Sustainable Development Goals?

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.

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09 12 2016

Four tips for embedding quality improvement in community health worker programmes

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.

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05 08 2016

How we are supporting the world health organization’s work on community health workers and what you can do

By Kate Hawkins

Back in January the Thematic Working Group on Supporting and Strengthening the role of Community Health Workers (CHWs) in Health Systems Development co-hosted a session at the Prince Mahidol Award Conference on “CHWs for Achieving UHC: Experience in using evidence to guide decision-making for CHW programs.” The event was something that we ran in partnership with USAID and the WHO Health Workforce Department. It was a step in the process of supporting WHO in their development of normative guidance on community-based practitioners.

The session examined three key areas: how evidence is used to inform decision-making; the effectiveness of different approaches to facilitate decision making and; how to support the use of evidence and capacity for decision-making in priority setting for CHWs. You can read the full report here.

Have your say

WHO have opened a public consultation on these issues, and more. The rationale behind the consultation is that,

“In the last few years, there has been growing interest and attention in the potential of various types of CHWs in reducing inequities in access to essential health services, particularly in under-served or excluded, vulnerable populations. The WHO Global Strategy on Human Resources for Health: Workforce 2030 encourages countries to adopt a diverse, sustainable skills mix, harnessing the potential of community-based and mid-level health workers in inter-professional primary care teams…The support for CHWs and their integration into the health system, however, remain uneven across and within countries. This is hindering the full realization of their potential contribution to the implementation of health policies based on primary health care”

The TWG would like to encourage members of Health Systems Global to feed into this process, bringing a wide-range of evidence and experiences from a variety of different settings. Some of our members are already engaged (for example Polly Walker of World Vision is a proposed member of the Guideline Development Group).But there is more that we can do to bring our collective knowledge to bear.

WHO are asking for feedback on the relevance of the Population, Intervention, Control, Outcome (PICO) framework that they have put together for a series of systematic reviews. Please asses their relevance and support this important process. They would prefer group rather than individual submissions. I hope that you can help.

The deadline for inputs is the 31 August 2016.

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Image credit: Marc Wathieu, Creative Commons license 2.0

04 08 2016

Improving the quality of services provided by community health workers

By Lilian Otiso, Pierre Barker, Diana Frymus, Kate Hawkins

Why Community Health Workers?

Across the globe, community health workers (CHWs) deployed in a variety of different roles and contexts (village health workers, community volunteers, lay counsellors, home-based care givers, etc.) have contributed substantial health benefits for community members, including mothers and children. In sub-Saharan Africa, CHWs have been an important strategy to address the severe shortages of skilled health workers, particularly for the poorest and most vulnerable populations.

Appropriately trained CHWs have the potential to address barriers to preventive and curative care, to bring care closer to communities, and provide accessible, appropriate services at household level. However, if community-based services are to be effective, it is important that CHWs receive appropriate support that spans training to supervision. The design of community-based programmes should include sustainable approaches that develop and maintain high quality performance by CHWs for the households and communities they serve.

Using Quality Improvement methods with CHWs

Quality Improvement (QI) approaches have been successfully implemented in low to middle income countries to improve the delivery of care at facility level. Increasingly, efforts have demonstrated that QI methods can be adapted to community settings to strengthen coverage, quality of care and retention in care for HIV and maternal and child health. A number of projects are trialing and testing different approaches to QI to better understand what works under what circumstances and how improvements in quality can be sustained over the longer term.

One key example is the USAID SQALE project. Building on the work of REACHOUT a community systems strengthening project, the USAID SQALE project is seeking to embed and study the implementation of QI at the community level in Kenya. As a first step, lack of supervision of CHWs was identified as a major barrier affecting quality of services and motivation. Subsequently, supervisors have been trained on how to conduct peer to peer and group supervision and provided with tools to facilitate the process.

Putting it all into action

In Kenya, there was an increased number of group supervision sessions compared to when the project begun and importantly, community health volunteers reported improvement in quality of supervision from fault finding to supportive and beneficial. When it comes to embedding these successes more broadly, community health volunteers (CHVs) led by a community health extension workers (CHEW) will be grouped into work improvement teams and trained on QI to enable them develop and review QI plans during their monthly supervision sessions.

The CHEWs from different work improvement teams will form a sub-county QI team led by their supervisor at the sub-county level. This team will also meet monthly to review reports and feedback from work improvement teams, prioritize problems and develop strategies and action plans for addressing those problems using QI approaches. Continuous mentorship will be provided by program staff and eventually transitioned to Ministry of Health staff responsible for community health programs similar to other QI programs. USAID SQALE will improve community data quality, measure maternal, newborn and child health outcomes. This is all as a result of the community QI approach.

Bringing QI and CHWs together

Health Systems Global has Thematic Working Groups (TWGs) that are looking at both QI and CHWs. There is a clear affinity between these TWGs, as they want to expand the conversation that goes beyond looking at how facilities can improve, and share the evidence for QI approaches at the community level.

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Please do get in touch with us if you have learning to share and we look forward to engaging with you in the future.

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Image credit: UNICEF Ethiopia, Creative Commons license 2.0