health

09 03 2018

On International Women’s Day we need to shine a spotlight on women in fragile and conflict-affected settings

This blog post is part of a wider HSG blog series to celebrate International Women’s Day 2018. In this series, HSG members provide their perspectives on why gender should be a critical component of UHC, and what we can do about it.

By Sally Theobald, Valerie Percival and Kate Hawkins

Attention to fragile and conflict-affected states is critical to achieving universal health coverage, along with progress on other Sustainable Development Goals on gender equity and social justice. We need to ensure that women’s needs are met during crises and war, and that we join up action here with longer term, sustainable solutions.

Gender inequities neglected

In our work on gender and post-conflict health systems – Building Back Better – we explored the extent to which gender had been addressed in health systems rebuilding in several post-conflict states, including Mozambique, Sierra Leone, Northern Uganda, Timor Leste, Zimbabwe, Cambodia and Bangladesh. We found limited attention to gender equity in rebuilding efforts, and that conflict-related inequitable health outcomes linger in post-conflict health systems. These have wide-reaching implications for the health of communities, which need addressing urgently.

Post-conflict opportunities

To borrow the strapline for International Women’s Day 2018 we need to “#pressforprogress” against pernicious gender inequities in health systems in fragile and conflict-affected contexts. Health systems are key employers and respected institutions within society; they both reflect and shape the social, political and economic context that they are part of, and the lack of emphasis on gender equity within health systems is a significant missed opportunity. The health system could, and should, be an arena for building greater gender equity in all society.

Policymakers assume that if you build health systems they will be equitable; yet there is little guidance for people who may want to take a gendered approach to planning and implementation. To help address this, we developed bench marks for gender equity to be addressed within the health system, and produced case studies to highlight change and promising practice, including indigenous efforts towards embedding gender equity, such as in post-conflict Bangladesh.

Supporting female health workers

Health systems strengthening efforts require a strong and supported health workforce. There are challenges here in fragile and post-conflict contexts, where health workers are few, due to death or out-migration. In these settings there is a particular need to recognise and support the vital work of women health workers at all levels of the health system. This was an area of focus in a recent webinar jointly hosted by the World Health Organisation, the Global Health Workforce Network and Women in Global Health. Our research on the ‘gendered health workforce’, conducted through the ReBUILD and RinGs programmes, was presented, highlighting not only the multiple challenges women health workers face in Sierra Leone, Zimbabwe, Cambodia and northern Uganda, but also the incredible resilience they show in continuing to deliver vital services despite threats to their own lives, and risks of sexual and gender-based violence.

On International Women’s Day we call for women health workers working in contexts of ongoing crises and conflict, such as Yemen, to be recognised, celebrated, supported and kept safe.

Pressing for progress

The recent launches of Canada’s Feminist International Assistance Policy and DFID’s Strategic Vision for Gender Equality (which has a specific focus on protecting and empowering girls and women in conflict, protracted crises and humanitarian emergencies) shows increasing focus on this issue, which is welcome. “Pressing for progress” means that all actors need to focus seriously on gender in their work. Strong, joined-up and gender transformative approaches to health systems strengthening are required.

Read the article

05 12 2017

Problem solving on maternal health: Experience of Shebedino Quality Improvement Team in Ethiopia

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.

Read the article

27 11 2017

A Community Health Worker gender action framework: Implications for decent work, rights, and responsibilities

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.

Read the article

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.

Read the article

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.

Read the article

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.

—

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

—

Image credit: Feng Yu/Shutterstock.com

27 03 2017

Emerging issues related to gender and community health workers

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’.

Link to the article

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

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.

Read the article

20161216_Health_after_conflict_-_Panel_slide

16 12 2016

How to get health systems evidence into policy and practice in fragile and conflict-affected settings

By Kate Hawkins, Pamoja Communications

This week I struggled through the Southern Rail train strike to attend a ReBUILD meeting in London. The long commute aside, this was a great opportunity to reconnect with colleagues and hear more about the consortium’s work and synthesised learning from the last few years.

Being a communications person I was particularly taken by the discussions about how to encourage research uptake in fragile and conflict-affected settings. An eminent panel – Gibson Mhlanga, Ministry of Health and Child Care Zimbabwe; Lara Ho, International Rescue Committee; Rene Loewenson, Training and Research Support Centre; and Egbert Sondorp, KIT – gave us their views. They were chaired by Freddie Ssengooba from Makerere University, who plays this sort of role effortlessly.

What did we learn?

Barriers

Fragile and conflict-affected settings have their own particular set of challenges when it comes to research uptake. Gibson Mhlanga talked about how a lack of funding for the health sector can prevent the translation of good evidence to change on the ground. To some extent this is a problem faced by all countries that fail to meet their commitments to financing the health sector, but can be more pronounced in these settings. When conflict or crisis abates, policy engagement may be trickier due to the multiplicity of stakeholders that one needs to relate to. In addition to the usual governmental stakeholders a range of donor and humanitarian actors may need to be taken into account. Egbert Sondorp talked about policy complexity, in that influencing must be more than ‘SWAP+PRSP+budget support’, and that after conflict or crisis, there can be a range of new settlements, directives, and regulations under construction which need to be understood and analysed. Finally, traditional academic methods of evidence generation (with their focus on academic publication and other incentives) may be at odds with more action-oriented approaches to the generation of new knowledge.

Solutions

Lara Ho talked of the need for demonstration projects to show to policy makers how potential interventions that have been used elsewhere might be adapted and implemented in fragile and conflict-affected settings. Just knowing that evidence exists is not necessarily sufficient to prompt change – new ideas need to be ‘brought alive’ so that they prompt the imagination. She suggested that exchange visits – where policy makers are accompanied to other countries to better understand how innovations have been implemented – can be a powerful tool for the uptake of evidence.

Rene Loewenson explained how the ‘tactical generation’ of evidence may be needed, in a fashion that points to policy solutions rather than uncovering weaknesses and problems. In this, a less positivist approach to evidence, which is inclusive of different development sectors and utilises participatory methods, can be particularly powerful. She and Egbert pointed out that the traditional time horizons of ‘projectised’ research projects of 3-5 years may not be sufficient to implement a longer term, systemic approach that enables researchers to seize ‘windows of opportunity’ to effect change.

Several speakers talked of the need to design research projects that meet the policy and programmatic needs of multiple stakeholders – implementers, decision makers, and communities – and that this requires an approach to the generation of research questions and approaches which is deeply embedded in the setting one is working in.

Hearing from the panel I was struck by how seldom I get to go to meetings where research uptake – rather than findings – are the centre of attention. Learning from other communications professionals employed by health systems projects and hearing from those grappling with similar challenges is always reassuring (we are facing similar problems) and enlightening (there are routes to change that we can experiment with). I commend ReBUILD for creating such a space and hope that we can facilitate more of these shared opportunities for discussion.

Read the article