By Kate Hawkins, 25 November 2013
The REACHOUT team came together for a Consortium meeting from the 4th– 8th of November in Amsterdam. Our meeting was hosted by the team at KIT who provided great facilitation, a wonderful venue and warm hospitality (despite the pouring rain). The meeting was a chance to catch up on progress over the last nine months and to strategise together about how to move forwards. It was exciting to see the volume and quality of the work that has been completed in the early stages of our project and lovely to connect with friends and colleagues, old and new.
I think it is fair to say that everyone was impressed by how far we have come. In the last nine months we have: put in place a strategy for capacity building under the leadership of James P Grant School of Public Health; created Country Advisory Groups of critical allies in each research setting and met with them to get feedback on our plans; held stakeholder meetings; formed an Expert Review Group for the Consortium as a whole; put in place systems for management of the project; secured ethical approval for our context analysis; collected lots of data from each country and analysed what we have; conducted a literature review; attended and presented at international conferences; and we are on the way to finalising our communications and research uptake plan.
A view from each country
At the meeting each country feedback learning from their context analyses, what follows is a whirlwind tour of the contexts that our research will take place in.
In Malawi REACHOUT will focus on Health Surveillance Assistants (HSAs) in Mchinji and Salima. HSAs are the lowest cadre of frontline health workers who provide Malaria, TB, HIV and child health services in hard to reach areas and are employed on a range of NGO projects and by Government. The system in which they work is often ‘dis-integrated’ from the formal health system and in need of regulation. Whilst HSAs are highlighted as a key cadre to deliver the essential health package as part of the sector wide approach they are also expected to work to deliver illness specific policies for such as those related to TB and Malaria. This can create challenges in terms of supervision and coordination and means that their roles and responsibilities often change. HSAs often complain of inadequate salaries and supplies such as pens, gum boots and registers. There are different systems of supervision and monitoring and evaluation across NGOs, Government, health centres, the district and national level which can cause confusion.
84% of the population of Ethiopia live in rural areas and in a setting with high maternal mortality which makes it a national priority. In Sidama there is high ante natal care (ANC) but low institutional delivery which is why it is a focus area for REACHOUT. The Health Extension Programme (HEP) started about a decade ago deploying salaried Health Extension Workers (HEWs) to deliver primary health services to the community. Recently, HEWs extend the services to the community using a ‘health development army’ which works closely with households. Health promoters, include Traditional Birth Attendants (TBAs), who used to work in the community have been integrated into the Health Development Army. HEWs are supposed to work on 16 health packages and because they have so many tasks to do their workload is high. They are also involved in other community activities which are crucial to the overall improvement of the community they are serving. The area that they have to cover, and the population size they are responsible for, influences their capacity to deliver services in the community.
In Kenya REACHOUT is concentrating on integrating HIV and community systems in Nairobi (the capital city) and Kitui (a rural area). Currently Community Health Workers (CHWs) receive basic training from the Government and cover 1000 households (5000 individuals) for whom they do health visits and referrals. They are volunteers from the community who provide preventive and promotive services and basic curative services for things like straightforward malaria. They are supervised by Community Health Extension Workers (CHEWs). The Community Health Strategy and Structures are currently in a state of flux and training curricula and a monitoring and evaluation strategy are being developed.
In Mozambique we are focussing on child health in rural areas (Moamba and Manhica). The Agente Polivalente Elementares (APE) programme was introduced in 1978 and was revitalised in 2010. It is expected to increase health service coverage from 40-60% of the population. In Mozambique health centres are mostly situated in urban areas and access to health care in rural areas is limited. The APE programme is viewed as a way providing access to basic health care to population in rural area currently with no or limited access. The role of promoting healthy lifestyles and preventing ill health due to poor sanitation, diahorrea, malaria and respiratory infections for children is mainly the responsibility of close-to-community providers who are paid a subsidy. The APE Programme went from being volunteer based to paying the workers a subsidy (not salary). APEs face challenges with regard to deficient supervision, pressure from donors to expand the APE responsibilities into other areas of ill-health, stock outs of medications and other supplies used by APEs, late payments of subsidies, large numbers of clients dispersed over wide areas and the fact that communities would like them to provide curative services too.
Indonesia is a huge and diverse country in geography, culture, ethnicity and religion and providing health care to rural and remote areas is a challenge. The maternal mortality rate is 359 per 100000 live births which is why it is a REACHOUT focus. There are a range of close-to-community providers related to maternal health in Indonesia. Village midwives provide ANC and post-natal services and attend the village integrated health post (posyandu) together with the village health volunteers (posyandu kaders) who are engaged in multiple tasks like child vaccination and growth monitoring . Alongside these Government paid midwives, there are trained and untrained TBAs who do home deliveries and accompany women to health facilities when necessary. The community can request a nurse or midwife placement in their village but they are not involved in the selection. It is difficult to recruit midwives to work in villages because of housing and education for their children. Some midwives report that they are on call 24 hours a day which is difficult to manage. Other challenges reported by close-to-community providers include a lack of clear supervisory systems, information feedback loops, and follow up on problems (such as equipment breakdown and building management). Whilst there is a universal insurance system that covers ANC visits, delivery and post-natal care, women are still not delivering in a facility because of the distance from health facilities, poor road access for ambulances and other transport means and a preference for delivering at home (sometimes with TBAs because they offer services embedded in traditional practices like massage, turning the baby and hot tamarind baths which women appreciate).
In Bangladesh we are working in Dhaka and Sylhet where there are pluralistic health systems and the market is characterised by an inappropriate skill-mix with inequitable distribution of providers including traditional healers, TBAs, and village doctors. Informal providers are providing the health services in the community and there is no systematic quality assurance or regulation. There are three categories of close-to-community providers, namely public sector providers; private community health workers who are managed by NGOs (including BRAC’s Shasthya Shebikas, Shasthya Kormis, etc.); and informal providers who are independent service providers embedded within the community. Healthcare financing is mostly out of pocket and people report that they like informal providers because they are from the community, easily accessible, provide door-steps services, provide medicines on credit and they are trusted. There is a lack of linkage between formal and informal providers and a lack of oversight creates difficulties in providing joined up and appropriate services at the community level.
All REACHOUT partners will have finalised their context analysis by the end of the year which will help them to prioritise which areas of the close-to-community programmes they will target for improvement. The meeting provided an opportunity to share and test out potential tools which will be used to implement the improvement cycles that we have planned for next year. Ensuring that the tools that we use and the areas we target have some common elements was one of the things that we focussed on when we met as we will synthesise learning across our different settings as well as offering recommendations for in-country stakeholders.
Participants left the meeting a little exhausted but full of ideas for how their research might roll out and with a renewed sense of solidarity about how we can work together and help each other grow as we move forward. Our next meeting will take place in Mozambique in March 2014 and we are looking forward to being hosted by our colleagues at University Eduardo Mondlane.