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20 August 2015

Life histories: a research method to capture people’s experiences of health systems in post-conflict countries

By Sarah Ssali, Sally Theobald and Kate Hawkins*

This blog post is part of a series on people-centred research methods for health systems development published in conjunction with a Twitter chat on the same topic. Please see below for links to other blog posts in this series.

The ReBUILD Consortium is conducting health systems research in post-conflict contexts. This brings with it several challenges, including: lack of data, recall and memory lapses, ensuring confidentiality and the changing contexts of conflict and displacement. Often people have experienced multiple traumatic events which many may want to forget, although these memories could be of importance to the reconstruction process. Both conflict and post-conflict rebuilding are political processes. So, attempts to rebuild a health system will be influenced by power relations, which in turn are shaped by historical, regional and social inequalities, and there is need to ensure that the experiences and realities of affected populations feed into the rebuilding process: life histories bring particular opportunities here.

What are life histories?
Life history interviewing is a qualitative method of data collection where people are asked to document their life over a period of time. It is a personal account of their life, in their own words and using their own personal time lines. Accordingly, they tend to be selective, contingent upon remembered events that are amenable to being told, be they fact or fiction.

Our study involved 47 heads of poor households (aged 45 years and above) in Gulu District, northern Uganda. Of these, 26 were women and 21 were men. Each life history was conducted by a pair of researchers, one interviewing and the other recording both manually and electronically. The heads of households were asked to narrate the story of their life as far back as they could remember, from whichever year, as long as it was before the war. They were asked to mark significant life events on a timeline covering the three key phases: before the war, during the war and after the war. The aim was to document changes in their households’ ability to cope with household health care costs over the three time periods. For each phase, they identified their major life event, why they considered it significant, and what memories they attached to it. For illnesses, they named the illness, the treatment sought, where treatment was sought from, how much was paid and the treatment outcome. As they narrated their life story, the researcher in charge of recording drew the timeline, matching the events with the years (if the respondent could remember it) and the outcomes.

The choice of determining what was a significant life event and why, health, health events, treatment sought, cost, what was paid and what was foregone to pay the cost of health care was left to the respondent to define and articulate. This was considered more empowering than choosing for them. Having told us their life experiences, they went on to give us their expectations of what good health care meant and recommendations for reconstruction. That way, we ceded some of our power as researchers, to participants to tell their own story other than just reproducing knowledge as part of the post war research industry. In addition to the lifelines drawn, the results of these life history in-depth interviews were transcribed, translated from Acholi into English, and analyzed thematically using Atlas ti software.

Examples of extracts from life histories
“…just only two things stick out for me: the sodomy I endured and how we left home going to the camp. We were chased from our homes in a very bad way, we only survived by God’s grace, it was not a good experience at all. Also there was a time we were abducted by the government army and they tied us with ropes and they were pouring on us red peppers [red chilli powder] just direct on our faces. We just escaped death narrowly”. (70 year old man).

“… we were on the run. … Sometimes they seriously fought and killed people. Here in my home, I was captured three times [by the rebels]. That was the year when the Kony war was severe; it was in the middle years. It was very bad. I cannot recall the year very well. … If you slept in the house, they could come and knock the door…if you opened, they ordered you to take them where people are, you see. There they would go and kill people in that home. I stayed badly here. We really faced problems here. The year?…I was captured three times…They captured my boy and went with him. They went with him. We started sleeping in the mission for the three years. Then it ended we are now here.” (72 year old woman)

Challenges
Like any other method there are challenges and advantages to this method. It’s a lengthy process and given the traumatic nature of the events experienced including death, abduction, torture and rape of women, men, girls and boys, developing rapport and trusting relationships is critical. Conversations need to be carefully and sensitively carried out.

The transcripts created a lot of data which takes time to record and analyse. The ability of one person to textualise the life of another for unknown readers is a challenge the researcher has to be cognizant of as they translate the life story into research reports or participate in research engagement activities, deciding which aspects to highlight and which to omit. Furthermore, decisions have to be made on re-representing the private/intimate details on people’s lives. This can create ethical dilemmas. Ensuring the confidentiality of vulnerable groups discussing their experiences of conflict, including for example male rape, within a homophobic context is critical.

Advantages
But for all the challenges outlined above we found life histories to be useful. They helped us explore and identify the dominant narratives of people’s lives within particular events and situations. These narratives were contextualised – they described how a particular event came to be significant, and how opinions and decisions change over time.

Life histories are good at enabling people to recollect the past and document change, especially where some events could have been missed out through other methods requiring simple recall of facts. People may not remember the actual details but remember the significant events.

Furthermore it is participatory and gives the respondent more voice than other deductive methods. We found that it empowers the respondent, giving them a more prominent role to decide what is significant, why it is significant and to locate themselves within the experience. As part of this it helps people to evaluate their lives, clarifying what life would have been and why it was so. At the same time it provides a history beyond the personal, the analysis helps to show that lives are not free floating but occur in a social context, hence are socially constructed.

What life histories taught us about health
The method demonstrated to us that choices about health are determined by forces beyond the health sector, such as gender relations, livelihoods, conflict, etc. Consequently, strategies to rebuild post-conflict health systems cannot be reduced to health interventions, but also need to encompass a focus on people’s livelihoods and social relationships. While the post conflict effort emphasised building/renovating health facilities, our life history participants spoke more of income generation strategies because with money, they could navigate the new post conflict health context which is characterised by poorly functioning public facilities and expensive but well facilitated private facilities. The life histories highlighted the importance of mental health as a key component of post conflict health reconstruction. They made prominent how men and women had experienced sexual and gender based violence. There is need to ensure services respond to the realities of all groups: and both women and men’s health needs should be provided for. We need to address people’s physical and psychological needs, and subsequently end the cycle of violence. Life histories also challenged common assumptions about war and disease, showing opportunities that existed in the war, such as ease of delivery of health services due to encampment.

We would be very interested to link up with other health systems researchers who are using a life history approach in other contexts and to think further what this method – and others that are people-centred – can contribute to the body of knowledge that we have.

* Sarah Ssali is a Senior Lecturer at the School of women and Gender Studies, Makerere University and Co-Pincipal Investigator on ReBUILD. She is also part of Research in Gender and Ethics: Building Stronger Health Systems (RinGs).

Sally Theobald works at Liverpool School of Tropical Medicine and has wide ranging experience of designing and implementing gender sensitive qualitative research projects on HIV, TB, SRH and health systems in Africa and Asia.

Kate Hawkins is Director of Pamoja Communications. She likes writing about health, gender and sexuality.

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18 August 2015

The ebola outbreak and the wider health system: understanding impact and the way forward in liberia

By Laura Dean, Anthony Bettee, Kate Hawkins, Sally Theobald and Karsor Kollie

During the recent Ebola outbreak Liberia lost over 185 of its professional health workforce. Trust between health workers and communities broke down and resources were diverted from routine health system activities to control the outbreak. This resulted in the near collapse of the health system as well as changes in the disease landscape and increased vulnerabilities related to the social determinants of health for many people. As the health system is rebuilt, it is critical that the full impact of the outbreak at all levels of the health system is understood from the perspective of different stakeholders, in order to put forward strategies to strengthen the resilience of the health system.

Small grant
In collaboration with the Ministry of Health in Liberia, COUNTDOWN colleagues were recently awarded a small grant for research engagement from the Thematic Working Group on Health Systems Research in Fragile and Conflict Affected States. We will use this to convene two stakeholder meetings, one at the national and one at the county level that explore the impact of the Ebola outbreak on the health system with a specific focus on the Neglected Tropical Disease (NTD) control programme. We aim to highlight the opinions of people whose voices are often not heard at such meetings, for example community members and frontline health staff. We hope these meetings will provide a unique opportunity to gain deeper understanding of the impact of health system collapse on vertical programmes and explore how these programmes can help support the wider system.

The Neglected Tropical Disease Programme in Liberia
The NTD control programme in Liberia is an integrated programme established in 2012 that engages with the health system from central Ministry of Health to the community level. During the Ebola outbreak the NTD programme ceased activity in order to support Ebola control, however it is now slowly beginning to resume activity. However before it starts up fully there is a need to understand in more detail the challenges faced in NTD control both prior to and since the Ebola outbreak. The stakeholder meetings allow reflections on the operations of the NTD control programme prior to the Ebola outbreak, as well as assessing how the Ebola outbreak may allow for a revitalisation of the programme to achieve a scaled-up, equitable response to NTDs in Liberia.

Follow-up
As a result of the meeting we hope to develop a research agenda for health systems with specific focus on NTD control in Liberia that we can begin to address within COUNTDOWN. The engagement of international stakeholders from other Ebola affected countries such as Sierra Leone aims to increase the transferability of this research agenda and its findings, as well encouraging south-south collaboration and lesson learning as health systems are rebuilt. Watch this space for more information and outputs from COUNTDOWN’s first stakeholder meeting in Liberia!

This blog post first appeared on the Cross-Talk blog.

Photo: Two women in front of Ebola billboard in Monrovia, Liberia. Credit: UNMIL/Emmanuel Tobey

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17 August 2015

Intimacy, love, freedom, heartbreak, separation and migration

By Kate Hawkins

A conference participant views the ‘Queer Crossings’ poster

Sitting in front of a South African poster on ‘queer crossings’ was one of my highlights from the recent Migrating Out Of Poverty conference in Singapore. It made me happy that one of my pet subjects – sexuality – was being addressed by such a stellar line-up of researchers studying gender, poverty and migration linkages.

I find it difficult to think about gender without a corresponding focus on sexuality as the two things so often intersect in interesting and important ways. It is particularly pertinent when we look at issues of women’s empowerment:

If for example, you look at women’s empowerment through a sexuality lens, you see a more complete and realistic picture of a woman: not a victim, nor an end-product ‘empowered’ woman, but a woman with a complex and changing life. You see a woman whose well-being depends, among other things, on making choices about her own body, about pleasure and about her own sexuality. You also see a woman who lives within or perhaps challenges the confines of social pressure and expectations about her behaviour. A woman’s sexuality and identity can affect many aspects of her life including her work and her means to earn a living, her family relations, her ability to move around in public, her opportunities to participate in formal and informal politics, and her access to education.

It is also a useful way of thinking about gender in terms of men and people who define themselves as something beyond/outside the binary of man and woman. (Even Facebook now has a list of over 58 gender options that people can choose from to describe themselves. Some of us scholars are lagging behind on this score!)

Sexuality came up in many of the sessions at the conference – even if it was rarely used as a frame of analysis.

Poverty, precarity and sexuality
Susie Jolly has written about the importance of housing to the realisation of sexual rights and desires and the constraining effects of poverty. This seemed relevant to some of the examples of migrant life spoken about at the conference. Trond Waage’s film, Les Mairuuwas, followed migrants from the Central African Republic in Northern Cameroon who were working as water carriers. One character didn’t see the point of a home, or felt that it was an unnecessary use of resources. But when he moved in to a room he realised that he had invested in the community and it also gave him the opportunity to have a sexual relationship. We heard from many presenters at the conference about the (inappropriate/inadequate) housing conditions of migrant workers. Some were living in their workplace with employers, particularly domestic workers. It would be interesting to better understand the effects of these living and working arrangements on migrants’ abilities to form intimate relationships and the wider effects on their lives.

‘Dangerous’ sexualities and the female migrant
There is a prevailing narrative about the sexual vulnerability of female migrants which was echoed in some of the discussions at the meeting and the presentation on employment brokers was particularly chilling in this regard. However speakers also pointed to the way that female migrants are often stigmatised on the grounds of their sexuality – which is imagined as undisciplined and unruly when far from home.

In a memorable talk about young women from Zimbabwe Stanford Mahati quoted one boy as saying ‘Good girls do not cross the border’. Mahati’s analysis of humanitarian workers’ formal and informal discourse around working migrant girls showed that they were often labelled as ‘promiscuous’, ‘lacking in morals’ and ‘far from innocent’. Meanwhile Ishred Binte Wahid spoke about notions of ‘purity’ in relation to Bangladeshi women migrants who travelled to work in the Gulf States. Female migrants found that religious piety (for example wearing the burkah) was a way of counteracting negative aspersions about what may have happened in their sexual lives whilst they were away from their families. She questioned the notion of female migration as inherently empowering and pointed to how it could sometimes reinforce patriarchal norms.

We heard from South African sex workers in the MOVE visual exhibition. Sex workers are arguably some of the most maligned ‘bad women’ in patriarchal societies’ bogus hierarchy of womanhood. Visual methods enabled them to take back control of the stories about their lives and express their humanity. Chantel, a participant from Johannesburg, wrote in her journal,

Telling my story is so powerful for me. Every day I look forward to writing or thinking about my story. I want to take images that show the way that sex workers are treated. That I am a person. This project let me do this. It helps me to take away stress and to know that I am not alone.

The conference was silent on the issue of the clients of sex workers, despite the fact that it is likely some of them are men characterised problematically in the HIV literature as ‘mobile men with money’. Migration researchers may have some interesting insights for their counterparts in health on this issue.

The pain and the liberation of separation
Some presentations at the conference explored the ways that prolonged separation due to migration could lead to challenges in maintaining ‘family unity’. One study from Indonesia showed how 18% of married migrants ended up getting divorced which was contrasted with a divorce rate on 7% in non-migrant families. This had particular impacts on the income of divorced women who also faced negativity from the wider community on account of their divorcee-status.

Deirdre McKay’s presentation of the lives of Philippine women working without documents in the UK explained how long separations with little chance of being reunited due to cost and visa restrictions created stress and a strain on family life. However, she also argued that living in chronic poverty can cause family tensions. She pointed to the potentially liberating aspects of separation in some circumstances and highlighted how when men are ‘dud’ husbands (i.e. they gamble, drink, or can’t look after money) there is often migration in lieu of divorce.

Future sexuality-migration exploration
As a newcomer to the field of migration studies it was fantastic to attend the recent conference. I hope that as work on gender continues there is critical reflection on the topic of sexuality and some cross learning with other programmes working on the poverty-sexuality links. In particular it would have been interesting to hear more about same sex desire and the migrant experience and to have a more explicit focus on heteronormativity. Interesting research from (my friends at) Galang in the Philippines described how lesbian women and trans men migrated because of homophobia and gendered discrimination. For these people migration (and the money earned) sometimes created opportunities for sexual freedom and improved status within the family but it could also leave people vulnerable to homophobic abuse. These are interesting insights which are ripe for further investigation in other contexts.
Kate Hawkins is the Director of Pamoja Communications. She works on communications and research uptake for projects looking at health, gender, sexuality, and more. Kate was the communications consultant on the Gendered Dimensions of Migration conference for the Migrating out of Poverty Research Programme Consortium.

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31 May 2015

A webinar to help define a health systems research agenda in fragile and conflict affected states

By Kate Hawkins

For some months now our team within the Thematic Working Group on Health Systems in Fragile and Conflict Affected States has been involved in a process of canvassing opinions on key research needs. This has included face-to-face meetings, a survey, and online discussion. This has enabled us to reach out to over 500 people in 28 different countries (over half of which could be characterised as fragile). This week we added a webinar to the portfolio of tools we have used to try and build a consensus with a wide range of stakeholders.

The challenges of conducting research
Our colleague Egbert Sondorp explained that as the work has developed the sheer magnitude of research needs has become apparent. We have also become aware of some of the barriers to high quality work in this area. These include infrastructural issues such as insecurity which can lead to the risk of ‘convenience sampling’. Travel bans imposed by donors can sometimes mean that bureaucracy trumps the need for good data. In many settings there is a shortage of researchers and data collectors and disruption of research infrastructures hinders health system research and can make processes like ethical clearance more challenging. Among donors there can be a lack of political will to provide ongoing, flexible financial support and so it is difficult to maintain continuity to manage the research process in a sustainable manner. There are real difficulties when it comes to research uptake. Too often research agendas are concocted by outsiders and therefore don’t necessarily tackle the issues that decision makers on the ground feel are most pressing. The plurality of stakeholders involved in the health sector post-conflict make it difficult to know who to target. Lack of state leadership and ownership of research can make it less likely that findings get used.

What have we learnt so far?
Aniek Woodward ably gave us a taste of some of the research issues that have been prominent in our discussions so far. These included the transition from emergency support to long term health system building. The importance of resilience – particularly in settings where populations experience recurrent shocks. She also raised the issue of non-state actors and how to ensure accountability in settings where the state is weak.

We were lucky to be joined by two great discussants Khalifa Elmusharaf and Nigel Pearson who interrogated some of the findings of our work. Khalifa pointed out that wars destroy trust, identity and social ties – community cohesion – and this has implications for health systems. What is needed in these settings are methods that bring the voice of marginalised citizens (women, refugees, disabled people etc.) into decisions about health systems. He made the great point:

‘If we don’t listen to people how will we plan accessible people-centered health services in post conflict settings?’

Nigel reiterated the point that we don’t just need enthusiastic outsiders to conduct this type of research. What is required are people with a deep knowledge of the context and environment – this calls for research into the type of research partnership models we employ and how funding is delivered. He stressed that too often shortcuts are taken in the research process – either in terms cherry picking the geographical areas covered or the methods that are used. In addition research can be hampered by problems of government legitimacy and sensitivity about questioning government decision making. He also made interesting points about gender and the employment of women in research and health care delivery its potential impact on equity and the amelioration of conflict.

Ethics, community engagement, local ownership and more!
Are webinars like, ‘talking to an invisible public’, as one of our panellists put it? Not in this case. With 32 audience questions in an hour we had great participation and a lot of important inputs to the research process to mull over. It is impossible to do justice to them all here but questions and issues raised included:

The importance of governance and leadership
How to conduct research in areas controlled by those who are hostile to outside interference – such as Al-Shabab in Somalia

The perception is of research not being a priority, particularly during first stages of emergency when there are pressing humanitarian needs

The need to build capacity in local research institutions
The ethics of research in these settings (risks to informants and ethical clearance, for example)
Is it right to sacrifice the highest quality of the research in order to get some insights?
What can we do in fragile settings in order to achieve community cohesion?
The need to focus not only on volume of aid but also how it is implemented/disbursed
Research on different service implementation strategies and models of care at the ground – health outcomes
How to ensure cross-sharing of evidence-based best practices and fragile state comparison

One particularly perplexing question related to whether this agenda applies to countries in an economic crisis such as Greece? So we certainly have a lot to consider as we move forward!

We will be contacting people who joined the webinar and following up on the issues raised. If you would like to join our group and be part of the discussion you can find us on LinkedIn. We hope to continue a discussion of these issues online. Be part of the conversation. Read our Storify of the event. Alternatively please contact Jan Randles Jan.Randles@lstmed.ac.uk.

A recording of the webinar can be found here: https://attendee.gotowebinar.com/recording/76320767420240641

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8 December 2014

A REACHOUT update from Ethiopia

By Kate Hawkins

Main messages:
The Quality improvement cycle will focus on community engagement, supervision and referral
This builds on the strengths of the existing system at multiple levels
REACHOUT research provide strategies to monitor and improve supervision policy and practice
REACH Ethiopia are working to improve the performance of close-to-community health programmes in Ethiopia (Health Extension Workers, or HEWs) through their first quality improvement (QI) cycle. Their overall focus is on improving supervision structures for HEWs and the community members engaged in work on health that they oversee, the Health Development Army (HDA).

There are a number of existing community engagement structures within the Ethiopian health system which the QI cycle will build on and seek to strengthen.

The Health Development Army facilitate a Pregnant Women’s Forum which all pregnant women in a Kebele should attend, as per government guidelines. In the Forum the family health card and Information, Education and Communications (IEC) materials are used to prompt discussion on safety and health during pregnancy and childbirth. These stress the importance of facility delivery and the danger signs to look out for during pregnancy and birth. This discussion is led by the HEWs and midwives and every woman has to prepare a birth and complication readiness plan.

The HDA leaders meet once a month. At these meetings religious leaders and other influential people in the community feedback on any health service issues or barriers that have arisen. They also play a role in identifying new pregnancies in their area and linking newly pregnant women to the HEWs. The HDA report to their HEWs – sometimes orally and sometimes in a written document if literacy is not an issue.

All HEWs are trained on Focussed ANC and on referral to the health centre (e.g. for HIV testing). Every woman should know the danger signs and the expected date of delivery. They use a standard checklist while providing ANC to pregnant mothers.

HEWs supervisors (the health centre focal people) and HEWs have been trained on supervision curriculum, maternal health, community engagement and coordination. Existing training materials have been adapted and used for further training. Trainers were drawn from Regional Health Bureaus, the Zonal Health Department, and the Woreda Health Office. Catchment Health Centre group supervision will be implemented and a group supervision guide will be provided for this. Individual supervision will be carried out every month using the checklist by the HEWs supervisors.

As part of group supervision referral sheets have been adapted and referral registers have been developed to support future tracking. A coordination meeting will be held with maternal health staff in hospitals and health centres to assess progress. Participant observation of the use of the ANC checklist has already occurred. This helped the team to understand how the ANC care was being provided before the training. They will do in-depth referral interviews and observation of community meetings as the QI cycle rolls out. The project is coordinated with the District Health Office.

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4 December 2014

A REACHOUT update from Indonesia

By Kate Hawkins

Main messages
The first Quality Improvement (QI) cycle will focus on strengthening the partnership between Village Midwives, Kaders, and Traditional Birth Attendants (TBAs)
The intended outcome of this work is increased referrals to health facility for delivery
Through the health promotion intervention the communication and advocacy skills of Village Midwives, Kaders and TBAs will be strengthened
There will be a focus on community engagement including male involvement
Interdisciplinary and multi-methods research will be applied to measure the outcomes of the QI cycle
The QI cycle in Indonesia is focussed on health promotion, partnership, and community engagement. This will be supported by interventions to strengthen the supervision of community health workers. Village Midwives in four villages in Cianjur (more than 200 community health workers) will be trained in health promotion and provided with counselling cards that help them explain the danger signs in pregnancy and childbirth and importance of childbirth in health facilities. In health promotion we will train village midwives and kaders in 4 villages in Cianjur. This is more than 200 CHWs. The Village Midwives and kaders will use home visits and appointments in the community intergrated health posts (Posyandu) to talk about this information. This also explains when referral should happen.

The second intervention is focused on partnership and community intervention. Close-to-community providers will be encouraged to stimulate broader stakeholder engagement on the topic of maternal health. Community forums only happen about once a year in some of the settings REACHOUT are working in. This means the barriers and the issues don’t get discussed. The team will encourage stakeholders to come together more often in partnership with village leaders.

The midwife coordinators – who oversee the village midwives – will be provided training related to supportive supervision.

Various methods will be employed to measure the impact of the intervention. Village Midwives will be observed at the Posyandu. The team will also conduct exit interviews with mothers who attended sessions to get a sense of their knowledge the delivery of information. To measure the partnership and community engagement element of the work the team will track the number of women who go to the facility for delivery as a result of advice from the Village Midwives, Kaders and TBAs and women’s perceptions of the importance of institutional delivery. They will track the number of home deliveries to see whether the TBA or Village Midwives are in attendance. For the community engagement strand of work we will monitor the number of meetings in community. To measure the effects of supportive supervision training the close-to-community providers will be asked to complete a motivation questionnaire. For health promotion the team will use numbers of people who deliver in a facility and will track the perceptions of women on the importance of delivering in a health facility. Whilst there is a policy on the relationship between the TBA and Village Midwife REACHOUT are innovating by bringing the Kaders in to this engagement. To stimulate support at the community level they will encourage more frequent community forums which are currently lacking. The team hope to improve the Village Midwife and Kader negotiation and advocacy skills.

One challenge is that there is still a great deal of trust in TBAs and preference for them even though they are forbidden from conducting deliveries at home by government policy. The REACHOUT team also believe that it is important to engage male partners as they are not very involved in decision making around delivery. This will require support from health and non-health stakeholders.

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2 December 2014

A REACHOUT update from Kenya

By Kate Hawkins, 2 December 2014

Main messages
There is an urgent need for enhanced supervision among community-level staff in Kenya
Formal policies for supervision of CHWs and CHEWS don’t currently exist
By testing group supervision, peer supervision, and other tools LVCT Health hope to support the Government in strengthening the Community Health Strategy
LVCT Health will work with NGO partners to adapt best practice
They may face challenges due to health system devolution and the withdrawal of funding for community health worker programmes from some donors
The REACHOUT team will be looking at supervision and the role of the Community Health Committees in monitoring. They are going to be giving supportive supervision training to the Community Health Workers (CHWs) peer supervisors, the Community Health Extension Workers (CHEWs) and the people who manage the CHEWs in the County and sub-County Health Management Teams. The CHWs work in a Health Unit but there are no supervisory tools in the government programme. LVCT Health are planning to map the tools used by other non-governmental, vertical programmes and adapt them and hope the government will take them up.

To monitor the intervention they will collect the referral reports from facilities on service utilisation. They will look at data collected by CHWs in the Community Based Health Information System. Notes from supervisory meetings will be analysed. They have a programme assessment tool and will use a motivation questionnaire that will also support data collection.

Stakeholder engagement has been key to the process. The team have involved the Government from the very beginning of the research process and have provided them with the findings from the context analysis. They have linked with monitoring and evaluation and standards staff in Government too and will ask them to review the tools that will be used in the study. A staff member from the Community Health Service is part of the research team.

The team have an opportunity to influence change in Kenya. There is a demand for supervision tools as none exist in Government programmes at present. However, challenges remain, funders appear to be pulling out of community health services as a lack of documentation means that they cannot see the impact of them.

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25 November 2014

A REACHOUT update from Malawi

By Kate Hawkins

Main messages
In Malawi the Quality Improvement Cycle will focus on strengthening supervision
The two districts we are working in currently use two different models of supervision: the cluster system and the block system
A three-prong checklist will be used to evaluate supervision
REACH Trust will conduct an economic evaluation based on the assumption that strengthened supervision will increase motivation, which will increase referral
Improving supervision could lead to an increase in Senior Health Surveillance Assistants adopting the REACHOUT
countries are beginning their Quality Improvement Cycles. This update provides a little more information on the type of issues REACH Trust in Malawi will be covering.

As agreed in a meeting with key stakeholders in Malawi, REACH Trust will be working on maternal, neonatal and child health. The focus of the Quality Improvement Cycle is on strengthening supervision in order to improve the performance of Health Surveillance Assistants.

To do this REACH Trust will adapt the supervision manual prepared by the REACHOUT Consortium and create a checklist for supervision. Training will be given to supervisors at the district, cluster and health facility levels. Each district has chosen eight health facilities for the Quality Improvement Cycles. The team have developed a 30 point supervision checklist based on community based maternal and newborn health, integrated community case management and the core functions of Health Surveillance Assistants. The Health Surveillance Assistants will have monthly group supervision meetings and senior Health Surveillance Assistants and Environmental Health Officers will have quarterly supervision meetings at district level.

Health Surveillance Assistants report to health facilities, usually health centres. The number of Health Surveillance Assistants per health facility can range from five to forty. In block supervision, practiced in Salima district, the Health Surveillance Assistants are split into groups of four and they have meetings which are documented and this is communicated to their supervisor. It is a form of peer supervision. The supervisor based at a health centre consolidates all information from the blocks and sends to the district and the individual reports are just used as back up. In cluster supervision followed in Mchinji district, the Assistant Environmental Health Officer is in charge of a cluster, which is a combination of two to three or four health centres. .

As part of the Quality Improvement Cycles, research is being conducted and several tools are in use. Besides a motivation questionnaire, a motivation topic guide has been put together in order to do in-depth interviews with at least six Health Surveillance Assistants in each of the districts. The referral topic guide will be used with Health Surveillance Assistants who run village clinics and women with children between 0 and 5 years of age who were once referred by particular Health Surveillance Assistants. REACH Trust have also developed a topic guide for focus group discussions with community members. This analysis will be augmented by data gathered through a programme assessment tool.

REACH Trust will also do an economic evaluation of their intervention. Referral will be one of the areas that they will base this on. This is underpinned by the assumption that improved supervision supports motivation, which contributes to better Health Surveillance Assistant performance which will be reflected through improved referral.

There have been a variety of meetings with stakeholders. In Mchinji District they met with the District Executive Committee’s Sub-Committee on Health – which is important in the context of devolution. At the meeting different people presented their projects and got feedback. It means that every NGO working on health in the district knows all the background to the REACHOUT project and what the research plans are. REACH Trust held another meeting in Salima District with the District Health Officer where the project was discussed further. The most recent meeting brought together stakeholders from the two intervention districts and had senior participants from the Preventive Health Department of the Ministry of Health. At this meeting they revised the supervision manual based on feedback from the stakeholders and came up with a framework for the construction of the supervision checklist.

One challenge that the team face is that the Ministry of Health have conducted interviews to appoint Senior Health Surveillance Assistants to officially be supervisors for Health Surveillance Assistants. This has implications for the Quality Improvement Cycle because the team are going to train supervisors who may not be the ones successful in the interviews. It is hoped that when the Senior Health Surveillance Assistant position gets brought in officially, there will be 50 Senior Health Surveillance Assistants per district across the country.

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6 November 2014

CHW central and the TWG announce an exciting new partnership on community health workers

By Kate Hawkins

Initiatives Inc.’s CHW Central and the Thematic Working Group on Supporting and Strengthening the Role of Community Health Workers in Health System Development are delighted to announce their decision to work together to improve the accessibility and applicability of evidence.

A meeting of minds
CHW Central, managed by Initiatives Inc. is a dynamic global web-based resource that promotes and engages CHWs, enables the wide and rapid sharing of information about CHW work and management, offers resources to help improve CHW programs and CHW performance, and provides a forum for continuous and online discussions and exchanges among CHWs, public health professionals and programme managers in the United States and across the globe. The Thematic Working Group is part of Health Systems Global and brings together academics, policy makers and people implementing programmes to share, explore and understand the existing evidence base and generate new knowledge to ensure that CHW programmes are accessible, equitable and efficient.

A growing body of research
There is a growing interest in the role of CHWs in strengthening health systems and supporting the drive to universal health coverage. We know that these health workers have enormous potential in connecting the health system with community needs and demands and filling the human resources gap. However, there is a need for more research evidence on what works in CHW programmes, under different circumstances, and how to overcome some of the significant challenges being faced.

“Many of our members are producing research which can assist CHWs in building stronger and more effective programmes. We are committed to translating these findings into formats and language which have resonance with CHWs and enable their feedback. Academics can’t do it all! It is great that we can work with intermediaries in the communications process like CHW Central.” (Lilian Otiso, chair of the Thematic Working Group)

Getting research into the hands of the people who can use it
Evidence has real value if decision makers and other research users can access it, understand it and apply it. Research which is informed by those people grappling with real world challenges is more likely to be used in practice.

To help ensure that evidence generated by the Thematic Working Group is more appropriately packaged and communicated to CHWs, and that the thinking of the researchers is informed by CHW feedback CHW Central and the Thematic Working Group are entering into a strategic partnership.

Donna Bjerregaard of Initiatives Inc. commented,
“CHW Central is more than its resources; its vision is an international community in which all CHW programmes effectively meet the needs of their populations. Our mission is to improve the quality of performance CHW programmes and CHWs through information and dialogue.”

To find out more about the partnership or to join the Thematic Working Group please email Faye Moody (Faye.Moody@lstmed.ac.uk) or join our discussion group on LinkedIn.

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Photographer: Polly Walker Title: No na trabadja pa no tabanca (we are working for our village); Traditional Birth Attendants pose after newborn training in Guinea Bissau. Location: Buba, Quinara region, Guinea Bissau

20 October 2014

REACHOUT honourable mention in photo competition

By Kate Hawkins

We are really proud that two of the REACHOUT partners (LVCT Health and The Eijkman Institute of Molecular Biology) were singled out for special praise in a recent photography competition which was organised by Research in Gender and Ethics (RinGs), a new cross-RPC partnership between Future Health Systems, ReBUILD and RESYST. The aim of the competition was to capture the everyday stories of the ways that gender plays out within health systems around the world. Our photos (above) were exhibited at the Global Symposium on Health Systems Research in Cape Town.

This was a great opportunity for us to demonstrate some of the work that close-to-community providers are doing in our respective settings. Raclicia Limato explains,

“The photograph shows Indonesian village health volunteers locally called “Kaders” in action. Kaders are non-salaried volunteers chosen by the village community to help the village midwife or nurse in organising the Posyandu. The Posyandu is a community integrated health post held monthly in the village to bring health services closer to the rural community.

The Posyandu functions mainly to provide preventive and health promotion services mainly to the mother and child. Typically a kader is expected to have basic literacy of school certification. They can be male or female. A five Kader, five table system with an activity per table is used to run a Posyandu. Their task is to register the women and children, which is what they are seen doing in the photograph. Other tasks they do are weighing under-five children, fill in the record book for growth monitoring, provide health and nutritional counselling and additional food supplementation. They also do home visits to check for pregnant women and inform of the Posyandu day.”

The image from Kenya demonstrates how, in an effort to reach underserved and marginalised populations, LVCT counselors criss-cross the hilly and rocky Maasai land terrain to carry out HIV Home-Based Testing and Counselling (HBTC). Redemta Atieno documented this process and spoke to key stakeholders,

“The HTC counsellor team leader Wilkista Nduko said her team is passionate about ensuring that this community is reached with HTC services. She at the same time noted that due to the location and terrain of the area, it is very hard to get to the villages. “The counsellors have to leave very early on empty stomachs to start the journey to the villages because if we delay the sun becomes very hot and it becomes difficult to walk for many hours,” she noted.

Mr Risa Mbelati, a community member who was tested with his two wives said he was happy with the services offered. “I am grateful to the team for coming this far to provide testing and counselling to us. I have received knowledge that would help me to stay negative and not put my family at risk.”

LVCT’s Community HTC Programme Officer who is attached to the APHIAplus program Ken Omugah said the aim of this exercise was to achieve government’s pledge of ensuring that by 2013, 80 percent of Kenyans know their correct and current status.

He cited lack of information as a hindrance in penetrating the community. “Some people here had never even heard of testing. It is amazing that after continuous and persistent sensitization we have had over 91 percent of new testers and we had husbands agreeing to test with their wives,” he beamed.”

To see the winning photograph and the shortlist of honourable mentions please visit the RinGs website.