Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel

Bugs in the Bed: Addressing the Contradictions of Embedded Science with Agile Implementation Research

Implementation research often fails to have its intended impact on what programs actually do. Embedding research within target organizational systems represents an effective response to this problem. However, contradictions associated with the approach often prevent its application. We present case studies of the application of embedded implementation research in Bangladesh, Ghana, and Tanzania where initiatives to strengthen community-based health systems were conducted using the embedded science model. In 2 of the cases, implementation research standards that are typically embraced without question were abandoned to ensure pursuit of embedded science. In the third example, statistical rigor was sustained, but this feature of the design was inconsistent with embedded science. In general, rigorous statistical designs employ units of observation that are inconsistent with organizational units that managers can control. Structural contradictions impede host institution ownership of research processes and utilization of results. Moreover, principles of scientific protocol leadership are inconsistent with managerial leadership. These and other embedded implementation science attributes are reviewed together with contradictions that challenged their pursuit in each case. Based on strategies that were effectively applied to offsetting challenges, a process of merging research with management is proposed that is derived from computer science. Known as "agile science," this paradigm combines scientific rigor with management decision making. This agile embedded research approach is designed to sustain scientific rigor while optimizing the integration of learning into managerial decision making.

Health for the People: Past, Current, and Future Contributions of National Community Health Worker Programs to Achieving Global Health Goals

National community health worker programs are at the dawn of a new era, given the growing recognition of their importance for achieving global health goals and for controlling the COVID-19 pandemic. Now is the time to provide them with the respect and funding that they need and deserve.

The Community Health Systems Reform Cycle: Strengthening the Integration of Community Health Worker Programs Through an Institutional Reform Perspective

To develop guidance for governments and partners seeking to scale community health worker programs, we developed a conceptual framework, collected observations from the scale-up efforts of 7 countries, workshopped the framework with technical groups and with country stakeholders, and reviewed literature in the areas of health and policy reform, change management, institutional development, health systems, and advocacy. We observed that successful scale-up is a complex process of institutional reform. Successful scale-up: (1) depends on a carefully choreographed, problem-driven political process; (2) requires that scaled program models are drawn from solutions that are available in a given health system context and aligned with the resources, capabilities, and commitments of key health sector stakeholders; and (3) emerges from iterative cycles of learning and improvement, rather than a single, linear scale-up effort. We identify stages of the reform process associated with each of these 3 findings: problem prioritization, coalition building, solution gathering, design, program readiness, launch, governance, and management and learning. The resulting Community Health Systems Reform Cycle can be used by government, donors, and nongovernmental partners to prioritize and design community health worker scale-up efforts, diagnose challenges or gaps in successful scale-up and integration, and coordinate the contributions of diverse stakeholders.

Strength in Diversity: Integrating Community in Primary Health Care to Advance Universal Health Coverage

The supplement highlights a systems approach that recognizes the communities' roles and their interactions with other health system actors to accelerate outcomes and reflect the diversity of the community health ecosystem. Several cross-cutting priorities emerge from the articles, namely coverage, community health financing, policy change, institutionalization, resilience, accountability, community engagement, and whole-of-society efforts.

Applying the Community Health Worker Coverage and Capacity Tool for Time-Use Modeling for Program Planning in Rwanda and Zanzibar

Community health worker (CHW) programs are a critical component of health systems, notably in lower- and middle-income countries. However, when policy recommendations exceed what is feasible to implement, CHWs are overstretched by the volume of activities, implementation strength is diluted, and programs fail to produce promised outcomes. To counteract this, we developed a time-use modeling tool-the CHW Coverage and Capacity (C3) Tool-and used it with government partners in Rwanda and Zanzibar to address common policy questions related to CHW needs, coverage, and time optimization.In Rwanda, the C3 Tool was used to analyze 2 well-established cadres of CHWs and 1 new one. The well-established CHW cadres were within a "manageable" workload range whereas the new cadre was projected to achieve less than half of assigned activities. This is informing ongoing changes to the CHWs' scopes of work. In Zanzibar, the C3 Tool was used to update the national community health strategy to include community health volunteers (CHVs) for the first time and determine how many CHVs were needed. The tool projected that 2,200 CHVs could achieve approximately 90% coverage of all defined services. Based on these figures, Zanzibar updated its national community health strategy, which officially launched in February 2020.We discuss lessons from these 2 experiences. Translating analysis into decision making depends not only on the programmatic will and motivation of governments but also on finding opportune timing for when policy and program processes allow for optimization of CHW investments. Further research is needed but our experience supports the value of a modeling tool to ground program plans within estimated constraints on CHW time.

Knowledge towards cervical cancer screening and associated factors among urban health extension workers at Addis Ababa, Ethiopia: facility based cross-sectional survey

BACKGROUND

Cervical cancer is preventable and remains a leading cause of avoidable death among women in the world. In a developing country, the knowledge of screening for cervical cancer behavior still very low. However, little is known about the knowledge towards cervical cancer screening of urban health extension workers in Ethiopia. This study aimed to assess knowledge towards cervical cancer screening and associated factors among urban health extension workers in Addis Ababa, Ethiopia, 2020.

METHODS

In this cross-sectional study, 312 urban health extension workers completed the survey in the Amharic language. Data collected using a structured questionnaire in a face-to-face interview. Descriptive and logistic regression analyses were conducted using SPSS version 26.

RESULTS

The mean age of the urban health extension workers was 20.41 ± 3.73 years and 55.1% were married. The majority of the participants (75.6%) had diploma educational level, and 38.1% of them had 1-2 years of work experience. More than half (51.6%) of the participants had poor knowledge about cervical cancer screening. Participants with work experience of 5-6 years (AOR = 4.32: 95% CI = 1.71,10.94) and those who had a monthly income of 5000-10,000 ETB (AOR = 3.75: 95% CI = 1.49,9.41) and greater than > 10,000 ETB (AOR = 3.08: 95% CI =1.06, 8.98) were positively associated with knowledge towards cervical cancer screening among urban health extension workers, p-value< 0.05.

CONCLUSION

This study indicated that the knowledge towards cervical cancer screening of urban health extension workers was inadequate. Urban health extension workers' work experiences and monthly income were found to be independent predictors of the knowledge towards cervical cancer screening of respondents. Therefore, urban health extension workers with low work experiences and those with small monthly income could be targeted for cervical cancer screening information and training interventions.

Using the Wilder Collaboration Factors Inventory to Strengthen Collaborations for Improving Maternal and Child Health

INTRODUCTION

The Wilder Collaboration Factors Inventory is a free, publicly available questionnaire about the quality and context of community collaboration. The purpose of this article is to share lessons from using this questionnaire in a North Carolina maternal and child health initiative.

METHODS

In 2015, the State's General Assembly funded five local health departments to implement evidence-based strategies for improving maternal and child health. Each health department formed a community action team for this purpose. Members of each community action team completed the Wilder Collaboration Factors Inventory (Inventory) in the first year of funding and again 1 and 2 years later. Technical assistance coaches also asked community action team conveners to complete a brief questionnaire annually, and used these as well as Inventory results to plan for improvements.

RESULTS

During the first year, community action teams emerged as strong in seeing collaboration in their self-interest. A primary challenge noted by conveners was engaging consumers on the community action teams. Strategies to address this included using social media and compensating consumers for attending meetings. By the second year, teams' average scores in engaging multiple layers of participation increased, and eight additional factors became strengths, which generally continued in year three. The most consistent challenge was supporting community action teams administratively.

DISCUSSION

The Wilder Collaboration Factors Inventory provided a feasible tool for identifying opportunities for improvement in several local, cross-sector partnerships, suggesting promise for other communities seeking to enhance their collective impact on maternal and child health.

A Cluster-Randomized Trial to Test Sharing Histories as a Training Method for Community Health Workers in Peru

BACKGROUND

Community health workers (CHWs) are increasingly deployed to support mothers' adoption of healthy home practices in low- and middle-income countries. However, little is known regarding how best to train them for the capabilities and cultural competencies needed to support maternal health behavior change. We tested a CHW training method, Sharing Histories (SH), in which CHWs recount their own childbearing and childrearing experiences on which to build new learning.

METHODS

We conducted an embedded cluster-randomized trial in rural Peru in 18 matched clusters. Each cluster was a primary health facility catchment area. Government health staff trained female CHWs using SH (experimental clusters) or standard training methods (control clusters). All other training and system-strengthening interventions were equal between study arms. All CHWs conducted home visits with pregnant women and children aged 0-23 months to teach, monitor health practices and danger signs, and refer. The primary outcome was height-for-age (HAZ)<-2 Z-scores (stunting) in children aged 0-23 months. Household surveys were conducted at baseline (606 cases) and 4-year follow-up (606 cases).

RESULTS

Maternal and child characteristics were similar in both study arms at baseline and follow-up. Difference-in-differences analysis showed mean HAZ changes were not significantly different in experimental versus control clusters from baseline to endline (P=.469). However, in the subgroup of literate mothers, mean HAZ improved by 1.03 on the Z-score scale in experimental clusters compared to control clusters from baseline to endline (P=.059). Using generalized estimating equations, we demonstrated that stunting in children of mothers who were literate was significantly reduced (Beta=0.77; 95% confidence interval=0.23, 1.31; P<.01), adjusting for covariates.

CONCLUSION

Compared with standard training methods, SH may have improved the effectiveness of CHWs as change agents among literate mothers to reduce child stunting. Stunting experienced by the children of illiterate mothers may have involved unaddressed determinants of stunting.

Women's satisfaction with their urban health extension programme and associated factors in Gondar administrative city, northwest Ethiopia: a community-based cross-sectional study

OBJECTIVES

Ethiopia is a developing country striving to achieve universal health coverage using the health extension programme. There is limited evidence about Ethiopian women's satisfaction with their urban health extension programme. Thus, this study was aimed at assessing the level of women's satisfaction with their urban health extension services and associated factors in Gondar administrative city of northwest Ethiopia and elucidate factors associated with its access and use.

DESIGN

Cross-sectional study.

SETTING

Community.

PARTICIPANTS

Randomly selected 744 women were interviewed using a structured interviewer-administered questionnaire.

OUTCOME

Satisfaction of women over 17 years of age with their urban health extension programme (use and services).

RESULTS

Some 29.4% (95% CI 26.2 to 32.5) of women were satisfied with their urban health extension programme. Divorced women (adjusted OR (AOR): 0.35, 95% CI 0.14 to 0.85), women in the age group of 45-53 years (AOR: 0.35, 95% CI 0.14 to 0.85), private employees (AOR: 0.35, 95% CI 0.14 to 0.85), unsatisfactory knowledge (AOR: 0.13, 95% CI 0.07 to 0.25) and perceived accessibility of health extension workers (AOR: 0.99, 95% CI 0.06 to 0.17) were factors associated with women's satisfaction with their urban health extension programme.

CONCLUSIONS

Women's satisfaction with their urban health extension programme was low. This finding was associated with age, marital status, occupation, knowledge of participants and women's perceived accessibility of services. Therefore, increasing awareness about the programme, promoting and improving accessibility of services, particularly by mothers, may augment the utilisation of the programme ultimately leads to efficient use of scarce healthcare resources in Ethiopia.

Mobile primary health care clinics for Indigenous populations in Australia, Canada, New Zealand and the United States: a systematic scoping review

BACKGROUND

Mobile clinics have been used to deliver primary health care to populations that otherwise experience difficulty in accessing services. Indigenous populations in Australia, Canada, New Zealand, and the United States experience greater health inequities than non-Indigenous populations. There is increasing support for Indigenous-governed and culturally accessible primary health care services which meet the needs of Indigenous populations. There is some support for primary health care mobile clinics implemented specifically for Indigenous populations to improve health service accessibility. The purpose of this review is to scope the literature for evidence of mobile primary health care clinics implemented specifically for Indigenous populations in Australia, Canada, New Zealand, and the United States.

METHODS

This review was undertaken using the Joanna Brigg Institute (JBI) scoping review methodology. Review objectives, inclusion criteria and methods were specified in advance and documented in a published protocol. The search included five academic databases and an extensive search of the grey literature.

RESULTS

The search resulted in 1350 unique citations, with 91 of these citations retrieved from the grey literature and targeted organisational websites. Title, abstract and full-text screening was conducted independently by two reviewers, with 123 citations undergoing full text review. Of these, 39 citations discussing 25 mobile clinics, met the inclusion criteria. An additional 14 citations were snowballed from a review of the reference lists of included citations. Of these 25 mobile clinics, the majority were implemented in Australia (n = 14), followed by United States (n = 6) and Canada (n = 5). No primary health mobile clinics specifically for Indigenous people in New Zealand were retrieved. There was a pattern of declining locations serviced by mobile clinics with an increasing population. Furthermore, only 13 mobile clinics had some form of evaluation.

CONCLUSIONS

This review identifies geographical gaps in the implementation of primary health care mobile clinics for Indigenous populations in Australia, Canada, New Zealand, and the United States. There is a paucity of evaluations supporting the use of mobile clinics for Indigenous populations and a need for organisations implementing mobile clinics specifically for Indigenous populations to share their experiences. Engaging with the perspectives of Indigenous people accessing mobile clinic services is imperative to future evaluations.

REGISTRATION

The protocol for this review has been peer-reviewed and published in JBI Evidence Synthesis (doi: 10.11124/JBISRIR-D-19-00057).

Expanding the use of community health workers in urban settings: a potential strategy for progress towards universal health coverage

Community health worker (CHW) programmes have been used for decades to improve access to health services in rural settings in low- and middle-income countries. With more than half of the world's population currently living in urban areas and this population expected to grow, equitable access to health services in urban areas is critically important. To understand the extent to which CHW programmes have been successfully deployed in low-income urban settings, we conducted a review of the literature between 2000 and 2018 to identify studies evaluating and describing CHW programmes implemented fully or partially in urban or peri-urban settings. We identified 32 peer-reviewed articles that met our inclusion criteria. Benefits have been documented in several urban settings in low- and middle-income countries including those to address TB/HIV, child health, maternal health and non-communicable diseases through a variety of study designs.

Community Ownership in Primary Health Care-Managing the Intangible

Although enduringly intangible, community ownership is foundational to primary health care. This intangibility is a reminder of what programs can and should do (create space for dialogue, question their own choices, expand diversity in stakeholder voices making sense of program-induced changes, including through evaluation) and what they cannot do (manage someone else’s ownership).

Mind the gap: scaling up the utilization of insecticide treated mosquito nets using a knowledge translation model in Isingiro district, rural south western Uganda

Background: The phenomenon of Knowledge Translation (KT) is a key intervention towards bridging the 'know-do' gap. We conducted a KT initiative in Isingiro district to positively change attitude and improve on the uptake of Insecticide Treated Mosquito Nets (ITNs) as a malaria prevention strategy. Methods: This was a community based interactive initiative that was carried out within the seventeen administrative units of Isingiro district using varied dissemination activities, namely: health talks; drama activities, and the sharing of ITNs success stories. Results: We reached out to 34 dissemination groups, comprising communal gathering, religious crusades, open markets, secondary schools, and district administration. In addition, we spot-visited 46 households to ascertain the physical presence of ITNs, and their appropriate use. The major intervention was improved knowledge base of malaria causation and prevention strategies. The indicators for improved knowledge were hinged on the five-interventions, namely: (a) communal sensitization on malaria to provide, (b) monitoring and support of selected households, (c) emphasis of ITN use as a malaria prevention strategy, (d) promotion of care for ITNs, and (e) promotion of ITN use. In all, the major output was improved knowledge base of malaria causation and prevention strategies by providing accurate information to redress the myths and misconceptions related to malaria and ITNs use. Conclusion: This undertaking describes a consolidated community intervention to promote ITN utilization. It is plausible that this intervention positively enhances and promotes uptake and utilization of ITNs.

Communities, universal health coverage and primary health care

Universal health coverage (UHC) depends on a strong primary health-care system. To be successful, primary health care must be expanded at community and household levels as much of the world's population still lacks access to health facilities for basic services. Abundant evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care. Policies and actions to improve primary health care must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Advancing the science of primary health care requires improved conceptual and analytical frameworks and research questions. Metrics used for evaluating primary health care and UHC largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand primary health care. Much of primary health care has taken place, and will continue to take place, outside health facilities. Involving community members in decisions about health priorities and in community-based service delivery is key to improving systems that promote access to care. Neither UHC nor the Health for All movement will be achieved without the substantial contribution of communities.

Community Engagement in Support of Moving Toward Universal Health Coverage

Community engagement describes a complex political process with dynamic negotiation and renegotiation of power and authority between providers and recipients of health care in order to achieve a shared goal of universal health care coverage. Though examples exist of community engagement projects, there is very little guidance on how to implement and embed community engagement as a concerted, integrated, strategic, and sustained component of health systems. Through a series of case studies, this article explores the factors that enable community engagement particularly with a direct impact on health systems.

Response to “How prepared is Africa to face COVID-19?” by Wadoum and Clarke

A recent commentary published in this journal correctly notes the important challenges that must be addressed to mitigate the effects of the COVID-19 pandemic in Africa. While we agree with the basic assumptions and arguments of their essay, we argue that common social institutional norms in most rural settings could be marshalled for organizing preventive measures.

Can social accountability improve access to free public health care for the poor? Analysis of three Health Equity Fund configurations in Cambodia, 2015–17

Within the context of universal health coverage, community participation has been identified as instrumental to facilitate access to health services. Social accountability whereby citizens hold providers and policymakers accountable is one popular approach. This article describes one example, that of Community-Managed Health Equity Funds (CMHEFs), as an approach to community engagement in Cambodia to improve poor people’s use of their entitlement to fee-free health care at public health facilities. The objectives of this article are to describe the size of its operations and its ability to enable poor people continued access to health care. Using data collected routinely, we compare the uptake of curative health services by eligible poor people under three configurations of Health Equity Funds (HEFs) during a 24-month period (July 2015–June 2017): Standard HEF that operated without community engagement, Mature CMHEFs established years before the study period and New CMHEFs initiated just before the study period. One year within the study, non-governmental organizations (NGOs) stopped operating the HEF nationwide and only the community-participation aspects of New CMHEF continued receiving technical assistance from an NGO. Using utilization figures for curative services by non-poor people for comparison, following the cessation of HEF management by the NGOs, outpatient consultation figures declined for all three configurations in comparison with the year before but only significantly for Standard HEF. The three HEF configurations experienced a highly statistically significant reduction in monthly inpatient admissions following halting of NGO management of HEFs. This study shows that enhancing access to free health care through social accountability is optimized at health centres through engagement of a wide range of community representatives. Such effect at hospitals was only observed to a limited extent, suggesting the need for more engagement of hospital management authorities in social accountability mechanisms.

Human resources and curricula content for early child development implementation: multicountry mixed methods evaluation

OBJECTIVE

The WHO recommends responsive caregiving and early learning (RCEL) interventions to improve early child development (ECD), and to achieve the Sustainable Development Goals' vision of a world where all children thrive. Implementation of RCEL programmes in low and middle-income countries (LMIC) requires evidence to inform decisions about human resources and curricula content. We aimed to describe human resources and curricula content for implementation of RCEL projects across diverse LMICs, using data from the Grand Challenges Canada Saving Brains ECD portfolio.

SETTING

We evaluated 32 RCEL projects across 17 LMICs on four continents.

PARTICIPANTS

Overall, 2165 workers delivered ECD interventions to 25 909 families.

INTERVENTION

Projects were either stand-alone RCEL or RCEL combined with health and nutrition, and/or safety and security.

PRIMARY AND SECONDARY OUTCOMES

We undertook a mixed methods evaluation of RCEL projects within the Saving Brains portfolio. Quantitative data were collected through standardised reporting tools. Qualitative data were collected from ECD experts and stakeholders and analysed using thematic content analysis, informed by literature review.

RESULTS

Major themes regarding human resources included: worker characteristics, incentivisation, retention, training and supervision, and regarding curricula content: flexible adaptation of content and delivery, fidelity, and intervention duration and dosage. Lack of an agreed standard ECD package contributed to project heterogeneity. Incorporation of ECD into existing services may facilitate scale-up but overburdened workers plus potential reductions in service quality remain challenging. Supportive training and supervision, inducement, worker retention, dosage and delivery modality emerged as key implementation decisions.

CONCLUSIONS

This mixed methods evaluation of a multicountry ECD portfolio identified themes for consideration by policymakers and programme leaders relevant to RCEL implementation in diverse LMICs. Larger studies, which also examine impact, including high-quality process and costing evaluations with comparable data, are required to further inform decisions for implementation of RCEL projects at national and regional scales.

Using mHealth to improve health care delivery in India: A qualitative examination of the perspectives of community health workers and beneficiaries

Background

mHealth technologies are proliferating globally to address quality and timeliness of health care delivery by Community Health Workers (CHWs). This study aimed to examine CHW and beneficiaries’ perceptions of a new mHealth intervention (Common Application Software [CAS] for CHWs in India. The objectives of the study were to seek perspectives of CHWs and beneficiaries on the uptake of CAS, changes in CHW-beneficiary interactions since the introduction of CAS and potential barriers faced by CHWs in use of CAS. Further, important contextual factors related to CHW-beneficiary interface and dynamics that may have a bearing on CAS have been described.

Methods

A qualitative study was conducted in two states of India (Bihar and Madhya Pradesh) from March-April 2018 with CHWs (n = 32) and beneficiaries (n = 55). All interviews were conducted and recorded in Hindi, transcribed and translated into English, and coded and thematically analysed using Dedoose.

Findings

The mHealth intervention was acceptable to the CHWs who felt that CAS improved their status in the communities where they worked. Beneficiaries’ views were a mix of positive and negative perceptions. The divergent views between CHWs and beneficiaries surrounding the use and impact of CAS highlight an underlying mistrust, socio-cultural barriers in engagement, and technological barriers in implementation. All these contextual factors can influence the perception and uptake of CAS.

Conclusions

mHealth interventions targeting CHWs and beneficiaries have the potential to improve performance of CHWs, reduce barriers to information and potentially change the behaviors of beneficiaries. While technology is an enabler for CHWs to improve their service delivery, it does not necessarily help overcome social and cultural barriers that impede CHW-beneficiary interactions to bring about improvements in knowledge and health behaviors. Future interventions for CHWs including mHealth interventions should examine contextual factors along with the acceptability, accessibility, and usability by beneficiaries and community members.

Psychological Impact of COVID-19 Pandemic on Frontline Health Workers in Low- and Middle-Income Countries

Healthcare systems in many countries have been overwhelmed by the coronavirus disease (COVID-19) pandemic, with increasing demands to contain and respond to the virus. The result has been increased pressure on frontline health workers. As the pandemic unfolds, the impact on health systems in low-income and middle-income countries (LMICs) is becoming apparent. In lower resource settings, the detrimental effects on frontline health workers will likely be significant due to fragmented infrastructure, low compensation, and significant shortages of necessary resources such as personal protective equipment. These high stress conditions, coupled with risk of infection and fears and anxieties among patients, can result in grave psychosocial consequences for frontline health workers, who play a vital role in delivering the bulk of primary care services in LMICs. In this narrative review, we consider the psychological impact of the COVID-19 pandemic on frontline health workers in LMICs. We describe the important role of frontline health workers, summarize existing literature on burnout and risks to mental health in this essential workforce, and consider how public health emergencies exacerbate these concerns to showcase their vulnerability to mental health impacts of COVID-19. We explore emerging research on the detrimental effects of the COVID-19 pandemic on health workers and consider possible approaches to mitigate these consequences. This review draws from existing studies and emerging evidence to highlight the critical need to consider the wellbeing of frontline health workers, and to address these challenges as health systems respond to the pandemic.

Development assistance for community health workers in 114 low- and middle-income countries, 2007-2017

OBJECTIVE

To estimate the level and trend of development assistance for community health worker-related projects in low- and middle-income countries between 2007 and 2017.

METHODS

We extracted data from the Organisation for Economic Co-operation and Development's creditor reporting system on aid funding for projects to support community health workers (CHWs) in 114 countries over 2007-2017. We produced estimates for projects specifically described by relevant keywords and for projects which could include components on CHWs. We analysed the pattern of development assistance by purpose, donors, recipient regions and countries, and trends over time.

FINDINGS

Between 2007 and 2017, total development assistance targeting CHW projects was around United States dollars (US$) 5 298.02 million, accounting for 2.5% of the US$ 209 277.99 million total development assistance for health. The top three donors (Global Fund to Fight AIDS, Tuberculosis and Malaria, the government of Canada and the government of the United States of America) provided a total of US$ 4 350.08 million (82.1%) of development assistance for these projects. Sub-Saharan Africa received a total US$ 3 717.93 million, the largest per capita assistance over 11 years (US$ 0.39; total population: 9 426.25 million). Development assistance to projects that focused on infectious diseases and child and maternal health received most funds during the study period.

CONCLUSION

The share of development assistance invested in the CHW projects was small, unstable and decreasing in recent years. More research is needed on tracking government investments in CHW-related projects and assessing the impact of investments on programme effectiveness.

The Capacities of Primary Health Care in Hungary: A Problem Statement

In the establishment, development, and provision of equal access to the health care system, the operation of adequate primary health care is essential and has undergone significant transformation in the most developed countries over the past decades. The central and eastern European countries, including Hungary, are struggling with the disadvantages of the traditional model of primary health care, based on independent general practitioner and family paediatrician practices: the ability of the system is extremely limited to meet emerging needs and is facing a chronic human resource crisis. In the current study, the functions, legislation, and challenges of the Hungarian primary health care system, as well as the basic interrelations of the development of vacant general practitioner and family paediatrician districts were examined, and the government measures for the sake of solving the occurrence of the vacancy and improving access in the lagging areas. (The situation of the other fields of primary health care—e.g., dental care, child care officer care, etc.—was not subject of the analysis.). The basic characteristics of the vacant districts (type by supplied age group, bounding region, population size, length of vacancy) were primarily examined by the analysis of categorical and metric variables, with the use of cross-tabulation and nonparametric correlation, while the discovery of soft interrelations was supported by an expert interview conducted with the professionals of the Primary Health Care Department of the National Health Care Services Centre. In Hungary, the fundamentals of primary health care are made up of the individual practices of general practitioners and paediatricians, and there is a growing concern about the permanent vacancy of the districts, and the fact that the system is less suitable for meeting the needs of the population. The ever-increasing number of vacant general practitioner and family paediatrician districts due to the growing shortage of professionals because of aging and emigration poses the burden of substitution on the physicians in existing practices, that concerns the access of more than a half million people to health care, almost 70 percent of which live in settlements with a population less than 5000 inhabitants.

Use of mobile technology by frontline health workers to promote reproductive, maternal, newborn and child health and nutrition: a cluster randomized controlled Trial in Bihar, India

Background

mHealth technology holds promise for improving the effectiveness of frontline health workers (FLWs), who provide most health-related primary care services, especially reproductive, maternal, newborn, child health and nutrition services (RMNCHN), in low-resource – especially hard-to-reach – settings. Data are lacking, however, from rigorous evaluations of mHealth interventions on delivery of health services or on health-related behaviors and outcomes.

Methods

The Information Communication Technology-Continuum of Care Service (ICT-CCS) tool was designed for use by community-based FLWs to increase the coverage, quality and coordination of services they provide in Bihar, India. It consisted of numerous mobile phone-based job aids aimed to improve key RMNCHN-related behaviors and outcomes. ICT-CCS was implemented in Saharsa district, with cluster randomization at the health sub-center level. In total, evaluation surveys were conducted with approximately 1100 FLWs and 3000 beneficiaries who had delivered an infant in the previous year in the catchment areas of intervention and control health sub-centers, about half before implementation (mid-2012) and half two years afterward (mid-2014). Analyses included bivariate and difference-in-difference analyses across study groups.

Results

The ICT-CCS intervention was associated with more frequent coordination of AWWs with ASHAs on home visits and greater job confidence among ASHAs. The intervention resulted in an 11 percentage point increase in FLW antenatal home visits during the third trimester (P = 0.04). In the post-implementation period, postnatal home visits during the first week were increased in the intervention (72%) vs the control (60%) group (P < 0.01). The intervention also resulted in 13, 12, and 21 percentage point increases in skin-to-skin care (P < 0.01), breastfeeding immediately after delivery (P < 0.01), and age-appropriate complementary feeding (P < 0.01). FLW supervision and other RMNCHN behaviors were not significantly impacted.

Conclusions

Important improvements in FLW home visits and RMNCHN behaviors were achieved. The ICT-CCS tool shows promise for facilitating FLW effectiveness in improving RMNCHN behaviors.

The National Village Health Guide Scheme in India: lessons four decades later for community health worker programs today and tomorrow

BACKGROUND

Based in part on the success of India's early community health worker (CHW) programs, the Government of India launched in 1977 a national CHW scheme-the Village Health Guides (VHGs)-to provide preventive, promotive, and basic curative care to rural populations. Although this program had promising origins in smaller demonstration projects, it failed to deliver the hoped-for impact at scale and was abandoned. Based on extensive evidence and experience, the World Health Organization and the World Health Assembly have strongly endorsed the value of national CHW programs and their integration into national health systems. Surprisingly, given the scale and importance of the VHG program and its pioneering nature as a national CHW program, little has been published describing this experience. This article is the second in a series that focuses on critical issues that face the effectiveness of large-scale CHW programs.

CASE PRESENTATION

Several systemic factors emerge as main contributors to the failure of the VHG Scheme, namely, a lack of support from the formal health sector, an overly hasty implementation of the scheme, and poor communication between the government and health centers about the role of the VHGs. The remuneration structure and the VHG selection process were at the root of the program's shortcomings at the implementation level.

CONCLUSION

National CHW schemes are an increasingly important tool for achieving universal health coverage and ending maternal and child deaths by 2030. Although the VHG Scheme was initiated over 40 years ago, the lessons described in this case highlight important considerations to help both current and future large-scale CHW programs avoid the same pitfalls.

Means, Motives and Opportunity: determinants of community health worker performance

The performance of community health workers (CHWs) typically depends on the interaction between their motivation (their intent to achieve personal and organisational goals) and the constraints that they face in doing so. These constraints can be both at the individual level, for example, whether the worker has the skills and knowledge required to deliver on their job role, and the organisational level, for example, whether the worker is provided with the resources required to perform. Designing interventions to improve the performance of CHWs requires identifying the constraints to performance in a particular context. Existing frameworks on CHW performance tend to be derived empirically, identifying a broad range of intervention design and contextual factors that have been shown to influence CHW performance. These may not always be able to guide policy makers to identify the precise cause of a specific performance problem in a particular context and develop an appropriate policy response. This article presents a framework to help practitioners and researchers diagnose the constraints to performance of CHWs and guide programmatic and policy responses. The Means, Motives and Opportunity (MMO) framework has been adapted from the SaniFOAM framework used to identify the determinants of sanitation behaviours. It is based on three interdependent and interacting domains: means (whether an individual is capable of performing), motives (whether an individual wants to perform) and opportunity (whether the individual has the chance to perform). A wide range of data sources are expected to be used when applying the MMO framework, especially qualitative research that captures the perspectives and lived realities of CHWs and their communities. In this article, we demonstrate how the MMO framework can be applied to identify the constraints to CHW performance using the case study of Anganwadi Workers (village nutrition workers) in Bihar, India.

Lessons Learned from the CORE Group Polio Project and Their Relevance for Other Global Health Priorities

Despite numerous setbacks, the Global Polio Eradication Initiative has implemented various community strategies with potential application for other global health issues. This article reviews strategies implemented by the CORE Group Polio Project (CGPP), including pursuit of the missed child, microplanning, independent campaign monitoring, using community health workers and community mobilizers to build community engagement, community-based surveillance, development of the capacity to respond to other health needs, targeting geographic areas at high risk, the secretariat model for non-governmental organization collaboration, and registration of vital events. These strategies have the potential for contributing to the reduction of child and maternal mortality in hard-to-reach, underserved populations around the world. Community-based surveillance as developed by the CGPP also has potential for improving global health security, now a global health priority.

Effect of early childhood development interventions implemented by primary care providers commencing in the neonatal period to improve cognitive outcomes in children aged 0-23 months: protocol for a systematic review and meta-analysis

BACKGROUND

Impacts of early childhood development (ECD) interventions (such as fostering attachment and responsiveness through communication, play and stimulation) are well known. Globally, there is increasing recognition of the importance of the 'golden' minutes, hours and days after birth for infant health and development. However, only one systematic review has examined ECD interventions implemented in the neonatal period (0-27 days), and this review only assessed interventions implemented by specialised providers. Primary care providers have many potential contacts with mothers and infants throughout the neonatal period. However, it is unclear how many research studies or programmes have examined the effectiveness of ECD interventions commencing in the neonatal period and which methods were used. To date, there has been no systematic review of the effect of ECD interventions delivered by primary care providers commencing in the neonatal period.

METHODS

Our overall aim is to conduct a systematic review of the effect of ECD interventions implemented by primary care providers in the neonatal period. We will assess effects by timing and number ('dose') of contacts with primary care providers. Subgroup assessment will include effects in disadvantaged infants such as those born with low birth weight and to mothers with mental health disorders. We will also assess effects in low- and high-income countries and by type of care provider. The primary outcome is cognitive status in children aged 0-23 months as measured using standardised scales. Secondary outcomes include other child neurodevelopment domains (speech, language, fine motor, gross motor, social, emotional, behaviour, executive functioning, adaptive functioning) in children aged 0-23 months. Effects on maternal mental health will also be assessed between 0-23 months postpartum. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library, WHO databases and reference lists of papers will be searched for relevant articles. Only randomised controlled trials will be included. A narrative synthesis for all outcomes will be reported. Meta-analyses will be performed where exposures and outcomes are sufficiently homogeneous. Guidelines for PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) will be followed.

DISCUSSION

This review appears to be the first to be conducted in this area. The findings will be an important resource for policymakers, primary care providers and researchers who work with young infants in primary care settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019122021.

Effects of team-based goals and non-monetary incentives on front-line health worker performance and maternal health behaviours: a cluster randomised controlled trial in Bihar, India

Introduction

We evaluated the impact of a ‘Team-Based Goals and Incentives’ (TBGI) intervention in Bihar, India, designed to improve front-line (community health) worker (FLW) performance and health-promoting behaviours related to reproductive, maternal, newborn and child health and nutrition.

Methods

This study used a cluster randomised controlled trial design and difference-in-difference analyses of improvements in maternal health-related behaviours related to the intervention’s team-based goals (primary), and interactions of FLWs with each other and with maternal beneficiaries (secondary). Evaluation participants included approximately 1300 FLWs and 3600 mothers at baseline (May to June 2012) and after 2.5 years of implementation (November to December 2014) who had delivered an infant in the previous year.

Results

The TBGI intervention resulted in significant increases in the frequency of antenatal home visits (15 absolute percentage points (PP), p=0.03) and receipt of iron-folic acid (IFA) tablets (7 PP, p=0.02), but non-significant changes in other health behaviours related to the trial’s goals. Improvements were seen in selected attitudes related to coordination and teamwork among FLWs, and in the provision of advice to beneficiaries (ranging from 8 to 14 PP) related to IFA, cord care, breast feeding, complementary feeding and family planning.

Conclusion

Results suggest that combining an integrated set of team-based coverage goals and targets, small non-cash incentives for teams who meet targets and team building to motivate FLWs resulted in improvements in FLW coordination and teamwork, and in the quality and quantity of FLW–beneficiary interactions. These improvements represent programmatically meaningful steps towards improving health behaviours and outcomes.

Trial registration number

NCT03406221

The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study

BACKGROUND

In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services.

METHODS

We used data from Indian Human Development Surveys done in 2004-2005 and in 2011-2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility.

RESULTS

Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI - 1.6-11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births.

CONCLUSIONS

Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

Community-orientated primary care: a scoping review of different models, and their effectiveness and feasibility in sub-Saharan Africa

INTRODUCTION

Community-orientated primary care (COPC) is an approach to primary healthcare (PHC) that originated in South Africa and contributed to the formulation of the Declaration of Alma-Ata 40 years ago. Despite this, PHC remains poorly developed in sub-Saharan African countries. There has been a resurgence of interest in strengthening PHC systems in the last few years and identifying key knowledge gaps. COPC has been an effective strategy elsewhere, most notably Brazil. This scoping review investigated COPC in the sub-Saharan African context and looked for evidence of different models, effectiveness and feasibility.

METHODS

Databases were systematically searched using a comprehensive search strategy to identify studies from the last 10 years. A methodological guideline for conducting scoping reviews was followed. A standardised template was used to extract data and compare study characteristics and findings. Studies were grouped into five categories: historical analysis, models, implementation, educational studies and effectiveness.

RESULTS

A total of 1997 publications were identified and 39 included in the review. Most publications were from the last 5 years (n = 32), research (n = 27), from South Africa (n = 27), focused on implementation (n = 25) and involving case studies (n = 9), programme evaluation (n = 6) or qualitative methods (n = 10). Nine principles of COPC were identified from different models. Factors related to the implementation of COPC were identified in terms of governance, finances, community health workers, primary care facilities, community participation, health information and training. There was very little evidence of effectiveness of COPC.

CONCLUSIONS

There is a need for further research to describe models of COPC in Africa, investigate the appropriate skills mix to integrate public health and primary care in these models, evaluate the effectiveness of COPC and whether it is included in training of healthcare workers and government policy.

The impact of paid community health worker deployment on child survival: the connect randomized cluster trial in rural Tanzania

Background

This paper reports on a rigorously designed non-masked randomized cluster trial of the childhood survival impact of deploying paid community health workers to provide doorstep preventive, promotional, and curative antenatal, newborn, child, and reproductive health care in three rural Tanzanian districts.

Methods

From August, 2011 to June 2015 ongoing demographic surveillance on 380,000 individuals permitted monitoring of neonatal, infant and under-5 mortality rates for 50 randomly selected intervention and 51 comparison villages. Over the initial 2 years of the project, logistics and supply support systems were managed by the Ifakara Health Institute. In 2013, the experiment transitioned its operational design to logistical support managed by the Ministry of Health and Social Welfare with the goal of enhancing government operational ownership and utilization of results for policy.

Results

The baseline under 5 mortality rate was 81.3 deaths per 1000 live births with a 95% confidence interval (CI) of 77.2–85.6 in the intervention group and 82.7/1000 (95% CI 78.5–87.1) in the comparison group yielding an adjusted hazard ratio (HR) of 0.99 (95% CI 0.88–1.11, p = 0.867). After 4 years of implementation, the under 5 mortality rate was 73.2/1000 (95% CI 69.3–77.3) in the intervention group and 77.4/1000 (95% CI 73.8–81.1) in the comparison group (adjusted HR 0.95 [95% CI 0.86–1.07], p = 0.443). The intervention had no impact on neonatal mortality in either the first 2 years (HR 1.10 [95% CI 0.89–1.36], p = .392) or last 2 years of implementation (HR 0.98 [95% CI 0.74–1.30], p = .902). Although community health worker deployment significantly reduced mortality among children aged 1–59 months during the first 2 years of implementation (HR 0.85 [95% CI 0.76–0.96], p = 0.008), mortality among post neonates was the same in both groups in years three and four (HR 1.03 [95% CI 0.85–1.24], p = 0.772). Results adjusted for stock-out effects show that diminishing impact was associated with logistics system lapses that constrained worker access to essential drugs and increased post-neonatal mortality risk in the final two project years (HR 1.42 [95% CI 1·07–1·88], p = 0·015).

Conclusions

Community health worker home-visit deployment had a null effect among neonates, and 2 years of initial impact among children over 1 month of age, but a null effect when tests were based on over 1 month of age data merged for all four project years. The atrophy of under age five effects arose because workers were not continuously equipped with essential medicines in years three and four. Analyses that controlled for stock-out effects suggest that adequately supplied workers had survival effects on children aged 1 to 59 months.

Trial registration

Registration for trial number ISRCTN96819844 was retrospectively completed on June 21, 2012.

Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries

Introduction

Countries aspiring to universal health coverage view close-to-community (CTC) providers as a low-cost means of increasing coverage. However, due to lack of coordination and unreliable funding, the quality of large-scale CTC healthcare provision is highly variable and routine data about service quality are not trustworthy. Quality improvement (QI) approaches are a means of addressing these issues, yet neither the costs nor the budget impact of integrating QI approaches into CTC programme costs have been assessed.

Methods

This paper examines the costs and budget impact of integrating QI into existing CTC health programmes in five countries (Ethiopia, Indonesia, Kenya, Malawi, Mozambique) between 2015 and 2017. The intervention involved: (1) QI team formation; (2) Phased training interspersed with supportive supervision; which resulted in (3) QI teams independently collecting and analysing data to conduct QI interventions. Project costs were collected using an ingredients approach from a health systems perspective. Based on project costs, costs of local adoption of the intervention were modelled under three implementation scenarios.

Results

Annualised economic unit costs ranged from $62 in Mozambique to $254 in Ethiopia per CTC provider supervised, driven by the context, type of community health model and the intensity of the intervention. The budget impact of Ministry-led QI for community health is estimated at 0.53% or less of the general government expenditure on health in all countries (and below 0.03% in three of the five countries).

Conclusion

CTC provision is a key component of healthcare delivery in many settings, so QI has huge potential impact. The impact is difficult to establish conclusively, but as a first step we have provided evidence to assess affordability of QI for community health. Further research is needed to assess whether QI can achieve the level of benefits that would justify the required investment.

Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all

Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

Piloting a participatory, community-based health information system for strengthening community-based health services: findings of a cluster-randomized controlled trial in the slums of Freetown, Sierra Leone

BACKGROUND

Although community engagement has been promoted as a strategy for health systems strengthening, there is need for more evidence for effectiveness of this approach. We describe an operations research (OR) Study and assessment of one form of community engagement, the development and implementation of a participatory community-based health information system (PCBHIS), in slum communities in Freetown, Sierra Leone.

METHODS

A child survival project was implemented in 10 slum communities, which were then randomly allocated to intervention (PCBHIS) and comparison areas. In the 5 PCBHIS communities, the findings from monthly reports submitted by community health workers (CHWs) and verbal autopsy findings for deaths of children who died before reaching 5 years of age, were processed and shared at bimonthly meetings in each community. These meetings, called Community Health Data Review (CHDR) meetings, were attended by community leaders, including members of the Ward Development Committee (WDC) and Health Management Committee (HMC), by the CHW Peer Supervisors, and by representatives of the Peripheral Health Unit. Following a review of the information, attendees proposed actions to strengthen community-based health services in their community. These meetings were held over a period of 20 months from July 2015 to March 2017. At baseline and endline, knowledge, practice and coverage (KPC) surveys measured household health-related behaviors and care-seeking behaviors. The capacity of HMCs and WDCs to engage with the local health system was also measured at baseline and endline. Reports of CHW household contact and assessments of CHW quality were obtained in the endline KPC household survey, and household contacts measured in monthly submitted reports were also tabulated.

RESULTS

The self-assessment scores of WDCs' capacity to fulfil their roles improved more in the intervention than in the comparison area for all six components, but for only 1 of the 6 was the improvement statistically significant (monthly and quarterly meetings in which Peer Supervisor and/or CHW supervision was an agenda item). The scores for the HMCs improved less in the intervention area than in the comparison area for all six components, but none of these differences were statistically significant. Topics of discussion in CHDRs focused primarily on CHW functionality. All three indicators of CHW functioning (as measured by reports submitted from CHWs) improved more in the intervention area relative to the comparison area, with 2 out of 3 measures of improvement reaching statistical significance. Five of 7 household behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 2 out of the 5 were statistically significant (feeding colostrum and appropriate infant and young child feeding). Four of the 6 care-seeking behaviors judged to be amenable to promotion by CHWs improved more in the intervention area than in the comparison area, and 1 was statistically significant (treatment of diarrhea with ORS and zinc). None of the findings that favored the comparison area were statistically significant.

CONCLUSIONS

This study was implemented in challenging circumstances. The OR Study intervention was delayed because of interruptions in finalizing the national CHW policy, two separate cholera epidemics, and the Ebola epidemic lasting more than 2 years. Weaknesses in the CHW intervention severely limited the extent to which the PCBHIS could be used to observe trends in mortality and morbidity. Nonetheless, the positive results achieved in the area of functionality of the CHW intervention and community structure capacity are encouraging. Results suggest there is value in further methodologically rigorous investigations into improving community-based health system functioning through a similar approach to community engagement.

Evaluating an MFI Community Health Worker Program: How microfinance group networks influence intervention outreach and impact

BACKGROUND

Community Health Workers (CHWs) are considered to be a cost-effective and inclusive solution to address the persistent health workforce shortage in many low and middle-income countries. In recent years, microfinance institutions (MFIs) got increasingly engaged in providing health services delivered by CHWs. Despite their growing importance, little is known about the impacts and implementation barriers of these mostly small-scale initiatives. This paper evaluates an MFI-led CHW program in the Philippines and studies the role of microfinance group networks in influencing program outreach and impact. The intervention aims at disseminating information in poor communities, improving health monitoring through increased check-ups and raising social support.

METHODS

Clustered randomized controlled trial in 70 communities in the greater area of Metro Manila, the Philippines. The main data was collected in a baseline and follow-up survey and is complemented with extensive sociometric network and geographical data. The main outcome variable is a composite health index based on 10 indicators. The role of the health worker's embeddedness and connectedness in the community for program success is tested using tools of social network analysis.

RESULTS

The intervention led to a 3.8% (95% confidence interval (CI) = 1.3, 6.4) improvement in the composite health outcome. Effects across indicators are mixed and mainly driven by changes in immediate health monitoring behavior: The probability for routine examinations increased in the treatment group by 10.6% (95% CI = 3.2, 18.1), for regular blood pressure checks by 9.6% (95% CI = 3.3, 15.9), and for having access to a health care provider by 7.2% (95% CI = 0.93, 13.5). No statistical effects on general knowledge and social support are observable. Social networks are a key driver of program outreach and impact. Close friends and acquaintances of health workers used and benefited substantially more from the program than more distant ties.

CONCLUSIONS

Despite the promising immediate behavioral impacts, it remains questionable to what extent such small-scale MFI initiatives can bring transformative and sustainable changes without external support. Microfinance group networks played an important role for the success of the health intervention and further research is needed to better understand how these affect the health care utilization decisions of the clients.

The Philani MOVIE study: a cluster-randomized controlled trial of a mobile video entertainment-education intervention to promote exclusive breastfeeding in South Africa

Background

In South Africa, rates of exclusive breastfeeding remain low and breastfeeding promotion is a national health priority. Mobile health and narrative entertainment-education are recognized strategies for health promotion. In-home counseling by community health workers (CHWs) is a proven breastfeeding promotion strategy. This protocol outlines a cluster-randomized controlled trial with a nested mixed-methods evaluation of the MObile Video Intervention for Exclusive breastfeeding (MOVIE) program. The evaluation will quantify the causal effect of the MOVIE program and generate a detailed understanding of the context in which the intervention took place and the mechanisms through which it enacted change. Findings from the study will inform the anticipated scale-up of mobile video health interventions in South Africa and the wider sub-Saharan region.

Methods

We will conduct a stratified cluster-randomized controlled trial in urban communities of the Western Cape, to measure the effect of the MOVIE intervention on exclusive breastfeeding and other infant feeding practices. Eighty-four mentor-mothers (CHWs employed by the Philani Maternal Child Health and Nutrition Trust) will be randomized 1:1 into intervention and control arms, stratified by neighborhood type. Mentor-mothers in the control arm will provide standard of care (SoC) perinatal in-home counseling. Mentor-mothers in the intervention arm will provide SoC plus the MOVIE intervention. At least 1008 pregnant participants will be enrolled in the study and mother-child pairs will be followed until 5 months post-delivery. The primary outcomes of the study are exclusive breastfeeding at 1 and 5 months of age. Secondary outcomes are other infant feeding practices and maternal knowledge. In order to capture human-centered underpinnings of the intervention, we will conduct interviews with stakeholders engaged in the intervention design. To contextualize quantitative findings and understand the mechanisms through which the intervention enacted change, end-line focus groups with mentor-mothers will be conducted.

Discussion

This trial will be among the first to explore a video-based, entertainment-education intervention delivered by CHWs and created using a community-based, human-centered design approach. As such, it could inform health policy, with regards to both the routine adoption of this intervention and, more broadly, the development of other entertainment-education interventions for health promotion in under-resourced settings.

Trial Registration

The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27th, 2018.

Addressing the First Delay in Saving Mothers, Giving Life Districts in Uganda and Zambia: Approaches and Results for Increasing Demand for Facility Delivery Services

The Saving Mothers, Giving Life initiative used 3 coordinated approaches to reduce maternal deaths resulting from a delay in deciding to seek health care, known as the “first delay”: (1) promoting safe motherhood messages and facility delivery using radio, theater, and community engagement; (2) encouraging birth preparedness and increasing demand for facility delivery through community outreach worker visits; and (3) providing clean delivery kits and transportation vouchers to reduce financial barriers for facility delivery. These approaches can be adapted in other low-resource settings to reduce maternal and perinatal mortality.

Saving Mothers, Giving Life (SMGL), a 5-year initiative implemented in selected districts in Uganda and Zambia, was designed to reduce deaths related to pregnancy and childbirth by targeting the 3 delays to receiving appropriate care at birth. While originally the “Three Delays” model was designed to focus on curative services that encompass emergency obstetric care, SMGL expanded its application to primary and secondary prevention of obstetric complications. Prevention of the “first delay” focused on addressing factors influencing the decision to seek delivery care at a health facility. Numerous factors can contribute to the first delay, including a lack of birth planning, unfamiliarity with pregnancy danger signs, poor perceptions of facility care, and financial or geographic barriers. SMGL addressed these barriers through community engagement on safe motherhood, public health outreach, community workers who identified pregnant women and encouraged facility delivery, and incentives to deliver in a health facility. SMGL used qualitative and quantitative methods to describe intervention strategies, intervention outcomes, and health impacts. Partner reports, health facility assessments (HFAs), facility and community surveillance, and population-based mortality studies were used to document activities and measure health outcomes in SMGL-supported districts. SMGL's approach led to unprecedented community outreach on safe motherhood issues in SMGL districts. About 3,800 community health care workers in Uganda and 1,558 in Zambia were engaged. HFAs indicated that facility deliveries rose significantly in SMGL districts. In Uganda, the proportion of births that took place in facilities rose from 45.5% to 66.8% (47% increase); similarly, in Zambia SMGL districts, facility deliveries increased from 62.6% to 90.2% (44% increase). In both countries, the proportion of women delivering in facilities equipped to provide emergency obstetric and newborn care also increased (from 28.2% to 41.0% in Uganda and from 26.0% to 29.1% in Zambia). The districts documented declines in the number of maternal deaths due to not accessing facility care during pregnancy, delivery, and the postpartum period in both countries. This reduction played a significant role in the decline of the maternal mortality ratio in SMGL-supported districts in Uganda but not in Zambia. Further work is needed to sustain gains and to eliminate preventable maternal and perinatal deaths.

A critical appraisal of the maternal and child health scenario in a metropolitan city in India with reference to achievements of millennium development goals

BACKGROUND

Post 2015, the Millennium Development Goals (MDGs) will undergo a transition to Sustainable Development Goals (SDGs). Therefore, it becomes necessary to assess the determinants influencing the present status of MDGs. This study was conducted to assess the progress, short comings related to the transition from MDGs to SDGs in a metropolitan city. It provides practical insights for extrapolating need based strategies related to the SDGs.

METHODS

Study was conducted in a metropolitan city, Mumbai. Situational analysis of the city was done using monthly and annual performance reports and key informant's interviews at city level. Qualitative analysis was done using thematic analysis.

RESULTS

The current infant mortality rate of Mumbai is 26.72 and under-five mortality rate is 38.7/1000 live births. The current MMR of mumbai is 88. The responses from the key informants' spanned three major themes: Concerns and challenges; Good practices and schemes in pipeline; and Opportunities envisioned. Eight major challenging areas were identified. Opportunities are sustainable models of public-private partnership; Involvement of NGOs and AYUSH practitioners; and IT sector involvement, HMIS, e- governance, and Corporate Social Responsibility (CSR).

CONCLUSIONS

Significant progress has been made in the field of maternal and child health (MCH), and sustained efforts are required. Maternal mortality figures may be illusive because of the effect of migration and referral cases. Socio-demographic issues of development need to be addressed through governance. Mechanism for intersectoral coordination, IT support, surveillance, and tracking of pregnant mothers needs to be developed. The linkage of MCH services with developmental programs needed.

Mothers' Experiences with Neonatal Care for Low Birth Weight Infants at Home; A Qualitative Study in the Hohoe Municipality, Ghana

PURPOSE

To explore knowledge and beliefs of mothers on low birth weight (LBW), examine care provision at home and societal perceptions of LBW infants.

DESIGN AND METHODS

This qualitative study was conducted using hermeneutic phenomenological approach. Data of mothers who delivered LBW infants within 2 years preceding the study were purposively extracted from the medical records of the Hohoe Municipality Hospital in Ghana. Twenty semi-structured interviews and three focus group discussions were conducted. A thematic analysis approach was performed using Atlas.ti.

RESULTS

Mothers identified and described LBW babies based on frailty, size and activity levels. LBW recognition was easier for multiparous mothers by comparing with previous deliveries. LBW was linked to poor maternal diet, diseases during pregnancy and heavy workload. Although most mothers perceived their LBW babies as healthy irrespective of the size a few home-care practises differed. Smaller LBW infants were less likely to be socially accepted. In the first few weeks after birth the care of LBW infants is the core responsibility of grandmothers. Primiparous mothers and those whose infants were smaller (<2 kg) quested for more information and support on LBW newborn care at home.

CONCLUSION

There is a need to increase knowledge on risk factors and tackle lapses in the recognition and care of LBW infants. Counselling on recommended neonatal care should begin during antenatal care and reiterated during postnatal care.

PRACTICAL IMPLICATION

Tailored in-depth and culturally-adapted counselling, discharge instructions and home-based postnatal visits targeted at LBW infants and their primary caregivers could improve care.

An extension of the Alma-Ata vision for primary health care in light of twenty-first century evidence and realities

This paper builds upon and extends the definition of primary health care in the 1978 Declaration of Alma-Ata. The definition proposes a stronger role for community-based delivery of services and community mobilization, participation and empowerment. It calls for a stronger integration with vertical, disease-specific programs. And, finally, it calls for a strong role for certain curative services (including basic and essential surgery) that many today would not consider as part of primary health care. There is growing evidence that communities can and should play a stronger role than has traditionally been the case, that community-level workers who are properly trained and supported can provide effective services outside of health facilities, and that primary health centers staffed with non-specialist physicians and even non-physician clinicians can perform many of the lower-level inpatient services now performed at first-level referral hospitals. An approach to primary health care that is appropriate to the local context and that merges local epidemiological priorities with the communities' perceived priorities will make it possible to engage communities as partners. Currently, essential and basic health care services are available to only one-half of the world's population. The full development of primary health care as envisioned here will accelerate progress in achieving Health for All as envisioned at the International Conference on Primary Health Care in 1978.

Practice of emergency obstetric care signal functions and reasons for non-provision among health centers and hospitals in Lake and Western zones of Tanzania

BACKGROUND

The Lake and Western Zones of Tanzania that encompass eight regions namely; Kagera, Geita, Simiyu, Shinyanga, Mwanza, Mara Tabora and Kigoma have consistently been reported with the poorest Maternal Newborn and Child Health (MNCH) indicators in the country. This study sought to establish the provision of Emergency Obstetric Care (EmOC) signal functions and reasons for the failure to do so among health centers and hospitals in the two zones.

METHODS

All the 261 public and private hospitals and health centers providing Obstetric Care services in Lake and Western Zones were surveyed in 2014. Data were collected using questionnaires adapted from the Averting Maternal Deaths and Disabilities (AMDD) tool to assess EmOC indicators. Managers in all facilities were interviewed and services, medicines and equipment were observed. Spatial Mapping was done using a calibrated Global Positioning System (GPS) Essential Software for Android and coordinates represented on digitalized map with Arc Geographical Information System (GIS) software. Population data were according to the 2012 Housing and Population National Census.

RESULTS

In total 261 health facilities were identified as providers of Obstetric care services, including 69 hospitals and 192 health centres which constitute an overall facility density of 8 per 500,000 population. The three most common EmOC signal functions available in the 3 months preceding the survey were oxytocics (95.7%), injectable antibiotics (88.9%) and basic newborn resuscitation (83.4%). The lowest proportions of facilities performed Cesarean section (25.7%) and blood transfusion (34.6%). Policy restrictions were the most frequent reasons given in relation to nonperformance of blood transfusion and Cesarean section when needed. Lack of training and supplies were the most common reasons for non availability of assisted vaginal delivery and uterine evacuation. Overall the Direct Case fatality Rate for direct obstetric causes was 3%. The referral system highly depended on hired or shared ambulance.

CONCLUSION

The provision of EmOC signal functions in Lake and Western zones of Tanzania is inconsistent, being mainly compromised by policy restrictions, lack of supplies and professional development, and by operating under lowly developed referral services.

"Our voices matter": a before-after assessment of the effect of a community-participatory intervention to promote uptake of maternal and child health services in Kwale, Kenya

Background

Community-participatory approaches are important for effective maternal and child health interventions. A community-participatory intervention (the Dialogue Model) was implemented in Kwale County, Kenya to enhance uptake of select maternal and child health services among women of reproductive age.

Methods

Community volunteers were trained to facilitate Dialogue Model sessions in community units associated with intervention health facilities in Matuga, Kwale. Selection of intervention facilities was purposive based on those that had an active community unit in existence. For each facility, uptake of family planning, antenatal care and facility-based delivery as reported in the District Health Information System (DHIS)-2 was compared pre- (October 2012 – September 2013) versus post- (January – December 2016) intervention implementation using a paired sample t-test.

Results

Between October 2013 and December 2015, a total of 570 Dialogue Model sessions were held in 12 community units associated with 10 intervention facilities. The median [interquartile range (IQR)] number of sessions per month per facility was 2 (1–3). Overall, these facilities reported 15, 2 and 74% increase in uptake of family planning, antenatal care and facility-based deliveries, respectively. This was statistically significant for family planning pre- (Mean (M) = 1014; Standard deviation (SD) = 381) versus post- (M = 1163; SD = 400); t (18) = − 0.603, P = 0.04) as well as facility-based deliveries pre- (M = 185; SD = 216) versus post- (M = 323; SD = 384); t (18) = − 0.698, P = 0.03).

Conclusions

A structured, community-participatory intervention enhanced uptake of family planning services and facility-based deliveries in a rural Kenyan setting. This approach is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3739-9) contains supplementary material, which is available to authorized users.

Health policy and system support to optimise community health worker programmes: an abridged WHO guideline

Optimising community health worker (CHW) programmes requires evidence-based policies on their education, deployment, and management. This guideline aims to inform efforts by planners, policy makers, and managers to improve CHW programmes as part of an integrated approach to strengthen primary health care and health systems. The development of this guideline followed the standard WHO approach to developing global guidelines. We conducted one overview of reviews, 15 systematic reviews (each one on a specific policy question), and a survey of stakeholders' views on the acceptability and feasibility of the interventions under consideration. We assessed the quality of systematic reviews using the AMSTAR tool, and the certainty of the evidence using the GRADE methodology. The overview of reviews identified 122 eligible articles and the systematic reviews identified 137 eligible primary studies. The stakeholder perception survey obtained inputs from 96 respondents. Recommendations were developed in the areas of CHW selection, preservice education, certification, supervision, remuneration and career advancement, planning, community embeddedness, and health system support. These are the first evidence-based global guidelines for health policy and system support to optimise community health worker programmes. Key considerations for implementation include the need to define the role of CHWs in relation to other health workers and plan for the health workforce as a whole rather than by specific occupational groups; appropriately integrate CHW programmes into the general health system and existing community systems; and ensure internal coherence and consistency across different policies and programmes affecting CHWs.

Effectiveness and sustainability of a diagonal investment approach to strengthen the primary health-care system in Ethiopia

Weakness of primary health-care (PHC) systems has represented a challenge to the achievement of the targets of disease control programmes (DCPs) despite the availability of substantial development assistance for health, in resource-poor settings. Since 2005, Ethiopia has embraced a diagonal investment approach to strengthen its PHC systems and concurrently scale up DCPs. This approach has led to a substantial improvement in PHC-system capacity that has contributed to increased coverage of DCPs and improved health status, although gaps in equity and quality in health services remain to be addressed. Since 2013, Ethiopia has had a decline in development assistance for health. Nevertheless, the Ethiopian Government has been able to compensate for this decline by increasing domestic resources. We argue that the diagonal investment approach can effectively strengthen PHC systems, achieve DCP targets, and sustain the gains. These goals can be achieved if a visionary and committed leadership coordinates its development partners and mobilises the local community, to ensure financial support to health services and improve population health. The lessons learnt from Ethiopia's efforts to improve its health services indicate that global-health initiatives should have a proactive and balanced investment approach to concurrently strengthen PHC systems, achieve programme targets, and sustain the gains, in resource-poor settings.

What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

OBJECTIVE

To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems.

METHODS

We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards.

FINDINGS

We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance.

CONCLUSION

Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.