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Shrestha P, Afsana K, Weerasinghe MC, Perry HB, Joshi H, Rana N, Memon ZA, Khaled N, Malhotra S, Bhardwaj S, Kafle S, Inagaki Y, Schimdt A, Hodgins S, Neupane D, Rao KD. Strengthening primary health care through community health workers in South Asia. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 28:100463. [PMID: 39301268 PMCID: PMC11410731 DOI: 10.1016/j.lansea.2024.100463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/31/2024] [Accepted: 07/31/2024] [Indexed: 09/22/2024]
Abstract
The growing health challenges in South Asia require further adaptations of community health worker (CHW) programs as a key element of primary health care (PHC). This paper provides a comparative analysis of CHW programs in five countries (Bangladesh, India, Nepal, Pakistan, and Sri Lanka), examines successes and challenges, and suggests reforms to better ensure highly performing CHW programs. To examine CHW programs in the region, we conducted a narrative review of the peer-reviewed and grey literatures, as well as eliciting opinions from experts. Common roles of CHWs include health education, community mobilization, and community-based services, particularly related to reproductive, maternal, neonatal, and child health. Some countries utilize CHWs for non-communicable diseases and other emerging health issues. To maximize the potential contribution of CHWs to achieving Universal Health Coverage, we recommend future research and policy focus on strengthening existing health systems to support the expansion of CHWs roles and better integrating of CHWs into national PHC systems. This is Paper 4 in the Series on Primary Health Care in South Asia, addressing areas that have the potential to revitalize health systems in South Asian countries. Funding The authors received financial support from the Department of Health Systems Development, WHO South-East Asia Regional Office (WHO SEAR).
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Affiliation(s)
- Prakriti Shrestha
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Kaosar Afsana
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | | | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Harsha Joshi
- India Primary Healthcare Support Initiative, Johns Hopkins India Private Ltd., Delhi, India
| | - Nisha Rana
- Nepal Development Society, Kathmandu, Nepal
| | - Zahid Ali Memon
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Nazrana Khaled
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Sumit Malhotra
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Simrin Kafle
- Department of Public Health, Aarhus University, Denmark
| | - Yoko Inagaki
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Austin Schimdt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Stephen Hodgins
- College of Health Sciences, School of Public Health, University of Alberta, Edmonton, Canada
| | - Dinesh Neupane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Puri MC, Guo M, Stone L, Shah IH. Integrating postpartum IUD counselling and insertion into routine maternity care in Nepal: Assessing trends over time. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001665. [PMID: 36963067 PMCID: PMC10032507 DOI: 10.1371/journal.pgph.0001665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 02/08/2023] [Indexed: 03/24/2023]
Abstract
To meet the postpartum family planning (PPFP) needs of women in Nepal, an intervention was launched to integrate PPFP counselling and postpartum IUD (PPIUD) insertion into maternity care. Women delivering in study hospitals over a period of 18 months were interviewed at the time of delivery and at 15 months following the end of the study enrollment period to assess if the impact of the intervention observed at the end of the study was maintained. Data were collected prior to the intervention, at the middle month of the intervention roll out, at the end of the enrollment period and 15 months after the end of the enrollment period. We compared PPFP counselling and insertion rates before, during, at the end of and after the intervention study period, using cross-tabulation and chi-square tests. Overall, PPFP counselling rates increased from 11% at the baseline month to 45% at the end of the enrollment in February 2017 and remained the same 15 months later in July 2018. PPIUD uptake, however, rose from a negligible 0.1% at the baseline to 4.3% in February 2017, but declined to 3.4% in July 2018. PPIUD uptake among women who were counselled showed a similar trend, increasing from 1.9% at the baseline to 9.6% in February 2017 and declining to 6.0% in July 2018. The intervention had an appreciable continued impact on PPIUD counselling rates and although PPIUD uptake rose during the intervention, this trend was not observed in the 15 months post-study follow up. The impact of the intervention was greater and persistent in hospitals that had a longer period of exposure to intervention. The results suggest that counselling was well integrated with the maternity care, though uptake of PPIUD dropped after intervention activities such as active monitoring, technical supervision, provision of IUDs and training were withdrawn. Trial registration: This study has been registered with Clinical Trial.gov. The registration number is NCT 02718222. Details about the study design have been published by Canning et al, 2016.
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Affiliation(s)
- Mahesh Chandra Puri
- Center for Research on Environment, Health and Population Activities (CREHPA), Kusunti, Lalitpur, Kathmandu, Nepal
- * E-mail:
| | - Muqi Guo
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Lucy Stone
- Faculty of Medicine, Health and Life Science, Swansea University Medical School, Swansea University, Wales, United Kingdom
| | - Iqbal H. Shah
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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Rahayuwati L, Ekawati R, Nurhidayah I, Hendrawati S, Agustina HS, Suhenda D, Rosmawati D, Ibrahim K, Fauziyyah RNP. Stakeholders' perceptions of family planning programs during the COVID-19 period: A descriptive qualitative study. ENFERMERIA CLINICA 2023; 33:S45-S49. [PMID: 36852162 PMCID: PMC9948302 DOI: 10.1016/j.enfcli.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/15/2022] [Indexed: 02/25/2023]
Abstract
Aim The number of unintended pregnancies and the decreasing use of contraceptives during the COVID-19 pandemic are of particular concern to the national population and family planning program. The successful implementation of the family planning program cannot be carried out by the government alone. Still, it requires strong synergy with stakeholders. The difference in perceptions among stakeholders, acceptors, and the community about family planning is crucial, so qualitative research is needed to identify this matter. This study explores stakeholders' perceptions of post-partum family planning programs and their barriers during the COVID-19 pandemic. Method This research uses a descriptive qualitative method, with participants consisting of family planning officers, cadres of family planning units, and the head of the family planning program. The data were collected through in-depth interviews and examined using content analysis. Results The results show that health workers and community leaders cooperated at the village and sub-district levels in realising the family planning programs. During the COVID-19 pandemic, services were stopped at the public health centre, especially long-term contraceptive method services. Stakeholders believe that barriers to the program's success include education level, negative perceptions, lack of training, and low trust in partners. Conclusion Cross-sectoral engagement is essential in increasing participation in family planning programs. Other critical success factors are support from husbands, community leaders, and local government.
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Affiliation(s)
| | | | | | | | | | | | - Dean Rosmawati
- National Population and Family Planning Board, Indonesia
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Dhital R, Silwal RC, Pokhrel KN, Pokhrel S, Tuladhar H, Bright S, Tunnacliffe EA, Thapa K, Makins A. Evaluating the impact of female community health volunteer involvement in a postpartum family planning intervention in Nepal: A mixed-methods study at one-year post-intervention. PLoS One 2021; 16:e0258834. [PMID: 34669735 PMCID: PMC8528303 DOI: 10.1371/journal.pone.0258834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction This is a one-year post-intervention study following an initiative to provide orientation to female community health volunteers (FCHVs) on postpartum family planning in Nepal. In light of positive results in the earlier post-intervention study, this study was designed to provide a more long-term perspective on sustainability by assessing the effect at one-year post-intervention. Methods This mixed-methods study was conducted in January 2020 in Morang district, Nepal. We collected quantitative data from a knowledge assessment of FCHVs who had participated in the intervention on postpartum family planning, data on their community-based counseling coverage and through interviews with postpartum mothers in two selected hospitals. Qualitative data were collected through six key informant interviews with health providers and four focus group discussions with FCHVs involved in the intervention. We performed descriptive and multivariate analyses for quantitative data and thematic analysis for qualitative data. Results In total, 206 FCHVs participated in the one-year post-intervention study with significant improvement in knowledge of postpartum family planning as compared to pre-intervention period. The adjusted odds ratios (AOR) for knowledge of the 5 key messages on postpartum family planning as compared to the pre-intervention period included 1) knowledge on postpartum family planning can be used immediately after birth (AOR = 18.1, P<0.001), 2) postpartum intra-uterine device (PPIUD) can provide protection up to 12 years (AOR = 2.9, P = 0.011), 3) mothers who undergo cesarean section can use PPIUD (AOR = 2.3, P<0.001), 4) PPIUD can be inserted immediately after birth (AOR = 6.2, P <0.001), and 5) women should go for follow-up immediately if the IUD strings are seen outside vulva (AOR = 2.0, P = 0.08). The FCHVs answering 4 or more questions correctly was 10 times higher (AOR = 10.1, P<0.001) at one-year post-intervention, whereas it was 25 times higher at immediate-post-test (AOR = 25.1, p<0.001) as compared to pre-intervention phase. The FCHVs had counseled 71% of the pregnant women (n = 538) within their communities at one-year post-intervention. The postpartum mothers in hospitals had a 2 times higher odds of being counseled by FCHVs during their pregnancy at one-year post-intervention (AOR = 1.8, P = 0.039) than in pre-intervention phase. The qualitative findings suggested a positive impression regarding the FCHV’s involvement in postpartum family planning counseling in the communities, however, supervision and monitoring over a longer term was identified as a key challenge and that may influence sustainability of community-based and hospital-based postpartum family planning services. Conclusion The FCHVs’ knowledge and community-based activities on postpartum family planning remained higher than in the pre-intervention. However, it declined when compared to the immediate post-intervention period. We propose regular supervision and monitoring of the work of the FCHVs to sustain progress.
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Affiliation(s)
- Rolina Dhital
- Green Tara Nepal, Kathmandu, Nepal
- Health Action and Research, Kathmandu, Nepal
- * E-mail:
| | | | - Khem Narayan Pokhrel
- Green Tara Nepal, Kathmandu, Nepal
- Tropical Health and Education Trust, Kathmandu, Nepal
| | | | - Heera Tuladhar
- Nepal Society of Obstetricians and Gynecologists, Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal
| | - Suzanna Bright
- International Federation of Gynecology and Obstetrics, London, United Kingdom
| | | | - Kusum Thapa
- Nepal Society of Obstetricians and Gynecologists, Paropakar Maternity and Women’s Hospital, Kathmandu, Nepal
| | - Anita Makins
- International Federation of Gynecology and Obstetrics, London, United Kingdom
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Kok M, Crigler L, Musoke D, Ballard M, Hodgins S, Perry HB. Community health workers at the dawn of a new era: 10. Programme performance and its assessment. Health Res Policy Syst 2021; 19:108. [PMID: 34641901 PMCID: PMC8506096 DOI: 10.1186/s12961-021-00758-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND While the evidence supporting the effectiveness of community health worker (CHW) programmes is substantial, there is also considerable evidence that many of these programmes have notable weaknesses that need to be addressed in order for them to reach their full potential. Thus, considerations about CHW programme performance and its assessment must be taken into account as the importance of these programmes is becoming more widely appreciated. In this paper, the tenth in our 11-paper series, "Community health workers at the dawn of a new era", we address CHW programme performance and how it is assessed from a systems perspective. METHODS The paper builds on the 2014 CHW Reference Guide, a compendium of case studies of 29 national CHW programmes, the 2018 WHO guideline on health policy and system support to optimize CHW programmes, and scientific studies on CHW programme performance published in the past 5 years. RESULTS The paper provides an overview of existing frameworks that are useful for assessing the performance of CHW programmes, with a specific focus on how individual CHW performance and community-level outcomes can be measured. The paper also reviews approaches that have been taken to assess CHW programme performance, from programme monitoring using the routine health information system to national assessments using quantitative and/or qualitative study designs and assessment checklists. The paper also discusses contextual factors that influence CHW programme performance, and reflects upon gaps and needs for the future with regard to assessment of CHW programme performance. CONCLUSION Assessments of CHW programme performance can have various approaches and foci according to the programme and its context. Given the fact that CHW programmes are complex entities and part of health systems, their assessment ideally needs to be based on data derived from a mix of reliable sources. Assessments should be focused not only on effectiveness (what works) but also on contextual factors and enablers (how, for whom, under what circumstances). Investment in performance assessment is instrumental for continually innovating, upgrading, and improving CHW programmes at scale. Now is the time for new efforts in implementation research for strengthening CHW programming.
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Affiliation(s)
- Maryse Kok
- Department of Global Health, KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | | | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Madeleine Ballard
- Community Health Impact Coalition, New York, NY, USA
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steve Hodgins
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Eva G, Gold J, Makins A, Bright S, Dean K, Tunnacliffe EA, Fatima P, Yesmin A, Muganyizi P, Kimario GF, Dalziel K. Economic Evaluation of Provision of Postpartum Intrauterine Device Services in Bangladesh and Tanzania. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:107-122. [PMID: 33795364 PMCID: PMC8087427 DOI: 10.9745/ghsp-d-20-00447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/10/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Postpartum family planning is an effective means of achieving improved health outcomes for women and children, especially in low- and middle-income settings. We assessed the cost-effectiveness of an immediate postpartum intrauterine device (PPIUD) initiative compared with standard practice in Bangladesh and Tanzania (which is no immediate postpartum family planning counseling or service provision) to inform resource allocation decisions for governments and donors. METHODS A decision analysis was constructed to compare the PPIUD program with standard practice. The analysis was based on the number of PPIUD insertions, which were then modeled using the Impact 2 tool to produce estimates of cost per couple-years of protection (CYP) and cost per disability-adjusted life years (DALYs) averted. A micro-costing approach was used to estimate the costs of conducting the program, and downstream cost savings were generated by the Impact 2 tool. Results are presented first for the program as evaluated, and second, based on a hypothetical national scale-up scenario. One-way sensitivity analyses were conducted. RESULTS Compared to standard practice, the PPIUD program resulted in an incremental cost-effectiveness ratio (ICER) of US$14.60 per CYP and US$91.13 per DALY averted in Bangladesh, and US$54.57 per CYP and US$67.67 per DALY averted in Tanzania. When incorporating estimated direct health care costs saved, the results for Bangladesh were dominant (PPIUD is cheaper and more effective versus standard practice). For Tanzania, the PPIUD initiative was highly cost-effective, with the ICER (incorporating direct health care costs saved) estimated at US$15.20 per CYP and US$18.90 per DALY averted compared to standard practice. For the national scale-up model, the results were dominant in both countries.Conclusions/implications: The PPIUD initiative was highly cost-effective in Bangladesh and Tanzania, and national scale-up of PPIUD could produce long-term savings in direct health care costs in both countries. These analyses provide a compelling case for national governments and international donors to invest in PPIUD as part of their family planning strategies.
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Affiliation(s)
- Gillian Eva
- Independent consultant, Washington, DC, USA.
| | - Judy Gold
- Independent consultant, Melbourne, Australia
| | - Anita Makins
- International Federation of Gynecology and Obstetrics, London, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department Women's and Reproductive Health, Oxford University, Oxford, UK
| | - Suzanna Bright
- International Federation of Gynecology and Obstetrics, London, UK
| | - Katherine Dean
- International Federation of Gynecology and Obstetrics, London, UK
| | | | - Parveen Fatima
- Obstetrical and Gynaecological Society of Bangladesh, Dhaka, Bangladesh
| | - Afroja Yesmin
- Obstetrical and Gynaecological Society of Bangladesh, Dhaka, Bangladesh
| | | | | | - Kim Dalziel
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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