Background
Methods
Study design
Recruitment of study participants
Survey design and development
Operational definition of UHC
Round one
PHC Principle | Sub-Attributes |
---|---|
Universal Health Coverage | Equity Access Comprehensiveness |
Community Participation | - |
Intersectoral Coordination | - |
Appropriateness | Effectiveness Cultural acceptability Affordability Manageability |
Round two
Data collection
Data analysis
Participants and public involvement
Positionality statement
Results
Round one
Characteristic | Frequency | Percentage |
---|---|---|
Country of residence (WHO Regions) | ||
Region of the Americas | 3 | 17.6 |
Brazil | ||
Canada | ||
Unites States of America | ||
African Region | 8 | 47.1 |
Ethiopia | ||
Ghana | ||
Kenya—3 participants | ||
Mozambique | ||
Rwanda | ||
Zambia | ||
South-East Asia Region | 4 | 23.5 |
Bangladesh | ||
India | ||
Indonesia | ||
Myanmar | ||
Eastern Mediterranean Region | 1 | 5.9 |
Pakistan | ||
Western Pacific Region | 1 | 5.9 |
Philippines | ||
Gender | ||
Male | 8 | 47.1 |
Female | 9 | 52.9 |
Age | ||
< 40 years | 5 | 29.4 |
> 40 years | 12 | 70.6 |
Qualification | ||
Doctoral Scientists | 9 | 52.9 |
Master’s degree | 6 | 35.3 |
Others | 2 | 11.8 |
CHW Program Experience | ||
Evaluation and Implementation | 11 | 64.7 |
Research and Evaluation | 2 | 11.8 |
Research and Implementation | 2 | 11.8 |
Research | 1 | 5.9 |
Others | 1 | 5.9 |
Years of Experience | ||
5–10 years | 8 | 47.1 |
10–20 years | 6 | 35.3 |
20 + years | 3 | 17.6 |
Round two
Principles | Activities | Level of agreement (%) |
---|---|---|
UNIVERSAL HEALTH COVERAGE | Provision of basic maternal, newborn and child health services | 93.8 |
Medical care services for physical and mental health | 93.3 | |
Appropriate distribution of resources (Staff and material) | 87.5 | |
Defining the catchment area | 86.7 | |
Community sensitization | 86.7 | |
Transparent distribution of resources | 86.7 | |
Outreach services to remote areas | 81.3 | |
Evaluation of the program implementation | 69.2 | |
Annual [re]planning for implementation | 57.1 | |
Equity | Equity-based planning from the beginning | 100 |
Identification of groups that are discriminated against | 100 | |
Removing financial and geographic barriers to health care | 100 | |
Implementation focused on vulnerable sub-populations | 93.8 | |
Service packages are adapted to the particular needs of disadvantaged groups | 93.8 | |
Provision of services in hard to reach areas | 87.5 | |
Gender mainstreaming | 85.7 | |
Broadening of selection criteria of CHWs e.g. low literacy groups and women | 78.6 | |
Bottleneck analyses | 68.8 | |
Program cost discussion with the community representatives | 50 | |
Access | Identification of the causes of low demand and utilization | 100 |
Ensuring all community members can access the program | 100 | |
Distribution of CHWs across a population | 93.8 | |
Addressing privacy and confidentiality | 81.3 | |
Ensuring financial protection | 68.8 | |
Training and mentorship of CHWs | 56.3 | |
Remuneration arrangements for CHWs in case of emergency | 56.3 | |
Role clarity between the community, CHWs and supervisors/program | 50 | |
Comprehensiveness | Provision of preventive, curative, and rehabilitative services | 100 |
Linkages with higher level service providers | 87.5 | |
Needs assessment | 81.3 | |
Referral for and management of endemic illnesses | 80 | |
Skilled CHWs | 66.7 | |
Pro-active CHWs | 53.3 | |
COMMUNITY PARTICIPATION | Engaging traditional and other community leaders | 100 |
Ensuring feedback by the community [and acting on it] | 92.9 | |
Involving community members in supervision of the program activities | 87.5 | |
A practical monitoring system incorporating data from communities and the health system | 87.5 | |
Joint ownership and design of CHW programs | 81.3 | |
Availability of health data to the community | 80 | |
Community sensitization and awareness of the program activities | 75 | |
The integration of CHWs in health care decisions | 75 | |
A balanced package of incentives for CHWs, both financial and non-financial | 62.5 | |
INTERSECTORAL COORDINATION | Senior leadership of the program—accessible and flexible | 93.8 |
CHWs working with community development personal and government officials | 93.3 | |
Addressing needs of water, sanitation, food, housing, transport | 87.5 | |
Horizontal integration at the service delivery level | 87.5 | |
Involvement of multiple ministries/sectors | 81.3 | |
Collaboration in governance structures from local to national level | 80 | |
Partner mapping: to identify all partners who are implementing CHW related interventions | 66.7 | |
Vertical integration within the health systems | 46.7 | |
APPROPRIATENESS | Need-based and context specific program design and implementation | 93.3 |
Prioritization of technically sound and operationally manageable service packages with max health impact | 86.7 | |
Competent CHWs | 86.7 | |
Respectable CHWs | 80 | |
CHW program follows international ethical and human rights standards | 66.7 | |
Effectiveness | Monitoring to assess outputs with reference to the stated goals | 100 |
Review of health outcomes and from an equity lens | 93.3 | |
Consistent access to required training, supplies and supervision for CHWs | 86.7 | |
Monitoring and performance systems | 80 | |
Clear coordination | 71.4 | |
Achievement of the target of the specific programs | 66.7 | |
Cultural acceptability | Community involvement in the selection of the CHWs | 100 |
CHWs are in high demand, have access to all community members | 93.3 | |
Monitoring to make sure that people understand the messages shared by CHWs | 86.7 | |
Community ownership | 85.7 | |
Community working with CHWs to address needs and concerns in an acceptable way | 66.7 | |
Situation analysis of the target population | 64.3 | |
Relevance of the primary health care, MNCH and reproductive health services | 60 | |
Affordability | Financial assessment of chosen intervention to envision sustainability | 86.7 |
Assess if transport cost is a barrier and provide subsidy/transport | 86.7 | |
Assess the ability of the local community to pay | 80 | |
Identify the costs of alternate interventions | 78.6 | |
Assess if the full spectrum of treatment needed is affordable | 73.3 | |
Provision of a basic package of health services that are cost effective | 66.7 | |
Drugs dispensed free to all people irrespective of their ability to pay | 53.3 | |
Manageability | Adequate human resource | 92.9 |
Regular provision of a comprehensive package of services at a high standard of quality to all in need | 86.7 | |
Adequate supportive supervision and performance review | 85.7 | |
Continuous adjustment of the role of CHWs as the program evolves with respect to communities’ needs | 85.7 | |
A balanced package of financial and non-financial incentives for CHWs | 66.7 | |
Majority of people are provided the needed services at the cost they can afford | 66.7 |
CHALLENGES | Level of agreement |
---|---|
Poor leadership and Governance | 93.3 |
Inadequate resource allocation | 93.3 |
Poor understanding of community needs | 92.9 |
Sustainable funding | 86.7 |
Geographic location | 80 |
Political commitment | 80 |
Intersectoral collaboration | 80 |
Inadequate human resource for health | 80 |
Understanding of PHC by the senior decision makers | 80 |
Top-down approach | 80 |
Adopting national approaches with flexible context-specific strategies | 78.6 |
Non-involvement of critical stakeholders in non-health sectors | 73.3 |
Misunderstanding of role of CHW as "doctor" | 53.3 |
Taking CHW programs outside the bio-medical framework | 50 |
PHC Principle | Indicator Activity | Examples of the activity |
---|---|---|
UNIVERSAL HEALTH COVERAGE | Service Provision | •Provide maternal, newborn and child health services •Provide medical care services for physical and mental health •Provide outreach services to remote areas •Horizontal integration at the service delivery level |
Selection and placement of CHWs | •Select CHWs based on a broad criteria not limited by a literacy threshold •Have CHWs in all areas of the country, even the remotest hamlets •Distribute CHWs across a population to make it feasible for the CHW workload and individual care seeking | |
Defined catchment area | •Define the catchment area with reference to the population that is to be served by the CHW program. This would facilitate needs assessment, service provision and connection to the formal health system in an organised manner | |
Community Sensitization | •Inform the community about the core activities of the coverage •Ensure the community is aware of their right to have access to the needed care | |
Needs assessment | •Identify varying needs of sub-population groups to provide equity-based care •Assess the staff and material needs of sub-population to distribute them accordingly •Assess what could work or not in each community in a manner (sensitive to social, economic and cultural aspects) and with a social determinants of health lens – Comprehensiveness | |
Equity | Planning | •Plan services that address the local inequities in service coverage and health outcomes across different types of demographics •Plan services with an understanding about dynamics of discrimination within the local context |
Implementation | •Provide services according to the needs of disadvantaged groups | |
Address financial and geographic barriers to health care | •No user fee especially in rural health centres •Provide PHC services close to the community through outreach | |
Access | Identification of the causes of low demand and utilization | •Identify physical barriers and other supply-based barriers like access to quality care and human resources for health, supplies and commodities |
Promote community access to the program | •Ensure that all community members can access the program irrespective of distance, ethnic or religious group, gender, age, social status, physical and mental state, and ability to pay | |
Ensure privacy and confidentiality | •Train CHWs to provide services considering privacy and confidentiality of the community members | |
Comprehensiveness | Provision of health services along the spectrum of preventive, curative, and rehabilitative services | •Presence of a functional health unit within the catchment area with primary health care activities |
Linkages with secondary and tertiary level services | •Establish linkages with other service providers and referral pathways to ensure comprehensiveness of a service package, especially if very few or no curative services are being provided directly by the CHWs •Collaborate in governance structures from local to national level | |
COMMUNITY PARTICIAPTION | Joint ownership and design of CHWPs | •Engage community representatives to make sure that they are aware and involved in the design, implementation and evaluation of the program •Involve community at all levels of decision making from planning, training, selecting and oversight of CHWs •Ensure feedback from the community |
Availability of health data to the community | •Ensure that the community is informed, provide feedback and participate in decision-making •Establish a practical monitoring system incorporating data from communities and the health system | |
INTERSECTORAL COORDINATION | Representation of non-health organisations on planning and governance structures of CHWPs | •Negotiate to promote health and addressing needs of water, sanitation, food, housing and transport |
Public private partnership | •CHW program works with [other actors] in the community development sector •CHW program works with government officials •Provide benefit packages to particular populations (e.g. cash transfers for pregnant and lactating woman or households below the poverty line) | |
APPROPRIATENESS | Context specific program design and implementation | •Plan and implement interventions which adhere to community culture and demand |
Evidence-based interventions | Prioritize technically sound and operationally manageable service packages with maximum health impact | |
Effectiveness | Monitoring health outcomes | •Assess health outcomes with reference to the stated goals and from an equity lens •Ensure that quality of care is an integral part of the monitoring systems |
Monitoring performance | •Assess the competence of CHWs regularly on to make sure that they are skilled to address poor health and confident to be pro-active in using these skills | |
Well-resourced CHWs | •Provide regular training, supplies and supervision to CHWs in order to ensure intended health outcomes | |
Cultural acceptability | Community involvement in the selection of the CHWs | •Consider factors influencing care-seeking by underserved groups e.g. language and other cultural norms |
Health Literacy | •Monitor that messages shared by CHW program [are such] to which people [relate to] and understand | |
Affordability | Cost effective interventions | •Assess the chosen and alternate interventions financially and in a context-specific manner •Assess if the full spectrum of treatment needed is affordable by the CHW program |
Identify and address financial barriers to health care | •Assess if transport cost is a barrier and provide subsidy/transport if necessary | |
Manageability | Adequate human resources | •Supervisors, program managers and frontline health staff must have the capacity, clear role, time and resources to provide adequate supportive supervision and performance review |
Proportionate service provision | •Consider the range and complexity of services along with the size of the population to be served | |
Continuous adjustment of the role of CHWs as the program evolves with respect to communities’ needs | •Full-time, salaried CHW versus part-time, voluntary CHW •Make sure that the time commitment and renumeration of the CHWs are according to service package and catchment area |
PHC Indicator-Activities for Universal Health Coverage
“Understanding inequities in service coverage and health outcomes across different types of demographics as well as dynamics of discrimination within the local context is indeed important. Service delivery approaches can and should be tailored and planned with these understandings in mind. Community Health Programs should contribute to building inclusive health systems for people of all abilities, gender identities, ethnicities, etc.” (Participant 4).
PHC Indicator-Activities for Community participation
“Data should indeed be available to communities in order for them to be informed, provide feedback and participate in decision-making etc., but making the data available alone does not indicate community participation” (Participant 4).
PHC Indicator-Activities for Intersectoral Coordination
“When all sectors understand their role in supporting health and well-being of the people, their actions are synergistic and implement their activities as horizontal programs and not as silo programs” (Participant 13).
PHC Indicator-Activities for Appropriateness
“Cultural acceptability is met when those who are defined as the objective of an intervention become the subjects and work with CHWs to address both needs and concerns in a way that is acceptable [by the community in the given context]” (Participant 9).
“It is important to look at financial barriers (including transport) and cost effectiveness of interventions as well as compare the costs of alternative interventions (i.e., alternative methods for service delivery), but it does not necessarily mean all drugs/services need to be dispensed ‘free of charge’ (though it should be noted that health financing evidence demonstrates that pre-payment and adequate risk-pooling reduces financial barriers)” (Participant 4).
Challenges in the application of PHC principles by CHWPs
“Some countries have very fragmented health systems – a unified health system makes the application of PHC principles more feasible. Contexts of marked social inequalities are especially challenging” (Participant 6).