Challenges and opportunities from using abortion harm reduction and value clarification and attitude transformation engagements for safe abortion advocacy in Uganda.

BACKGROUND: From 2018, the International Federation of Gynecologists and Obstetricians (FIGO) implemented the Advocating Safe Abortion project to support national obstetrics and gynecology (Obs/gyn) societies from ten member countries to become leaders of Sexual and Reproductive Health and Rights (SRHR). We share experiences and lessons learnt about using value clarification and attitude transformation (VCAT) and abortion harm reduction (AHR) as strategies for our advocacy engagements. METHODS: The advocacy goal of ending abortion-related deaths followed predefined pathways from an extensive needs assessment prior to the project. These pathways were strengthening capacity of the Obs/gyn society as safe abortion advocates; establishing a vibrant network of partners; transforming social and gender norms; raising awareness of the legal and policy environment regarding abortion, and promoting the generation and use abortion data for evidence-informed policy and practice. Our advocacy targeted multiple stakeholders including media, policy makers judicio-legal, political and religious leaders, health workers and the public. RESULTS: During each engagement, facilitators required audiences to identify what roles they can play along the continuum of strategies that can reduce maternal death from abortion complications. The audiences acknowledged abortion complications as a major problem in Uganda. Among the root causes for the abortion context, audiences noted absence of an enabling environment for abortion care, which was characterized by low awareness about the abortion laws and policy, restricted abortion laws, cultural and religious beliefs, poor quality of abortion care services and abortion stigma. CONCLUSION: VCAT and AHR were critical in enabling us to develop appropriate messages for different stakeholders. Audiences were able to recognize the abortion context, distinguish between assumptions, myths and realities surrounding unwanted pregnancy and abortion; recognize imperative to address conflict between personal and professional values, and identify different roles and values which inform empathetic attitudes and behaviors that mitigate abortion harms. The five pathways of the theory of change reinforced each other. Using the AHR model, we delineate strategies and activities which stakeholders could use to end abortion deaths. VCAT enables critical reflection of views, beliefs and values versus professional obligations and responsibilities, and promotes active attitude and behavior change and commitment to end abortion-related deaths.

Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology.

In 2019 the International Federation of Gynecology and Obstetrics (FIGO) embarked on an initiative that aims to strengthen the capacity of 10 national societies of obstetrics and gynecology (ObGyn) in advocacy for safe abortion. In 2018 needs assessments that entailed a desk study, interviews, and stakeholder workshops were conducted in Benin, Cameroon, Côte d'Ivoire, Kenya, Mali, Mozambique, Panama, Peru, Uganda, and Zambia. The general aim of the needs assessments was to gain a deeper understanding of the contextual situation and identify the needs of ObGyn societies in relation to safe abortion advocacy. This paper provides a cross-country analysis of the outcomes of the needs assessments and reflects on the capabilities, barriers, and opportunities to strengthen this role of ObGyn societies. Common barriers, such as unavailability of services, lack of technical guidance, unawareness and ambiguity about the legal framework, provider attitudes, and abortion stigma, pose challenges for ObGyn societies to work constructively on safe abortion advocacy. However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers' advocacy role. Five strategies were developed to strengthen the capacity of ObGyn societies in safe abortion advocacy.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation.

BACKGROUND: The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation. METHODS: We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members. RESULTS: We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector. CONCLUSIONS: Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

Decentralising and integrating HIV services in community-based health systems: a qualitative study of perceptions at macro, meso and micro levels of the health system.

INTRODUCTION: HIV services at the community level in Kenya are currently delivered largely through vertical programmes. The funding for these programmes is declining at the same time as the tasks of delivering HIV services are being shifted to the community. While integrating HIV into existing community health services creates a platform for increasing coverage, normalising HIV and making services more sustainable in high-prevalence settings, little is known about the feasibility of moving to a more integrated approach or about how acceptable such a move would be to the affected parties. METHODS: We used qualitative methods to explore perceptions of integrating HIV services in two counties in Kenya, interviewing national and county policymakers, county-level implementers and community-level actors. Data were recorded digitally, translated, transcribed and coded in NVivo10 prior to a framework analysis. RESULTS: We found that a range of HIV-related roles such as counselling, testing, linkage, adherence support and home-based care were already being performed in the community in an ad hoc manner. However, respondents expressed a desire for a more coordinated approach and for decentralising the integration of HIV services to the community level as parallel programming had resulted in gaps in HIV service and planning. In particular, integrating home-based testing and counselling within government community health structures was considered timely. CONCLUSIONS: Integration can normalise HIV testing in Kenyan communities, integrate lay counsellors into the health system and address community desires for a household-led approach.

Limits and opportunities to community health worker empowerment: A multi-country comparative study.

BACKGROUND: In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'Empowerment of communities'. To be able to empower the communities they serve, we argue, it is essential that CHWs themselves be, and feel, empowered. We present here a critique of how diverse national CHW programs affect CHW's empowerment experience. METHODS: We present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used. RESULTS: CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact. CONCLUSIONS: While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters.

Exploring perceptions of community health policy in Kenya and identifying implications for policy change.

BACKGROUND: Global interest and investment in close-to-community health services is increasing. Kenya is currently revising its community health strategy (CHS) alongside political devolution, which will result in revisioning of responsibility for local services. This article aims to explore drivers of policy change from key informant perspectives and to study perceptions of current community health services from community and sub-county levels, including perceptions of what is and what is not working well. It highlights implications for managing policy change. METHODS: We conducted 40 in-depth interviews and 10 focus group discussions with a range of participants to capture plural perspectives, including those who will influence or be influenced by CHS policy change in Kenya (policymakers, sub-county health management teams, facility managers, community health extension worker (CHEW), community health workers (CHWs), clients and community members) in two purposively selected counties: Nairobi and Kitui. Qualitative data were digitally recorded, transcribed, translated and coded before framework analysis. RESULTS: There is widespread community appreciation for the existing strategy. High attrition, lack of accountability for voluntary CHWs and lack of funds to pay CHW salaries, combined with high CHEW workload were seen as main drivers for strategy change. Areas for change identified include: lack of clear supervisory structure including provision of adequate travel resources, current uneven coverage and equity of community health services, limited community knowledge about the strategy revision and demand for home-based HIV testing and counselling. CONCLUSION: This in-depth analysis which captures multiple perspectives results in robust recommendations for strategy revision informed by the Five Wonders of Change Framework. These recommendations point towards a more people-centred health system for improved equity and effectiveness and indicate priority areas for action if success of policy change through the roll-out of the revised strategy is to be realized.

How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature.

BACKGROUND: Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs. METHODS: We searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized. RESULTS: Few studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. CONCLUSIONS: Research on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance.

Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review.

Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review.A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance.When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.