How gender is socially constructed in policy making processes: a case study of the Adolescent and Youth Health Policy in South Africa.

BACKGROUND: Gender equality remains an outstanding global priority, more than 25 years after the landmark Beijing Platform for Action. The disconnect between global health policy intentions and implementation is shaped by several conceptual, pragmatic and political factors, both globally and in South Africa. Actor narratives and different framings of gender and gender equality are one part of the contested nature of gender policy processes and their implementation challenges. The main aim of this paper is to foreground the range of policy actors, describe their narratives and different framings of gender, as part exploring the social construction of gender in policy processes, using the Adolescent Youth Health Policy (AYHP) as a case study. METHODS: A case study design was undertaken, with conceptual underpinnings combined from gender studies, sociology and health policy analysis. Through purposive sampling, a range of actors were selected, including AYHP authors from government and academia, members of the AYHP Advisory Panel, youth representatives from the National Department of Health Adolescent and Youth Advisory Panel, as well as adolescent and youth health and gender policy actors, in government, academia and civil society. Qualitative data was collected via in-depth, semi-structured interviews with 30 policy actors between 2019 and 2021. Thematic data analysis was used, as well as triangulation across both respondents, and the document analysis of the AYHP. RESULTS: Despite gender power relations and more gender-transformative approaches being discussed during the policy making process, these were not reflected in the final policy. Interviews revealed an interrelated constellation of diverse and juxtaposed actor gender narratives, ranging from framing gender as equating girls and women, gender as inclusion, gender as instrumental, gender as women's rights and empowerment and gender as power relations. Some of these narrative framings were dominant in the policy making process and were consequently included in the final policy document, unlike other narratives. The way gender is framed in policy processes is shaped by actor narratives, and these diverse and contested discursive constructions were shaped by the dynamic interactions with the South Africa context, and processes of the Adolescent Youth Health Policy. These varied actor narratives were further contextualised in terms of reflections of what is needed going forward to advance gender equality in adolescent and youth health policy and programming. This includes prioritising gender and intersectionality on the national agenda, implementing more gender-transformative programmes, as well as having the commitments and capabilities to take the work forward. CONCLUSIONS: The constellation of actors' gender narratives reveals overlapping and contested framings of gender and what is required to advance gender equality. Understanding actor narratives in policy processes contributes to bridging the disconnect between policy commitments and reality in advancing the gender equality agenda.

Multiple pathways to scaling up and sustainability: an exploration of digital health solutions in South Africa.

BACKGROUND: With the aim to support further understanding of scaling up and sustaining digital health, we explore digital health solutions that have or are anticipated to reach national scale in South Africa: the Perinatal Problem Identification Programme (PPIP) and Child Healthcare Problem Identification Programme (Child PIP) (mortality audit reporting and visualisation tools), MomConnect (a direct to consumer maternal messaging and feedback service) and CommCare (a community health worker data capture and decision-support application). RESULTS: A framework integrating complexity and scaling up processes was used to conceptually orient the study. Findings are presented by case in four domains: value proposition, actors, technology and organisational context. The scale and use of PPIP and Child PIP were driven by 'champions'; clinicians who developed technically simple tools to digitise clinical audit data. Top-down political will at the national level drove the scaling of MomConnect, supported by ongoing financial and technical support from donors and technical partners. Donor preferences played a significant role in the selection of CommCare as the platform to digitise community health worker service information, with a focus on HIV and TB. A key driver of scale across cases is leadership that recognises and advocates for the value of the digital health solution. The technology need not be complex but must navigate the complexity of operating within an overburdened and fragmented South African health system. Inadequate and unsustained investment from donors and government, particularly in human resource capacity and robust monitioring and evaluation, continue to threaten the sustainability of digital health solutions. CONCLUSIONS: There is no single pathway to achieving scale up or sustainability, and there will be successes and challenges regardless of the configuration of the domains of value proposition, technology, actors and organisational context. While scaling and sustaining digital solutions has its technological challenges, perhaps more complex are the idiosyncratic factors and nature of the relationships between actors involved. Scaling up and sustaining digital solutions need to account for the interplay of the various technical and social dimensions involved in supporting digital solutions to succeed, particularly in health systems that are themselves social and political dynamic systems.

Are rhetorical commitments to adolescents reflected in planning documents? An exploratory content analysis of adolescent sexual and reproductive health in Global Financing Facility country plans.

BACKGROUND: The Global Financing Facility (GFF) offers an opportunity to close the financing gap that holds back gains in women, children's and adolescent health. However, very little work exists examining GFF practice, particularly for adolescent health. As momentum builds for the GFF, we examine initial GFF planning documents to inform future national and multi-lateral efforts to advance adolescent sexual and reproductive health. METHODS: We undertook a content analysis of the first 11 GFF Investment Cases and Project Appraisal Documents available on the GFF website. The countries involved include Bangladesh, Cameroon, Democratic Republic of Congo, Ethiopia, Guatemala, Kenya, Liberia, Mozambique, Nigeria, Tanzania and Uganda. RESULTS: While several country documents signal understanding and investment in adolescents as a strategic area, this is not consistent across all countries, nor between Investment Cases and Project Appraisal Documents. In both types of documents commitments weaken as one moves from programming content to indicators to investment. Important contributions include how teenage pregnancy is a universal concern, how adolescent and youth friendly health services and school-based programs are supported in several country documents, how gender is noted as a key social determinant critical for mainstreaming across the health system, alongside the importance of multi-sectoral collaboration, and the acknowledgement of adolescent rights. Weaknesses include the lack of comprehensive analysis of adolescent health needs, inconsistent investments in adolescent friendly health services and school based programs, missed opportunities in not supporting multi-component and multi-level initiatives to change gender norms involving adolescent boys in addition to adolescent girls, and neglect of governance approaches to broker effective multi-sectoral collaboration, community engagement and adolescent involvement. CONCLUSION: There are important examples of how the GFF supports adolescents and their sexual and reproductive health. However, more can be done. While building on service delivery approaches more consistently, it must also fund initiatives that address the main social and systems drivers of adolescent health. This requires capacity building for the technical aspects of adolescent health, but also engaging politically to ensure that the right actors are convened to prioritize adolescent health in country plans and to ensure accountability in the GFF process itself.

Taking stock of 10 years of published research on the ASHA programme: examining India's national community health worker programme from a health systems perspective.

BACKGROUND: As India's accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale. METHODS: We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW-health systems interface framework. RESULTS: A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results. CONCLUSION: Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.

Can community action improve equity for maternal health and how does it do so? Research findings from Gujarat, India.

BACKGROUND: Efforts to work with civil society to strengthen community participation and action for health are particularly important in Gujarat, India, given that the state has resources and capacity, but faces challenges in ensuring that services reach those most in need. To contribute to the knowledge base on accountability and maternal health, this study examines the equity effects of community action for maternal health led by Non-Government Organizations (NGOs) on facility deliveries. It then examines the underlying implementation processes with implications for strengthening accountability of maternity care across three districts of Gujarat, India. Community action for maternal health entailed NGOs a) working with community collectives to raise awareness about maternal health entitlements, b) supporting community monitoring of outreach government services, and c) facilitating dialogue with government providers and authorities with report cards based on community monitoring of maternal health. METHODS: The study combined qualitative data (project documents and 56 stakeholder interviews thematically analyzed) with quantitative data (2395 women's self-reported receipt of information on entitlements and use of services over 3 years of implementation monitored prospectively through household visits). Multivariable logistic regression examined delivery care seeking and equity. RESULTS: In the marginalised districts, women reported substantial increases in receipt of information of entitlements and utilization of antenatal and delivery care. In the marginalized and wealthier districts, a switch from private facilities to public ones was observed for the most vulnerable. Supportive implementation factors included a) alignment among NGO organizational missions, b) participatory development of project tools, c) repeated capacity building and d) government interest in improving utilization and recognition of NGO contributions. Initial challenges included a) confidence and turnover of volunteers, b) complexity of the monitoring tool and c) scepticism from both communities and providers. CONCLUSION: With capacity and trust building, NGOs supporting community based collectives to monitor health services and engage with health providers and local authorities, over time overcame implementation challenges to strengthen public sector services. These accountability efforts resulted in improvements in utilisation of public sector services and a shift away from private care seeking, particularly for the marginalised.

Program assessment of efforts to improve the quality of postpartum counselling in health centers in Morogoro region, Tanzania.

BACKGROUND: The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania. METHODS: Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10). RESULTS: While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment. CONCLUSIONS: Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged.

Reflecting strategic and conforming gendered experiences of community health workers using photovoice in rural Wakiso district, Uganda.

BACKGROUND: Community health workers (CHWs) are an important human resource in Uganda as they are the first contact of the population with the health system. Understanding gendered roles of CHWs is important in establishing how they influence their performance and relationships in communities. This paper explores the differential roles of male and female CHWs in rural Wakiso district, Uganda, using photovoice, an innovative community-based participatory research approach. METHODS: We trained ten CHWs (five males and five females) on key concepts about gender and photovoice. The CHWs took photographs for 5 months on their gender-related roles which were discussed in monthly meetings. The discussions from the meetings were recorded, transcribed, and translated to English, and emerging data were analysed using content analysis in Atlas ti version 6.0.15. RESULTS: Although responsibilities were the same for both male and female CHWs, they reported that in practice, CHWs were predominantly involved in different types of work depending on their gender. Social norms led to men being more comfortable seeking care from male CHWs and females turning to female CHWs. Due to their privileged ownership and access to motorcycles, male CHWs were noted to be able to assist patients faster with referrals to facilities during health emergencies, cover larger geographic distances during community mobilization activities, and take up supervisory responsibilities. Due to the gendered division of labour in communities, male CHWs were also observed to be more involved in manual work such as cleaning wells. The gendered division of labour also reinforced female caregiving roles related to child care, and also made female CHWs more available to address local problems. CONCLUSIONS: CHWs reflected both strategic and conformist gendered implications of their community work. The differing roles and perspectives about the nature of male and female CHWs while performing their roles should be considered while designing and implementing CHW programmes, without further retrenching gender inequalities or norms.

Gendered health systems: evidence from low- and middle-income countries.

BACKGROUND: Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems. METHODS: The research used a combination of mixed, quantitative, qualitative and participatory methods, demonstrating the applicability of diverse research methods for gender and intersectional analysis. Within each study, the researchers adapted and applied a variety of gender and intersectional tools to assist with data collection and analysis, including different gender frameworks. Some researchers used participatory tools, such as photovoice and life histories, to prompt deeper and more personal reflections on gender norms from respondents, whereas others used conventional qualitative methods (in-depth interviews, focus group discussion). Findings from across the studies were reviewed and key themes were extracted and summarised. RESULTS: Five core themes that cut across the different projects were identified and are reported in this paper as follows: the intersection of gender with other social stratifiers; the importance of male involvement; the influence of gendered social norms on health system structures and processes; reliance on (often female) unpaid carers within the health system; and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis within health systems research. CONCLUSION: The implications of the diverse examples of gender and health systems research highlighted indicate that policy-makers, health practitioners and others interested in enhancing health system research and delivery have solid grounds to advance their enquiry and that one-size-fits-all heath interventions that ignore gender and intersectionality dimensions require caution. It is essential that we build upon these insights in our efforts and commitment to move towards greater equity both locally and globally.

Government helper and citizen advocate? A case study of the multiple roles and pressures facing a nongovernmental organization contracted by government to strengthen community health in northern India.

While nongovernmental organizations (NGOs) can potentially strengthen valuable citizen political engagement, NGOs that are increasingly oriented towards donor and government contracts may instead contribute to depoliticizing development. Amidst competing pressures, NGO experiences and agency in managing multiple roles require examination. We present a qualitative case study of an NGO implementing a government-designed intervention to strengthen Village Health, Sanitation, and Nutrition Committees (VHSNCs) in rural north India. Despite a challenging context of community scepticism and poor government services, the NGO did successfully form VHSNCs by harnessing its respected interlocutor status, preexisting relationships, and ability to "sell" the VHSNC as a mechanism for improving local well-being. While the VHSNC enabled community members to voice concerns to government officials, improvements often failed to meet community expectations. NGO staff endured community frustration on one hand and rebuffs from lower-level officials on the other, while feeling undersupported by the government contract. Consequently, although contracted to strengthen a community institution, the NGO increasingly worked alongside VHSNC members to try to strengthen the public sector. Contrary to assumptions that NGOs become "tamed" through taking government contracts, being contracted to deliver inputs for community participation was intertwined with microlevel political action, though this came at a cost to the NGO.

Negotiating power relations, gender equality, and collective agency: are village health committees transformative social spaces in northern India?

BACKGROUND: Participatory health initiatives ideally support progressive social change and stronger collective agency for marginalized groups. However, this empowering potential is often limited by inequalities within communities and between communities and outside actors (i.e. government officials, policymakers). We examined how the participatory initiative of Village Health, Sanitation, and Nutrition Committees (VHSNCs) can enable and hinder the renegotiation of power in rural north India. METHODS: Over 18 months, we conducted 74 interviews and 18 focus groups with VHSNC members (including female community health workers and local government officials), non-VHSNC community members, NGO staff, and higher-level functionaries. We observed 54 VHSNC-related events (such as trainings and meetings). Initial thematic network analysis supported further examination of power relations, gendered "social spaces," and the "discourses of responsibility" that affected collective agency. RESULTS: VHSNCs supported some re-negotiation of intra-community inequalities, for example by enabling some women to speak in front of men and perform assertive public roles. However, the extent to which these new gender dynamics transformed relations beyond the VHSNC was limited. Furthermore, inequalities between the community and outside stakeholders were re-entrenched through a "discourse of responsibility": The comparatively powerful outside stakeholders emphasized community responsibility for improving health without acknowledging or correcting barriers to effective VHSNC action. In response, some community members blamed peers for not taking up this responsibility, reinforcing a negative collective identity where participation was futile because no one would work for the greater good. Others resisted this discourse, arguing that the VHSNC alone was not responsible for taking action: Government must also intervene. This counter-narrative also positioned VHSNC participation as futile. CONCLUSIONS: Interventions to strengthen participation in health systems can engender social transformation. However they must consider how changing power relations can be sustained outside participatory spaces, and how discourse frames the rationale for community participation.

Principles and processes behind promoting awareness of rights for quality maternal care services: a synthesis of stakeholder experiences and implementation factors.

BACKGROUND: Promoting awareness of rights is a value-based process that entails a different way of thinking and acting, which is at times misunderstood or deemed as aspirational. METHODS: Guided by the SURE framework, we undertook a secondary analysis of 26 documents identified by an earlier systematic review on promoting awareness of rights to increase use of maternity care services. We thematically analysed stakeholder experiences and implementation factors across the diverse initiatives to derive common elements to guide future efforts. RESULTS: Interventions that promote awareness of rights for maternal health varied in nature, methodological orientation, depth and quality. Materials included booklets, posters, pamphlets/ briefs and service standards/charters. Target populations included women, family members, communities, community structures, community-based and non governmental organizations, health providers and administrators, as well as elected representatives. While one initiative only focused on raising awareness, most were embedded within larger efforts to improve the accountability and responsiveness of service delivery through community monitoring and advocacy, with a few aiming to change policies and contest elections. Underlying these action oriented forms of promoting awareness of rights, was a critical consciousness and attitudinal change gained through iterative capacity-building for all stakeholders; materials and processes that supported group discussion and interaction; the formation or strengthening of community groups; situational analysis to ensure adaptation to local context; facilitation to ensure common ground and language across stakeholders; and strategic networking and alliance building across health system levels. While many positive experiences are discussed, few challenges or barriers to implementation are documented. The limited documentation and poor quality of information found indicate that while various examples of promoting awareness of rights for maternal health exists, research partnerships to systematically evaluate their processes, learning and effects are lacking. CONCLUSION: Rather than being aspirational, several examples of promoting awareness of women's rights for quality maternity care services exist. More than mainly disseminate information, they aim to change stakeholder mindsets and relationships across health system levels. Due to their transformatory intent they require sustained investment, with strategic planning, concrete operationalization and political adeptness to manage dynamic stakeholder expectations and reactions overtime. More investment is also required in research partnerships that support such initiatives and better elucidate their context specific variations.

Primary health care workers' views of motivating factors at individual, community and organizational levels: a qualitative study from Nasarawa and Ondo states, Nigeria.

BACKGROUND: Current efforts to motivate primary health workers in Nigeria focus on better financial incentives, and the role of other motivating factors has received less attention. The aim of this study is to explore individual and organizational determinants, their interactions and effects on motivation. METHODS: Exploratory qualitative research, involving semi-structured interviews with 29 primary health workers (doctors, nurses, midwives and community health workers), was conducted in Nasarawa and Ondo states in Nigeria. Nine key informant interviews were conducted with government officials. Interviews were digitally recorded, transcribed and coded. Thematic analysis was conducted to identify common themes, as well as unique narratives. RESULTS: Results from this study suggest that health workers are motivated by individual (vocation, religion, humanity and self-efficacy) and organizational (monetary incentives, good working environment) factors and community recognition. Supervision and leadership provided by the officer in charge as compared with that by external agencies appeared to have a positive effect on motivation. CONCLUSIONS: Policy makers and donor agencies should take into account a broader range of factors while designing strategies to motivate the health workforce. The study also underscores how officer in charges with enhanced skills are likely to motivate health workers by creating a more supportive environment.

Synergies, strengths and challenges: findings on community capability from a systematic health systems research literature review.

BACKGROUND: Community capability is the combined influence of a community's social systems and collective resources that can address community problems and broaden community opportunities. We frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. We sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs). METHODS: We searched for journal articles published between 2000 and 2012 related to the concepts of "community", "capability/participation", "health systems research" and "LMIC." We identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability. RESULTS: When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed. Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality. CONCLUSIONS: Strengthening community capability is critical to ensuring that community participation leads to genuine empowerment. Our simpler framework to define community capability may help researchers better recognize, support and assess it.

Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda.

BACKGROUND: Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. METHODS: A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. RESULTS: Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women's access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. CONCLUSIONS: This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.

Determinants of Utilization and Community Experiences with Community Health Volunteers for Treatment of Childhood Illnesses in Rural Sierra Leone.

In 2010, at the same time as the national roll out of the Free Health Care Initiative (FHCI), which removed user fees for facility based health care, trained community health volunteers (CHVs) were deployed to provide integrated community case management of diarrhea, malaria and pneumonia to children under 5 years of age (U5) in Kambia and Pujehun districts, Sierra Leone. After 2 years of implementation and in the context of FHCI, CHV utilization rate was 14.0 %. In this study, we examine the factors associated with this level of CHV utilization. A cross-sectional household-cluster survey of 1590 caregivers of 2279 children U5 was conducted in 2012; with CHV utilization assessed using a multiple logistic regression model. Focus groups and in-depth interviews were also conducted to understand communities' experiences with CHVs. Children with diarrhea (OR = 3.17, 95 % CI: 1.17-8.60), from female-headed households (OR = 4.55, 95 % CI: 1.88-11.00), and whose caregivers reported poor quality of care as a barrier to facility care-seeking (OR = 8.53, 95 % CI: 3.13-23.16) were more likely to receive treatment from a CHV. Despite low utilization, caregivers were highly familiar and appreciative of CHVs, but were concerned about the lack of financial remuneration for CHVs. CHVs remained an important source of care for children from female-headed households and whose caregivers reported poor quality of care at health facilities. CHVs are an important strategy for certain populations even when facility utilization is high or when facility services are compromised, as has happened with the recent Ebola epidemic in Sierra Leone.

Equally able, but unequally accepted: Gender differentials and experiences of community health volunteers promoting maternal, newborn, and child health in Morogoro Region, Tanzania.

BACKGROUND: Despite emerging qualitative evidence of gendered community health worker (CHW) experience, few quantitative studies examine CHW gender differentials. The launch of a maternal, newborn, and child health (MNCH) CHW cadre in Morogoro Region, Tanzania enlisting both males and females as CHWs, provides an opportunity to examine potential gender differences in CHW knowledge, health promotion activities and client acceptability. METHODS: All CHWs who received training from the Integrated MNCH Program between December 2012 and July 2013 in five districts were surveyed and information on health promotion activities undertaken drawn from their registers. CHW socio-demographic characteristics, knowledge, and health promotion activities were analyzed through bi- and multivariate analyses. Composite scores generated across ten knowledge domains were used in ordered logistic regression models to estimate relationships between knowledge scores and predictor variables. Thematic analysis was also undertaken on 60 purposively sampled semi-structured interviews with CHWs, their supervisors, community leaders, and health committee members in 12 villages from three districts. RESULTS: Of all CHWs trained, 97% were interviewed (n = 228): 55% male and 45% female. No significant differences were observed in knowledge by gender after controlling for age, education, date of training, marital status, and assets. Differences in number of home visits and community health education meetings were also not significant by gender. With regards to acceptability, women were more likely to disclose pregnancies earlier to female CHWs, than male CHWs. Men were more comfortable discussing sexual and reproductive concerns with male, than female CHWs. In some cases, CHW home visits were viewed as potentially being for ulterior or adulterous motives, so trust by families had to be built. Respondents reported that working as female-male pairs helped to address some of these dynamics. CONCLUSIONS: Male and female CHWs in this study have largely similar knowledge and health promotion outputs, but challenges in acceptance of CHW counseling for reproductive health and home visits by unaccompanied CHWs varied by gender. Programs that pair male and female CHWs may potentially overcome gender issues in CHW acceptance, especially if they change gender norms rather than solely accommodate gender preferences.

Initial experiences and innovations in supervising community health workers for maternal, newborn, and child health in Morogoro region, Tanzania.

BACKGROUND: Supervision is meant to improve the performance and motivation of community health workers (CHWs). However, most evidence on supervision relates to facility health workers. The Integrated Maternal, Newborn, and Child Health (MNCH) Program in Morogoro region, Tanzania, implemented a CHW pilot with a cascade supervision model where facility health workers were trained in supportive supervision for volunteer CHWs, supported by regional and district staff, and with village leaders to further support CHWs. We examine the initial experiences of CHWs, their supervisors, and village leaders to understand the strengths and challenges of such a supervision model for CHWs. METHODS: Quantitative and qualitative data were collected concurrently from CHWs, supervisors, and village leaders. A survey was administered to 228 (96%) of the CHWs in the Integrated MNCH Program and semi-structured interviews were conducted with 15 CHWs, 8 supervisors, and 15 village leaders purposefully sampled to represent different actor perspectives from health centre catchment villages in Morogoro region. Descriptive statistics analysed the frequency and content of CHW supervision, while thematic content analysis explored CHW, supervisor, and village leader experiences with CHW supervision. RESULTS: CHWs meet with their facility-based supervisors an average of 1.2 times per month. CHWs value supervision and appreciate the sense of legitimacy that arises when supervisors visit them in their village. Village leaders and district staff are engaged and committed to supporting CHWs. Despite these successes, facility-based supervisors visit CHWs in their village an average of only once every 2.8 months, CHWs and supervisors still see supervision primarily as an opportunity to check reports, and meetings with district staff are infrequent and not well scheduled. CONCLUSIONS: Supervision of CHWs could be strengthened by streamlining supervision protocols to focus less on report checking and more on problem solving and skills development. Facility health workers, while important for technical oversight, may not be the best mentors for certain tasks such as community relationship-building. We suggest further exploring CHW supervision innovations, such as an enhanced role for community actors, who may be more suitable to support CHWs engaged primarily in health promotion than scarce and over-worked facility health workers.

Profile, knowledge, and work patterns of a cadre of maternal, newborn, and child health CHWs focusing on preventive and promotive services in Morogoro Region, Tanzania.

BACKGROUND: Despite impressive decreases in under-five mortality, progress in reducing maternal and neonatal mortality in Tanzania has been slow. We present an evaluation of a cadre of maternal, newborn, and child health community health worker (MNCH CHW) focused on preventive and promotive services during the antenatal and postpartum periods in Morogoro Region, Tanzania. Study findings review the effect of several critical design elements on knowledge, time allocation, service delivery, satisfaction, and motivation. METHODS: A quantitative survey on service delivery and knowledge was administered to 228 (of 238 trained) MNCH CHWs. Results are compared against surveys administered to (1) providers in nine health centers (n = 88) and (2) CHWs (n = 53) identified in the same districts prior to the program's start. Service delivery outputs were measured by register data and through a time motion study conducted among a sub-sample of 33 randomly selected MNCH CHWs. RESULTS: Ninety-seven percent of MNCH CHWs (n = 228) were interviewed: 55% male, 58% married, and 52% with secondary school education or higher. MNCH CHWs when compared to earlier CHWs were more likely to be unmarried, younger, and more educated. Mean MNCH CHW knowledge scores were <50% for 8 of 10 MNCH domains assessed and comparable to those observed for health center providers but lower than those for earlier CHWs. MNCH CHWs reported covering a mean of 186 households and were observed to provide MNCH services for 5 h weekly. Attendance of monthly facility-based supervision meetings was nearly universal and focused largely on registers, yet data quality assessments highlighted inconsistencies. Despite program plans to provide financial incentives and bicycles for transport, only 56% of CHWs had received financial incentives and none received bicycles. CONCLUSIONS: Initial rollout of MNCH CHWs yields important insights into addressing program challenges. The social profile of CHWs was not significantly associated with knowledge or service delivery, suggesting a broader range of community members could be recruited as CHWs. MNCH CHW time spent on service delivery was limited but comparable to the financial incentives received. Service delivery registers need to be simplified to reduce inconsistencies and yet expanded to include indicators on the timing of antenatal and postpartum visits.