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Hafez S, Munyati BM, Zeno K, Gbozee CKZ, Jusu M, Reeves MS, Wesseh CS, Wiah SO, AlKhaldi M, Johnson K, Subah M. Examining the gender imbalance in the National Community Health Assistant Programme in Liberia: a qualitative analysis of policy and Programme implementation. Health Policy Plan 2022; 38:181-191. [PMID: 36069652 PMCID: PMC9923372 DOI: 10.1093/heapol/czac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/31/2022] [Accepted: 09/06/2022] [Indexed: 11/12/2022] Open
Abstract
The Revised National Community Health Services Policy (2016-2021) (RNCHSP) and its programme implementation, the Liberian National Community Health Assistant Programme (NCHAP), exhibit a critical gender imbalance among the Community Health Assistants (CHAs) as only 17% are women. This study was designed to assess the gender responsiveness of the RNCHSP and its programme implementation in five counties across Liberia to identify opportunities to improve gender equity in the programme. Using qualitative methods, 16 semi-structured interviews were conducted with policymakers and 32 with CHAs, other members of the community health workforce and community members. The study found that despite the Government of Liberia's intention to prioritize women in the recruitment and selection of CHAs, the planning and implementation of the RNCHSP were not gender responsive. While the role of community structures, such as Community Health Committees, in the nomination and selection of CHAs is central to community ownership of the programme, unfavourable gender norms influenced women's nomination to become CHAs. Cultural, social and religious perceptions and practices of gender created inequitable expectations that negatively influenced the recruitment of women CHAs. In particular, the education requirement for CHAs posed a significant barrier to women's nomination and selection as CHAs, due to disparities in access to education for girls in Liberia. The inequitable gender balance of CHAs has impacted the accessibility, acceptability and affordability of community healthcare services, particularly among women. Strengthening the gender responsiveness within the RNCHSP and its programme implementation is key to fostering gender equity among the health workforce and strengthening a key pillar of the health system. Employing gender responsive policies and programme will likely increase the effectiveness of community healthcare services.
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Affiliation(s)
- Sali Hafez
- *Corresponding author. Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, 9 Tavistock PI, London WC1H 9SH, United Kingdom. E-mail:
| | | | - Katie Zeno
- American University School of International Service, 4400 Massachusetts Avenue NW, Washington, DC 20016, United States
| | - Catherine K Z Gbozee
- Cuttington Graduate School of Professional Study and Health System Strengthening Unit, Last Mile Health Liberia, 77C6+984, Monrovia, Liberia
| | - Mbalu Jusu
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, 9 Tavistock PI, London WC1H 9SH, United Kingdom
| | - Mantue S Reeves
- Mekelle University and the Monitoring, Evaluation and Research Unit, Last Mile Health Liberia, 77C6+984, Monrovia, Liberia
| | - C Sanford Wesseh
- The Department of Health and Vital Statistics, the Ministry of Health, SKD Boulevard, Congo Town 1000, Monrovia, Liberia
| | - S Olasford Wiah
- Director, Community Health Services Division, the Ministry of Health, SKD Boulevard, Congo Town 1000, Monrovia, Liberia
| | - Mohammed AlKhaldi
- Faculty of Medicine, School of Physical and Occupational Therapy, Person-Centred Health Informatics Research-PCHI lab, McGill University, 3605 Rue de la Montagne, Montréal, QC H3G 2M1, Canada
| | - Kristin Johnson
- Department of Public Health, Boston University, Boston, MA 02215, United States
| | - Marion Subah
- Department of Nursing, Catholic University of America, United States and Country Director, Last Mile Health Liberia, 77C6+984, Monrovia, Liberia
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Khalid S, Dixon S, Vijayasingham L. The gender responsiveness of social entrepreneurship in health - A review of initiatives by Ashoka fellows. Soc Sci Med 2021; 293:114665. [PMID: 34954676 DOI: 10.1016/j.socscimed.2021.114665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022]
Abstract
There are vocal calls to act on the gender-related barriers and inequities in global health. Still, there are gaps in implementing programmes that address and counter the relevant dynamics. As an approach that focuses on social problems and public service delivery gaps, social entrepreneurship has the potential to be a closer health sector partner to tackle and transform the influence of gender in health to achieve health systems goals better. Nevertheless, social entrepreneurs' engagement and impact on gender and health remain understudied. Using the Ashoka Fellows database as a sampling frame in November 2020 (n = 3352, health n = 129), we identified and reviewed the work of 21 organizations that implemented gender-responsive health-related programmes between 2000 and 2020. We applied the UNU-IIGH 6-I Analytic Framework to review the gender issues, interventions, included populations, investments, implementation, and impact in each organization. We found that a low proportion of fellows engage in gender-responsive health programming (<1%). Many organizations operate in low-and middle-income countries (16/21). The gender-responsive programmes include established health sector practices, to address gendered-cultural dynamics and deliver people-centred resources and services. Interestingly, most organizations self-identify as NGOs and rely on traditional grant funding. Fewer organizations (6/21) adopt market-based and income-generating solutions - a missed opportunity to actualise the potential of social entrepreneurship as an innovative health financing approach. There were few publicly available impact evaluations-a gap in practice established in social entrepreneurship. All organizations implemented programmes at community levels, with some cross-sectoral, structural, and policy-level initiatives. Most focused on sexual and reproductive health and gender-based violence for predominantly populations of women and girls. Closer partnerships between social entrepreneurs and gender experts in the health sector can provide reciprocally beneficial solutions for cross-sectorally and community designed innovations, health financing, evidence generation and impact tracking that improve the gender-responsiveness of health programmes, policies, and systems.
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Affiliation(s)
- Shazmin Khalid
- United Nations University International Institute for Global Health, UKM Medical Centre, Jalan Yaacob Latiff, 56000, Kuala Lumpur, Malaysia; School of Business, Monash University Malaysia, Jalan Lagoon Selatan, 46150, Bandar Sunway, Selangor Darul Ehsan, Malaysia
| | - Shrijna Dixon
- United Nations University International Institute for Global Health, UKM Medical Centre, Jalan Yaacob Latiff, 56000, Kuala Lumpur, Malaysia; Rockefeller College of Public Affairs and Policy, University at Albany- State University of New York 1400 Washington Ave, Albany, NY, 12222, USA
| | - Lavanya Vijayasingham
- United Nations University International Institute for Global Health, UKM Medical Centre, Jalan Yaacob Latiff, 56000, Kuala Lumpur, Malaysia.
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Lutwama GW, Kok M, Jacobs E. An exploratory study of the barriers and facilitators to the implementation of community health worker programmes in conflict-affected South Sudan. Confl Health 2021; 15:82. [PMID: 34794466 PMCID: PMC8600860 DOI: 10.1186/s13031-021-00422-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 11/09/2021] [Indexed: 11/20/2022] Open
Abstract
Background Community health workers (CHWs) are crucial for increasing access to health services to communities. Due to decades of conflict and under-funding, access to health care in South Sudan remains severely limited. To improve equitable access to healthcare, the government has introduced “the Boma Health Initiative (BHI)”, a strategy to harmonise community health programmes across the country. In order to scale up the BHI, it is necessary to assess the recent CHW programmes and draw lessons for future implementation. This study aimed to explore the characteristics, barriers, and facilitators to the implementation of CHW interventions in South Sudan between 2011 and 2019. Methods The study used a qualitative approach drawing from 26 key informant interviews and a scoping review of 21 Health Pooled Fund (HPF) programme reports from October 2016 to June 2018 and policy documents from 2011 to 2019. The results were thematically analysed based on a conceptual framework on factors influencing the performance of CHWs. Results Funding of CHW programmes has come from international donors, channelled through non-governmental organisations (NGOs) that have implemented a variety of CHW programmes. Communities have been participating in the selection of voluntary CHWs, intervention areas, and occasionally in the supervision of activities performed by CHWs. The coordination mechanisms among stakeholders have been weak, leading to wastage and duplication of resources. Although training of CHWs is done, training duration was short, and refresher-trainings were rare. There were and still are disparities in the type of incentives provided to CHWs. Monitoring and supportive supervision activities have been insufficient; drug misuse and stock-outs were common. Conclusion Despite their challenges, CHW programmes can be implemented in conflict-affected South Sudan if the local human capital is leveraged and engaged by NGOs as implementing partners. Robust coordination efforts are required to build synergies among stakeholders for the effective implementation of the BHI strategy.
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Affiliation(s)
- George William Lutwama
- Health Pooled Fund, American Embassy Residency Road, Juba, South Sudan. .,KIT Health, Royal Tropical Institute, Mauritskade 63, Amsterdam, 1090 HA, The Netherlands.
| | - Maryse Kok
- KIT Health, Royal Tropical Institute, Mauritskade 63, Amsterdam, 1090 HA, The Netherlands
| | - Eelco Jacobs
- KIT Health, Royal Tropical Institute, Mauritskade 63, Amsterdam, 1090 HA, The Netherlands
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Chowdhury R, McKague K, Krause H. How workers respond to social rewards: evidence from community health workers in Uganda. Health Policy Plan 2021; 36:239-248. [PMID: 33881139 PMCID: PMC8058949 DOI: 10.1093/heapol/czaa162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 11/14/2022] Open
Abstract
This paper investigates the effect of a non-financial incentive-a competitive annual award-on community health workers' (CHWs) performance, an issue in the public health literature that has not been explored to its potential. Combining data on a competitive social 'Best CHW' award with the monthly performance of 4050 CHWs across Uganda, we examined if introducing social recognition awards improved the performance of CHWs. In contrast to predominant explanations about the effect of awards on motivation, our first multilevel mixed-effect models found that an award within a branch (consisting of ∼30 CHWs) was negatively associated with the performance of the local peers of the winning CHW. Models focused on non-winning branch offices revealed two additional findings. First, a branch showed underperformance if a CHW from any of the three neighbouring branches won an award in the previous year, with average monthly performance scores dropping by 27 percentage points. Second, this negative association was seen only in the top 50th percentile of CHWs. The bottom 50th percentile of CHWs exhibited increased performance by 13 percentage points. These counter-intuitive results suggest that the negative response from high performers might be explained by their frustration of not winning the award or by emotions such as envy and jealousy generated by negative social comparisons. Our results suggest that more fine-grained examination of data pertaining to motivators for CHWs in low-income countries is needed. Motivational incentives like awards may need to be customized for higher- and lower-performing CHWs.
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Affiliation(s)
- Reajul Chowdhury
- Corresponding author. Agriculture and Consumer Economics, University of Illinois, Urbana – Champaign, 59 Mumford Hall, 1301 W. Gregory Drive Urbana, IL 61801, USA. E-mail:
| | - Kevin McKague
- Shannon School of Business, Cape Breton University, Sydney, Nova Scotia B1M 1A2, Canada
| | - Heather Krause
- Principal Data Scientist, Datassist, Toronto, ON M4Y 3E1, Canada
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McKague K, Harrison S, Musoke J. Gender intentional approaches to enhance health social enterprises in Africa: a qualitative study of constraints and strategies. Int J Equity Health 2021; 20:98. [PMID: 33838679 PMCID: PMC8035608 DOI: 10.1186/s12939-021-01427-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 03/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health social enterprises are experimenting with community health worker (CHW) models that allow for various income-generating opportunities to motivate and incentivize CHWs. Although evidence shows that improving gender equality contributes to the achievement of health outcomes, gender-based constraints faced by CHWs working with social enterprises in Africa have not yet been empirically studied. This study is the first of its kind to address this important gap in knowledge. METHODS We conducted 36 key informant interviews and 21 focus group discussions between 2016 and 2019 (for a total of 175 individuals: 106 women and 69 men) with four health social enterprises in Uganda and Kenya and other related key stakeholders and domain experts. Interview and focus group transcripts were coded according to gender-based constraints and strategies for enhanced performance as well as key sites for intervention. RESULTS We found that CHW programs can be more gender responsive. We introduce the Gender Integration Continuum for Health Social Enterprises as a tool that can help guide gender equality efforts. Data revealed female CHWs face seven unique gender-based constraints (compared to male CHWs): 1) higher time burden and lack of economic empowerment; 2) risks to personal safety; 3) lack of career advancement and leadership opportunities; 4) lack of access to needed equipment, medicines and transport; 5) lack of access to capital; 6) lack of access to social support and networking opportunities; and 7) insufficient financial and non-financial incentives. Data also revealed four key areas of intervention: 1) the health social enterprise; 2) the CHW; 3) the CHW's partner; and 4) the CHW's patients. In each of the four areas, gender responsive strategies were identified to overcome constraints and contribute to improved gender equality and community health outcomes. CONCLUSIONS This is the first study of its kind to identify the key gender-based constraints and gender responsive strategies for health social enterprises in Africa using CHWs. Findings can assist organizations working with CHWs in Africa (social enterprises, governments or non-governmental organizations) to develop gender responsive strategies that increase the gender and health outcomes while improving gender equality for CHWs, their families, and their communities.
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Affiliation(s)
- Kevin McKague
- Cape Breton University, 1250 Grand Lake Road, Sydney, Nova Scotia Canada
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Rahman M, Jahir T, Yeasmin F, Begum F, Mobashara M, Hossain K, Khan R, Hossain R, Nizame FA, Jain A, Leontsini E, Unicomb L, Luby SP, Winch PJ. The Lived Experiences of Community Health Workers Serving in a Large-Scale Water, Sanitation, and Hygiene Intervention Trial in Rural Bangladesh. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073389. [PMID: 33805884 PMCID: PMC8037636 DOI: 10.3390/ijerph18073389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 11/16/2022]
Abstract
Community health workers (CHWs) are key to implementing community-based health interventions and quality can be enhanced by better understanding their lived experiences. The WASH Benefits, Bangladesh trial engaged 540 female CHWs to promote varying health intervention packages. We report on factors influencing their lived experiences during the trial, to aid future recruitment, training and retention of CHWs. Nine focus groups and 18 in-depth interviews were conducted with CHWs. Focus groups and interviews were transcribed and thematic content analysis performed to summarize the results. All CHWs described experiencing positive working conditions and many benefits both socially and financially; these contributed to their retention and job satisfaction. Their honorarium was commonly applied towards their children's education and invested for income generation. CHWs gained self-confidence as women, to move unaccompanied in the community and speak in public. They earned respect from the community and their family members who helped them manage their family obligations during work and were viewed as a resource for advice on health and social issues. Many participated in family decision-making from which they were previously excluded. Health programs should foster a positive experience among their CHWs to aid the recruitment, retention and development of this important human resource.
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Affiliation(s)
- Mahbubur Rahman
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
- Correspondence: ; Tel.: +88-017-1200-1294
| | - Tania Jahir
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Farzana Yeasmin
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Farzana Begum
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Mosammot Mobashara
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Khobair Hossain
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Rizwana Khan
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Rezwana Hossain
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Fosiul Alam Nizame
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Anika Jain
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (A.J.); (E.L.); (P.J.W.)
| | - Elli Leontsini
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (A.J.); (E.L.); (P.J.W.)
| | - Leanne Unicomb
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka 1212, Bangladesh; (T.J.); (F.Y.); (F.B.); (M.M.); (K.H.); (R.K.); (R.H.); (F.A.N.); (L.U.)
| | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Peter J. Winch
- Department of International Health, John Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA; (A.J.); (E.L.); (P.J.W.)
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Patel MI, Khateeb S, Coker T. Lay Health Workers' Perspectives on Delivery of Advance Care Planning and Symptom Screening Among Adults With Cancer: A Qualitative Study. Am J Hosp Palliat Care 2020; 38:1202-1211. [PMID: 33267632 DOI: 10.1177/1049909120977841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Advance care planning and symptom screening among patients with cancer require team-based approaches to ensure that these services are equitably and appropriately delivered. In several organizations across the United States, we trained and employed lay health workers (LHWs) to assist with delivering these services for patients with cancer. The aim of this study was to understand LHWs' views on delivering these services. METHODS We conducted semi-structured interviews with 22 LHWs in 6 US-based clinical cancer care settings in 4 large cities. We recorded, transcribed, and analyzed interviews using the constant comparative method of qualitative analysis. RESULTS Participants noted the importance of their role in assisting with the delivery of advance care planning (ACP) and symptom screening services. Participants noted the importance of developing relationships with patients to engage openly in ACP and symptom screening discussions. Participants reported that ongoing training provided skills and empowered them to discuss sensitive issues with patients and their caregivers. Participants described challenges in their roles including communication with oncology providers and their own emotional well-being. Participants identified solutions to these challenges including formal opportunities for introduction with oncology clinicians and staff and grievance sessions with LHWs and other team members. DISCUSSION LHWs from several organizations endorsed the importance of their roles in ensuring the delivery of ACP and proactive symptom screening. LHWs noted challenges and specific solutions to improve their effectiveness in delivering these important services to patients after their diagnosis of cancer.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, 6429Stanford University School of Medicine, Stanford, CA, USA.,Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.,Center for Primary Care and Outcomes Research/Health Research and Policy, 6429Stanford University School of Medicine, Stanford, CA, USA
| | - Sana Khateeb
- Division of Oncology, 6429Stanford University School of Medicine, Stanford, CA, USA
| | - Tumaini Coker
- Seattle Children's Research Institute, Seattle, WA, USA.,Department of Pediatrics, 12353University of Washington School of Medicine, Seattle, WA, USA
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