Teralynn Ludwick | October 2015
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Presentation at the Global Maternal Newborn Health Conference, October 19, 2015

Background: Evidence supports community health worker (CHW) capacity to improve maternal and newborn health in less-resourced countries. However, scaling up and operating effective CHW systems is complex. Best practices for CHW program scale up could be better identified and understood through applying evaluative frameworks for system functionality.

Methodology: Between 2012-2014 Healthy Child Uganda (HCU), a Canadian-Ugandan university partnership, collaborated with Bushenyi Health District in Uganda to roll out a comprehensive, district-wide, maternal, newborn, and child health-strengthening initiative including training of ~1500 volunteer, health promotion-focused CHWs.   During the post-intervention, qualitative assessment, CHW units were ranked (high, medium, low performing) by project staff. Focus groups were selected via stratified, random sampling of CHW units and random sampling of individuals within units. Semi-structured focus groups sought CHW experiences and perspectives on 7 pre-identified system components identified by other research and HCU experience. Responses were transcribed and translated before conducting content analysis. Ratings were assigned to each system component for each group based on CHW responses.

Results: Eight focus groups represented CHWs from 4 high/medium and 4 low performance teams. Of the 7 system components analyzed, lowest ratings across CHW units related to ‘supervision’, ‘linkage to health centre’, and ‘peer support’.  ‘Supervision’ and ‘linkage to health centre’ ranking correlated most closely with differences in CHW unit performance. Issues identified by CHWs included absentee supervisors, referral system challenges, and lack of engagement/respect by health workers. CHWs associated supportive supervision with confidence in skills, CHW cohesion, effective referral systems, and community credibility.

Conclusions: This study demonstrates use of a systems framework for analyzing CHW system performance. Analysis from this intervention assessment highlights ‘supportive supervision’ and ‘linkage to health centre’ as performance-related. Planners should carefully consider supervision structure, facility orientation and related training to overcome common system challenges.