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Reaching out and linking in: Heath systems and close-to-community services

Final Report Summary - REACHOUT (Reaching out and linking in: Heath systems and close-to-community services)

Executive Summary:
There has been renewed global interest in the roles and use of close-to-community (CTC) providers of health care to achieve universal health coverage. Existing research has shown CTC providers to be effective in expanding the reach of services and improving health in certain circumstances but the focus is often country specific and focused on one disease only. In practice, disease-specific (vertical) programmes (e.g. tuberculosis, malaria or HIV control) use CTC providers as the final common pathway for expanding access to all their programmes. CTC providers are torn between the competing demands of various programmes, having multiple supervisors and reporting structures and with limited holistic support and poor coordination of their work. Little is known about the experiences and perspectives of CTC providers themselves and whether expanding this largely voluntary cadre is an overall effective, equitable or efficient way of achieving universal health coverage and the broader Sustainable Development Goals. REACHOUT is a multi-country study conducted in Africa and Asia that set out to explore this gap and generate evidence able to inform policymakers at both global and national level. REACHOUT’s overall aim is to understand and improve the equity, effectiveness and efficiency of CTC services in rural areas and urban slums in six countries in Africa and Asia: Bangladesh, Ethiopia, Indonesia, Kenya, Malawi and Mozambique.
Over the last five years, the consortium has conducted implementation research with communities, CTC providers, health care workers and policymakers in these six countries. The results of this work
have put a spotlight on the importance of the unique interface role that CTC providers play between the communities they serve and the wider health system - in developing and implementing interventions; in designing and evaluating training curricula for group supervision; in pioneering quality improvement approaches for community health and in shaping policy debates. The consortium’s research provides insights into:
• the importance of the community, local and national context and intervention design factors in influencing CTC provider performance
• the importance of the interface role that CTC providers play in linking the communities they come from with the formal health sector. CTC providers are affect by community norms and relationships. For example, the gender norms can impact upon CTC provider performance and well-being, patient access and outcomes. The interface role of CTC providers requires a new approach to health systems analysis that takes the ‘software’ and relational elements of the role into account and redefines the term ‘community health systems’
• new approaches to assessing measuring and improving quality of community health programmes. A local focus on quality and quality improvement can support CTCT providers to achieve their potential and improve the reach and uptake of health services. Simple robust methods that encourage local ownership and new tools that enable iterative learning can support this process.
• the key factors that influence priority setting and decision-making for community health equity. The role that CTC providers can play in creating more equitable health systems by providing care and referral at the household level to families who may find it difficult to access health services due to geographical location, poverty and other elements of inequality. The financial (and other) costs of delivering CTC programmes where they are most needed and the implications for donor and national budgeting.

The insights outlined above are captured in a range of formal research products available at These include systematic reviews, over twenty papers published in peer reviewed journals, theoretical frameworks, and a range of communication products targeted at policy/decision-makers.
Project Context and Objectives:
When we conceptualised and initiated REACHOUT, many countries were striving to achieve the Millennium Development Goals (MDGs) and universal health coverage (UHC). Five years later, they have shifted focus to the Sustainable Development Goals but the agenda for quality and access to healthcare for all remains highly relevant and sadly unachieved.

Public health services in Africa and Asia are struggling to serve poor and vulnerable communities that bear the brunt of the global burden of disease. It is now 40 years since the Alma Alta Declaration spearheaded a focus on community health, and led to many countries investing in community health workers (CTC providers) who received basic training and were often volunteers. However, from the 1980s onwards, programmes involving CTC providers went into decline due in part to political instability, economic policies and difficulties in financing. CTC providers tended to be given inadequate support, and were sometimes seen as lacking legitimacy. In an effort to reach out to underserved communities, health policy makers and practitioners are once again turning to strengthen CTC services. Health systems research on the equity, effectiveness and efficiency of this important interface cadre was required to learn from what went wrong previously and not make the same mistakes again.

REACHOUT considered CTC providers to be a diverse group who are a critical interface between communities and the rest of the health system. There are many types of CTC providers, such as community health workers, midwives, traditional birth attendants, informal private practitioners and lay counsellors, delivering a wide range of services in different contexts but limited to those with no professional qualifications. Their roles include education, counselling, screening and point-of-care diagnostics, treatment, follow-up and data collection. The scope of their work ranges from maternal and child health to HIV counselling and testing or TB diagnosis. The differences in their experiences within contexts also extends to payment and terms of service, training, etc.

What CTC programmes have in common is their reliance on staff who live and work at the community level, engaging with people in their own dwellings or workplaces. By meeting people in their homes, CTC providers are in a unique position to observe and understand the factors that influence health, gaining insights that may have been missed if the consultation had taken place in a health facility. Clues relating to poverty, nutrition, family size, bed net use, alcohol dependency and other information which is otherwise difficult to obtain may become obvious. This means that there is true potential for CTC services to strengthen delivery of health services through tailoring services to best meet the needs and realities of individuals and households, and making more appropriate links to the health sector and beyond.
CTC providers are embedded within communities and can offer opportunities to strengthen health services in an equitable, effective and efficient manner, though these are often unmet. Vertical, disease-specific programmes that use CTC providers for service delivery tend to give limited consideration to the multiple workloads and competing priorities they face. Services struggle to plan and manage their human resources resulting in high staff attrition and poor effectiveness; and the quality and supervision of services vary widely. CTC services often lack monitoring and evaluation (M&E) systems and referral mechanisms to formal health facilities are poorly tracked or recorded. The contribution of CTC services is often not known , poorly valued and their potential not maximised. There is a need for the formal health system to better understand the context and conditions of CTC services in order to strengthen and support these critical services to better realise their potential.
Our overall aim in REACHOUT was to understand and improve the equity, effectiveness and efficiency of CTC services in rural areas and urban slums in six countries: Bangladesh, Ethiopia, Indonesia, Kenya, Malawi and Mozambique.
Our Objectives
• To build capacity to conduct and use health systems research to improve CTC services. This was an integral part of the way REACHOUT worked and was conducted on three levels: in research to fill knowledge gaps, in implementation of CTC services and in evidence-informed policymaking relevant to CTC provider roles and management. Capacity development involved a needs assessment for training as well as mapping and sharing of south-south expertise.
• To identify how community context, health policy and interactions with the rest of the health system influence the equity, effectiveness and efficiency of CTC services. This objective laid the foundation for REACHOUT. It involved a multi-method context analysis that took into account a wide range of factors influencing CTC services and their likely interdependencies.
• To develop and assess interventions with the potential to make improvements to CTC services. This objective built on objective 1 by adapting a common analytical framework and methodology to identify and test improvements to CTC services. Each country focused on selected priority areas, based on national health priorities and capacity need and conducted two improvement cycles. Findings contributed to intra- and inter-country comparison to gain common lessons from the interventions while maintaining focus on health priorities.
• To inform evidence-based and context-appropriate policymaking for CTC services. This objective ensured both short term and sustainable impacts on strengthening CTC services. Strategic partnerships were developed between researchers, policymakers and practitioners at different levels.

Our guiding principles
To achieve these objectives, we had the following principles as fundamental to our approach:
• Included voices of CTC providers, the community, policymakers and other stakeholders
• Measured impact or lack of impact of the interventions
• Ensured that lessons were able to influence future programming at national level
• Agreed a common methodology so that inter-country comparison is possible
• Ensured synergistic working with similar EC-funded research studies.
• Maintained capacity development as an integral component at all levels

Country selection
We selected countries with established national programmes of CTC services. The six countries have different health systems organization and represent different geographical regions, population sizes and average income levels. Learning from this heterogeneity, enabled us to generate common lessons and analyse them against our overarching REACHOUT aim and objectives. The six non-EU partners have the following attributes:
1. A focus on CTC provision in rural areas and/or urban poor informal settlements
2. Expertise in health systems and health priority areas relevant to current CTC services, such as maternal and child health, malaria, HIV or TB.
3. They are embedded institutions: either service providers working in close collaboration with health policymakers, or research organisations with demonstrated strengths in working with service providers and policymakers.
4. Expertise in multiple disciplinary perspectives in health systems research
5. Evidence of successful participation in collaborative research initiatives
6. Have worked or are working together and with European research institutions.

District selection
The criteria for selection were:
• CTC providers working in districts providing services related to health priorities
• Suitable for intra-country comparison
• Located in rural and/or urban informal settlements
• Show a range of circumstances relevant to the country context (accessibility; poverty levels; geographic diversity; types of service available.
Countries were also asked to consider the potential for inter-country comparison with other REACHOUT partners when making their district selection.

Our timeline
REACHOUT ran from February 2013 to January 2018. We divided our research into three phases of data collection and analysis: context analysis (18 months, Feb 2013 – Jul 2014), researcher-led quality improvement cycle 1 (18 months, Aug 2014 – Jan 2016) and locally-embedded quality improvement cycle 2 (18 months, Feb 2016 – Jul 2017) with 6 months of intercountry analysis (Aug 2017 – Jan 2018) to conclude.

Our methods for implementation research in community health systems
We used both qualitative and quantitative research methods at multiple levels of the health system from national to community level in the six intervention countries. Our study design was complex and iterative to allow for both inter- and intra-country comparisons as well as depth and detail on what worked for whom, where, in the local contexts.

Methods for context analysis: A conceptual framework developed from a systematic review of the literature guided the country context analyses in each partner country. The country specific context analyses sought to understand the various influences on the success of CTC provider effectiveness and equity and explore the challenges they face. These detailed studies used multiple methods to review policy and existing data, including a range of qualitative research methods with stakeholders at multiple levels of the system, CTC providers and the communities they service and questionnaires with CTC providers. An additional layer of inter-country analysis compared findings within and across the contexts and identified common emerging themes.

Methods for quality improvement cycle 1: Based on common emerging themes (supervision, referral, community engagement, and coordination), each country team selected one or more focus areas for improvement during quality improvement cycle 1. In this researcher-led quality improvement cycle, supportive supervision was the most broadly implemented intervention. A curriculum was developed and piloted by the Kenyan REACHOUT team and all six countries implemented this in some form, training supervisors in the benefits of and skills related to the approach, modalities (peer, group, or one-on-one) and regularity. The intervention was evaluated using some consortium-wide tools (perceived supervision scale, common topic guides for qualitative interviews and focus groups, program assessment tool) and some context-specific research tools, including innovative methods such as most significant change, photovoice, and case studies in various areas.

Methods for quality improvement cycle 2: The overarching goal of quality improvement cycle 2 was to achieve embedment of quality improvement approaches for community health in each REACHOUT focus country. By the end of REACHOUT local district or service delivery managers and their teams had the knowledge, capacity and values to undertake quality improvement to strengthen community health systems. Founded on a common training curriculum delivered in three phases and based on principles of simplicity and flexibility, these training materials were adapted to each context. This work was underpinned by a SWOT analysis on quality improvement in community health. REACHOUT’s capacity development approach was evaluated using common qualitative tools, information flow mapping, costing, and other specific tools as determined by country teams.
Methods for inter-country analysis: Generating the robust inter-country findings required common objectives and a careful balance between common tools and methods on the one hand and ensuring contextual appropriateness at all phases of the work on the other. We ensured rigor through:

• including an extensive capacity development component. This was an explicit output of inter-country collaboration - within our research teams, with policymakers, CTC providers, and also through institutional and system capacity (e.g. for absorption of health systems research evidence). Capacity development was linked to the study phases – design, analysis and writing up and was conducted through both a training and a mentoring, face-to-face coaching approach with named individual senior staff responsible for country and topic areas
• creating clear and conducive governance structures for the consortium that included data sharing agreements
• having a focus on shared values and strong relationships, building trust over the lifetime of the project. This enabled true data sharing and open critique and analysis in a supportive environment
• conducting an initial intensive context analysis phase to deepen understanding within each country, build capacity in research methods and analysis and share that understanding across researchers in all sites. Six context analysis reports and country-specific papers are available here; more specific reflections are also available on our website in the form of blogs, presentations and posters
• balancing our common methodological approach with flexibility to adapt to context. For each phase, the consortium tools and approaches were developed centrally and adapted based on the local teams’ experience of the health system. Versions were iterated and changes documented but a common minimum data set was generated in all contexts.
• using similar timelines so that each phase (context analysis, quality improvement cycle 1 and quality improvement cycle 2) was roughly the same length, giving a sense of continuity across phases to the research teams
• using consortium meetings to progress the inter-country analysis through site visits, through engaging national policymakers (who were invited to attend alongside their REACHOUT counterparts) and through dedicated sessions to explore what was common and what was different across contexts
• working with national policymakers as co-producers of knowledge. National policymakers attended both country advisory groups and consortium meetings, were listed as co-investigators, co-authored papers and input to the design and analysis of REACHOUT meaning that our findings were more easily presented to national technical working groups, adopted into strategy documents and taken up by partners.

Project Results:
Introduction to Results
Over the last five years, teams in the six REACHOUT countries have developed capacity and conducted multiple levels of longitudinal qualitative and quantitative implementation research. The results of this work have put a spotlight on the importance of the interface role that CTC providers play between the communities they serve and the wider health system - in developing and implementing interventions; in designing and evaluating training curricula for group supervision; in pioneering quality improvement approaches for community health and in shaping policy debates. We summarize our findings in four sections: intervention design factors and context; importance of the interface role; assessing, measuring, and improving quality; and priority setting and decision-making for community health.
In this section, we report for each objective in the following way: results on context analysis are presented first followed by findings from the two quality improvement cycles, as this presents findings chronologically. The capacity and policy influence (objective 4) is covered in the findings under impact.
Intervention design factors and context
Through a systematic review of the literature we found that broader context, the health system and the intervention design all interact to influence CTC provider performance. These findings are published in two papers[1,2] accompanied by a conceptual framework that guided the context analysis phase of the research and are summarised below.
CTC provider performance is influenced by a mix of factors (and actors) that form a complex web of interactions. It can be measured at two levels. At the level of the individual CTC provider, there are determinants of performance such as self-esteem, motivation, attitudes, competencies, guideline adherence, job satisfaction, and capacity to facilitate empowerment of communities. At the level of the end-user (the community) we can assess utilization of services, health seeking behaviour, adoption of practices promoting health and community empowerment.
Contextual factors, including those related to community and political contexts, can influence CTC provider performance. Community-related contextual factors can be related to gender norms and values in the society. For example, in some countries, there is a preference for female CTC providers to be working in sexual, reproductive and maternal health, as societal gender norms often mean that it is seen as more appropriate for women to interact with other women about these type of health issues and there may be challenges for women CTC providers to involve men in reproductive health issues.
Health system factors, such as the way health care is financed and organized, can also influence performance of CTC providers. An example of a health system factor is the availability and implementation of CTC provider-related policies. In several countries, the lack of a regulatory framework for CTC providers has resulted in fragmentation of salaries among different types of CTC providers and lack of career opportunities, resulting in demotivation of CTC providers, which can lead to lower performance.
Intervention design factors influence CTC provider performance and are the easiest to intervene in comparison to contextual or health system factors. If programme implementers know how certain features of an intervention affect performance, interventions can be shaped and adjusted to yield optimal CTC provider performance. The most prominent intervention design factors that shape CTC provider performance are[1]:
• Tasks can affect performance. CTC providers usually deliver preventive health services, but often, they are more recognized by the community and have higher self-esteem and motivation, if curative services are added to their tasks. This was shown in our Mozambique findings.
• Human resource management is key. Selection of CTC providers with specific characteristics, such as higher education level, experience with the health conditions to be dealt with, fewer household duties, and lower wealth lead to better competencies, good attitudes and less attrition of CTC providers. For example, CTC providers in Bangladesh who reported to be dependent on the income they earned through their work as CTC providers were more active and less inclined to drop out when compared to CTC providers with more income. Program managers need to look for the best mix for the context and services that will be delivered through CTC providers.
• A balanced workload, in line with expectations and incentives, enhances performance. However, CTC providers around the world often report about the negative effects of high workloads, for example increased loss to follow-up of clients. In addition, a lack of clarity regarding CTC provider roles often leads to unrealistic expectations from people in the community or health system, resulting in demotivation of CTC providers.
• A mix of financial and non-financial incentives, paid or delivered at a predicable time, generally enhances CTC provider motivation and thereby performance. Supervision is essential for CTC provider motivation. Performance appraisal generally leads to enhanced motivation and attitudes. Continuous training also results in better motivation and job satisfaction for CTC providers.
• Quality assurance is also a point of attention. The use of clear and well-communicated operating procedures and programmatic guidelines is helpful, especially in settings where task shifting is taking place. CTC providers’ role to facilitate community monitoring of health programmes in their areas can empower communities and at the same time satisfy CTC providers.
• Community and health system links are important influencers of performance, because of the intermediary position of CTC providers. In many programmes, community support, selection and monitoring are associated with increased motivation and self-esteem. Recognition by other health staff leads to enhanced recognition from the community leading to greater CTC provider motivation and self-esteem. Coordination and communication with other health staff was associated with better quality of care and higher coverage of hard-to-reach areas.
• Sufficient resources and logistics, including transport and CTC provider kits, and the use of job-aids (simple tools used to support treatment decision-making) increase motivation and competencies of CTC providers.
Typology of CTC providers
There are many different types of CTC providers and they vary in nomenclature. Standing and Chowdhury put forward a categorization of different types of CTC providers, based on their roles[3]. General CTC providers execute shifted tasks in health prevention and curative care in a context of human resource shortage. Specialized CTC providers focus on conditions that are of high prevalence or great public health need. Advocates or instructors are expert patient advocates or peer educators who empower those affected by various diseases to take responsibility for their own health. Facilitator CTC providers are community mediators serving as local facilitators to enable people to develop solutions to problems, access resources, negotiate market alternatives and be aware of their rights. These different types of CTC providers would require different selection and recruitment processes, incentives, training, supervision and supplies. Therefore, it was important for us to assess the typology of CTC providers in the six REACHOUT country contexts.
We identified a wide variation in the general features of CTC providers within and between contexts. Within contexts, types can complement each other with general, trained CTC providers with defined tasks being supported by specialized CTC providers with additional training on the one hand and by advocate and or instructor CTC providers, often minimally trained, on the other hand.
General CTC providers were identified in all our countries. Advocate or instructor CTC providers were peer educators empowering community members to behave in a healthy way or supporting general CTC providers in executing of certain tasks, like growth monitoring. Specialized CTC providers were focussing on specific health issues, such as reproductive health in case of family welfare assistants in Bangladesh. Facilitator CTC providers were not identified in the six countries, although in all contexts, facilitation of community problem solving and advocacy for rights was part of the general job description of CTC providers.
Many general CTC providers recently got expanded, more specialized tasks (for example, health surveillance assistants in Malawi providing curative services for childhood illnesses). General CTC providers were mostly supposed to work full-time, whereas specialized and advocate/ instructor CTC providers worked less than full-time on a voluntary basis. Sizes of catchment areas varied widely per country and CTC provider type.
Variations in the selection and recruitment of CTC providers ranged from selection and recruitment by professional bodies according to pre-set criteria (for example village midwives in Indonesia, health surveillance assistants in Malawi and health extension workers in Ethiopia) to CTC providers being selected by the community according to criteria developed by the community (community health volunteers in Kenya, Agentes Polivalentes Elementares in Mozambique and NGO community health workers in Bangladesh). Involvement of the formal health system in CTC provider selection seems to be related to the embedment of the CTC provider in the formal health system, whether they were general or specialized CTC providers. Gender plays an explicit role in selection in several contexts, namely Bangladesh, Ethiopia and Indonesia. In these countries, CTC providers are preferred to be female; and in Ethiopia all Health Extension Workers are women
We found that supervision and training also varied widely. Again, supervision from the formal health system was available for (general and specialized) CTC providers embedded in the health system. CTC providers that have an official supervision task themselves are salaried, general CTC providers. Most of the times, they supervise other voluntary general CTC providers or advocate/ instructor CTC providers. Most of the general and specialized CTC providers are officially trained (initial and continuous training) by the health system, the training duration varied per country. Advocate/ instructor CTC providers were trained in a more ad-hoc way, following health campaigns or specific (vertical) NGO programmes. In Ethiopia and Malawi, advocate/instructor CTC providers were supposed to be trained by general CTC providers.
In all countries, at least one type of CTC provider is remunerated, often the general CTC provider and in two instances the specialized CTC provider (in Bangladesh and Indonesia). Incentives and supplies varied widely and were sometimes related to vertical NGO-led programmes. When curative services were part of the CTC provider responsibilities, supplies like kits, drugs and other commodities were provided to the CTC provider.

Importance of Context in Six Countries
We found that the current context of rapid urbanization in Bangladesh had an impact on how close-to-community services are conceptualised in theory and delivered in practice. Dhaka City is projected to become the fourth largest city in the world by 2025 with 22 million people due to its rapid urban migration and growth in urban slum populations. A majority of informal settlements are located in low-lying, flood prone areas, with poor drainage, limited formal garbage disposal and minimal access to safe water and sanitation and services, and receive limited support from the government. The conditions of high population density and poor sanitation exacerbate the spread of disease and other kinds of vulnerability.
Bangladesh has a pluralistic health system, and CTC providers are an obvious resource within both government and NGO sectors. CTC providers have been seen for several decades as an alternative to the complete professionalization of the health workforce in Bangladesh. Both governmental and NGO CTC providers are utilized for community health programmes, including family planning services, sexual and reproductive health (SRH) services, preventive services (for example, immunization and vitamin A distribution.) and several curative services (for example, management of childhood pneumonia, neonatal sepsis and TB control). Though both the government and NGOs run community health programmes, NGOs have been instrumental in scaling up these programmes.
For the private sector the number of CTC providers and the structure is very complex, as it includes health actors from both formal and informal categories. Formal CTC providers are the staff of the NGOs and government, whereas the informal CTC providers are drug sellers, homeopaths, traditional birth attendants, and other traditional practitioners. Both types of CTC providers play a key role as negotiators between communities and health systems to provide sexual and reproductive health services (including for legal early term abortion, or menstrual regulation) for women of Bangladesh and often act as a bridge between them in various contexts. Informal providers often maintain an informal personal link to the formal health sector and make referrals, when required, though these are rarely tracked. Management of informal providers is usually based on personal relationships with formal CTC providers in the organizations, rather than a formal structured process. Supervision and support of the informal providers was limited and often checklist based, with limited coordination between partners and disparate and duplicate processes for community engagement.

In 2004, the national government introduced the Health Extension Programme to provide quality promotive, preventive and selected curative health care services to ensure universal access, with special attention to mothers and children, targeting them at the household level. The development, recruitment and training of a cadre of women CTC providers was key to the Health Extension Programme. They are recruited from the local community, as this has been shown to improve relationships with community members, and trained for one year to provide community-based services.
We found that the national rollout of an all-female cadre of salaried health extension workers had a profound influence on how community services were prioritised, supported and linked to the health system of Ethiopia. REACHOUT focused on maternal health services provided in rural areas by Health Extension Workers in Southern Ethiopia, Sidama Zone, which has the lowest coverage of institutional delivery and postnatal care in the region. Client costs incurred for maternal health services at hospitals and unavailability of logistics and infrastructure affected the service utilization and the performance of the Health Extension Workers.
Heath Extension Workers are the largest cadres of CTC providers, though Traditional Birth Attendants and the Health Development Army support antenatal care, referral of pregnant mothers, postnatal care and community mobilization. The level of community engagement with these cadres varies depending on their alignment with traditional values and practices. Many NGOs work on capacity building and supply of logistics and supplies to motivate the Health Extension Workers – however, this has led to a lack of coordination of partners in some areas. Mismatch between the workload and Health Extension Workers’ salary, which is lower than other government employees, limited education or transfer opportunities. Limited supervision and referral uptake were intervention design factors that also influenced the motivation and performance of the Health Extension Workers. Limited feedback and absence of referral forms affected the referral system while irregularity, fault finding and inadequate feedback compromised supervision.

We found that the decentralization of the health care system in Indonesia emphasised community empowerment, giving clear roles to close-to-community providers. Three initiatives namely: the community health centres known as Puskesmas; community integrated village health posts called Posyandu and the village midwife programme were started in the latter half of the 20th century to bring health services closer to the community and to improve the high maternal mortality. The initiatives function to provide integrated curative, preventive and health promotion activities particularly mother and child services to rural communities. In the initial phase, considerable progress in maternal mortality was observed, however, the crises persisted and the challenges facing the village midwife programme became more evident. Additionally, the decentralisation of the health system in 2001 gave management authority to the districts, and shifted health care delivery closer to the community, creating deliberate structures for community engagement.
The main maternal health CTC providers are the village midwives or nurses, the Posyandu kader (village health volunteers) and traditional birth attendants. In REACHOUT, our work focused primarily on the kaders. They may refer mothers to the midwives, who are also their supervisors, for antenatal care and skilled delivery. The kaders provide basic child health care services as well as health promotion (including family planning) in the community through the Posyandu including some home visit. Coordination in the Posyandu is through the district health office, but due to the complexity of public health financing in Indonesia this also involves other government structures.

We found that devolution of health care and national revision of community health policy provided both opportunities and threats to equitable community health service provision in Kenya. Kenya has a national policy for CTC health services known as the as the Community Health Strategy. The plan was developed in 2006 to reform primary health care at the community level as a result of declining health indicators reported in the Kenya Demographic Health Survey 2003. The strategy included training and supporting of volunteers referred to as community health volunteers who are linked to primary health facilities through community health extension workers. It defines the roles and functions of the community health extension workers and volunteers, selection and recruitment, training, supervision, governance and M&E. The programme has been implemented with varying degrees of success in implementation of primary health services by government as well as vertical programmes run by NGOs delivering HIV, TB and malaria.

Our analyses showed that generally the 2006 community strategy was being implemented to deliver primary health care services such as maternal and child health and sanitation. However, there was some variation from the policy in the areas of training, supervision and incentives, with strongly fault-finding and administrative supervision practices. CTC providers were accepted and appreciated by the facility-based providers and communities, but the community engagement in the strategy was varying with minimal support provided beyond recruitment. Community members reported that they had been referred to health services by the volunteers and that there had been adoption of healthy practices by communities. In 2010, the Kenyan constitution devolved responsibility for health care to county level in an effort to improve health equity. Then in 2014, the community health strategy underwent a national review by the Division of Community Strategy with the aim of increasing the number of community health extension workers and their responsibilities, while also revising the role and number community health volunteers. The revision was aimed at addressing shortcomings noted in the previous strategy and aligning it to successful models in other countries. However, in light of devolution of healthcare financing and decision-making to the county level, this policy had been only partially implemented by county governments and many had failed to coordinate the multiple partners working at community level and had not adequately funded community health services, threatening the equity and quality of services.

We found that multiple vertical programmes were using close-to-community providers to expand the reach of services in Malawi’s under-resourced health care system. In Malawi, the employment of CTC providers by the public health system takes place in a context of acute human resources shortages, identified as a key barrier to achieving the Millenium Development Goals, particularly in the health sector. One prominent CTC provider cadre in Malawi is that of the Health Surveillance Assistants. The Malawi Ministry of Health defines a Health Surveillance Assistant as a Primary Health Care worker serving as a link between a health facility and the community. Health Surveillance Assistants were regarded as an outstanding cadre because they are clearly linked to the health system, have national coverage thereby making their services relatively equitable and accessible, and are on government payroll, enabling their services to be sustainable.
Health Surveillance Assistants have performed a number of duties over the years. Presently, their tasks cover community health, family health, environmental health, prevention and control of communicable diseases, and management and administration – as well as referral of more serious cases to facility-based healthcare services. Driven by the task-shifting philosophy and poor coordination among multiple NGO partners, the duties and responsibilities for Health Surveillance Assistants have expanded such that some Health Surveillance Assistants are not able to list all the activities they are required to perform. Supervision structures are often duplicated and conducted in parallel adding to the workload. Health Surveillance Assistants face challenges related to poor remuneration, inadequate tools of trade and lack of a clear career path and therefore any lack of clarity around incentive structures and remuneration among the multiple actors wanting to work through them lead to serious mistrust between different actors, impeding CTC provider performance. While Health Surveillance Assistants are a key CTC cadre in Malawi, there are other CTC providers playing important roles in Malawi. Such providers include Traditional Birth Attendants, expert patients, community based distribution agents and community care providers. In addition, formal structures exist for community engagement through village health committees.

Mozambique [11,12]
We found that the geographical remoteness and the limited access to health care professionals in Mozambique affected both the design and tasks of the community health programme and the quality of service provided and meant that community members had high expectations for CTC providers. In Mozambique, REACHOUT focused its attention on the country’s formal CTC providers, known as Agentes Polivalentes Elementares. The Agentes Polivalentes Elementare programme was originally conceived and introduced in 1978 as a strategic solution to improve access to healthcare services for the rural population. The programme faced challenges since implementation and so the Ministry of Health decided to revitalize the Agentes Polivalentes Elementare programme in 2007, introducing a new training curriculum in 2010, with modified terms of reference and policy for payment of a monthly subsidy.
The initial Agentes Polivalentes Elementare Programme (developed in 1978), faced challenges which resulted in interruption of programme implementation in mid-1990s. These challenges include:
• Agentes Polivalentes Elementares felt abandoned due to almost inexistent supervision and a progressive decrease in support from the National Health Service (NHS), although many continued to receive medication and supply kits from MoH
• Different Agentes Polivalentes Elementare training curriculums and methodologies, implemented mainly by NGOs supporting Ministry of Health resulted in multiple vertical programmes and poor coordination.
• Referrals by Agentes Polivalentes Elementares were not taken up by the community and not acknowledged or used by the facility when patients arrive.
• Agentes Polivalentes Elementares were regarded as volunteers and were supposed to receive support from their communities (i.e. helping with their subsistence farming; providing foodstuffs, giving presents as recognition of their work, etc.), which became scarce; community engagement and accountability was limited.
• NGOs implemented a system of subsidies and provided other incentives for those under their supervision, which led to increased frustration of existing and active APEs in early 1990´s
• Agentes Polivalentes Elementares were seeking opportunities to become part of the National Health Service and were frustrated not be able to join NHS
• Communities viewed Agentes Polivalentes Elementares as health services providers demanding more curative services from them, which also led some Agentes Polivalentes Elementares to become “private health care providers” charging fees for their services.
Despite revitalization of the Agentes Polivalentes Elementare programme in 2010, considerable challenges remain including: sustainability of the programme, integration of former Agentes Polivalentes Elementares to current training, payment of subsidies, persisting weak monitoring and supervision of Agentes Polivalentes Elementares, challenges ensuring gender balance during selection of Agentes Polivalentes Elementare candidates (with the majority being men, contrary to policy documents), challenges with home visits due to poor road access, despite the distribution of bicycles.
Common Emerging Themes
The consortium wide discussions and inter-country analysis process led to the emergence of four common themes across the contexts. The basis of this selection was: 1) were key themes that emerged in the qualitative context analysis; 2) were most feasible to work on; 3) met policymaker priorities; and 4) had some momentum from other partners also working on them. These key findings from the inter-country analysis of these themes are expanded below.
Supervision systems[12,5]
Supervision was seen both as a factor for improving performance of CTC providers and as a demotivator. In Ethiopia, Health Extension Workers mentioned that supervision motivates them to work hard, and that they consider supervision as a recognition and acknowledgment of their work. There were similar findings in Bangladesh, Indonesia (for supervision of kaders by midwives) and Kenya (where community health volunteers appreciated the inputs of the supervisory community health extension workers). While some sort of supervisory system is usually part of the health system or programme (except for informal providers in Bangladesh), we identified shortfalls in frequency, regulatory and approach to supervision that hampered CTC providers’ performance in all study countries. Sometimes the system exists on paper but is not implemented, as reported by certain CTC provider cadres in Bangladesh, Indonesia and Kenya, or only very irregularly (Ethiopia, Malawi, Mozambique). In Kenya supervisors at both the community and health system level lacked clear guidelines, except for those engaged by vertical NGO programmes, resulting in inconsistencies in the methods and frequency of supervision. There are many different types of supervisors, both from the community and the health system, leading to a lack of clarity regarding supervisory roles and varied practice.
The heavy workload and under-funding also presented barriers, as their inability to spend (enough) time on their supervisory tasks affected the quality of supervision (Kenya, Malawi, Mozambique). Lack of resources needed for adequate transport to enable supervision was a barrier in all countries. In Mozambique, supervisory visits were often postponed (from monthly to quarterly), due to a lack of physical (vehicles) and financial resources (for fuel, supervisor allowances), in combination with long distances and difficult access to communities. On the other hand, where resources are available for supervisor allowances, supervision was sometimes driven by the need for additional income for supervisors, rather than supervisee or programme needs (Malawi).
The nature, approach and regularity of supervision emerged as key area shaping CTC provider experiences. In most countries, supervisors are seen as directive (focusing on fault-finding, blaming, providing only negative feedback;(Ethiopia, Indonesia, Malawi and Mozambique), rather than supportive (focusing on constructive feedback, problem-solving, learning; as reported by some NGOs in Bangladesh, home-based HIV counsellors in Kenya) is seen by supervised CTC providers as a problem. In the case of Ethiopia, Health Extension Workers mentioned that supervisors are looking for mistakes, instead of acknowledging their strengths and addressing their weaknesses. A lack of feedback during or after supervision is also seen as a problematic, as it reduces learning and opportunities to make improvements (Ethiopia, Kenya, Malawi, Mozambique).
A lack of supervisor training and guidelines was identified as a barrier to quality supervision and linked to CTC providers’ performance (Ethiopia, Kenya, Malawi). In Ethiopia, the limited skills and knowledge among HEW supervisors are seen as weaknesses by CTC supervisees, and they are not trained in supervision as a part of their qualification. Standardized training of supervisors and Community Health Committee members accompanied by harmonized guidelines and clear, well-communicated procedures for supervision are seen as necessary as part of a broader quality assurance package for the CTC strategy. The availability of standardized procedures, guidelines and tools was seen as helpful (Kenya for HBTC), and the lack thereof as problematic (Indonesia, Kenya for CTC providers).
Coordination of multiple programmes and actors
Weak coordination structures were reported to hamper CTC providers’ performance in Kenya and Malawi. This has to do with the existence of vertical programmes. In Kenya and Malawi insufficient integration and coordination of various NGO priorities and focus were reported to cause duplication and gaps of services and inequities in conditions for CTC providers. In Bangladesh, limited regulation of the health services was reported, with a plurality of providers working in parallel with little or no coordination. Mozambique used to face problems associated with many NGOs working in parallel to the government systems, but now the government has taken more control to address this. Differences between material incentives may still exist, but only among provinces; within one province CTC providers will receive the same incentives. The importance of the private sector was especially reported in Bangladesh, and in Indonesia as part of the midwifery services. In other countries, the plurality of informal providers in the community was reported as well, e.g. on Bangladesh it is estimated that less than 20% of the curative health services are offered to the general population through public-sector providers. This situation requires advance communication, coordination and referral mechanisms. Findings in Malawi have shown the (often negative) impact of multiple competing vertical programmes working through health surveillance assistants. This incentive structure leads to serious mistrust between different actors, impeding CTC performance.
Community engagement
Engaging with communities, through community participation in the recruitment and supervision of CTC providers, were key elements to establishing community ownership and enabling providers’ performance. These emerged as key challenges in Ethiopia, Kenya, Indonesia and Malawi, where community members expressed limited trust and buy-in, and as strengths in Mozambique and Bangladesh. Community engagement, where present, generated ownership, created trust and acceptance and was a motivating factor.
In many countries, the policy and practice of involving beneficiary communities in the recruitment and selection process for CTC provider candidates existed (Indonesia, Kenya, Mozambique), but not always or only nominally (Bangladesh for formal providers, Ethiopia). In Indonesia and Kenya both aspects were noted: some CTC providers (kaders, community health volunteers) were community members recruited by the community, while others (midwives, community health extension workers) were professionals selected and employed by the health system, with no community involvement. In Kenya, this was viewed as a lack of community ownership. A lack of involvement of the wider community (and not just the village leaders) in the selection of CTC providers risked leading to the rejection of providers and resentment of the activities and the resources associated with this role in Kenya and Indonesia. In Indonesia community meetings are attended by village heads, community members, including Family Welfare Society members, and others, and selection is by consensus. The head of Puskesmas and midwives are involved in suggesting candidates; so, apart from the village leaders, others are also involved in selecting the kaders. Only sometimes do community governance roles take the form of accountability, as community members take part in supervision (Mozambique) or, in Kenya, in monitoring progress through ‘dialogue days’. The effectiveness of governance structures and community engagement that gave meaning to the aim of representing communities and representation of more marginalized and vulnerable groups emerged as an important issue in Kenya and Malawi. Overall, communities even within one region or country are not homogeneous and this is an important issue when it comes to community participation and contextualization.
Referral and feedback
Our findings reaffirm what the international literature on CTC providers has extensively documented: that timely detection of health problems and referral to the appropriate level of care is a key role of CTC providers. The importance that CTC providers attach to the referrals they make and whether these bear fruit is also a common theme. Both our study findings and the international literature review show that a well-functioning upstream referral system is critical to the ability of CTC providers to perform well and to meet the expectations of the beneficiary communities; any weaknesses in the upstream referral chain (such as a lack of referral transport facilities), paired with sometimes negative community perceptions regarding the quality of referral services, undermines the performance and effectiveness of CTC interventions.
Study participants identified key bottlenecks hampering the referral process (from CTC providers to health facilities) as the long distances to facilities and the lack of transport for clients in need. For example, in Ethiopia, Kenya and Malawi, CTC providers reported that beneficiary communities expect them to not merely tell them where to go and when, but also to facilitate and support the actual process of transfer; they felt that the lack or unreliability of resources for transporting clients was a major factor hindering performance. Not only do they feel they failed; the clients and community also let them know their disappointment.
Whenever and wherever the referred patients are treated well at higher levels of care, the CTC providers’ credibility with the communities improved, and this helps them do their work better. CTC providers reported that if the beneficiary communities have a negative perception or have had bad experiences in terms of the quality of care at higher levels of care, including regarding whether they were treated with respect and dignity, the CTC providers’ standing with the beneficiary community suffered. This illustrates the intricate linkage between CTC provider experiences and the performance of the broader health system – and underpins their role as part of the health system. In Ethiopia, Bangladesh and Indonesia referral was sometimes not acted on by clients because of the perceived unfriendly attitude of higher-level health staff. CTC providers feel that they are bearing the brunt of any failure of the health system and were at the front line to ensure that a referral comes to fruition. Thus uncertainty regarding the upward referral chain undermined their credibility in the communities, their performance and negatively affected their experiences and relationships
Overall feedback to CTC providers was limited or nonexistent. In Kenya, there is supposed to be a feedback system from the facility to the CTC provider, which is not the case in Bangladesh (government sector) and Malawi. In Ethiopia and Mozambique a system exists but lacks implementation. Evidence from the study countries showed that, while having formal processes and formal feedback loops helps, their mere presence is not sufficient to make the referral processes work. On the contrary, we found that CTC providers are less concerned about receiving formal feedback than with the ability of the higher-level facilities to provide the required services in a respectful and dignified manner.
Importance of the interface role
CTC providers have a unique position between communities and the health sector. A key contribution of REACHOUT to the international debate on CTC providers is the importance of taking their interface role into account when designing programmes and developing interventions to improve performance.
Common emerging themes on interface and conceptual framework[5,11,13]
During the context analysis, it emerged that relationships are the glue that support CTC providers in their interface role. The strength of CTC providers’ relationships influences their motivation and performance, which can affect the quality of the services they provide. To understand the importance of relationships to the work of CTC providers, REACHOUT conducted a qualitative comparative study with a “realist lens”, from context analysis data in Ethiopia, Kenya, Malawi and Mozambique.
Trusting relationships between CTC providers and their communities were found to be a result of: feelings of connectedness, familiarity, serving the same goals, and free discussion; the perception that CTC providers serve in the community’s interest and enhanced recognition, respect and credibility from the community; and feelings of CTC provider self-fulfillment.
The way in which programmes are designed can support trusting relationships. For example, it helps if CTC providers are recruited from the place that they would be working in, with the involvement of diverse community representatives in decision-making. The involvement of volunteers as an official element of the programme is perceived to be helpful, as is the involvement of traditional leaders. Trusting relationships could be enhanced if curative tasks are shifted to CTC providers. In contexts where gender norms clearly shape interactions, and discussions (for example in SRHR) and access to households having female CTC providers is important.
Other broader contextual elements that are considered important included: valuing and promoting community participation; a history and value of volunteerism, and the importance of and respect for traditional leadership at the community level.
Trusting relationships between CTC providers and the health sector are related to feelings of connectedness and serving the same goals (from both sides) and CTC providers’ belief that they are supported. Other studies have identified additional mechanisms, for example, related to health professionals reporting that CTC providers assist them in reducing their workload. For the mechanisms to take place, the following programme-related contextual factors are found to be important: professional support structures to be available; curative tasks to have been shifted to CTC providers; and regular and visible supervision to take place.
We found that weak relationships between CTC providers and their supervisors and managers are a result of disrespect and doubts from the health sector about CTC providers’ competencies; CTC providers feeling disconnected, unfamiliar and unsupported, or having a lack of confidence or perceptions of dishonesty and unfairness in supervisors and management; and misunderstandings related to lack of communication (from both sides). In some cases, weak relationships between CTC providers and their supervisors or managers have a negative knock-on effect on the strength of CTC providers’ relationships with their communities.
In Ethiopia, some communities perceive CTC providers as dishonest if they are (forced to be) involved in politics. In Malawi, some communities perceive CTC providers as not trustworthy if volunteers received different and irregular incentives, as a result of multiple vertical programmes.
The comparative study demonstrates a complex interplay of factors influencing trust, and thereby the strength of relationships, between CTC providers, their communities and actors in the health sector. This led to us developing a conceptual framework on CTC provider performance, which explicitly conceptualizes the interface role of CTC providers. Various categories of factors influencing CTC provider performance are distinguished in the framework: the context, the health system and intervention hardware and the health system and intervention software. Hardware elements of CTC provider interventions comprise the supervision systems, training, accountability and communication structures, incentives, supplies and logistics. Software elements relate to the ideas, interests, relationships, power, values and norms of the health system actors. They influence CTC providers’ feelings of connectedness, familiarity, self-fulfillment and serving the same goals and CTC providers’ perceptions of support received, respect, competence, honesty, fairness and recognition. The framework shines a spotlight on the need for programmes to pay more attention to ideas, interests, relationships, power, values and norms of CTC providers, communities, health professionals and other actors in the health system, if CTC provider performance is to improve.
In light of these findings, ‘community health systems’ need redefining and a health systems analysis cannot simply take the WHO building blocks into account. We must move beyond traditional hardware thinking to incorporate a better appreciation of software elements in both our research and program design.
Tools for measuring complex constructs at the interface
Measurement of how supportive supervision is or what the motivational outcome of a particular intervention is an important step in designing supportive supervision interventions that meet the needs of CTC providers working at the interface. How CTC providers at the interface experience supervision and the outcomes in terms of their motivation are complex constructs that are difficult to measure quantitatively. In other words, questions like ‘is your supervision supportive?’ or ‘do you feel motivated?’ can be easily misunderstood.
At the beginning of REACHOUT there were no existing tools for measuring the supervision and motivational outcomes of CTC providers from their own perspective. We developed and validated simple tools to measure perceived supervision and motivational outcomes in low- and middle-income countries. Twelve questions, informed by the extant literature on health worker supervision, underwent exploratory factor analysis. We then employed structural equation modelling with 741 CTC providers to assess the factorial validity, predictive validity, and internal reliability of the questions at three time-points, over 8-months. We developed a robust, 6-item measure of perceived supervision, capturing regular contact, two-way communication, and joint problem-solving elements as being critical from the perspective of CTC providers. When assessed across the six countries, over time, the perceived supervision score was also found to have good validity and internal reliability. Scores at baseline positively and significantly predicted a range of performance-related outcomes at follow-up. REACHOUT has developed the first validated tool that measures supervisory experience from the perspective of CTC providers and is applicable across multiple, culturally-distinct global health contexts with a wide range of CTC provider typologies. Simple, quick to administer, and freely available in ten languages[14], the tool could assist practitioners in the management of community health programmes and was used in monitoring the impact of the supportive supervision approach in quality improvement cycle 1 of REACHOUT that is described next.

Developing and using group supervision that addresses the interface
Supportive supervision was the most broadly implemented intervention; all six countries implemented this in some form, training supervisors in a supportive group supervision approach. The supportive supervision curriculum was developed and piloted by the Kenyan REACHOUT team, based on their previous experience in this area. The curriculum covers six days’ worth of material and was used with supervisors of CTC providers. It includes: definition of roles; national policies and tools; how to design a refresher training programme; how to facilitate group supervision and peer support; tools for self-reflection and observed practice; how to feedback on reports; and what support supervisors need. It was developed using and adult learning approach with the underlying principle that community health service providers should always feel a ‘value-add’ for participating in supervision and not come to fear or avoid it. Rather supervision should be seen as an opportunity to share their concerns, help them to overcome the challenges they have experienced in their work or personal life, and to learn more about the work that they are carrying out through the knowledge sharing and coaching of the supervisor. Seeing supervision only as ‘line-management’ may limit the effectiveness of the supervision in improving quality and eventually lead to supervisees becoming demoralised. Rather its role was seen as creating and open dialogue and a mentoring relationship to help CTC providers report, identify and resolve the problems they have leading to genuine improvements in competencies over time. The effects of this intervention were complex, with confounding factors including availability of transportation, remoteness of the community, and support of senior supervisors within the health system playing important roles. However, impact was observed in several areas (from immediate to downstream):
1. Approach to supervision, frequency of supervision, attendance at supervision as measured by attendance registers and the perceived supervision scale
2. Motivation and performance of CTC providers – as assessed by our qualitative findings triangulated with the motivational outcomes scores
3. Health outcomes and referral adherence – as documented in referral and uptake data as part of routine register reviews

Gender at the interface
The ways in which gender roles impact on the ability of women, men, boys, girls and people of other genders to access healthcare is well documented. Findings from the context analysis, highlighted how gender roles and relations shape the opportunities and challenges CTC providers face in realising their unique role as an interface linking communities and health systems. While it varies by context, CTC providers are predominantly women, often of lower socio-economic status, who have limited career opportunities. Gender norms and power relations play out in complex and contextually specific ways and are also subject to change through time. Our analysis brought out several key areas affected by gender and power relations: acceptability of services; attrition of CTC providers; and mobility and safety within the community.

• Acceptability of services was affected by CTC provider’s sex: in all countries, female CTC providers were perceived to be more able than male CTC providers to encourage pregnant women to access facilities and in Mozambique and Malawi cultural norms formed a barrier to male CTC providers visiting women in their homes. In Kenya, the lack of male CTC providers was perceived to be a barrier to effective family planning and voluntary counselling and testing services for HIV[8].
• Causes of attrition often varied by sex of CTC provider too. In rural areas of Ethiopia, Kenya, and Malawi attrition or transfer among female CTC providers was attributed to marriage that caused women to move out of their (home) village. Whereas attrition rates of male volunteers in both rural and urban areas in Kenya and Malawi was high due to the gendered role of men as breadwinners, making commitment to a voluntary role challenging.
• Safety was a challenge to service provision in urban informal settlements in Kenya and Bangladesh, and to some degree in rural contexts in Kenya. In Kenya, there were reports of threats of violence by husbands to CTC providers for conducting HIV testing and reports of rape of CTC providers. Participants suggested that female CTC providers needed to be accompanied by security officers. In Bangladesh however, trust and respect for CTC providers from community members enabled women to negotiate these safety challenges, and largely work freely and without difficulty outside the home.
Assessing, Measuring, and Improving Quality
Developing a phased approach to integrating quality improvement approaches into community health
Quality improvement cycle 2 in REACHOUT focused on locally owned approaches to quality improvement for community health. In order to embed quality improvement approaches into community health across REACHOUT we developed a training and mentoring system suitable for use with CTC providers, their supervisors and programme managers. Quality improvement capacity development efforts were guided by a common approach across the six countries. Similar steps were followed by all country teams, with contextual adaptations to training materials, participants and levels of engagement with health system stakeholders as determined by country researchers. A description of each phase of the intervention follows:
• Phase 1: Development of the common quality improvement curriculum was conducted at the international level. This step engaged two quality improvement experts in the UK with good knowledge of the community health programmes in each country context and of the overall REACHOUT project.
• Phase 2: Training of Trainers in quality improvement for REACHOUT country teams together with national policymakers for community health programmes was conducted over four days in October 2015 in Cianjur, Indonesia as part of the annual project meeting.
• Phase 3: Adaptation of quality improvement curriculum to country contexts was done by REACHOUT country teams and other stakeholders who had been trained in the quality improvement approach. Almost all country teams conducted significant adaptation and simplification of the curriculum to ensure comprehension by the target trainees. Through the engagement with a wider group of local stakeholders materials were aligned to relevant contexts, existing standards and guidelines for service.
• Phase 4: Implementation of three short workshops interspersed with periods of implementation of the approach by new quality improvement teams. In workshop 1 an introduction to quality for community health and team-led problem identification, root cause analysis, prioritization and solution generation for the priority problem. Teams were formally established and agreed to a schedule of meetings. Workshop 2 reviewed data collected by the teams on the selected quality improvement problem and assessed progress to date, along with modifications of the approach if needed. Workshop 3 included a learning and exchange session bringing in quality improvement teams from different sites, their supervisors and various other stakeholders.
Interspersed with the training activities were periods of implementation of the quality improvement approach by teams. This work, supported by REACHOUT mentors/trainers, was the equivalent of what the quality improvement teams will do on a recurrent basis after the conclusion of the training phase. quality improvement team members at each site planned to meet on a regular basis. These meetings occurred at a fixed venue and allowed for regular assessment of progress against quality improvement action plans, enabling teams to continuously identify problems and generate solutions or interventions to address those problems, based on their local criteria for prioritization.

Data quality
Our findings highlighted the challenges of poor data quality in community health programmes and linked improvements in data quality to the roles of local quality improvement teams for community health. In all countries with community health programmes, close-to-community providers collect data about the people that they serve and the services that they provide. Depending on the country, these services include a mixture of health promotion, disease prevention, referral, and curative and disease management services. These community-level health data are essential to monitor the performance, quality, coverage and equity of community health programmes. Historically however, the quality of data reported by CTC providers is perceived by policy- and decision-makers to be low therefore at the higher levels of health systems, there is little trust in the data reported from community level and thus it is not routinely used at these levels for decision-making. In the few studies that have been carried out to assess the quality of data reported by CTC providers, it has indeed been found to be poor and this was borne out by our sub-study in Kenya and Malawi.
REACHOUT assessed quality using a recognised framework to assess if it met the standards for: accuracy, reliability, completeness, timelyness, integrity and confidentiality. REACHOUT country teams conducted qualitative interviews at national, district (or equivalent mid-level) and CTC level to explore what data are collected to measure or assess performance and quality of community health programmes. In Kenya and Malawi, this was taken further with a sub-study to formally assess the quality of data reported by CTC barriers and identify barriers and facilitators to reporting high-quality data. The following were our key findings:
• Not all CTC providers are provided with standard reporting tools by their governments leading to improvisation such as using exercise books or cardboard for data collection
• In countries where standard reporting tools for CTC providers do exist, these are often unavailable (stocked out)
• In countries where standard reporting tools for CTC providers do exist and CTC providers are in possession of them, these are often not used regularly and/or correctly. Sometimes the tools are too bulky or heave to comfortably carry and walk around with due to their size and/or the number of different data reporting tools they are expected to use. Furthermore, these tools are often written in technical language that the CTC providers do not understand and are not provided with training or supportive supervision to help them understand.
• CTC providers often do not receive feedback from the higher levels of the healthcare system meaning they do not see themselves as part of the larger healthcare system and perceive there is no real demand for the data that they report
High-quality data are fundamental to priority-setting; in the absence of good data, politics and power fill the vacuum of evidence, driving inequities in communities and health systems.

Case studies on using quality improvement approaches in countries
Case study: Quality improvement in Ethiopia
In Ethiopia, REACHOUT’s approach was across three core areas: community engagement, referral linkage and supportive supervision. Initially, 45 health centre staff supervising CTC providers were trained in quality improvement in Shebedino, which was then expanded to a total of 81 in nine health centres.
The health centre quality improvement teams spoke of how integral the cyclical quality improvement approach has become to their work - and they have the health benefits to show for this dedication. The comprehensive problem-solving approach that they adopted has gone beyond maternal health, impacting across health services from HIV to TB. The teams now also have a dedicated budget for quality improvement activities which they plan and implement on a regular basis linking facilities and CTC providers.
In Abela health centre catchment area, the team not only spoke to the increase in rates of complete ANC attendance – which has increased to 81% - but shared their other aspirations: not content with just ‘model households’, the team have set their sights on creating a ‘model village’. Woinadega health centre spoke of their pro-equity approach; identifying patients with special requirements implementing three-step programme to better serve them. This includes waiving payment for services, establishing an CTC outreach programme and implementing a microfinance initiative to improve their socio-economic position. Tesfaye, the head of Dulecha health centre, also spoke of the importance of teamwork “Many threads together are strong enough to tie a lion”.
But in answer to the all-important question...Will it be sustained? “Without a doubt, no question. It is our routine task. Our knowledge and practice is due to REACHOUT training. Quality is one component of health centre reform, which is also part of the government initiative, so REACHOUT’s focus on quality is aligned with the government initiatives of health centre reform,”Gebre Tunga, head of Abela helath centre. “REACHOUT is a kind of spice to add flavour to the dish, but we are the cooks, it’s our own work, so we will continue to do it,” Solomon Daniel, head of Telamo health centre

Case study: referral cards in Bangladesh
Through the initial context analysis REACHOUT Bangladesh identified that there are no formal links between formal and informal CTC providers and the client referral process faces many challenges. Poor instruction on the referral process, limited referral and interaction between formal and informal providers have negative impact on the health of poor people, especially Menstrual Regulation clients.
To minimize the gap between formal and informal providers the following interventions were carried out through two quality improvement cycles:
• Facilitative referral training for both formal and informal CTC providers to strengthen their capacity of referral. Facilitative referral is a process where a CTC provider provides continuous assistance and all necessary information of the service to the client
• A revised referral card for both organizations to implement effective referral
The pre-existing referral card was a single page of paper printed on both sides. One side had the address and the service hours of the clinic. The other side had the available health services of the respective clinic. There was no way to document the information of the client and the referrer and had no way to track the referral. To revise the referral card REACHOUT Bangladesh applied a participatory approach of discussion with different level of staff from the partner organizations. CTC providers were asked to list out the information they would want to see in a referral card and to draw a draft referral card during their first facilitative referral training. The draft was shared with CTC providers’ supervisors who gave feedback. Researchers designed a referral card addressing all the suggestions. The management of the partner organisations approved the design and the concept of the revised referral card. Final proofreading and editing was done involving the clinic managers of the intervention areas. REACHOUT Bangladesh printed and distributed revised cards among the partner organisations and trained CTC providers on its use in a ‘facilitative referral training’. The revised referral card has two parts with the same serial number printed on both. One part is for the referrer to keep with himself/herself and another part is handed over to the client to carry it to the clinic while accessing services. The referral card has referrer’s name, referrer’s cell number, date of the referral, due date by which the client has to visit the clinic for the service considering her last menstrual period (LMP), the address of the clinic, and the service hours of the clinic. The client’s name and client’s cell number is printed only in the referrer’s part to track the client and to maintain client’s confidentiality.
One pharmacist said: “This referral card is like an ID is good, if a client show this card she gets the benefit and she is satisfied. This referral card is better than the previous slip. It is a document that I can send with the patient to the clinic. If the patient takes the service or not I will know that... If I give this referral card to the patient, she will be happy because I told her if you show this card you will have the treatment quickly and you don't have to face any problem.” (in-depth interview)
The formal and informal CTC providers and supervisors of formal CTC providers appreciated the revised referral card as it helps them:
• To keep records and to track the referred clients and the referrer
• To ensure that the referral fee is paid to the referrer as they also keep a part which is a proof of their work
• The referral card is itself documentary evidence of the referral system
• The address printed on the referral card helps the client to get to the appropriate clinic
Priority setting and decision-making for community health
In REACHOUT, we observed that many respondents across health systems levels identify equity as a guiding principle yet equity is rarely reflected in policies or in implementation of service delivery. Mid-level decision-makers, who often hold greatest power compared with CTC health workers and community members, perceive building health facilities as the most appropriate way to achieve health equity. Community members who have a more holistic understanding are not yet sufficiently empowered to understand the benefits and limitations of choices available to them or to reflect this within the priorities they identify. There is wide variation between sites even in the same country, with emerging examples of stronger, more equitable health priority-setting as well as its opposite.
Overwhelmingly, power dynamics are fundamental to understanding decisions and choices in the health system. We found a lack of clarity surrounding roles for decision-making actors, inadequate information, unclear criteria and processes for guiding priority-setting. Within the confusion created by the limited guidance and capacity, opportunistic actors have seized available power to manipulate priorities to align with personal objectives, such as political re-election. The resulting increase in complexity blurs lines of accountability creating a situation that makes progress beyond a single elected term challenging. This has led to increased focus on tangible curative services, stifling opportunities for strengthening quality and community-based primary health care.

Equity of CTC provider programmes
Through a systematic review[15], REACHOUT has found that CTC providers are able to address both supply side barriers (aspects of health systems that hinder service uptake) and demand side barriers (factors influencing the ability to use health services at the individual, household or community levels) to uptake of health services. However, it is important that policymakers consider design features which may hinder equity when planning programmes. These include supply side barriers such as low numbers of health workers (including CTC providers), time to reach services, cost of services and demand side barriers to accessing both CTC provider services and uptake of health facility services, such as demand for services and information about health care, waiting time, indirect and opportunity costs, education, household expectations, community and socio-cultural preferences and gender roles and relations.
The review highlighted gaps in the extent to which quality is monitored with regards to equity stratifiers. Quality is widely identified as being a central tenet shaping equity. It would therefore be expected that the quality of services provided by CTC providers would be evaluated during studies which monitored equity. However, this review revealed quality was assessed in only five studies, four of which evaluated client satisfaction and one of which assessed use of more effective versus less effective anti-malarial treatment provided by CTC provider. None of the included studies assessed the technical quality of services provided by the CTC provider according to any equity stratifier. This finding reveals a disparity between this review’s findings and the literature on quality of care, which includes equity as one of the six dimensions of quality health care (effective, efficient, accessible, acceptable/ patient centred, equitable and safe). For CTC provider programmes to ensure quality equitable service provision for all groups it is vital that quality improvement approaches (which measure and understand performance gaps, before introducing, monitoring and evaluating interventions to close these gaps) include an equity focus. Various tools for quality improvement have already been created, such as the CHW AIM Tool and the authors would propose that equity be added as an additional programmatic component to ensure regular and consistent application of an equity lens during quality improvement approaches for CTC provider programmes.
We found that CTC provider programmes across diverse contexts promote more equitable access and use of CTC provider services at household level and have the potential to contribute towards improved uptake of referral for health facility services. However, care must be taken by policymakers and implementers to take into account CTC provider programme features which can influence the equity of services provided during planning and implementation of CTC provider programmes. The quality of CTC provider services for differing socio-demographic groups and the role of CTC providers in empowering communities to address underlying social determinants for change are key gaps in the current CTC provider evidence base. It is vital that equity indicators are included within routine CTC provider monitoring, reviewed and acted upon; and that equity is incorporated within quality improvement approaches for community health to ensure that the pro-equity statements in CTC provider policies do not evaporate in practice. We recommend that evidence based decision-making by policy- makers take into consideration the underlying programme features which influence the equity of CTC provider interventions in addition to performance (motivation and competencies); effectiveness and cost-effectiveness.

Policymaker engagement in REACHOUT
Communication and research uptake efforts across our whole programme of work have been central to the way in which REACHOUT works. Our aim was to embed a quality improvement cycle approach within local structures and systems and provide close-to-community providers, and those who support them, with the skills and tools to better perform their roles. This could not occur without work to build learning networks and to identify and improve working practices, policies, and institutional habits that were acting as a barrier to change. We have communicated with academic and policy stakeholders at the national and international level – not just about our findings, but also about the process of conducting the research and the successes and challenges that we have faced along the way.
“We have placed an emphasis on the supply side – communicating with stakeholders who we feel are key to the change process about what we believe needs to happen. But we have also focused on the demand side - through research uptake work. If you are a farmer you cannot just throw seeds on the ground and expect them to grow. You need to take account of the soil, the climate, any pests etc. These will differ depending on where you are planting. That is research uptake work, preparing the ground so that ideas can bed-in and flourish, so the seeds of your research can grow long roots.”- Kate Hawkins, Communications Manager, REACHOUT
By working with key stakeholders throughout the research process, country-level understanding and ownership of the results was greater. Bringing local policymakers to other countries for visits, involving them in consortium meetings, and then bringing inter-country findings to the table for discussion and critique has made REACHOUT’s influence on policymaking and programming disproportionately large for its budget. Policymakers in the six REACHOUT countries at national and sub-national level have strengthened capacity to understand and utilize health systems research as well as building engagement across levels of the health system to value and support CTC providers, a key component of human resources for health – as evidenced by their increased engagement with and championing of community health services.
We used the following engagement approaches at different phases of the project:
• Planning the partnership: Communication capacity audit, stakeholder mapping to identify challenges and facilitators, policy and practice analysis
• Selecting research areas: Target audiences supported definition of priorities
• Developing methodology: Focus on simple tools that could be understood and used by local implementers
• Data collection: Inclusion of relevant stakeholders throughout the process and regular feedback to policymakers
• Analysis: Transparency about positionality
• Dissemination: In multiple formats for different audiences
Case study: Devolution in Kenya[7]
Given the short timeframe since devolution was introduced in Kenya (2013), little is known about how and why priorities for health are set and how this influences effective and equitable coverage of community-based primary health care at county level. In 2015 and 2016, we carried out the first large-scale qualitative study of post-devolution priority-setting for community-based health services in Kenya. We found that while devolution has great potential for increasing health equity and universal health coverage, health equity improved and service availability mainly expanded in only a few previously neglected counties. For the majority of counties, the process, power and politics behind county decisions were undermining community health, health equity and progress towards universal health coverage.
Devolution is transforming the balance of power in Kenya by reducing the role of national bureaucrats and sub-county health implementers and increasing the degree of decision-making power at the (new) county level. Here multiple political, technical and community actors, each with their own values and motivations, must compete to influence the priority-setting process. This changing balance of power has wide-reaching implications for community-based primary health care and for achieving Universal Health Coverage. With the balance of power frequently favouring politicians rather than technical actors there can be a failure to address patronage norms which limit accountability and transparency. This emphasis on meeting political needs within priorities may result in diversion of priorities away from effective community-based health services which progress UHC, towards visible infrastructure, as has been noted elsewhere. The lack of clear processes for resolving differing values during the priority-setting process and the uneven (and typically limited) engagement and empowerment of community members to participate in priority-setting further undermines progress towards Universal Health Coverage. Politicians have increased influence and may be motivated to provide services which appeal to their electorate, consolidate political support and maximise their voter base in pursuit of re-election. Given such political processes, less visible community-based health services risk being neglected.
In post-devolution Kenya we found that several counties have stated universal health coverage and community health services for all as priorities, but with different interpretations or adaptations of both. By contrast other counties do not yet have adequate focus or capacities to ensure vulnerable groups are not left behind, risking failure to realise Universal Health Coverage. There remains a critical opportunity to build political backing at sub-national (county) levels for planning and investing in community-based primary health services.

Governance in a decentralized system
Devolution reforms in both Indonesia and Kenya have brought extensive changes to governance structures and mechanisms for financing and delivering health care. Working through fully decentralised structures has implications for governance and health service delivery. Community health approaches are ideally suited to contribute towards attaining many of devolution’s most common objectives, including community participation, responsiveness, accountability and improved equity. We set out to examine governance across health systems levels with implications for community health services, identifying similarities and differences in two countries at different stages in the devolution journey for health care in two countries at different stages in the devolution journey for health care: Indonesia at 15 years post devolution and Kenya at three years.
We found that Indonesia and Kenya experience many similar challenges in ensuring good governance for health, which threaten the success of devolution reforms, despite a 15-year difference in timeframes with devolution between countries. In both countries, devolution reforms transformed power relationships; increasing political, fiscal and administrative responsibilities at sub-national levels and introducing opportunities for citizen participation in both countries. In both contexts the impact of these mechanisms, however, has been undermined by insufficiently clear guidance surrounding the priority-setting process; a failure to address pre-existing negative contextual norms and informal practices; varied values among key decision-makers, such as the value of visible and politically popular infrastructure over invisible community health services; limited capacity for health priority-setting and limited genuine community accountability and engagement within the newly created civic forums. Consequently, priorities in both contexts are too often placed on tangible and visible curative services rather than less visible health promotion and disease prevention services.
Comparing priority-setting for community health across both countries, at differing points in their journey with devolution, provides opportunities for Kenya to learn from Indonesia’s longer experience with devolution. In Indonesia we have observed practices and norms which have become entrenched within priority-setting processes, such as failure to adequately address pre-existing negative contextual norms and informal practices such as patronage, manipulation of power by local leaders to direct priorities favourable to them and their voters, varied capacity and values contributing to varied priorities between districts, limited actions to translate policy around community participation into meaningful citizen engagement within decision-making. Meanwhile, in Kenya we heard examples of many of these same issues, not yet entrenched but on track to become so unless challenged. Our findings present lessons for consideration not only for Kenya, but also for other countries planning or implementing devolution reforms.

Cost-effectiveness of CTC providers[16]
We assessed the cost-effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. Overall, the numbers of lives saved increased in all districts, varying from 5.78 lives saved per 100 000 population in south-west Sumba, Indonesia to 26.33 lives saved per 100 000 population in Kasarani, Kenya. In Shebedino, Ethiopia, more children’s lives were saved in the older cohort (1–59 months) compared to the younger cohort (younger than 1 month). Conversely, in south-west Sumba (Indonesia), Takala (Indonesia) and Kasarani (Kenya) districts, more lives were saved in the younger cohort, compared to the older cohort.
Costs differed across the countries, reflecting differences in the design and operational features of the programmes. For example, pre-service training costs were considerably higher in Ethiopia as compared to Kenya, capturing differences in the length of pre-service training (1 year in Ethiopia versus 10 days in Kenya). Annual salary costs for Indonesia were considerably higher than in Ethiopia, reflecting differences in the educational attainment between the community-based practitioners and local economic factors. In Kenya, cost of stationery and registers contributes the highest proportion to total cost accounting for over 50% of total cost. This reflects the low level of other costs including the volunteer status of the practitioners in Kenya and the government perspective taken.
Incremental costs per life-year gained were $999 in Shebedino (Ethiopia), $3396 in south-west Sumba (Indonesia), $2470 in Takala (Indonesia) and $82 in Kasarani (Kenya). All three programmes were cost-effective when using the willingness-to-pay threshold value as a reference. Univariate sensitivity analyses show that cost-effectiveness is most sensitive to uncertainties in the estimates of life-years gained. The probabilistic sensitivity analyses suggested that the programmes in all four study districts are likely to be cost-effective (> 80% probability) assuming a willingness-to- pay threshold of one to three times each country’s GDP per capita.
Given the assumptions made, we find each community-based practitioner programme to be cost-effective and to improve coverage of essential services. Several studies have also found a variety of community-based programmes to be cost-effective compared to facility-based interventions delivered by other types of health workers. Cost-effectiveness was most sensitive to uncertainty in the estimation of life-years gained. Given that life-years gained were estimated indirectly from coverage data or in the case of Kenya from potentially less robust evidence on coverage change, further research on the effectiveness of community-based practitioner programmes should be a priority.

Costing quality improvement
We costed the establishment and support to project-independence of Ministry of Health quality improvement teams for community health in five of the REACHOUT countries. There is some evidence that quality improvement approaches can address quality gaps at community level but there is limited appetite among stakeholders for integrating these approaches as information on the additional costs and benefits are lacking – and perceptions are that these approaches are complex and costly.
We found that the in-person trainings were the most expensive part of the intervention. However, the annualized costs of Ministry-led quality improvement per capita of population served are projected to be low, at 0.15EUR or less in all sites. Similarly, the budget impact of Ministry-led quality improvement for community health is minimal, showing a national scale-up of the programme would represent less than 0.1% of current annual government health expenditure in all sites.
The costs of quality improvement for community health are low in absolute terms. By including cost as a criterion in the quality improvement problem prioritization matrix, managers can improve allocative efficiency of resource use at the local level. The approach faces methodological and attribution challenges to demonstrate health impact as we look to move from affordability to a value-for-money assessment.

Embedding change
Embedding describes the process of quality improvement being absorbed into the health system structures and workflow as a part of the culture. Quality improvement, as an approach for enhancing performance and service quality of CTC healthcare providers, does not stand as an independent, vertical intervention like those for malaria or hypertension for example. Rather, quality improvement is an approach that is applied to a service delivery platform, helping managers prioritise across disease area or programmes and overcome systemic verticalisation of programmes by NGO, public and private health sectors. It relies on people being able to implement the approach and ‘see’ the change or the results of their work concretely. We aimed to make our learning from REACHOUT sustainable to ensure a legacy at the end of the project and to this end worked to ensure the changes had a chance of being taken up by the community health systems for the longer term - a process we termed embedding.
The need for capacity development through training and mentoring in quality improvement approaches is likely to remain until it becomes an integral part of working. It is not something that is a small change in workflow – rather, it is a change in mindset, approach and way of working. To kick-start this change, training must be tailored to the local programme, use simple materials and outline feasible, simple steps to change in behaviour.
Our findings also showed that supportive supervision of CTC providers was an important foundation for successful quality improvement implementation as well as a target of quality improvement interventions in some sites. Supportive supervision sessions provided an opportunity for supervisors to provide explicit feedback on the data collected by CTCs. This explicit use of the data they collected helped CTC providers to value their role in collecting the data and work to improve its integrity. Similarly, when supervisors came to point out capacity gaps of CTC providers, the use of their data was helpful in gaining consensus rather than defensive reactions. This in turn allowed the quality improvement teams to effectively implement proposed activities in the quality improvement change plans following training and capacity building on quality improvement.
In general, the downstream impact of quality improvement was mainly in two areas: improving supervision including feedback and strengthening the referral system, the focus areas of the quality improvement teams’ interventions. To embed these approaches, we are working with district quality improvement teams to support advocacy to district decision-makers for small budget allocations to this work, as well as working with supervisors to ensure that these supportive approaches continue to underpin their work with CTC providers regardless of tool or topic.
Capacity Development
Approach: Capacity strengthening for CTC research is one of the objectives of REACHOUT consortium and was core to all stages of our work. We used a holistic approach to capacity strengthening and focused our efforts on the individual, institutional and environmental levels. For REACHOUT, this includes researchers/research institutions, policy makers and CTC providers. The REACHOUT consortium followed Bates’ five step process of capacity strengthening to take forward its capacity building objectives[17]. The CTC provider capacity development in supervision and quality improvement is described above and the policymakers in the “engaging policy makers” section (e.g. health systems research evidence use), so in this section we are focusing on researcher capacity development.

The objective of capacity strengthening for the researchers was to support them in their ability to design, conduct and use health systems research to improve CTC services. Different activities were undertaken at the individual and institutional level to address this objective. At the individual level, REACHOUT researchers were trained on different research areas, including: mixed methods research; quantitative data analysis; scientific and creative writing and disseminating research findings through a variety of media. Major activities at the institutional level included: establishing structured supervision and mentorship systems; developing a research and ethics review system within the institution to strengthen the institutional capacity for research.
Key outputs of this work include:
• Inventory on capacity strengths and needs followed by development of a capacity development strategy and monitoring framework
• Eight Consortium Meetings, including capacity development and training sessions as well as practical field visits and knowledge exchanges on local health systems
• Participation in international symposia (Health Systems Global 22014 (in Cape Town) and 2016 (in Vancouver); Community Health Workers Symposium 2017)
• South-South exchanges between REACHOUT staff from different partner country teams on key issues related to the project as well as wider institutional capacity development[18,19]
• 23 peer-reviewed publications (and counting) and several policy briefs and blogs, the majority of which were led by junior researchers
• MSc and PhD student supervision and mentorship
In the course of REACHOUT, there have been several areas that have been contributed to by PhD students as an explicit component of the capacity development strategy:
• Our illumination of the interface role of CTC providers and the impacts of software elements on performance were led by a PhD project (Maryse Kok, Royal Tropical Institute; completed)
• Our work on equity and priority-setting in community health systems, with a focus on the Kenyan context, was conducted as part of a PhD project (Rosalind McCollum, Liverpool School of Tropical Medicine; completed).
• Our gender focus has been strengthened through a PhD project (Rosie Steege, Liverpool School of Tropical Medicine) focusing specifically on gender and recruitment of CTC providers in Mozambique and gender, CTC providers and m-health in Ethiopia (in progress).
• Our work on economic evaluation of quality improvement in community health systems has been led by a PhD student (Meghan Kumar, Liverpool School of Tropical Medicine; in progress).
• Our research on the community engagement in health systems governance has been part of a PhD project (Robinson Karuga, Amsterdam Free University; in progress).
Based on our findings, we recommend that policymakers:
• acknowledge the importance of context and intervention design factors on the performance of CTC providers. How the service is designed has an impact on how effectively, efficiently and equitably it can be delivered. In other words, policy dictates things like the selection and recruitment, training and supervision, responsibilities, remuneration of CTC providers and these ‘hardware’ elements underpin the performance and equity of CTC health programmes. This was identified as an issue in our systematic review and was confirmed by our empirical findings. What arose in addition is that culture, gender and local context affect the success of programmes and there is an important role for contextualization even of inter-country standards and approaches. [1,2]
• recognise the interface role as a central element affecting the performance of CTC providers. This means designing interventions that support CTC providers in linking communities with health systems, praising and recognizing the importance of building trusting relationships in communities and acknowledging how hard it can be to be caught between community and health system priorities in resource limited contexts. Developing tools and skills that take this into account (for example: in problem solving, in supportive approaches to supervision and in community entry) means we are both empowering CTC providers and listening to CTC voices, keeping them central to the debate. The role of CTC providers at the interface of communities and health systems is an opportunity for understanding the strengths and the weaknesses of CTC programmes. Policymakers and programmers and can ensure these voices are heard both in communities and in the halls of the Ministry of Health. This focus on the ‘software’ elements of the CTC provider role is a new addition to the global debate arising out of our inter-country analysis.[1,20–22]
• agree on a definition of quality of healthcare at community level and then set out to assess, measure and improve quality. Without common understandings of quality, we found that CTC providers were not working toward the same things and programmes did not have data to assess success and areas for improvement. The quality of routine data for community health was so poor across all six contexts that it undermined robust strategic planning and decision-making. We found data quality could be improved through simple, affordable local solutions. We also pioneered quality improvement approaches for community health and found that CTC provider performance quality could be improved through training and supporting community health quality improvement teams to own, analyse and use their data in a way that addressed local problems. While all six country teams showed benefits and impacts from quality improvement approaches at community level, the underpinning papers are still in development as this represents the work from the third and final REACHOUT research cycle.[7,22]
• Identify and influence the decision-making and priority setting processes for community health. We found that decision-makers required data on costs, cost effectiveness and affordability and demonstrated that using community health workers can be cost effective for programmes and that the absolute costs of training them in quality improvement were low and very affordable for national programmes. We also found that when resources for health are limited the relative importance of power, the election cycles, governance and devolution increases and that these political factors have disproportionate impacts on the financing and equity of community health programmes. Several REACHOUT countries had elections during the lifetime of the project and we witnessed firsthand the use of CTC providers in political activities at household level. Two REACHOUT countries have a devolved system of health care and others are actively decentralizing health decision-making, so lessons learned on devolution and its impact on equity and governance are likely to be critical as this shift occurs. Proactively addressing the political economy of community health with strategies that focus on the (often distal and less visible) health benefits requires strategic alliances across sectors and time. [16,23]
The REACHOUT consortium has brought together a unique set of partners from African and Asian countries with large-scale CTC programmes. Findings across contexts were remarkably consistent despite wide variations in system structure and typology, implying that our recommendations and learnings are likely to be relevant even beyond these six countries. The findings from our research have been published in high-impact health systems journals and have stimulated the global debate on quality at the community level of health systems and the interface role of CTC providers.
While the REACHOUT consortium was formally brought together by EC financing, the relationships built by individuals and institutions through inter-country analysis mean that the network is going to flourish and grow beyond this funding period. Future collaborations within the network in research, communication, and capacity development are ongoing and in development to strengthen the global evidence base on how best to develop, strengthen and sustain community health systems. Looking forward, we will continue to research whether the positive changes in supervision and quality improvement will sustain and change the health systems permanently for the better.

1 Kok MC, Dieleman M, Taegtmeyer M, et al. Which intervention design factors influence performance of community health workers in low-and middle-income countries? A systematic review. Health Policy Plan 2015;30:1207–27. doi:10.1093/heapol/czu126
2 Kok MC, Kane SS, Tulloch O, et al. How does context influence performance of community health workers in low- and middle-income countries ? Evidence from the literature. Published Online First: 2015. doi:10.1186/s12961-015-0001-3
3 Standing H, Chowdhury AMR. Producing effective knowledge agents in a pluralistic environment: What future for community health workers? Soc Sci Med 2008;66:2096–107. doi:10.1016/J.SOCSCIMED.2008.01.046
4 Mahmud I, Chowdhury S, Siddiqi BA, et al. Exploring the context in which different close-to-community sexual and reproductive health service providers operate in Bangladesh: a qualitative study. Hum Resour Health 2015;13:51. doi:10.1186/s12960-015-0045-z
5 Kok MC, Kea AZ, Datiko DG, et al. A qualitative assessment of health extension workers’ relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance. Hum Resour Health 2015;13. doi:10.1186/s12960-015-0077-4
6 Nasir S, Ahmed R, Kurniasih M, et al. Challenges that Hinders Parturients to Deliver in Health Facilities: A Qualitative Analysis in Two Districts of Indonesia. Makara J Heal Res 2016;20:79–87. doi:10.7454/msk.v20i3.6072
7 McCollum R, Otiso L, Mireku M, et al. Exploring perceptions of community health policy in Kenya and identifying implications for policy change. Health Policy Plan 2016;31:10–20. doi:10.1093/heapol/czv007
8 Otiso L, McCollum R, Mireku M, et al. 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. BMJ Glob Heal 2017;2:e000107. doi:10.1136/bmjgh-2016-000107
9 Kok MC, Namakhoma I, Nyirenda L, et al. Health surveillance assistants as intermediates between the community and health sector in Malawi: exploring how relationships influence performance. BMC Health Serv Res 2016;16:164. doi:10.1186/s12913-016-1402-x
10 Chikaphupha KR, Kok MC, Nyirenda L, et al. Motivation of health surveillance assistants in Malawi: A qualitative study. Malawi Med J 2016;28:37. doi:10.4314/mmj.v28i2.2
11 Give CS, Sidat M, Ormel H, et al. Exploring competing experiences and expectations of the revitalized community health worker programme in Mozambique: an equity analysis. Hum Resour Health 2015;13:54. doi:10.1186/s12960-015-0044-0
12 Ndima SD, Sidat M, Give C, et al. Supervision of community health workers in Mozambique: a qualitative study of factors influencing motivation and programme implementation. Hum Resour Health 2015;13:63. doi:10.1186/s12960-015-0063-x
13 Kok MC, Ormel H, Broerse JEW, et al. Optimising the benefits of community health workers ’ unique position between communities and the health sector : A comparative analysis of factors shaping relationships in four countries. Glob Public Health 2016;0:1–29. doi:10.1080/17441692.2016.1174722
14 Perceived Supervision Scale. accessed 20 Mar 2018.
15 McCollum R, Gomez W, Theobald S, et al. How equitable are community health worker programmes and which programme features influence equity of community health worker services? A systematic review. BMC Public Health 2016;16. doi:10.1186/s12889-016-3043-8
16 Mcpake B, Mcpake B, Edoka I, et al. Cost-effectiveness of community-based practitioner programmes in Ethiopia , Indonesia and Kenya. 2015.
17 Bates I. Designing and measuring the progress and impact of health research capacity strengthening initiatives. BMC Proc 2015;9:S9. doi:10.1186/1753-6561-9-S10-S9
18 REACHOUT partners from Asia, Africa and Europe converge for their annual meeting in Bangladesh - REACHOUT consortium. accessed 27 Mar 2018.
19 Close-to-community providers and community action to address maternal health in Cianjur, Indonesia - REACHOUT consortium. accessed 27 Mar 2018.
20 Kane S, Kok M, Ormel H, et al. Limits and opportunities to community health worker empowerment: A multi-country comparative study. Soc Sci Med 2016;164:27–34. doi:10.1016/J.SOCSCIMED.2016.07.019
21 Theobald S, Hawkins K, Kok M, et al. Close-to-community providers of health care: increasing evidence of how to bridge community and health systems. doi:10.1186/s12960-016-0132-9
22 Kok MC, Broerse JEW, Theobald S, et al. Performance of community health workers : situating their intermediary position within complex adaptive health systems. 2017;:1–7. doi:10.1186/s12960-017-0234-z
23 Vaughan K, Kok MC, Witter S, et al. Costs and cost-effectiveness of community health workers: evidence from a literature review. Hum Resour Health 2015;13:71. doi:10.1186/s12960-015-0070-y
Potential Impact:
Implementation research from REACHOUT across six countries in Africa and Asia has strengthened evidence about the role of close-to-community (CTC) healthcare providers in improving healthcare services for underserved populations in sub-Saharan Africa and Asia.
CTC providers have been framed as a (low-cost) method of overcoming the crisis in human resources for health which many countries are experiencing, particularly in low- and middle-income countries. Because they are located within the communities that they serve it is expected that CTC providers will provide important insights into the social determinants of health. REACHOUT has provided guidance on how the equity, efficiency and effectiveness of CTC health services can be improved to support the push to achieve Universal Health Coverage and the Sustainable Development Goals.
Specifically, the consortium provided insights into:
• the importance of the local and national context and intervention design factors in influencing CTC provider performance
• the importance of the interface role that CTC providers play in linking the communities they come from with the formal health sector. CTC providers are affect by community norms and relationships. For example, the gender norms can impact upon CTC provider performance and well-being, patient access and outcomes. The interface role of CTC providers requires a new approach to health systems analysis that takes the ‘software’ and relational elements of the role into account and redefines the term ‘community health systems’
• new approaches to assessing measuring and improving quality of community health programmes. A local focus on quality and quality improvement can support CTCT providers to achieve their potential and improve the reach and uptake of health services. Simple robust methods that encourage local ownership and new tools that encourage iterative learning can support this process.
• the key factors that influence priority setting and decision-making for community health equity. The role that CTC providers can play in creating more equitable health systems by providing care and referral at the household level to families who may find it difficult to access health services due to geographical location, poverty and other elements of inequality. The financial (and other) costs of delivering CTC programmes where they are most needed and the implications for donor and national budgeting.
The insights outlined above are captured in a range of formal research products, for example systematic reviews, empirical papers from REACHOUT countries, theoretical frameworks, and communication products which were created for stakeholders outside academia, most notably policy/decision makers at sub-national, national and international levels.
REACHOUT took a purposeful approach to communications and research uptake which involved identifying and engaging key stakeholders from the outset and building communities of practice for collaborative working. This was led by the contexts in which we were working at operated at the international, national and sub-national levels and the opportunities that were created and which came into being through outside influences. There was a focus on south-south exchange and learning across contexts.

Dissemination activities
REACHOUT has been actively disseminating results through: publications, policy briefs, in-person events, traditional and social media and word of mouth.
Specifically, we have reported:
Articles published in the popular press: 126
Oral presentation to scientific audiences: 21
Poster presentations at national or international conferences: 32
Organised workshops and conference panels: 51
Videos: 2
Website: 1
Thematically, dissemination activities and immediate impact are captured here.
• The importance of the local and national context and intervention design factors in influencing CTC provider performance
o CTC programme governance and management
Hundreds of CTC providers and their supervisors in the six REACHOUT countries were trained in supportive supervision approaches. This is part of a quality improvement scheme that builds on policy-mandated feedback sessions to improve their structure, regularity and value to quality of care. As a result, it has altered the way that CTC supervision is conducted in Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique. The intervention has led to new referral and tracking systems from informal providers in Bangladesh, improved capacity in health promotion and referral among kaders in Indonesia and influenced the content of supportive supervision curriculum in national training for community health worker supervisors in Malawi, underpinning the new Malawian community health strategy [Government of Malawi National Community Health Strategy 2017-2021]. As a result of the REACHOUT intervention, there is now an expanded national quality improvement agenda in Kenya, with the Kenyan Quality Model for Health extending standards supported by tools and training to the community health level.
Similarly, policymakers in six countries at national and sub-national level have attended a series of workshops, meetings and dissemination events related to REACHOUT and have thereby have gained capacity to understand and utilize health systems research as well as building engagement across levels of the health system to value and support CTC providers, a key component of human resources for health. A total of 11 policymakers from REACHOUT countries completed South-South learning visits during the project, and their blogs are available on the REACHOUT website.
o The effects of gender norms and relations within close-to-community programmes and how these can impact upon worker satisfaction and well-being and patient outcomes and access
The evidence base around gender and community health workers is very under-developed. Although gender was not the primary focus of our work we have been able to make a significant contribution to this area and stimulate policy interest at the international level. We have presented at international events, for example, Theobald presented at a World Health Assembly event on gender, leadership, and health systems in fragile contexts where our insights were shared. She shared the stage with Honourable Minister of Health for Liberia among others [1]. Theobald also chaired a webinar [2] on gender and community health workers which brought together academics from India, DRC, Gaza. This webinar was referenced by the WHO in a background paper, Women’s contribution to sustainable development through work in health: using a gender lens to advance a transformative 2030 agenda, for the High Level Commission on Health Employment and Economic Growth [3]. This research also led to a symposium for international women’s day in 2017 in Nairobi that brought together government, civil society and academic stakeholders to reflect on this topic [4]. More recently Theobald chaired, and Chikaphupha sat on, a panel on gender and community health workers at the Global Forum on Human Resources for Health [5].
• The interface role that CTC providers play in linking the communities they come from with the formal health sector
As part of Health Systems Global, REACHOUT supported the creation of an international Thematic Working Group on community health workers, which is explicitly designed to foster greater attention to CTC providers’ role in health systems development. The group has a global membership of academics, policymakers, and practitioners of community health who use it to share learning across contexts [288 members in a google group and 364 members in a LinkedIn community (as of January 2018)]. It was previously led by three members of REACHOUT staff (Otiso - Kenya, Hawkins and Moody – UK) since its creation in 2014. In 2017, REACHOUT Malawi team member Chikaphupa was elected to be co-chair by the membership, replacing Otiso. The group has brought together international experts to convene meetings, online events, and dialogue. One of its most significant impacts was the special supplement that it organized in Human Resources for Health, which included several REACHOUT-themed papers. The working group is closely linked to the WHO team that is overseeing the creation of the guidelines on Community Health Workers. One of the group’s Steering Committee members, Ms. Polly Walker, provides a bridge between the two initiatives [6].
• New tools that can be used to highlight challenges in close-to-community programming and encourage iterative learning with a range of stakeholders to overcome these.
For example, the Perceived Supervision Score and Motivational Outcomes quantitative questionnaires, piloted and fully field tested. The Perceived Supervision Score is simple, quick to administer, and freely available in ten languages [7]. This tool has the potential to assist practitioners in the management of community health programmes and has already been used in monitoring the impact of the supportive supervision approach in quality improvement cycle 1 of REACHOUT.
• The role that close-to-community providers can play in creating more equitable health systems by providing care and referral at the household level to families who may find it difficult to access health services due to geographical location, poverty and other elements of inequality
CTC providers are thought of as a means of ‘reaching the unreached’ population. Yet without strong referral and supervision linkages between them and the facility-based healthcare services, equity will not be achieved. The focus on improving referral systems in Bangladesh and Mozambique has improved patient tracking and follow up to ensure they reach the care that they need.
• The financial (and other) costs of delivering close-to-community health programmes where they are most needed and the implications for national budgeting
In partnership with colleagues in WHO Geneva, we have spearheaded work on costing and cost-effectiveness related to community health workers. Publications in the WHO Bulletin led to this issue being highlighted in an editorial by staff from the Global Health Workforce Alliance, World Bank, Ministry of Health in Ethiopia, and UNAIDS [8]. This led to the development of a joint brief with WHO’s Global Health Workforce Alliance which explores lays out the strengths and weaknesses of the current evidence in this area. [9]
• Capacity building for health systems researchers
As a result of REACHOUT’s work and capacity development of junior researchers in consortium countries, we have seen several Southern-led peer-reviewed papers published. Further, at the international "Contribution of Community Health Workers (CHWs) toward attainment of the Sustainable Development Goals (SDGs)" conference in Kampala, Uganda in February 2017, REACHOUT was well-represented. Despite only one country PI participating, REACHOUT was strongly represented by junior researchers, presenting 12 posters and oral presentations, a panel discussion, and a keynote address – leading the dissemination of the work [10].

Impact-to-date of REACHOUT activities
REACHOUT’s work has increased the visibility of CTC health workers at several levels (national, regional, and international) in academic and policy circles for public health and health systems. More general areas of impact and opportunities for future impact are captured below.
Impact at country level
Community-, district- and national-level work at all levels of the health systems in six countries has led to improved capacity, policy changes and improved community health service quality and uptake. At national level, REACHOUT has had a beneficial impact on the way that CTC supervision is conducted in Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique.
Some further examples of national impact in the countries in which we worked include:
• We have expanded the national quality and quality improvement agenda in Kenya (KQMH) with standards, tools and training for community health.
• In Sidama Zone, Ethiopia, we have incorporated mHealth into the way that Health Extension Workers provide services to strengthen the likelihood of improved data quality. As a result, we have seen quantitative improvements in attendance at antenatal services in Ethiopia, leading to increased facility delivery and improved maternal health outcomes.
• In Bangladesh, we have led two national NGOs to introduce new referral and patient tracking mechanisms, increasing client tracing and timely service provision, improving linkages of informal CTC providers and their clients to formal healthcare services.
• We have improved the capacity of kaders to offer maternal health promotion advice in our target settings in Indonesia.
• We have shaped the curriculum for the Health Surveillance Assistant supervisory system across the country in Malawi.
Impact at the regional level
We have also had an impact upon academic engagement and policy development within the Africa region. In 2016, our work was cited by the Health Systems and Services Cluster WHO Regional Office for Africa in their report “Implications for large-scale CHW programs in the WHO African Region” [11]. This was to inform the Regional Forum on Strengthening Health Systems for the SDGs and UHC. The costing and financing work also has potential for influence at this level in the future.
Impact at the international level
REACHOUT and the Community Health Worker Thematic Working Group have been able to collectively draw attention to these issues with the team responsible for creating normative guidance on community health workers within WHO, which has led to a formal consultation on a community health worker policy. The first step of this process has been a series of systematic reviews on priority areas, which are currently underway. The process of guideline development is still ongoing; however, when WHO launched their public hearing the call for participation included four references from REACHOUT (out of a total of fourteen) demonstrating how this relatively young research project has impacted upon thinking in the field [12].
REACHOUT co-sponsored the first international symposium on Community Health Workers which took place in Kampala in 2017. We were part of the organising committee, co-authors of the conference statement, and provided several plenary, oral, and poster presentations. There are plans to institutionalise this event so that it occurs every two years in different geographical locations. Many of the issues raised in the conference statement [13] speak directly to REACHOUT findings.

UNICEF also put out a call for a coordination group to manage the research and information agenda associated with the scale up of community health worker programming – with a view to understanding the challenges being faced in a range of contexts and how knowledge about this topic could be better managed. This emerged through the WHO policy development process and the March 2017 USAID meeting on institutionalising community health programmes, attended by Otiso (REACHOUT Kenya PI) as the coordinator of the Kenya country delegation.

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