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Bossert, Thomas

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Bossert, Thomas
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    Performance of volunteer community health workers in implementing home-fortification interventions in Bangladesh: A qualitative investigation
    (Public Library of Science (PLoS), 2020-04-01) Sarma, Haribondhu; Jabeen, Ishrat; Luies, Sharmin Khan; Uddin, Md. Fakhar; Ahmed, Tahmeed; Bossert, Thomas; Banwell, Cathy
    Introduction BRAC, an international development organisation based in Bangladesh, uses female volunteer community health workers called Shasthya Shebika (SS), who receive small incentives to implement its home-fortification interventions at the community level. This paper examines the individual, community and BRAC work environment factors that exert an influence on the performance of SS. Methods This qualitative study was conducted between the period of June 2014 to December 2016 as part of a larger evaluation of BRAC’s home-fortification programme. Data were collected through in-depth interviews, focus group discussions, and key informant interviews and analysed thematically. The participants were SS and their supervisors working for BRAC, caregivers of children aged 6–59 months, husbands of SS, village doctors, and Upazila Health and Family Planning Officers. Results Younger, better educated and more experienced SS with positive self-efficacy were perceived to have performed better than their peers. Social and community factors, such as community recognition of the SS’s services, social and religious norms, family support, and household distance, also affected the performance of the SS. There were several challenges at the programme and organisational level that needed to be addressed, including appropriate recruitment, timely basic training and income-generation guidance for the SS. Conclusion BRAC’s volunteer SS model faces challenges at individual, community, programme and organisational level. Importantly, BRAC’s SS require a living wage to earn essential income for their family. Considering the current socio-cultural and economic context of Bangladesh, BRAC may need to revise the existing volunteer SS model to ensure that SS receive an adequate income so that they can devote themselves to implementing its home-fortification intervention.
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    Attitudes towards primary care career in community health centers among medical students in China
    (BioMed Central, 2016) Zhang, Lingling; Bossert, Thomas; Mahal, Ajay; Hu, Guoqing; Guo, Qing; Liu, Yuanli
    Background: Very few of the primary care doctors currently working in China’s community health centers have a college degree (issued by 5-year medical schools). How to attract college graduates to community services in the future, therefore, has major policy relevance in the government’s ongoing efforts to reform community health care and fill in the long-absent role of general physicians in China. This paper examined medical school students’ attitudes towards working in communities and the factors that may affect their career choices in primary care to inform policy on this subject. Methods: A cross-sectional survey was designed upon the issuance of community health reform policy in 2006 by the Chinese government. The survey was conducted among 2714 medical students from three medical schools in representative regions in China. Binomial and multinomial regression analyses were carried out using a collection of plausible predictors such as place of rearing, income, etc. to assess their willingness to work in communities. Results: Of the 2402 valid responses, besides 5.7 % objection to working in communities, 19.1 % expressed definite willingness. However, the majority (41.5 %) of students only consider community job as a temporary transition, in addition to 33.7 % using it as their backup option. The survey analyses found that medical students who are more likely to be willing to work in communities tend to come from rural backgrounds, have more exposure to community health reform, and possess certain personally held value and fit. Conclusion: To attract more graduates from 5-year medical schools to work in communities, a targeted recruiting approach or admission policy stands a better chance of success. The findings on the influencing factors of medical students’ career choice can help inform policymakers, medical educators, and community health managers to improve the willingness of swing students to enter primary care to strengthen basic health services. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0472-5) contains supplementary material, which is available to authorized users.
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    Harmonization of community health worker programs for HIV: A four-country qualitative study in Southern Africa
    (Public Library of Science, 2017) De Neve, Jan-Walter; Garrison-Desany, Henri; Andrews, Kathryn; Sharara, Nour; Boudreaux, Chantelle; Gill, Roopan; Geldsetzer, Pascal; Vaikath, Maria; Bärnighausen, Till; Bossert, Thomas
    Background: Community health worker (CHW) programs are believed to be poorly coordinated, poorly integrated into national health systems, and lacking long-term support. Duplication of services, fragmentation, and resource limitations may have impeded the potential impact of CHWs for achieving HIV goals. This study assesses mediators of a more harmonized approach to implementing large-scale CHW programs for HIV in the context of complex health systems and multiple donors. Methods and findings We undertook four country case studies in Lesotho, Mozambique, South Africa, and Swaziland between August 2015 and May 2016. We conducted 60 semistructured interviews with donors, government officials, and expert observers involved in CHW programs delivering HIV services. Interviews were triangulated with published literature, country reports, national health plans, and policies. Data were analyzed based on 3 priority areas of harmonization (coordination, integration, and sustainability) and 5 components of a conceptual framework (the health issue, intervention, stakeholders, health system, and context) to assess facilitators and barriers to harmonization of CHW programs. CHWs supporting HIV programs were found to be highly fragmented and poorly integrated into national health systems. Stakeholders generally supported increasing harmonization, although they recognized several challenges and disadvantages to harmonization. Key facilitators to harmonization included (i) a large existing national CHW program and recognition of nongovernmental CHW programs, (ii) use of common incentives and training processes for CHWs, (iii) existence of an organizational structure dedicated to community health initiatives, and (iv) involvement of community leaders in decision-making. Key barriers included a wide range of stakeholders and lack of ownership and accountability of non-governmental CHW programs. Limitations of our study include subjectively selected case studies, our focus on decision-makers, and limited generalizability beyond the countries analyzed. Conclusion: CHW programs for HIV in Southern Africa are fragmented, poorly integrated, and lack long-term support. We provide 5 policy recommendations to harmonize CHW programs in order to strengthen and sustain the role of CHWs in HIV service delivery.
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    Design of an impact evaluation using a mixed methods model – an explanatory assessment of the effects of results-based financing mechanisms on maternal healthcare services in Malawi
    (BioMed Central, 2014) Brenner, Stephan; Muula, Adamson S; Robyn, Paul Jacob; Bärnighausen, Till; Sarker, Malabika; Mathanga, Don P; Bossert, Thomas; De Allegri, Manuela
    Background: In this article we present a study design to evaluate the causal impact of providing supply-side performance-based financing incentives in combination with a demand-side cash transfer component on equitable access to and quality of maternal and neonatal healthcare services. This intervention is introduced to selected emergency obstetric care facilities and catchment area populations in four districts in Malawi. We here describe and discuss our study protocol with regard to the research aims, the local implementation context, and our rationale for selecting a mixed methods explanatory design with a quasi-experimental quantitative component. Design: The quantitative research component consists of a controlled pre- and post-test design with multiple post-test measurements. This allows us to quantitatively measure ‘equitable access to healthcare services’ at the community level and ‘healthcare quality’ at the health facility level. Guided by a theoretical framework of causal relationships, we determined a number of input, process, and output indicators to evaluate both intended and unintended effects of the intervention. Overall causal impact estimates will result from a difference-in-difference analysis comparing selected indicators across intervention and control facilities/catchment populations over time. To further explain heterogeneity of quantitatively observed effects and to understand the experiential dimensions of financial incentives on clients and providers, we designed a qualitative component in line with the overall explanatory mixed methods approach. This component consists of in-depth interviews and focus group discussions with providers, service user, non-users, and policy stakeholders. In this explanatory design comprehensive understanding of expected and unexpected effects of the intervention on both access and quality will emerge through careful triangulation at two levels: across multiple quantitative elements and across quantitative and qualitative elements. Discussion Combining a traditional quasi-experimental controlled pre- and post-test design with an explanatory mixed methods model permits an additional assessment of organizational and behavioral changes affecting complex processes. Through this impact evaluation approach, our design will not only create robust evidence measures for the outcome of interest, but also generate insights on how and why the investigated interventions produce certain intended and unintended effects and allows for a more in-depth evaluation approach.
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    Sustainability of health information systems: a three-country qualitative study in southern Africa
    (BioMed Central, 2017) Moucheraud, Corrina; Schwitters, Amee; Boudreaux, Chantelle; Giles, Denise; Kilmarx, Peter H.; Ntolo, Ntolo; Bangani, Zwashe; St. Louis, Michael E; Bossert, Thomas
    Background: Health information systems are central to strong health systems. They assist with patient and program management, quality improvement, disease surveillance, and strategic use of information. Many donors have worked to improve health information systems, particularly by supporting the introduction of electronic health information systems (EHIS), which are considered more responsive and more efficient than older, paper-based systems. As many donor-driven programs are increasing their focus on country ownership, sustainability of these investments is a key concern. This analysis explores the potential sustainability of EHIS investments in Malawi, Zambia and Zimbabwe, originally supported by the United States President’s Emergency Plan for AIDS Relief (PEPFAR). Methods: Using a framework based on sustainability theories from the health systems literature, this analysis employs a qualitative case study methodology to highlight factors that may increase the likelihood that donor-supported initiatives will continue after the original support is modified or ends. Results: Findings highlight commonalities around possible determinants of sustainability. The study found that there is great optimism about the potential for EHIS, but the perceived risks may result in hesitancy to transition completely and parallel use of paper-based systems. Full stakeholder engagement is likely to be crucial for sustainability, as well as integration with other activities within the health system and those funded by development partners. The literature suggests that a sustainable system has clearly-defined goals around which stakeholders can rally, but this has not been achieved in the systems studied. The study also found that technical resource constraints – affecting system usage, maintenance, upgrades and repairs – may limit EHIS sustainability even if these other pillars were addressed. Conclusions: The sustainability of EHIS faces many challenges, which could be addressed through systems’ technical design, stakeholder coordination, and the building of organizational capacity to maintain and enhance such systems. All of this requires time and attention, but is likely to enhance long-term outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1971-8) contains supplementary material, which is available to authorized users.
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    A qualitative and quantitative performance evaluation of Swaziland’s Rural Health Motivator program
    (F1000 Research, Ltd., 2017) Geldsetzer, Pascal; Vaikath, Maria; de Neve, Jan-Walter; Bärnighausen, Till; Bossert, Thomas
    Background: Community health workers (CHWs) are increasingly used to increase access to primary healthcare, and considered to be a key health worker cadre to achieve the UNAIDS 90-90-90 target. Despite the recent policy interest in effectively designing, implementing, and evaluating new CHW programs, there is limited evidence on how long-standing CHW programs are performing. Using the CHW Performance Logic model as an evaluation framework, this study aims to assess the performance of Swaziland’s long-standing national CHW program, called the rural health motivator (RHM) program. Methods: This study was carried out in the Manzini and Lubombo regions of Swaziland. We conducted a survey of 2,000 households selected through two-stage cluster random sampling and a survey among a stratified simple random sample of 306 RHMs. Additionally, semi-structured qualitative interviews were conducted with 25 RHMs. Results: While RHMs are instructed to visit every household assigned to them at least once a month, only 15.7% (95% CI: 11.4 – 20.4%) of RHMs self-reported to be meeting this target. Less than half (46.3%; 95% CI: 43.4 – 49.6%) of household survey respondents, who reported to have ever been visited by a RHM, rated their overall satisfaction with RHM services as eight or more points on a 10-point scale (ranging from “very dissatisfied” to “very satisfied”). A theme arising from the qualitative interviews was that community members only rarely seek care from RHMs, with care-seeking tending to be constrained to emergency situations. Conclusions: The RHM program does not meet some of its key performance objectives. Two opportunities to improve RHM performance identified by the evaluation were increasing RHM's stipend and improving the supply of equipment and material resources needed by RHMs to carry out their tasks.
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    “Once the delivery is done, they have finished”: a qualitative study of perspectives on postnatal care referrals by traditional birth attendants in Ebonyi state, Nigeria
    (Springer Nature, 2017) Chukwuma, Adanna Deborah Ugochi; Mbachu, Chinyere; Cohen, Jessica; Bossert, Thomas; McConnell, Margaret
    Background While 79% of Nigerian mothers who deliver in facilities receive postnatal care within 48 h of delivery, this is only true for 16% of mothers who deliver outside facilities. Most maternal deaths can be prevented with access to timely and competent health care. Thus, the World Health Organization, International Confederation of Midwives, and International Federation of Gynecology and Obstetrics recommend that unskilled birth attendants be involved in advocacy for skilled care use among mothers. This study explores postnatal care referral behavior by TBAs in Nigeria, including the perceived factors that may deter or promote referrals to skilled health workers. Methods This study collected qualitative data using focus group discussions involving 28 female health workers, TBAs, and TBA delivery clients. The study conceptual framework drew on constructs in Fishbein and Ajzen’s theory of reasoned action onto which we mapped hypothesized determinants of postnatal care referrals described in the empirical literature. We analyzed the transcribed data thematically, and linked themes to the study conceptual framework in the discussion to explain variation in TBA referral behavior across the maternal continuum, from the antenatal to postnatal period. Results Differences in TBA referral before, during, and after delivery appear to reflect the TBAs understanding of the added value of skilled care for the client and the TBA, as well as the TBA’s perception of the implications of referral for her credibility as a maternal care provider among her clients. We also found that there are opportunities to engage TBAs in routine postnatal care referrals to facilities in Nigeria by using incentives and promoting a cordial relationship between TBAs and skilled health workers. Conclusions Thus, despite the potential negative consequences TBAs may face with postnatal care referrals, there are opportunities to promote these referrals using incentives and promoting a cordial relationship between TBAs and skilled health workers. Further research is needed on the interactions between postnatal maternal complications, TBA referral behavior, and maternal perception of TBA competence.
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    Improving the performance of community health workers in Swaziland: findings from a qualitative study
    (Springer Nature, 2017) Geldsetzer, Pascal; de Neve, Jan-Walter; Boudreaux, Chantelle; Bärnighausen, Till; Bossert, Thomas
    Background: The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre. Methods: The CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance. Results: Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: i) increased monetary compensation of CHWs, ii) a more reliable supply of equipment and consumables, iii) additional training, and iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance. Conclusions: While this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.
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    Iran’s Health Reform Plan: Measuring Changes in Equity Indices
    (Tehran University of Medical Sciences, 2018) ASSARI ARANI, Abbas; ATASHBAR, Tohid; ANTOUN, Joseph; Bossert, Thomas
    Background: Two years after the implementation of the Health Sector Evolution Plan (HSEP), this study evaluated the effects of the plan on health equity indices. Methods: The main indices assessed by the study were the Out-of-Pocket (OOP) health expenditures, the Fairness in Financial Contribution (FFC) to the health system index, the index of households’ Catastrophic Health Expenditure (CHE) and the headcount ratio of Impoverishing Health Expenditure (IHE). Results: The per capita share of costs for total health services has been decreased. The lowered costs have been more felt in rural areas, generally due to sharp decrease in inpatient costs. Per capita pay for outpatient services is almost constant or has slightly increased. The reform plan has managed to improve households’ Catastrophic Health Expenditure (CHE) index from an average of 2.9% before the implementation of the plan to 2.3% after the plan. The Fairness in Financial Contribution (FFC) to the health system index has worsened from 0.79 to 0.76, and the headcount ratio of Impoverishing Health Expenditure (IHE) index deteriorated after the implementation of plan from 0.34 to 0.50. Conclusion: Considerable improvement, in decreasing the burden of catastrophic hospital costs in low income strata which is about 26% relative to the time before the implementation of the plan can be regarded as the main achievement of the plan, whereas the worsening in the headcount ratio of IHE and FFC are the equity bottlenecks of the plan.