Abbreviations

ACAPS - Assessment Capacities Project

AIDS - Acquired Immune Deficiency Syndrome

AMW - Auxiliary midwive

ANC - Anti Natal Care

BCC - Behavior Change Communication

BHS - Basic Health Staff

BvA - Budget versus Actual

CBHA - Community Based Health Activities

CBO - Community-Based Organisation

CD - Country Director

CHD - Country Health Director

C-HMIS - Community-based Health Management Information System

CHW - Community Health Worker

CMT - Country Management Team

EMoc - Emergency Obstetric Care

FFF - Family planning, Food supplementation, Female literacy

GIS - Geographic Information System

GOBI - Growth monitoring, Oral rehydration Theraphy, Promotion of Breastfeeding and Immunisations

GPS - Global Positioning Systems

HC - Health Center

HIV - Human Immunodeficiency Virus

IDP - Internally Displaced Person

IEC - Information, Education and Communication

INGO - International Non Government Organisation

JIMNCH - Joint Initiative for Maternal, Newborn and Child Health

KAP - Knowledge, Attitude and Practice

KPC - Knowledge, Practice and Coverage

KPI - Key Performance Indicator

M&E - Monitoring and Evaluation

MMCWA - Myanmar Maternal and Child Welfare Association

MNCH - Maternal, Newborn, and Child Health

MoU - Memorandum of Understanding

MRCS - Myanmar Red Cross Society

NGO - Non Government Organisation

OECD - Organisation for Economic Cooperation and Development

OpsCO - Operations Coordinator

ORS - Oral Rehydration Solution

PC - Project Coordinator

PHC - Primary Health Care

PO - Project Officer (Merlin Staff)

PONREPP - Post-Nargis Recovery and Preparedness Plan

PSI - Population Services International

RHC - Rural Health Center

SEARO - WHO Regional Office for South-East Asia

SFP - Security Focal Point

SMT - Senior Management Team

SPSS - Statistics Package for Social Science

TB - Tuberculosis

TBA - Traditional Birth Attendants

TMO - Township Medical Officer

UN - United Nations

UNICEF - United Nations Children's Fund

USAID - United States Agency for International Development

VHC - Village Health Committee

VHW - Volunteer Health Worker

VTHC - Village Tract Health Committee

WASH - Water, Sanitation and Hygiene Promotion

WHO - World Health Organization

Author contributions:

Author contributions:

Paul Sender is the former Country Director for Merlin in Myanmar 2008-2013 and the inspiration behind this publication. He is currently the Fund Director with the 3MDG Fund in Myanmar

Nicola Watt is a programme manager in the UN and Commonwealth Department at the Department for International Development in the UK. In 2012 Nicola undertook her MSc (Public Health) research in Laputta with Merlin

Fiona Campbell is Head of Health Policy for Merlin in Myanmar

Kelly Macdonald is an independent Public Health Behaviour Change Communication specialist based in Myanmar

Chris Grundy is a Lecturer in Geographical Information Systems at the London School Hygiene and Tropical Medicine

Michael Jordan is the former Operations Manager with Merlin Myanmar 2010 -2013

Emma Child is an independent Monitoring and Evaluation specialist based in Myanmar

Melora Simon is a health management consultant working with a large consultancy agency. In 2009 Melora undertook a pro-bono review for Merlin on the cost-effectiveness of its community based programmes

Introduction Community-Based Health Programming in Myanmar

Paul Sender

Introduction Community-Based Health Programming in Myanmar

Paul Sender The purpose of compiling this publication is not to claim a position which is either authoritative or comprehensive. Rather, Merlin is making the contents available to a wider audience in order to contribute towards overall efforts to ensure that community-based health programmes are better delivered to meet the health needs of their intended beneficiaries. Significant efforts have been made globally in terms of design and consensus building regarding the optimal package of low-cost, high impact interventions for contexts comparable to Myanmar. Furthermore, perhaps, an over-emphasis seems to be placed upon community-case algorithms as the cornerstone of community-based health programming, to the exclusion of other necessary components of programme design and implementation. In order that the reader gain an appreciation of the organic growth of Merlin’s programme in Myanmar, a brief description is included below, which details the changes within the country programme over time Figure 1 Programme implementation timeline

Merlin’s community-based programmes were established in Myanmar in 2004. For a variety of reasons—which have their origin in the particularities of the operating context—up until recently, Merlin’s Community-Based Healthcare Activities (CBHA) have been designed, structured and delivered in isolation from the wider public health system, and especially in isolation from health facilities which physically exist as part of the public health system. Under the country programme design, Merlin’s own staff have been responsible for the training, supply (both of non-pharmaceutical and pharmaceutical items) and supervision of volunteer health workers (VHWs) and village health committee (VHC) members The volunteer health workers comprise both community health workers (CHWs) who deliver promotive, preventative and curative health services, as well as the auxiliary midwives (AMWs) whose focus is upon meeting the antenatal, perinatal and postnatal health needs of mothers as well as their neonate or infant.

Merlin’s programmes area characterised by: 1. Delivery of health care to populations living within very distinct contexts across areas of the

county. These areas include the southern Ayeyarwady Delta, north-western Chin State and Sagaing Region, as well as in northern Shan State in the east of Myanmar. Merlin current programmes are illustrated in Figure 2 below.

Figure 2 Merlin’s current programmes

2. A focus upon attaining service delivery at scale across widespread and remote geographical areas. At the time of writing, Merlin is supporting almost 1400 volunteer health workers working within 1100 villages and providing health care to a coverage population of almost 850,000 persons.

3. Changes over the time period since 2008 in the scale and scope of programming. These changes have mostly arisen in response to either permission to work in new geographical areas, or in response to new funding opportunities. Funding streams to health, whether in the form of national budgetary allocations to the Ministry of Health, or from international aid assistance, have been extremely limited. Both limited funding for Merlin’s programmes, together with constraints in terms of permissions to work across wide areas, have resulted in a bias in choice of areas where and how Merlin can work.

Programmatic focus and programmatic development Alongside the expansion of scale and scope of Merlin’s CBHA programme, it has made efforts, to identify gaps in programme quality. Merlin’s responses to these identified gaps as well as the need to document and define the programme approach have resulted in pieces of work which form the basis for this publication. Figure 3 outlines the themes which have formed the focus for programme development, whilst Figure 4 outlines the process by which this work has been undertaken. This publication does not fully document all work which Merlin has undertaken to strengthen community-based health programme delivery and it is anticipated that future publications will document areas which are not covered here. Figure 3 Themes which have formed the focus for Merlin’s programme development

Figure 4 The process by which Merlin has undertaken its work

Chapter 1 outlines the overall theoretical and practical context in which organisations like Merlin undertake community-based health care programmes, and outlines some of the current thinking and debates related to its provision. This chapter provides an overall history and rationale for these programmes, providing evidence of their effectiveness in the context of countries like Myanmar. Chapter 2 provides an outline of Merlin’s approach to community-based health programming, covering technical aspects of providing these services. This chapter is based on a handbook for Merlin’s staff working at the community level as guidance for their activities. It also details the range of other kinds of guidance which staff will need as they deliver community-based health interventions. The content of the chapter is specific to Merlin’s approach and it defines only one out of many possible approaches. Readers may find this chapter useful when thinking about their own work and organisations. More than any other chapter, the contents of this chapter—in the form of the handbook—are subject to continual revision based upon on-going monitoring and evaluation of Merlin’s programmes.

Chapter 3 covers how Merlin has adapted and adopted its ‘standardised’ approach as outlined in Chapter 2 in different areas and contexts around the country. This chapter considers the complexities and challenges of implementing a ‘standardised’ health intervention over contexts that differ widely in terms of measures of poverty, marginalisation, and drivers of inequity, such as the presence of armed conflict. Given the geographical limitations of where Merlin works, this chapter is not all encompassing of the entire country, but rather highlights important aspects of local adaptation for consideration in programme design whilst also providing an approach to the process of adaptation itself. Chapter 4 details Merlin’s approach to the delivery of the Behaviour Change Communication (BCC) component of its programme. In 2010, Merlin undertook a technical review of its programme and moved away from a previous approach in which volunteer health workers provided a broad range of primary health care interventions. Merlin recognised that behaviour change communications interventions were, in all likelihood, the most challenging to deliver and ensure reach to target populations. This chapter discusses what behaviour change communication is and is not—an important distinction in a context in which it is often confused with general health education, before continuing to describe what Merlin has done to improve its behaviour change communication approach, especially at the level of the individual volunteer health worker. The chapter also considers lessons from other programmes. Chapter 5 on using geographic information systems (GIS) in community-based health programming grew out of a recognition of the complexities of managing programmes at an ever increasing scale. Until 2010, Merlin focussed upon the measure and review of aggregate health data, which does not, however, help it identify variation in outputs among a vast network of field implementers. To correct the potential loss to programme efficiency, Merlin has made efforts to develop a means to present and analyse disaggregated outputs through the use of geographic information systems. This chapter discusses what GIS is; how to set them up in an organisation like Merlin, and most importantly, how to make use of the information and data acquired through the systems to provide feedback and inform programming decisions. Chapter 6 covers the operational approaches that an organisation like Merlin needs in order to manage a large community-based health programming portfolio, focussing on the operational processes, rather than on service delivery aspects of managing and overseeing programmes. It provides, for example, an outline of Merlin’s internal programme cycle management processes. This chapter may be of particular interest to those who are intending to embark upon CBHA interventions. Chapter 7 is based on work Merlin commissioned to review and formalise its monitoring of the Myanmar programme. Monitoring and evaluation is an essential part of any programme as it allows an organisation to ensure the quality of its programming and further develop and refine its work. This chapter highlights the range of monitoring mechanisms that Merlin has put in place across all levels of its programmes, although the monitoring framework described here may not be appropriate for all programmes. Nevertheless, this framework helps an organisation understand what data it needs, why, and to think about how to collect it. Mapping data flows, as done here, from the most basic through to the level of analysis, demonstrates how specific issues can be raised to the attention of the organisation as a whole. Unless decision-making is based upon information which is itself generated from data subject to verification and quality control, then programme efficiency and effectiveness will be severely compromised.

Chapter 8 is the outcome of an outside review of Merlin’s unit-costing of its community-based health programming using an activity-costing approach. The author has analysed the evidence base for an optimal coverage ratio of volunteer health worker to population. Although the organisation was not able to implement the changes in the form that was suggested, nevertheless, the input contributed to Merlin making significant changes in its activity-costing approach. Chapter 9 the final chapter attempts to summarise some of the key messages from the various

contributions and provide a commentary on delivering better community based health programmes to meet the health needs of the population, in the future. The chapter looks at how this learning can feed into discussions and decisions on community based health care within the wider public health system in a changing Myanmar context.

Chapter 1 The Case for Community-Based Healthcare Programmes

Nicola Watt

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Chapter 1 The Case for Community-Based Healthcare Programmes

Nicola Watt Particularly in poor countries, community health worker programmes are not cheap or easy but are nonetheless a good investment, since the alternative in reality is no care for the poor living in geographically peripheral areas (Lehmann and Sanders 20071)

Definitions and Scope This chapter introduces briefly the evidence base underlying community-based health care programmes, and their position within Myanmar, as an introduction to the rest of the chapters. From the outset, it is important to recognise that this area is fraught with difficulties of definition and terminology, not least the widely differing views on what ‘community-based’ might mean. McElroy, for example, ventures a typology with four categories: community as setting, community as target, community as resource and community as agent2. For some commentators, the setting alone is not enough to define a community-based approach, and the involvement of community members in design and implementation is required. This difference, which to some will seem unimportant, has a parallel in the continuing debates about primary health care more generally, and whether it is a ‘level’ (for example, ‘primary care’) or an ‘approach’ (primary health care, or PHC)3. Pragmatically, for the purposes of this chapter, ‘community-based health activities’ apply to all preventive, promotive and curative health activities that take place at the community level and involve community members in their delivery, although not necessarily in their design. In line with the focus within the Asia region, the focus of this chapter will be primarily on the delivery of activities by lay people, commonly referred to as community health workers (CHWs), although a large number of other terms exist4. The Lehmann and Sanders quote above gives the suggestion that a WHO study group gave in 1989, that ‘Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers’.

1U. Lehmann and D. Sanders. 2007. ‘Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers’. Geneva: World Health Organization. 2K.R. McLeroy, B. L. Norton, et al. 2003. ‘Community-based interventions’. American Journal of Public Health, 93, 529-533. 3 For a fairly recent overview, see People’s Health Movement. 2011. ‘Primary health care: a review and critical appraisal of its “revitalisation”’. Global Health Watch 3. Rio de Janeiro. 4SEARO 2008. ‘Revisiting Community-Based Health Workers and Community Health Volunteers’, Report of the Regional Meeting: Chiang Mai, Thailand, 3–5 October 2007. New Delhi: World Health Organization.

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More specifically, the latest Cochrane review uses the definition of ‘any health worker who:

perform functions related to healthcare delivery,

are trained in some way in the context of the intervention, but

have received no formal professional or paraprofessional certificate or tertiary education

degree’5.

This is closer to the definition that WHO has used recently: ‘A health worker who has received training that is outside the nursing and midwifery medical curricula but is, nevertheless, standardized and nationally endorsed. This category can include health workers with a range of different roles and competencies and those that are providing essential services in a health facility, or in the community as part of, or linked to, a health team at a facility’6. Since there are already several comprehensive reviews about community health workers (see ‘Recommended Readings’ at the end of this chapter), this chapter does not set out to review again the evidence for community health workers. Rather, the intention is to set out key points from the historical background and current issues sufficiently, to form a better understanding of their role in the Myanmar context and provide the backdrop for the remainder of the book: community health worker theory and practice as developed and applied by an INGO working in Myanmar.

A Brief History of Community Health Workers Community health workers have been in turn embraced and ignored, or even dismissed, by health literature and policy circles over the many decades of their existence. From their origins, most notably in China’s barefoot doctors, they increasingly enjoyed wide acclaim, with their endorsement in the Alma Ata declaration in 1978 as an important tool in achieving the vision of ‘health for all’. As set out in reviews over the years, a very large number of countries, not by any means limited to developing countries, experimented with some sort of outreach, volunteer or lay health worker programme, particularly in the 1970s and 1980s. However—inevitably—community health workers were found not to be a panacea. The programmes had mixed success for various reasons and the learning from these programmes has become the basis for recent reports setting out recommendations about the implementation of community health worker programmes (see below)7. Their mixed success, however, was not the only reason for the fact that community health worker programmes fell out of favour. As referred to above, there are parallels with debates around other aspects of primary health care. As early as 1980, there were voices that argued that the ‘comprehensive’ primary health care vision was idealistic, and that a more selective approach

5S. A. Lewin, J. Dick et al. 2005. ‘Lay health workers in primary and community health care’. Cochrane Database of Systematic Reviews. 6WHO 2008. ‘Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines’. Geneva. 7For a recent analysis, see A. Liu, S. Sullivan et al. 2011 ‘Community Health Workers in Global Health: Scale and Scalability’. Mount Sinai Journal of Medicine, 78, 419-435. For a reminder that many of the challenges were recognized early on, see G. Walt 1990. Community Health Workers: Just another pair of hands, Milton Keynes, Open University Press.

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was needed, highlighting the challenges of defining primary health care8. UNICEF’s 1982 ‘GOBI’ (growth monitoring, oral rehydration therapy for diarrhoea, promotion of breastfeeding and childhood immunizations) strategy emerged from these ideas9. Birth spacing/family planning (F), food supplementation (F) and the promotion of female literacy (F) were added subsequently (GOBI-FFF)10. As several commentators, including those referred to here and in the recommended readings have noted, there was a discernible shift in global attention to the cost-effectiveness of specific interventions, in line with shifting macroeconomic policy, and away from the goals of being community-led and ‘comprehensive’. Community health workers were arguably one victim of this shift. In the past few years, however, just as there has been a revival of interest in horizontal, ‘health systems strengthening’ approaches, there has been a reawakening of interest in community health workers, including from WHO and a corresponding increase in literature, reports and discussion. This suggests a cyclical trend, with the popularity of primary health care, health system strengthening, and community health worker programmes in approximate counterpoise with that of ‘vertical’ programming. Whatever the reasons, the call to scale up community health worker programmes is loud and clear. The UN Millennium project has called for a ‘massive’ training programme of community-based workers in several areas, including health ‘to overcome the immediate scale-up constraints in human resources’11. WHO includes community health worker-type services in its models for increasing the coverage of a range of health services, notably HIV and maternal and child health. Although the original work of the Commission on Macroeconomics and Health in 2001 did not explicitly refer to community health workers, instead using the more general term ‘outreach’, later papers estimating the costs of scaling up along the same lines did refer to them12. The recent Earth Institute task force report has called for a million community health workers to be trained13. Consistently, reports point to the huge potential for cost effective and ‘quick’ gains, particularly in maternal and child health.

The Role of the Community Health Worker Today The successive shifts of attention in global health discourse have arguably led to a confluence (some might say confusion) of ideas and terminology. The community health worker approach currently championed by WHO and other organisations focuses on the delivery of a tightly circumscribed set of interventions, not dissimilar from the ‘GOBI-FFF’ toolkit, together with antibiotics for community case management, since these are the interventions where there is better agreement about cost effectiveness. For example, the Cochrane review highlighted above, reports ‘promising benefits in promoting immunisation uptake and breastfeeding, improving TB

8 Compare J.A. Walsh &K. S. Warren. 1980. ‘Selective Primary Health-Care - an Interim Strategy for Disease-Control in Developing-Countries’.Social Science & Medicine Part C-Medical Economics, 14, 145-163 and S. B. Rifkin &G. Walt. 1986. ‘Why Health Improves - Defining the Issues Concerning Comprehensive Primary Health-Care and Selective Primary Health-Care’. Social Science & Medicine, 23, 559-566. 9UNICEF 1982. The State of the World’s Children. 1982-83. New York 10M. Claeson & R.J. Waldman. 2000. ‘The evolution of child health programmes in developing countries: from targeting diseases to targeting people’, in Bulletin of the World Health Organization, 78, 1234-1245. 11UN Millennium Project 2005. Investing in Development: A Practical Plan to achieving the Millennium Development Goals. New York: United Nations Development Program. 12L. van Ekdom, K. Stenberg et al. 2011. ‘Global cost of child survival: estimates from country-level validation’, inBulletin World Health Organization, 89, 267-277. 13The Earth Institute 2011. One Million Community Health Workers Technical Task Force Report. New York.

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treatment outcomes, and reducing child morbidity and mortality when compared to usual care’ but that for other maternal and child health interventions the evidence was insufficient. The Earth Institute task force report says, ‘The evidence indicates that a well-implemented community health workforce can improve health-seeking behaviours and provide low-cost interventions for common maternal and child health issues, while enabling improvements in the continuum of care’. This is subtly different from the original vision of community health workers as part of the comprehensive primary health care ‘package’. Organisations implementing community health worker programmes cannot afford to get involved in differences in terminology (not to mention ideology), but it is helpful to bear their existence in mind when considering both the optimal role of the community health worker and how to maximise their effectiveness. Even within a single country, the varied expectations of donors and the wide range of organisations involved in community health is likely to result in a wide range of activities within the broad definitions mentioned above. What is clear from the existing scholarship and the large number of high level policy documents, is that despite significant differences in definition, concept, purpose and activities, community health workers are active and valued in a wide range of settings in many countries around the world, including fragile states. There is substantial momentum behind plans to increase their numbers and there is certainly consensus that the need is critical, both in Sub-Saharan Africa but also in parts of Asia, particularly South East Asia. While health policy trends have come and gone, community health workers have shown themselves to be remarkably durable, and able to adapt with the shifting political and economic landscape. The appeal of community health workers clearly lies in the absence of a large enough health workforce and problems in the functioning of the public health system, factors that have been particularly highlighted with relation to fragile states but which are also true to varying extents of other low-income countries facing challenges of remoteness and rurality14. However, in light of the factors identified as necessary for success, there is a conundrum, which Walt (1990) noted in her analysis: effective volunteer health programmes seem most effective only where there is support from, and integration within, a health system, yet they are needed precisely because of deficiencies in the health system. The challenge, therefore, for INGOs, civil society and the parts of the system (public and private) that are functional is to compensate for that support, without creating parallel systems or undermining development efforts–the necessary balance between short and long-term intervention that has been described elsewhere: ‘Stakeholders should aim not only to save lives and protect health but also to bolster nations’ ability to deliver good-quality services in the long run’15. The grey and peer-reviewed community health worker literature is less clear about the extent to which this can be successful.

The effectiveness of Community Health Workers Given the disappointments of the ‘first wave’ of community health worker programmes, and the continued emphasis on cost-effectiveness, it is unsurprising that much of the recent literature, and the several comprehensive and strategic reviews that exist, focus on questions of impact and

14W. Newbrander, R. Waldman et al. 2011 ‘Rebuilding and strengthening health systems and providing basic health services in fragile states’ inDisasters, 35, 639-660. 15 W. Newbrander et al 2011.

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effectiveness. Several factors were recently identified by the Global Health Workforce Alliance as being essential for the success of community health worker programmes:16

coherent inclusion in the wider health system

community involvement in selection

appropriate training

continual community needs assessment

established referral protocols

effective supervision and monitoring

Other reviews have similarly extracted lessons, identifying similar lists, adding variously community involvement, the importance of incentives and retention structures and the importance of wider national and international political and economic factors. A review looking specifically at how successful national scale-up can be achieved, a challenge already highlighted in the early days of community health worker programming, draws out five principles, which overlap with those above but additionally include the need for a formal plan, the incorporation of innovations and sustainable financing to support17. The Earth Institute report concentrates on five themes, including linkages with primary health care systems as before, and careful design and planning, but also careful costing, and an overview of the current national policy and implementation landscape. There is also relevance to the Global Fund for AIDS, TB and Malaria’s ‘community systems strengthening’ framework, which recognises the essential place for volunteers in delivery and outlines the following themes: enabling environments; community networks; resources and capacity building; community activities; organisational and leadership strengthening; and monitoring and evaluation. USAID’s community health worker ‘functionality matrix’ has twelve areas, including most of these but broken down into more detail: training, supervision, incentives, documentation, and referral. Programmatic and wider contextual elements are not included. The seemingly endless variations may be slightly bewildering, and it is tempting to dwell on subtle differences, for example the changing emphasis placed on the community’s role in selection with the different definitions of community health worker used. However, taken at a higher level, there is something of a consensus in the literature. The placement of a volunteer health worker programme within a strong primary healthcare system comes across particularly strongly, as does the need for proactive management and supervision. Thus the policy direction is that as long as community health workers are concentrating on interventions that are proven to be cost effective, and as long as there is a plan in place and the support factors are lined up, they can be a very strong element in the efforts to meet the Millennial Development Goals even in regions that are currently falling behind.

16See Bhutta et al in the recommended readings

17A. Liu, S. Sullivan et al 2011.

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Community Health Workers in the Context of Myanmar Community Health Workers in South East Asia Community health workers have a long and rich history in South East Asia. A SEARO conference held in Thailand in 2007 reviewed these experiences and resolved to ‘promote, develop and sustain’ community health worker programmes. Examples can be drawn from within the South East Asia region of programmes which have been cited frequently as ‘successful’ and can also be probed to identify the ways in which programmes can go wrong. In the Asian context, programmes that are often highlighted as ‘success’ stories include those from Bangladesh, Pakistan (where the health indicators are not dissimilar from Myanmar) and Thailand. Bangladesh is one of the two countries, the other being Ethiopia, which highlight the central role community health workers had in their progress in a recent book about achieving ‘good health at low cost’18. Interestingly, the case study on Thailand in the same book focuses more on the developments of the mainstream health service. The suggestion of a purposeful shift in Thai policy in this direction had come early in the days of community health worker programmes. Inevitably, programmes that have been analysed and re-analysed to understand their strengths have also been used to highlight difficulties with implementation and scale-up. For example case studies from such successful programmes as Pakistan and Ethiopia are also used in Liu’s review highlighted above to illustrate the pitfalls of community health worker programming. There are particular challenges in transforming successful small-scale programmes into national ones. Community Health Workers in Myanmar Myanmar had adopted a primary health care approach even before the declaration of Alma Ata. Since its inception, a holistic—rather than selective—approach to primary health care has been implemented, meaning the delivery of primary health care and health education focusing on integrated management of maternal and childhood illness, tuberculosis and malaria control, water, sanitation and hygiene promotion. All elements of primary health care are included in the National Health Plan, which sets out community based health care as one of its priorities. The approach is based on the four basic underlying principles of universal access to health care; community involvement and self-reliance; cost-effective interventions and lastly, multi-sectoral actions for health. Community health workers have been trained since the late 70’s with the aim of covering all villages within the country with a volunteer to support health education, assist in sanitation and immunisation activities and coordinate with health facilities for early referral. The auxiliary midwife cadre have been trained since the mid 80’s with the aim of providing antenatal care, safe and clean home delivery for mothers who could not go the health centre and to assist midwives in their maternal and child health activities. The original target was to have an auxiliary midwife for every two villages but this has subsequently been re-set to have an auxiliary midwife in every village. A range of agencies, both UN and NGO have been supporting the health sector in Myanmar over many years. Prior to the lifting of sanctions and restrictions on Myanmar in early 2012, the primary avenue for support to health has been through community based health care programmes. There have been a few exceptions to this, one of which has been the Joint Initiative in Maternal,

18D. Balabanova M. McKee and A. Mills (eds.) ‘Good health at low cost’ 25 years on: what makes a successful health system? London: London School of Hygiene and Tropical Medicine.

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Neonatal and Child Health (JIMNCH, previously ‘PONREPP’) in the Ayeyarwady Delta where donors and the Ministry of Health agreed to support the health system alongside community based health care elements within a co-ordinated township approach. This and other exceptions aside, recognising the limitations of the community based approach to the delivery of health care, particularly when not closely linked to higher levels of the health system, overall the approach has provided a viable option for supporting access to essential health care for a range of UN and non-governmental organisations, including Merlin, over recent years. Merlin have been supporting the health sector in Myanmar since 2004, expanding and responding to both acute and chronic health crises. A significant aspect of Merlin’s work in Myanmar to date has been its Community-Based Health Activities (CBHA) programme, aimed ‘at ensuring marginalised and potentially vulnerable communities are able to access reliable and appropriate health services - specifically children under five years of age and pregnant women’. In 2012, Merlin’s programmes supported community-based health care for over 850,000 people in Myanmar through a network of 1,400 village health workers (community health workers and auxiliary midwives) across more than 1,100 villages. Approaches to community based health programmes, however, differ across agencies working within the country. A recent review of those working in community-based programmes identified at least fifty organisations involved in community-based health activities. The vast majority of these programmes make use of volunteers, although not necessarily “community health workers”: some have a more general development role. Approaches to volunteer selection and training also vary, as does the degree to which workers are linked to or integrated within existing structures. At present it is estimated that only about 10 per cent of the population is covered by community-based health activities outside any government support, and that the variation in approaches to targeting services and distribution of volunteers may limit a comprehensive scale up across the country in the future.

Looking Ahead Despite more than fifty years of policy and practice, there are still many unknowns about community health worker programmes. The many gaps in the research base identified across the reviews referred to here include: the cost-effectiveness of community health worker programmes, including that the

evidence base for cost reduction compared to professional services is currently weak; whether community health worker programmes promote equity and access; the effectiveness of paid workers vs. voluntary workers and of different models of

remuneration, payment or incentivisation; quality and effectiveness of care; and sustainability, including the effectiveness of different

approaches to ensure programme sustainability and the identification of innovative mechanisms of maintaining sustainability.

We could add to this list of unknowns the uncertain outcomes of changes in national, regional and global economic and political conditions. This is particularly pertinent in Myanmar, where transition is underway in areas of governance and the economy, with gains in peace and stability in many areas. The next few years will be critical in the development of the health system and reaching goals such as universal health coverage. Community-based health programmes will have a critical role to play in this. Those involved in implementing community-based health programmes therefore have a responsibility to support the continued improvement in

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programme implementation, to overcome current challenges and ensure on-going lesson learning and research supports effective health policy development. Working together in close coordination, INGOs, local NGOs, donors and the Myanmar government can help make community health worker programmes as effective as possible, thus bringing about better health outcomes for the population within the country.

Recommended Readings Bhutta, Z.A, Z. S. Lassi et al. 2010. ‘Global Experience of Community Health Workers for Delivery

of Health Related Millennium Development Goals: A Systematic Review, Country Case Studies, and Recommendations for Integration into National Health Systems’. Geneva: Global Health Workforce Alliance.

Haines, A. D. Sanders et al. ‘Achieving child survival goals: potential contribution of community health workers’, inLancet, 369, 2121-2131.

Lehmann, U and D. Sanders. 2007. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Geneva: World Health Organization.

Lassi, Z. S., B.A. Haider et al. 2010. ‘Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes’, inCochrane Database of Systematic Reviews.

UNICEF 2004. ‘What works for children in South Asia: Community health workers’ (working paper). Kathmandu.

Chapter 2 Merlin’s Model for Community-Based Health Activities (CBHA)

Chapter 2 Merlin’s Model for Community-Based Health Activities (CBHA)

Introduction Within the framework for community based programming in Myanmar outlined in chapter 1, the following chapter looks at the approach to CBHA adopted by Merlin. The approach has been developed over many years and has been captured in the organisation’s Community Based Health Activities Handbook. This chapter outlines the main components of the approach. More in-depth analysis of some of the specific elements of the approach are found in later chapters. Merlin’s approach to CBHA aims to ensure that marginalised and vulnerable communities are able to access reliable and appropriate health services, close to their homes. The services are targeted at children under five years of age and pregnant women. Merlin’s approach promotes the link between communities and the local public health services through the involvement of Basic Health Staff and Township Health Authorities. The approach relies on the strength of local communities and the volunteers who support the service. Two key cadres of volunteer underpin Merlin’s approach: Community Health Workers (CHWs), who support the diagnosis and treatment of children under five years of age, and Auxiliary Midwives (AMWs) who support pregnant women from the antenatal to postnatal period, including the care of neonates, a critical target group. Forty per cent of all deaths under five years of age occur in the neonatal period. Community participation is also strengthened through the Village Health Committee (VHC), a group of individuals chosen by the community, who work with the volunteers and support health within the villages. Committee members are themselves volunteers who represent the community. Further details on the approach and the technical guidance, documents and the manuals which support the approach, can be found in Merlin’s Community Based Health Activities Handbook. Implementing a CBHA Programme The CBHA programme is implemented at village level within a township. The number of villages per township differs depending on the locality. Villages are selected for support based on a number of criteria. These include: the population of the village and distance to the rural health centre or sub rural health centre; whether the village is “hard to reach”; whether there are vulnerable populations, and the epidemiology of the village. Within each village, Merlin staff work with key CBHA stakeholders to deliver the CBHA activities. These key stakeholders are outlined below. At the heart of any CBHA are the community volunteers.

Community health workers (CHW) Community health workers are crucial to the success of community-based health activities. The community health worker is someone from the village that the community can trust and respect. They must also be able to give time for volunteer work. The Village Health Committee(VHC) is involved in the selection of the community health workers by nominating candidates for the position. Where possible, women are encouraged to take the role. The selection criteria for CHWs are defined by the Department of Health. A potential candidate will be a resident of the village; be between 18 and 50 years of age and in good health; be educated to middle school level and have good communication skills. The candidate should also be able to serve the community for at least 3 years after training and be able to work with Basic health Staff. Selected candidates attend the CHW Basic Training course. This is a month-long course, and is compulsory for all new community health workers. It is conducted at the Township Health Department office. Trainees attend 21 days of classroom work before continuing with a further 7 days of practical training at their respective Rural Health Centres or Sub Centres. The basic training is limited to 30 candidates. Each day of training lasts 6 hours, adding up to a total of 126 hours. The training follows the Department of Health’s Community Health Worker Curriculum, which details time allocations for each subject. Candidates undergo a final examination on the last day of training. After training, all community health workers start work under the direct supervision of their respective Basic Health Staff in the area of the Rural Health Centre for a week. Only after this supervision are community health workers allowed to start work in their village. The basic training is complemented by update trainings. In the past, Merlin conducted three- or five-day community health worker refresher trainings every year. This training is now incorporated into the regular monthly meetings with CHWs. Relevant portions of the two original refresher curricula are used in these meetings. In addition to the basic and update training there are additional trainings on specific topics such as malaria and tuberculosis which are also used in monthly update trainings. Once trained, Merlin staff support community health workers to carry out their community responsibilities as outlined in the relevant MoH guidelines and manuals. This support includes the provision of a standard drug kit, IEC materials, and on-going monitoring and support. The duties of the CHWs include: Giving health education and mobilising the community to promote active

participation Assisting in the Communicable Disease Control Program Undertaking environmental sanitation activities Assisting in treating patients and making referrals Assisting in the Extended Programme of Immunization Participating in family health care programmes Promoting good nutrition practices Gathering basic information about health, births and deaths Submitting reports

In addition Merlin also supports community health workers to undertake some additional activities to enhance their role within the community. These duties include: using specially prepared Information, education and communications (IEC) materials; using algorithms for the

diagnosis and treatment of diseases; undertaking drug management of patients; taking an active part in village heath committees, and participating in other Merlin activities, such as bed net surveys or nutrition screenings. Merlin supports community health workers to attend and participate in regular monthly volunteer health worker meetings or monthly Rural Health Centre meetings conducted with Basic Health Staff (BHS). The choice of training topics at these meetings depends on identified needs, for example, changes in government policy, drug regimes, or seasonal variation. Merlin may provide suggestions to the Basic Health Staff for topics based on their findings during visits to their respective areas. All community health workers within the RHC area are expected to attend the monthly meetings. These meetings are a key part of the routine supervision of the network of volunteer health workers. A CHW attending all monthly meetings, update days, and village health committee quarterly meetings will receive 20 full days of contact with Merlin teams each year. Volunteer health workers who do not attend the monthly meeting are visited in their villages within two weeks. The monthly meetings are important opportunities for Merlin staff to meet volunteers, discuss work, and give the necessary support to the volunteer health workers in their role. These meetings are also important opportunities to promote BHS involvement in the supervision and update training of volunteers, and for the collection of morbidity data and essential activity data, as well as for the delivery of essential medicines.

Auxiliary Midwives (AMW) The Auxiliary Midwife is a critical cadre of volunteer health worker. The AMWs are the frontline maternal health care providers for remote communities and integral to the implementation of the maternal and new-born care component of Merlin’s Maternal and Child Health programme. AMWs are selected from local candidates who are literate, reside in the village, and are likely to remain in the community for some time. They are selected by the village health committee. The majority of AMWs are female but this is not compulsory. Traditional Birth Attendants (TBA) may be selected for training if they show a willingness to learn new techniques and skills.

As with the community health worker training, the auxiliary midwife training also includes basic and refresher training elements. The AMW basic training is 6 months and is compulsory for all new auxiliary midwives. The first three months of training is devoted to theory and training takes place at the township health

department. The second three months of training is practical training based at the respective Rural Health Centre under the supervision of the health assistants and midwives. At the end of the first three months, new auxiliary midwives sit an examination. Training is only complete when the AMW has passed this exam and also received approval from the basic health staff at the end of the auxiliary midwife-in-training practical training. The six months basic training is designed to enable the AMW to deliver basic obstetric care including prenatal, natal, postnatal and newborn care.

AMWs also receive refresher training every year. The refresher training allows the AMWs to go over aspects of their work and original training that they may not have seen within a given year. The Department of Health has created a refresher curriculum which covers three days. This training can be extended to five days to include extra topics such as essential breastfeeding and infant and young child feeding practices, as necessary. Merlin supports the six months basic training and regular refresher trainings for all AMWs. The training is undertaken by staff from the Township Health Department, with Merlin staff playing a supportive role. Following training, Merlin supports the AMWs with a basic kit of drugs and equipment and on-going mentoring and supervision. The auxiliary midwives are encouraged to attend monthly meetings and participate in the update trainings on a regular basis. AMWs have a range of key responsibilities to ensure woman are supported throughout their pregnancy and beyond. These duties include identifying pregnant mothers as early as possible and giving antenatal care within their agreed authority, as well as referring pregnant woman showing danger signs to the hospital. AMWs will also provide health education to pregnant and lactating women to promote healthy eating and prevent locally endemic diseases, and encourage all pregnant women to prepare thoroughly for delivery. In some cases AMWs will conduct home delivery where this is necessary and take care of newborn babies. AMWs will also support infants by providing education on good feeding practices such as exclusive breastfeeding (for six months) and the start of supplementary feeding at the age of six months. AMWs also monitor the growth and nutrition status of infants and pre-school children in the village regularly. As such the AMWs have an important role in supporting the Basic Health Staff in their maternal and reproductive health care activities.

As with the CHWs, Merlin supports the AMWs to undertake a number of duties to complement those assigned to them in the Department of Health guidelines. These include: participating in community activities and activities of the village health committees; conducting behaviour change communication (BCC) and health education sessions; distributing clean delivery kits to pregnant mothers; conducting family planning; drug prescription and treatment and management. AMWs are also requested to support proper record-keeping and reporting; to attend trainings and regular monthly update meetings and to support other Merlin activities. Monitoring and assessing the auxiliary midwives takes place on a quarterly basis.

VHWs with dual responsibilities According to Ministry of Health policy, and thus Merlin’s guidelines, all villages except those with a Rural Health Centre or Sub-Rural Health Centre aim to have one community health worker and one auxiliary midwife. However, due to a variety of factors, there are some villages where this is not possible. In these areas some volunteer health workers have taken on dual roles and responsibilities covering both the CHW and AMW positions. Reporting of duties: Both community health workers and auxiliary midwives record their activities in daily registers. These form the basis of the monthly reports that are submitted to Merlin. Auxiliary midwives also keep records in the ‘Maternal and Child Health Register which is part of the MoH’s data collection at township level health. Merlin reviews the ‘Daily Register’ and ‘Monthly Reports’ as well as the ‘Maternal and Child Health Register’ to check on AMW activities. Village Health Committees (VHC) The Village Health Committee is part of National Health Policy guidelines. These committees are headed by the Chairman or responsible person and include heads of related government departments and representatives from the social organizations as members. Heads of the health departments are designated as secretaries of the committees at the respective level. Merlin supports the formation of new village health committees where they are absent, or helps revitalize them in areas where they are currently non-functioning. The Village Health Committee is a management committee. Training is provided on general management as well as health issues. Currently there is no general management training for VHCs from the government. Merlin has therefore prepared a simple training outline for the VHCs. In addition, Village Health committee trainings in health related areas include: primary health care, malaria and tuberculosis based on MoH documents. Merlin implements all primary health care based activities in partnership with the community. Merlin’s vision is that the Village Health Committee leads and represents the village in all health and water and sanitation (WASH) activities. One of the most important responsibilities of the committee is to coordinate all the activities of stakeholders, such as villagers, volunteer health workers, basic health staff, local authorities, and other organisations. Merlin staff encourage and facilitate the village health committee in the development of an action plan, which forms part of basic village health committee training. Committee members disseminate the information from the trainings to community members. Village health committees hold at least one or two meetings every month and keep records of meetings in the form of minutes. At the end of every quarter, there is a quarterly meeting at which one representative from each committee (together with their respective volunteer health worker) attends. In this quarterly meeting, each committee presents their activities, and discusses problems on health or WASH issues with members from other committees. Merlin provides some incentives to the village health committees based on performance. Merlin staff visit village health committees whenever they are in the village to monitor the volunteer health workers. Staff contact the village health committee in advance to ensure that

they are available and have time to meet and discuss issues. During the visits Merlin staff discuss the health and WASH activities of the Village Health Committee with its members; look at their meeting records and check the frequency of the meetings. Merlin staff also check that the committee has developed an action plan and are taking forward their objectives according to the plan. Community The success of the primary health care approach depends on the active participation of the community. Merlin staff discuss community-based programmes with key members of the village including Village Health Committee members and with village authorities and elders. Merlin staff spend time within the villages to gain an understanding of the culture, norms, and barriers to healthy behaviour. This information helps guide the targeting of messages to the Volunteer Health Workers and the Village Health Committee members. Information from the village is collated and added to the monthly reports from Merlin staff. This informal information gathering is very useful for guiding future programming. Other Important Stakeholders A number of other important stakeholders are found at village level. Merlin works with a number of these individuals and groups to support the wider programme. These include: Traditional Birth Attendants: There is currently no national policy on traditional birth attendants. However, this group remain key actors in the area of maternal and child health at village level. They are often used by women in the community. Merlin does not train traditional birth attendants but supports them to improve their practice. The Township Health Department provides a booklet, ‘A Discussion of the Do’s and Don’ts of a Traditional Birth Attendant’, which is used in Merlin’s programmes. School teachers: School teachers have an important role to play in child health. Merlin provides training to teachers on child health topics in conjunction with the Township Health Department. Merlin also engages with other stakeholders such as private general practitioners; the Myanmar Maternal and Child Welfare Association (MMCWA); the Myanmar Red Cross Society (MRCS) and other NGOs, local and international, where appropriate to programme areas. Support to referral An essential component of all Merlin’s community-based health programmes is support to the referral mechanism from the village to the township hospital and other facilities for severe, life-threatening health issues, especially emergency obstetrics care (EmOC). Merlin staff work with the Volunteer Health Workers and the Village Health Committees to advocate for the referral service and ensure that it is well advertised within the community in every village. Merlin supports the initial establishment of the referral system in the village and also encourages villagers to collect and manage the emergency funds necessary for the system to operate. Merlin staff provide guidance to the Volunteer Health Workers on selection criteria, dangers signs, and emergency referral, and guidance to the Village Health Committee on emergency referral funds. Staff also help mobilize the community to ensure that the emergency referral mechanism works effectively. Merlin provides financial support to patients requiring emergency referral. Payments cover the costs of transport to and from the facility, meal costs for the patient, and hospital treatment

costs (to an agreed limit). Further information on Merlin’s support to emergency referrals is available in Merlin’s publication “Addressing maternal and child health morbidity and mortality – supporting emergency referrals – evidence from Merlin’s programme in Laputta, April 2012” The emergency referral system is also an important aspect of Merlin’s wider support to referral including for malaria and TB. Merlin staff supervise the volunteer health workers to ensure they provide correct malaria treatment and make emergency referrals where necessary. Correct referral of tuberculosis suspects is also vital. Merlin staff ensure that volunteer health workers and all villagers understand the tuberculosis referral policy and procedures. Conclusion Merlin’s ‘model’ of community based health care is closely aligned to Ministry of Health policy and processes and provides an approach to extend access to essential health services at the community level. The goal is to further link the current processes to the wider health care system and with Basic Health Staff to ensure the sustainability of the approach in the longer term.

Chapter 3 Implementing a Standardised Model of Community-Based

Health Care in Myanmar: Lessons for Health Policy Fiona Campbell

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Chapter 3 Implementing a Standardised Model of Community-Based

Health Care in Myanmar: Lessons for Health Policy Fiona Campbell

Introduction As mentioned in the previous chapters, the aim of Merlin’s programme in Myanmar is to support improved health through increasing access to essential health services, particularly in poor and marginalised populations. Merlin has operationalised this aim through the development of a standardised approach to community-based health care as outlined in chapter 2. The model is designed to be implemented effectively by Merlin, and by others, with the potential to scale up across the country. The context in Myanmar is diverse, with both complex geographical and political challenges. The diversity includes remote mountainous areas with limited communications and areas prone to natural disasters; throughout the country there are areas of on-going conflict. In addition, the overall health system is weak, particularly in more remote parts of the country. Donor agencies may also place a priority on certain diseases, which while critical, may limit the availability of wider services in some parts. These contextual factors present challenges for a standardised approach. Experience to date within Merlin has shown that, even when working within a standardised approach, there is no ‘one-size fits all’ to community-based health programmes. The lessons that Merlin has learned in adapting and modifying its approach provide valuable insights into how and why it is necessary to tailor the programming to particular contexts. This learning has the potential to inform policy and decision-making beyond the organisation and may provide important lessons for the Ministry of Health and others who wish to expand community-based services in Myanmar. This chapter looks at the factors shaping the development of Merlin’s model to date; the lessons that have been learned from the adaptations to the standard approach; why they have been needed, and how this can help inform wider policy discussions.

Factors shaping the development of Merlin’s current model A range of factors have helped shape Merlin’s current model of community-based health programming. International, national and organisational policies, as well as other contextual factors have all contributed to defining the current approach. These policies and factors are both within and beyond the health system. The rationale for Merlin to work at community level to date has been influenced by the policies of international donors and the Ministry of Health. In the Myanmar context until recently, community-based health programmes have been a principal means by which donors have funded health services. This situation reflected the restrictions on donors to engage directly with the Myanmar government, of which the Ministry of Health and the health system is part. The Ministry of Health, in turn, had also been reluctant to allow international organisations any significant access to the system. As of 2012, this situation has changed and it is expected that there will be a

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continuing greater emphasis on support to the government system in the future. However the legacy has shaped the emphasis placed at the community level by Merlin and other agencies, and shaped the approach adopted. This has been largely outside the wider health system with a few notable exceptions. Merlin and some other agencies have used Ministry of Health policies and guidelines to underpin their programmes, and this has influenced the nature of the selection, training and placement of community volunteers (CHWs and AMWs) as well as the support provided to them. Details of Merlin’s standardised programme design have been provided in Chapter 2 and are further taken up in chapter 8, which discusses Merlin’s efforts to standardise the model to ensure that it is cost-effective and provides a quality service. This chapter looks at some of the challenges to standardisation of the approach in the Myanmar context.

Challenges to a standardised approach A number of contextual factors impact on the feasibility of implementing a ‘standard’ approach in the country. These factors include:

Population distribution Geographical landscape Health system challenges Insecurity Donor priorities

Each of these factors has had an impact on Merlin’s community-based health programming and is discussed below: Population distributions and density The distribution of the population within Myanmar is uneven. Differences between states and regions provide an illustration of the overall picture. For example Kayah State has a population of 344,000, while Mandalay Region has 8,216,000. Variation in population density is also important. In 2010, the population was as low as 15 and 17 persons per square kilometre in Chin and Kachin States respectively, but over 200 in Mandalay Region, Ayeyarwady Region, and Mon State. A comparison of Merlin’s programmes in Laputta Township, Chin State, and Sagaing Region illustrates how this variation translates at the village level. All three programme areas exhibit large variations in village size within their respective areas. In Laputta Township, village size ranges from less than 75 to above 3000 people; in Chin State the variation is between 60 and 1600; while in Sagaing Region the variation ranges from less than 60 to over 9000 people. These population densities and distributions have obvious implications for the numbers and distribution of volunteer health workers, as discussed in the next section. Geographical context Myanmar exhibits a huge diversity in geographical and topographical make-up. Merlin is currently working in areas which differ markedly in terms of topography. For example, Merlin’s programmes in Chin State and Sagaing Region are in remote, hilly areas, which contrast starkly with the Ayeyarwady Delta with a network of rivers and creeks. These differences have implications for communications within communities, access to services and thus the approach needed to the design of community based programmes.

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Health system challenges Overall, the health system in Myanmar is vastly under-funded and understaffed. In addition to the overall lack of resources, there is wide variation in the distribution of the resources that are available. Health staff tend to be concentrated in urban areas; remote and rural populations are particularly poorly served by the government system. Gaps in the provision of key basic health staff, such as midwives, are evident in many townships. These gaps are illustrated in the variation in key health staff across different Merlin programme areas. For example, in Laputta Township, the numbers of midwives in post are relatively high with only four vacancies across the township in June 2012. This is in contrast to Kutkai Township in northern Shan State, where only 11 per cent of the health facilities in the rural areas of the township are staffed. Out of a target of forty-seven midwives for the township, only fifteen were available in 2012. These variations have an impact on the potential to link with the wider health system and to support a continuum of care from community level through to higher levels of service. Insecurity Many parts of Myanmar experience ongoing conflict. Conflict has an impact on the availability of, and access to, health services. Health staff may be unable to reach their designated facilities and populations may be unable to access services safely. In addition, supplies of drugs and equipment may be disrupted and lacking. Internal displacement impacts on access to health care as well as the ability of the system to cater for the increased needs of the people. Conflict may also generate additional health needs. Some diseases may be exacerbated through disruption to routine health services, such as immunisation and certain chronic diseases can worsen in emergency situations. Conflict and insecurity therefore have significant implications for need as well as access to health care, and the potential role and delivery of community-based programmes. Donor priorities Donor priorities have also influenced the nature of the services that organisations such as Merlin provide in villages. The Three Diseases Fund and Global Fund have been major donors to community based-programmes for malaria, tuberculosis, and HIV in the country over recent years. The disease specific focus has influenced and dominated the nature of community-based programmes in some areas, with implications for access to a more comprehensive primary health care service at community level.

The impact of the contextual factors on Merlin’s standardised approach These and other factors have influenced the “standardised” approach to community based programming adopted by Merlin in project areas. The following section looks at how the approach has been adapted in different programmes to date to take account of these factors and ensure that it is most relevant. Working within the wider government health system – the Laputta experience As discussed in chapter 2, in the majority of cases Merlin’s community-based health programming model has developed as an effective and efficient means of delivering a package of essential

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health maternal and child health services at the community level, largely outside the wider public health system. One exception to this has been Merlin’s programme in the Delta region. Since Cyclone Nargis in May 2008, the opportunities for external actors, including NGOs, to engage with the national health system in the Ayeyarwaddy Delta region have expanded dramatically, well beyond the opportunities in other parts of the country. Donors have widened the range of interventions that they will support and the Ministry of Health has allowed an increased involvement for external actors in the health system. These favourable circumstances have influenced Merlin’s approach in Laputta Township, where Merlin has been implementing a ‘coordinated township approach’ to health service delivery. The approach in Laputta combines support to basic health staff and township authorities with that to community based health activities. This wider support includes training basic health service staff, the provision of drugs and equipment at facilities, such as rural and sub-rural health-care centres, and transport funds for midwives to allow them to travel to villages and undertake their outreach activities. Access to health services at the community level are more closely linked with access to services by trained health staff and facilities resulting in a strengthened “continuum of care”.1 This approach has implications for an organisational ‘standard’ model. The experience in Laputta has highlighted the role of the Ministry of Health in supporting community-based programmes within a wider government health system, in particular, the critical role of the midwife in linking communities to facility-level care. Within current Ministry of Health policy, the midwives (and other BHS) are responsible for the supervision of community health workers and auxiliary midwives, and for promoting health education and other activities in the villages. Currently, Merlin’s organisational ‘standard’ model charges project staff with this responsibility. In Laputta, Merlin is working to promote joint supervision visits with the township health staff, which will go some way to strengthening their role in oversight of community level interventions in the future and thus promoting their longer term sustainability. The Laputta experience demonstrates the opportunities within the changing context in Myanmar and the potential to link with the government health system. In the future, as it becomes increasingly possible for international agencies to support the health system at facility level and above, it is likely that the role of ‘stand-alone’ community-based health programmes will become increasingly less relevant. Working in different geographical contexts and varying population densities The geographical and population diversity within Myanmar has implications for a model based on any standard population distribution. Ministry of Health policy aims for one community health worker and one auxiliary midwife per village. To date, Merlin has generally tried to follow this policy and posted one community health worker per village and one auxiliary midwife for every two to three villages. The result of Merlin’s current distribution is varying ratios of health workers to population across different Merlin programme areas. A distribution pattern based on villages takes no account of the size of the villages or the case load of individual community workers. 1 A ‘continuum of care’ means that the population will be able to access at the level closest to them, for example the community, and then be referred up through the system to more experienced staff and support if needed. It also refers to a ‘continuum of care’ from birth through infancy, childhood, and beyond.

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The figures of population coverage by village health worker have been translated into ratios of volunteer health worker per 1000 population for comparison in table 1. Almost twice the number of community health workers per population are available in the Chin and Shan State programmes to those in Sagaing and Ayeyarwady Regions. For auxiliary midwives, the difference in ratios is even more obvious. Table 1: CHW and AMW distribution in programme areas

Programme area CHW/1000 population AMW/1000 population Chin State

2.25 1.2

Sagaing Region

1 0.29

Ayeyarwady Region

1 0.5

Shan State

2.5 1.25

Merlin’s experience of working across very different contexts in Myanmar thus demonstrates the challenge of working within a standardised approach to distribute community workers and the need to determine distribution in relation to contextual factors. Merlin is currently assessing ways to determine a rational distribution of community workers. Factors such as population size, distance of villages from health facilities, distances of villages from one another, and their make-up in terms of population as well as burden of disease are all likely to be important as factors influencing how people access village health workers, and therefore how programmes are designed. Working in conflict-affected areas: Merlin’s experience in Shan State The presence of conflict has major implications for the population’s access to health services, both on the supply and the demand side. In northern Shan State, Merlin is implementing a community-based programme in Kutkai Township. The township is directly affected by conflict2. Findings from Merlin’s assessment prior to the start of the programme revealed the impact of the conflict on the potential accessibility of different areas, as illustrated in Figure 1. In such a setting, the role of community health workers becomes critical in promoting access to essential health services. However the context has required some additional considerations in terms of the approach adopted. In Kutkai Township, Merlin used a conflict-sensitive approach to implementation, that is, the agency aimed to be aware of the potential for any engagement to exacerbate underlying tensions within communities, for example if there is a perception that Merlin is favouring one party over another. Merlin therefore designed the approach to safeguard the organisation as well as the communities as far as possible in this respect.

2 The conflict in Kutkai is directly related to the on-going conflict in Kachin state between KIA and Myanmar Government. An resolution or worsening of the situation in Kachin State will likely impact positively or negatively respectively on the situation in Kutkai township

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Figure 1: Potentially accessible and inaccessible areas in Kutkai Township, December 2011 In choosing areas in which to engage, Merlin looked at the needs of communities, but also at which communities were included in the programme. In addition, the choice of community health workers and auxiliary midwives were based on ensuring representation from different groups, also critical for communication across the township. Merlin also adopted an approach that allowed for the targeting of villages based on a number of criteria including: the presence of internally-displaced persons (IDPs), geographical distance from a functioning health facility, high levels of malnutrition, and conflict or insecurity. The Shan programme has demonstrated that the approach can be adapted to conflict affected contexts. The project is currently completing its first year of implementation and .the project villages are within the more accessible parts of the township. Learning lessons from the initial start-up of the programme will be a critical for Merlin to understand how best to extend the model across the township as well as apply it in other conflict-affected settings. Working with different priority health issues: the Chin State and Sagaing Region experience Merlin’s programmes in Chin State and Sagaing Region have been partly funded under the Global Fund, which provides resources to support activities related to tuberculosis and malaria. Community health workers are trained to provide a set of interventions related to the control of these priority diseases. Under these grants they are not trained to deal with other health problems. The drugs and equipment provided to them are also limited to the target diseases. In an attempt to ensure access of villagers to wider essential health services, Merlin has dove-tailed funding from other sources to provide maternal, new-born, and child (MNCH) services in some villages. Community health workers are trained to deal with the ‘standard’ set of maternal and child health issues. The programmes in Chin State and Sagaing Region have shown that it is possible to use funding from a variety of sources to ensure that populations therefore have access to a more comprehensive package of essential services beyond specific targeted diseases.

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Figure 2: Support for TB, Malaria, and Primary Health Care in Chin State and Sagaing Region

Focussing on Outcomes Another way to look at the need for adaptation of a ‘standard’ approach is to focus on the outcomes sought. The aim of Merlin’s community-based health programme is to improve health by increasing the access of community members to essential MNCH services. Adopting a standardised approach has ensured consistency and quality of programme inputs. Basing the approach on Ministry of Health policy guidelines has promoted the long-term institutionalisation of the programme. Focussing on the outcomes sought can help in making decisions on the optimal approach in a given context. The key outcomes that Merlin has sought include:

1. Ensuring a comprehensive package of services Ensuring that populations have access to a comprehensive package of services which addresses the major burden of disease is critical for tackling the major causes of morbidity and mortality and thus meeting targets such as the Millennium Development Goals 4,5 and 6. The experience of Chin and Sagaing programmes has shown that ensuring that populations have access to maternal and child health services in addition to tuberculosis and malaria is an important aspect of addressing communities’ needs as well as delivering a comprehensive approach.

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2. Ensuring a continuum of care A community-based approach is limited, by the ability and authority of community workers to diagnose and treat conditions, and by the lack of access to more sophisticated equipment and skills. This limited set of services will always result in a limited impact on health. Ensuring a continuum of care across different age groups and across different levels of the health-care system is a critical aspect to providing essential health services. Ensuring a link between the community and the appropriate higher level of service is a vital aspect of the continuum of care. As the Laputta Township programme has shown, working in collaboration with the township authorities and the basic health staff allows direct support to the health system and strengthens this link. While this particular approach is not yet applicable in other programme areas, Merlin has adopted strategies to support referrals to facility level and thus a continuum of care, as far as possible in all programmes.

3. Ensuring equity The role of community-based health care in ensuring access to essential services is critical. In contexts where the health system is weakest or the working environment most difficult, it is an approach which is often vital for ensuring access to health interventions. As all programmes have shown, parts of townships may be more inaccessible than others but the use of community health workers in these hard-to-reach areas can be an effective means of promoting better access and thus equity. Adapting approaches to these particular contexts may be critical, whether this is to be sensitive to conflict or to address challenges in villages visited less frequently by midwives by extending the roles and responsibilities of community volunteers.

4. Ensuring sustainability of services As the Laputta Township example illustrates, the long-term sustainability of community-based health programming requires institutionalisation of the programme within the Ministry of Health and other government structures. Adopting approaches that promote this institutionalisation, for example by using Ministry of Health policy and guidelines, and improving the links between community-based health care and the wider health system, are critical aspects of ensuring this outcome for Merlin’s programmes. In addition, sustainability of on-going programmes relies on the availability and commitment of community health workers. Community health workers are volunteers recruited from their communities. As a recent review of support to community based health workers across a range of agencies found, all agencies report problems with retention of community workers. Factors behind the attrition need further investigation, but a standardised model for recruitment and support of volunteers across the country may not be helpful. Rather, tailoring the approaches to best accommodate different local and context specific needs, may be most effective.

What do Merlin’s efforts mean for organisational and wider policy development? Merlin’s efforts to standardise the current ‘model’ have been critical in promoting an efficient and effective approach to community-based health programming. Creating a strong model for a programme, based on national policy has provided a framework which can be adapted to meet the needs in specific situations. Merlin has adapted its model to ensure that it remains effective and relevant in different contexts. Experience from Merlin’s programmes has shown that

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adaptation can ensure that a community-based programme takes account of the prevailing health system, in terms of access to facilities and trained health staff; takes account of donor priorities, while also providing a comprehensive service, and also takes note of specific geographical and political issues. The model, adapted as needed, ensures that there is a degree of consistency and standards and that an effective and quality health service is delivered whatever the environment.

Chapter 4 The Role of Behaviour Change in Preventing Ill-Health in

Community-Based Health Care Programmes Kelly Macdonald

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Chapter 4 The Role of Behaviour Change in Preventing Ill-Health in

Community-Based Health Care Programmes Kelly Macdonald

The previous chapters have outlined a model of, and challenges to, providing community-based health care in Myanmar. In many of the programmes in the country, and previously with Merlin, the focus has been on providing curative health services to individuals in the community and the roles and responsibilities of the people providing these services. This chapter moves into the preventive aspects of community-based health care that works at the level of the population, rather than the individual. In 2010, Merlin reviewed its programme to ensure that the approach was addressing the demand side elements of its health programme. This chapter discusses some of the experiences that Merlin has had, and learned from, in making the programme more effective in terms of addressing attitudinal or cultural barriers to healthy behaviours. The first part of the chapter discusses what measures must be incorporated into community-based health care for people to prevent ill health; challenges to do so, and roles and responsibilities in preventive health. The second part of the chapter describes how Merlin has strengthened its preventive health approach by using appropriate behaviour change communication (BCC) strategies to deal with realities in communities. Reducing the disease burden in rural Myanmar communities requires linking curing illness and treating symptoms with stopping easily preventable illnesses from occurring in the first place.

Community-based preventive healthcare In community-based healthcare, preventive health requires that, when possible, people take an active role in averting ill health for themselves and their families. Rather than merely seeking services when ill, people must take thoughtful actions to avoid poor health outcomes. People have to change attitudes, beliefs, or actions that keep themselves or others to do so. Preventive community-based health therefore targets entire communities. In this way, it is not only the individual that must change their actions, but often the entire community or population. For example, a mother may have heard about the benefits of children sleeping under a mosquito net, but if the rest of the community does not embrace this practice, it will be difficult to change the behaviour of the individual. Preventive health strategies that affect an individual’s health outcomes are targeted to the entire community, as the gains are population-wide.

Behaviour change communication A preventive health approach in a community-based health care programme relies on communication strategies to change a specific group’s behaviour for a desired outcome. This is termed ‘behaviour change communication (BCC)’. To change behaviour, people must know and believe in the correct facts about a particular health outcome and have sufficient motivation and ability to make these changes. Knowing the facts is not enough for all people to change their behaviours. Behaviour change strategies must understand and address underlying reasons and motivations as to why people do or do not practice a specific behaviour to prevent ill health.

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The role of behaviour change communication in preventive health programming is chiefly threefold:

increasing people’s knowledge and awareness of the

benefits of making a change in their behaviour; encouraging people to talk about why they do or do

not practice a particular behaviour; and delivering meaningful messages that will help people

make a change or sustain a new behaviour.

Increasing awareness and knowledge The first part of changing behaviour is to provide basic information about why people should stop a specific behaviour, or why they should adopt an alternative behaviour. What will the resulting health benefits be? For example, Merlin and other organisations in Myanmar provide information about the benefits of exclusive breast-feeding for the first six months of an infant’s life. This information, provided continuously, tells people of good health outcomes, encourages them to reflect on their own and others’ behaviour, decide if they believe the information or not, and ultimately decide whether or not to adopt the practice of exclusive breast feeding. ‘Health education’ is the most common activity conducted in behaviour change communication. Educating people about aspects of their health is one of the easiest aspects of behaviour change communication, as it relies on workers or volunteers to spread the information. However, information alone does not always change behaviour. Health education is the first part of behaviour change and, more often than not, is the stage in a behaviour change approach at which organisations in Myanmar have remained. Staff in Merlin Myanmar unknowingly revealed that this is where their understanding of fostering behaviour change had remained: After conducting numerous health education sessions, some Merlin project staff members and community health workers became frustrated and resigned to the fact that the majority of people would not change, no matter how many times they were given information that could help them avoid ill-health. At the end of one of the health education sessions, on maternal and child health and the danger signs in pregnancy, a project staff member commented, ‘We give them the information and they understand, but nothing changes. A lot of the women don’t act on our messages – they don’t do what we tell them’. Merlin was aware of this dilemma from the results of its knowledge, attitude and practice surveys. Data showed that community members could provide the correct responses, as they had the knowledge, but survey and clinical results showed that there was little difference in their practice – they knew, but did not act on their knowledge.

Understanding barriers to change The point where health education is not having the desired effect is where targeted behaviour change starts. Merlin has come to understand that behaviour change strategies must be aimed clearly at the group or groups of people who are not acting upon health education messages. The key to behaviour change is to find out why people do not change their behaviours or maintain certain beliefs that result in ill health. Finding those reasons, however, is not straightforward or easy—various techniques must be used to really understand the reasons. People make and act on decisions for a variety of reasons, which only they can know. Changing behaviour is a lengthy and irregular progression filled with stops, starts and restarts. For this reason, incorporating

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behaviour change approaches into a health programme can be a long process, requiring inputs other than mere health information, and can fall outside the normal length of the project cycle. For example, in Merlin, the programme had not set out to explore formally the reasons why some women seek ante-natal care or use trained birth attendants, and why other women do not. Such a formal exploration was not part of Merlin’s understanding of behaviour change at the time. Merlin, like other organisations, only provided women with basic health information on the benefits of seeking ante-natal care, using trained birth attendants and on ways to avoid harmful traditional practices. Informally, however, some of the community health workers and project staff members were gleaning bits of information crucial to understanding underlying reasons or barriers to these women taking action, but these were never incorporated into the project. Most likely this was because nobody understood the importance of this seemingly ‘meaningless’ information, in the sense that it could not be fitted within the pre-existing framework. For example, in informal discussions with women, bits of information related to the choices women do or do not make started to come out: ‘Men are the decision makers in the family and have control over our finances’, or, ‘my mother and aunts say they had lots of children and they never had any health problems’. It was also extremely relevant that women of reproductive age and pregnant women were the sole recipients of the health information. This example highlights the problem that, while the women had the knowledge, they alone could not act upon it. Other people were ‘barriers’ preventing them from acting upon their knowledge, yet Merlin’s health information had not been targeted to older ‘aunties’ or men. Wherever organisations try to promote behaviour change, they may find that each positive change may face specific barriers based on culture, the community and other external influences. Some behaviours however are more difficult than others for people to change. The easiest victories in promoting behaviour change happen when people understand clearly the benefits of change: They identify the new action with an immediate outcome, or there is widespread acceptance among the community and the new behaviour becomes an accepted practice. Often these successes are in health-seeking behaviours, which encourage people to seek timely and appropriate diagnosis and treatment for such illnesses as diarrhoea or tuberculosis. Individuals witness the transition from a sick person to a healthy person and recovery becomes an incentive to seek services. Drugs are provided for free, intervention is often minimal, and the results are immediate. The outcome—good health—is a direct, visible consequence of the action. Another ‘easy win’ is when a group of people comes together to practice the new behaviour. Vaccination campaigns, in which mothers all bring their children to be vaccinated at the same time, encourage all mothers to do the same. In such situations, a young mother often does not want to be seen opposing the rest of the community. Such considerations of peers’ opinions can be an encouragement to new mothers if there is wide acceptance among the community to adopt or practice particular positive behaviours. However, peer opinion can be just as discouraging if the group does not believe in the benefits of a particular action or behaviour. For example, older women may not believe a health education message that discourages women from carrying heavy loads or doing manual labour during the first trimester because they themselves did that kind of labour, had children, and had no ill effects. Even if the young women to whom this message is targeted understand and accept the information, they cannot practice it because of the beliefs and experiences of older women in the community. It is much more difficult to persuade people to adopt positive behaviours related to preventive health largely because it is difficult for them to see any immediate results or benefits. In preventive health care, people must believe that adopting a new way of thinking and behaving

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will have the promised outcome of better health. They must, in effect, invest now for a future state of good health. Sometimes this investment requires financial, material, or time resources that villagers do not have or do not see the importance of making. In villages where it works, Merlin has found that habitual behaviours are hardest to change, and new behaviours that require many steps or are time consuming, are the slowest to be adopted. For example, diarrhoea can easily be prevented through basic hygiene, particularly hand washing before eating and ensuring that drinking water is clean. While people in the villages say they have heard messages about washing their hands before eating, they do not always follow them. ‘When we come in from the fields, we’re hungry and can’t wait. Nothing bad has ever happened to us from not washing our hands, so why should we change?’ To many people, there is no immediate link between what they did (or did not do), their ‘health knowledge’, and any bouts of diarrhoea, which in any case villagers tend to view as ‘normal’ or unavoidable. Merlin found the same kind of resistance when introducing methodical steps for the villagers to take to ensure clean drinking water. People were less likely to adopt behaviours that required new and time-consuming actions or material inputs. To ensure clean drinking water, there are many steps which may include fetching water from a long distance, difficulties in finding a clean water source, transporting water, finding a sanitary storage pot with a lid, and taking the water from the storage container in a sanitary way before drinking. Villagers often found it difficult to ensure all of these steps and thus they did not completely adopt the new behaviour, or only adopted those changed behaviours that they were able to. Successful preventive behaviour change demands that people believe that the financial and time investments they make will result in healthier outcomes for them and their families. Ultimately, exploring underlying barriers to action means that an organisation develops ways that encourage people to talk and discuss openly their opinions, fears, and beliefs about a particular behaviour being promoted. Project staff and community health workers must listen actively, encourage people to talk while providing the right information at the right time. Depending on the length of time an organisation has been working with the community, there is a good chance that the community will already be familiar with specific health information and have developed a trusting relationship with that organisation. At this point, clinical health knowledge is secondary to understanding what motivates or inhibits people from acting on the health knowledge. Once the organisation and its members have gathered in-depth information regarding why people do or do not practice certain health behaviour, then they must develop meaningful messages and methods to influence people to change their minds and ultimately their behaviour.

Messages for changing behaviour Messages are not always slogans, but rather a way of persuading a particular group of people to change their beliefs, attitudes and practices for a particular beneficial outcome. Organisations that have been successful at changing behaviour have done so because they have developed meaningful messages or targeted messages that the audience can relate to and understand. A targeted message is a convincing reason that also specifically addresses any underlying reasons of that group not to practice a particular behaviour. Messages are targeted at a specific group, for example mothers—the primary target group—or at other people—a secondary target

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group—who may influence individuals in the primary group to act or think in a certain way, such as men or ‘aunties’ associated with women of reproductive age. Such targeting was highlighted earlier in this chapter with the example of Merlin’s work with mothers as a primary target group, to change their behaviour associated with delivery, to include antenatal care and delivery with a skilled birth attendant. The effort met with varying success, likely in part because Merlin did no direct work with the men and the older women in the community who influenced the women’s behaviour, or who decided for them whether or not they would deliver with a skilled birth attendant. Health programmes aimed at behaviour change must also work with these secondary target groups to ensure success. In this instance, Merlin’s messages had to persuade husbands and the ‘aunties’ of the importance of having the younger women adopt this new behaviour. Again, in this situation, the organisation must investigate the reasons why this secondary group resists the behaviour change—there may be reasons related to customary beliefs or finances, among others. Working with these secondary target groups is extremely important to getting the desired health outcome of the programme. The way to develop targeted messages may differ for each group, even though the overall outcome may be the same: for instance, having women call in a skilled birth attendant for delivery. The content of the message and the way the message is delivered will likewise differ for each group. Merlin has found that it is extremely important for staff involved in health programmes to listen to the various target groups and understand their reasons, beliefs, and attitudes towards a particular behaviour. Only then can they develop a persuasive and properly-tailored message. There is no ‘one size fits all’ approach to creating a targeted health message.

Communicating for behaviour change Merlin has found that changing behaviour relies on good communication that includes both a way of communicating to people, and tools to encourage the involvement and increase the receptivity of the audience to the messages. The following section outlines some of the learning that Merlin has acted on to make the communication more effective.

The communication tools are what organisations use to capture people’s attention to help change their behaviour, as well as continue to reinforce a new behaviour. Often, people identify a communication tool as information, education, and communication (IEC), usually understood as pamphlets or posters. Rather, true IEC is anything that communicates information to people in order to educate them about a new behaviour and its benefits. A communication tool is more than a pamphlet—it can be board games, scene card games, songs, or spontaneous role-playing that involves the community as actors. These are all examples of interactive tools that encourage people to come together and be involved in the learning process. In a session that Merlin conducted, a member of the community brought up the saying, ‘If I listen, I forget. If I see, I know. If I do, I remember’. Programme staff can use these tools to help discuss something in a fun and informal setting in a participatory learning process. A good facilitator should be listening to the discussion to understand what the community believes and understands about the promoted health behaviour and barriers to accepting it. Only by this understanding, can the facilitator start to address the barriers. The communication approach is how an organisation goes about communicating to people. This generally includes facilitated methods and self-learning. Ultimately both rely on good communication skills, which are a pre-requisite for encouraging successful behaviour change.

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Good communication relies on two-way dialogue: each party must listen and speak to the other. The health educator and the community members must both speak and listen to each other. Communicating to encourage behaviour change means that the teacher-student role is erased and that the facilitator encourages discussion with, and participation from, the audience. ‘Facilitated methods’ are the most common way organisations deliver their messages; a health educator or community health worker facilitates a group in a discussion. This often takes the form in which a community health worker explains a health message verbally, usually using posters and pamphlets as visual tools.

In Myanmar, these materials are often used in a one-way teaching style following the model of the traditional Myanmar teacher-student relationship in which there is little room for questioning. If health educators follow this model repeatedly, the audience will become immune to the message. However, with good communication skills, a community health worker can use a range of tools to engage the community in a facilitated discussion not only to present health information, but also to explore the community’s views and problems related to their uptake of the behaviour being promoted. Other kinds of facilitated methods based on good communication are one-to-one or informal, small group discussions. For these methods to be useful, they require interactive participation of the audience. Informal discussion requires that the facilitator asks probing questions and listens to responses in order to uncover barriers that may be impeding behaviour change. This kind of discussion also requires trust between the two groups, and a willingness to engage in open and frank discussion. Creating this environment is much more difficult as it requires the health worker to pull out information in subtle ways.

‘Self-learning’ involves activities that the community can do by themselves or with minimal reliance on the community health worker. Videos, comic books and stories, theatre and television programmes, exposure to mass media advertisements on the radio, newspapers, and billboards are all examples of possible self-learning tools. These media have little or no input from the community health worker and expose people to health messages without their direct involvement other than as passive observers. These tools allow people to reflect on the message that is presented to them. If the community health worker follows up by leading a discussion about the message people have viewed, what they think and about their beliefs, the messages may be more effective. Only once the community health worker can effectively communicate with a group and start to encourage the community to discuss their views openly, can they understand why people do or do not change their behaviour, what motivates some people to change, and what the barriers for others are. This information is critical to developing messages, or persuasive advice that addresses these reasons. These key messages must then be delivered back to the community in an equally engaging manner.

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Challenges to behaviour change in Myanmar In Myanmar, a main problem organisations conducting behaviour change communication, such as Merlin, face is that the term itself has become a catch-all without having a shared understanding of what it is and what it encompasses. More often than not, ‘health education’ is termed ‘behaviour change’ in project reports and proposals, but real behaviour change activities, as discussed above, are rarely implemented. The problem with relying on health education alone is that this approach is based on the transfer of knowledge, and knowledge alone does not change behaviours. Another problem is that organisations do not implement a variety of behaviour change activities, but rather most commonly health education lectures are the sole activity conducted. Often in Myanmar, communicating health information follows a one-way, student-teacher model, with little room for asking questions. The community stops listening to the messages, and the ‘health talks’ they hear tend to be similarly repetitive and boring. Behaviour change should not be an activity done for itself, but rather be worked into on-going overall project activities. It should be complementary rather than a stand alone activity. Tools to engage the community and share messages, such as games or short role playing, are not the end product of an activity. Rather they are merely aids to help communicate and engage the community in adopting new, healthy behaviours. Organisations must look through the entire range of components that go into changing other people’s behaviour and integrate these into on-going project activities. For example, both communication skills and tools to engage the community are essential to find either barriers or motivations to change behaviour. When a volunteer health worker is in the community, they can use any tool together with their communication skills to probe into health behaviours. How the messages are communicated to a group is just as important as the message itself. A key problem for NGOs relates to programme and donor cycles. The entire behaviour change process is cyclical and long-term–much longer than the duration of a single donor funding cycle. Creating changes in behaviour takes time, yet within these cycles, there is relatively little time to undertake comprehensive behaviour change activities, such as conducting in-depth research into barriers, understanding motivations for those who practice the behaviour, or finding ways to promote change persuasively. As a result, health education is the basic activity that organisations perform, given the limited time and resources available. Often, organisations simply continue to do what they have always done since information pamphlets readily available, and they can conduct such information activities within the timeframe of a programme cycle. However, bringing about lasting change in peoples’ health behaviours relies on a set of iterative and inter-related activities, of which health education is but one aspect, carried out over a long period of time.

Merlin’s Behaviour Change Communication Approach to Community Rural Health – A Case Study Merlin has run health education activities within its community rural health programmes over many years. As stated above, Merlin reviewed its programme in 2010 to ensure that the approach addressed the demand side elements of its health programme as far as possible. The findings of this internal review highlighted that Merlin’s community rural health programme had a strong curative focus but in comparison, relatively less of a focus on prevention. The reason for this was that Merlin had prioritised clinical trainings with field monitoring and reporting which emphasised diagnosis and treatment. At the same time, community health workers and auxiliary

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midwives emphasised distributing medications and treatment when dealing with the community. The organisation as a whole had a hiring culture that employed primarily general practitioner doctors to implement activities at all levels. Merlin’s activities to date had thus resulted in a programme with solid curative outcomes that led to changes primarily in communities’ health-seeking behaviours. These are substantial gains in any health programme and these successes also built the communities’ trust and confidence in Merlin. However, because Merlin’s approach has focused on curative interventions, there had been little room to address preventive health behaviours in the community, and as a result, there were fewer gains in preventive health behaviour changes. Merlin used basic, one-way health education messages using standard project posters and pamphlets. Neither the community health workers nor the auxiliary midwives made full use of their time in the community in informal discussions, nor did they investigate the communities’ attitudes and beliefs towards certain health behaviours. These key community health volunteers had not been taught to explore the reasons why people were not adopting the desired behaviour. Rather, the volunteers had been taught to tell the community what to do repeatedly. Therefore, the review concluded that in using this basic health education approach, Merlin had most likely changed as many people’s behaviours as it could until the organisation changed the approach. A Two-Phase Approach to (Re-)Introducing Behaviour Change Communication into Merlin’s Programme Based on the review findings, key members of the programme teams jointly developed a new approach to conducting behaviour change. Merlin wanted the new approach to emphasise preventive care, build on existing programme strengths, and phase in behaviour change activities that would streamline into on-going activities, rather than have them be perceived as an additional set of activities and additional work burden. The overall concept was to match the ‘hardware’—the clinical skills—with the ‘software’, or the communication methods of the volunteer health workers. The context of these ideas is that Merlin trains and uses community health workers to involve villagers in improving their own health. Merlin had focused primarily on providing volunteer health workers with basic clinical skills (diagnosis and treatment protocols) and drugs for treatment (hardware) to help improve community health. At the same time however, community health members also need skills to communicate health information better (software), as well as help people make informed decisions to adopt healthy behaviours. Volunteer health workers know what health information to communicate to villagers, but must improve how they communicate it. This combination of ‘hardware’ and ‘software’ provides better equipment and skills that volunteers need to bring about healthy outcomes. Based on these concepts, the programme teams designed a new approach to address this ‘software’. Phase 1 - Health education through improved communication skills and

confidence building The first phase of the new approach emphasised developing community health workers’ and Merlin Project officers’ skills and confidence to deliver health education messages in a more interactive and participatory manner, and also gave them the tools they needed to develop these skills. The traditional culture of learning in Myanmar has resulted in health education having a one-way, didactic approach similar to student-teacher relations. This first phase therefore also aimed to encourage new and more interesting ways for workers and officers to interact with the community, with an emphasis on community participation and on questioning why new

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behaviours are so important. Once volunteer health workers felt confident to interact in this manner, they could appreciate the real work of understanding underlying attitudes and values towards a particular health behaviour. The first phase was based on the following concepts: Participatory methods :Key to the success of Merlin’s behaviour change approach is the extent to which the organisation normalises participatory and interactive methods of communicating at all levels, not only for volunteer health workers. The entire organisational culture should reflect participatory engagement, meaning that during regular meetings, activities, or workshops, the organisation fosters interactive learning and sharing from everyone, not just project officers and community health workers. Project officers and community health workers must have first-hand experience from their interactions with senior staff in order for them to be able to adopt new ways of interacting with the community. Merlin staff were requested to set an example in the ways they communicate with community health workers. All levels of staff must be comfortable with and promote interactive ways of communicating. Examples of ways that Merlin has tried to implement this approach include at monthly rural health meetings, which project officers and project assistants conduct with community health workers in an interactive, rather than didactic, manner. Merlin introduced spontaneous role playing as a means to check on the diagnostic and treatment protocols of the volunteer health workers. ‘Spontaneous role playing’ is a sort of game in which three or four people create a three to five minute dialogue based on a particular health issue. Ideally, the players should demonstrate the correct treatments, or in the instance of working with the community, the correct behaviour or examples of the barriers to the behaviour1. Once the community health workers are confident in this technique, they can then use it within their practice. As this mode of interactive communication becomes ‘normal’ for Merlin, Community health workers are more confident to adopt these kinds of new methods into their work with the communities. Learning by doing:Methods to encourage behaviour change should be easy and easily incorporated into on-going activities. Developing appropriate, easy-to-use tools helps community health workers engage with their audience in interactive ways without any formal training other than that of simple instructions given to them in monthly meetings. They can use these tools immediately and learn more about each one as they use them. These methods can be easily integrated into normal routine activities with the community as a group, or small groups of people at a time. Learning tools can be a re-creation of other tools that peer organisations have developed, such as malaria “snakes and ladders”, or picture card games that show a health issue and the appropriate behaviour, or a new tools can be created such as the spontaneous role play (as discussed above) or any other created game – anything to get the community actively involved. These tools can help Merlin and community health workers break the ice with the group, get people to feel comfortable, forget the teacher/student learning style and create a fun and relaxed atmosphere. Once tools are created, it is probable that people will open up with questions and concerns about the behaviour. In this informal learning environment, Merlin can

1 Previous role plays conducted by Merlin were based on health theatre that involved a trained group with organized dialogue and acting. It was resource intensive, both financially and time, without lasting effects on the community’s health behaviour. People understand role play to be in this form and are hesitant to use it because it is quite resource consuming.

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explore levels of understanding surrounding the health issues and the communities concerns about adopting the behaviour. Phase 2 - Communicating for behaviour change through targeted messages

using in-depth communication skills This second phase builds upon the interactive skills elaborated in Phase I above and goes beyond delivering health education information by probing into problems around adoption of key health behaviours. Once community health workers feel confident interacting in a more informal and participatory manner with community members when they deliver health information, it is also possible for them to develop listening and probing skills. Community health workers must listen closely to responses community members give during discussions and games and learn to probe delicately for answers to the question, ‘why?’. Merlin has found that because of the learning culture in Myanmar, this concept of listening and probing without imparting information is difficult to teach health educators, who may not have been exposed to this communication style. People may view as intrusive being asked their rationales behind a belief, attitude, or practice. However, a good facilitator with the proper communication skills required to talk informally can pull out bits of information without the community necessarily being aware of it. Interactive tools are therefore a first step to put a group at ease and allowing the members to feel free to talk openly. The community health worker can take these opportunities to ask questions without seeming to gather information. Gathering information can be done informally through the health workers, as can large-scale research, to understand barriers to the community adopting a specific change. Informal research is an excellent tool, one which can be used continuously, to help an organisation understand where communities are in the process of changing their behaviours. This research can also provide background information upon which to build more formal research about barriers. Formal research can also help an organisation see the extent to which various communities have the same concerns in common and can then target resources to address these concerns. In this context, the organization can decide whether to explore a given problem in greater depth through formal research questions. Once an organisation understands barriers to changing behaviour they can then develop specific messages to persuade people to adopt new, healthy behaviours. Through such targeted messages and appropriate ways of communicating these messages, people can start considering changing their health beliefs, attitudes and behaviours. Targeted messages ideally address specific concerns that people have around a behaviour change that an organisation promotes. These reasons include financial, time, or material resources; religion; culture; and status or the perceptions of other people. Targeted messages work best when they go beyond health information and address underlying barriers without bias or prejudice—if people feel they are being judged, they may feel disinclined to change. How the health worker delivers a message is as important as the message itself.

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Challenges in Introducing Behaviour Change Communication into Merlin’s Programme In implementing the two-phase programme outlined above, Merlin has faced a number of challenges, the first being that any kind of promotion of behaviour change takes time. All levels of the organisation have had to adopt and endorse the approach. For a clinical organisation to emphasise preventive health behaviour has meant some changes in strategy that have meant placing less emphasis on curative activities at the beginning of implementation. Senior management has had to re-think the kinds of people it hires in order to have leadership that have skill sets which include both communication and clinical skills. Senior management has had to demonstrate their commitment to promoting preventive health care as a way to show community health workers that they are expected to do the same. Adopting this approach has also required an initial injection of financial resources to develop tools, provide on-the-job training and allow sufficient time for people to learn and adopt new organisational behaviours. Given the time frame of behaviour change, Merlin has had to determine how to measure change. As surveys have revealed, gauging the knowledge among target communities is not a good indicator of actual changes in behaviour. Qualitative indicators may include, for example, looking through the types of questions communities ask as indicative of where they are in the change process. These questions also reflect whether it is just knowledge they are seeking, or whether they are questioning their culture, past experiences, or anything else. Recording the types of questions can provide evidence that people are moving through the process of change. An organisation can use this evidence to create new kinds of messages. If ‘level of changed behaviour’ is the only outcome recorded, a project may seem to have failed in the short term. Merlin has had to find indicators that gauge slow change, no matter how small. Merlin has also had to be aware of the repetitiveness of the tools it uses in the approach – for example, over time people will become bored with games, and so has had to think of new ways for the community health workers to engage with the community. Merlin is committed to addressing stages of behaviour change and creating new messages with new tools as the community changes. Similarly, because not all volunteer health works have good communication skills and many cannot or will not take on the new roles as outlined above, Merlin has had to find people with an appropriate combination of skill sets. In community-based health care, avoiding illness is as important as providing treatment. However, for many organisations in Myanmar, clinical aspects are often the sole focus of their work; providing basic health information second. Merlin is an organization that has been able to deliver high-quality clinical trainings and services in their community based health programmes. It has also the initial steps to change its preventive health approach. Merlin has investigated how to bolster its preventive efforts to reduce the burden of easily preventable illnesses though behaviour change. Behaviour change is about persuading people to do something they do not want do, and not about a lack of information. Thus, communities have benefited from Merlin investing in finding out why people resist good health practices and developing messages that persuade the community to change.

Chapter 5 Geographic Information Systems (GIS) and Community-Based

Health Care Chris Grundy

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Chapter 5 Geographic Information Systems (GIS) and Community-Based

Health Care Chris Grundy

Background and the meaning of ‘GIS’ Merlin originally developed in-country experience in the use a geographic information systems in programme needs assessment and monitoring at the time of Cyclone Nargis. This involvement led to Merlin and other agencies implementing the Assessment Capacities Project (ACAPS), which now provides support to multi-sector assessments in natural disaster and complex emergency situations. Merlin recognised that with better mapping of humanitarian statistics at the village level, humanitarian responses could be better tailored to suit each village. This concept has subsequently been expanded to cover the planning and delivery of community health programmes in the country more generally, and especially in remote areas of Myanmar, where there may be limited access. This chapter looks at the use of GIS in community based programmes based on Merlin’s experience to date. Mapping and simple spatial analysis has played a role in public health for hundreds of years, with the earliest known map of disease being of bubonic plague in Naples in 1692, and the most famous being John Snow’s map of the cholera outbreak on Broad Street in London, in 1854.1In fact, maps have been made for every important public health issue from the plague onwards and their use has tracked various significant diseases. By the time doctors and scientists started to look at diseases such as malaria and African Trypanosomiasis, cartographers had become standard in most health-related surveys and expeditions. Today, geographical methods are used in every area of public health. A constant stream of new applications makes these methods quicker, easier and more relevant to creating specific health data. This plethora of methods, software, and tools has led to some confusion over the terminology related to ‘geographical information systems’ or ‘GIS’. Even the name is a source of some discussion, whether ‘geographical information science’ or something else may be more suitable. The main misconception, however, is that GIS is not one piece of software that allows users to produce maps and analyse data. ‘GIS’ is a term that covers all the methods or techniques that allow the researcher to track locations, and includes hand-drawn maps, spatial statistics, global positioning systems (GPS), spatial surveys, GIS software, internet mapping, and satellite images, among others. GIS is therefore very much like statistics, in that the methodology is central, and there are a variety of tools available to carry out that methodology. Despite the fact that geographic information systems have been around for a long time, outside of academia, other researchers have been slow to use some of its tools. This reluctance in part stems from the misconception that GIS software is difficult to use and requires considerable investment in order to get any benefit. This situation is, however, finally starting to change thanks to internet mapping and freeware, and also to increased efforts to translate academic research into practice. Now most large NGOs and even many smaller ones, use at least some of the GIS tools available, with many organisations investing in staff and software to allow for more complex analysis to inform their work.

1 Thomas Koch. 2005. Cartographies of Disease: Maps, Mapping and Medicine. Redlands CA: ESRI Press.

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What is Required to Implement GIS Requirements can be broken down into three sections: data, staff and equipment-software. In the past, these requirements put many agencies off using geographic information systems. These requirements, however, do not have to have large financial implications. Rather, they simply ensure the suitability of the methods being applied. There are just as many excellent examples of GIS within organisations that have made minimal financial investment as in those that have invested large sums. Crucial to the success or failure of using geographical information systems is the staff of an organisation – not only those who will actually carry out the GIS work, but how the organisation will support that work and who will champion the importance of GIS at a senior level. While an organisation can bring in a GIS professional, it is not required. Almost anyone can be trained to carry out at least some GIS tasks, but beyond the basics, computer skills and experience with datasets are vital. While using specific GIS software is not required, most of the methodology under GIS has some computing elements, and as such people with better computer skills will therefore find learning GIS easier. This is also true for people who already have experience related to data collection and analysis. Many of the reasons organisations use GIS are to build datasets for display or analysis, and many of the problems that people encounter are not specific to working with GIS. People who already have experience putting datasets together and cleaning, managing and using them will not have to learn these skills as part of their GIS training. For these reasons, organisations often enlist data managers to carry out the GIS work. While these data managers often make excellent GIS workers, they are not the only option—anyone with computer and data management skills, will be suitable. A common mistake when organisations establish geographical information systems is to assume that choosing staff members to carry out the work will be the only requirement in terms of staff. Often, organisations simply shift GIS work onto someone’s workload without shifting any of their other work elsewhere. Rarely do people not already have enough work to fill their time without taking on new responsibilities. When they are given additional responsibilities, the result is that they must rush the GIS work, and they have little time to practice their GIS skills or develop the GIS aspects of their work. Organisations must therefore support GIS work and ensure that GIS staff can set aside enough time to fully use and develop GIS without making staff feel that they are not meeting their other responsibilities. The final aspect to using geographic information systems is training and support to staff. While capable staff may be able to pick up many of the technical skills related to GIS, it is a false economy for organisations to believe that allowing them to learn that way is cheaper than investing in training, which in any case does not have to be expensive. There are countless ways to fund or work training into programmes without it being a direct drain on resources. For example, organisations may take advantage of capacity-building programmes that are supported by funding agencies , and write training costs into funding proposals, or work with universities on research projects which include some training as part of the work. Whichever route is taken, organisations must think of GIS training as a long-term investment and not just something finished after a two day course. The selection of trainers and collaborative partners is as important as the staff and their training. As a simple rule, the trainers should have experience working in the same field as the organisation is working in, although this field need not be specific to the country. They should understand the type of problems an organisation is likely to come across and the GIS methodology that will give the organisation the most benefit. Ideally the trainers should be people with whom the organisation can form long-term links to allow long-term support and

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development. GIS staff members will always have questions either about problems or further uses. Having a support network that they can consult, will be vital. There are indeed circumstances in which bringing in a GIS professional is necessary or better than trying to train current staff. Projects requiring advanced analysis, or when an organisation plans to carry out multiple projects from the start, are examples of times when employing a dedicated GIS staff member will have real benefit. A person with more experience will also have the advantage of being able to suggest where geographical information systems can fit into the programming, since they will be able to concentrate on applications instead of having to learn new skills. This decision has cost implications, but at some point, if an organisation is to make full use of GIS, good skills will be necessary, and it may be more efficient to start at full speed rather than building slowly.

After GIS Staff is in Place – Next Steps After an organisation has selected their staff, the next element required is data. It is a common assumption that finding geographical datasets is the most important part of establishing a GIS setup, when in fact the first stage is to create a structure for data in a way that allows it to be used. The phrase ‘garbage in, garbage out’ is as true for GIS as anything else, so it is vital for an organisation to carefully examine data to see what can be used, where there are gaps, and where there must be standardisation. At the same time, it is possible to look at how the data are going to be used, what data will be used purely for analysis, and what will be mapped. If an organisation is to create maps using GIS software, then they must find geographical datasets that show the location of the data to be mapped. Often these will be datasets such as administrative boundaries, which may be available online for free on sites such as the Global Administrative Areas Database, or village locations, which may be found through online place-name gazetteers. As a rule, the more detail an organisation requires, the more likely it is that they will either have to collect data themselves or buy commercial datasets. Links with other organisations and groups are key: it is likely the data exists somewhere, and talking to other GIS users in the country, government departments, or research organisations is always the first place to start the search. The search does not have to be about throwing money at the problem, but rather careful planning and making best use of the skills within the organisation. Online mapping communities and websites are increasingly becoming a major supplier of geographical datasets for use in geographical information systems. The relationship between NGOs and data has changed rapidly over the last few years—most NGOs are currently looking at what data they have and how they store and use it. A key element to this process that is often forgotten is the meta-data related to the projects, interventions, or work. Simple kinds of information are useful to include with the actual data: when a given intervention started and who funded the work. Organisations often record this information but fail to put it into databases, not seeing how it will be useful to GIS work. In fact, this type of information can provide some of the simplest and quickest benefits and should be some of the first data that staff prepare for use. The final requirement is software and equipment to carry out the geographical information systems methods of interest. There is a wide variety of GIS and mapping software available both free and commercially, offline and online. Commercial software is by far the most powerful. The two main pieces of software available commercially are ‘ArcGIS’ and ‘MapInfo’. Each organisation will have to consider the pros and cons of each package, and depending on which elements they need, each package can cost several thousand dollars. The companies that make the software,

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however, appear to understand the importance of NGO and humanitarian work and offer special rates for such organisations. Freeware has always been available, but only in the last few years has any package built up the functionality and support to make it a viable option for organisations. Currently, the package ‘Quantum GIS’ provides most of the functionality that many organisations will ever need for their mapping and basic analysis in a piece of software that is relatively easy to use. The statistical package ‘R’ also features a mapping package, although this is more complicated to use. The final option is internet mapping packages, such as ‘Google Earth’. These mainly allow users to overlay simple information on top of standard images, and as such, can be used for simple mapping, such as clinic locations. There is an increasing number of add-ons to build on to the basic functionality Google Earth. In any case, packages like ArcGIS are considerably more powerful and easier to use than freeware. Given that the majority of funding agencies will pay for GIS software, it is well worth looking at available options, at least over the long term. If an organisation is going to use GIS in any depth across its programmes, it is likely that they will use a range of products, which can be useful: one person in the field may have very different requirements from head office, and using many programmes allows full use of the range of available software. In terms of equipment, with their ever increasing power, almost any computer purchased in recent years will run almost all the software. Very large hard drives, big monitors, and powerful processors help if carrying out complex analysis or mapping very large datasets, but are not vital. An organisation need consider these items only if GIS is going to play a major role in its work. Perhaps the most common GIS-specific equipment is now global positioning systems (GPS) receivers, which allow individual locations to be collected and then mapped, and can also be used to map roads and any other feature of interest. Most NGOs now have a collection of receivers, even if the data are never mapped. Changes in mobile phone technology mean that these are also slowly becoming more useful for mapping as well. Increasingly, data is being collected on devices such as mobiles with coordinates attached to the information. It will be some time however before mobile phones can replace GPS, and for the next decade, GPS will remain an important aspect of GIS data collection.

Models of establishing GIS within organisations There is no single way to establish GIS within an organisation, although there are definite ways to be avoided and possible threats. The use of GIS in a company either comes about through a single project, with a particular group within an organisation using it, or through an organisation as a whole adopting it. The least likely to fail is a ‘project-led’ model, in which GIS is required for a specific piece of work. In this case, the organisation knows all the requirements, can write costs into the budget or request funds, and the staff workload may be adjustable. At the end of specific project, the organisation can decide whether to continue using GIS in other programmes. Often the lessons learnt from the first project lead to use in other work, with a steady expansion to the whole organisation. This gradual development means investment is spread over time and the resources the organisation allocates increase with demand. This may not be the most cost- or time-effective way to develop a geographical information system, as requirements are based on a project-by-project basis. This model does, however, allow an organisation to see the benefits of using GIS before making a major investment. The ‘group-led’ model refers to an organisation investing in GIS for several projects. Someone in the organisation has used GIS before and can see how using GIS across the organisation would be useful. Given that many of the resource requirements are the same across projects, this model is

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more efficient than working project by project. An organisation can distribute investments across projects by increasing the number of uses for each investment. As with the project model, an organisation can stage development over time, using appropriate methods for each project in increasing complexity, in this way, the cost benefits become clear. There is a risk of duplicating work if different groups within the organisation follow this path at the same time. At some point, the organisation as a whole can make decisions related to GIS across the various groups to increase efficiency. The final model, organisation-wide implementation, is the most difficult but the most efficient. This model requires more initial investment, with an organisation having to hire dedicated GIS staff to work across an organisation. Usually, staff members select a pilot project to show the usefulness of GIS through the organisation over time. By looking at the organisation as whole, there are savings by not duplicating work, the ability to spread costs over more projects, and greater benefits due to the number of projects using GIS. This model can also ensure that good practices are learned and avoid the problem of an organisation learning as much from their mistakes as their successes, as can happen under the project-led model. It is also easier to set up support and training for an entire organisation with links to research groups, which may bring in other benefits. Apart from the initial costs, the main drawbacks to this model are ensuring that it is accessible to the people who need it, that it is not too rigid, and that it allows users to use it in a way that suits them. An organisation may put pressure on the users to show successful results, which can be very damaging. Whichever path an organisation follows, the factors that cause GIS to fail tend to be the same. The largest factor is competition. Surprisingly, groups within an organisation often compete against each other, seeing GIS as a ‘trophy’ that shows how good a particular group or even an individual within the organisation is. Sections within an organisation may compete against each other for control, refuse to accept central or shared resources, and may even try to hinder others’ work. This type of in-fighting related to GIS tends to be fatal, and years can be wasted before different groups within an organisation start to work together. In such cases, the results tend to be severe: either GIS implementation fails outright, or shows no benefits and the money seems wasted. Less serious, but just as expensive, are cases in which sections within an organisation compete to show themselves as key to the success of GIS, which can lead to duplication of effort, costs, and work. Another factor that can impede the development of GIS is how people judge its success. Often the area least expected is where the biggest benefits of GIS will manifest. Unfortunately, many people consider the use of GIS successful when the systems show positive results in a particular way, for example, showing the source of an outbreak, reduced costs of an intervention, or a disease hot spot. When the results are not what is expected—often no fault of the GIS setup—staff or the organisation may consider GIS to have failed and stall further investment. The best GIS setups therefore avoid such problems by being flexible, and everyone concerned must accept that there will be some projects that are great successes and others that are not. Geographical information systems will help most organisations to some degree, and their benefits will come much more quickly if obstacles are not put in their way and if they are used frequently, rather than leaving them unused. The benefits will become clear. If an organisation follows these provisos, then GIS will save or raise considerably more money than it costs to run.

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Building a GIS programme No matter whether starting out, moving to a new country, or into a different field, successful GIS programming tends to follow the same series of steps, starting with building the database and ending with analysis. Skipping steps can lead to mistakes. Preparing the database is the first step in the process – without data, nothing can be accomplished. In public health, data is often the single largest limitation—for example, when data is not available at the local level, or where there are problems with confidentiality, meaning that nothing can be mapped. People working on GIS must examine the limitations of the data, where there are gaps or missing data, and what the codes associated with the data mean. The amount of work needed to put the data into a workable format depends on the origin or how data were stored. The final step is to look at how the organisation can use the data in GIS, and how to locate it on maps, if applicable. This step may require searching for administrative boundary datasets, or using GPS coordinates, or combinations of both. It will also require comparison between, or checking against, geographical data with data in the database. It is not unusual to find that a dataset of village locations does not include every village in the health data, or that names vary between the two sources. Cleaning and coding the data at this point, if done well, will ensure that the dataset will be useable and will save time in the future. Global positioning systems (GPS) may be used during data collection. For example, in projects with field work or that are based at the project level, it is possible to collect village or clinic locations during these visits. Data can then be used in maps. Once the data has been obtained and properly prepared, the next step is to produce simple maps. It is common to think of mapping as not proper GIS as such, yet the vast majority of GIS work in public health, is mapping. Some of the quickest and biggest results come from mapping. Maps serve several purposes: Building confidence in staff members’ ability in GIS; allowing a visual exploration and therefore better understanding of the data; checking for errors, such as incorrect coordinates putting points in the wrong location; and allowing information to be examined both internally and with others. The first maps can show the specific locations where an NGO is working. At first these maps may not seem useful, but in fact, apart from allowing one to check whether the data are correct, they are useful in communicating with policy makers and funding agencies. Figure 1 shows the villages that Merlin Myanmar work in, and has split the map up into three parts showing how Merlin’s area of work has increased over three years. This display allows the map to show a funding agency exactly how their money has been spent, showing the increase in the number of villages and coverage. While it is possible to show this information in tabular form, it does not have the same visual impact. Policy makers relate more positively to maps than to tables. At times, GIS may be used as a way to bring money into an NGO, thus bringing in funds for a particular area of interest. If doing so increases the money available to an NGO, then the use of GIS may be considered a success – as long as organisations maintain a flexible understanding of success.

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At the same time, it is possible to display outcome data on maps, such as numbers of cases, rates of disease, drug treatments provided, or whatever the outcome of an intervention. At this point, GIS staff members will have to make decisions and gain skills to improve presentation, such as the selection of colours and symbols—in map production, the most amount of time is spent making the map look presentable, by for example choosing the colours to use. Choosing standard colours used each time a certain variable or type of variable is displayed can save a lot of time. Staff members may also have to choose which variable to display and exactly how to display it.

Figure 2 again shows data from Merlin’s programmes, in this case the number of cases of malaria detected in each village, with the villages grouped into categories based on the data mapped. Using this type of map allows the local situation to be displayed; show villages that have the greatest problems, and allows for very local targeting of interventions.

Figure 3 shows the same data, but mapped using a set of groupings based on low, medium, and high for the country. This map shows something completely different. It shows that malaria is not a great problem in this part of the country, even though there is some local variation, as shown in Figure 2. Being able to display data using various classifications or groupings is a key part to extracting the most benefit from geographical information systems. The more maps staff produce and the more they use GIS, the more obvious it becomes that many of the problems that arise have to do with epidemiology and not GIS. Having created confidence in the data and the descriptive style of maps, GIS staff can start to include some simple analysis. This can take two main forms: calculating distances and linking data based on location. These are simple functions within most GIS software and represent moving from simple mapping functions through adding information to data for analysis.

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Figure 4 shows five-kilometre circles around villages which have a community health worker supported by Merlin. Initially this map can show which villages share health workers, or how efficient the current setup is. Straight line distances like this may not always be valid, but they are a simple way to begin analysis. A mistake is to make the initial analysis overly complicated and spend too much time on details. It is more important to keep making progress while being aware of the limitations of the method used. In this case, while the distance displayed may not be

the exact distance travelled—there may be barriers—the figure can show whether sharing community health workers is possible in some locations. It may be possible to provide an initial list of villages, which can be analysed further at project level. Another function that is simple to use is to link data based on location, wherein two datasets are placed over each other, assigning values from one on to the other. A few common datasets can be used, such as elevation or climate information. Figure 5 shows the elevation, with villages placed on top of it. If this were a spatial overlay, then the elevation of each village could be added to the table of villages so that it could be used outside of GIS. These data may then be used in analysis to look at the impact or importance of that factor, for example, the role of elevation in the rate of malaria. At this stage, GIS has become fully integrated into all aspects of an NGO’s work, from basic descriptive to statistical analysis. As the skills, datasets, and experience of the staff grow, the analysis can become more sophisticated, with new applications for the information becoming apparent. Allowing these applications to develop naturally may show that, for example in Figure 4, a more detailed spatial location analysis could help an organisation decide where best to place community health workers.

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Conclusion This chapter has presented a basic introduction to GIS. There is no one way to set up geographical information systems, or a standard set of requirements. Rather, what is required depends on the nature of the organisation and how it wishes to develop GIS. What is more important is avoiding internal disputes over who controls GIS; how it will be judged a success, and to make most of whichever software or method suits each person and project. Use local staff where simple skills are required, but accept when it is best to work with or employ a GIS expert. An organisation is best served by using GIS throughout, making the most of all the data available.

Chapter 6 Providing Operational Oversight to Merlin’s Community-Based

Health Activities in Myanmar Michael Jordan

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Chapter 6 Providing Operational Oversight to Merlin’s Community-Based

Health Activities in Myanmar Michael Jordan

Introduction As previous chapters have shown there is a variety of elements to a community based programme. These elements need to be effectively managed by the organisation to ensure a successful outcome. Providing operational oversight to Merlin’s programmes in Myanmar involves a wide ranging and holistic approach which goes beyond delivery and implementation. It includes all aspects of programme management leading to the achievement of agreed programme goals. The approach follows the elements of the project management cycle and incorporates project planning, implementation and reporting as well as budget oversight, human resource recruitment and management. The approach also includes strategy development, donor liaison, health and humanitarian policy engagement and advocacy, as well as representation at various levels. In essence ‘operational oversight’ and management means the efficient and effective implementation of Merlin’s, programmes and coordination between all sectors. It ensures that any given programme or project and grant is implemented in line with planned activities, expected outcomes and timelines and adheres to the agreed country strategy. It also ensures that Merlin Myanmar contributes to the organisation’s global goals.

Management Structure Merlin Myanmar’s programme management is supported through a Country Office and a number of programme and project site offices. The country office is based in Yangon. The team in Yangon includes a number of senior managers in programme management, health, policy, finance, administration, HR, and logistics. The Country Management Team (CMT) provides the overall strategic direction and programme management oversight to the country programme, with CMT members sharing programme management responsibilities under the overall direction of the Country Director. Each programme or project site office is managed through a Senior Management Team. Team members differ slightly between sites to reflect particular programme needs. However like the country office team, these teams include specialists in management, health administration, logistics and HR. Senior project staff report to Yangon. At the project level, staff supervise and interface with communities, the volunteer health workers and Village Health Committees. At the time of writing (2013), Merlin employs 253 staff members and supports 1,200 villages and 1,400 volunteers. Merlin’s office in London provides oversight and guidance to the country programme.

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Partners Merlin’s principle partner in Myanmar is the Ministry of Health. The relationship involves regular liaising, cooperation and coordination in order to carry out the programmes covering primary health care, with a focus on MNCH, malaria, tuberculosis and sexually transmitted infections and HIV. At the present time Merlin is not involved in any partnership with local NGOs or CBOs, though this is being considered as part of programme development. In addition Merlin works with other INGOs as opportunities arise.

Communications The need to manage a geographically spread programme requires a well-functioning communication system. Satellite phone usage is not yet available in Myanmar. Merlin relies on mobiles, land lines, fax and internet connections for its communications. These are available and function reasonably well in major towns, but may not be available or have poor coverage in programme or project site areas. To mitigate the challenges of this situation, detailed travel routes are adhered to; villages with landlines mapped, and departure and arrival times for all vehicles recorded. Relevant documents are sent to and filed at main offices and regular local staff meetings are held to disseminate and receive information. In addition, Yangon-based staff members undertake regular programme visits to discuss a range of topics with programme staff and to observe implementation at first hand. Programme staff also visit Yangon to be involved in a wide range of workshops, trainings, and meetings. Information sharing is further supported through the dissemination of Senior Management Team (SMT) meeting minutes, grant meeting minutes, and monthly reports, which are circulated to all relevant parties. The Yangon office maintains communications with the London office on a regular basis. Merlin also has communication trees between organisations locally, both in programme and project areas and Yangon. These trees are designed to share information, primarily in the case of emergency situations or problems with security.

Programme management Merlin teams at country and project levels are involved in a range of activities to support the management of programmes through the programme cycle. Merlin’s programmes are guided by the country strategy which outlines the key areas of Merlin’s programming. This includes support to: a co-ordinated township approach to health care provision, community-based primary health care interventions, emergency referrals, and WASH activities. Various factors influence where and how Merlin works including which townships are contained in the organisation’s Memorandum of Understanding (MoU) with the Ministry of Health. These factors are incorporated into the strategy. New projects are developed within this overall strategic framework. Assessments Merlin carries out a needs assessment at the beginning of each project using internal staff as assessors. Merlin also incorporates external information in its assessments. Merlin undertakes baseline surveys for both health and WASH activities, usually in the form of ‘Knowledge, Practice and Coverage (KPC)’, or ‘Knowledge, Attitude and Practice (KAP)’ surveys in addition to a needs assessment. Given the nature of the context in Myanmar, Merlin also increasingly includes a conflict assessment as part of its assessment process. The organisation also assesses its own

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capacity to implement. In addition the communities’ desire to be involved in a project, and the presence of local community management structures, for example Village and Village Tract Health committees also feature in the assessment and subsequent programme decision making process. Project Planning The information from the various assessments is used to support project planning. Merlin in Myanmar relies principally on institutional funding to support its work. Funding is primarily through responses to calls for proposals from a range of donors. The timeframe for submitting concept notes and proposals is often short and with no guarantee of a successful outcome. Merlin reviews new funding sources as they arise. Currently there is little unrestricted funding available which limits the flexibility within the programme to respond to opportunities, or to work outside areas of donor interest. Proposals are developed using the information from programme and project sites and from assessments in new areas. As part of the process Merlin prepares a draft budget based on estimated required costs at the time of submitting a concept note, which is later expanded and confirmed in the final proposal. Once a proposal is accepted by a donor, planning takes place at various interconnected levels: senior staff in Yangon liaise with senior programme staff in drawing up concrete activity, procurement, human resource and administrative plans, and put these into action. New staff often need to be recruited and international procurement orders placed. Senior programme staff will receive input from local staff, who in turn will have consulted directly with communities. Programme staff also discuss implementation with key local stakeholders, for example the District Medical Superintendent. Finalisation of the implementation plan will be agreed between Yangon, the programme and project sites and other relevant stakeholders before the start. Start-up Once a proposal is agreed, Merlin creates work plans and activity plans, procurement plans and budget forecasts for the length of the grant. Merlin also distributes information, education, and communication (IEC) materials explaining Merlin’s mission, presence and interventions to key stakeholders. Starting a project in a new area is more challenging than in existing areas. The most recent example of a new project start up is Merlin’s intervention in Kutkai Township in northern Shan State. Following the assessment, Merlin staff met with local authorities, located an office, warehouse and staff accommodation, hired vehicles, initiated procurement of required assets and recruited new staff. Experienced Merlin staff from other projects were also brought in for short periods to help with start-up. Rapid recruitment of all required staff was completed. Start-up support from a second donor helped in allowing a significant portion of the initial needs for the project to be in place by the time the principle grant commenced. Project Implementation Merlin’s programme model has been discussed in chapter 2. As mentioned in previous chapters, the geographical locations of Merlin’s programmes are quite distinct. Each location has its own challenges for project implementation. The impact on this on Merlin’s ‘model’ of engagement has been discussed in chapter 3. These geographical issues are reflected in the challenges for management and communications, including distance management. Merlin has attempted to overcome these challenges with the use of various communication tools. Visits of project officers and project assistants are the main means by which Merlin gives support to the community programmes, and in particular the volunteer health workers and village health

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committees. Staff after work in teams to conduct a visit. They use checklists to assess the performance of volunteer health workers and village health committees, against their roles and responsibilities. Staff members pass on additional information as required and help with data collection forms, checking pharmaceutical quantities and replenishing them as necessary. Other staff also undertake regular programme visits. The monthly meetings (at rural health centre level in Laputta and the volunteer health worker meetings in Chin and Shan States) are the means by which the volunteers are brought together. A key purpose of these meetings is gathering data sheets, disseminating updated information, and providing training. Attendance rates at these vary from around 65% to 95%, and are influenced by the distances to be travelled; available transport (Merlin covers transport costs), weather and road or river conditions; other work commitments; the ability to take time off, and health status. For volunteer health workers who do not attend, project staff carry out follow up visits to collect data sheets or reports; replenish supplies and convey messages. Meetings for village health committees are held quarterly, with usually one to two members of each village health committee attending, one of which is generally the chairman. The main purpose of these meetings is information sharing. Community health workers and auxiliary midwives, are frequently members of a village health committee. An important role of the committee is the collection and management of funds for emergency referrals. Funds available range widely from one village to another, depending on the willingness and ability of community members to contribute, and whether money drawn from the fund is reimbursed. Further details of Merlin’s referral system in Laputta can be found in Merlin’s paper, ‘Addressing maternal and child morbidity and mortality—supporting emergency referrals: Evidence from Merlin’s programme in Laputta’. For WASH activities, Merlin teams are responsible for oversight in the villages. The team will plan the interventions with the relevant committees, ensure any necessary materials arrive, and assist in project design, and monitor construction and distribution. Monitoring and Evaluation Merlin’s country programme in Myanmar is guided by a monitoring and evaluation framework for health programming, and is described in Chapter 7. In addition to internal monitoring, donors may carry out regular monitoring visits to ensure that Merlin complies with the terms of the agreement or contract. External evaluations of Merlin’s work are also undertaken, conducted by a consultant. Reporting Merlin has both internal and external reporting obligations. Internal reporting is driven by the country programme, either at the request of the London office or by the country office, often as a means to gather sufficient information for reports required by donors. Each report has a person designated to ensure its completion and a deadline for sending to the recipients. Principal reports include the ‘Health Technical Report’, monthly reports (such as a monthly report or situation report for London office), in addition to logistics, finance and administration reports. External reports are chiefly written for donors and comprise of both financial and narrative reporting. In Myanmar, a further reporting schedule is required to provide local authorities with details and progress on projects. From an operational perspective, the most important reports to be received from the programme sites are the monthly reports and grant meeting minutes. The Country Management Team discuss issues arising from the reports. Further action is taken as needed.

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Logistics Merlin in Myanmar has a number of comprehensive logistics policies and procedures that are adhered to for all procurement, asset management, transport and warehousing. These are based on organisational policies and procedures and adapted as necessary for the country programme. In-country procurement is usually relatively simple and reasonably quick. International orders usually require a longer time frame. A lead time of six months is often required. Customs clearance in Myanmar and the paperwork involved in this can be time-consuming. Merlin purchases medicines from approved donor suppliers.

Finance The Country Director is the chief budget holder for all grants received by Merlin. Additional members of staff at various levels have limited authorisation to sign off on designated amounts. Budget forecasts are prepared by finance staff in conjunction with project staff on a monthly basis for all grants. Budget forecasts include a BvA (budget versus actual) over a specific timeframe, plus forecast information. They also take into account committed costs.

Recruitment Merlin is committed to equal opportunities and does not discriminate on the basis of gender, ethnicity, or religion in its employment practices. Merlin’s programmes in Myanmar are guided by the humanitarian principles of humanity, independence, impartiality and neutrality. International staff are recruited by London office, according to the Merlin is recruitment policies and based on a job description and recruitment authorisation form submitted by the country office. All national staff are recruited through the human resource and administration department in Yangon. There are a number of challenges associated with the recruitment and deployment of both international and national staff. These include the timeframe required to support the process for staff recruitment and deployment and retaining staff in remote areas. Delays in the recruitment of staff and staff turnover can have a significant impact on programme delivery. Merlin does not directly employ the volunteer health workers. Communities select them and they serve on a voluntary basis. This is also the case for the village health committee and village tract health committee members. The organisation does, however, support all groups in targeted locations. Due to the voluntary nature of their roles, they are not obliged to remain in post. For a number of reasons, the attrition rates for volunteers is high, with many seeking jobs and moving away from their home areas, or suffering illness or dying. The volunteers may or may not be replaced. Any delay in replacement leads to the disruption of delivery of services and has a negative impact on the population numbers reached.

Support to staff Inductions are crucial to help new staff members become part of the Merlin team, and provide an opportunity for them to familiarise themselves with Merlin’s programmes and procedures in Myanmar. All new staff—international and national—receive a range of briefings when they

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start work. In addition an induction in sector or department policies, procedures and past and on-going programming relevant to the post, is also undertaken. All staff members receive an appraisal with their line manager before the end of their probation period; and then every six months. During appraisals, staff and line manager discuss the member of staff’s work and professional advancement, set objectives, identify training needs, and reflect on successes and challenges. Merlin place the safety and security of all staff as the highest priority. A Security Focal Point (SFP) is identified in all programme and project sites. These individuals report incidents and are charged with taking any required action. Reporting of any incidences is also communicated through the communication trees within Merlin as well as with external actors in all areas. Merlin has created a number of guidelines to support analysis and response to safety and security threats. The documents are updated every six months unless a specific incident occurs requiring an immediate change.

Key Documents Merlin Myanmar has developed a number of tools, systems, policies and procedures to support programme implementation. It has produced a range of guidelines, frameworks, and manuals for reference by all staff members to guide them in achieving programme goals; ensuring targets are reached; outputs and outcomes delivered; timelines met; and budgets neither significantly under- or over-spent, whilst also ensuring cost effectiveness, sustainability, staff safety and security and compliance with both Merlin and donor requirements. The main reference documents are outlined in the table below.

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Key In-Country Documents for Operations

TITLE COMMENTS

PLANS 1. Country Strategic Plan 3 – 5 year plan 2. National Safety and Security Plan Includes site specific plans and topic specific

annexes, e.g. river boat operation MANUALS 1. Programmes Admin Manual (Human

Resource-Administration) Includes all elements of project cycle and key points regarding sectors and departments

2. Merlin Myanmar Finance Manual (Finance)

Finance policies, procedures, documentation and donor reporting

GUIDELINES 1. Field Operations Guideline (Health) Explains the roles of volunteer health workers and aspects of Merlin’s work in villages

2. Warehousing Guidelines (Logistics) Systems, policies and procedures HANDBOOKS 1. Community Based Health Activities

Handbook (Health) Covers all aspects of Merlin’s Health programming

POLICIES 1. Procurement Policy (Logistics) Policies, procedures and documentation 2. Asset and Inventory Management

Policy (Logistics) Policies, procedures, systems and documentation

3. Fleet Management Policy (Logistics) Policies, procedures and documentation 4. Finance Policy (Finance) Policies, procedures and documentation 5. National Staff Policy and Procedures

(Human Resource-Administration) All policies, procedures, documentation, terms and conditions of employment and allowances

6. Merlin Myanmar Recruitment Policy (Human Resource-Administration)

Procedures to be followed for recruitment of staff

7. Emergency Referral Policy (Health) Emergency referral mechanism at township level and payments to patients

8. Tuberculosis referral Policy (Health) Referral mechanism at township level and payment to patients

FRAMEWORKS 1. Merlin Myanmar Accountability Framework

How Merlin is to be accountable to donors, beneficiaries and other stakeholders at all levels of its programming

2. Merlin Myanmar Monitoring and Evaluation Framework

Focussed on data collection and analysis from field sites

CODES 1. Merlin Myanmar Code of Conduct To be adhered to by all Merlin staff during their work, when representing Merlin, and including obligations when away from the work place.

LEARNING 1. Addressing maternal and child health morbidity and mortality – supporting emergency referrals – evidence from Merlin’s programme in Laputta April 2012

Describes Merlin’s experience of implementing an emergency referral system in Laputta

2. Strengthening Human resources for health in Myanmar – lessons from Merlin’s role in supporting midwives in Laputta October 2012

Describes Merlin’s support to midwives in Laputta township as part of the JIMNCH programme.

POLICY STATEMENTS

1. Merlin’ programming in conflict affected areas. November 2012

Briefly outlines Merlin’s approach to working in conflict affected areas in Myanmar

2. What does Value for Money mean for Merlin in the Myanmar context?

Briefly outlines how Merlin approaches Value for Money in its programmes

Chapter 7

Monitoring and Evaluation of Community-Based Health Care Interventions

Emma Child

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Chapter 7 Monitoring and Evaluation of Community-Based Health Care

Interventions Emma Child

Monitoring and Evaluation Monitoring and evaluation (M&E) is one of the most important parts of the project management cycle. It is the management of activities and decision-making procedures used during the life of a project. This chapter provides an account of standard monitoring and evaluation practices and how Merlin, based on its learning, has worked to improve its practices in this area. Essentially, monitoring and evaluation provides the information or evidence upon which the organisation makes crucial decisions and conclusions about the project being implemented. While Merlin Myanmar had in place several data collection tools within the organisation, such as questionnaires and checklists, it did not have an over-arching monitoring and evaluation framework or integrated system. In recent years, Merlin has worked to consolidate the disparate processes that were in place to create a single, consolidated ‘toolbox’ that can generate all the information needed, without creating duplication. There are many accepted definitions of monitoring and evaluation, but the following are simplified versions of the Organisation for Economic Cooperation and Development (OECD) definitions: Monitoring means continuous, systematic collection of data on specified indicators to provide stakeholders in an on-going intervention with information about the extent of progress and achievement of objectives, while evaluation means the systematic and objective process of determining the worth or significance of an intervention. The term ‘intervention’ as used in this chapter can be any type of community-based health care initiative—activities, projects, programmes, strategies or policies. Monitoring and evaluation principles apply equally to all types, although the approaches will likely vary. Monitoring and evaluation are inter-related concepts and tasks. The key characteristics and differences are that monitoring is on-going and continuous, whereas evaluations, typically conducted periodically during or after an intervention, are periodic and time-bound. Monitoring is an internal process and is the responsibility of staff, but evaluations can be internal, external or participatory and are the responsibility of an evaluator.

Intervention Design and Indicators An organisation can create the most practical and efficient monitoring and evaluation system if it directly corresponds to the design of the community-based health intervention. The design of an intervention—the hierarchy of objectives or its logic—is most commonly presented in a logical framework matrix, or ‘log frame’. It is the indicators and means of verification that define how the organisation will monitor and evaluate the achievements of the intervention. The indicators, in turn demonstrate whether the objectives, outputs or outcomes have been achieved. Organisations will find it beneficial to spend sufficient time on determining the indicators, usually when writing the proposal, or when reviewing them during the start-up stage

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of the intervention. The type of indicators community-based health interventions use will vary according to the hierarchy of objectives, or the logic of the intervention, in the log frame1:

An impact indicator measures the goal, aim, purpose, or overall objective; An outcome indicator measures a specific objective; An output indicator measures the output or result; and A process indicator measures an activity.

Impact, outcome and, to a certain extent, output indicators are more likely to be assessed during evaluations; process and, to a certain extent, output indicators will be assessed on an on-going basis as part of monitoring an intervention. That being said, a good monitoring and evaluation system will lend information to the impact and outcome indicators. Evaluators can reflect upon and use this information at specific times, most often towards the end of an evaluation. In community-based health care interventions, the monitoring and evaluation systems can become too unwieldy. A common problem is to have too many indicators. An organisation can greatly facilitate the management and increase the efficiency of the process by obtaining the minimum amount of information to determine whether or not the organisation is achieving the objectives, outputs, or outcomes of an intervention. The indicators themselves must be measurable, and it must be possible to obtain reliable information for that indicator at a reasonable cost – if either of these is not the case, they should not be included as indicators. Similarly, any indicator whose verification requires specific, elaborate procedures that must be set up, are also best avoided. Whenever possible, it is ideal to build on existing sources and procedures already involved in the implementation of an intervention, in order to keep complexities and costs down. This summary highlights the importance of involving all staff members who have expertise and responsibilities in monitoring and evaluationduring the design of the intervention.

Monitoring and Evaluation Framework A monitoring and evaluation framework (or ‘plan’) sets out the structure of an organisation’s monitoring and evaluation systems and procedures related to an intervention. This framework should address the following:

Component Explanation Example What information is collected?

Intervention indicators described in detail, together with any other necessary information

Number of mothers assisted by auxiliary midwives or total live births2

How is the information collected or reported?

Tools used to collect the information

Auxiliary midwives’ monthly reports

Who is responsible to collect or report the information?

Staff primarily responsible for collecting data; avoid sharing final responsibility

Auxiliary midwives

Who else is involved in collecting or reporting the information?

Subsidiary staff needed to help the responsible person collect information

Intervention Officer

1 Terminology varies between agencies; the terms here reflect the usage of many donors to community-based health care programming in Myanmar. 2 Corresponding to a log frame indicator such as ‘At least 75 per cent of births in target villages are assisted by a trained Auxiliary Midwives by the end of the intervention’.

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When is it done? Frequency or interval at which the information will be collected

Monthly, by the second week of each month

To whom should the information be given?

Staff to whom the information will be submitted for analysis or interpretation

Database Officer (data entry) Management Team (monthly) Donor (annually) Auxiliary midwives (semi-annual bulletin)

How is the information used?

Purpose for which interpreted information will be used

Monitor achievements against targets Annual donor reports Feedback loop

Historically, Merlin’s monitoring and evaluation systems had evolved incrementally without any pre-determined structure or frame, meaning that the overall framework was constructed retrospectively. In the end, the system had become fairly sophisticated. Merlin organised its monitoring and evaluation framework by the type of information collected, rather than by individual indicators, which is the norm. After piecing together the various parts of its existing monitoring and evaluation practices, Merlin reflected on the parts of the whole to ask:

Is there a clear flow of information, and are there any overlaps, duplication or gaps? Is there a suitable balance between process and outcome information? Is there a clear distinction between day-to-day monitoring and periodic evaluation or

reflection? Are the sources of information and tools employed varied? Are there sufficient checks and balances on data quality? Are feedback loops identified, whereby information flows back to the implementation

or project level? After reviewing and updating their monitoring and evaluation framework, Merlin presented it in two ways: A summary presentation, to understand what the overall structure and how the parts fit together drawn in a schematic diagram, and a more detailed presentation, which gives staff members guidance on how to put the system into practice, which took the form of a table.

Data Collection Tools As with the monitoring and evaluation framework, Merlin developed specific data collection tools to meet its needs. As Merlin had lacked an overall monitoring and evaluation framework, so there were many kinds of data collection tools, which were not consolidated into a smaller ‘toolbox’ that would generate the same information without duplication. In other words, Merlin’s systems were overly complex and time-consuming. The cornerstone of Merlin’s monitoring and evaluation system for its community-based health interventions is the capturing of data related to the primary healthcare, disease-specific or health promotion services of a given intervention. This capturing requires the ‘front-line’ workers, the volunteer health workers to record information about their consultations and other activities with community members. Merlin then aggregates this information across the whole intervention. For example, Merlin requires different forms of information from the various types of volunteer-community health workers (CHWs) and auxiliary midwives (AMWs). These forms include daily registers, in which volunteers record each patient consultation. AMWs keep records for each pregnant woman and summarise the data from all consultations and patients in a monthly report. Merlin’s previous experiences showed that an overly complex system can create difficulties for volunteer health workers to provide the data easily and accurately and thatkeeping the data

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tools as simple as possible works best and is in keeping with the educational background, familiarity, and expectations of volunteer towards data collection and reporting. Merlin ensures that the data collected is accurate by providing training and on-the-job support to volunteers, being careful to allow sufficient time for this training to be absorbed fully. During the process of improving the monitoring and evaluation systems, a ‘data quality checkpoint’ was also built into the submission process, in which community health workers and Merlin staff review and correct the reports at the time of submission. A Project Officer (and at times Project Assistant) visits each volunteer health worker in their village once or twice a month and hold monthly meetings for all the volunteers to review their daily register and check for the accuracy of the data. The project staff also review the volunteer monthly reports for proper translation of data from daily registers. The purpose of these visits and meetings is not only to check the data quality, but also the quality of the service that the volunteers provide though review of actions such as whether the volunteers have been following treatment algorithms. Merlin’s monitoring and evaluation system employs a variety of other types of data collection tools: Checklists, to understand project staff members’ tasks during routine monitoring visits Testing, to capture the level of theoretical knowledge and skills among village health

workers Beneficiary questionnaires, exit interviews with patients, or Knowledge, Practices and

Coverage (KPC) surveys, to determine the level of knowledge and adoption of practices among community members, or to solicit feedback from patients about community healthcare workers’ services. Merlin use an exit interview for pregnant women and caregivers

A scoring matrix, to assess community healthcare workers’ performance to ensure the quality of the care delivery

The purpose of using such tools is both to establish the starting point of the intervention and to measure subsequent changes during, or at the end of, its implementation. It is therefore very important to establish a baseline (a measurement or description of the pre-existing conditions before a project starts) by gathering information at the start of an intervention. Any indicators with words such as ‘improve’, ‘increase’, ‘decrease, reduce’ or ‘change’ imply a baseline, but others may also require one as well. In the case of Merlin, in trying to get the right tools and make them as useful as possible, the tools or the reporting formats were often changed, causing confusion among the implementing staff and volunteers, so much so that some were no longer motivated to work. Merlin has changed the approach, to review and revise the tools at a specific time during implementation—although not too frequently—rather than modifying them through on-going, ad hoc amendments. A key lesson Merlin has learned has been to test data collection tools in the programme before applying them widely and to avoid unmanageable and confusing revisions for the staff members. Merlin now undertakes testing with a small group of designers and users, prior to wider use. Even a short period of testing is enlightening for all involved.

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In the development of tools, Merlin has taken into account some basic, practical considerations: The length of time needed to use the tool. In most circumstances, Merlin considers an hour

to administer a community questionnaire too long as people lose interest and answer questions half-heartedly. An hour to conduct a focus group discussion, on the other hand, is often not long enough

The complexity of the language. Avoiding technical terms and complicated sentence structures when asking questions of community members or community health workers is best

Translation into the local language/s, especially for tools used by community health workers to collect primary health care service data. Translation of other tools administered by project staff, for example questionnaires for community members, should also be done to maintain methodological integrity. Merlin are translating the tools into Chin languages and into languages appropriate to mixed communities in northern Shan State

Physical layout of the forms. Merlin found that the size of fonts or blank spaces directly contributed to mistakes in filling the forms and these have been amended accordingly

Written guidance on how to properly fill out forms. Merlin tries to accompany each tool with instructions for those that may need them, for example, ‘data dictionaries’ in the volunteer health workers’ daily register forms

Reporting Merlin has integrated its monitoring and evaluation system with the rest of its programme management functions relying on regular staff report formats for valuable monitoring data, while also meeting the internal and external reporting needs of the given intervention. Routine project implementation and management reports from Merlin staff, especially field staff, are a valuable source for monitoring information and are also used to verify other sources. One area where Merlin had developed inefficiency in its original monitoring and evaluation system was requesting the same information in different reports from different parts of the organisation. Merlin found it necessary in certain cases, such as volunteer health worker health education sessions, drug consumption, and village health committee meetings, to have the same data from more than one source in order to be able to validate it. However Merlin was not always undertaking the comparisons to determine accuracy and taking action accordingly. In fact, this ‘triangulation’ process may only be necessary at the beginning of an intervention, and for data known to be particularly vulnerable to under, over-, or inaccurate reporting. Merlin’s monitoring and evaluation systems rely on other project implementation documentation, such as training attendance records, IEC materials distribution lists, or drug stock inventories. This procedure also required staff to repeat information in their own reports, constituting wasted time. As a result of the focus on monitoring data, Merlin has come to understand that staff reporting should include qualitative assessments, problem-solving and ‘forward planning’, as these reveal potential problems related to the successful outcome of an intervention before the data does. Indicators only indicate; they do not explain why certain changes do, or do not, happen.

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Data Management Merlin has placed great importance on addressing data management, which is crucial to a well-functioning and efficient monitoring and evaluation system. ‘Data management’ is how data, after being collected, is recorded, systematised and analysed. Merlin uses its monitoring and evaluation information in a variety of ways: To assess and support the performance of community health workers To monitor outcomes of patient treatment To follow up with patients, volunteer health workers, health centres or hospitals To assess the quality of health service delivery and the delivery of other intervention

activities To compare planned targets against actual achievements To identify problems and bottlenecks in intervention progress For learning and forward planning To be accountable to donors, governments, beneficiary communities and other external

stakeholders To motivate implementers in the field by illustrating achievements and learning

Merlin’s sophisticated monitoring and evaluation system generates a high volume of information that must be systematised through a database, and has built a ‘Community-Based Health Management Information System (C-HMIS)’. Merlin uses Microsoft Access to manage this data. Merlin had originally used Microsoft Excel spread sheets, but found them unfit for the task, although they are still used sometimes to export data for final manipulation and graphic representation. Merlin has developed a particularly good spread sheet in Excel which uses data exported directly from its C-HMIS Access database to report on health outcome indicators for each project in an automated fashion. Qualitative data, such as information on health knowledge, skills or practices that have been collected from questionnaires—as long as they are designed properly—can be systematised and analysed easily, using database programmes designed for the social sciences. Qualitative data is now being systematically and routinely collected as part of programme implementation – and is entered into an EpiData database and analysed using SPSS statistical software. Researchers analyse and interpret manually other kinds of qualitative data generally gathered in smaller quantities, such as through key informant interviews and focus group discussions.

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For quality control of the data, Merlin has built a number of quality control mechanisms into its data management procedures: Technical training of staff who have data management responsibilities in the proper use of

database software or automated spread sheet functions, in order to reduce the potential for human error in data entry and analysis

Work load management of data entry staff, to avoid rushing, which inevitably creates human error

Random spot checks of original paper forms and soft copies of data sheets in order to extrapolate wider error rates and rectify recurring errors

Triangulative comparison of results from various data sources on the same indicators in order to validate findings

Automatic check points built into database design. The Merlin Myanmar C-HMIS Access database has seven checkpoints built into it: five related to malaria, one related to oral rehydration solution, and one related to amoxicillin usage

Following up unexpected results and data outliers, to rule out data entry and data analysis errors

Archiving hard and soft copies of data forms, to leave a trail from source to reported data for accountability purposes

Database filing and back-up protocols, to reduce confusion between users and to ease handovers between in-coming and out-going staff

Roles and Responsibilities Merlin has explored different staffing structures related to monitoring and evaluation: having a senior staff member who specialises in monitoring and evaluation, in whom overall responsibility sits, and who is independent from the line management of individual programmes; and having monitoring and evaluation functions integrated into programme staff positions, with no specialised monitoring and evaluation unit or staff member. Each model has respective advantages and disadvantages. Most recently, Merlin has chosen the latter, following the use of a hybrid model. Key monitoring and evaluation responsibilities now sit with the Country Health Director. Advantages Disadvantages Independent M&E unit or staff member

-Has specialised knowledge -Higher quality of M&E -Independence from interventions, preventing bias.

-Programmes do not own their M&E -False divide between programming and M&E -Expensive for small projects

M&E integrated into programmes

-Gain efficiencies in programming and M&E tasks -Maintain ownership of M&E by programme staff

-Gaps in knowledge of M&E good practices -Distraction of programme staff from ‘pure’ implementation, slowing pace

After determining the Monitoring and Evaluation Framework and programme structure, Merlin developed a monitoring and evaluation ‘roles and responsibilities’ matrix to outline its implementation. This is a table listing the requirements of each staff position in terms of completing forms or reports, their frequency and submission deadlines, and to whom they should be submitted.

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Regardless of which structure is used, it is critical that all staff members with a monitoring and evaluation function are adequately prepared to carry out their roles fully. As monitoring and evaluation becomes a speciality within the development sector, developing the capacity of staff in monitoring and evaluation is critical. Merlin has trained staff in basic skills such as the use of automated function in Excel spread sheets when keeping track of outputs, thereby creating savings in efficiencies and reducing the potential for human error; skills in designing and administering questionnaires and focus group discussions, thereby significantly increasing data validity; and advanced database skills, thereby boosting the power and use of the data collected. These are positives steps.

Chapter 8 Delivering Community-Based Health Interventions Efficiently

and Cost Effectively Melora Simon

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Chapter 8 Delivering Community-Based Health Interventions Efficiently

and Cost Effectively Melora Simon

The focus of this chapter is on the possibility of achieving a more efficient—and therefore more cost-effective—model of delivering community-based interventions. In 2009, Merlin decided to consider ways to improve programme efficiency, especially in light of the substantial scale of Merlin’s operations1. It therefore commissioned an external review of its community-based health programme in order to identify elements within the programmes which could be modified to improve efficiency, cost-effectiveness, and sustainability. This chapter recounts some of the major findings of this external review and discusses how, as an organisation, Merlin has worked to improve its cost effectiveness. Although it has not been able to implement all of the recommendations of the review, nevertheless as an organisation it has reflected carefully upon them, a process which in itself forced it to think through areas of management and operation. Restructuring and reorganisation are topics of relevance to many international NGOs, who may be dependent on several funding streams in order to implement their programmes. As happened to be the case in Merlin, parallel funding can create inefficiencies or redundancies, as organisations may be forced to compartmentalise their operations in response to funding opportunities. The general themes outlined in this chapter have on-going relevance for community-based programme design and delivery, irrespective of whether the Ministry of Health, an INGO or other actor is delivering the intervention. This chapter will be useful to any implementing agency as Myanmar moves towards ensuring universal health coverage and targeting community-based healthcare interventions towards populations living in remote, rural areas.

Background and Context In 2009, Merlin was running community-based health programmes covering two distinct geographical areas of Myanmar: Laputta Township in Ayeyarwady Region and four contiguous townships across Chin State and Sagaing Region, through a network of more than 750 volunteer health workers. Managing an operation of this scale presented a significant challenge. In the last quarter of the year, Merlin commissioned an evaluation to identify ways to improve the sustainability of its volunteer health worker programme. The reviewers used an analytical framework to observe and understand Merlin’s operations that was more familiar to management consultancies than to non-governmental work. A central concern of this review was to find ways to make the volunteer health worker programme, sustainable. The term ‘sustainability’ had two components: to create a lower-cost, higher-impact delivery model which would help Merlin secure long-term funding to finance its programmes. Merlin relies on donor funding, so that reductions in per capita costs would make the programme more cost-effective and therefore more attractive in its fund-raising efforts. The

1External consultants, including myself, undertook this review on pro-bono basis. We work within the health consultancy arm of a large management consultancy agency.

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second component was to make the programme more sustainable for the volunteer health workers themselves. Their participation is crucial to the success of the programme, yet there had been a roughly 20 per cent drop-out rate. Anecdotal evidence suggested that for some volunteers, their other, main livelihoods, such as agricultural work, made it difficult for them to participate in the volunteer program throughout the year. For the people this programme was meant to serve, such dropouts created uneven quality and access. The review therefore looked for ways to reduce the costs of the programme, especially management costs—representing the majority thereof—and increase ways for the volunteers to generate income. Such efforts to improve the situation of the volunteers while doing their work would obviate the need to seek more outside funding. The review did not explicitly consider the effectiveness of the programme, which other reviews have covered. This focus on reducing drop-out rates amongst volunteers through increased income generation must, however, be understood within the overall health policy framework in Myanmar. There has long been disagreement whether providing volunteers with financial incentives is an appropriate long-term policy strategy to increase the sustainability of programmes. No organisation has yet found a viable alternative or adopted a comprehensive strategy to motivate, or increase the retention rate among, volunteers.

Technical Points of the Review The starting point of the assessment involved a desk review of existing data about the health needs of the population from the World Health Organisation. Because of the paucity of data available for Myanmar, only data related to HIV/AIDS and malaria in the country were available, out of which the review inferred other data points. The review identified substantial variation in the geographic distribution of disease, an important fact given that Merlin had operations in different parts of the country. For malaria, for example, areas of Chin State were high risk, whereas areas of Sagaing and Ayeyarwady Regions were much lower risk. The review then compared the financing and operations of Merlin’s two community health worker programmes, the one in Laputta, and the other in Chin-Sagaing , bearing in mind context-specific factors across the dissimilar areas. The two programmes had very different origins. The Chin State-Sagaing Region programme came out of a funding opportunity from the European Commission, which targeted uprooted populations and maternal and child health. Merlin had supplemented this grant with another for malaria from the Three Disease Fund. The Laputta programme developed from a disaster relief programme, first shortly after the Asian tsunami in 2004, and then later after Cyclone Nargis in 2008.

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As a result, there was considerable variation among the programmes, from the scope of practice of the community health workers, to the level and type of supervision and support they received, and the drugs and supplies available to them. For example, the supervisory ratio in Chin State-Sagaing Region was one supervisor to ten volunteer health workers, whereas in Laputta the ratio was one to sixty eight. The remoteness of populations was clearly a factor contributing towards this difference, but not necessarily a complete explanation. These differences in operating models resulted in highly divergent cost structures, with little evidence that the more expensive model was more effective than the less expensive. The review also revealed a mismatch between supply and demand, such as in the volunteer health workers’ kits and the medicines the volunteers themselves provided to clients. The review thus identified standardisation as one way to reduce costs and improve the efficiency and effectiveness of the programmes. Furthermore, the review found there was little on-going performance management, especially at the community level. Merlin undertakes comprehensive and robust programme reviews as part of its grant reporting, but typically at the time, it did not use these reviews to inform day-to-day management. It had in place explicit programme goals and performance indicators, but it had not broken them down into daily targets that could help leadership, supervisory staff, or the volunteers themselves understand how well they were working to achieve the goals.

The review came up with four ways to improve programme delivery: Standardisation; The programmes in the two distinct geographical areas varied along multiple dimensions, resulting in different cost structures and reporting frameworks. Standardisation and streamlining of the operating model across distinct geographical sites could improve efficiency and make budgeting, fund-raising, and communication more straightforward. Each of these elements was placing a considerable time, and therefore resource, demand on management staff. Alignment of supply with demand; Use and consumption patterns suggested that 20 per cent of the medicines and supplies in the kit provided to volunteer health workers accounted for 80 per cent of demand. While this pattern of demand had to be compared to expected morbidity and mortality to ensure the provision of adequate service delivery coverage, the kit contents also had to be adjusted to ensure a match. Local procurement was possible where cost-effective and where quality-assurance could be guaranteed. Performance management; The review revealed that there was a large amount of unexplained variation between townships, and no doubt between individual volunteer health workers. The review suggested creating a monthly performance scorecard or ‘dashboard’ to use in monthly dialogues to understand the root causes of variation and reduce it. Income generation for volunteer health workers; The volunteer health workers are already very effective, but providing them with a source of income in the form of franchise-based social marketing of branded preventative and curative products would improve retention and compliance among them. The following sections elaborate each of these recommendations in greater depth.

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Standardisation and Alignment of Supply with Demand As discussed above, costs and management structure differed dramatically between the two volunteer health worker programmes, with an almost seven-fold difference in the ratio of workers to supervisors, but with little observable difference in effectiveness. In addition, use and consumption patterns of the medical kits varied significantly, but did not appear to be driven by differences in disease burden. These differences had significant implications for Merlin, in demands placed upon the country programme, the funds that it must raise, and upon the financial and operational management.

A problem was that donors could perceive as too high the overall per capita costs of the volunteer health worker programme, making it hard for Merlin to justify those costs, especially given the lack of data to suggest that the more expensive programmes performed better

Programme costs were not standardised, making it difficult for management to know how much funding to request in grant proposals

Programme costs were not well categorised into fixed and variable components, making it difficult to understand the impact of growth or contraction on costs

Programme activities were not fully standardised, making it difficult to achieve fully economies of scale in training and procurement

Neither programme activities nor reporting requirements were standardised, making it difficult to set benchmarks between programmes, define grant-based performance indicators, or manage overall performance targets across the country

Working with staff from each programme site and comparing the performance against the benchmarks of other non-governmental organisations operating in similar conditions in Myanmar, the reviewers developed a new operating model which streamlined and standardised the supervisory staffing and volunteer health worker ratio, as illustrated in Figure 1. Figure 1: Staff structure for VHW program

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Although the review allowed room for Merlin to customise this structure based on local needs—for example, to expenses related to transport infrastructure or staffing needs—the programme model was standardised with one ‘Project Officer’ and one ‘Project Assistant’ position for every twenty volunteer health workers. At the same time, the review assessed other costs with an eye towards streamlining and standardisation. The reviewers found it was feasible for Merlin to reduce the number of field offices, which made for lower operation, maintenance, and staff costs. Merlin management had already begun to reduce the number of expatriate staff members in an effort to build the capacity of nationals and reduce costs. The cost to employ and house expatriate staff was, on average, more than four times that of national staff and double that of the most experienced and skilled national staff. The review suggested ways to lower programme costs by bringing monitoring and evaluation in-house, which was more feasible with a standardised programme. Consumable costs were also reduced, in large part by streamlining the kit of essential medicines and equipment provided to each volunteer health worker and aligning supply with demand. By standardising the kit, several opportunities for bundling and streamlining procurement were uncovered, for example, iron with folic acid for antenatal care; and oral replacement salts with zinc for diarrhoea. Items used infrequently and not considered essential medicines were eliminated. In addition, the review showed that a handful of drugs represented 80-90 per cent of consumption, as illustrated in Figure 2. Figure 2: Four drugs account for 80-90 % of consumption

Overall consumption is much higher in Laputta, through anti-malarial and ORS used less frequently

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Many of these drugs provided symptomatic relief, rather than preventative or curative effects, raising the question whether the workers were doing enough to address primary causes of morbidity and mortality. At the same time, standardisation provided an opportunity for Merlin to stop the practice of giving each volunteer a full refill whenever some of their supplies ran low, and instead to begin to refill only what was needed, with a focus on the most commonly-dispensed items. This new practice would also reduce inventory. Overall, these changes, if implemented, would reduce costs from about $4,000 annually per volunteer, to just over $2,500, as illustrated in Figure 3. Figure 3: Revised CHW Model has an annual cost per CHW of about $2,500

The model was also developed with cost accounting in mind – the review identified fixed costs, variable costs, and those that moved in a step function, so that both staff numbers and budgets could be adjusted appropriately based on expansion and contraction plans.

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Performance Management and income generation for volunteer health workers The review observed that creating standardisation would allow Merlin to manage performance more effectively, both between and within programmes. ‘Performance management’ here indicates a set of tools and processes that create transparency and accountability related to progress towards specific objectives. The review therefore recommended that as a first step, Merlin should establish clear ‘key performance indicators’ (KPIs), targets, and areas of accountability. Ideally, Merlin should balance these indicators across clinical, operational, financial and staff dimensions. Ideally, the overall key performance indicators and targets should be established by the country management team, and individual sites and departments should develop their own key performance indicators and targets under this overall framework. At the time of the review, Merlin had in place a robust quality measurement programme, which it made use of to report in grant narratives. Working with the country management team and leaders from the programme sites, the reviewers developed a draft ‘dashboard’ of fewer than twenty-five performance metrics, as illustrated in Figure 4. Figure 4: Merlin Myanmar CHW Dashboard – Key Performance Indicators

This dashboard covered five domains: quality, population coverage, activity, efficiency, and management effectiveness. Merlin was already collecting the vast majority of these at one site at least, although not all areas in all places, a situation which again highlighted the need for standardisation. An initial analysis of available data within a given State or Region revealed variation between townships unlikely to be explained by differences in need or disease burden. This situation is illustrated in Figure 5.

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Figure 5: Chin/ Sagaing Dashboard – August – September 2009

This new performance management system would enable Merlin to understand this variation by engaging front-line staff in problem-solving dialogue to help reduce it and bring everyone to a higher level of performance. In the end, Merlin was unable to implement the dashboard as the reviewers recommended it, as the complicated formulation proved unfeasible. Nevertheless, Merlin benefited greatly from the insights of the reviewers, which prompted it to present the recommendation. After the review in 2009, performance management became a key focus of the programme, but the system of performance measurement ended up being much simpler - a response to the context of working in Myanmar. A key insight was to see that when, as an organisation, it identified problems with performance, a useful response was not to focus on the deficiencies of the individual, but to see rather what could be done to address the problem as an organisation, or what could be done to support the individual, or whether there was something in the context of the programme that had been overlooked. This new approach has proved effective, with benefits cascading down to each volunteer health worker, who is responsible for delivering health education and providing basic preventive and curative health services for a catchment area. Although they are volunteers, the workers operate within a governance structure: each one is nominated by the Village Health Committee of a village and has a project officer (and project assistant) above them who is responsible for providing training, support, and oversight. The volunteers can be held to account for their performance and supported to improve through a set of individual targets such as the ones in Figure 6 and the reward and consequence management system described in Figure 7.

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Figure 6: Example performance management rubric CHWs

Figure 7: Example reward and consequence regime

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Programme Sustainability through Income Generation for volunteer health workers The final recommendation of the review had to do with creating income for the volunteer health workers to help make the work more sustainable for them and their families and to increase retention. The reviewers explored the franchise-based social marketing model Population Services International, Myanmar (PSI) uses to allow their volunteer health workers to earn income by selling branded health promotion and medical products that the Ministry of Health has not mandated to be made available for free. PSI subsidised these items so that they could be sold at an affordable price to patients, yet still generate a profit for the volunteer. Each of these products has demonstrated impact on the morbidity and mortality burden in the country, and under PSI’s ‘theory of change’, the small user fee attached to the product ensures that people will use them, unlike products they receive for free. Although there were many details to be worked out, the reviewers saw this as a good model for creating locally-driven funding to improve the sustainability of the programme for the volunteer health workers.

Merlin’s programmes in 2012 The context in 2012 has changed significantly from 2009, when the review was commissioned. The four recommendations outlined above are still relevant to the delivery of community-based interventions, and any organisation working in community-based health care in the country will face similar problems and circumstances. Over the past three years, Merlin has undertaken considerable work to address the first three recommendations. The Ministry of Health will need to address the fourth recommendation through national policy, and poses the greatest challenge to policy development. Compared to three years earlier, by 2012 Merlin was focused upon the eventual goal of institutionalising and incorporating the community-based programmes into the public health system of the Ministry of Health. The recommendations of 2009 however have proved important and whilst Merlin has in main accepted the recommendations of the review, it has made substantial changes to the performance management framework originally proposed as a consequence of a number of further studies. Merlin uses a performance management scoring tool to determine adherence of community health workers and auxiliary midwives, which has proved to be a simple tool for monitoring one aspect of the quality of the service delivery. Furthermore it has developed geographic information systems mapping of outputs and performance measures, which allows it to present unexplained variations in performance visually, and as a consequence, seek underlying explanations (see Chapter 5).

Chapter 9 Conclusions and the way forward

Paul Sender

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Chapter 9 Conclusions and the way forward

Paul Sender The preceding chapters have provided an outline of the various efforts taken to promote improved delivery of Merlin’s community based health programmes, to better meet the health needs of the population in Myanmar. These experiences and challenges are part of an on-going dialogue within the organisation to turn experience into learning: trying new ideas, evaluating them, and building on the findings for the future. As the introduction asserted, the purpose of this publication has not been to claim that Merlin’s approach represents either an authoritative position, or one that is comprehensive. Rather by making the learning available to a wider audience, Merlin hopes that it will be useful for other agencies, within and beyond Myanmar, in the development and implementation of their own programmes. In addition it is hoped that the publication will contribute to the discussion on the role of community based health care in the Myanmar context at this time - in terms of promoting equity, reaching universal health coverage, and addressing the current high burden of disease, particularly in infant, child and maternal morbidity and mortality. At a global level, the evidence suggests that community based health care remains an important approach to extending the reach of essential heath services across a range of contexts, and there is substantial momentum behind plans to increase the numbers of community volunteers in many countries. The appeal to expand the community level cadre is, in part, a response to the challenges of under-resourced health systems and a lack of sufficient trained health staff to deliver a basic package of health care. However this very situation presents a challenge for the success of the community approach. The effectiveness of volunteer health programmes, is to a great extent, dependant on support from, and integration with, the health system. In the Myanmar context, the National Health Plan includes all elements of primary health care, with community health care as one of the priorities. However approaches to community based programming differ across agencies working in the country with implications for quality, scale up and sustainability. Agreement on an approach to delivery, aligned to the public health system, could therefore support a more comprehensive scale up across the country. Merlin’s approach to community health programming aims to promote the link between communities and the wider public health system. Community participation is strengthened through the support to Village Health Committees who work with the volunteers and support health within the villages Over the years, Merlin has refined its approach to develop a “standardized” model. This has allowed Merlin to scale up coverage and ensure quality implementation. However the context in Myanmar is diverse and Merlin has also realised that a “one size fits all” will not always be appropriate to deliver the quality of care that is required. Adapting the model to accommodate the various contextual factors is both necessary and important. This has been easier to do from the basis of a strong core approach and a vision of what is expected in terms of outcomes. Merlin has followed Ministry of Health guidelines and policies, worked with Ministry of Health staff in training of community health workers, and promoted the links between community health workers and the health system, wherever possible. This includes the supervision of

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community health workers by midwives and other BHS. This approach has offered opportunities for supporting the current system and should better promote the integration of the community based programme into existing systems in the future. This approach has also offered the opportunities to foster the linkages between the community and higher levels of care, strengthening the continuum of care, and thus the quality of health services received by populations. This is particularly vital when addressing maternal and child mortality. In addition linking the community level programmes with higher levels of the health system such as at township and regional levels, also provides the opportunity to discuss the learning from programmes and advocate for turning the policy on community healthcare into practice. Many of the health issues faced by communities, are preventable. Changing behavior within communities to protect themselves from disease, or take the correct action when a problem is identified , is therefore a critical aspect of addressing the high burden of morbidity & mortality faced by communities. The role of BCC in preventing ill health has been outlined in chapter-4 based on Merlin’s experience. This experience has reinforced the point that behavior change is about persuading people to do something different – it is not solely about information. This requires a continuous investment as a means to engage communities and present messages. BCC is therefore not a one-time exercise. Merlin has also invested in information systems to support its programmes. These have provided data which can help map programme inputs and outputs and monitor the effectiveness of programme implementation. In the longer term ensuring that the key elements and lessons from this experience are embedded in the township health information management system will be an important contribution to ensuring the long term effectiveness of community based programmes within the public health system. Ensuring that community based programmes are cost-effective has also been touched upon in the publication. As outlined in chapter 8, it is possible to make programmes more cost-effective by reducing costs and introducing new elements of cost-recovery. However with the increasing opportunities to work with the health system in Myanmar, the most likely means to promote cost-effectiveness, as well as sustainability, will be to strengthen the links between the community health care elements and the wider public health system. This means supporting the routine supervision of community health volunteers within the schedules of midwives and other BHS, and ensuring that community health workers are able to deliver a defined package of cost effective services at the local level, and refer patients to higher levels of care when necessary. The recent lesson learning exercise from the Joint Initiative on Maternal and Child Health Care, conducted at the end of 2012, highlighted the important role played by community health workers in the delivery of essential services within the township and the impact that they can have (JIMNCH, 2013). This is particularly the case in “hard to reach” areas of townships where it may be very difficult to reach communities effectively with the current public health system. Understanding how best to support this community cadre within the wider public health system is a vital part of maximizing their contribution and ensuring the sustainability of the approach. Key policy areas that this publication has highlighted include the distribution of volunteers, and how this relates to different contexts in Myanmar and to issues of cost and sustainability; the definition of their roles vis a vis professional health cadres, such as midwives and other BHS; the nature of the essential package that they deliver at community level, including treatment protocols; and issues around how they can best be supported to ensure good performance and

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retention. These and other key policy issues should form part of the on-going discussions and process to revise the National Health Policy. As a way forward a systematic review of the role of volunteer health workers in the Myanmar context, bringing together the wealth of experience and learning from the Ministry of Health and development partners to date, would provide a strong basis for ensuring that community based health programmes play an effective role in delivering on improved health, in the changing Myanmar context. Merlin hopes that the information contained in this publication will help support this dialogue.