Exploring competing experiences and expectations of the revitalized community health worker programme in Mozambique: an equity analysis

Abstract

IntroductionMozambique launched its revitalized community health programme in 2010 in response to inequitable coverage and quality of health services. The programme is focused on health promotion and disease prevention, with 20 % of community health workers’ (known in Mozambique as Agentes Polivalentes Elementares (APEs)) time spent on curative services and 80 % on activities promoting health and preventing illness. We set out to conduct a health system and equity analysis, exploring experiences and expectations of APEs, community members and healthcare workers supervising APEs.MethodsThis exploratory qualitative study captured the perspectives of a range of participants including women caring for children under 5 years (service clients), community leaders, service providers (APEs) and their supervisors. Participants in the Moamba and Manhiça districts, located in Maputo Province (Mozambique), were selected purposively. In total, 29 in-depth interviews and 9 focus group discussions were conducted in the local language and/or Portuguese. A framework approach was used for analysis, assisted by NVivo10 software.ResultsOur analysis revealed that health equity is viewed as linked to the quality and coverage of the APE programme. Demand and supply factors interplay to shape health equity. The availability of responsive and appropriate services led to tensions between community expectations for curative services (and APEs’ willingness to perform them) and official policy focusing APE efforts mainly on preventive services and health promotion. The demand for more curative services by community members is a result of having limited access to healthcare services other than those offered by APEs.ConclusionThis study highlights the need to pay attention to the determinants of demand and supply of community interventions in health, to understand the opportunities and challenges of the difficult interface role played by APEs and to create communication among stakeholders in order to build a stronger, more effective and equitable community programme.

Who is a community health worker? – a systematic review of definitions

“…Some CHWs have additional roles of providing treatment for basic clinical conditions and minor ailments such as malaria and diarrhoea [ 15 , 38 , 39 , 44 , 55 , 95 , 99 , 122 ]. Other CHWs provide basic obstetric case management but the CHWs providing this have completed post-secondary formal training in order to provide these services [ 28 , 30 , 32 , 52 ].…”

Optimising the benefits of community health workers’ unique position between communities and the health sector: A comparative analysis of factors shaping relationships in four countries

“…In Kenya, the gender preferences seemed to be mixed. In Mozambique, unrealistic expectations from the community regarding curative tasks of APEs were more profound than in the other countries (Give et al, 2015). This could be a result of health facilities being less accessible: Mozambique has the largest catchment population per CHW, while the country has a challenging topography.…”

“…Elements of CHW programme design such as support, accountability and communication structures can influence relationships. When those structures do not function optimally, CHWs can face significant challenges in building trusting relationships with community members and actors in the health sector, leading to demotivation and tensions as a result of trying to accommodate conflicting interests and expectations (Give et al, 2015;Kok, Kea, et al, 2015;Maes & Kalofonos, 2013). Similarly, when contextual issues such as gender norms are ignored, relationships may be undermined as well (Viswanathan et al, 2012).…”

Close-to-community providers of health care: increasing evidence of how to bridge community and health systems

“…Qualitative research in Mozambique by Give et al [ 2 ] also reveals how demand and supply factors interplay to shape the APE’s task prioritisation and hence impact on health equity. Give et al [ 2 ] argue that APEs found themselves caught between community demands for broader curative services while the official policy largely limits their focus. APEs showed agency in co-constructing a middle path acceptable to all.…”

“…APEs showed agency in co-constructing a middle path acceptable to all. Saprii et al, Kok et al and Give et al [ 2 , 4 , 6 ] demonstrate the impact of weak health systems on CTC provider credibility and ability to fulfil their role. For example, in India, the health centres that ASHAs link to are ill-equipped and poorly functioning with negative consequences for the ASHA’s ability to inspire trust and credibility in the community [ 6 ].…”