Data collection took place between May 1st and June 6th, 2021. Fifteen KII and 16 FGs were conducted in the two countries. A total of 169 people participated in this study (Table 1). Nine program reports that were reviewed for data extraction into the excel tool. The documents included: Assessment study for Community Health in Ngo Dakala and Ngo Ku (South Sudan); Community Health Trainer Training Workshop Report (CAR); community consultations and engagement meetings report (Grevai. CAR); community consultations and engagement meetings Report (Ouandaogo in CAR); Community volunteers training reports (Ouandaogo, Grevai); Community volunteers field activities report (CAR); Training of Trainers report (CAR).
Table 1
Role and gender distribution of the participants
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South Sudan
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Central African Republic
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Key informant interviews2
|
Total participants = 15
|
Total participants = 7
|
Total participants = 8
|
|
Males
|
Females3
|
Males
|
Females
|
MoH
|
2
|
0
|
1
|
0
|
ICRC
|
2
|
0
|
1
|
2
|
HNS
|
1
|
1
|
2
|
0
|
CRC/ICRC delegate in the field
|
1
|
0
|
2
|
0
|
Focus groups
|
Total groups = 16
Total participants = 154
|
Groups = 12
Participants = 114
|
Groups = 4
Participants = 40
|
CHW/volunteers
|
# FG: 2
Total number of participants (all groups combined): 20
Type of group: Mixed (male and female)
Catchment areas: Ngo Dakala (1), Ngo Ku (1)
Female participants: 6
Male participants: 14
|
# FG: 1
# Participants: 10
Type of group: Males only
Catchment areas: Ouandaogo
|
#FG: 1
# Participants: 10
Type of group: Females only
Catchment areas: Ouandaogo
|
Community leaders/ elders
|
# FG: 2
Total number of participants (all groups combined): 20
Type of group: Mixed (male and female)
Catchment areas: Ngo Dakala (1), Ngo Ku (1)
Female participants: 5
Male participants: 15
|
# FG: 1
# Participants: 10
Type of group: Males only
Catchment areas: Ouandaogo
|
# FG: 1
# Participants: 10
Type of group: Males only
Catchment areas: Ouandaogo
|
Community members (men, women, and adolescents)
|
# FG: 4
Total number of participants (all groups combined): 39
Type of group: Males only
Catchment areas: Ngo Dakala (2), Ngo Ku (2)
Adult men: 2 groups, 19 participants
Adolescent boys: 2 groups, 20 participants
|
# FG: 4
Total number of participants (all groups combined): 35
Type of group: Females only
Catchment areas: Ngo Dakala (2), Ngo Ku (2)
Adult women: 2 groups, 15 participants
Adolescent girls: 2 groups, 20 participants
|
|
The following section is organized according to the study’s objectives and identified thematic areas relating to the delivery of RMNCAH services in armed conflict settings. The thematic areas were: 1. feasibility, 2. barriers to the delivery of RMNCAH services, and 3. strategies to improve agility and responsiveness for program delivery in armed conflict settings.
1. Feasibility of delivering community based RMNCAH services in armed conflict
Figure 1 provides an overview of the implementation process for delivery of RMNCAH services in armed conflict settings in CAR and South Sudan. The analysis of the program implementation reports, and key informant interviews showed that the implementers engaged the tribal chiefs, community leaders, elders, beneficiary groups, including men and women in both countries, prior to program implementation. Details of community engagement and implementation outcomes can be found in Table 2.
Table 2
Community engagement and implementation outcomes after one year of program (November 2020 to December 2021) implementation in CAR and South Sudan
Outcomes
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CAR
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South Sudan
|
Community consultations
|
Participants: men, women, adolescents, and village elders
Number of meetings: 51 meetings (31 in Ouandago and 20 in Grevai)
Number of villages engaged: 68 villages (39 in Ouandago and 29 in Grevai)
Location: Villages
|
Participants: Village elders
Number of meetings: 12
Location: Basic Health Centres
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CHW identified by community
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175 CHWs and 6 supervisors identified and trained
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73 BHWs4 and 7 supervisors identified and trained
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Training sessions and refreshers
|
11 additional trainers trained, 13 coaching sessions, no refreshers in the first year
|
31 BHWs received coaching sessions, 1 refresher training for all the trained BHWs
|
Material support
|
175 CHW tool kids, education materials, job aids and data collection tools distributed
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73 CHW tool kids, education materials, job aids and data collection tools distributed
|
Motivation
|
175 bicycle, 2 football competitions
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7 bicycle, monthly incentive US$ 25
|
Ongoing community engagements and referrals
|
6 monthly meetings, 1community-based referral system
|
No consistent process
|
Household visits
|
18,726
|
4,790
|
Case referrals
|
495 referred
|
10,955 cases seen; 8,748 cases referred
|
Unanticipated consequences of the program through community led actions
|
1,587 new latrines constructed, 2,389 dish rack constructed
|
-
|
Our analysis of the program implementation reports showed that community consultations and engagements in CAR and were arranged through extensive community mobilization by the Central African Republic Red Cross Society (CRCA); took place in villages where a rapid scan of health needs was previously completed (Table 2). In South Sudan, chiefs and village elders were directly consulted where planned activities were explained to them, and their permissions were sought to engage with the community and took place in local Basic Health Units
In CAR, The CHWs were trained on eight topics Knowledge of the Red Cross Movement; Introduction to Community Health; CEA (Community Engagement and Accountability); PSEA (Prevention and Response to Sexual Exploitation and Abuse) and PSS (Psychosocial Support); Communication for behaviour change; Project Management and Monitoring and Evaluation; safe motherhood & child health; The training curriculum, materials and content were derived from standard Red Cross/IFRC manuals & curriculum and the local Red Cross (CRCA) community health guidelines and materials. The training was delivered in local churches, health centres, local Red Cross offices, and even under trees. Since literacy is low across the country, andragogical training, which trains people to share knowledge through pictures and means other than written words, was part of the CHW training package. The trainings increased the knowledge levels for the CHW/BHWs; the difference in mean scores for pre-test (63.3% (95% CI, 60.2 to 66.3)) and post-test (80.6% (95% CI, 78.4 to 82.8)) was statistically significant, (p < 0.0001). One group of trainees (n = 11) was surveyed daily about their satisfaction with the training, with more than 50% satisfied by Day 3. Additionally, the level of satisfaction increased as the training progressed, with most participants (60%) conveying a high level of satisfaction by Day 5. The supervision process entailed one supervisor responsible for mentoring, monitoring activities, replenishing supplies, and resolving service delivery issues for 10 to 15 CHWs.
KII and FG analysis provided further insights regarding factors contributing to feasibility of delivering health services in armed conflict affected areas. Engaging community elders, who were considered ‘gate keepers’ to the community, emerged as an overarching theme, underpinning which was the importance of gaining community ‘trust,’ entry into the community, to improve buy in by the community, identify and retain CHWs. Building trust was especially important in armed conflict settings where communities were forced to move into the bush.
To facilitate the process of community engagement, our participants identified three themes linking to feasibility of service delivery in armed conflict settings: (i) well-defined and clear messaging regarding the available services, (ii) inclusive participation for community consultations and (iii) delivery of those services by someone from the community.
The elders, community leaders and program implementers identified well defined, clear messaging in local languages to be an effective way to gain community trust and buy in and easily deliver services. “If clear message is delivered and they understand the situation and they know what is going to take place and they will accept. - once they understand it by implementing in the project”- Program implementer, South Sudan.
Although, there was an emphasis on engaging village elders, in our focus group discussions with adolescent boys and girls, it was strongly recommended the need of engaging adolescent more to bring their perspectives to the table. “…it is not a problem to engage village elders because they have more and more experience and they have so much more information than adolescents” - Adolescent boys group, South Sudan.
“…for me the problem in engaging elder because – they may not [be] qualify [ied] person to deliver the information or have problem in his eyes or something like this and you [know] in the earlier time there was no education”- Adolescent boys group, South Sudan.
Commitment to stay with the community during the conflict was identified as key to selecting community healthcare worker volunteers. Both countries have low literacy rates, therefore, reading or writing was not a pre-requisite for all community volunteers. However, the volunteers/CHW worked in pairs in each village, at least one of the pair was expected to be able to read and write. One key informant from CAR described the eligibility criteria for CHW as: “They have to be native to the village or the neighbourhood, and they cannot be insolent or insulting. Must not be minors but must be men and women who can read/write and are respected. Volunteers in the community elect people and send a list [volunteers from each village are selected from the list]”- Description of eligibility criteria for CHW recruitment by a Key Informant in CAR.
2. Barriers to implementation of community-based RMNCAH services in conflict-affected areas
Barriers to implementation of community-based RMNCAH services in conflict-affected areas emerging from analysis of KII and FGs, were clustered under two main themes:
-
Barriers to community engagement, community-based assessments, delivery and monitoring of health services (sub-themes: security issues, trust issues, lack of resources, difficulties in accessing health services, lack of motivation, and knowledge and communication gaps).
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Barriers to identification, recruitment, training, and supervision of CHWs (sub-themes: socio-cultural issues, lack of motivation, logistical issues, knowledge, and communication gaps).
Security-related issues, which included the threat of acute conflict, uncertainty amidst protracted conflict, and physical barriers between government sectors and areas controlled by armed groups, emerged as a significant hindrance to all aspects of program implementation. Knowledge and communication gaps pertained to language barriers, health literacy, data literacy and miscommunications about available services and budget allocation. Language barriers were a consistent sub-theme for barriers across the implementation process. Figure 2 provides details of the contributing factors and interconnectedness of barriers to implementation of RMNCAH services in armed conflict affected settings.
3. Strategies for context specific agile and responsive programing in conflict settings
Our participants identified several solutions to overcome the barriers and strategies to improve context specific health programming. These strategies were organized under eight themes to serve as strategies for program implementers to include throughout program cycle, inclusive of the program design and planning phase, to improve agility and responsiveness, especially in armed conflict contexts.
3.1: Community engagement and leadership
Engaging chiefs, elders, community leaders, and relevant stakeholders was identified as the most important strategy to ensure community responsiveness, especially in conflict settings. “Must identify the key actors in armed conflicts and understand their role and whether it is possible to engage them” – Key informant, CAR.
“Chiefs were there [community engagement and assessment sessions] so that provide legitimacy” – Key informant, South Sudan.
Engage the communities through elders and chiefs to ensure that community partners understand the project well and support its rollout in communities. “..once they [community leaders] understand it by implementing in the project, this is where you justify [your presence in the community]” – Key informant, South Sudan.
Some KIIs in CAR and South Sudan identified having an official workshop or meeting with the communities to discuss the project scope to clarify expectations and effective community engagement to ensure that the communities are engaged throughout the implementation process.
3.2: Collaboration and negotiating safe passage
Agility in service delivery was improved by working closely with local health authorities, including Health Facility Staff, local Red Cross societies/committees, the community leaders and representatives, and military authority/armed groups of respective areas for project implementation. “..discussing with the unarmed men to show them the advantage of the programs, how it helps their families, their wives not have to give birth at home”- Key informant, CAR.
“They should be [able to] disseminate [information] for military about ICRC works and their views, and also let them train more volunteers by give them skills and knowledge.”- Community leaders group South Sudan
Collaborating with the Ministry of Health in project orientation and reporting is essential as they may often face access constraints to conflict-affected areas, whereas ICRC can access them. Safe passage was identified as essential to continue the work in the area. The participants emphasized the need to inform all political elements, including armed groups, about the planned activities, including any assessments. Crossing checkpoints was fraught with unknown dangers. The passage is safer if all the factions are aware of the activities and the implementers, CHW supervisors and CHWs are provided with proper legal documents.
3.3: Comprehensive delivery of services within communities
Communities emphasized the need to identify with one trustworthy service provider for all their needs as being more acceptable. Allow NGOs to be responsible for the comprehensive delivery of services in one area, such as healthcare. Rather than fragmenting services between NGOs in one community, it will be easier for the community to connect with one organization delivering all the health and related services. Having CHWs embedded in the community with adequate supplies is vital in conflict-affected settings as war may ensue at any time and communities are blocked. With proper resources, CHWs within the communities can provide the necessary support and care during an acute outbreak of conflict. “…[availability of] emergency box drugs so in case if there is anything bad [war/conflict] happened we may go with our treatment” – Women’s group South Sudan.
Another aspect of enhancing the agility of health service delivery was setting up a well-structured referral system for referrals from the community to the health facilities. The participants identified that reinforcing community relay capacity was essential in conflict settings, especially when the populations are displaced due to the conflict.
3.4: Logistical considerations to improve access
Distances and transportation emerged as crucial barriers to accessing CAR facilities. However, more importantly, this was a challenge for CHWs and their supervisors to reach the communities to deliver their services. Providing CHWs and their supervisors with bicycles was identified as a solution to distance, lack of transportation, and poor road infrastructure. The participants also identified weatherproof resources such as raincoats, boots, and rainproof bags to protect learning material as essential, especially during the rainy season. The supervisors suggested that their area of supervision should be divided into smaller manageable areas, so access to CHWs in their assigned areas is manageable. Better coordination between NGOs to set training times and avoiding any sessions during rainy and harvest seasons were likely to improve CHW participation in the training process.
3.5: Bridging knowledge and communication gaps
All the participants agreed that the training and services should be provided in local languages, and through the use of innovative approaches such as use of use of pictures and figures to train CHWs and educate the communities was identified as a solution. To build awareness in the communities, health workers can engage in discussions in the local language and explain health-related concepts by breaking them down to easily understandable and relatable ideas. Using easy-to-understand mini-modules and methods to repeat the information multiple times was suggested to train CHWs.
3.6: Empowering women and adolescents
Identifying women leaders with the support of the communities, setting up training that does not impact their daily lives, and support networks for women were identified as necessary to improve mother and child health in these conflict-affected communities. Engaging men to educate them about the importance of empowering women to participate as CHWs, supervisors, and leaders in delivering primary health services was essential in ensuring that women are part of the process.
There was consensus among adolescent focus groups, both boys and girls, in expressing the need to be included in assessments and wanted to be trained as CHWs to support their peers and communities.
3.7: Resources and incentives
The issue of financial incentives was where we found discordance among the participants. Better financial incentives were identified as a solution to lack of motivation, especially those stemming from competing priorities. Program implementers and some community leaders viewed financial incentives as a demotivator for community-based work. In their view, this work was based on charitable and innate goodwill for their communities—CHWs who provided these services viewed this as extra work. Despite intending to do good for their communities, they needed to find livelihood to ensure they could provide a decent means to their families. There was consensus on need for more resources such as medicines, basic first aid, and training materials were needed.
3.8: Training and awareness
Participants in CAR raised the importance of working modalities to transfer knowledge to local community members to ensure service continuation and sustainability. Another strategy to improve program agility is to provide ongoing training responsive to community needs, conduct continued ongoing needs assessments, and adjust accordingly. It is essential to ensure that regular trainings are taking place during peacetime so the CHWs are ready to respond, and all stakeholders are aware of the activities. “we need to talk and motivate others [and] agencies during peacetime to train and disseminate their roles and view to the military side to reduce suspected rumors and to know the importance of these services” – CHW group South Sudan.
Additional strategies identified by the participants were regular refreshers for CHWs and supervisors in partnership with the government, engaging monitors in planning activities, including supervision-related activities and training for data monitoring, highlighting the importance of data in planning. “Lack of qualified or experience community health workers is a major gap... The strategies will [entail] going back [partnering with] to the government [to set up trainings in partnership with the government]. If people are trained, they can help communities” – Key informant, South Sudan.
Engaging community members and using unique and innovative approaches, such as radio communications and local means of arts and expression to set up awareness campaigns, is another way to improve responsiveness and agility in delivering health services. Awareness campaigns focusing on promoting messaging against Gender-Based Violence (GBV) and other health messages through the engagement of women and youth are likely to improve community responsiveness. “…we need to be engaged because we need for us health workers from women and from youth and from boys and girls in our community to learn about the work for the next time these people can’t come around [because of war] they [CHWs living in community] will do it”- Women’s group South Sudan.
[2] MoH: Ministry of Health; ICRC: International Committee of the Red Cross; HNS: Host National Society; CRC:Canadian Red Cross
[3] Preference was given to female participants, limited in recruiting female participants for KII as the sampling pool for females in leadership position was limited.
[4] In the communities in South Sudan, it was easier to find CHWs as most of those had been identified through the government’s Boma Health Initiative Policy. Boma Health Workers or BHWs a network of volunteers organized by the Ministry of Health in South Sudan works in communities to bridge the gap between community and health facilities. The network consists of the Boma Health Committee, the Boma health workers, and the Boma health supervisors.