Three different scenarios for policy development and implementation are considered. The context assumed for all scenarios is the same as in the case-study, i.e. Pernambuco
State and Municipality of Recife, the State Capital. All scenarios assume that the Federal policy documents such as the NPHCP and FHS, which are under the responsibility of the Federal government, remain unchanged. All scenarios are based on the evidence emerging from both the literature review (Chapter I) and the case-study (Chapter II) i. e. that in order to improve CHWs’ performance in RMNCH some systemic cross-cutting issues related to the role of CHWs are addressed. Of course, the possibility to address systemic issues decreases along the levels of responsibility and become minimal, yet still existing, at the micro-level of FHTs.
Policy packages include the main policy contents which are listed in the Policy Compendium, with the addition of specific RMNCH technical inputs, for example training, contents, guides, job-aids. Policy contents, for this specific purpose, have been here described with some greater level of detail than in the Compendium and may be further adapted to represent aspects of the policy that can be implemented at the micro-level, for example the identification of community consultation mechanisms may be narrowed down to the identification of specific community stakeholders.
The first scenario (Box 6) assumes that no commitment is taken at Municipal level and that a few interventions can be implemented only in one or two districts, i.e. at a scale similar to that of the intervention trial analyzed in Chapter II.
Box 6 RMNCH-specific limited policy package 1. Specific RMNCH training
2. Action oriented RMNCH Guide
3. Nurses (1 per FHT) trained in guide content and supervisory skills 4. Periodical meeting among CHWs about the application of the guide
5. Set up, at District and FHT level, mechanisms to monitor responsiveness of health system to cases referred by CHWs and feedback information to CHWs 6. Ensure adequate time and space for periodical meetings at FHT together with
the supervisory nurse to address difficulties arising in their work 7. Simple practical data collection for use at District and FHU level
8. Community stakeholders identified and involved in monthly meetings to monitor and assess interventions and address emerging issues
The second scenario (Box 7) assumes that the policy commitment is taken only at Municipal level (City of Recife), that the main policy focus remains RMNCH, and that some cross cutting issues regarding CHWs’ work are addressed as functional to improve CHW’s in RMNCH.
Box 7 RMNCH specific extended policy package
1. Program coordinators identified (doctor or nurse plus a CHW) 2. Specific RMNCH training
3. Action oriented RMNCH Guide
4. Nurses identified for supervision (1 per FHT) trained in guide content and supervisory skills
5. Periodical M&E meeting among all CHWs about the application of the guide 6. Minimum professional incentive plan (e.g. extra training opportunities, special
mention for best performing CHWs)
7. Mechanism set up at District or FHT level to monitor responsiveness of HS to cases referred by CHWs
8. Adequate time and space for periodical meetings within FHTs to address difficulties arising in their work
9. Simple practical data collection tool for use at District and FHU level
10. Collaboration with other health professionals (e.g. social service) for administrative tasks
11. Community involvement & communication package defined by working group (E- messages, leaflets)
12.Community counterparts identified and involved in monthly meetings to monitor and assess interventions and address emerging
The third scenario assumes that State Government and Municipal authorities collaborate to develop a policy package to improve the performance of CHWs which includes not only RMNCH (comprehensive policy package, Box 8). This approach, fully recognizing that most barriers are of a cross-cutting nature and not specific of RMNCH technical contents, includes policies which are mostly aimed at improving the performance of CHWs irrespective of specific technical contents, and a few interventions addressing specific RMNCH related needs, particularly related to training and job aids and tools.
Box 8 Comprehensive policy package Cross cutting components
1. Mandatory initial training of 1200 hours as defined in PACS, as requisite for CHWs to start working; mandatory 400 hours training for all CHWs which did not yet receive the training
2. Training ensured also for nurse professionals in charge of training and/or supervision 3. Continuous education plan that includes 40 hours of CE every 5 years, based on State and or Municipal priority areas
4. Minimum professional incentive plan (e.g. extra training opportunities, special mention for best performing CHWs)
5. Clear guidance for health district managers and FHT coordinators about role of CHWs, their duties and rights, supervision and coordination
6. CHW coordinators identified (nurse plus CHW) and given some monetary incentives 7. Result based financial incentive plan revised with participation of CHWs
8. Minimum toolkit for CHWs to use with community (transport vouchers, basic commodities e.g. for improving water and sanitation and nutrition at household level) 9. Specific administrative tasks assigned to other health professionals (e.g. social service) 10. Mechanisms to monitor responsiveness of HS to cases referred by CHWs and feed back information to CHWs
11.Adequate time and space for periodical meetings within the FHT to address difficulties arising in their work
12. Simple practical data collection for use at District and FHU level 13. Mechanism for periodical consultation with communities enforced
14. Community involvement & communication package defined by working group (E- messages, leaflets
15. Community counterparts identified and involved in monthly meetings to monitor and assess interventions and address emerging issues
RMNCH-specific interventions
16. specific RMNCH training, similar to that proposed in the intervention trial 17. action-oriented guide for all tasks related to RMNCH
focused materials such as books, simple RMNCH data collection tool)
All policy packages should be discussed through a consultation process with health professionals’ representatives and with community representatives and leaders. For the minimum package which could be implemented at District level, the consultation should involve all professionals.
3.3.1 Prioritization model
We propose here a model to assess the policy options included in the three policy packages according to priority criteria. The model could be used as an exercise not only at policy-makers level, but at different levels of the system as a way to increase the awareness about making policy decisions.
Table 24 shows how the model could be applied to a sample of policies included in the policy packages which have been previously described. This kind of assessment is highly contextual and are usable for multi-stakeholder Delphi-like consultations, and may be graded using Likert 5 scales (Likert, 1932; Grime & Wright, 2016).
Table 24 Proposed framework to prioritize policy options to improve the performance of CHWs, applied to a sample of policy actions
Main policy content Expectedimpact
Political institutional and implementation feasibility Financial viability Equity
Mandatory initial training (CHWs) Training in teaching methodologies and supervisory skills (I&S nurses) CPD plan (CHWs)
Professional incentive plan (CHWs) Guidance and performance indicators regarding CHWs roles (District
managers and FHU coordinators) Result based monetary incentive plan (CHWs)
Minimum toolkit to be used to address typical community issues such as transport vouchers, W&S and nutrition basic commodities (CHWs) Community integrated multi-sector social plan
Guidance on periodic consultation of community health council
4. Discussion
4.1 From analytical modeling to policy development: strengths and limitations of the