Challenges in Implementing Community-Based Healthcare Teams in a Low-Income Country Context: Lessons From Ethiopia’s Family Health Teams

Document Type : Original Article

Authors

1 Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia

2 Health Research and Technology Transfer Office, SNNPR Regional Health Bureau, Hawassa, Ethiopia

3 Centre for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia

Abstract

Background 
Addressing chronic diseases and intra-urban health disparities in low- and middle-income countries (LMICs) requires new health service models. Team-based healthcare models can improve management of chronic diseases/complex conditions. There is interest in integrating community health workers (CHWs) into these teams, given their effectiveness in reaching underserved populations. However healthcare team models are difficult to effectively implement, and there is little experience with team-based models in LMICs and with CHW-integrated models more generally. Our study aims to understand the determinants related to the poor adoption of Ethiopia’s family health teams (FHTs); and, raise considerations for initiating CHW-integrated healthcare team models in LMIC cities.
 

Methods 
Using the Consolidated Framework for Implementation Research (CFIR), we examine organizational-level factors related to implementation climate and readiness (work processes/incentives/resources/leadership) and systemlevel factors (policy guidelines/governance/financing) that affected adoption of FHTs in two Ethiopian cities. Using semi-structured interviews/focus groups, we sought implementation perspectives from 33 FHT members and 18 administrators. We used framework analysis to deductively code data to CFIR domains.
 

Results 
Factors associated with implementation climate and readiness negatively impacted FHT adoption. Failure to tap into financial, political, and performance motivations of key stakeholders/FHT members contributed to low willingness to participate, while resource constraints restricted capacity to implement. Workload issues combined with no financial incentives/perceived benefit contributed to poor adoption among clinical professionals. Meanwhile, staffing constraints and unavailability of medicines/supplies/transport contributed to poor implementation readiness, further decreasing willingness among clinical professionals/managers to prioritize non-clinic based activities. The federally- driven program failed to provide budgetary incentives or tap into political motivations of municipal/health centre administrators.
 
Conclusion 
Lessons from Ethiopia’s challenges in implementing its FHT program suggest that LMICs interested in adopting CHW-integrated healthcare team models should closely consider health system readiness (budgets, staffing, equipment/medicines) as well as incentivization strategies (financial, professional, political) to drive organizational change.

Keywords


  1. Eckert S, Kohler S. Urbanization and health in developing countries: a systematic review. World Health Popul. 2014;15(1):7-20. doi:10.12927/whp.2014.23722
  2. The Lancet Diabetes & Endocrinology. Urbanisation, inequality, and non-communicable disease risk. Lancet Diabetes Endocrinol. 2017;5(5):313. doi:10.1016/s2213-8587(17)30116-x
  3. Elsey H, Agyepong I, Huque R, et al. Rethinking health systems in the context of urbanisation: challenges from four rapidly urbanising low-income and middle-income countries. BMJ Glob Health. 2019;4(3):e001501. doi:10.1136/bmjgh-2019-001501
  4. World Health Organization (WHO). Adherence to Long-Term Therapies: Evidence for Action. Geneva: WHO; 2003.
  5. Lim J, Chan MM, Alsagoff FZ, Ha D. Innovations in non-communicable diseases management in ASEAN: a case series. Glob Health Action. 2014;7:25110. doi:10.3402/gha.v7.25110
  6. Bai X, Nath I, Capon A, Hasan N, Jaron D. Health and wellbeing in the changing urban environment: complex challenges, scientific responses, and the way forward. Curr Opin Environ Sustain. 2012;4(4):465-472. doi:10.1016/j.cosust.2012.09.009
  7. Damery S, Flanagan S, Combes G. The effectiveness of interventions to achieve co-ordinated multidisciplinary care and reduce hospital use for people with chronic diseases: study protocol for a systematic review of reviews. Syst Rev. 2015;4:64. doi:10.1186/s13643-015-0055-x
  8. Franklin CM, Bernhardt JM, Lopez RP, Long-Middleton ER, Davis S. Interprofessional teamwork and collaboration between community health workers and healthcare teams: an integrative review. Health Serv Res Manag Epidemiol. 2015;2:2333392815573312. doi:10.1177/2333392815573312
  9. Mitchell P, Wynia M, Golden R, et al. Core Principles & Values of Effective Team-Based Health Care. NAM Perspect. 2012;2(10). doi:10.31478/201210c
  10. Ferrante JM, Balasubramanian BA, Hudson SV, Crabtree BF. Principles of the patient-centered medical home and preventive services delivery. Ann Fam Med. 2010;8(2):108-116. doi:10.1370/afm.1080
  11. Joint principles of the Patient-Centered Medical Home. Del Med J. 2008;80(1):21-22.
  12. Perry HB, Zulliger R, Rogers MM. Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health. 2014;35:399-421. doi:10.1146/annurev-publhealth-032013-182354
  13. Xyrichis A, Ream E. Teamwork: a concept analysis. J Adv Nurs. 2008;61(2):232-241. doi:10.1111/j.1365-2648.2007.04496.x
  14. Clements D, Dault M, Priest A. Effective teamwork in healthcare: research and reality. Healthc Pap. 2007;7 Spec No:26-34. doi:10.12927/hcpap.2013.18669
  15. Kvarnström S. Difficulties in collaboration: a critical incident study of interprofessional healthcare teamwork. J Interprof Care. 2008;22(2):191-203. doi:10.1080/13561820701760600
  16. Finn R, Learmonth M, Reedy P. Some unintended effects of teamwork in healthcare. Soc Sci Med. 2010;70(8):1148-1154. doi:10.1016/j.socscimed.2009.12.025
  17. O'Reilly P, Lee SH, O'Sullivan M, Cullen W, Kennedy C, MacFarlane A. Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: an integrative review. PLoS One. 2017;12(5):e0177026. doi:10.1371/journal.pone.0177026
  18. Lewin K. Resolving Social Conflicts and Field Theory in Social Science. American Psychological Association; 2004. doi:10.1037/10269-000
  19. Rogers EM. Diffusion of Innovations. 5th ed. New York, NY: Free Press; 2003.
  20. Schein EH. Organizational Culture and Leadership. San Francisco, California: Jossey-Bass; 2010.
  21. Batras D, Duff C, Smith BJ. Organizational change theory: implications for health promotion practice. Health Promot Int. 2016;31(1):231-241. doi:10.1093/heapro/dau098
  22. Glasgow RE, Harden SM, Gaglio B, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019;7:64. doi:10.3389/fpubh.2019.00064
  23. San Martín-Rodríguez L, Beaulieu MD, D'Amour D, Ferrada-Videla M. The determinants of successful collaboration: a review of theoretical and empirical studies. J Interprof Care. 2005;19 Suppl 1:132-147. doi:10.1080/13561820500082677
  24. Ermias A, Bogaert J, Wogayehu F. Analysis of city size distribution in Ethiopia: empirical evidence from 1984 to 2012. J Urban Manag. 2019;8(2):237-244. doi:10.1016/j.jum.2018.12.007
  25. World Health Organization (WHO). Noncommunicable Diseases Country Profiles, 2018: Ethiopia. Geneva: WHO; 2018.
  26. WHO Africa. Ethiopia launches investment case for noncommunicable diseases. WHO news. https://www.afro.who.int/news/ethiopia-launches-investment-case-noncommunicable-diseases. Published 2019. Accessed February 24, 2020.
  27. John Snow Inc. Ethiopia’s Primary Health Care Reform: Practice, Lessons, and Recommendations. Addis Ababa: John Snow, Inc; 2018.
  28. John Snow Inc. Ethiopia’s Urban Health Extension Worker Program. Addis Ababa: John Snow, Inc; 2018.
  29. Fetene N, Linnander E, Fekadu B, et al. The Ethiopian health extension program and variation in health systems performance: what matters? PLoS One. 2016;11(5):e0156438. doi:10.1371/journal.pone.0156438
  30. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322-1327. doi:10.2105/ajph.89.9.1322
  31. Durlak JA, DuPre EP. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol. 2008;41(3-4):327-350. doi:10.1007/s10464-008-9165-0
  32. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi:10.1186/1748-5908-4-50
  33. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117. doi:10.1186/1471-2288-13-117
  34. Peres CR, Caldas Júnior AL, da Silva RF, Marin MJ. [The community health agent and working as a team: the easy and difficult aspects]. Rev Esc Enferm USP. 2011;45(4):905-911. doi:10.1590/s0080-62342011000400016
  35. Angwenyi V, Aantjes C, Kondowe K, et al. Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi. BMJ Glob Health. 2018;3(Suppl 3):e000996. doi:10.1136/bmjgh-2018-000996
  36. Kinkel HF, Marcus T, Memon S, Bam N, Hugo J. Community oriented primary care in Tshwane district, South Africa: assessing the first phase of implementation. Afr J Prim Health Care Fam Med. 2013;5(1):477. doi:10.4102/phcfm.v5i1.477
  37. Marcus TS, Hugo J, Jinabhai CC. Which primary care model? a qualitative analysis of ward-based outreach teams in South Africa. Afr J Prim Health Care Fam Med. 2017;9(1):e1-e8. doi:10.4102/phcfm.v9i1.1252
  38. Allan HT, Brearley S, Byng R, et al. People and teams matter in organizational change: professionals' and managers' experiences of changing governance and incentives in primary care. Health Serv Res. 2014;49(1):93-112. doi:10.1111/1475-6773.12084
  39. Kane SS, Gerretsen B, Scherpbier R, Dal Poz M, Dieleman M. A realist synthesis of randomised control trials involving use of community health workers for delivering child health interventions in low and middle income countries. BMC Health Serv Res. 2010;10:286. doi:10.1186/1472-6963-10-286
  40. Hall P. Interprofessional teamwork: professional cultures as barriers. J Interprof Care. 2005;19 Suppl 1:188-196. doi:10.1080/13561820500081745
  41. D'Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu MD. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J Interprof Care. 2005;19 Suppl 1:116-131. doi:10.1080/13561820500082529
  42. Mickan S, Hoffman SJ, Nasmith L. Collaborative practice in a global health context: common themes from developed and developing countries. J Interprof Care. 2010;24(5):492-502. doi:10.3109/13561821003676325
  43. Bidwell P, Thomas S, Stringhini S. Understanding how incentives influence motivation and retention of health workers. In: Kabene SM, ed. Human Resources in Healthcare, Health Informatics and Healthcare Systems. New York: IGI Global; 2011:63-78. doi:10.4018/978-1-61520-885-2.ch004
  44. Kane S, Gandidzanwa C, Mutasa R, et al. Coming full circle: how health worker motivation and performance in results-based financing arrangements hinges on strong and adaptive health systems. Int J Health Policy Manag. 2019;8(2):101-111. doi:10.15171/ijhpm.2018.98
  45. Saint-Pierre C, Herskovic V, Sepúlveda M. Multidisciplinary collaboration in primary care: a systematic review. Fam Pract. 2018;35(2):132-141. doi:10.1093/fampra/cmx085
  46. Moosa S, Derese A, Peersman W. Insights of health district managers on the implementation of primary health care outreach teams in Johannesburg, South Africa: a descriptive study with focus group discussions. Hum Resour Health. 2017;15(1):7. doi:10.1186/s12960-017-0183-6
  47. Garfield C, Kangovi S. Integrating Community Health Workers Into Health Care Teams Without Coopting Them. Health Affairs Blog; 2019. doi:10.1377/hblog20190507.746358
  48. Khemani S, Chaudhary S, Scot T. Strengthening Public Health Systems: Policy Ideas from a Governance Perspective. Vol 9920. Washington, DC: World Bank; 2020.
  49. Tendler J, Freedheim S. Trust in a rent-seeking world: health and government transformed in Northeast Brazil. World Dev. 1994;22(12):1771-1791. doi:10.1016/0305-750x(94)90173-2
  50. Austin-Evelyn K, Rabkin M, Macheka T, et al. Community health worker perspectives on a new primary health care initiative in the Eastern Cape of South Africa. PLoS One. 2017;12(3):e0173863. doi:10.1371/journal.pone.0173863
  51. Donnelly C, Brenchley C, Crawford C, Letts L. The integration of occupational therapy into primary care: a multiple case study design. BMC Fam Pract. 2013;14:60. doi:10.1186/1471-2296-14-60
  52. Macfarlane F, Greenhalgh T, Schofield T, Desombre T. RCGP Quality Team Development programme: an illuminative evaluation. Qual Saf Health Care. 2004;13(5):356-362. doi:10.1136/qhc.13.5.356
  53. Sicotte C, D'Amour D, Moreault MP. Interdisciplinary collaboration within Quebec Community Health Care Centres. Soc Sci Med. 2002;55(6):991-1003. doi:10.1016/s0277-9536(01)00232-5
  54. Mitchell GK, Tieman JJ, Shelby-James TM. Multidisciplinary care planning and teamwork in primary care. Med J Aust. 2008;188(S8):S61-64. doi:10.5694/j.1326-5377.2008.tb01747.x
  55. Varghese C, Nongkynrih B, Onakpoya I, McCall M, Barkley S, Collins TE. Better health and wellbeing for billion more people: integrating non-communicable diseases in primary care. BMJ. 2019;364:l327. doi:10.1136/bmj.l327
  56. Wang X, Sun X, Birch S, et al. People-centred integrated care in urban China. Bull World Health Organ. 2018;96(12):843-852. doi:10.2471/blt.18.214908
  57. Woratanarat T, Woratanarat P, Lekthip C. Primary Health Care Systems (PRIMASYS): Case Study from Thailand. Geneva: World Health Organization; 2017.
  58. Massuda A, Hone T, Leles FAG, de Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Glob Health. 2018;3(4):e000829. doi:10.1136/bmjgh-2018-000829
  59. Kok MC, Broerse JEW, Theobald S, Ormel H, Dieleman M, Taegtmeyer M. Performance of community health workers: situating their intermediary position within complex adaptive health systems. Hum Resour Health. 2017;15(1):59. doi:10.1186/s12960-017-0234-z
  60. Ludwick T, Morgan A, Kane S, Kelaher M, McPake B. The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature. Health Policy Plan. 2020;35(8):1039-1052. doi:10.1093/heapol/czaa049
  61. Kane S, Kok M, Ormel H, et al. Limits and opportunities to community health worker empowerment: a multi-country comparative study. Soc Sci Med. 2016;164:27-34. doi:10.1016/j.socscimed.2016.07.019