In an ideal world, numerous stakeholders contribute to policy development, including policymakers, implementers and, as importantly, the individuals and communities who will be affected by the policies. All too often, this broad-based input simply doesn’t happen, which contributes to policies that are not well designed or effectively implemented.
Through the Advancing Partners & Communities (APC) Project, funded by USAID, our team wanted to see whether it was possible to use human-centered design (HCD) to bridge the gap between policy-making and implementation. HCD, originally used in private-sector applications, is gaining traction in global health as a way to stimulate problem-solving for social issues. So in 2015, when the Government of Tanzania launched a policy process for designing a new community-based health program, we jumped at the chance to apply an HCD approach to policy and program development.
Tanzania (like many countries in sub-Saharan Africa) struggles with a severe shortage of health care workers, especially in remote areas. The Tanzanian Government plans to address this shortage by deploying a new cadre of professional community health workers (CHWs) in underserved communities, and has already begun training the first cadre of CHWs. We wanted to support this national effort by engaging the breadth of “users” at the local level who would be involved in policy implementation. By applying an HCD process we could uncover potential barriers and identify thoughtful solutions to help ensure effective implementation.
Our work took place in Mbeya region in southwest Tanzania, which has among the highest HIV prevalence rates in the country. We conducted 61 interviews with stakeholders working across the health system who would be responsible for program implementation: community members, CHW candidates, local leaders, health facility managers, and district officials. Their inputs provided insights on daily realities in Mbeya, and illuminated the questions and concerns of these diverse stakeholders. A major concern, among district officials, was how to manage and sustain the CHW program on their limited budgets. CHWs also worried about funding. For 23-year-old trainee Erick, the CHW post represented a dream job, but the cost of training far exceeded his savings. Erick’s concern is relevant, and CHWs like him may be financially supported through partner organizations.
We listened and learned about the potential challenges and increasing demands that could come with the new CHW program and developed an interactive, solutions-focused workshop to address concerns. During the two-day event in February 2016, a cross-section of the Mbeya community (30 participants, including officials, prospective CHWs and their potential clients, faith- and community-based leaders, and others) talked, debated, imagined, and created their vision of a functioning CHW program in Mbeya.
The workshop started with a smile. Instead of putting on name tags, participants were asked to write down something that makes them smile. They then worked in teams to describe a CHW program vision that would make their communities smile. One-third envisioned a Mbeya with CHWs deployed, working, and supported by communities. Two-thirds defined success in terms of improved health knowledge throughout communities–and as a result, a reduced burden on health facilities. Mbeya wanted a CHW program that delivered results.
Participants then built a “wall” to identify challenges that might block implementation of the new CHW system. Through interactive role play, attendees “experienced” these challenges in all their complexity. This exercise fostered empathy among the stakeholders working in various roles across the health system. Together, they worked through nine “brainstorm challenges” to break down the wall of barriers, stimulating ideas for a successful CHW program. These sessions, yielded new perspectives towards supporting collaborative, working relationships with one another – on encouraging behavior change: ” Show love for what they (CHWs) are doing…via SMILING.” On motivating CHWs: “Set clear goals…” “acknowledge their work…”
And by the end, each workshop participant made a personal commitment to help the program succeed.
We used the input from the Mbeya workshop participants to develop themes on all aspects of the CHW program – from budgeting and planning to the CHW selection process to program monitoring. Priorities and recommendations for the short and longer term were presented to the Government of Tanzania for incorporation into the final design of the national CHW program, and to Mbeya’s regional government for integration into its local implementation plan.
The CHW program implementation process is only beginning in Tanzania. But the enthusiasm and passion expressed during the HCD pilot suggests the rich contribution of communities in national policy process. Participants in Mbeya called for adequate funding, more selective training, a defined scope of work, and better communication and outreach to ensure the success of the CHW program. Aspiring CHW Erick puts it simply: create the conditions where CHWs can flourish. “I want to share challenges and I will need guidance. Help me when I need help. And give me the tools to do my job when I need them… That will motivate me perfectly!”