DISCUSSION OF THE FINDINGS
5.2. PROCESS EVALUATION OF COMMUNITY HEALTH WORKERS’ (CHWs) MALARIA HEALTH EDUCATION PROGRAM
5.2.1. Inputs (Resources and Staff)
CHWs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
82 FRPPXQLWLHVLQ1HSDODQGDUHJHQHUDOO\UHVSRQVLEOHIRUKRXVHKROGV86$,' D DQG LQ ,QGLD WKH IHPDOH &+: YROXQWHHUV VHW RI ULJKWV EDVHG DFWLYLWLHV ZKLFK HQDEOHG DFFHVV WR EDVLF SXEOLF VHUYLFHV DV IXQGDPHQWDO HQWLWOHPHQWV ZHUH VHFXUHG WKURXJKZRPHQெVHPSRZHUPHQWDQGFRPPXQLW\DFWLRQ +DLQHVHWDO 2QO\RQHVWXG\LQ0DOLUHSRUWHGWKHXVHRIPDOH&+:VEXWWKHLUPDLQRFFXSDWLRQVZHUH DJULFXOWXUH DQG KRXVH FKRUHV 3HUH] +DPDG\ 'DVWDJLUH $OWPDQQ
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ெV FRPPXQLW\ +HDOWK VWUDWHJ\ RI ZKLFK UHTXLUHG WKHP WR EH UHVLGHQW LQ WKH FRPPXQLW\UHVSHFWHGPHPEHUVRIWKHFRPPXQLW\DQGOLWHUDWH:LQWHU
7KLUGO\ WKLV VWXG\ IRXQG WKDW WZR WKLUGV RI WKH &+:V Q OHIW VFKRRO DW SULPDU\VFKRROZLWKRQO\UHDFKLQJVHFRQGDU\VFKRROOHYHODQGRQO\
KDYLQJ DWWHQGHGXQLYHUVLW\ )LYH KDG QRWEHHQ WR VFKRRO DWDOO 7ZHQW\VL[ RI WKH
&+: UHFRUGV KDG QR UHFRUGV RQ HGXFDWLRQ 7KLV ILQGLQJ OLQNV WR WKH UHFRPPHQGDWLRQIURPWKH:+2WKDWFRPPXQLW\+HDOWKZRUNHUVVKRXOGKDYHDOHYHORI EDVLF HGXFDWLRQ WKDW HQDEOHV WKHP WR UHDG ZULWH DQG GR VLPSOH FDOFXODWLRQV :+2 7KHILQGLQJVRIRXUVWXG\ZHUHVLPLODUWRWKHVWXG\FRQGXFWHGLQ0DOLE\3HUH]
%D HW DO ZKR IRXQG WKDW DOWKRXJK RI FRPPXQLW\ +HDOWK ZRUNHUV KDG VRPHSULPDU\VFKRROLQJGLGQRWNQRZKRZWRUHDGDQGZULWH1RUHFRUGRIVSHFLILF TXDOLILFDWLRQVIRUWKH5ZDQGDQ&+:VZHUHIRXQGZKHUHDVLQ6RXWK$IULFDWKH6RXWK
83
$IULFDQ 4XDOLILFDWLRQV $XWKRULW\ 6$4$ D UHJLVWHUHG WKDW FRPPXQLW\ +HDOWK ZRUNHUV UHTXLUH D QDWLRQDO FHUWLILFDWH TXDOLILFDWLRQ &RPPXQLW\ +HDOWK ZRUN DW OHYHO WKUHH
7KHIRXUWKDUHDLQORRNLQJDWWKHUROHRIWKH&+:VLVHQVXULQJWKDW0DODULDLVLQFOXGHGLQ WKHFRUHZRUNRIWKH&+:,QWKLVVWXG\WKHPDLQIRFXVRIWKHRIWKH&+:UROHV ZDVEHLQJLQFKDUJHRI&%,0&,ZKLFKKDGDELJFRPSRQHQWRI0DODULDPDQDJHPHQW DQG SUHYHQWLRQ ZLWK WKH UHVW HTXDOO\ GLVWULEXWHG EHWZHHQ VRFLDO DIIDLUV DQG PDWHUQDO +HDOWK $OWKRXJK LQYROYHG LQ GLIIHUHQW DFWLYLWLHV WKHVH &+:V VXSSRUWHG WKH &%,0&,
&+:GXULQJPDVVGLVWULEXWLRQVRIWUHDWHGQHWV7KLVSDWWHUQVFRQIRUPVZLWKWKHZRUNRI
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
Funding for community Health worker (CHW) programs: 7KH ILQGLQJV IURP WKLV VWXG\VKRZHGWKDWWKH*RYHUQPHQWRI5ZDQGDSURYLGHVLQFHQWLYHVWRHOLJLEOHFRPPXQLW\
+HDOWK ZRUNHUV &+:V $OO &+:V UHFHLYHG FRPSOLDQFHPRWLYDWLRQ DW WKH UHVSHFWLYH +HDOWKFHQWUHVLQWKHIRUPRIPRQH\JLYHQWRFRRSHUDWLYHRI&+:VPRELOHSKRQHVJXP ERRWVXPEUHOODV7VKLUWVDQGDEDFNEDJHQJUDYHGZLWKSLFWXUHVRIPRVTXLWRHV,WZDV RIFRQFHUQWKRXJKWKDWQRQHRIWKH&+:UHFRUGVLQGLFDWHGDQ\ELF\FOHVJLYHQ&+:V DUHQRWJLYHQDPHDQVRIWUDQVSRUWDQGWKH\DUHUHTXLUHGWRJRWRWKH+HDOWKFHQWHUWR UHWULHYHFRPPRGLWLHDQGFRQVXPDEOHV7KXVELF\FOHVJLYHQIDFLOLWDWHWUDYHODQGWRDQG IURP WKH +HDOWK FHQWHUV DQGDFFHVVLELOLW\ WR WKH FRPPXQLWLHV ZKRP OLYH LQ WKH YLOODJH ZKHUHWKHUHLVLQIRUPDOVWUHHW0LQLVWU\RI+HDOWK
84 7KH 0LQLVWU\ RI +HDOWK F LV RI WKH RSLQLRQ WKDW SHRSOH LQ 5ZDQGD PXVW WDNH UHVSRQVLELOLW\ IRU WKHLU RZQ +HDOWK +RZHYHU WKH JRYHUQPHQW VHHNV WR HQFRXUDJH SDUWLFLSDWLRQ IURP ORFDO FRPPXQLWLHV LQ +HDOWK PDWWHUV E\ PHDQV RI WKH &RPPXQLW\
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
+HDOWKZRUNHUVLQWKH*DXWHQJSURYLQFHRI6RXWK$IULFDZLOOEHSDLGDVDODU\RIQRWOHVV WKDQ 5 $ VWXG\ FRQGXFWHG LQ 7DQ]DQLD E\ $QGUHZ HW DO IRXQG FRQWUDVWLQJ YLHZV RQ SD\PHQW RI &+:V ZLWK IRXU VWXGLHV LQGLFDWLQJ WKH &+:V ZHUH XQSDLGYROXQWHHUVDQGIRXURWKHUVLQGLFDWLQJWKH\ZHUHSURYLGHGSD\PHQW
Provision of Insecticide Nets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
85 OHDVWRIKRXVHKROGVSRVVHVVLQJDWOHDVWRQH,71DQGDWOHDVWWZR0LQLVWU\RI +HDOWK
7KH ILQGLQJV RI WKLV VWXG\ DUH VLPLODU WR D SUHYLRXV VWXG\ FRQGXFWHG LQ 5ZDQGD WR HYDOXDWH //,71 FRYHUDJH DQG GLVWULEXWLRQ ZKLFK UHSRUWHG WKDW LQ RI KRXVHKROGV KDG DQ ,71 DQG RI FKLOGUHQ XQGHU ILYH \HDUV DQG RI SUHJQDQW ZRPHQ KDG VOHSW XQGHU RQH WKH SUHYLRXV QLJKW 86$,' D 7KH VDPH VWXG\
UHSRUWHG WKDW LQ 5ZDQGD KDG VLJQLILFDQWO\ LQFUHDVHG //,71 FRYHUDJH DPRQJ FKLOGUHQ XQGHU ILYH ZLWK D PDVV //,71 GLVWULEXWLRQ OLQNHG WR D QDWLRQZLGH LQWHJUDWHG +HDOWK DQG PHDVOHV YDFFLQDWLRQ FDPSDLJQ 86$,'D DQG WKDW LQ WKH 'HPRJUDSKLF +HDOWK 6XUYH\ '+6 VKRZHG WKDW RI KRXVHKROGV RZQHG DW OHDVWRQH,71DQGWKDWRIFKLOGUHQDQGRISUHJQDQWZRPHQKDGVOHSWXQGHU RQH86$,'D
Medication for the treatment of Malaria: 7KHILQGLQJVRIWKLVVWXG\VKRZHGWKDWWKH
&+:V DUH IROORZLQJ WKH UHFRPPHQGDWLRQV RI WKH :+2 LQ WHUPV RI WKH WUHDWPHQW RI 0DODULDQDPHO\WKHKRPHPDQDJHPHQWRI0DODULD+00LQDFRXQWU\ZKHUHPHGLFDO VHUYLFHVDUHQRWHDVLO\DFFHVVLEOH:+27KHILQGLQJVDUHDOVRLQDFFRUGDQFH ZLWKDVWXG\GRQHLQ5ZDQGDE\86$,'DZKLFKFRQFOXGHGWKDWWKHSURPRWLRQ RIWLPHO\WUHDWPHQWVHHNLQJDQGWKHSURSHUXVHRI$UWPHWKHU/XPHIDQWULQH$/UHGXFHV 0DODULDGLVHDVHV
+RZHYHU WR SURYLGH KRPH WUHDWPHQW WKH &+:V QHHG WR KDYH WHVWLQJ DQG WUHDWPHQW UHVRXUFHV $ VWXG\ FRQGXFWHG LQ 7DQ]DQLD E\ 1JDVDOD HW DO UHFRPPHQGHG WKDWWKHH[LVWLQJUHVRXUFHVOXVHGE\&+:VVXFKDVGLJLWDOWKHUPRPHWHUVSDUDFHWDPRO WDEOHWV D GRVLQJ FKDUW IRU $UWPHWKHU/XPHIDQWULQH DQG $UWHPLVLQEDVHG FRPELQDWLRQ WKHUDS\$&7IRUILUVWOLQHWUHDWPHQWRIXQFRPSOLFDWHGPDODULDZHUHHVVHQWLDO
2XU VWXG\ KRZHYHU VKRZHG WKDW RQO\ WKH FRPPXQLW\ +HDOWK ZRUNHUV
&+:VZKRZHUHLQFKDUJH&%,0,&UHFHLYHG$UWHPHWKHU/XPHIDQWULQH$/IURPWKH +HDOWKFHQWUHIDFLOLW\IRUDQDQWLPDODULDPHGLFDWLRQVHHDQQH[XUH)XUWKHUPRUHLWLV
86 RI FRQFHUQ WKDW QRQH RI WKH &+: UHFRUGV LQGLFDWHG DQ\ GLJLWDO WKHUPRPHWHUV 3DUDFHWDPROWDEOHWVRUGRVLQJFKDUWVIRU$UWPHWKHU/XPHIDQWULQH
$VHFRQGLVVXHLQWHUPVRIPDQDJHPHQWLVWKHXVHRI5DSLG'LDJQRVWLF7HVWV5'7 2XUVWXG\IRXQGWKDWWKHVHZHUHJLYHQWR&+:VDQGWKLVLVHQFRXUDJLQJDVWKHDGGLWLRQ RI5'7VDWWKHFRPPXQLW\OHYHOHQKDQFHVWKHDELOLW\WRGLIIHUHQWLDWHDPRQJWKHGLIIHUHQW FDXVHVRIIHYHUDQGWKXVSURYLGHVPRUHDSSURSULDWHWUHDWPHQW86$,'D7KLVLV LQOLQHZLWKWKH1DWLRQDO0DODULD&RQWURO3URJUDP10&3LQ5ZDQGDZKLFKFRQWLQXHVWR VFDOHXS5DSLG'LDJQRVWLF7HVW5'7V7RGDWHWZHQW\HLJKWRIWKHGLVWULFWVKDYH LQWURGXFHG WKH 5DSLG 'LDJQRVWLF 7HVW 5'7V LQWR WKH FRPPXQLW\ FDVH PDQDJHPHQW
&&0SDFNDJHDQGDOOGLVWULFWVDUHLQGLIIHUHQWSKDVHVRIWUDQVLWLRQWRWKHIXOOFRPPXQLW\
FDVH PDQDJHPHQW SDFNDJH DV GHILQHG LQ WKH 5HYLHZHG &RPPXQLW\ +HDWK 6WUDWHJ\
86$,'D
Travel: &+:V VWUHQJWKHQ WKH +HDOWK V\VWHP DQG VDYH WKH SRSXODWLRQ IURP KDYLQJ WR ZDONORQJGLVWDQFHV WRWKHQHDUHVW +HDOWKFHQWUH $FFRUGLQJWR86$,' EPDQ\
UXUDOFRPPXQLWLHVDUHORFDWHGKRXUVIURPWKHQHDUHVW+HDOWKFOLQLFPDNLQJPHGLFDOFDUH SDUWLFXODUO\ SUHYHQWDWLYH +HDOWKFDUH D FKDOOHQJH IRU IDPLOLHV &RPPXQLW\ +HDOWK ZRUNHUV &+:V DUH PDNLQJ WKHVH DYDLODEOH LQ 5ZDQGD E\ LPSURYLQJ DFFHVV WR FDUH
%LQDJZDKR 7KH ILQGLQJV RI WKLV VWXG\ LQGLFDWHG WKDW &+:V KDYH WR WUDYHO DW OHDVWRQHNLORPHWUHWRUHDFKHDFKKRXVHKROG