Reaching out and linking in: Health systems and close-to-community services (REACHOUT)

Countries which are striving to provide universal health care coverage and achieve the Millennium Development Goals (and the subsequent Sustainable Development Goals) are increasingly implementing close-to-community (CTC) health services to engage their efforts. There is a need for health systems to understand the context and conditions in which these services operate in order to realise their potential. By working with some of the CTC providers, REACHOUT aims to identify how CTC services can best be delivered, documenting generic lessons for system development and strengthening. Building on a strong partnership, this project endeavours to maximise the equity, effectiveness and efficiency of CTC services in rural and urban slum areas of six countries: Indonesia, Bangladesh, Mozambique, Ethiopia, Kenya and Malawi. In addition, it aims to strengthen capacity at three levels: CTC service providers, researchers and policy actors.

The objectives of the REACHOUT consortium are:
1. To build capacity in order to conduct and use health systems research to improve CTC services.
2. To identify how community contexts, health policies and interactions with the rest of the health systems influence the equity, effectiveness and efficiency of CTC services.
3. To develop and assess interventions with the potential to make improvements to CTC services.
4. To inform evidence-based and context-appropriate policies for CTC services.

In 2013 and 2014, the REACHOUT Bangladesh team established a country advisory group (CAG) with 10 experts of sexual and reproductive health (SRH) in Bangladesh. The team have completed a desk review of the existing situation of the health workforce and an assessment of regulation and structures in urban slums. The team has completed a multi-method context analysis, including mapping community health workers CHWs among the four slum settings. For this context analysis an ethics protocol was submitted to the Liverpool School of Tropical Medicine (LSTM). REACHOUT Bangladesh has conducted three stakeholder meetings with close to community (CTC) providers, researchers and with policy actors.

The findings from the context analysis and feedback from stakeholders led to the development of initiatives for the quality improvement cycle 1 plan (QIC1). For QIC 1, REACHOUT Bangladesh prepared a training manual titled “Facilitative Referral Training Manual” to train CTC service providers and adopted another training manual from LSTM titled “Supportive Supervision Training Manual” to train supervisors of from nine selected clinics from Marie Stopes Bangladesh (MSB) and Reproductive Health Services Training and Education Program (RHSTEP). In addition, a new referral card for the clinics of our partner organisationswas introduced in QIC1.

Under capacity strengthening activities, REACHOUT Bangladesh has completed an audit of capacity building initiatives in eight consortium countries. This audit was focused on research capacity at the institution and individual level, resulting in the development of an action plan for each country to minimise capacity gaps.

International partners:
• Liverpool School of Tropical Medicine, UK
• Royal Tropical Institute (KIT), Amsterdam, Netherlands
• James P Grant School of Public Health, BRAC University
• Liverpool Voluntary Counselling and Testing for HIV (LVCT), Kenya
• Eduardo Mondlane University, Mozambique
• Reach Trust, Malawi
• Eijkman Institute for Molecular Biology, Indonesia
• Hidase Hulentenawi Agelglot Yebego Adragot Mahber, Ethiopia.

National partners:
Marie Stopes Bangladesh (MSB)
Reproductive Health Services Training & Education Program (RHSTEP)

Donor: European Commission

Context analysis: In 2014, the REACHOUT Bangladesh team completed a context analysis of close-to-community (CTC) health services on sexual and reproductive health care in Bangladesh, with a particular focus on menstrual regulation. The CTC context analysis study was conducted in four selected study sites in Bangladesh: two slums in Dhaka (Kallyanpur, Keranignaj) and two slums in Sylhet (Ghashitola, Lakkatura). Each study site fell in the catchment area of clinics of Marie Stopes Bangladesh and Reproductive Health Services Training & Education Program (RHSTEP), both of which provide sexual and reproductive health services including menstrual regulation. The CTC context analysis study identified the need to strengthen referral procedures and supervision of CTC health services. Thus, the REACHOUT Bangladesh team provided training on supportive supervision and facilitative referrals to CTC providers and supervisors during the quality improvement cycle one (QIC1).

Based on one of the findings of the context analysis, a paper titled “Exploring the context in which different close-to-community sexual and reproductive health service providers operates in Bangladesh: a qualitative study” was published in the peer reviewed journal Human Resources for Health in 2015.

Quality improvement cycle one (QIC1): Throughout 2015, REACHOUT Bangladesh has provided training on supportive supervision and facilitative referral for CTC service providers and their supervisors in nine clinics - seven from MSB and two from RHSTEP. The objective of the supervisors training was to train supervisors from the partner organisations (MSB and RHSTEP), to provide effective supervision to the close-to-community providers working in the fields of sexual and reproductive health and providing menstrual regulation (MR) services, and to improve the supervisors’ existing core competencies in MR service delivery, client care and ensuring improved quality.

The objective of the facilitative referral training was to increase their contribution to the service delivery process and build their self-esteem, to gain more competence in performing new and different tasks with regards to referrals, keeping them motivated and improving their communication and coordination with other health personnel within and across organisations. The team has provided supportive supervision training to 37 supervisors and facilitative referral to 151 CTC providers.

Capacity strengthening: Two members from the REACHOUT Bangladesh team visited the Liverpool School of Tropical Medicine, UK on June-July 2015, where they were involved in finalising the action plans for each partner country.

An abstract titled ‘Strengthening capacity to conduct research on close-to-community providers: a case study from a research consortium working in Africa and south-Asia’ led by Sadia Chowdhury ( a member of the REACHOUT Bangladesh team) was accepted at the 22nd Canadian Conference on Global Health (CCGH) at Montreal, Canada in November 2015. Findings from REACHOUT’s capacity audit were presented in a poster.