School of Medicine UCSF
June – August 2014
It’s about systems. The questions that we ask in research are always specific but the answers seem, invariably, to be broader.
Ostensibly, my project this summer was to examine two rather discrete questions: how is the provision of care for pneumonia in children under 5 by community health workers (CHWs) is perceived by caregivers of those children and how well is community health worker provision of care accepted by formal health sector worker. These seem like two question that would have two dimorphic answers with “Good” or “Bad” for the first and “Yes” or “No” for the second. I researched heavily on these questions and learned a bit about what others had thought of the oversimplified questions I had conceptualized. However, in spite of my supposedly extensive preparation, I was completely taken aback when I arrived in rural Homabay County.
My first task was to conduct a series of focus group discussions (FGD) to learn from key stakeholders about the integration of CHWs into the health system. There, I went through my checklist of questions – prepared with extensive support from my Kenyan principle investigator – and yet the conversation seemed to take me in other directions. After each FGD, I found myself talking with the program coordinator that was accompanying me to understand more of the organization of the overall health system and how each piece of the system interacted with the others. I eventually was able to get some conceptualization of the structure (and even made some fun powerpoint slides!) but I think my first introduction to this systems complexity was actually the most instructive.
I was sitting in my focus group in in the idyllic Mbita District Hospital situated on a narrow peninsula flanked by Lake Victoria when I brought up the question of CHW stipends. From my reading, I knew that the government policy was to not pay CHWs, however, I learned about a separate, concurrent program funded by the Global Fund that was paying CHWs. Furthermore, it was a program that was utilizing CHWs for the providing care for malaria in a manner very similar to iCCM (the program I was studying). Due to this program, there was jealousy brewing between the groups of CHWs, those in the iCCM program who received no stipend and those in the Global Fund program who did. In Sindo, a small and impoverished town south of Mbita, I heard the plea of program administrators who conveyed a “damned-if-you-do, damned-if-you-don’t” conundrum of trying to require too much of funders. Be too permissive and you get perverse incentives like the one I described above or be too restrictive and lose the support altogether for potentially helpful program.
This imbalance of compensation plays into the micro-level interaction of a CHW providing care for a sick child or when a nurse mentors a CHW on how to diagnose fast breathing. The results of my research will ultimately help to answer those simple, dimorphic questions that I posed earlier, but I hope that I am able to convey the complexity of the situation in a way that attempts to buck the overly sterilized nature of many investigative endeavors.
I am eternally grateful for the opportunity to study and learn about being a practitioner in global health. A single summer is not an opportunity to define a career or do anything of great import. I did nothing of the sort. Rather, the summer in Kenya provided me a chance to understand a question from a perspective that more closely approximates reality than any paper, book, article or haiku. It was an opportunity to take off my western colored glasses and explore.