Our results are divided into five sections. The first two (3.1 and 3.2) integrate our qualitative data with quantitative monthly monitoring data on the program’s performance indicators. We then present additional qualitative data in sections 3.3, 3.4 and 3.5, specifically on group motivation, politicization and integration with the health system
3.1. CHC Meetings, Governance and Planning
The 23 CHCs conducted 498 group meetings over the 24-month period (June 2019-June 2021), with an average of 0.90 meetings per month per CHC (Table 2), close to the program goal of 1 group meeting per month. Importantly, no group was found to cease functioning over the project period. Meeting frequency was highest in Les Irois (1.15/month) and lowest in Dame Marie (0.76/month). Overall, we found substantial variation in meeting frequency per month and attendance over time, with a high level of monthly fluctuation shown by most groups (Figure 2). Nine (39%) CHCs held more than 1 group meeting per month on average. The lowest preforming group was found in Anse d’Hainault (0.46 meetings per month) while the highest was in Les Irois (1.8/month). Every group (23/23) did not hold a monthly meeting at least 4 times over the reporting period. In some months, CHCs held more than one planning meeting; 87% (20/23) held at least 2 meetings during two different months and 11/23 (48%) held 2 meetings for 4 or more months. Five (22%) CHCs did not hold monthly meetings for 5 or more months during the reporting period
Table 2
CHC meetings and attendance (June 2019-June 2021)
Commune
|
Number of CHCs
|
Total # CHC meetings
|
Average number of meetings per month
|
Average meeting attendance
|
Anse d'Hainault
|
6
|
117
|
0.81
|
94%
|
Chambellan
|
3
|
60
|
0.83
|
82%
|
Dame Marie
|
6
|
110
|
0.76
|
79%
|
Les Irois
|
4
|
107
|
1.15
|
82%
|
Moron
|
4
|
104
|
1.08
|
89%
|
Total
|
23
|
498
|
0.90
|
85%
|
Qualitative data found that CHC activities were strongly influenced by governance processes, especially the original approach taken in the selection of members as well as a set of roles and responsibilities in management. CHC members strongly linked the transparent membership selection process, which ensured a diversity of community representation, to the effectiveness of CHC activities and their sustained functioning. Group members remained very positive about membership composition more than two years into the CHC program. This was attributed largely to the initial emphasis on transparency and diverse member selection, and contrasted it to the more top-down and opaque selection process used in many other development and health projects in Haiti. Most CHCs included at least some of the following community stakeholders: ASCPs, ASEC and CASEC, as well as mayor, teachers and business owners. Only 4 groups had problems that required changing leadership.
Few members left the CHC groups during this time and attendance at monthly meetings remained high throughout the two-year period; the average attendance rate at monthly meetings was 85% across the 5 communes (Table 2). In roughly half of CHCs (12/23) average meeting attendance was 85% or higher; the commune with the lowest average attendance, in Dame Marie, had an attendance average of 71%. In some groups, specific political leaders would only attend at certain times of year when it was in their interest.
Interview data showed that CHCs planned activities from month-to-month, rather than taking a more long-term view with clear schedules and agreed agendas. Some additional planning did take place for special events and holidays but, on the whole, there was a great deal of fluidity to the ways groups self-organized. This was reflected in the fluctuation of meetings and activities (Figure 2). Refresher training workshops were organized in 2018-2020 to build capacity for CHC planning; 39 separate workshops were organized at the commune level, which allowed each CHC to participate on 3 different occasions.
Our interviews found that CHCs adapted the implementation guidelines provided by program staff in ways that made sense to them and aligned with shared group priorities. Without any specific emphasis by project staff, most CHCs created their own oaths, mission statements and songs, and many also formed WhatsApp or Short Message Service (SMS) chat groups. In our interviews, group decision-making was described in terms of consensus generation, although issues and challenges certainly emerged. The most common included concerns about the distance some members had to travel to attend meetings, the reimbursement of small expenses used by individual members and a lack of protocols and guidance in planning. While in general, most CHCs appeared to have strong leadership teams, a number of groups expressed problems with coordinators trying to dominate their groups. Members attempted to rotate the areas where activities were performed, and expressed frustration at the fact that their coordinators often tried to focus solely on geographical areas favorable to them. In this regard, members emphasized the need for the “separation of power” and emphasized the power dynamic of group membership. Some recommended sub-dividing CHCs into smaller groups given that some sub-communes involved large geographical distances without travel reimbursements, but this has yet to been done.
3.2. Frequency and type of community-based anti-malaria activities
During the 24-month period, a total of 876 CHC-led community-based anti-malaria activities were performed and 68,078 individuals were reached during these activities (Table 3 and 4). On average, we found that each CHC conducted 1.59 community-based activities involving 123 community members per month, lower than the original goal of 4 community-based activities per month. As with the monthly meetings, we found substantial variation in frequency, activity type and number of people reached, with a high level of monthly fluctuation shown by most groups (Figure 2).
Table 3
CHC community-based activities
Commune
|
Number of CHCs
|
Average number of activities per month/CHC
|
Environmental hygiene activities
|
Awareness- raising activities
|
Other activities
|
Total number of community-based activities
|
Anse d’Hainault
|
6
|
1.82
|
115
|
150
|
34
|
262
|
Chambellan
|
3
|
1.26
|
41
|
60
|
10
|
91
|
Dame Marie
|
6
|
1.15
|
83
|
105
|
27
|
166
|
Les Irois
|
4
|
1.65
|
80
|
87
|
15
|
158
|
Moron
|
4
|
2.07
|
110
|
113
|
33
|
199
|
Total
|
23
|
1.59
|
429
|
515
|
119
|
876
|
As with monthly meetings, there was no consistent trend in how CHCs organized community-based activities. 91% (21/23) of CHCs conducted 4 or more activities during at least one month, with 39% (9/23) conducting 4 or more activities for 3 months or more during the reporting period. All CHCs did not organize activities during 2 or more months during the reporting period, and 61% (14/23) CHCs did not organize activities during 5 or more months. Overall, we found that CHCs in Anse d’Hainault and Moron communes organized more activities per month compared to Chambellan, Dame Marie and Les Irois. 26% of CHCs (6/23) conducted, on average, 2 or more activities per month; four groups conducted less than 1 activity per month on average. The most active group was in Anse d’Hainault (2.8 activities/month on average), which reported conducting 4 or more activities per month for 46% (11/24 months) of the reporting period.
Table 4
Number of people reached by CHCs
Commune
|
Population
|
Number of CHCs
|
Total # of community-based activities
|
Total number of reported individuals reached during activities
|
Average number of people reached by CHC per month
|
Anse d’Hainault
|
40,143
|
6
|
262
|
26,789
|
186
|
Chambellan
|
29,179
|
3
|
91
|
7,972
|
111
|
Dame Marie
|
42,731
|
6
|
166
|
10,607
|
74
|
Les Irois
|
25,777
|
4
|
158
|
10,192
|
106
|
Moron
|
34,360
|
4
|
199
|
12,518
|
130
|
Total
|
172,189
|
23
|
876
|
68,078
|
123
|
Over the reporting period, community-based interventions consisted of malaria awareness-raising activities (n=515), environmental sanitation activities (n=429), and a series of “other” activities (n=119). Awareness-raising activities included: education about malaria prevention, public meetings at schools and churches, public education, awareness-raising about MDA and/or IRS campaigns, education about fever-seeking behaviour and promoting malaria test and treat strategy. Environmental hygiene activities included: doing environmental improvement, sensitizing community members on environmental sanitation, and organizing and participating in community-based environmental sanitation campaign.
Most environmental sanitation activities focused on garbage clean-up and stagnant water sources. Garbage clean-up typically concentrated on plastic objects, empty pots, coconuts, shells and tires, while efforts to address stagnant water sources involved cleaning and draining canals along roads and homes (See Figure 3). Our interviews and observations with CHC members found that these activities were infrequently targeted to Anopheles breeding sites (the vector of malaria) and that the campaigns likely over-emphasized general clean-up instead of mosquito control. Larger campaigns were often organized to correspond to festivals or holidays. Clean-up equipment was provided to each CHC to facilitate and encourage environmental sanitation activities. CHC members asked for further guidance on how best to target their efforts, including how to involve the Ministry of Public Works and local government authorities.
CHCs also conducted regular education activities in a variety of places. In our interviews, members especially stressed the importance of school and church meetings and sensitization. In schools, children were encouraged to discuss anti-malaria education with their families once they returned home. Churches were seen as very influential venues to spread information and mobilize support for early diagnosis and treatment, given the high level of trust to church leaders. As with environmental sanitation campaigns, CHCs also organized educational outreach during festivals and holidays, as well as during the specific anti-malaria campaigns organized by MSPP, including MDA and IRS campaigns. Megaphones provided to CHC were used for sensitization and were used during door-to-door community education. Education also targeted individuals at household water kiosks, bus stops, public squares, markets, and street corners.
CHCs emphasized their ability to “change behaviors” and that this awareness-raising capacity was something that MSPP could leverage in their anti-malaria outreach activities. However, members requested more training on behavior change techniques; many found it very challenging and time-consuming. While CHCs believed that they had increased knowledge of malaria and helped reduce malaria, it was not clear if their activities targeted local malaria hotspots or areas with active cases. Interviews in 2020 suggested that some CHC members had provided direct support to people with malaria symptoms including advising and supporting them to seek treatment and sensitizing pharmacies, mobile drug vendors, herbalists and traditional doctors (hougan) in malaria testing and treatment. However this was unfortunately not systematically documented by the CHCs.
3.3. Negotiating volunteerism and project inputs
Community engagement programs in the health sector tend to generate reasonable expectations from community members and volunteers that some financial benefits will accompany them. The completely volunteer-based nature of the CHCs required careful negotiation to avoid misperceptions and demotivation. In our qualitative data and field visits, group members frequently mentioned a sense of mission, feeling valued, being useful, various statements of solidarity (“working for and with the population”) and, as one member stated, “patriotism allows us to work together to protect the community.” On the other hand, members consistently mentioned the lack of small incentives and remuneration as a major barrier to CHC participation, the fact that members are “busy people” and that, while they are willing to volunteer, “life is expensive and this inhibits people to participate in the CHCs.”
The original aim of the program was to avoid direct cash incentives and to emphasize the “volunteer-based” nature of the program. This was motivated by the recognition that when community groups receive financial remuneration they tend to stop functioning once the external funding ceases. The CHC model drew upon a previous approach to community health service delivery that was widespread in Haiti in the 1970s and 1980s. In this way, there was a historical analogue to community members working collectively and voluntary to plan and carry out health outreach in their communities. Although the program began making this clear in 2018, there was an implicit assumption from some members that forms of incentives and remuneration would be provided at some time. In our 2019 interviews, and during routine monitoring, CHC members emphasized the need for small financial and non-financial incentives and that these would make a big difference to their overall motivation and effectiveness. This included the need for regular trainings and larger group meetings with MSPP:
“We have had training but we must understand that people must have continuous training because reporting work is difficult for our level. We're not used to it.” CHC member, interview, 2020.
Members also mentioned the need for more education materials, as well as community training material, small incentives to help with group meetings, T-shirts, and cleanup materials. As a result, a flexible incentive of $100 USD per month (10,000 HTG) was provided to each CHC in late 2018 to assist with the group meetings. This was clearly understood to be a small incentive for drinks/snacks during meetings to help organize their work and was reduced to $100 USD every two months in 2019. After approval by MSPP, T-shirts with the MSPP logo were provided, and all members believed this would increase the visibility and legitimacy of their work. Clean-up materials (boots, rakes, pickaxes, wheelbarrows, shovels, and machetes) were given to each group. In 2019, nearly a dozen motorcycles were provided to MSPP to help with MSPP supervision and support to the CHCs.
While the interviews in 2019 found continued expectations of greater financial incentives and resources, these expectations were less in 2020 but not completely gone. All CHCs reported that they had community activity plans that had not been realized due to a lack of funds: for water, sweet drinks, food, and local alcohol (rum was requested especially in remote areas by community volunteers involved in environmental cleanup). Members repeatedly highlighted that they have used their own resources to attend meetings and, in some cases, to organize community outreach. All CHCs reported having to use their own money to buy water for people during some activities during some months. They understood that MSPP staff have access to travel and salary funds, and do not understand why greater resources are not provided to them for travel and community outreach. Members questioned the meaning and nature of “volunteering”, in this regard. CHC members also mentioned that “volunteers” in other health programs (e.g., vaccination) still receive a small stipend to cover their transport and food at a minimum, albeit these programs operate only for a few days on an annual basis.
“Volunteering does not mean spending your entire life and even your savings. We do not have money. If you are organizing an activity you may need water. You have to take it into account.” CHC member, interview, 2020.
Inputs, however, can also contribute to group demotivation. A good example of this involved our effort to establish an electronic data reporting system. Before 2019, MSPP staff would physically visit each CHCs on a monthly basis to collect paper Monitoring & Evaluation (M&E) forms. To improve efficiency and timeliness of reporting, we distributed in December 2019, smart-phones that enabled online or offline data collection followed by upload to a cloud-based server via telecom or WiFi connection. After distributing a phone to each CHC secretariat, we then held a training workshop explaining their use. A few months after the system was launched, it was clear that it was not working. We found a number of challenges in the 2020 interviews with the phone system: coordinators keeping the phones (and appropriating them), lost and broken phones, difficulties recharging the phones for communication and reporting, and a general lack of internet connection in many of the sub-communes. Providing phones to the secretariat meant that the phones became the personal property of one individual, and this generated conflict in many groups. In mid-2020, we transitioned to having a program staff member call each CHC focal person and collect monthly M&E data by voice call. These monthly calls also became an opportunity for program staff to build relationships with CHC members; the regular contact allowed CHC members to debrief about monthly activities and allowed staff to encourage members in their work.
3.4. Politicization and community mobilization
Group outreach activities had to negotiate certain political and social dimensions, which was described by CHC members as “politicization.” On the one hand, some CHC members were labeled to be opportunists: “they will sneak into every NGO opportunity and try and take advantage of things” (CHC member, interview, 2019). On the other hand, political profiteering was also seen as an accepted, somewhat beneficial, aspect of the CHCs since members could leverage the group for their political ends. Balancing this was important and discussions about politicization reduced significantly in 2020, and appeared to have decreased with time.
CHC members saw their role as facilitating and mobilizing other community members to engage in specific field activities, such as malaria awareness and environmental sanitation, rather than conducting the bulk of the field activities themselves. CHC members “recruited” people in their social network, which relied on their existing social ties, often a relative or neighbor. CHC activities, therefore, had an impact on their reputation at the community level; community members, in turn, were suspicious that members were receiving some form of salary or remuneration: "Moun lajan yo” (interpretation: They are using people for their benefit). Many stressed that volunteering, “does not exist in poor countries [like Haiti]” and that people with links to a development and health program always find some way to benefit personally. This generated some level of community suspicion about CHCs membership being voluntary. An often-repeated example involved the widespread perception that previous bed net distributions in 2017 had lead to misappropriations whereby volunteers had used their positions to sell the nets in the local market. To address this, some members called on MSPP to communicate the voluntary nature of CHC group membership and outreach to communities and transparent reporting of CHC finances by the treasurer. The original emphasis on transparency with selecting members and holding meetings in each sub-commune with a wide variety of stakeholders helped to address these concerns.
The politicization of CHCs appeared to be much stronger in urban centers, especially in Dame Marie, and involved the spreading of rumors about CHC members being paid for their work and tied to specific political parties. While the presence of local authorities in the groups was generally felt to give CHCs more legitimacy, this created a problem in Dame Marie (a town with many complex political tensions) that were addressed through a series of meetings with local leaders. Despite the fact these CHC meetings take place in the town, group members in Dame Marie have been the most persistent in asking for travel per diems from project staff.
“Some people think [the CHC members] have the money and don't want to collaborate. In the country, a lot of community actions are done with money. The policy of separating money decreases community participation. You want to eliminate a pool of water in front of a person's house, sometimes that person who should be helping asks you for money to do it. Before 1986 [the year of the fall of the Duvalier regime], a person would be ashamed to see someone else come and do it.” CHC member, interview, 2020.
To mobilize community members, CHCs had to occasionally provide some incentives, as mentioned above. CHC members stressed that their ability to offer small incentives was an important part of local mobilization and that remote areas make demands that resemble aid interventions and the traditional form of Haitian "Konbit."
“The committee is very helpful. Community members show interest, however poverty causes frustrations that people have on committee members. There is a culture and all people receive money to work. So when they have little interest in the community. I think this work should allow the community to change its mentality.” CHC member, interview, 2020.
3.5. Relationships with vertical malaria programs and the Ministry of Health
Our qualitative interviews found challenges with the way malaria program partners and MSPP engaged with the CHCs. The original goal for the CHCs was for them to act as central mediators between Malaria Zero program activities and their local communities. However, the multi-partner nature of the consortium and associated challenges in coordination and communication with subcontractors used for MDA and IRS implementation, along with political events in Haiti, created more fragmented and ambiguous circumstances.
Vertical interventions, such as IRS and MDA, were viewed by CHC members as a reasonable opportunity for them to obtain some financial remuneration for their hard work. However, contrary to original plans, CHCs were not involved in planning for the first targeted MDA and IRS campaign in 2018. CHCs were involved in social mobilization and community education as part of this campaign, but the process of recruiting community members to assist the campaign was primarily done by local health staff rather than CHCs. In some cases, the coordinator of the CHC was involved in the selection but without involving the other CHC members. Health staff and CHC coordinators often appointed family members instead of transparently picking members:
“The coordinator delegated his sister to participate in MDA activities instead of choosing a committee member. Committee members were frustrated. They make choices based on their political affiliation, allies and friends.” CHC member, interview, 2019.
This created resentment and anger from many CHC members, who stressed that the whole planning process should have started with group meetings and conducted in the same transparent approach used for the formation of the groups. There was a feeling that CHCs had been excluded from the malaria campaign, which had “lots of vehicles” and “per diems.” While some CHC members were selected to assist with the MDA, this created protest from the other members who strongly felt that they should be involved since this was work that was remunerated.
It was also unclear to CHC members why some communes and sub-communes were targeted for MDA and IRS while others were not targeted. The targeted MDA/IRS campaign in 2018, for example, targeted OUs in 4 of the 5 communes with CHCs (8,709 households and 36,338 people), based on risk models (Chang et al, manuscript under review; Hamre et al., manuscript under development). However, the rationale for selection was not sufficiently explained to, or understood by, CHCs or to communities across the communes ahead of time and furthered rumors of favoritism in the distribution of activities and benefits. These recruitment and communication challenges were improved slightly in the 2019 IRS campaign but not fully addressed. On the other hand, CHCs played a valuable role in adverse event monitoring. In the 2020 MDA, four cases of Stevens-Johnson Syndrome (SJS) occurred among approximately 42,000 people who were treated in Roseaux and Jeremie, leading to a halt of the campaign before the MDA reached the five original CHC communes. The CHC groups in these communes had played an important role in explaining this difficult decision to community members. CHC groups conducted active side effect case detection within their communities, as few participants reported side effects to local health centers, possibly due to a fear of being diagnosed with COVID-19. They visited voodoo temples to inquire if voodoo priests had seen people with the signs and symptoms of SJS and other potential side effects. They also conducted door-to-door visits to look for people with side effects and remind them about the need to visit the closest health center if they experienced side effects from MDA.
While implementation of these vertical interventions did not fully leverage the CHCs as originally envisioned, interviews in 2019 and 2020 also showed that CHC members felt that health staff from MSPP were not providing sufficient support and integrating them into routine activities. There was a general feeling that MSPP needed to show “more mutual respect and partnership” (CHC member, interview, 2019). Groups involved MSPP in different ways; in some cases, nurses and community health workers were part of the CHC membership while in others they would participate occasionally in activities and as observers during meetings. All groups stressed the need for greater supervision and regular contact and involvement by MSPP, with greater clarity of roles and responsibilities. In our 2019 interviews, the MSPP staff at the commune level that we spoke to did not know where most CHCs meet nor did they have a calendar of action. Many had never attended a meeting. This perceived lack of involvement by MSPP was confusing for CHC members and contributed to a sense of demotivation. There was a strong feeling that MSPP was not supporting the groups. This led to groups being very critical of the leadership and support of MSPP. CHCs believed that MSPP should actively promote the groups, integrate them in their routine activities such as larval surveillance and vector control outreach, organize collaborative education activities during large events and holidays (including World Malaria Day on April 25th of each year) and integrate members in malaria case investigation. They stressed the need for higher-level committees that could convene different government departments to address larger vector control problems, specifically involving roadwork and public infrastructure including garbage collection.
CHC members also highlighted the need to better link their work to that of health workers. A number of CHCs expressed frustration that when they would recommend people to seek malaria tests, the tests would be unavailable. Stockouts were not communicated to the groups, and CHCs felt that there should be better overall communication between local health officers, MSPP and the CHCs. CHCs also noted the lack of linkage with the vector control division and asked for larvicides and the ability to monitor larval habitats. In particular, CHCs felt “overwhelmed” by large stagnant water sources and requested more support to address them. There was a general feeling that the CHCs could not overcome many of the problems in the fight against malaria without further coordination and action.
Our interviews in 2019 and 2020 also found that many members did not feel sufficiently trained on malaria, and that MSPP should conduct additional trainings. Some interviews raised questions about the knowledge of CHC members; for example, they may not know the name of the mosquito that transmits malaria or the name of the pathogen and some were confused about how malaria elimination can occur in the absence of eliminating mosquitoes (a common belief found in the formative research).
Efforts were planned in late 2019 and early 2020 to address these issues, specifically providing financial support to MSPP to attend regular meetings, a range of additional workshops and training, and building this support into routine MSPP budgets. The COVID-19 pandemic, however, prevented these planned trainings, workshops and field visits. An effort to integrate the CHCs into the COVID-19 pandemic response was also planned but then abandoned due to the changing nature of the pandemic and the perceived low mortality rate in the region. During the first half of 2020, however, the health system was significantly affected as facilities closed and patients were fearful of seeking care as they viewed health facilities as a source of transmission of the novel coronavirus.