CHC meetings, governance and planning
The 23 CHCs conducted 498 group meetings over the 24-month period (June 2019-May 2021), with an average of 0.90 meetings/month per CHC (Table 2). This was close to the programme goal of 1 group meeting per month. 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 (Fig. 2). Nine (39%) CHCs held more than one group meeting per month on average. The lowest preforming group was found in Anse d’Hainault (0.46 meetings/month) while the highest was in Les Irois (1.8/month).
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 programme. This was contrasted it to the more top-down and opaque selection process used in many other development and health projects in Haiti. Some leadership changes were required in 4 groups during the study period, due primarily to dropout rates.
The average attendance rate at monthly meetings was 85% across the 5 communes (Table 2), and few members left the groups during the study period. The commune with the lowest average attendance, in Dame Marie, had an attendance average of 71%. Qualitative data suggested that groups in more urban areas (which includes Dame Marie) had less attendance and meetings compared to those in peri-urban and rural areas.
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 (Fig. 2).
CHCs adapted the implementation guidelines in ways that made sense to them and aligned with shared group priorities. Most CHCs created their own oaths, mission statements and songs, and many also formed WhatsApp or Short Message Service (SMS) chat groups. These efforts emerged spontaneously. Group decision-making was described in terms of consensus generation. Common challenges involved 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 most CHCs appeared to have strong leadership teams, a number 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 tried to focus solely on geographical areas favorable to them. CHC 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.,
Frequency and type of community-based anti-malaria activities
Each CHC conducted an average of 1.6 community-based activities involving 123 community members per month, lower than the original goal of 4 community-based activities/month (Tables 3 and 4).
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 (Fig. 2). CHCs in Anse d’Hainault and Moron communes organized more activities per month compared to Chambellan, Dame Marie and Les Irois. 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. These differences were discussed in terms of leadership and motivation.
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 sanitation 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 Fig. 3). Interviews and observations with CHC members (as per the guidance of entomologists from MSPP) showed that these activities were infrequently targeted to Anopheles breeding sites 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.
CHCs also conducted education activities. In our interviews, members especially stressed the importance of school and church meetings and sensitization. In schools, children were encouraged to discuss malaria information 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 with church leaders. As with environmental sanitation campaigns, CHCs also organized educational outreach during festivals and holidays, and MDA and IRS campaigns organized by the Ministry of Health (MSPP). Megaphones provided to CHC were used for sensitization at water kiosks, bus stops, public squares, markets, and street corners as well as and during door-to-door education.
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 not systematically documented by the CHCs.
Negotiating volunteerism and project inputs
The 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, and various statements of solidarity (“working for and with the population”). 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 programme was to avoid direct cash incentives and to emphasize the “volunteer-based” nature of the programme. 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. After an initial trial period in 2018, a flexible incentive of $100 USD(10,000 HTG) was provided to each CHC every two months to assist with the group meetings. This was clearly understood to be an incentive for drinks/snacks during meetings to help organize their work and was reduced to $100 USD every two months in early 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.
While interviews in 2019 found a continued expectation of greater financial incentives and resources, these reduced in 2020. All CHCs reported that they had community activity plans that had not been realized due to a lack of funds: for water, 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. 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 programmes (e.g., vaccination) still receive a small personal stipend to cover their transport and food at a minimum, albeit these programmes 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 also contributed to demotivation, as shown by our effort to establish an electronic data reporting system. Before 2019, MSPP staff would physically visit each CHC 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. A few months after the launch, we found a number of challenges with the phone system: coordinators keeping the phones, lost and broken phones, difficulties recharging the phones, and a general lack of internet connection. In mid-2020, programme staff transitioned to calling each CHC focal person to collect monthly M&E data by voice call. These monthly calls also became an opportunity for programme 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.
Politicization and community mobilization
Group outreach activities had to negotiate political and social dimensions, 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 malaria awareness and environmental sanitation rather than conducting the field activities themselves. CHC members “recruited” people in their social network, namely relatives or neighbours. Community members, in turn, were suspicious that the CHCs were receiving large salaries or remunerations: “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 programme always find some way to benefit personally. This generated 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. The original emphasis on transparency with selecting members, transparently reporting CHC finances by the secretariat, and holding meetings in each sub-commune with a wide variety of stakeholders on this issue helped to address these concerns.
The politicization of CHCs appeared to be much stronger in urban centers, especially in Dame Marie (with the lowest average meeting and community activity rates), and involved the spreading of rumours about CHC members being paid for their work and tied to specific political parties.
Relationship with the vertical malaria programme and Ministry of Health
Our qualitative interviews found challenges with the way malaria programme partners and the Ministry of Health (MSPP) engaged with the Community Health Councils (CHCs). 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. This created resentment and anger from many CHC 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.
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 4 of the 5 communes with CHCs based on risk models but the rationale for selection was not sufficiently explained to, or understood by, CHCs or communities across the communes ahead of time. This furthered rumours of favoritism in the distribution of activities and their benefits.
These recruitment and communication challenges were improved slightly in the 2019 IRS campaign but not fully addressed.
Interviews in 2019 and 2020 showed that CHC members strongly felt that health staff from MSPP were not providing sufficient support and integrating with their activities. 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. This perceived lack of involvement by MSPP was confusing for CHC members and contributed to a sense of demotivation.
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 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 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.
Interviews in 2019 and 2020 also found that many members did not feel sufficiently trained on malaria. 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).