Does the delivery of integrated family planning and ... - Oxford Journals

Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine ß The Author 2007; all rights reserved. Advance Access publication 26 September 2007

Health Policy and Planning 2007;22:404–414 doi:10.1093/heapol/czm034

Does the delivery of integrated family planning and HIV/AIDS services influence community-based workers’ client loads in Ethiopia? Andreea A Creanga,1* Heather M Bradley,1 Aklilu Kidanu,2 Yilma Melkamu3 and Amy O Tsui1

Accepted

9 July 2007 Community-based reproductive health agents (CBRHAs) can increase community knowledge of and offer immediate access to reproductive health services, including HIV/AIDS. Due to growing interest in integration of family planning and HIV services in Ethiopia, it is important to examine whether CBRHAs are efficiently offering both service types. The present analysis uses survey data collected from Ethiopian CBRHAs and examines associations between agents’ demographic, personality and work-related characteristics and their capacity to provide integrated services and have high client volumes. Multivariate probit and bivariate probit regression models are fitted for the two outcomes of interest. Nearly half of CBRHAs in our sample offer integrated services, but this is not jointly associated with increased productivity. Personality traits and work experience are more strongly associated with agents’ capacity to provide integrated services than demographic characteristics, while agents’ gender and work-related characteristics are significantly associated with increased likelihood of serving more clients.

Keywords

Community-based workers, reproductive health, HIV/AIDS, family planning, service integration, client volume

KEY MESSAGES

Community-based reproductive health agents (CBRHAs) supplement government health workers’ outreach by providing primary health services, increasing community knowledge and offering immediate access to reproductive health services, including HIV/AIDS prevention and care.

CBRHAs in Ethiopia are already performing integrated HIV and family planning services.

Personality traits and work experience are more significantly associated with agents’ performance of integrated service delivery than demographic characteristics, while agents’ gender and work-related characteristics are significantly associated with their likelihood of serving many clients.

1

Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

2

Miz-Hasab Research Center, Addis Ababa, Ethiopia.

3

Department of Community Health, Addis Ababa University, Addis Ababa, Ethiopia.

* Corresponding author. Population, Family and Reproductive Health Department, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205–2179, USA. Tel: þ1 410–955–2232. Fax: þ1 410–955–0792. E-mail: [email protected]

Introduction Community-based health worker programmes have increased access to basic health care services in many resource-poor countries with limited health care coverage. Community-based workers are engaged in outreach and education, as well as direct health services, largely in primary health care areas of

404

COMMUNITY-BASED DELIVERY OF HIV AND FAMILY PLANNING SERVICES

maternal and child health, family planning, HIV/AIDS, malaria and environmental hygiene and sanitation (Nsutebu et al. 2001; Ministry of Health, Ethiopia 2004a; Douthwaite and Ward 2005; Jokhio et al. 2005). While they receive small monthly salaries in some countries, many work on a voluntary basis with minimal allowances for travel or per diem. Increasingly, as national recognition of public health programmes grows and community-level health education and promotion efforts gain scale, the lower level workers acquire a disproportionate burden for implementing national vertically organized health programmes. Community health workers supplement the outreach responsibilities of the health system workers who provide primary health services. The Family Guidance Association of Ethiopia initiated the first community-based distribution programme in Ethiopia through which community residents as lay health workers delivered contraceptive methods and services (Pathfinder International/Ethiopia 2004). Currently, community-based reproductive health agents (CBRHAs) are an integral part of the health delivery system in Ethiopia, a predominantly rural country with limited health service access. Several NGOs and community-based organizations are implementing communitybased reproductive health programmes with financial and logistic support from international organizations and donor agencies. A recent study estimated that 30 organizations are coordinating CBRHAs and 12 840 CBRHAs were working in seven out of nine administrative regions in the country (Ministry of Health, Ethiopia 2004a). The same assessment revealed that most sponsor organizations engage CBRHAs using the ‘door step’ approach (64%), in which agents provide services through household visits, followed by ‘community mobilization’ (50%), which includes health outreach and advocacy activities with community and religious leaders, and ‘depot or market place’ models (14%), in which services are provided in agents’ houses or in markets (Ministry of Health, Ethiopia 2004a). CBRHAs have been credited with increasing both contraceptive knowledge and prevalence in project areas (Pathfinder International/Ethiopia 2003), as well as providing satisfactory reproductive health services from clients’ perspectives (Ministry of Health, Ethiopia 2004a). These are considerable achievements in a country with a total fertility rate of 5.4 children per woman (Central Statistical Agency and ORC Macro 2006), where roughly 85% of the country’s 74.8 million people reside in rural areas (Population Reference Bureau 2006). Despite CBRHA contributions, unmet need for contraception is high, ranging geographically from 19 to 43% for women aged 15–49 (Birhan Research and Development Consultancy 2004) and reduced negligibly from 36% in 2000 to 34% in 2005 at the national level (Central Statistical Authority and ORC Macro 2001; Central Statistical Agency and ORC Macro 2006). Current estimates for modern contraceptive use are modest, although increasing from 8% in 2000 to 15% in 2005 among women of childbearing age (Central Statistical Authority and ORC Macro 2001; Central Statistical Agency and ORC Macro 2006). CBRHAs report serving many women who would not otherwise visit a family planning clinic due to concerns about confidentiality, but client load data are scarce (Bradley et al. 2006). However, a 1997 article reports that

405

some Ethiopian agents serve upwards of 30% of the eligible women in their communities (Redwine 1997), and an evaluation project in the two regions with the largest cadre of CBRHAs in the country reports that both community leaders and sponsor organizations distribute commodities and other resources based on CBRHAs’ monthly and quarterly self-reports of new and continuing clients (Bradley et al. 2006). While CBRHA assistance has typically been mobilized for reproductive and maternal and child health care in Ethiopia, there is a growing need for them to provide HIV/AIDS-related services ranging from referral for voluntary counselling and testing (VCT) to home-based care for people living with HIV/AIDS, especially given the rising HIV prevalence in the rural areas (Ministry of Health, Ethiopia 2004b). Recent data estimate that more than one million people (1.4% of the population) are infected with HIV (Central Statistical Agency and ORC Macro 2006). CBRHAs often distribute condoms directly to households under their family planning mantle, a service of direct relevance to reducing the transmission risk of all sexually transmitted infections, including HIV. Increasing community knowledge about HIV/AIDS has been an important CBRHA achievement in Ethiopia — one recent CBRHA programme evaluation reports that over 40% of survey respondents identified CBRHAs as their primary source of HIV/AIDS information (Pathfinder International/Ethiopia 2004). In addition to outreach work, however, there is evidence suggesting that CBRHAs can perform a range of direct HIV/ AIDS services (Nsutebu et al. 2001; Pathfinder International/ Ethiopia 2004), as well as client referrals to VCT clinics. The integration of HIV and family planning services is often endorsed as an effective way to maximize limited health care resources. In addition to increasing operational efficiency, several factors argue for integrating HIV and family planning services. The number of HIV-infected women has increased in recent years and more than half of HIV-infected persons are now women of reproductive age, who are often in need of contraceptive services (Ministry of Health, Ethiopia 2004b). Offering family planning services to VCT clients and people living with HIV/AIDS may slow the spread of the HIV by increasing appropriate contraceptive use among HIV-positive individuals (Kagaayi 2004; Sweat et al. 2004). Additionally, individuals at high-risk for HIV acquisition may be more likely to reduce their sexual risk behaviour when presented with the dual benefits of family planning practice, i.e. prevention of both unwanted pregnancy and HIV infection (Askew and Berer 2003). Because of the growing interest in reproductive health and HIV service integration in Ethiopia, it is helpful to examine whether CBRHAs are engaged in integrated HIV and family planning service delivery. Several studies have explored motivations for communitybased workers to provide service to the community, including financial benefits, hope for eventual remuneration, a sense of social responsibility or altruism, the ability to gain work experience, a visible social presence in the community and project ownership (Kironde and Klaasen 2002; Afsar and Younus 2005). One study in Nepal found that an enabling community climate is particularly important to engaging and sustaining these workers’ performance (Chhetry et al. 2005). The same study identified the most common barriers to their

406

HEALTH POLICY AND PLANNING

productivity to be lack of supplies, lack of supervisory support, skill limitations and low levels of community trust (Chhetry et al. 2005). An Ethiopia-based study found that the most frequently mentioned advantages of CBRHA service were personal interest, higher prestige in the community, potential source of future employment and additional income (Ministry of Health, Ethiopia 2004a). CBRHAs in Ethiopia provide health outreach services on a voluntary basis. It is common for them to receive non-monetary incentives such as uniforms or supplies, as well as small travel allowances, but not salaries. Overall, 40.9% of agents in Ethiopia receive incentives, ranging from commission on sales to clothing, accessories and bicycles (Ministry of Health, Ethiopia 2004a). Towards the end of 2004, the Ethiopian Ministry of Health introduced a new outreach programme, called the health extension package (Center for National Health Development in Ethiopia 2006). Health extension workers (HEWs) are intensively trained for 1 year and then deployed to rural regions of Ethiopia. The HEWs are full-time workers paid from governmental resources, and one of their responsibilities is to supervise CBRHAs and other community health workers in the field. As of late 2004 several thousand HEWs have been deployed in the country, and are continuously supervised by the Ethiopian Ministry of Health. Because CBRHAs have proven to be such an integral part of the health system, it is important, from a programmatic perspective, to understand their capabilities and motivations for providing health services, helping policy and programme planners know when and under what conditions to mobilize their involvement, especially for supervisory needs. The aims of this study are to: (1) examine associations between CBRHAs’ demographic, personality- and work-related characteristics and their capacity to provide integrated HIV and family planning services and serve large numbers of clients, and (2) assess the extent to which performing integrated HIV and family planning service delivery is associated with increased productivity, as measured by CBRHAs’ client load.

Data and methods A situation analysis was conducted between April and May 2005 by an Ethiopia-based research firm, Miz-Hasab Research Center, in order to obtain current information on CBRHAs’ activities, productivity and motivations in woredas (administrative districts) in two regions of Ethiopia: Amhara and Oromiya. The woreda situation analysis was carried out in 12 of 52 woredas belonging to five zones in the two regions. The 12 woredas were selected purposively based largely on their geographic location to ensure the fieldwork team was able to cover a sufficient area and sample of CBRHAs with available resources. Each woreda was expected to have approximately 30–50 CBRHAs variously sponsored by different service organizations but all reporting regularly to their woreda supervisors. The 12 woredas engaged a total of 470 CBRHAs. All agents appearing for their monthly supervisory meetings were asked to consent to an interview, using a standardized questionnaire. The most common reason for agents’ absence at the supervisory meeting was involvement in political activities related to the national election. Supervisory meetings take place bi-monthly between every agent and his or her individual

supervisor, and monthly at the woreda level when all agents and supervisors meet with woreda leaders and discuss work progress and ways to overcome existing challenges. The final sample included 340 CBRHAs, representing most (72%) of the active agents in sampled woredas. The present analysis uses survey data collected by Miz-Hasab Research Center interviewers from the 340 CBRHAs and examines factors behind CBRHA motivations for performing integrated service delivery and achieving high client loads.1 Interviewers were hired from the Miz-Hasab Research Center and were not associated with the CBRHA programme at any time. The first outcome variable, provision of integrated services, was constructed from four variables, two related to family planning service provision (counselling, provision of pills and condoms, referrals for long-term contraceptive methods) and the other two to HIV service provision (counselling on HIV prevention and prevention of mother-to-child transmission of HIV, training families to care for HIV-positive family members including prevention of opportunistic infections, providing support and nutrition counselling). Agents were coded as providing integrated family planning and HIV/AIDS services if they answered positively to: (a) providing or referring for contraceptives, and (b) referring for VCT or providing services to people living with HIV/AIDS or their families. The second outcome variable, high client volume, was constructed as a binary variable, with agents serving more than 110 clients during the 3-month period preceding the interview coded as having high client volumes. This cut-off point represents the upper third of the client load distribution in the sample and signifies approximately two clients per day over a 5 day working week in 11 of the 12 weeks duration covered. The key covariates are grouped in three categories: demographic characteristics (age, sex, marital status, education level, religion, primary occupation and involvement in other community service), personality-related characteristics (being comfortable talking about HIV/AIDS with men and women of all ages, and reporting the primary work motivation as personal interest in the work, enjoying meeting new people or performing service for the community), and work-related characteristics [sponsor organization, years of experience working as a CBRHA, number of households visited in the last month and number of kebeles (smaller administrative districts than woredas) where the agent has worked as a CBRHA]. Education level is categorized as none, 1–6 years, 7–10 years or 10 þ years. Religion is coded as Orthodox, Muslim or Protestant, and primary occupation as agricultural, non-agricultural or unemployed. The provision of additional community work was categorized as none, being a community leader, either religious or administrative at the kebele or woreda level (smaller and larger administrative districts, respectively) or providing other type of community work. Interviewed agents represent the following sponsor organizations: Pathfinder International/Ethiopia, Abebech Gobena Yehitsanat Kibikebena Limat Dirijit and Oromiya Development Association. One of these sponsors (noted as X) engages the largest number of CBRHAs in the two study regions. CBRHAs’ duration of experience is categorized as 1–24 months, 25–48 months or 48 þ months. The number of monthly household visits is categorized as 1–10, 11–20 or 20 þ.


Exploratory uni- and bivariate analyses were conducted and multivariate probit regression models were fitted for the two outcomes of interest: provision of integrated services and reporting high client volume, adjusting for demographic, personality- and work-related characteristics. Additionally, in order to address the possible endogeneity between the two outcome variables, that is the potential that one outcome is correlated with unobservable factors that affect the second outcome, a bivariate probit regression model using both variables was fitted adjusting for the same key covariates included in the two separate probit models. We expected the two outcomes to be joint, i.e. the same agents with higher client volumes to be the ones providing integrated services. This hypothesis was tested using the bivariate probit model which fitted maximum-likelihood two-equation probit models for the two binary outcomes that vary jointly as a function of explanatory variables. The basic formulation of the bivariate probit model is as follows: X bi1 xi1 þu1 yi1 ¼ F X yi2 ¼ F bi2 xi2 þu2 , where y1 and y2 are the two binary dependent variables, while u1 and u2 are the random errors distributed as standard bivariate normal variables with correlation coefficient rho (r). We estimated the marginal effects of independent variables, where a marginal effect is the probability of performing integrated services or having high client volumes, alone (based on the probit model) or jointly (based on the bivariate probit model) per unit (or category) of each covariate, holding all other covariates constant at their means in the respective regression model. We also performed a likelihood ratio test to test whether r is different from zero. We use probit and bivariate probit regression to estimate the parameters of the two separate and one joint models, respectively, for the two outcomes and compare their results. The probit model provides a better fit and is thus more appropriate than the logit model for the outcome distributions in these data.

Results Table 1 summarizes the CBRHA sample’s characteristics. More than half of the CBRHAs are female (62%) and the vast majority are married (92%); 42% of them are younger than 31 years and almost one-third are older than 35 years. The agents are relatively well educated with almost 71% having more than 7 years of schooling and only 3% having no education. All but 17% of the agents interviewed are involved in other community service apart from their CBRHA work — 45% of them report being community leaders, and almost 38% report involvement in some other type of community work. Table 1 also provides detail on the sample composition by performance of integrated HIV/AIDS and family planning services, as well as provision of reproductive health services to more than 110 clients over a 3-month period. Performing integrated service delivery differs significantly by religion, primary occupation and involvement in other community

407

work. Agents reporting a non-agricultural occupation have a higher likelihood of performing integrated services than agents with agricultural occupations or who are unemployed. An interesting finding is that almost 55% of agents who are community leaders, either religious or administrative, are performing integrated services, while only about 38% of the agents who are not involved in other community work do so. Performance of integrated service delivery, conducted by approximately 48% of agents, differs significantly by all personality-related characteristics. A majority of 71% of agents who report liking meeting new people as their primary work motivation are offering integrated services; however, 42% of agents who did not report liking meeting new people are offering integrated services. Similarly, more than three-fifths (63%) of those who report being comfortable talking with either men or women about HIV/AIDS offer integrated services, while only 38% of agents who did not report being comfortable talking with either men or women about HIV/AIDS do so. Performing integrated service delivery also differs by agents’ years of working experience; only 29% of agents with less than 25 months of experience working as CBRHAs deliver integrated services, but 56 and 47% of those with 25–48 months and more than 48 months of experience, respectively, provide such services. Having high client loads as a CBRHA only differs significantly by gender, sponsor organization and the number of monthly household visits. Table 2 shows results for two regression models examining integrated service delivery and influences on high productivity, as measured by client volume. Protestant community-based agents are significantly less likely to offer integrated HIV and family planning services, when compared with Orthodox agents. Agents who are community leaders are significantly more likely to offer integrated HIV and family planning services compared with agents without additional community functions. Statistically significant positive associations are observed between performing integrated service delivery and comfort in talking with men and women about HIV/AIDS, as well as reporting meeting new people as a primary work motivation. The sponsor organization affiliation shows a significant negative association with service integration; sponsor X’s CBRHAs are less likely to perform integrated service delivery than agents from other organizations. Having more than 2 years of CBRHA experience and visiting more than 20 households in the last month are significantly and positively associated with performing service integration. Based on the marginal effects estimated after the probit regression model for service integration, male agents are only 2% more likely to offer integrated services relative to female agents. Agents who are community leaders are 14% more likely to offer integrated HIV and family planning services than agents with no additional community contribution. Agents who are comfortable talking about HIV/AIDS and those who report liking to meet new people as a primary work motivation are 19 and 24%, respectively, more likely to perform integrated service delivery than their counterparts. Finally, agents with 24–48 months and more than 48 months of CBRHA experience are 28 and approximately 16%, respectively, more likely to offer integrated service delivery for their clients when compared to those with 2 or less than 2 years of experience. Agents who

408


Table 1 Percentage distribution of CBRHAs’ characteristics and differentials in performing integrated HIV and family planning service delivery and having a high client volume by demographic, personalityand work-related variables (n ¼ 340) No. (%)

Covariates

Service integration (%)

High client volume (%)

Demographic variables Sex Male

130 (38.2)

50.0

23.9*

Female

210 (61.8)

46.2

39.1

Marital status Unmarried

Table 1 Continued No. (%)

Service integration (%)

High client volume (%)

Yes

262 (77.1)

45.8

37.8*

No

78 (22.9)

53.9

18.0

1–24 months

62 (18.2)

29.0*

21.0

25–48 months

146 (42.9)

56.2

36.3

132 (38.9)

47.0

35.6

Covariates Work-related variables Sponsor organization X

CBRHA experience

29 (8.5)

58.6

34.5

>48 months

311 (91.5)

46.6

33.1

Monthly households visited 1–10

99 (29.1)

43.4

18.2*

18–30

144 (42.4)

49.3

36.8

11–20

148 (43.5)

46.0

39.2

31–35

93 (27.4)

43.0

34.4

>20

93 (27.4)

54.8

39.8

103 (30.3)

49.5

27.2

218 (64.1)

48.6*

32.6

Worked as CBRHA in more than one kebele

53 (15.6)

62.3

39.6

Yes

76 (22.4)

42.1

36.8

No

264 (77.6)

49.2

32.2

Yes

318 (93.5)

50.9

34.0

No

22 (6.5)

0.0

22.7

Yes

167 (49.1)

97.0

33.5

No

173 (50.9)

0.0

33.0

Yes

162 (47.7)

100.0

34.0

No

178 (52.3)

0.0

32.6

Yes

113 (33.3)

48.7

100.0

No

207 (66.7)

47.1

Married and in union Age

>35 Religion Orthodox Muslim Protestant

69 (20.3)

33.3

30.4

Provide family planning services

Education None

11 (3.2)

36.4

9.1

88 (25.9)

53.4

28.4

7–10 years

165 (48.5)

48.5

37.0

>10 years

76 (22.4)

40.8

34.2

35

0.205 (0.196)

0.081 (0.077)

0.238 (0.200)

0.081 (0.066)

Education None 10 years

0.002 (0.513)

0.001 (0.204)

0.742 (0.623)

0.276 (0.236)

Religion Orthodox Muslim Protestant

ref

ref

ref

ref

0.320 (0.226)

0.127 (0.089)

0.402* (0.225)

0.148* (0.086)

0.438** (0.208)

0.170** (0.077)

0.320 (0.207)

0.105 (0.064)

Primary occupation Agriculture Non-agriculture Unemployed

ref

ref

ref

ref

0.244 (0.235)

0.097 (0.093)

0.274 (0.242)

0.099 (0.091)

0.091 (0.271)

0.036 (0.107)

0.122 (0.290)

0.043 (0.105)

Community work None

ref

ref

ref

ref

0.355* (0.219)

0.141* (0.086)

0.129 (0.229)

0.045 (0.080)

0.005 (0.231)

0.002 (0.092)

0.099 (0.237)

0.035 (0.084)

No

ref

ref

ref

ref

Yes

0.490*** (0.160)

0.193*** (0.062)

0.090 (0.165)

0.031 (0.058)

Community leader Other community work Personality-related variables Comfortable talking with men and women of all ages about HIV/AIDS

Report ’for personal interest’ as primary work motivation No

ref

ref

ref

ref

Yes

0.081 (0.175)

0.032 (0.070)

0.078 (0.178)

0.027 (0.061)

Report ’like meeting people’ as primary work motivation No

ref

ref

ref

ref

Yes

0.619*** (0.217)

0.242*** (0.081)

0.315 (0.219)

0.104 (0.068) (Continued)

410


Table 2 Continued Service integration

High client volume

Coef. (std. error)

Marginal effects (std. error)

Coef. (std. error)

Marginal effects (std. error)

No

ref

ref

ref

ref

Yes

0.321 (0.246)

0.125 (0.093)

0.140 (0.250)

0.050 (0.091)

No

ref

ref

ref

ref

Yes

0.735*** (0.222)

0.285*** (0.081)

0.751*** (0.234)

0.228*** (0.060)

Covariates Report ’like performing community service’ as primary work motivation

Work-related variables Sponsor organization X

CBRHA experience 1–24 months 25–48 months >48 months

ref

ref

ref

ref

0.726*** (0.226)

0.283*** (0.084)

0.343 (0.237)

0.120 (0.083)

0.393* (0.234)

0.156* (0.092)

0.452* (0.243)

0.160* (0.087)


ref

ref

ref

ref

11–20

0.024 (0.189)

0.010 (0.075)

0.593*** (0.204)

0.208*** (0.071)

>20

0.467** (0.217)

0.185** (0.084)

0.444** (0.226)

0.161** (0.084)

Worked as CBRHA in more than one kebele No

ref

ref

ref

ref

Yes

0.149 (0.199)

0.059 (0.078)

0.399** (0.200)

0.146** (0.076)

Note: Figures are statistically significant at a level of: *P < 0.1; **P < 0.05; ***P < 0.01.

behind increased productivity, as is serving more than one kebele compared with serving only one kebele. Moreover, agents sponsored by organization X are significantly more likely to have served more than 110 clients over a 3-month period. The marginal effects after the probit model for high client volume show that male and Muslim agents are almost 19 and 15%, respectively, more likely to have high client loads when compared with female agents and those of Orthodox religion. Also, agents with more than 4 years of CBRHA experience are 16% more likely to have high client volumes when compared with those with 2 or less than 2 years of such experience, and agents working in more than one kebele are 15% more likely to report high client loads than those working in only one kebele. Furthermore, if the agent visited between 11 and 20 or more than 20 households in the prior month, he or she is 21 and 16%, respectively, more likely to have provided reproductive health services to more than 110 clients in the 3 months preceding the survey, compared with agents who visited 10 or less households in the same period of time. Interestingly, the associations between the various demographic, personality- and work-related characteristics of the CBRHAs and the two outcomes of interest show similar statistical significance in both the two separate (univariate) probit and the bivariate probit regression models (Table 3). The likelihood ratio test shows that providing integrated services does not increase the likelihood of serving more clients (r ¼ 0.020, P ¼ 0.846, see footnote to Table 3). Thus, our assumption that the two outcomes are jointly dependent on the covariates is not supported by results of the bivariate probit regression.

The marginal effects estimation after the bivariate probit shows that only about 15% of the agents providing integrated HIV and family planning services have served more than 110 clients in the 3 months before the interview. Male agents are approximately 10% more likely to provide integrated services and have high client volume when compared with female agents, while Muslim agents are 12% more likely than agents of Orthodox faith to do so. When both outcomes are examined together, agents’ education level is positively associated with provision of integrated services to high client loads, so that workers with 7–10 years of education are 18% more likely to provide integrated services to many clients than agents with no education (P < 0.1). On the other hand, agents who are comfortable talking about HIV/AIDS with clients of all ages are significantly more likely to provide integrated services and simultaneously serve high client loads. Agents with more than 2 years CBRHA experience, those serving more than 10 households monthly and those working in multiple kebeles are between 10 and 15% more likely to both offer integrated services and have high client volumes.

Discussion CBRHAs are recognized to be the ‘backbone’ of the reproductive health service system in Ethiopia (Bradley et al. 2006). Particularly given CBRHAs’ recent arrangement of being supervised by the newly deployed health extension workers, as well as the need for all community-based providers to take on additional HIV/AIDS responsibilities and improve the range and quality of reproductive health services in Ethiopia,


411

Table 3 Results from the bivariate probit regression model of performing integrated HIV and family planning service delivery and having high client volume on demographic, personality- and work-related variables (n ¼ 340) Covariates

Service integration Coef. (std. error)

High client volume Coef. (std. error)

Y ¼ 0.145 Marginal effects (std. error)

ref

ref

ref

0.046 (0.218)

0.568*** (0.234)

0.095** (0.044)

Demographic variables Sex Female Male Marital status Unmarried Married and in union

ref

ref

ref

0.108 (0.299)

0.279 (0.306)

0.065 (0.076)

Age 18–30

ref

ref

ref

31–35

0.254 (0.190)

0.076 (0.190)

0.019 (0.037)

>35

0.204 (0.196)

0.238 (0.200)

0.060 (0.037)

Education None

ref

ref

ref

10 years

0.001 (0.513)

0.744 (0.624)

0.130 (0.147)

Religion Orthodox Muslim Protestant

ref

ref

ref

0.320 (0.226)

0.402* (0.225)

0.122*** (0.061)

0.439** (0.208)

0.319 (0.207)

0.091 (0.032)

Primary occupation Agriculture Non-agriculture Unemployed

ref

ref

ref

0.244 (0.235)

0.274 (0.242)

0.082 (0.060)

0.091 (0.271)

0.119 (0.291)

0.008 (0.060)

Community work None Community leader Other community work

ref

ref

ref

0.355* (0.219)

0.129 (0.229)

0.064 (0.047)

0.004 (0.230)

0.098 (0.237)

0.016 (0.049)

Personality-related variables Comfortable talking with men and women of all ages about HIV/AIDS No

ref

ref

ref

Yes

0.490*** (0.160)

0.089 (0.165)

0.075** (0.037)

Report ’for personal interest’ as primary work motivation No

ref

ref

ref

Yes

0.080 (0.175)

0.078 (0.178)

0.003 (0.036)

Report ’like meeting people’ as primary work motivation No

ref

ref

ref

Yes

0.618*** (0.217)

0.315 (0.218)

0.009 (0.046)

Report ’like performing community service’ as primary work motivation No

ref

ref

ref

Yes

0.321 (0.246)

0.139 (0.250)

0.019 (0.047) (Continued)

412


Table 3 Continued Covariates

Service integration Coef. (std. error)

High client volume Coef. (std. error)

Y ¼ 0.145 Marginal effects (std. error)

Work-related variables Sponsor organization X No

ref

ref

ref

Yes

0.733*** (0.222)

0.750*** (0.234)

0.055 (0.041)

CBRHA experience 1–24 months 25–48 months >48 months

ref

ref

ref

0.724*** (0.226)

0.343 (0.236)

0.148*** (0.053)

0.392* (0.234)

0.451* (0.243)

0.129** (0.055)


ref

ref

ref

11–20

0.024 (0.189)

0.592*** (0.204)

0.095** (0.045)

>20

0.467** (0.217)

0.444** (0.226)

0.146** (0.058)

Worked as CBRHA in more than one kebele No

ref

ref

ref

Yes

0.149 (0.199)

0.398** (0.201)

0.146** (0.046)

Note: Figures are statistically significant at a level of: *P < 0.1, **P < 0.05 or ***P < 0.01. Log-likelihood ¼ -382.649; Wald 2 (46) ¼ 116.15; r ¼ 0.020; likelihood-ratio test of r ¼ 0: P ¼ 0.846.

CBRHAs’ characteristics and motivations for volunteerism warrant monitoring and closer analysis. Our study suggests that personality traits, duration of CBRHA experience and willingness and/or ability to visit more households are strongly associated with providing integrated service delivery. The personality-related characteristics found to be significantly related to performing integrated services were being comfortable talking about HIV/AIDS with clients of the same and opposite gender and enjoying meeting new people. Conversely, a personal interest in health work and enjoying community service were not found to represent significant motivations for CBRHAs to perform integrated HIV and family planning services. On the other hand, personality traits do not seem to have important influences on agents’ output level, measured as the number of clients over a 3-month period, whereas all work-related characteristics and being male are positively associated with productivity. Interestingly, being a community leader is significantly associated with agents’ willingness to provide integrated HIV and family planning service delivery but not to serve a high number of clients. This active involvement of community leaders in communitybased programmes creates a sense of responsibility and ownership for such projects and enhances their overall support for the CBRHAs. This finding provides one possible explanation of the success of CBRHAs programmes in Ethiopia. Greater CBRHA working experience is significantly associated with an increased likelihood of both providing integrated services and serving a high number of clients. Similarly, agents visiting more than 10 households monthly are significantly more likely to be in the high productivity group, while agents’ likelihood of offering integrated services is higher only for those visiting more than 20 households monthly. Having the experience of working in more than one kebele as a CBRHA is strongly associated with serving more clients but not with delivering integrated services. Similarly, the sponsorship

and supervision offered by organization X seems to increase agents’ productivity but not necessarily promote HIV and family planning service integration. Given that organization X was known to perform more strongly in one of the two regions from which the sample was selected, we stratified the analysis by region but observed no change in the results. Thus, agents supervised by sponsor X are significantly more likely to have served more than 110 clients over 3 months but also significantly less likely to provide integrated services. In comparison with results from a study of community-based health workers in Botswana, which found that agents were not aware of who their supervisors were (Walt et al. 1989), CBRHAs in Ethiopia were knowledgeable about their supervisors and the vast majority of them identified either the implementing organization or the actual sponsor organization for which they worked. Evaluating the impact of community-based reproductive health programmes in Ethiopia or the quality of care offered by these programmes was not the purpose of our study. Yet, the present study shows that CBRHAs are providing integrated HIV/ AIDS and family planning services, but does not identify these agents as the same ones reporting high client loads. The most important finding is that CBRHA provision of integrated HIV and family planning services is not strongly associated with serving more clients as we assumed. One might expect that agents who provide integrated services in a more effective, time-saving manner are not only meeting broader health service needs in the community but also reaching more clients. The extent to which CBRHAs provide integrated services in Ethiopia and report high client volumes is, however, limited; only about 15% of agents do both. Based on the results from the bivariate probit regression, male, Muslim agents, with 7–10 years of education, who are comfortable talking about HIV/AIDS with men and women of all ages, have more than 2 years of CBRHA experience, visit more than 10 households


monthly and have served multiple kebeles are more likely than agents with other characteristics to provide integrated services to a high number of clients in Ethiopia. Several recommendations for CBRHA programme managers and supervisors can be gleaned from the associations found in these data. First, these results suggest that promoting integrated service delivery in Ethiopia likely will not increase the volume of clients served by CBRHAs, which has important implications for programme resource needs. CBRHAs have, for the most part, income-generating occupations and are often involved in other community work. As a result they have finite time available for health service delivery and this constrains their ability to serve many clients. While integrated service delivery is likely advantageous for increasing clients’ access to multiple health services, it appears to increase the amount of time that agents must spend with each client. If CBRHAs are increasingly expected to provide integrated HIV and family planning care to households, the overall number of agents will need to be augmented to maintain current outreach levels. Thus, more resources are needed for CBHRA programmes if integrated service delivery is to be a priority. Secondly, our findings suggest that programme managers should consider personality traits when recruiting agents. Comfort with discussing HIV/AIDS with men and women of all ages and an affinity for meeting new people were positively associated with integrated service delivery, and these are both attributes that could be incorporated in either screening or training of new agents. Thirdly, agents with more experience are more likely to perform integrated services and also more likely to serve larger client loads. Therefore, strategies for retaining agents should be developed in the interest of the association between agents’ experience and increased productivity. Increasing incentives proportionally with agents’ work experience, establishing a system for promotions or a more interactive supervision scheme may help supervisors to retain agents. Lastly, given the government’s new policy of deploying the better-trained HEWs at the community level to supervise CBRHAs, we can expect several consequences—a higher turnover of CBRHAs, recruitment of some of the more experienced and educated CBRHAs into the health extension programme, and an increase in CBRHAs’ quality of care and the number of services they offer at the expense of productivity. This is why a valid referral system should be put in place and the working relationships between the different types of community health workers should be well defined. The study has several limitations. First, because of the crosssectional nature of the data, we are able to identify only associations rather than causal relationships between agents’ characteristics and the outcomes of interest. Secondly, although the survey went into depth in assessing the performance and characteristics of the majority of active agents in the 12 selected woredas, the sample is not a probability one and thus cannot claim to be representative of all CBRHAs in the two Ethiopian regions. However, the selection and training of CBRHAs are standardized throughout the country; all have monthly review meetings and receive similar supervision irrespective of their geographic location or sponsor organization. The selected woredas include six predominantly Muslim and six

413

predominantly Christian districts, and are not unlike other woredas in Ethiopia in terms of access to reproductive health services or availability of contraceptive supplies, which are provided by Pathfinder International Ethiopia for the majority of CBRHAs programmes in the country. Thirdly, caution must be exercised in interpreting the personality-related characteristics because these measures are subjective and agents’ answers may change over time. Additionally, we cannot assess if these attributes are mutable, that is, whether they can be cultivated through training or experience, or they are intrinsic to the agents’ character. Lastly, recall bias can be a concern for the work-related covariates, especially with regard to reports of the number of clients served in the 3 months preceding the survey and the experience working as a CBRHA. However, because interviews were conducted at the time of monthly supervisory meetings where agents are asked to provide information on client loads and to bring their client records, the information provided during the interviews is likely to be unbiased. On the other hand, in order to address the potential bias introduced by poor record keeping, we chose to dichotomize the client volume variable and use the 66th percentile as a cut-off.

Conclusions CBRHAs supplement government health workers’ outreach by providing primary health services, increasing community knowledge and offering immediate access to reproductive health services, including HIV/AIDS prevention and care. Due to a growing interest in HIV/AIDS and family planning service integration, it is important to examine whether community workers are efficiently integrating these two service types in Ethiopia. Our data suggest that many CBRHAs in Ethiopia are already performing integrated HIV and family planning services. Personality traits and work experience are more significantly associated with agents’ performance of integrated service delivery than demographic characteristics, while agents’ gender and work-related characteristics are significantly associated with their likelihood of serving many clients.

Endnote 1

This study is a secondary analysis of data collected in March 2005 by the Miz Hasab Research Center (MHRC) for an evaluation of a private sector reproductive health project. MHRC followed its human subjects research protocols and obtained informed consent from all subjects.

Acknowledgements The authors wish to express their appreciation to the following individuals who provided generous assistance in enabling this study: Pierre Ngom, Tilahun Giday, Mengistu Asnake and Sahlu Haile. The field staff of the Miz Hasab Research Center are also acknowledged, as is support from the Bill and Melinda Gates Institute for Population and Reproductive Health. Thanks are also extended to two anonymous reviewers.

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