How do community health committees build capacity for community health systems strenghtening? A realist evaluation in Uganda
Citation:GILMORE, BRYNNE, How do community health committees build capacity for community health systems strenghtening? A realist evaluation in Uganda, Trinity College Dublin.School of Psychology.PUBLIC HEALTH AND PRIMARY CARE, 2018
Brynne Gilmore PhD Thesis_Global Health 2017.pdf (PDF) 130.9Mb
Background: Community-based interventions are widely accepted as an integral component of decentralisation strategies aimed at reducing inequity in health and achieving Primary Health Care for All within less resourced settings. Interventions with a health systems strengthening, and in particular community systems strengthening, focus are likely to have more impactful and sustainable effects. Community organisation strategies that aim to increase communities capacity are particularly suited to contribute to community systems strengthening. One such intervention is the introduction of community health committees; however, little is known about how these committees work to achieve community systems strengthening, especially given the varied contextual conditions in which they are implemented. Using systems thinking perspectives, this thesis aims to address this gap by exploring generative causality which explains how, why and for whom community health committees build capacity for community systems strengthening within a low-income context. Methods: A mixed methods realist evaluation with two intra programme case studies in North Rukiga, Uganda was conducted. As a form of theory based evaluation, realist evaluations work to understand what works, for whom, and why through the elicitation of context-mechanism-outcome configurations. Specifically suited to the study of complex health interventions, exploring the generative causality of programmes allows for contextually informed, transferable findings. Within this thesis three distinct phases of research occurred. Phase 1 involved the elicitation of the initial programme theories through a combination of literature and document reviews and key informant interviews. The findings from the initial programme theory informed the study design and data collection tools for phase 2. This phase consisted of the two case studies, which were conducted to refine the initial programme theories. The case studies were run within a Maternal and Child Health Programme in Uganda that utilised community health committees as a core implementation strategy. Methods within all case studies consisted of focus group discussions, semi-structured in-depth interviews, observations and surveys. Case studies were analysed using the context-mechanism-outcome configuration as an analytical tool on an individual case basis. In phase 3 of this research the case study programme theories from phase 2 were synthesised to produce a middle range theory that addresses the study question. Results: Results for how community health committees work best, for whom, and why can be defined within socio-ecological levels aligned to: individuals within the committee, the committee as an organisation, the committees and its interaction with communities and community stakeholders, and the committee within the wider social environment. Each level has a resulting theory that is of middle-range, which when taken together explain the operationalization of community health committees across the socio-ecological levels. Findings show that generative causation for how, why and for whom, the community health committees work relate to interacting contexts and mechanisms both within and across the socio-ecological levels. Specific findings highlight: CHCs connectivity to the community and their resulting social identify, their motivating factors for involvement, and their cultural capital (individual level); CHCs intragroup categorisation, their managerial processes, and their social capital and its resulting rewarded power (organisational level); their linkages and partnerships with other community stakeholders as a result of shared identity and common goals, and their community integration (community level); and the socio-political environments in which they work, the strength of their implementing partners, and the level of collaborative community support (societal level), all explain how CHCs work (or don t) for capacity building. Discussion: Moving beyond traditional positivist studies that work to ascertain if something works, to studies that aim to explore the generative causation of why and how something works is an important strategy within health promotion interventions to provide more contextually informed findings. The use of a realist evaluation within this thesis enabled the exploration of community health committees and the factors that influence their ability to contribute to capacity building across multiple socio-ecological levels. As such these contextually relevant findings can be tailored and transferred to other settings. This thesis also contributes to the methodological advancement of realist studies. As the use of realist evaluation within low-income countries is underexplored, considerations for its continued advancement and recommendations within this field are presented.
Author: Gilmore, Brynne
Publisher:Trinity College Dublin. School of Psychology. Discipline of Psychology
Type of material:Thesis
Availability:Full text available