BackgroundThe WHO health systems Building Blocks framework has become ubiquitous in health systems research. However, it was not developed as a research instrument, but rather to facilitate investments of resources in health systems. In this paper, we reflect on the advantages and limitations of using the framework in applied research, as experienced in three empirical vaccine studies we have undertaken.DiscussionWe argue that while the Building Blocks framework is valuable because of its simplicity and ability to provide a common language for researchers, it is not suitable for analysing dynamic, complex and inter-linked systems impacts. In our three studies, we found that the mechanical segmentation of effects by the WHO building blocks, without recognition of their interactions, hindered the understanding of impacts on systems as a whole. Other important limitations were the artificial equal weight given to each building block and the challenge in capturing longer term effects and opportunity costs. Another criticism is not of the framework per se, but rather how it is typically used, with a focus on the six building blocks to the neglect of the dynamic process and outcome aspects of health systems.We believe the framework would be improved by making three amendments: integrating the missing “demand” component; incorporating an overarching, holistic health systems viewpoint and including scope for interactions between components. If researchers choose to use the Building Blocks framework, we recommend that it be adapted to the specific study question and context, with formative research and piloting conducted in order to inform this adaptation.SummaryAs with frameworks in general, the WHO Building Blocks framework is valuable because it creates a common language and shared understanding. However, for applied research, it falls short of what is needed to holistically evaluate the impact of specific interventions on health systems. We propose that if researchers use the framework, it should be adapted and made context-specific.

Background. After 2 decades of focused efforts to eradicate polio, the impact of eradication activities on health systems continues to be controversial. This study evaluated the impact of polio eradication activities on routine immunization (RI) and primary healthcare (PHC).Methods. Quantitative analysis assessed the effects of polio eradication campaigns on RI and maternal healthcare coverage. A systematic qualitative analysis in 7 countries in South Asia and sub-Saharan Africa assessed impacts of polio eradication activities on key health system functions, using data from interviews, participant observation, and document review.Results. Our quantitative analysis did not find compelling evidence of widespread and significant effects of polio eradication campaigns, either positive or negative, on measures of RI and maternal healthcare. Our qualitative analysis revealed context-specific positive impacts of polio eradication activities in many of our case studies, particularly disease surveillance and cold chain strengthening. These impacts were dependent on the initiative of policy makers. Negative impacts, including service interruption and public dissatisfaction, were observed primarily in districts with many campaigns per year.Conclusions. Polio eradication activities can provide support for RI and PHC, but many opportunities to do so remain missed. Increased commitment to scaling up best practices could lead to significant positive impacts.

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Many actors in global health are concerned with improving community health worker (CHW) policy and practice to achieve universal health care. Ethnographic research can play an important role in providing information critical to the formation of effective CHW programs, by elucidating the life histories that shape CHWs' desires for alleviation of their own and others' economic and health challenges, and by addressing the working relationships that exist among CHWs, intended beneficiaries, and health officials. We briefly discuss ethnographic research with 3 groups of CHWs: volunteers involved in HIV/AIDS care and treatment support in Ethiopia and Mozambique and Lady Health Workers in Pakistan. We call for a broader application of ethnographic research to inform working relationships among CHWs, communities, and health institutions.

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability.

BackgroundMany Community Health Workers (CHWs) experience the same socioeconomic and health needs as their neighbors, given that they are by definition part of their communities. Yet very few studies aim to measure and characterize experiences of deprivation, poverty, and wellbeing among community health workers. This study quantitatively examines deprivation and wellbeing in Ethiopia’s Women’s Development Army (WDA), a massive unpaid community health workforce intended to improve population health and modernize the country.MethodsWe conducted a survey of 422 volunteer WDA leaders and community members in rural Amhara state, part of a mixed-methods ethnographic study of the experiences of women in the WDA. The survey asked a variety of questions about respondents’ demographics, education, assets, and access to government services. We also used survey measures to evaluate respondents’ levels of household food and water security, stressful life events, social support, work burden, and psychological distress.ResultsVolunteer WDA leaders and community members alike tend to have very low levels of schooling and household assets, and to be heavily burdened with daily work in several domains. Large proportions are food and water insecure, many are in debt, and many experience stretches of time with no money at all. Our survey also revealed differences between volunteer WDA leaders and other women that warrant attention. Leaders are less likely to be married and more likely to be divorced or separated. Leaders are also more likely to experience some aspects of food insecurity and report greater levels of psychological distress and more stressful life events. They also report slightly less social support than other women.ConclusionsIn rural Amhara, women who seek out and/or are sought and recruited for leader roles in the WDA are a population living in precarity. In several domains, they experience even more hardship than their neighbors. These findings highlight a need for careful attention and further research into processes of volunteer CHW selection, and to determine whether or not volunteering for CHW programs increases socioeconomic and health risks among volunteers. CHW programs in settings of poverty should stop using unpaid labor and seek to create more paid CHW jobs.

P a k i s t a n ' s l a d y h e a l t h w o r k e r l a b o r m o v em e n t a n d t h e m o r a l e c o n o m y o f h e r o i s m