Bridging the Gap - CONNECT Update: August 2024

Developed by the Lao Ministry of Health and Ministry of Home Affairs in response to COVID-19 with the support of WHO and partners, the CONNECT initiative is enhances local governance and community engagement for equitable access to public services, particularly health. It aims to improve equity through enhancing existing governance and community structures and capacity for community engagement, while also strengthening trust between villagers, health services and local government.

Practically, this involves a three-module series of workshops, with multiple levels and participants from local governance structures and different stakeholders, as well regular supportive supervision by central, provincial and district officials, ongoing support via digital platforms, and training and support around health service outreach and delivery. Outcomes differ based on community priorities, but often focus on vaccination, maternal and child health indicators, and birth registration (partially to ensure eligibility for basic services).

Currently supported by USAID, the Australian Government and Luxembourg, as of July 2024, CONNECT has reached more than 230 villages across 10 provinces (including Vientiane Capital), with a target of 14 provinces by the end of 2024, and support already in-place for expansion to all provinces.

Measuring impact: new research findings

External evaluators thoroughly monitor CONNECT's impact, with several reports recently concluded. While mid-term impact research continues, multiple short-term impacts have been identified. A 3 161-response survey before and within three months following CONNECT implementation in 12 villages across Khammouan, Bokeo, Champasack and Xaysomboun Provinces showed:

1. Increase in essential service uptake for maternal health, and improved attitudes towards using primary care. Among 144 recently pregnant women, the research found a 14% increase in giving birth at health centres. Additionally, among 67 pregnant women, intention to give birth at a health centre increased to 92%, following CONNECT implementation. Both results came with a decline in actual or plans to deliver at home. Practically, health centre deliver several benefits: support from a skilled birth attendant, a higher likelihood of post-birth vaccination and birth registration, and increased access to care and referral in case of complications, but with less travel required than a potentially distant hospital. Overall, it likely reflects increased trust in local health centres and community support to reach them, including among women who did not directly participate in CONNECT activities.
   
2. Increased trust in health providers. Across all community survey respondents, the survey showed a marked increase in trust in local health centres following CONNECT implementation, increasing from just over one-third (36%) to over half (53%). Evaluators developed a set of eight Lao-tailored trust-indicating categories, including: reduced reports of experiencing discrimination, increased confidence in health provider skills and availability of treatment, and improved health center reputation. In villages where CONNECT had been implemented the results showed an increase in trust across all categories, across all community members, with the greatest increase among members of ethnic minorities.
   
3. Increased vaccination uptake and confidence, especially among ethnic groups and previously unreached communities. Additional evaluation of vaccination in selected ethnically diverse, low coverage areas also shows promising results after CONNECT support. This includes a seven-fold increase in first dose COVID-19 vaccine uptake in 25 "high-risk" villages - communities where previous COVID-19 vaccination efforts had limited success - in Xieng Khouang province ahead of the 2022 National Games.

These results are included in a recently published article in the British Medical Journal Global Health, co-authored by the Lao Minister of Health. The research identified how CONNECT directly addressed the reasons for previous low vaccination rates through: effective local-context culturally sensitive communication, leveraging existing community structures and influential individuals in a multisectoral approach, and increased community motivation through improved satisfaction, ownership, and relationships.

Increase in first-dose COVID-19 vaccination among ethnic and religious minority populations in Xieng Khouang after introducing CONNECT support among 24 villages (average (median) number vaccinated per village).

The evaluation collected multiple examples of action on the social determinants of health, including increased support for poor families, transport and access to health facilities, emergency funding, and accessible health information in areas where CONNECT has been implemented.

For example, in Hinboun district, Khammouane province, district/village authorities set up a shared fund to support families in need of emergency health funding. Villagers reported authorities have been offering greater support towards families with heightened vulnerability (e.g. poor families or those with disabled family members through visiting their houses and helping them to access health services).

The findings are covered in the following reports:

• WHO, 2024. Evaluating Community Engagement in Public Health: The Case of The Connect Initiative in Lao PDR. Summary Report of the Key Operational and Evaluation Insights from the Village-based Data Collection.
• WHO, 2024. Addressing Social Determinants of Health in Lao PDR: Local Solutions to Promote Health Equity.

Documenting learning and insights

As CONNECT's expansion continues, stakeholders are working to ensure learning and insights are documented, reported and shared. The following articles have been recently published, with several more accepted or under review:

• Haenssgen MJ, Elliott EM, Phommachanh S….Kubota S et al. Trust in Healthcare: Methodological and conceptual insights from mixed method research in Lao People's Democratic Republic. British Medical Journal Global Health 2024;9:e014640. doi:10.1136/bmjgh-2023-014640
• • Phrasisombath K, Kubota S, Elliott EM, Horiuchi S…Phoummalaysith B et al. Reaching the unreached through building trust: a mixed-method study on COVID-19 vaccination in rural Lao PDR. British Medical Journal Global Health 2024;0:e014680. doi:10.1136/bmjgh-2023-014680
• Valentine N, Solar O, Castedo A.,…Kubota, S., Elliott E, et al., (2022). Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative. International Journal of Equity in Health 21 (Suppl 3): 193 https://doi.org/10.1186/s12939-022-01798-y
• Marco J. Haenssgen, Elizabeth M. Elliott, Sysavanh Phommachanh, Ounkham Souksavanh, Hironori Okabayashi, Shogo Kubota. Community engagement for stakeholder and community trust in healthcare: Short-term evaluation findings from a nationwide initiative in Lao PDR. Social Science & Medicine, 354. https://doi.org/10.1016/j.socscimed.2024.117079

Next steps for CONNECT

A number of options are currently being explored. This includes potential institutionalization within various government structures, to best utilize community-level resources in the long-term. Additionally, discussions on expanding its multi-sector approach with other partners are ongoing to broaden CONNECT's impact.

Finally, options are being explored to integrate CONNECT insights and learnings into formal health sector education programmes, as part of pre-service education.

The results reported here reflect the short-term effects in villages where CONNECT was directly introduced. Ongoing evaluations are underway to explore mid-term effects and broader impacts.

Public link

Please use the above public link if you want to share this noodl on another website.