Global Community Health Collaborative Model Description
Peace Care utilizes the Global Community Health Collaborative (GCHC) model, an innovative model enhancing a Community Based Participatory Action Research (CBPAR) framework by emphasizing the sustainable translation of evidence-based global health through a unique community-university partnership that leverages the infrastructure of a trusted development agency. The GCHC model is designed to function in collaboration with many types of development agencies. For the purposes of illustration, the Peace Corps will be used as the example organization. The GCHC model has significant potential due to multiple factors.
It is a highly iterative process ideal for broad application. The GCHC model is a multidisciplinary collaboration between multiple schools and departments within a university and cycles yearly, allowing for longitudinal projects that expand with each academic year. Rigorous evaluation of the model will contribute significantly to the public health and primary health care research in global communities, specifically by allowing for future iterations of the process in additional, expanded settings.
It applies knowledge contextually with strong consideration of sustainability. This GCHC model operates with the premise that in order to sustainably address global health and adequately reduce disparity, solutions should originate and be developed primarily with community involvement, through (or with the amelioration of) existing health systems, and with the use of appropriate technology. In this context, the GCHC model establishes an equitable partnership between the community and researchers, and within each phase, the community is empowered through a community advisory board and a local co-investigator. This ensures an emphasis on priorities as they are perceived within the community. University resources ensure that solutions are rooted in the principles of evidence-based primary health care and public health and that capacity is built within the local human resource and health systems.
It leverages existing resources. By leveraging the established trust, infrastructure, and resources of agencies in place (such as the Peace Corps) the GCHC model is well positioned to have an immediate and sustainable impact. Peace Corps Volunteers (PCVs), being integrated within the community and trained extensively in cultural competency and local language, are highly qualified field workers. Peace Care works with PCVs who have training and a background in health. These PCVs already work in a highly sustainable manner by always collaborating with a local counterpart. Because the Peace Corps is a governmental organization, all initial project plans and final outcomes will be reported directly to the Ministry of Health.
This model is innovative in terms of building research capacity in low and middle income countries (LMICs). The potential for significant impact comes from the ability to transfer the training capacity of the the academic center, in collaboration with local physicians and existing health care workers, to the improving of health care capacity within the LMIC community. It places an emphasis on selective decentralization in the management and sustainability of the projects by functioning within the host country's existing health structure with direct communication with the Ministry of Health. Thus, the projects require strong local and national buy-in. At the same time, it encourages local community involvement and ownership of the projects by working directly with local health officials and the local board of health longitudinally, pre- and post- intervention, with the on-site long-term liaison being the Peace Corps Volunteer or other agency field worker. In this light, there is minimal distortion of government health programs as interventions are necessarily in line with the Ministry of Health objectives, and siphoning of host country personnel is avoided entirely as the primary goal is to train the local health care workforce. The structure of this model avoids the possibility of U.S. professionals primarily acting on their own agenda to the detriment of the host community. Instead, the needs and priorities of the local community are fostered. There are six phases of the health collaborative:
Phase 1: Partnership Formation
This GCHC begins with the community. Community members where a Peace Corps Volunteer (PCV) with a background and focus on health is currently working requested the initiation of a collaborative. During this phase, all stakeholders are oriented to the process, a representative from the investigative team makes an initial site visit, a project definition and charter is formalized defining the scope of the project, and an initial Institutional Review Board (IRB) process is initiated.
Phase 2: Assessment
A general community health assessment is conducted using focus groups and key informant interviews. Data are evaluated and discussed by the community advisory panel, Peace Care, and the academic institution, and the primary issues are identified. A secondary assessment is then conducted exploring the assets and barriers to the health service delivery of the selected focus issues. A strategic planning process is conducted to set short term and longer term intervention goals.
Phase 3: Intervention Development
A realist literature review and synthesis of the evidence of community- based and low-resource-setting primary health care -based projects is conducted and expanded for the focus issues. Curriculum and intervention development is guided by the following considerations: sustainability, appropriate technology, local cultural norms, ethical standards, scalability, scientific evidence, ability to build health care delivery capacity, and use of the Training of Trainers model. The community advisory panel and PCV provides guidance concerning cultural norms, realities on the ground, logistical concerns, and priority areas and together with the university team, adapts the designed intervention to be most effective within the local milieu. Finally, during the development phase, specific outcomes data will be defined for future collection in the implementation and evaluation phases.
Phase 4: Project Implementation
Health Service Capacity Building: The implementation phase occurs during a short term visit by the university team who receives a cultural and community orientation early in the visit. The team conducts training conferences to transfer skills and knowledge according to the developed curriculum. Train-the-trainer courses take place allowing local health leaders to be certified educators. The newly certified trainers then train others with support from the visiting team.
Sustainability Component: Local trainers and health officials, as well, develop the following guidelines for subsequent interventions, in order to encourage sustainability within the existing health structure.
Community or Health Service Implementation: Identification of target population, public health education outreach, clinical patient management (referral and management options and patient follow-up), and documentation (documentation of results and health center and district level reports)
Service Management: Identification of managerial body and delineation of oversight process
Service Financing: Patient level costs and financing for referral and management
Quality Control: Certification of clinicians, certification of trainers, confirmation of results, and in-service training / refresher course for trained health workers
Strategic Planning: Expansion of services and trainings for additional health workers within the community and surrounding regions, population mass clinical interventions (when appropriate), projection of subsequent partnerships and additional service implementation, and preliminary plan for expansion of projects
Working directly with local leaders to develop plans according to these considerations will encourage sustainable capacity strengthening in neighboring communities and creates enormous potential for future local expansion of the project.
Global Health Education: Each project, as well, involves the global health education of US trainees (resident physicians, medical, public health, graduate and undergraduate students) and integrates the following into the intervention phase: clinical teaching, formal didactics with local professionals, medical education, research training, strategic planning, and practical global health experience. Trainees will learn about global health themes including cultural awareness, global health disparities, community based research implementation, and low income country clinical practice. As well as learning through practical experience, the trainees also take on roles in the training itself. The trainees assist with the development and logistical planning of the curricula, as well as the implementation and evaluation of the curricula, when appropriate, with oversight from university faculty.
Phase 5: Evaluation
The GCHC model will be evaluated through two separate methodologies:
Process Evaluation: Each phase is critically evaluated qualitatively by all stakeholders involved (community, health workers, PCVs, and investigative team) through focus groups and key informant interviews to gather feedback on the quality of the implementation, suggestions for the refinement of delivery components, information regarding the relationship between program context and process as well as the link between intervention and outcomes, and observations on ways to improve the overall quality of the program. We also assess and document the degree of fidelity and variability in program implementation. This allows for improvement of the methodology with each subsequent iteration of the collaborative, as well as creates an environment of equal consideration among all stakeholders.
Outcomes Evaluation: We collect baseline data and develop interventions that are well incorporated into the established health system, so that we may reliably and precisely measure our impact.
Interventions Evaluation: Practitioner level: Number of individuals trained, technical skills quality at initial training and subsequently. Population level: Number of patients impacted, positive results, referral rates, and management outcomes. Prevalence data are determined. Information Dissemination: Number of people reached, population surveys assessing knowledge, health system utilization, and satisfaction.
Global Health Education Evaluation: Pre- and post-participation assessment expectations and knowledge of trainees. Qualitative analysis of journal reflections.
Phase 6: Dissemination
The investigative team disseminates project outcomes to other communities within country and to other countries to replicate best practices for development of health service infrastructure. A project website will be jointly maintained by the community and Peace Care to publish the results of the project and share knowledge with other interested communities. Peace Care maintains a catalogue of intervention models and completed project reports accessible by anyone.