Implementing community-based health program in conflict settings: documenting experiences from the Central African Republic and South Sudan

Background The delivery of quality healthcare for women and children in conflict-affected settings remains a challenge that cannot be mitigated unless global health policymakers and implementers find an effective modality in these contexts. The International Committee of the Red Cross (ICRC) and the Canadian Red Cross (CRC) used an integrated public health approach to pilot a program for delivering community-based health services in the Central African Republic (CAR) and South Sudan in partnership with National Red Cross Societies in both countries. This study explored the feasibility, barriers, and strategies for context-specific agile programming in armed conflict affected settings. Methods A qualitative study design with key informant interviews and focus group discussions using purposive sampling was used for this study. Focus groups with community health workers/volunteers, community elders, men, women, and adolescents in the community and key informant interviews with program implementers were conducted in CAR and South Sudan. Data were analyzed by two independent researchers using a content analysis approach. Results In total, 15 focus groups and 16 key informant interviews were conducted, and a total of 169 people participated in the study. The feasibility of service delivery in armed conflict settings depends on well-defined and clear messaging, community inclusiveness and a localized plan for delivery of services. Security and knowledge gaps, including language barriers and gaps in literacy negatively impacted service delivery. Empowering women and adolescents and providing context-specific resources can mitigate some barriers. Community engagement, collaboration and negotiating safe passage, comprehensive delivery of services and continued training were key strategies identified for agile programming in conflict settings. Conclusion Using an integrative community-based approach to health service delivery in CAR and South Sudan is feasible for humanitarian organizations operating in conflict-affected areas. For agile, and responsive implementation of health services in conflict-affected settings, decision-makers should focus on effectively engaging communities, bridge inequities through the engagement of vulnerable groups, collaborate and negotiate for safe passage for delivery of services, keep logistical and resource constraints in consideration and contextualize service delivery with the support of local actors. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-023-09733-9.

Preamble: The next series of questions I will ask you specifically relate to the role of community health workers and volunteers specifically regarding recruitment, training, delivery of health services, and supervision. Suggested questions 1. Firstly, please describe the processes used to recruit CHWs and/or volunteers? [Probes] • How are potential recruits identified? • Have you been responsible for supervising CHW/volunteers? • What were some of the major challenges you faced? 3. How can the process of supervision be facilitated to better support the supervisor and the CHWs/volunteers? Theme 7: Opportunities for, challenges and solutions to monitoring-(South Sudan, CAR, CRC, ICRC) Preamble: Moving forward from our focus on CHWs/volunteers, I will now ask you some questions about program monitoring. Suggested questions 1. Can you please describe some of the existing mechanisms for program monitoring? [Probes] • Who is responsible for monitor? • How does monitoring take place?
• What do you find are some of the biggest challenges involved in monitoring program implementation in [name of context]?
• How do you propose these challenges could be remedied? Theme 8: Improving agility of community-based health services in conflict settings South Sudan, CAR, CRC, ICRC) 1. Could you highlight what you believe are the major gaps in delivery of community-based health services in conflict settings? 2. What strategies to you think could be employed to improve the responsiveness of programming community-based health services programming to conflict settings? Closing Questions: Is there anything else that you wish to add? Would you be comfortable being contacted for follow-up when the project has been implemented?

Focus Group Discussion Guide: Beneficiaries (South Sudan & CAR) Advanced Partnerships in Health (APiH) Expected participants:
Two focus groups (one in each country). 6 to 10 participants per focus group with beneficiaries (12 to 20 participants in total). Ensuring groups are gender balanced and equal representation of women including mothers and also including fathers and adolescents in the group.

Interview guide:
Semi structured-open ended guide (data collectors are expected to explore) Theme 1: Opportunities for, challenges and solutions to safe and responsible engagement of the elders and community leaders -(South Sudan, CAR, CRC, ICRC) Suggested questions 1. Do you believe it usefulness for you and your community leaders to engage in delivery of community-based health programs? [Probes] • What do you believe are some of the barriers to engagement? • How do you believe engagement can be improved? Please provide any suggestions for possible solutions to overcomes the barriers the group has identified. Theme 2: Opportunities for, challenges and solutions to delivery of health services by (CHWs)/Volunteers-(South Sudan, CAR) Suggested questions 1. As people who access and use of health services, can you discuss some of your experiences receiving health services that were being delivered by CHWs and/or volunteers? [Probe] • What are some of the challenges? • How do you believe delivery of health services by these CHWs and volunteers can be improved? Theme 2: Improving agility of community-based health services in conflict settings (South Sudan, CAR, CRC, ICRC) 1. Please discuss/describe some of the key shortcomings in the delivery of health services in your community? 2. Considering your context, how do you believe the response to you and your community's health needs and delivery of health services can be improved?