Informal childcare centres have mushroomed in the informal settlements of Nairobi, Kenya to meet the increasing demand. However, centre providers are untrained and the facilities are below standard putting children at risk of poor health and development. We aimed to co-design and test the feasibility, acceptability, cost and potential benefits of a communities of practice (CoP) model where trained community health volunteers (CHVs) provide group training sessions to build skills and improve practices in informal childcare centres.n = 68) and CHV (n = 20) knowledge and practice scores before and after the intervention were assessed and compared. Intervention benefits were examined using linear regressions adjusting for potential confounding factors. We conducted in-depth interviews with 10 parents, 10 CHVs, 10 centre providers and 20 local government officials, and two focus groups with CHVs and centre providers. Qualitative data were analysed, focusing on feasibility, acceptability, potential benefits, challenges and ideas for improvement. Cost for delivering and accessing the intervention were examined.A CoP model was co-designed with sub-county health teams, centre providers and parents with inputs from Kidogo, government nutritionists and ECD experts and implemented in 68 childcare centres by trained CHVs. Its feasibility and potential benefits were measured quantitatively and qualitatively. Centre provider (p < 0.05) and quality of centre environment  following the intervention. CHVs’ scores showed no significant changes due to pre-existing high knowledge levels. Qualitative interviews also reported improvements in knowledge and practices and the desire among the different participants for the support to be continued. The total explicit costs were USD 22,598 and the total opportunity costs were USD 3,632 .The intervention was acceptable and feasible to deliver within existing government community health systems; 16 CHVs successfully facilitated CoP sessions to 58 centre providers grouped into 13 groups each with 5–6 centre providers, each group receiving four sessions representing the four modules. There were significant improvements in provider knowledge and practice (effect size = 0.40; A simple model delivered by CHVs was feasible and has potential to improve the quality of informal childcare centres. Leveraging these teams and integration of the intervention into the health system is likely to enable scale-up and sustainability in Kenya and similar contexts. There is clear evidence that investing in early childhood development (ECD) during the critical period between birth and 5 years of life can have lasting benefits in the life of the child , reduce Despite the increased focus on ECD, limited attention has been given to the development and provision of childcare centres in LMICs. The focus on childcare is particularly important in this era of rapid urbanization, with over half the world’s population living in urban settings. It is estimated that by 2050, 56% of the population in Africa and 64% in Asia will be living in towns and cities . UrbanizQuality childcare centres have the potential to provide multiple benefits to children, families and communities  through While there are gaps in policy provision in Kenya, the Government of Kenya has outlined guidelines for childcare centres such as the Early Childhood Development Service standard guidelines that were instituted in 2006 . HoweverThis was an uncontrolled pre-post study that utilized both quantitative and qualitative methods. It was the final phase of a three phase study which employed a sequential mixed-methods  design . The oveThe study was conducted in two informal settlements (Korogocho and viwandani) in Nairobi, Kenya. These settlements were selected as their population includes a high proportion of women working outside the home the majority of whom work for a daily wage in the informal sector.The socio-demographics profiles of these communities have been well characterized by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) , within To meet the childcare needs of families in these settlements, there are many informal, low quality, but affordable childcare centres . Following our initial mapping exercise, we categorised childcare centres as: (i) faith-based run by and often located within religious institutions, (ii) centre-based, small centers often run small centres often run by NGOs or private organisations, (iii) home-based run from within a resident’s (predominantly women) own house with limited facilities or training, and (iv) school-based attached to a primary school. Following the mapping of childcare centres and co-design workshops with local government, community health teams, parents and childcare centre providers, school-based centres were excluded from the intervention implementation . This alhttps://www.york.ac.uk/media/healthsciences/documents/research/public-health/Implementation%20Manual.pdf.The co-designed intervention includes training of CHVs to deliver a series of monthly group meetings with approximately six childcare providers in their catchment areas . CHV training and subsequent CoP meetings cover: (i) learning through play including making toys from locally available material, (ii) safety and security including child safeguarding, (iii) essential child health, sanitation, hygiene, and nutrition, and (iv) business management including tracking income and expenditure see . Group mFollowing the initial mapping  we conduStudy outcomes included those related to the implementation process, i.e., the feasibility and acceptability of the intervention; potential benefits of the intervention, and cost of its implementation. Feasibility and acceptability were assessed using data from the simple assessment tool, and implementation observations as well as qualitative interviews that captured perspectives of community health teams , centre providers and parents. Intervention benefits were measured quantitatively using centre provider and CHV knowledge and practices scores, and centre quality scores. A costing tool was used to capture all relevant implementation costs. The outcome measures are summarised in Feasibility and acceptability assessments: We analysed the results of the visit assessments conducted by CHVs and documented all aspects of the intervention including (1) the training and supervision of CHVs who deliver the intervention; (2) the number of supportive supervision visits made by each CHV to childcare centres; (3) the number of CoP groups established and sessions run, a record of participants in each group (number and names), the duration and topics covered.To gain a more detailed assessment of the feasibility and acceptability, and content of the supportive supervision and CoP sessions, the research team observed eight CoP sessions  and 10 childcare centre visits over the 5-month implementation period. These observations followed an observation guide to identify facilitators and barriers facing the childcare providers in implementing the recommended skills and practices and reflections on the interaction between the CHVs and childcare providers. These were assessed by a team of trained field interviewers using Kidogo tools that were adapted to the informal settlements.Assessing intervention benefits: Baseline and endline assessments were, respectively, conducted in February and October 2021. The assessments included: (1) Knowledge and practices questionnaire for CHVs and providers on the key domains child protection, responsive caregiving, learning through play, health, nutrition, WASH, and business administration. (2) Detailed quality assessment of the centre environment based on the same domains assessed in the CHV and centre provider KAP. (3) Implementation data: We recorded of numbers of participants that attended each session, the number of sessions delivered, visits made to by each CHV. This information was collected by our research team and CHVs. KAP assessments were conducted virtually, while centre environment and observations of the sessions were done face-to-face.In line with our sequential mixed methods approach, the results of the questionnaires and changes in knowledge, attitude and practice scores were used to sample 10 childcare providers for qualitative interviews. The aim was to understand experiences from those who had improvement in their knowledge and practices, and those who did not. The interviews focused on the acceptability of the intervention and any challenges and barriers providers faced in improving quality in their childcare centres. Ten CHVs were selected based on their questionnaire scores to participate in interviews and also in two focus groups following 5 months of implementation. The interviews with CHVs captured their personal experiences of the training and implementation of the intervention. The focus groups allowed a more detailed discussion on the barriers and facilitators to implementation, possible improvements and potential sustainability within the community health system.Because of the COVID-19 pandemic and related restriction on face-to-face interactions, in-depth interviews and KIIs were conducted virtually, while the FGDs were done face-to-face. The blended approach with face-to-face and remote options of data collection and engagements minimized physical contact and hence risk to infection transmission so that over the entire duration of the study, there was no case of COVID -19 reported among our teams and participants. We took extra measures to ensure that quality data was collected especially in the case where telephone or zoom interactions were conducted. These measures included spot checks with participants, and reviewing the data to ensure completeness of the questionnaires.We conducted in-depth interviews with 10 parents whose children used the childcare centres involved in the CoP sessions to understand if they had noticed any changes or had any feedback on the intervention. We interviewed 20 local government officials at different levels including national level, county level and sub-county level to identify any facilitators and barriers to implementation and their views on integration within the work of community health teams and possibilities for scale-up.The number of respondents used for the different qualitative interviews were considered to be sufficient to provide representative views. For the policy makers and implementers interviews, all the participants who were involved in the intervention development were interviewed. However, for the CHVs and centre providers and parents, we selected 10 participants from each group with a representation from the two locations, and inclusion of CHVs, centre providers and parents from centres which had high, moderate and low scores in quality and skills on childcare at the end line assessments. Sample size of 10–20 participants included in the qualitative interviews for each group were considered sufficient to provide the required information. Purposeful sampling based on specific criteria allowed collection of balanced information on the participants’ experiences of the intervention.Qualitative in-depth interviews and focus groups were conducted by two researchers (LO and PA) experienced in qualitative methods and data collection with a detailed knowledge of the intervention and the context of childcare within the informal settlements. Interviews with providers were conducted in their centres in Swahili; interviews with parents were conducted in their homes in Swahili, and CHVs were interviewed at a community venue in Swahili while KII with Local government officials were interviewed in English both face-to-face (in their offices) and on phone/virtual. The focus groups were held in community centres. All interviews and focus group discussions were audio-recorded and transcribed as soon as possible after they were held. Interviews and focus group discussions were conducted in Swahili and later transcribed and translated for analysis.We documented (1) number and duration of the training and supervision of CHVs and CHAs who delivered the intervention; and the number of trainers and trainees attended; (2) the number of supportive supervision visits made by each CHV to childcare centres and their duration; and (3) the number of CoP groups established and sessions run, a record of CHVs, CHAs and participants in each group (number and names), the duration and topics covered.https://data.imf.org ].The explicit costs included fees, expenses or allowances paid for the training for the intervention , and, delivery of the CoP sessions and follow-up supervisory visits (CHVs and care providers if applicable), including those borne by other partners. These amounts were recorded by the study team as part of financial records. We also estimated opportunity costs of time of the personnel involved by multiplying their respective hourly wage by their working time on the intervention. They were collected in local currency: Kenyan Shillings (KSh) 2021 prices and presented alongside USD for total costs (1 USD = 109.64 KSh)  at baseline to 66% [95% CI: ] at endline (= 0.002) . There wcant see .p = 0.005). This improvement was driven mainly by the business management  and child nutrition  domains, each recording significant positive differences. Among the three centre types, only home-based centres registered a significant (positive) difference in the mean centre provider KAP scores   .Of the 20 CHVs who were trained for supportive supervision, 17 participated in the intervention and were interviewed in the baseline and endline surveys, hence formed our panel data for analysis. More than half of the CHVs were from Viwandani (59%). Their mean age was 48 (SD = 6) and most (88%) were female. A majority (71%) had at least secondary education.p = 0.002)  change, i.e., providing support supervision domain  .n = 16) that were eligible for inclusion in the intervention, so we purposefully used only 6 out of the 10 CHVs to lead the CoP sessions. The remaining four were put on waiting list to help in case any of the 6 became unavailable.Feasibility and acceptability was assessed quantitatively based on the number of CHVs that were effectively trained and conducted the CoP sessions and follow up visits, and the number of centre providers who successfully completed all the modules. This was with reference to the target numbers. As shown in A total of 68 centre providers  were eligible for the intervention, and all accepted the invite to participate. These were grouped in groups of 5–6 centre providers for the CoP sessions. Each group was managed by a CHV in charge and one back up CHV. This resulted in three groups in Korogocho and 10 groups in Viwandani. Attendance records show that all 68 centre providers attended the four modular CoP intervention facilitated by the CHVs. 117 CoP sessions altogether were conducted by the CHVs and observed by the CHAs including 27 in Korogocho, and 90 in Viwandani. Hence a total of 136 follow up visits were successfully made by the CHVs.The venue was rented at KSh 3,000/day for 9-day training in two occasions. The breakfast and lunch were provided at KSh 800/person-day for training and KSh 700/person-day for CoP sessions. The training programme was delivered by trainers from Kidogo and costed KSh 25,000/person-day for 20 person-days. The allowance paid to the CHVs and CHAs were KSh 1,000 per day and KSh 2000 per day for training and CoP sessions, respectively. The allowance paid to the CHVs for follow-up visits was KSh 700 per visit. A payment of KSh 200 per session was also given to centre providers to cover the expenses of arranging extra personnel when they attended CoP sessions, if applicable. Twenty CHVs and eight CHAs attended the training. Including necessary printing costs, the explicit costs of organizing and attending the training were estimated at KSh 1,094,100 . Ninety-seven CoP sessions were delivered by two CHVs with one CHA and twenty were delivered by one CHV and one CHA. The payment for cover arrangement was given out on three occasions for each centre provider. The explicit costs of CoP sessions were therefore KSh 1,271,300 . Each centre provider received two follow-up visits, costed at KSh 95,200 (USD 868). In addition, 16 CHVs and 2 CHAs were paid allowance for their activities in initial mobilization and CoP session organizing. This explicit administration cost was estimated at KSh 17,000 (USD 155).To estimate the opportunity costs of time for CHVs and CHAs, the CHAs were costed at KSh 65,000 per month and the CHVs at KSh 3,500 per month, the latter of which had been proposed but yet to come in effect over the implementation period. The partially recorded CoP sessions indicated a median duration of 3.83 h/session  in Korogocho and 3.00 h/session  in Viwandani. The median duration of follow-up visits was 2.00 h/visit  in Korogocho and 1.34 h/visit . The opportunity costs of the CHAs were estimated at KSh 212,727  for attending training, KSh 137,940  for CoP sessions , and KSh 616 (USD 6) for administration. The estimated opportunity costs of the CHVs were KSh 28,636 (USD 261) for attending training, KSh 13,662 (USD 125) for CoP sessions , KSh 4,048 (USD 37) for follow-up visits , and KSh 530 (USD 5) for administration.The total explicit costs were KSh 2,477,600  and the total opportunity costs were KSh 398,159  .Within this feasibility study, we also measured the potential benefits of the intervention on the key outcomes, i.e., centre quality, and the knowledge and practices of both CHVs and centre providers. As shown in p = 0.005). Crude and adjusted analyses revealed a significant positive effect of the intervention on centre providers’ knowledge and practices (p = 0.002). Without adjusting for confounders, the mean quality score following 5 months’ implementation of the intervention was 0.55 SD higher than at pre-intervention . Adjusting for the same confounders mentioned above, the mean quality of childcare score was 0.56 SD higher at post-intervention than at pre-intervention . In other words, the CoP intervention significantly improved the quality of childcare centres. The CoP intervention did not have a significant effect on knowledge and practices of the CHVs . Of the eight domains, only one showed a significant (positive) change, i.e., providing support supervision domain  (As shown in ractices . Without= 0.002) . There w= 0.002) .The qualitative findings contributed to our understanding of changes in knowledge and practices in relation to the four main topics of the intervention. In addition to the insights on the impacts of the training and CoP sessions on the four areas of learning through play, safety, health and business management, the qualitative data provided further insights on the implementation and impact of the intervention. These included: (i) the influence of the slum context; (ii) the changing roles of CHVs, childcare centres and providers and; (iii) the need to extend the reach of the intervention. Quotes relating to these themes are provided in the Despite the improvements highlighted in both the questionnaire and the qualitative findings, the context of the informal settlements continually undermined the ability of childcare centre providers to implement their new skills and improve their practice. This was seen across the areas covered in the CoP sessions. For example, while there was convergent evidence across qualitative respondents and quantitative results regarding nutrition knowledge and practices, the economic challenges facing families and providers undermined the possibility of adding additional fruit, vegetables and greater variety of food in the centres.The quantitative findings indicated how the centre providers, particularly those running home-based centres learnt how to manage the finances and running of their centres. Others however, explained how the business training had helped them to decide on a fee scale that would cover their costs, although they felt unable to increase the price for existing parents, who were already struggling to pay the existing charges. This may explain why none of the parents interviewed complained of fee increases. While parents were still unhappy at the poor physical structures of the childcare centres, both providers and parents shared examples of centres being reorganised to promote play and providers making and using toys they made themselves from local materials as practiced in the CoP sessions. In a few of the centres, CHVs reported inconsistences in the centre providers that attended the sessions. Frequent changes of the centre providers or assistants interfered with the content that was given to the providers, and the overall benefit (knowledge and skills improvement) in that particular centre. So the CHVs felt that such childcare centres did not fully benefit from the sessions because different centre providers were trained on different sessions.While all the CHV’s had been active in their communities, many explained how systematically visiting childcare centres and supporting them to improve child health and development had not been part of their previous routine work. All CHVs interviewed expressed their enthusiasm for the new role. This change in the role of CHVs clearly took a while to become established and accepted by the childcare providers, particularly those in home-based centres who were not used to receiving any support, as shown in the quantitative results. The observations of the CoP sessions and the interviews with providers highlighted their enthusiasm for the knowledge and skills that they gained throughout the intervention. Parents were frequently encouraged by the increased competency of the childcare providers and several commented on ways that they could be further trained and supported. This was particularly true in relation to health, both in the provision of medicines for minor illnesses by the providers themselves or by taking the child to hospital if needed. Parents frequently talked about the challenges they faced in accessing health care for their children due to their long working hours and long commute journeys. Many felt that the childcare centres could usefully become a point of access for child health programs including immunizations.The high number of private and informal childcare centres within the slums and the ease with which inexperienced providers can open a centre was recognised by all participant groups. CHVs were enthusiastic about the project and felt that CHVs in other areas could be trained to deliver the programme in their own catchment areas as part of their routine activities which further indicated acceptability of the intervention.The current study aimed to evaluate the feasibility acceptability, cost and potential benefits of a community of practice (CoP) model for improving the quality of informal childcare services in two informal settlements in Nairobi. Quantitative and qualitative findings revealed strong indicators of feasibility and acceptability of the intervention among various stakeholders including parents, CHVs, centre providers, policy makers at the National, County and sub-county level in health and education sectors. The findings clearly show that it is feasible to train CHVs to deliver training and support supervision of centre providers on provision of quality childcare services when the content is tailored to their level of education and embedded in their routine work. The data also show a potential for the intervention to improve centre provider knowledge and practices, and the quality of the childcare centre environment.The feasibility and acceptability of the CoP intervention is attributed to the community participatory approach that was used from the co-design stage, through implementation to evaluation of the model. We involved government representatives, non-government stakeholders , and the local community  first to identify the gaps in quality, the issues facing informal childcare and ideas on how they can be addressed. We jointly co-designed the model and CHVs were identified to deliver it. We noted and applied the learning during the implementation and at the end, we jointly refined the model and put together a manual describing the content and its delivery. Participating in and contributing to the development and implementation of the intervention promoted buy-in and sense of ownership among various stakeholders, and made it easy for the research team to obtain genuine feedback on how the intervention can be optimized. Community involvement in health programmes has far reaching benefits in promoting community programmes  and for The success of CHV and centre provider training sessions was majorly a result of how they were administered – spacing the topics a month apart to allow internalization and application, but also utilizing the interactive approach and taking into account the low literacy and socio-economic levels of both the CHVs and centre providers. Administering the sessions in the local language and use of simple tools made the sessions easy to administer and follow up to be done.It is important to note also that effective engagement of CHVs in community programmes requires that they are incentivized. In this study, CHVs were given transport reimbursement and a day’s allowance whenever they engaged in the programme activities. Despite that it was a small allowance it contributed significantly to their motivation and willingness to deliver the intervention. The role of community health workers or volunteers in supporting health care programmes in communities is increasingly being recognized. There has been a lot of debate on how CHVs can be fairly remunerated for the work they do and how they can be motivated to continue supporting community initiatives. Our findings are consistent with those from other low income settings where incentives including transport reimbursement, recognitions and stipends resulted in significant motivation for CHVs to support community health programmes , 42. In We leveraged on the existing infrastructure, particularly the CHV system to deliver the programme. The CHVs were supported and supervised by the community health assistants (CHAs) and nutritionists as was the practice within the community health strategy at no extra cost, apart from the transport reimbursement when CHAs attended meetings. Costing data revealed that the explicit cost of the entire intervention was 22,589 USD, of which 41%  were allowances paid to CHVs and CHAs for training and intervention activities. In contrast, the estimated opportunity cost of time of CHVs and CHAs were only 3,632 USD. It poses questions for decision makers to consider: is the incentive sustainable outside of the study setting, given the budget? For scale-up of the CoP intervention and its integration into the routine practice, a balance must be struck in the long run, between reduced or even removal of incentives and increased basic salary for CHVs. At the higher level, decision makers at the national and County level  were continually consulted and their approval to use the sub-county teams to deliver the programme was obtained. Imbedding the intervention in the existing system made implementation cheaper and easier and hence contributed to its feasibility. Research has shown that successful community programmes are those that have utilized existing infrastructure . The intIn addition to the evidence on the acceptability and feasibility of the CoP intervention, our findings  also indicate a potential of the intervention to improve the knowledge and practices of centre providers as well as the quality of the centre environment. It is important to note that home-based centres had the worst level of quality, and these appeared to be a major driver of mean score on quality. Home-based centres which characterised the majority of centres in Korogocho, showed marked improvements in quality after the intervention revealing a differential benefit of the intervention for this type of centres. The obvious explanation is that the majority of these were of poorer quality at the start and were not receiving any form of support or training prior to the intervention and hence they need this training most. The finding indicates that future interventions should prioritise home-based centres. Absence of changes in CHVs’ knowledge scores was most likely because they already had sufficient knowledge at baseline and therefore there was limited window for a significant change attributable to the training.It should be noted that this was a feasibility study for which sample size was not powered to measure effects of the intervention, however, the fact that it shows indicators for the benefits points to its potential to improve childcare in informal settlements. Full impact of the intervention can be established using larger studies with well powered sample sizes and longer follow up.It should be noted that, while formal, well-equipped centre-based care with appropriate facilities and adequate numbers of ECD-trained staff may be seen as the ideal, without major investment and subsidization, such provision within informal settlements is unlikely, particularly in the short-term. There is increasing recognition of the dynamism and entrepreneurial spirit found within informal settlements, challenging a rethink of simplistic dichotomies where the ‘informal’ is seen as wholly negative and in contrast to formal services . This caIn conclusion, it can be very challenging for providers to improve their centres within the context of informal settlements. However, change is possible, particularly for the least supported and poor quality home-based centres. This highlights the potential of an affordable intervention, grounded within the existing public community health system to improve the quality of childcare centres, holding out the hope for improvements in child health and development outcomes. The current study provides insightful evidence on how a participatory approach can be effectively used to design and deliver an intervention to improve informal childcare services in a resource limited setting. To our knowledge, this model is the first of its kind and its potential lies in the co-design, community involvement and integration approach that was used in its development and delivery. The evidence on its feasibility and acceptability from the community as well as the indicators for potential impact provide a promise for an impact evaluation study including its benefits for child outcomes which will in turn inform further evaluation of its impact at scale. It would be useful for future studies to explore a multi-sectoral approach to implementation of the intervention by strengthening the links with similar initiatives across sectors to avoid parallel systems but also to ensure sustained funding. The implementation manual, detailing the topics and delivery, is a valuable product that can be used to support wider implementation in Kenya and could be adopted or adapted to other low income settings. Future studies exploring and addressing the barriers to regulation and licensing of informal childcare centres are needed since it was clear from the data that the majority of the childcare were neither registered/licensed nor receiving any support from the government. Lack of clarity of the regulations as well as unachievable expected standards and high fees are major barriers to registration of informal childcare centres.While we had to collect some data virtually, this may have limited the depth of discussion and reflections. We attempted to mitigate these limitations by doing spot checks by going back to randomly selected households that were interviewed by the field team and asking a sample of the questions to compare the agreement of the responses.There are very large variations in the quality scores according to the type of centre at baseline and some scores  decrease between baseline and endline. It is not clear why but it might be that centre providers focused on certain areas at the cost of other aspects. The variations probably had some implications to overall findings presented.The current study primarily aimed to assess the feasibility of a co-designed CoP model, but not powered to assess impact on centre provider KAP or quality of environment, or child outcomes. Hence the data reported here only provide an indication for possible benefit of the intervention. For the same reason, we costed the intervention however, it would not be appropriate to examine cost effectiveness without robust effects data in terms of improvement of quality or child outcomes (not measured). Future studies designed to rigorously evaluate impact on centre quality and child outcomes as well as cost effectiveness are underway..The raw data supporting the conclusions of this article will be made available by the authors, without undue reservationThe studies involving human participants were reviewed and approved by Amref Health Africa’s Ethics and Scientific Review Committee ESRC, Kenya  and from the University of York . The participants provided their written informed consent to participate in this study.MN co-led the acquisition of funding, conceptualization, investigation, and methodology, led the preparation of the manuscript, project administration and supervision, and participated in data curation and formal analysis, review and editing of the manuscript. NL led data analysis and curation, and participated in project administration, and editing of the manuscript. LO participated in the project administration, data curation, formal analysis, and writing. KO participated in the conceptualization of the investigation and methodology of the study, project administration, data curation, formal analysis, and writing. PA participated in project administration, data visualization, and editing of the manuscript. RM, SH, and MK participated in project administration, data visualization, and writing. AR and MA-O participated in project administration, data curation and visualization, and writing of the manuscript. PK-W participated in the conceptualization, investigation and methodology, project administration, data curation and visualization, and writing. EK-M contributed to the design and supported the administration of the project, and writing. HE led funding acquisition, conceptualization, investigation, and methodology, co-led project administration and supervision, and formal analysis and manuscript writing. All authors contributed to the article and approved the submitted version.SH and MK were employed by Kidogo Innovations, Nairobi, Kenya.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Community engagement (CE) is an important component of public health research and program implementation, especially in low- and middle-income countries. More recently, CE activities have been utilized to develop partnerships in research and program implementation processes, and advocate for policy recommendations with the aim to improve acceptance and reduce disparities of public health research activities and benefits in the involved communities. Utilizing the tacit knowledge gained from the Global Polio Eradication Initiative, this paper highlights the contributors and challenges to the implementation of the GPEI program’s community engagement initiatives from an implementers’ perspective. The study took a mixed methods approach to analyze data collected from the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) project, which conducted an online survey and hosted key informant interviews with individuals who had been engaged with the GPEI program from 1988 onwards for at least 12 or more continuous months. An analysis of data limited to individuals  who were primarily involved in CE activities revealed that around 24% were front-line healthcare workers, 21% were supervisors and 8% were surveillance officers. CE activities mainly focused on building trust within the communities, addressing misinformation, myths and fears around vaccinations, mobilization to reach high-risk or hard to reach populations, as well as building ownership and buy in from the communities. The strength of the implemental process of a program (38.7%) was among the key drivers of success, coupled with personal beliefs and characteristics of the implementers (25.3%). Social, political, and financial forces received mixed opinions as to their importance, depending on the stage of execution and readiness of the communities to accept the programs. Lessons learnt from the GPEI program provide tried and tested best practices and evidence for strategies that would work in diverse backgrounds with some customization to suit the needs of the situation. Community engagement, a blend of concepts and approaches based on mutual respect and inclusion to achieve shared goals and visions among diverse actors at the community level, is a complex strategy. Community engagement (CE) has been variously framed as community involvement, community consultation, community participation, and community partnership in public health research, and holds different meaning for different stakeholders , 2. CE hThe advances in technology are also changing the way public health researchers are engaging with communities in data collection as well as implementation and roll out of health interventions, and there are unanswered questions in how these interactions are mutually and ethically beneficial for all those involved . HoweverThe Global Polio Eradication Initiative (GPEI), i.e., World Health Organization (WHO), Center for Disease Control and Prevention (CDC), United Nations Children’s Fund (UNICEF), Bill and Melinda Gates Foundation (BMGF) and Rotary International, aimed at eradicating poliomyelitis, is one of the largest public health programs ever undertaken globally. Over the years, the GPEI has implemented and revamped various strategies, including CE, to increase immunization coverage for polio vaccines, and has worked to reduce the burden of polio, improved surveillance systems, and expanded health access to vulnerable and hard-to-reach populations , 14. GivThe study’s analysis was informed by data collected from the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) project, which conducted an online survey to capture perspectives of individuals involved in GPEI across diverse contexts, in seven focus countries, Afghanistan, Bangladesh, the Democratic Republic of Congo (DRC), Ethiopia, India, Indonesia and Nigeria, that represent different geographical regions and income classifications, and that had high activity in the polio eradication campaign . The surThe sample for the STRIPE polio survey comprised of those individuals 18 years and above who were directly involved in the implementation of the eradication program under GPEI from 1988 onwards for at least 12 or more continuous months at the global level, and in the seven countries. This sample was taken from an enumerated source population of 193,096 individuals that fit the sampling criteria, and the response rates varied from country to country, ranging from 7% in Ethiopia to 35% in the Democratic Republic of Congo . DetaileFor the purposes of this study, the analysis was restricted to individuals who selected community engagement as one of the three goals they spent most of their time on within the GPEI activities. Community engagement was operationally defined as organized efforts to improve demand and uptake of polio vaccines via improved campaign outreaches, behavioral change interventions, advocacy with community leaders, and other strategies to counteract misinformation and trust among discrete populations. All analyses were conducted using STATA I/C (version 15) . A sub-sDescriptive analyses were used to report frequency and percentages of those individuals involved in community engagement across various demographic characteristics  and perceptions of those individuals towards the facilitators and barriers to the implementation of community engagement activities. Free text survey responses on successes and barriers to implementation of CE, as well unintended consequences, and solutions, were extracted into an excel sheet and coded manually using focused coding techniques . The codThe study was approved by the Institutional Review Board of the Johns Hopkins Bloomberg School of Public health and was deemed to be “non-human subjects research” as no personal health information or any identifiers were collected from the participants (IRB No: 00008721). Informed consent was obtained from all research participants. Survey participants were provided a written consent statement prior to accessing the survey. Oral consent was obtained from KII participants and from phone-based survey participants.Of the 3,659 individuals who completed the STRIPE survey and had at least one year of experience working on GPEI activities, 1,105 (32.1%) worked mainly on the polio program goal of community engagement (CE) and were part of this analysis. The average length of time working in community engagement was 8.7 years (±6.5); 312 (31.1%) respondents had been working for 10 to 20 years, 316 (31.5%) for 5 to 9 years, and 309 (30%) for 1 to 4 years. A total of 65 (6.5%) individuals had more than 2 decades of experience being involved with CE . The conThere was no significant association between years of experience and multiple levels of engagement. Of those who had more than 2 decades of experience, two-third of these individuals had worked only at one level. Working at district and sub-district levels was also associated with more years of engagement. Similarly, the years of engagement were also significantly associated with those who worked as front-line health care workers, Expanded Program on Immunization (EPI) managers, and those who were at an advisory capacity at the national level. These were significant at a p value of 0.001 or less.More than 24% of the individuals engaged in community engagement were front-line health workers (n = 266) followed by supervisors  and surveillance officers . 129 (11.7%) individuals were involved at the global, national, or sub-national level in an advisory or strategy development capacity in assisting with the objective of community engagement.Based on the free text responses from the survey, the self-reported community engagement activities covered diverse strategies, including strategies to mobilize community members for action, engage prominent figures and faith leaders, seek participation of marginalized populations and challenge stereotypes and social hierarchies among others.An overwhelming majority of the community engagement activities self-reported by the respondents fit well within the scope of social mobilization e.g., engaging champions and leaders from the community to spearhead the messaging around the program or involving faith leaders and religious structures as safe places to discuss and troubleshoot concerns about program implementation. Other strategies such as house to house promotions via pamphlets and sharing outcomes of the program through trusted members of the community fall within the scope of community action. Based on the Consolidated Framework for Implementation Research that guided the development of the survey tool, the facilitators and barriers to community engagement activities were segregated as internally or externally facing.  InternalOf all the respondents who participated in the online survey, 194 individuals also participated in the key informant interviews. Data from respondents who were engaged in community engagement activities were included in the below thematic analysis .Among the respondents who were engaged in community engagement activities, 38.7% reported that the implementation process  played a key role in facilitating engagement with the community . RegularThere were instances in Northern Nigeria that then very much affected the whole Central Africa area zone in terms of the ability to carry out some of the vaccination activities going all the way back to the early 2000s to 2004, 2005 and resulted in outbreaks following that. I think these types of challenges led to the program having to really modify some of its strategies specifically related to communication and communicating with not only influential stakeholders but also mothers and caretakers and all the way down at the community level, things like that have in a sense the adversity that’s kind of presented to the program, it’s forced the program to grow and to change–National level, NigeriaFurther, the implementation process that facilitated success of CE activities involve discussions, real-time learning and feedback, task shifting and sharing resources among collaborators, as highlighted below:…we learned the importance of working closely with other partners. We may have similar program. To save resources we will share tasks to reduce duplication of activities and wastage of resources. One partner takes some tasks, and the other takes another one. I remember when they asked us to support review meeting. We then ask another partner who is working on the same area. We discuss and one of us paid for the per diem and the other partner paid for the rent. This helps you to broaden your imagination in doing a good work–sub-national level governmental organization.–Sub-national level, EthiopiaThe process of implementation was however also a significant challenge for around 23.9% of the survey respondents, 46.6% of whom believed that difficulty in engaging key individuals, stakeholders, and other appropriate organizations in implementing the polio program was a major challenge. Around 33% (of the 23.9%) suggested that the perceived complexity of the polio eradication program–scope and duration of implementation, multifaceted approach, lack of internal communication–were challenges to achieve the objective of community engagement.In addition, the personal characteristics of the individuals implementing the CE activities within an implementing organization  facilitated the success of the community engagement activities, according to 25.3% of the respondents. In situations where positive individual characteristics worked synergistically with strong leadership, significant gains were achieved with the implementation of the CE activities as mentioned below-It’s a combination of the design, the quality of the work, the commitment of these local staff, whether they were unpaid community-level workers, to the full-time staff at the secretariat level, and a lot of the people working in the CORE Group member project offices in these countries …. Again, some of that is the leadership skills of these national directors and the staff that they surrounded themselves with, but there was a real commitment to this–Global levelOn the contrary, 18.5% of the surveyed individuals experienced significant challenges due to the personal characteristics of individuals working in their organizations. Those respondents (68.6% (n = 140) who encountered challenges with individuals with negative attitude towards the polio eradication activities reported that the lack of commitment towards the program was a major hindrance. Limited resources for use and incentives, lack of connection with leadership, below par compensation for work put towards the engagement activities, and poorly trained workforce impacted the motivation and workflow of health workers involved in CE activities, and the actual delivery of those activities, as mentioned below. In some settings, these factors were exaggerated by the mere lack of functioning and sustainable health care systems to support the GPEI activities. It is however important to note that the perceived lack of health worker motivation derived from a complex set of factors that were not just restricted to CE activities but applied across the other GPEI programmatic objectives.… what is ticking is that there is no real follow-up, especially of the hierarchy… There are tools they must give us to function better, the central office is also limited. Let us have training to have knowledge not acquired on the school bench. Let them also equip structures starting from the central office, it will work better. Let them fix the pay especially for the community relays because it is a difficult job, it is they who work in the field, it is they too who give us the data that we take to the hierarchy. They are threatened. The hierarchy benefits from it but those who do the work on the ground do not benefit from it. During the campaign, they [community relays] say they waste their time all day. They are also parents and at the end of 3 days they are given only $15. And while they are working for the country, their children are suffering—sub-district level IT techniciancommunities themselves  were a barrier to enacting community engagement activities, as reported by 48.9% of the individuals. The perception of communities towards the polio program and related field activities was a major challenge (50.8%). Some communities were resistant or non-accepting of the polio vaccination, which translated to push back and suspicion of related community engagement activities, especially in low-resource communities. Socioeconomic inequities  combined with personal religious beliefs, disinformation and misinformation about vaccinations, and the influence from spiritual healers and alternate medicine practitioners negatively impacted the uptake of CE activities in some of these low-resource communities. Furthermore, an assumption that literate folks in these communities were aware of the importance of vaccinations (and were therefore targeted by CE activities) further contributed to challenges in implementing the CE activities overall -The …. awareness is not as intensive as it should, whether at the local level or at the higher, at the let me say the literate level because you tend to do the awareness with the illiterate more than the literate. … You may think they are literate, but they still need to be told and they still need to be educated, enlightened … because usually when we are giving non-compliance it is usually more of the literate people–sub-national level, Nigeriapolitical climate acted as both a facilitator (23.4%) and a barrier (24.6%) to the implementation of various community engagement activities. Support and acceptance of the program objectives from national and sub-national political players as well as buy-in from local governments made it easier for the front-line workers and others to implement community engagement activities with ease.The On the contrary, some teams faced resistance from policy makers making it difficult to engage with communities. In some locations, the evolving and dynamic state of the political structure was not conducive to coordinated action by implementers. These also led to security concerns due to armed conflict and migration of communities. The general mistrust as well as poor utilization of available resources by government agencies were some politically inclined issues that created challenges in community engagement activities. Local teams innovated to get around the security risks by collaborating with the military in some regions such as Afghanistan and Nigeria -… so, in Afghanistan it is such a complex situation that the basic principles that we set for program was the program neutrality. We just wanted to have the program as much neutral as possible without any visible engagement of any parties of conflict. Then the second basic principle that we set is the safety and security of the vaccinators, because this is also important, that those people were going and serving those areas—sub-national level, Afghanistan… in some of the areas of Nigeria the innovation which we call RIC, Reaching Inaccessible Child—it is an innovation where actually some of those areas which are already identified, their vaccination and even sometimes surveillance is done by military personnel all by themselves–sub-national level, Nigeriaeconomic climate also played a role in hindering the respondents (29.4%) from implementing community engagement activities successfully. Lack of funds for procurement of supplies, poor remuneration and insufficient incentives or compensation demotivated front-line workers in conducting the engagement activities to their fullest extent.The It was hinted by a few that improved and targeted dissemination and distribution of the messaging around the polio campaign would lead to more open engagement with communities. Respondents mobilized the community by involving local celebrities, faith and religious leaders and traditional healers to provide crafted messaging to raise awareness about the campaign, as suggested below:… people have concerns about vaccines, and they are refusing vaccines. This is a negative point…we had to talk to them several times and managed to convince them. We involved community in the discussion with elders and their representatives. We also involved community volunteers. We have 3 to 4 committees of volunteers in every district. They have specific days for refusal families and target them with the collaboration of community elders and volunteers. We convince them and give vaccine for the children–Sub-national level, AfghanistanWe also trained Malik  and provided messages through TVs and mosques. We also trained staff of clinics such as CHWs [community health workers] to do community awareness. We have resolved this issue. The other big thing we have done is the recruitment of local people for teams and this has been instrumental in tackling this issue. Team members are recommended by local elders, so they are from the community; they have relatives there and are trusted by families–Consulting firm, AfghanistanSome respondents suggested engagement of community members in the planning and execution of activities on the ground to provide the communities with ownership and control of the campaign.positive changes this (program) has brought to women in spite of some terrible acts of violence.”In some countries, like Afghanistan, where experiential evidence from the field had shown that social norms were against women working as vaccinators, especially in rural areas, female members of the community that were employed as front-line workers and vaccinators were given access to households and could make sure all children were getting immunized while gaining employment. As shared by a respondent, “Due to the interaction of local government agencies with the communities during awareness campaigns and door-to-door visits by front-line health care workers, surveillance for other communicable and non-communicable diseases improved, setting a system for obligatory notification of causes other than polio. Collaborations were seen to organize health camps in underserved areas, promote hand washing, importance of nutrition and other related topics.From the health system, obviously, the people in society become [more] aware of prevention. Because [there is better access] to other vaccines for example Measles, Rubella, Hepatitis, Hepatitis A, Influenza. Our people have become aware of immunization…. In some locations, health facilities teamed up to conduct additional services such as malnutrition screening, latrine coverage and bed net checking for malaria–sub-national level, IndonesiaAdditionally, health education and training programs were conducted for field staff to provide them with the knowledge required to improve communication with communities. These programs also supported capacity building of the staff in other aspects of the program that could be translated to other service delivery programs. The development of infrastructure to support the polio program also provided the strength for localities to address other health-related programs.Not only did the health service delivery strengthen, but the training programs also provided to sustain the polio program produced trained workforce in the fields of surveillance, monitoring and evaluation, communication, logistics management, partnership building, networking, coordination, innovation, micro planning, multi culture working approach, observation, and date analysis among others… This not only reduced mistrust towards the government but also increased awareness of vaccinations among communities and their confidence in health care providers and caregivers.In hard-to-reach areas, the polio program supported the delivery of other basic clinical and curative services by providing a channel for others to engage in interdisciplinary and intersectoral activities–sub-national level implementing organization- district level, NigeriaThe awareness programs and health education activities conducted to raise awareness within communities was found to have developed interest in youth to focus on science and biology. The mobilization programs also improved literacy of local communities in health services delivery, access, and basic hygiene such as maintaining clean environment and living healthy life.The findings from this study show that individuals involved in community engagement activities faced multiple barriers in the implementation of specific activities geared towards achieving the objectives of the Global Polio Eradication Initiative. Community engagement activities were mainly targeted to increase vaccine acceptance and improve awareness and trust within communities that would assist in achieving the overall objective on increasing polio vaccination coverage. Over the years of implementation, the GPEI program transitioned to engage more with communities via its community engagement strategies, which improved its understanding of the importance of buy-in from end users. Based on the country context, community-based surveillance, campaign monitoring, cross-border initiatives and presence of community mobilizers were among a few innovative strategies that were implemented to improve vaccination uptake in communities  Past repConflict was a deterrent in the initial efforts at community engagement activities in different settings as implementation processes were not able to embrace the contextual and cultural nuances of the community. There was backlash in the form of distrust and struggle in carrying out planned activities, as well as violence towards the front-line health care workers and vaccinators, who were primarily part of the same communities , 29, 30.Interactions with fellow workers as well as communities defined the trajectory of the program, leading to differing perceptions of success. The process of implementation was a big facilitator in making the community engagement efforts a success to support the eradication program . The plaThe external environment–a mix of social, political, economic, and technological issues–was highlighted as a key barrier to engagement with communities to deliver the intervention. The social structure has played an important role in supporting the implementation of maternal and child health programs, HIV/AIDS prevention campaigns, nutrition programs, among others , 38–40. The feedback from the individuals involved in engaging with communities reiterated the importance of collaborating with local governments and leaders, high profile residents and religious influencers in crafting the implementation strategy of the program. Their support in raising awareness and helping fight rumors and taboo around polio and vaccinations in general was necessary to have more communities comply with the vaccination program , 46. In While many studies have highlighted the lack of knowledge and awareness among communities to comply with vaccination programs, this study showed that the individual characteristic of employees, their attitude towards the programs as well their inherent knowledge and beliefs towards vaccinations in general had an impact on how they interacted with the communities in delivering the vaccinations , 52. PerIt is important to reflect on what the findings from this study mean against the backdrop of recent rise in the outbreaks of vaccine-derived polio virus (cVDPV) globally. For instance, cases of cVDPV type 2 (cVDPV2) ranged from 1 (in Ethiopia and Indonesia) to 255 (Democratic Republic of Congo) in 2022 across the seven countries considered in this study [The study does have some limitations. First, while the survey tool was created within a particular framework and clear definitions were provided; responses and recall biases might have been introduced in the data as responders may not have addressed the questions in the same frame. Therefore, it is important to keep in mind how some of the variability in the responders’ perceptions may have influenced our conclusions while extrapolating these findings across other service delivery programs. Second, the study reflected its findings with a focus on the internal and external factors that lead to the success of the CE activities–detailed analyses are required to delineate the perceptions of respondents across specific roles towards CE activities. Third, we did not have information on the specific time periods when a respondent was engaged in CE activities to be able to capture change in perception to CE over the years. However, we know that the bulk of our respondents (>60%) had 10 years’ experience or less, and our findings may be influenced by recency bias.Community engagement has become an integral component of program implementation and plays a unique and important role in the success of a program. Understanding and executing strategies to engage communities in a program process is critical to recognize the nuances that can streamline the uptake of an evidence-based program within communities and fulfil the objective of the program. The nuances recognized from a program as large scale as the Global Polio Eradication Initiative can support and preempt the thinking and strategizing around barriers to community engagement for other similar programs that aim to reduce mortality and morbidity within communities due to communicable and non-communicable diseases. Lessons learnt from this initiative provide tried and tested best practices and evidence for strategies that would work in diverse backgrounds with some customization to suit the needs of the situation.S1 Table(DOCX)Click here for additional data file.S1 Questionnaire(DOCX)Click here for additional data file.


Catastrophic health expenditure refers to situations where households face financial ruin due to high healthcare costs. For household spending on health services, the lack of pre-payment mechanisms to equalize the low payment capacity and risk, and the inability of countries' health financing systems to fulfill their duties adequately all contribute to the creation or increase of the risk of catastrophic health expenditure. This situation has devastating effects on poor households first, but if the prevention mechanisms are insouciant, it can threaten the health system of the entire country. The research aims to assess the impact of the pre-paid financing model implementations and income levels on the ability of countries to reduce the risk of catastrophic health expenditure.The paragraph explains the data used in the study, which is taken from OECD countries between 2003 and 2019. It also mentions the statistical models used in the study, which are static and dynamic panel regression models.The findings indicate that pre-paid financing models, such as those based on taxation, can help reduce the risk of catastrophic health expenditure. The study also reveals that income levels play a role in this regard, with countries with higher incomes being better able to reduce the risk of catastrophic health expenditure.The study suggests that healthcare financing systems should aim to provide effective services and financial protection to improve universal health coverage and reduce the risk of catastrophic health expenditure. Further researches using different health indicators and inputs could add to the existing literature on how to limit catastrophic health expenses and address other related questions. Following the United Nations Millennium Declaration adopted in 2000 with the participation of 189 countries, the determined targets were transformed into an action plan. The goals in the development and poverty eradication section of the declaration are to reduce poverty and hunger, combat ill health, gender inequality, lack of education, lack of access to clean water, and environmental degradation. Goals in the field of health include reducing child mortality, improving maternal and child health, and combating HIV/AIDS, malaria, and other diseases. Improving health is central to the millennium development goals because poverty negatively impacts health and poor health leads to loss of income and catastrophic health expenditures  as a mechanism that guarantees equitable access to basic promoting, preventive, curative, and rehabilitative health interventions for all citizens at an affordable cost, thereby ensuring access equality. Healthcare financing is a health system function that mainly serves universal health coverage by providing effective service and financial protection . The heaThree factors must be present for catastrophic expenditures to arise; the presence of health services requiring out-of-pocket payments, low household capacity to pay, and lack of prepayment mechanisms for risk pooling. Out-of-pocket costs include all health-related expenditures that households make while receiving services, such as examination fees, purchase of medicines, materials, or devices, and hospital bills. The definition of household paying capacity is the non-subsistence expenditure of the household. Subsistence expenditures include basic needs such as food, shelter, and clothing. Prepayment refers to the situation where funds for health are collected through taxes and/or insurance contributions .CHEs occur when out-of-pocket health payment as a share of the household income or capacity to pay exceeds a predetermined threshold level . CatastrCatastrophic healthcare expenses are not solely due to expensive medical procedures or treatments. Just as a minor health expenditure can force a low-income household to cut back on essential expenses such as food, housing, or education, significant health expenses can lead to financial ruin and bankruptcy for wealthy individuals and families . TherefoThere are two different methods for calculating catastrophic health expenditures; the first is based on expenditure, and the second is on the income approach. According to the expenditure approach, catastrophic health expenditure occurs when out-of-pocket health expenditure exceeds a certain point of the total expenditure other than the basic expenses made by individuals to sustain their lives. The generally accepted rate is between 45 and 55%. However, because of deficiencies in calculations, this approach has been criticized . On the In addition to enabling people to access care when needed, national health financing systems must shield households from financial disasters by reducing out-of-pocket expenditures. But catastrophic expenses do not automatically disappear with increased income. In the longer term, the aim should be to develop prepayment mechanisms such as social health insurance, tax-based financing of health services, or some mix of prepayment mechanisms. In this direction, this research aims to examine the effects of countries' prepaid financing model implementation and income levels on their capacity to reduce the risk of catastrophic health expenditures.This paper investigates the impact of prepayment financing models, in other words, the extent and existence of public health expenditures and income on the capacity to reduce the risk of catastrophic health expenditures with static and dynamic panel regression analysis for 34 OECD countries from 2003 to 2019.N units, and T number of observations, N and T are higher than one  per capita, and the total out-of-pocket health expenditure per person in the relevant year, representing out-of-pocket expenditure. The study examined the health systems  of different countries to assess the impact of their prepayment mechanisms. Grouping takes into account the presence or absence of a prepaid model in the country's health services, which are primarily financed by public premiums and taxes. For this, the existence of a prepaid model is accepted as being 70% above the weighted average of public health expenditures among health expenditures.The data consists of annual data between 2003 and 2019. For this reason, panel data analysis was used. Israel and New Zealand were excluded from the data set and analyses due to missing data from the 36 OECD countries, resulting in a total of 34 countries being studied. STATA 13.0 was used for all estimations.The gross domestic product based on purchasing power parity (PPP) per capita GDP as an income-level proxy and domestic general government health expenditure  were used as an indicator along with the risk of catastrophic health expenditures. The share of the risk of catastrophic health expenditures for surgical procedures, public health expenditures and income level data were accessed from the World Bank database. It was used a panel model controlling fixed and time effects and used also dynamic model  due to the endogeneity .The fixed effects regression model used in the research is as follows:The dynamic model regression model used in the research is as follows:i is for the countries, and t shows the time. The source of the data in the model, descriptive statistics, and other necessary explanations are given in In the above equation: β is for the independent coefficients, In the study, the countries whose data are available for the period between 2003 and 2019 were included and used a balanced panel data method. The reason why the data were cut in 2019 in the study is that the data for the last year announced for all the variables included in the model is 2019. In other words, 2019 is the most recent data.The study sample consists of annual data from 34 OECD countries between 2003 and 2019. Before the model prediction for static regression modal results, the model's structure was tested to reach more accurate results in the study. The presence of time and/or unit effects in the model was tested with F and LR tests to see whether the model was classical regression. The least squares estimator, a classical regression estimator, gives biased results in the presence of unit or time effects. For this reason, in panel regression models, it should be tested first whether there is a unit or time effect in the model. The null hypothesis of the F and LR tests states that there is no unit or time effect, while the alternative states that there is a unit or time effect .Researchers should investigate the relationship between the unit/time effects in the model and the independent variables. If there is a correlation between the independent variables and the unit/time effect in the model, researchers should use a fixed effects model. In this case, where the use of fixed effects model estimators is appropriate, if there is no relationship between the unit effects in the model and the independent variables, it would be more appropriate to use random effects model estimators instead of the fixed effects model. In the presence of unit/time effect, Hausman Test is used to test the relationship between these effects and independent variables .i, xit = 0) condition is obtained by the Hausman test.Hausman test is used to make a valid choice between fixed effects and random effects, examining whether the difference between the parameter estimators of the fixed-effect model and the parameter estimators of the random model is statistically significant , 17. Sinp) cannot be trusted. In this direction, the Modified Wald test for heteroscedasticity assumption, LBT and Durbin Watson tests for autocorrelation hypothesis, and Pesaran CD tests for correlation between units were applied. The results of the tests showed that there are deviations in all three assumptions, so the current model cannot be used because it includes inter-unit correlation, autocorrelation, and heteroscedasticity. In heteroscedasticity, autocorrelation, and inter-unit correlation, the Driscoll and Kraay standard error correction estimator is one of the robust estimators  shows that there is autocorrelation and AR (2) tests show that there is no autocorrelation problem as expected. When the obtained test results are evaluated collectively, it is concluded that the panel regression estimation results can be interpreted properly. The small sample correction suggested by Windmeijer  was madeectively . As exceIt is seen that all of the variables that are determinants of catastrophic health expenditure for surgical services are also significant at 1% confidence levels and the coefficients are consistent with expectations just like static regression model. As a result of both static and dynamic regression models, it is concluded that the share of public health expenditures in total health expenditures and per capita income calculated according to purchasing power parity have a negative statistically significant effect on the risk of catastrophic health expenditure for surgical services between 2003 and 2019 for 34 OECD countries.Globally, although the share of out-of-pocket payments in health expenditures decreases, its share in income does not decrease because, in public health expenditures, states tend to establish an inclusive health system to prevent threats that may arise, especially for their citizens who are in poverty or at risk of poverty . It is aA study has shown that as the size of the pooled financial mechanism in healthcare financing increases, out-of-pocket expenditures decrease and the budget allocated to healthcare expenses effectively increases. From this perspective, out-of-pocket spending exhibits similar characteristics to catastrophic healthcare expenditures . On the However, studies have shown that in terms of health outcomes, countries with less health expenditure will have a higher impact on the increase in health indicators for each unit of health expenditure that increases. In this case, another important question arises that needs to be discussed. Will the catastrophic health expenditure reduction results of 0.0003 in 1 unit of income level increase or 0.39 in 1 unit of health expenditure increase have a higher impact or how much impact will they have in developing countries? Boz et al.  found thThe datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/supplementary material.The author confirms being the sole contributor of this work and has approved it for publication.