This presentation explains what we have learnt about quality improvement in community health programmes in the six countries that we work in, their similarities and differences, and future directions.

1. Quality Improvement in community
health: A multi-country study in Asia
and Africa
Dr Miriam Taegtmeyer
PI, REACHOUT
Liverpool School of Tropical Medicine
The REACHOUT project is
funded by the European Union 1
12th June 2016

2. Outline
• Aims, approach and process
• Challenges faced by close-to community
providers
• Inter and intra-country analysis
• Embedding Quality Improvement
• Future directions

3. We work with close-to-community providers of
health services
"Universal Health Coverage focused solely on expanding
access and NOT simultaneously addressing quality will have
limited impact on population health”
HLSP Summary Brief, June 2014SDG 3.8

4. Six countries, three E’s
QUITY
FFICIENCY
FFECTIVENESS

5. A platform for research that is…
• Working at the interface
between community and
health systems in a range
of contexts
• Variety of priority areas
including maternal
health, SRHR
• Working WITH health
systems on embedded
interventions
• Working ON health
systems over time

6. 5-year approach to our research
Context
analysis
Quality
improvement
Quality
embedding
Improved equity,
effectiveness and
efficiency of
CHW services
1. Build capacity
in health
systems
research
2. Identify
influence of
context, policy
and health
system
3. Develop and
assess
interventions
4. Inform
evidence based,
context
appropriate
policy making
Multiple methods

7. Adding detail to a framework

8. A systematic review

9. Inter- or intra-country?
District 1 District 2 District 3
“It was my husband’s
decision. If my husband has
already called the TBA, I
don’t (refuse)”
“some women after being
identified by [CHWs}, they
don't want to come to the
facility. They complain
…‘My husband and
mother-in-law don’t allow
me to go’”
“But on the due date, she
was not the one who made
the decision, but the
husband, mother in law or
mother. If they husbands
insist to have the baby with
the [TBAs] service, she will
just obey”
“The community still
believes strongly in the
[TBA] because [TBA] sends
the prayers for the safety of
both the mother and the
baby. Another thing the
mothers like is because
they also give massage”
“they don't want to go
outside [to health facility]
and lose the placenta. If
the placenta is not buried
inside home it is
considered as bad fortune”
“If we do delivery at home,
there is hot water, there is
traditional drugs which is
drank to wash the womb
until it is cleaned”

10. Cianjur, Indonesia
It was my husband’s
decision. If my husband has
already called the TBA, I
don’t (refuse)
some women after being
identified by [CHWs}, they
don't want to come to the
facility. They complain
…‘My husband and
mother-in-law don’t allow
me to go’
But on the due date, she
was not the one who made
the decision, but the
husband, mother in law or
mother. If they husbands
insist to have the baby with
the [TBAs] service, she will
just obey
The community still
believes strongly in the
[TBA] because [TBA] sends
the prayers for the safety of
both the mother and the
baby. Another thing the
mothers like is because
they also give massage
they don't want to go
outside [to health facility]
and lose the placenta. If
the placenta is not buried
inside home it is
considered as bad fortune.
If we do delivery at home,
there is hot water, there is
traditional drugs which is
drank to wash the womb
until it is cleaned
Inter- or intra-country?

11. Inter- or intra-country?
Cianjur, Indonesia Sidama Zone, Ethiopia
It was my husband’s
decision. If my husband has
already called the TBA, I
don’t (refuse)
some women after being
identified by [CHWs}, they
don't want to come to the
facility. They complain
…‘My husband and
mother-in-law don’t allow
me to go’
But on the due date, she
was not the one who made
the decision, but the
husband, mother in law or
mother. If they husbands
insist to have the baby with
the [TBAs] service, she will
just obey
The community still
believes strongly in the
[TBA] because [TBA] sends
the prayers for the safety of
both the mother and the
baby. Another thing the
mothers like is because
they also give massage
they don't want to go
outside [to health facility]
and lose the placenta. If
the placenta is not buried
inside home it is
considered as bad fortune.
If we do delivery at home,
there is hot water, there is
traditional drugs which is
drank to wash the womb
until it is cleaned

12. Cianjur, Indonesia Sidama Zone, Ethiopia SW Sumba, Indonesia
It was my husband’s
decision. If my husband has
already called the TBA, I
don’t (refuse)
some women after being
identified by [CHWs}, they
don't want to come to the
facility. They complain
…‘My husband and
mother-in-law don’t allow
me to go’
But on the due date, she
was not the one who made
the decision, but the
husband, mother in law or
mother. If they husbands
insist to have the baby with
the [TBAs] service, she will
just obey
The community still
believes strongly in the
[TBA] because [TBA] sends
the prayers for the safety of
both the mother and the
baby. Another thing the
mothers like is because
they also give massage
they don't want to go
outside [to health facility]
and lose the placenta. If
the placenta is not buried
inside home it is
considered as bad fortune.
If we do delivery at home,
there is hot water, there is
traditional drugs which is
drank to wash the womb
until it is cleaned
Inter- or intra-country?

13. Now a detailed framework

14. How can we improve quality of
community health programmes?
• Supervision
• Community engagement
• Referral
• Communication and coordination
among service providers

15. Plan
Define
MonitorImprove
Evaluate
Quality Improvement Cycle:
Researcher-led

16. Plan
Define
MonitorImprove
Evaluate
Quality Improvement Cycle:
District-led

17. Embedding Quality Improvement
Strengths
• Guidelines/standards and
tools for community health
• Engagement of MoH,
community and other
stakeholders with QI
approach through
REACHOUT
• Implementation research
capacity of REACHOUT
teams to evaluate progress
Weaknesses
•Guidelines/tools overload & lack
of alignment
•Lack of dissemination of
guidelines/tools
•Low quality of data
•Limited capacity for data
collection, analysis & use at
district level
•Limited advocacy for QI in health
•Lack of financial systems &
dedicated budget for QI

18. • What is possible in
complex adaptive
systems?
• How do we handle data
availability and quality
problems?
• Can we convincingly
model impacts on health
for system process
indicators?
Future directions: Costing

19. Future directions: Devolution
National – policy maker
Province – limited
decision making capacity
District – key decision
making role
Community level – village
level decision making
National - policy maker
County – key decision
making role
Sub-county – former
decision making role re-
centralised to county
Community level – play
role in public participation
Indonesia - 2001 Kenya - 2013

20. Devolution
• Expectations of
improvement– to service
delivery (Indonesia) and
in terms of inequities
(Kenya)
• Challenge in satisfying
community expectations
• Potential for earmarked
health funds and CHWs
for political propaganda
“Kader got incentive and
batik uniform from Mr. C. He
always gives batik. When we
got higher incentive, we
know who we are going to
choose (in the local
election). We don’t have to
do anything else, just to
choose him at the election."
(024 Kader CJ)

21. Future directions: gender equity
Mobility
Acceptability
Household decision-
making
Safety
Marriage
Family support
Competing demands
Accessibility
Attrition
Remuneration
Recruitment
Retention
Supervision
Career progression
Policies & guidelines
Community Individual Health System

22. Future directions: Gender equity
• To what extent gender is acknowledged in Community
Health Worker policy documents?
• What are the challenges/opportunities in implementing
gender responsive policies?
• How does gender effect the interface role between the
community and the health system in Mozambique and
Ethiopia?

23. Summary
• REACHOUT is a great platform for testing and
embedding quality improvement initiatives in
community health.
• Shifting from project-led to district-led
approaches raises complex questions that go
beyond health and into politics, people, power
• We need context specific understandings of
ownership against each stage of the quality
assurance cycle for community health.

24. Find out more
• Visit us http://www.reachoutconsortium.org
• Follow us www.twitter.com/REACHOUT_Tweet
• Papers in thematic series on close-to-
community providers in Human Resources for
Health
• Join the Thematic Working Group at Health
Systems Global, contact Faye Moody –
faye.moody@lstmed.ac.uk