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Quality Improvement in community health: A multi-country study in Asia and Africa

Dr Miriam TaegtmeyerPI, REACHOUTLiverpool School of Tropical Medicine

The REACHOUT project is funded by the European Union

12th June 2016

Outline

• Aims, approach and process• Challenges faced by close-to community

providers• Inter and intra-country analysis• Embedding Quality Improvement• Future directions

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

Six countries, three E’s

QUITY

FFICIENCY

FFECTIVENESSE

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

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

Adding detail to a framework

A systematic review

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”

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?

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

Cianjur, Indonesia Sidama Zone, Ethiopia SW Sumba, IndonesiaIt 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?

Now a detailed framework

How can we improve quality of community health programmes?

• Supervision• Community engagement• Referral• Communication and coordination

among service providers

Plan

Define

MonitorImprove

Evaluate

Quality Improvement Cycle: Researcher-led

Plan

Define

MonitorImprove

Evaluate

Quality Improvement Cycle: District-led

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

• 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

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

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)

Future directions: gender equity

MobilityAcceptability

Household decision-makingSafety

MarriageFamily support

Competing demandsAccessibility

Attrition

RemunerationRecruitmentRetention

SupervisionCareer progression

Policies & guidelines

Community Individual Health System

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?

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.

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