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Quality improvement and Community Health Worker performance: A mixed

method research study Dr Lilian Otiso LVCT Health, Kenya

Innovating for Maternal and Child Health in Africa (IMCHA): Training for Implementation Research TeamsSouthern Sun Hotel, Nairobi17th December 2015

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Aim and objectives

Aim: To maximize the equity, effectiveness and efficiency of close-to-community (CTC) services in rural areas and urban slums in six countries: Mozambique, Indonesia, Kenya, Malawi, Bangladesh and Ethiopia.

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A unique platform

• Works with range of Community Health Workers (CHWs)• Across different country contexts over time – rural and

urban• Research that goes beyond single disease programmes – a

health systems approach• Innovative methods• Building capacity for embedded research on CTC providers • Monitoring different outcomes – maternal and child

health, TB, HIV

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In a nutshell

Context analysis

Quality improvement

(QI)

Quality embedded

Improved equity, effectiveness and efficiency of CTC

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

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Context analysis

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Context analysis framework

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Common areas for QI

Country Focus areasBangladesh Supervision

ReferralEthiopia Supervision

ReferralPregnant women forum + health development army leaders meeting

Kenya SupervisionCommunity dialogue days

Indonesia SupervisionCommunity engagementHealth promotion

Malawi SupervisionPerformance (best practice)

Mozambique Supervision(Referral)

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QI Cycle

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Mixed Methods – QI cycle

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Mixed methods research

• Three main types used:– Exploratory - context analysis – Explanatory - motivation questionnaires and IDIs – Triangulation - influence of supervision on

performance of CHWs• program assessment, questionnaires, In Depth Interviews

(IDIs) and Focus Group Discussions (FGDs) and Observation, QI tracking and referral tracking • Inter-country analyses

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Pitfalls of mixed methods research

• O’Cathain (2008) • Draft baseline reports highlighted gaps in the

mixed methods research– Reported components separately– Lack of understanding of why the different

components of MMR– No attempt to integrate data– Emphasis on one form over the other

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Capacity building

• Young researchers training on mixed methods research

• Peer review of reports • Country level follow

up training for various components e.g. quantitative

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Mixed methods research training

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Key results

• Supportive supervision was confirmed to be motivating and improving CTC performance (quantitative and qualitative findings). Peer approaches also worked (Ethiopia)

• QI tracking - frequency of meetings (observed) not as regular as reported. Variation in quantitative and qualitative in Kenya

• Post training follow up - supervisors did not apply the skills learned (Indonesia, Bangladesh)

• Increased community engagement and CTC training increased linkage and ANC forum attendance (Ethiopia and Indonesia)

• Referral tracking revealed gaps in data quality and flow

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Next steps: Embedding QI

• REACHOUT is an unique opportunity for analysis within and between countries on what works, for whom and where

• Our QI approaches have been successful but are not sustainable on their own

• The challenge now is to move from researcher led to district led systems that assure the quality of community health

• This requires a culture shift in the thinking of national programmes, donors, vertical projects.

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Embedding: needs local ownership

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Universal Health Coverage and Quality

Everyone has access to quality health services that they need without risking financial hardship from paying for them.

• Need to ensure basic standards of quality of care• Motivate providers and professionals to improve• Activate patient and public demand for quality

"UHC focused solely on expanding access and NOT simultaneously addressing quality will have limited impact on population health”

HLSP Summary Brief, June 2014

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Acknowledgements

• EU – funding • Dr Miriam Taegtmeyer, LSTM - coordinator• REACHOUT Team • Governments of Kenya, Malawi, Ethiopia,

Mozambique, Indonesia, Bangladesh• CTC providers

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Find out more

• Visit us on 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

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www.lvcthealth.org

THANK YOU!

lotiso@lvcthealth.orgwww.lvcthealth.org