Michael Kimani and Regeru Njoroge Regeru
There is a growing recognition of the importance of supervision and mentorship of community health workers as means of improving and enhancing their performance. However, the most effective ways of supervising community health workers are still unclear. Technology and social media are emerging as one mechanism for improving supervision in low- and middle-income countries, including Kenya.
In Kenya, Community Health Services are provided by Community Health Volunteers (CHVs). Their primary role is health promotion and increasing the uptake of essential health services (such as antenatal care, skilled delivery and immunization) at primary healthcare level through referral. CHVs are supervised by Community Health Extension Workers (CHEWs), who in turn are supervised by Sub-County Health Managers. Within the USAID SQALE program, quality improvement in community health services is being driven by Work Improvement Teams (WITs) which operate at community and sub-county level. These teams identify problems affecting the quality of community health services, analyze the causes for these problems and develop solutions that are implemented through their work plans. Each Community Health Unit supported by USAID SQALE has its own WIT and the sub-counties in which these community units are located have a Sub-County WIT. Within this structure are County and Sub-County Quality Improvement Coaches – these are people, who both by virtue of their designation but also their passion for Quality Improvement, have taken the lead in implementation as coaches and supervisors. These Coaches have been taught that supervision has three main functions: administrative, educative and supportive.
In the first year or so of the program, due to the number and wide geographical spread of Community Health Units in each County, Coaches found it difficult to coordinate their coaching/supervision visits to align with key activities being carried out by the WITs, such as WIT meetings and CHV supervision meetings. This meant that coaching did not take off as hoped. County Coaches suggested that WhatsApp could be used to arrange visits and meetings, avoiding the hassle of multiple, separate phone calls to several people and allowing for real-time updates. WhatsApp saved the Coaches money, as mobile network providers in Kenya now provide WhatsApp use for free. This resulted in the establishment of a Quality Improvement WhatsApp group in each County. The members of these groups are: the County Coaches; the Sub-County Coaches; the CHEWs; the heads of the primary healthcare facilities linked to the Community Health Units; and LVCT Health staff.
The WhatsApp groups have vitalized the Quality Improvement revolution and are providing a means for the Coaches to realize the three functions of an effective supervisors. Administratively, implementation of Quality Improvement in community health services involves monthly WIT meetings, organization of community-based activities such as dialogue days and facility-based activities like tracking referrals made by CHVs. The WhatsApp Groups have allowed Coaches and WIT representatives to schedule activities each month to ensure availability of all the relevant people.
In terms of education, the WhatsApp groups have allowed County Coaches to share updates from the County level such as new policies or changes in policy, as well as disseminate key community health service documents such as CHV job aides which can be sent via WhatsApp as downloadable PDFs.
Finally, and perhaps most importantly, in terms of support, the WhatsApp groups have become a source of great moral support for each of the WITs who are met with congratulations and words of encouragement as they provide updates on activities that they have carried out by sharing photos with descriptions. Furthermore, this environment also stimulates friendly competition with no WIT wanting to be left behind as others share their progress.
In conclusion, the USAID SQALE program seeks to embed a culture of Quality Improvement in the delivery of community health services. We have found that an effective way of doing this is taking advantage of tools such as WhatsApp that are a part of the everyday lives of those leading the Quality Improvement revolution.