Publications and tools

About the Program

USAID SQALE program brochure

The USAID SQALE program aims to improve Maternal and Child Health in Kenya by improving the quality of community health services. This short document provides an introduction to our aims and objectives and our model. Read the brochure...


How can we achieve Universal Health Coverage with quality? A quality improvement model for community health from Kenya

This brief describes how the USAID SQALE program has taken quality improvement to the community level in Kitui, Migori and Nairobi Counties in Kenya. It gives an overview of the model used and key lessons that have been learned in the course of implementation. It concludes with lessons for policy and practice. Read the brief...


Making the Invisible Visible


The unfinished agenda in community health: the design, governance and quality of CHW programs



We want to encourage the scale up of the USAID SQALE model to other counties in Kenya and other countries. To facilitate this we have made public a selection of the tools used by the program. Browse the tools...


Creating a forum for shared learning and advocacy in strengthening community health systems

The USAID SQALE program has implemented simple, innovative, quality improvement capacity building for front line workers. County teams were brought together in events that created a dynamic, interactive learning environment. They ensured inclusive participation across cadres and levels of the health system.

“Do you trust that data?” – A mixed-methods study assessing the quality of data reported by Community Health Workers in Kenya and Malawi

High-quality data are essential to monitor and evaluate the performance, quality and equity of community health programmes. We conducted research in Kenya and Malawi and found there are large discrepancies in the values reported by Community Health Workers and those reported by their supervisors.

Quality improvement in community health: A novel approach to improve performance and outcomes of community health programs in Kenya

Universal Health Coverage needs to encompass a focus on health service quality. We explored how Quality Improvement can be used to improve quality of community health programs and their outcomes through implementation research.

Opening the black box: How to measure quality of household visits by community health workers in Kenya?

Lately policymakers have been urged to include quality in any conversation about Universal Health Coverage. Now that discussion needs to expand to cover the lowest level of the healthcare system, community health. Our Community Follow-Up Tool has been tested as a ’rapid assessment’ approach for QI teams in Kenya. There is widespread acceptance of its utility from national to community levels.

Event reports

USAID SQALE Learning Event Report 2019

USAID SQALE has regularly held learning events to help stakeholders in the Kenyan community health system communicate the results of their quality improvement interventions, share lessons learned and strategise about next steps. This multi-media report from our meeting in 2019 outlines what changes have happened in community health, the impacts that USAID SQALE has had on national level policy and tools, and how communities and health care staff plan to sustain positive change in the longer term.

Quality Improvement for community health services: Learning Event Report

In October 2017 representatives from community to national level participated in a two day “festival of learning” that formed the third phase of the USAID SQALE Program quality improvement training model. The overall aim of the event was to share experiences and learn from one another. Twenty-four Work Improvement Teams from Nairobi and Kitui counties came together for the first time to share their experiences. Nairobi County hosted the event, with over 100 participants and facilitators, which comprised of twenty-four quality improvement teams, Kitui and Migori Counties and participants from the National Ministry of Health Departments for Community Health and Health Standards, Quality Assurance and Regulation. Read the report...

USAID SQALE program symposium report

The USAID SQALE symposium (Bridging the Quality Gap - Strengthening Quality Improvement in Community Health Services) was held on the 29 September 2016 and brought together a wide range of stakeholders – from government, communities, the health service, non-governmental organizations, research institutes and universities, and funders – to share learning on quality improvement. It aimed to strengthen knowledge of how these methods can be applied at the community level. During the symposium different speakers shared information on the success of Kenya's community health program and some of the ways that quality improvement can help tackle challenges that are being faced in the country. Read the report...


Journal articles

“It’s like these CHCs don’t exist, are they featured anywhere?”: Social network analysis of community health committees in a rural and urban setting in Kenya

In Kenya, Community Health Committees (CHC) were established to enhance community participation in health services. Their role is to provide leadership, oversight in delivery of community health services, promote social accountability and mobilize resources for community health. CHCs form social networks with other actors, with whom they exchange health information for decision-making and accountability. This case study aimed to explore the structure of a rural and an urban CHC network and to analyze how health-related information flowed in these networks. Understanding the pathways of information in community settings may provide recommendations for strategies to improve the role and functioning of CHCs.


Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries

This paper examines the costs and budget impact of integrating quality improvement into existing CHW health programmes in five countries (Ethiopia, Indonesia, Kenya, Malawi, Mozambique) between 2015 and 2017. Based on project costs, costs of local adoption of the intervention were modelled under three implementation scenarios. Annualised economic unit costs ranged from $62 in Mozambique to $254 in Ethiopia per CTC provider supervised, driven by the context, type of community health model and the intensity of the intervention. The budget impact of Ministry-led QI for community health is estimated at 0.53% or less of the general government expenditure on health in all countries (and below 0.03% in three of the five countries).

The missing piece: quality in community health programmes

A focus on optimising community health should be an integral part of the broader discourse on the quality of health care. We believe that CHWs can ignite the demand for quality, ensuring that services at all levels meet people's preferences, needs, and expectations and build trust in health systems. CHWs are in a unique position to amplify the voices of the vulnerable and to ensure that the push for UHC is not at the expense of equity. Embedding quality improvement into community health services and fully integrating these services into primary care systems will also improve the efficiency and efficacy of referrals. This integration will also help health systems to shift their focus from reactive curative care to more proactive health promotion and preventive care that maintains health and wellbeing at the community level.