Quality improvement encourages a multi-disciplinary team approach to problem solving, monitoring and ultimately improving the quality of community health services. This session at our 2019 Learning Event enabled participants to feedback on what is working well and what should change.
Participants felt that there is an appropriate mix of people in community-level WITs. However, adding the area Chief to the community teams would be useful as they have community respect and influence and can pass messages through dialogue days and social mobilizations. When chiefs are unavailable Village Elders could step in to play this role. There are other people who are influential in the community, Mama Mboga (vegetable sellers), Mama Mawe (people who sit on stones all day as they wait to go wash clothes and do other household tasks) and butchers are also very influential in the community as ‘antenna’ (for early case detection). They hear all the rumours and gossip in the community and as a result are a good source of information. For similar reasons faith-based leaders and Nyumba kumi (community police) should also be considered important influencers.
At the sub-county level pharmacists need to be aware of what is happening in the community in order to ensure appropriate medicines are available and also to refill the CHVs’ kits. In addition, participants felt it would be good to add the sub-county nutritionist to QI structures in relation to growth monitoring indicators.
The key to optimal working practices in the WIT have been a culture of respect - particularly for diverse opinions, cooperation, passion, frequent meetings, the representation of different capacities, the inclusion of representatives of different sub-groups such as young people, delegation and rotation of roles (such as chair) to promote equity and the integration of CHVs from community units that are not supported by USAID SQALE.
A challenge identified in the USAID SQALE collaboration is that there have been changes to the initial WIT composition as people have been transferred and new staff do not necessarily have training in QI. Another challenge is that while there is a desire for Levels 1 and 2 to work together sometimes people at Level 2 are too busy to provide the required inputs.
Community and facility linkage has rapidly improved during the implementation of the program. Facility-in-Charges did not initially attend WIT meetings but after QI training this has changed. Before USAID SQALE, facility personnel did not always appreciate CHVS. After sensitization, they recognized and appreciated their work and they began encouraging CHVs to bring people to the facilities to receive services which gave the CHVs confidence and motivation. It also helped when Facility-in-Charges started taking people in using the referral form from the CHVs, it showed an appreciation. We heard from participants that every month meetings are held to review the MOH 514, to identify poor performing indicators and link up with facility for solutions like immunization. Sub-county representatives come to do QI coaching and all Community Health Assistants (CHAs) attend sub-county WITS to get ideas and implement at the community level. The sub-county face challenges in doing supportive supervision because of poor transport and terrain. Sometimes the community works hard but the credit goes to the people at the top which causes demotivation at the lower level. Data quality is much better than previously at the community level. This has prompted a similar desire for quality at data at the sub-county level.
Participants explained that there are plans to share learning from USAID SQALE, for example rolling it out to other CHUs with the support of the county and development partners. Resources are needed for a number of activities including training. There are best practices like the mapping of pregnant mothers to ensure they achieve the fourth ANC visit and the CHV desk at the facility which it would be good to replicate elsewhere. However, in general different approaches to community services are used by different partners and these should be harmonized.