Reflections on a three-year journey in quality improvement in community health

By Lynda Keeru

As the USAID SQALE project comes to an end, teams took time to reflect on the changes that have occurred in community health over the past three years. This took place at the final learning event as you can read in the multimedia report.  The legacy of USAID SQALE is large and it has impacted on national level policy and tools and how communities and health care staff plan to sustain positive change in the longer term.

There was one fervent desire among all stakeholders present at the meeting to witness the progress of the quality revolution in community health services spread to more counties in the country beyond the three pilot countries (Migori, Kisumu and Nairobi). This is attainable through working together to ensure and demand community health services built on a foundation of quality.

In a gripping opening address by Dr Vicki Doyle, she challenged the participants to remain passionate in order to keep the revolution burning. She went ahead and asked them to be courageous, and to challenge and keep questioning, as quoted in the report:

“We can’t have a quiet revolution, we need to shout so don’t stay quiet. We want to make things better for our communities. You are the first people to do Quality Improvement (QI) at the community level. People didn’t think that we could do it, but you are leading the way, you are leading the revolution. To lead a revolution, you need passion and courage to go beyond the status quo and to challenge the way that things are done.”

Read the report to learn about the exciting and interactive poster presentation session characterized by walls covered with a collage of rainbow coloured charts that represented three years of work, an ear-splitting whistle and palpable tension in the room as presenters gave it their all, vying to win the coveted Learning Event Awards. With technical support from the LVCT team, the community teams were able to display their hard-earned results on the posters.

This report, that is hot off the press, also explores seven topics that were discussed by participants during the World Café session.

• Sustaining Quality Improvement
• Collaborating for Quality Improvement of community health services
• Quality Improvement Impact
• Innovating for community engagement
• Helping communities to be more resilient
• Communicating data
• Informing the Community Health Strategy

There were many takeaways to consider from the first day like the brilliant quote from Dr Kandie:

“We need to send the stories of QI to the politicians so that you become a learning site for others to take your expertise from. Although USAID SQALE is scaling down, the ideas and the structures that have been created can endure. It can also be scaled up to other counties. I would like to thank all the foot soldiers for QI at the community level for their efforts.”

The second day of the learning event was ushered by a challenging and eye-opening speech by Prof Miriam Taegtmeyer who provided the participants of the workshop with the importance of evidence driven research and data. In the same breath, she advised them to be kind to themselves saying:

“Evidence can be difficult. Gathering it is not easy and the tools that we have from government don’t always allow us to gather the information that we need. Presenting evidence is also challenging and choosing the right format is key. It needs to be clear to us and clear to other people. Interpreting evidence is difficult. Evidence takes time and improvement on the basis of evidence takes time. We can see progress from the evidence presented here in your posters.”

Miriam also challenged policy makers; asking them to ensure that the evidence collected is actually put into use.

In his address, the Activity Manager for the USAID SQALE program from USAID, Sila Kimanzi said that USAID was incredibly proud to have partnered with LSTM, LVCT Health and the community as they demonstrated that community QI can be institutionalized. He called upon the counties to strengthen their collaboration with other partners to ensure that the gains of USAID SQALE are sustained.

In a diverse set of panelists with representation from all three USAID SQALE pilot counties and moderated by Dr Lilian Otiso, there were rich discussions on the journey of implementing the USAID SQALE program and its impact. In Migori for example, due to the training and mentorship by the USAID SQALE team, they had started Data Quality Assessment (DQA) and mapping and tracking of pregnant mothers to ensure that they are visited by a Community Health Volunteer (CHV) each month and that they complete the recommended four Antenatal Care (ANC) appointments.

For Judy Macharia, the Nairobi Community Health Strategy Coordinator, community QI was God sent. She explained:

“Nairobi county’s reporting rates and timeliness used to be at 30%-40% but now they are nearer 95%. Before USAID SQALE, we also had less than 10% coverage and now we are at 53%. Our improved data after the implementation of the program has now led to interest from other development partners who are supporting us as a result.”

Gladys Mutinda, who is one of the partners, from Afya Uzazi observed that as a result of the USAID SQALE program, CHVs’ consciousness of quality had improved. CHVs have a better understanding of the importance of the work that they do. They know that the evidence that they collect is used for learning and decision making which is a great motivation. The report contains more of these findings and lessons that are county specific.

Midway through the second day of the learning event, the Facilitators’ manual for Quality Improvement of Community Health Services was launched, by Dr Charles Kandie, the Head of Quality Assurance, to be used by the national and county governments to be able to train health managers and community health workers in QI of community health services.   

In the research findings section of the report, we find out the results of the research carried out as part of the USAID SQALE program. This includes the LQAS survey which is a household survey method that is commonly used for baseline and follow-up assessments to assess the coverage of services provided especially where resources are limited. The second set is preliminary findings from the USAID SQALE research on the cost of community QI and preliminary findings from the USAID SQALE research on community participation.

Towards the close of the Learning Event, the organizers ran a participatory session to consolidate learning and develop sustainability plans. The Talking Wall session enabled participants to visually capture key lessons from USAID SQALE learning, develop sustainability plans post USAID SQALE funding and to publicly declare their commitment to continuing the Quality Revolution. These were creatively put up on the walls in the form of trees containing roots, which represent the wisdom generated by implementing the program and the fruits on the branches represented the impacts as a result of community QI.

In the true fashion of USAID SQALE learning events, the event was concluded on a high with the Quality Improvement Awards to celebrate excellence in community health services. The report contains all the categories in the competition and a detailed list of the winners. Congratulations to all winners and to USAID SQALE project team members!