News & Commentary

17 August 2015

Quality improvement methods as a people-centred approach to community health

By Miriam Taegtmeyer*

This blog post is part of a series on people-centred research methods for health systems development published in conjunction with a Twitter chat on the same topic. Please see below for links to other blog posts in this series. 

Community health workers (CHWs) have been in the news recently with calls for the scale up of close-to-community (CTC) health programmes being heralded as a ‘good buy’ for development. But how do we ensure that these programmes run efficiently and equitably in ways that are owned by health care staff, CHWs and communities? This is the question that the REACHOUT consortium is seeking to explore with its project in Bangladesh, Ethiopia, Indonesia, Kenya, Malawi and Mozambique. The CTC providers we work with include CHWs, midwives, traditional birth attendants, informal private practitioners and lay counsellors.

Four key areas of concern have emerged that have potential to undermine CHW programme effectiveness and equity: 1. supervision; 2. community engagement; 3. referrals; and 4. coordination between stakeholders. Scale-up of CHW programmes is seen as a way of reaching universal health coverage, but rapid scale-up that does not address these concerns poses a potential risk to service quality and equity.

What methods have we used?

Over the last few years we have started to identify how CTC services can best be delivered, to implement change and to document lessons. In our first year we combined literature reviews with an in-depth context analysis in each country.

Currently we are doing research on the impact of group supervision as a means to improve performance and community engagement. The challenge is to build on these research foundations, shifting away from researcher-led data collection to an embedded culture of data collection and use for quality improvement and for monitoring equity among the teams of health professionals delivering these services. CHWs form important intermediates between communities and the health sector and locally developed solutions have a far better chance of success.

The people in health systems need to lead programme improvements

We define quality improvement as a systematic approach to planning defining, monitoring, improving and evaluating community health programmes. Through our work we are embedding into CHW scale-up, tried and tested quality improvement methods that are easy to use, simple to do and where data are collected, analysed and used by communities and CHWs to improve things.

It is not without its challenges. Government standards and guidelines are not widely known or disseminated and few people in the health system and in the community are clear on what their roles in quality improvement for community health might be. There are far too many tools and documents that are not owned by communities and CHWs. The photo above was taken at a national stakeholder workshop and shows piles of guidelines, strategies and tools that had never been sent out to regions and districts.

A few simple, robust tools chosen and used locally have far more chance of success. When you accept that there is no need to get everything perfect straight away it turns out that quite a small change, done well, can be very inspiring.

I am really looking forward to the twitter chat on people-centred research methods for health system development and would love to hear from others trialling innovative methods. You can find out more about the chat on the HSG webpage or follow the Twitter hash tag #HSR2015 and visit us at @reachout_tweet.

* Miriam Taegtmeyer is a Senior Clinical Lecturer at the Liverpool School of Tropical Medicine and co-Director of the REACHOUT Consortium. Prior to this Miriam worked in the UK National Health Service (NHS) as well as in Kenya where she was the founder-director of a Kenyan non-governmental organization providing technical assistance for HIV services in resource-poor countries. She is a member of the HSG Thematic Working Group on Supporting and Strengthening the role of Community Health Workers in Health System Development. 

Other blog posts in this series:

Archived comments

Maryse Kok 17 August 2015 at 14:26

I agree, tools should be simple and easy to use for both CHWs and supervisors. They should have added value for both of them as well. In the REACHOUT study in Malawi, one health surveillance assistant reported that the newly introduced, simple monthly workplan tool helped her in organizing her work and checking whether she was on schedule. For the supervisor, the tool is used during supervision and for performance appraisal purpose. A small change, with important results in terms of motivation.

Miriam Taegtmeyer 18 August 2015 at 08:22

Thanks Maryse. Other REACHOUT countries have found that a simple program assessment tool that asks key stakeholders to score a range of programme dimensions has been a useful way of tracking progress and initiating debate about prioirty areas of action.