A presentation that describes the REACHOUT approach to studying close-to-community providers with quality improvement interventions designed to improve the performance of programmes.

1. Quality improvement and
Community Health Worker
performance: A mixed method
research studyDr Lilian Otiso
LVCT Health, Kenya
1
Innovating for Maternal and Child Health in Africa (IMCHA):
Training for Implementation Research Teams
Southern Sun Hotel, Nairobi
17th December 2015

2. Aim and objectives
Aim: To maximize the equity, effectiveness and
efficiency of close-to-community (CTC) services
in rural areas and urban slums in six countries:
Mozambique, Indonesia, Kenya, Malawi,
Bangladesh and Ethiopia.
2

3. A unique platform
• Works with range of Community Health Workers (CHWs)
• Across different country contexts over time – rural and
urban
• Research that goes beyond single disease programmes – a
health systems approach
• Innovative methods
• Building capacity for embedded research on CTC providers
• Monitoring different outcomes – maternal and child health,
TB, HIV
3

4. In a nutshell
Context analysis
Quality
improvement
(QI)
Quality
embedded
Improved equity,
effectiveness and
efficiency of CTC
services
1. Build capacity
in health
systems
research
2. Identify
influence of
context, policy
and health
system
3. Develop and
assess
interventions
4. Inform
evidence based,
context
appropriate
policy making
Multiple methods
4

5. Context analysis
5

6. Context analysis
framework
6

7. Common areas for QI
Country Focus areas
Bangladesh Supervision
Referral
Ethiopia Supervision
Referral
Pregnant women forum +
health development army
leaders meeting
Kenya Supervision
Community dialogue days
Indonesia Supervision
Community engagement
Health promotion
Malawi Supervision
Performance (best practice)
Mozambique Supervision
(Referral) 7

8. QI Cycle
8

9. Mixed Methods –
QI cycle
9

10. Mixed methods
research
• Three main types used:
– Exploratory - context analysis
– Explanatory - motivation questionnaires and IDIs
– Triangulation - influence of supervision on
performance of CHWs
• program assessment, questionnaires, In Depth Interviews
(IDIs) and Focus Group Discussions (FGDs) and
Observation, QI tracking and referral tracking
• Inter-country analyses
10

11. Pitfalls of mixed
methods research
• O’Cathain (2008)
• Draft baseline reports highlighted gaps in the
mixed methods research
– Reported components separately
– Lack of understanding of why the different
components of MMR
– No attempt to integrate data
– Emphasis on one form over the other
11

12. Capacity building
• Young researchers
training on mixed
methods research
• Peer review of
reports
• Country level follow
up training for
various components
e.g. quantitative
12

13. Mixed methods
research training
13

14. Key results
• Supportive supervision was confirmed to be motivating
and improving CTC performance (quantitative and
qualitative findings). Peer approaches also worked
(Ethiopia)
• QI tracking - frequency of meetings (observed) not as
regular as reported. Variation in quantitative and
qualitative in Kenya
• Post training follow up - supervisors did not apply the
skills learned (Indonesia, Bangladesh)
• Increased community engagement and CTC training
increased linkage and ANC forum attendance (Ethiopia
and Indonesia)
• Referral tracking revealed gaps in data quality and flow
14

15. Next steps:
Embedding QI
• REACHOUT is an unique opportunity for analysis
within and between countries on what works, for
whom and where
• Our QI approaches have been successful but are
not sustainable on their own
• The challenge now is to move from researcher led
to district led systems that assure the quality of
community health
• This requires a culture shift in the thinking of
national programmes, donors, vertical projects. 15

16. Embedding: needs
local ownership
16

17. Universal Health
Coverage and Quality
Everyone has access to quality health services that
they need without risking financial hardship from
paying for them.
• Need to ensure basic standards of quality of care
• Motivate providers and professionals to improve
• Activate patient and public demand for quality
"UHC focused solely on expanding access and NOT simultaneously
addressing quality will have limited impact on population health”
HLSP Summary Brief, June 2014
17

18. +
18

19. Acknowledgements
• EU – funding
• Dr Miriam Taegtmeyer, LSTM - coordinator
• REACHOUT Team
• Governments of Kenya, Malawi, Ethiopia,
Mozambique, Indonesia, Bangladesh
• CTC providers
19

20. Find out more
• Visit us on http://www.reachoutconsortium.org
• Follow us www.twitter.com/REACHOUT_Tweet
• Papers in thematic series on close-to-community
providers in Human Resources for Health
• Join the Thematic Working Group at Health
Systems Global, contact Faye Moody –
faye.moody@lstmed.ac.uk
20

21. 21
www.lvcthealth.org
THANK YOU!
lotiso@lvcthealth.org
www.lvcthealth.org