By Kate Hawkins, Maryse Kok, Kingsley Chikaphupha and Meghan Bruce Kumar
“There is significant data collection through various methods and implementers of community health. HSA’s are technically assigned to complete over 40 M&E forms and processes while there are currently 15 different types of data used in community health. The amount of data collection creates a burden for implementers around consistency and quality of data that is weakened by insufficient quality assessments and training for data collection… Multiple processes for data collection also raises questions around data quality given the amount of time needed to devote to multiple M&E processes as well as limited trainings and supervision.”
Malawi National Community Health Strategy 2017 - 2022
As the drive for Universal Health Coverage and the Sustainable Development Goals (SDGs) has led to a push for greater health service access, the issue of sustaining and embedding quality in the ways in which these services are delivered has gained prominence.
Measurement of quality and attribution of its effects in health is challenging at any level. But little is known about how quality is assessed within community health programmes, who are on the frontline of health service delivery in many low- and middle-income settings. The degree to which new initiatives like the Lancet Commission on Quality in Health Systems will include community health programming and the role of close-to-community health providers is currently unclear.
Health systems are shaped around well analysed power asymmetries. Relatively less powerful staff who labour at the interface of the community and health sector are rarely canvassed on their opinions of quality nor are their voices prominent in the decision-making processes that effect their daily labour. At the more local level differences in the personal characteristics of community health workers and their supervisors (such as sex, educational level, class, experience of poverty etc.) also act to reinforce power asymmetries.
This brief explores how close-to-community health providers in Malawi perceive quality as an aspect of their work and highlights some key challenges which may hinder the definition, measurement, and achievement of quality at the community level. It is based on research conducted by REACH Trust.
We found that Health Surveillance Assistants, the community health workers that operate in Malawi, experienced many challenges which hindered the provision of what they would consider a ‘quality’ service, these included:
This project is funded by the European Union.