A 'D.I.V.A.' in Malawi: From the Field: Improving Program and Data Quality

Last week, I participated in a quality improvement (QI) training for 12 of our site coordinating community health workers (CHWs). Designed to improve our prevention of mother to child (HIV) transmission (PMTCT) programs across Malawi, the QI training introduced a process to assist CHWs in systematically evaluating programming and data quality.

Nested within a Ministry of Health training facility, the session began as is customary here in Malawi: with a prayer. The Regional Manager then facilitated discussion on the CHWs' experiences in utilizing the QI process three months after the first workshop. Many were enthusiastic about the successes of the process, acknowledging that it allowed them to identify gaps in their site’s current activities and services. The QI program also assisted CHWs in identifying challenges in current service provision. Singere, one of the CHWs, learned that our organization's relationship with that health facility was negatively impacting services, as sometimes eligible clients were not referred.

Following these reflections, the Director of Monitoring and Evaluation facilitated the workshop on completing the QI process. Using an interactive style, he invited CHWs to help identify the three month sample period and then described how the random sample of 25 clients would be obtained. After identifying the sample, CHWs were required to transfer the information (by hand) from their client logbooks to a worksheet, and finished by calculating totals and percentages of complete entries. Along with other management staff, I supervised the CHWs as they completed the worksheet. Some were very quick to complete the process; others required more assistance in understanding the instructions and performing calculations.

After a delicious sleep-inducing lunch of nsima, meat, and veggies, the CHWs were instructed to compare client data from the morning session’s three-month sample and the previous session’s three-month sample. They were encouraged to observe the target they set for an indicator of interest, while also setting a new goal. This prompted a vibrant discussion on sites’ achievements and areas for improvement, as well as areas of focus for the next quarter. Violet, one of the CHWs, observed that attendance at the second antenatal visit declined from 20% to 18% over the two three-month sample periods. As she worked through the second half of the worksheet, she selected this as her indicator of focus for the next quarter. Through reflection and discussion, she identified the problem as being the location of the PMTCT program tent at this facility; it was behind the antenatal ward where clients would receive services. In response to this problem, she suggested creating a schedule whereby a staff member is always waiting for clients at this particular facility. She set a target of 50% second antenatal visit for the next follow-up session in December.

Overall, the one-and-half-day workshop provided an interactive opportunity for CHWs and senior management to review program functioning as well as the quality of data recorded. The workshop was not without its challenges, as it required a lot of time and supervision for women who had – at most – a high school diploma. Regardless, the CHWs demonstrated their capability and wiliness to be an active part of improving the PMTCT programs. Instead of management pointing out program and data shortcomings, the CHWs had the opportunity to discover the depth of the problem and to form a plan of action in response, uniquely allowing them to take ownership of the data analysis process. It is too early to see the impact that initiating this QI process will have on our data or programming, but as results are thus far promising, we will be introducing this process at the remaining 35 sites.