Quality Improvement field internship in Mwandama (MALAWI)

-Dr. Rohitashva Agrawal (Rohit) (MBBS, PGDMLE, FAGE)

Malawi – warm heart of Africa

Mwandama cluster

Verbal Autopsy & e Health Goals : • Assess patterns of mortality using the

data.• Asses the gaps in e health system. • Assist e health specialist in CommCare

system .• Verification of mortality data.

Activities : • Direct observation of verbal autopsies.• Analysis of the mortality data. • Interviews of the team member responsible for VA.• Edited questionnaires of the VA system.• Provided feedback to the team members on the importance of VA.

Activities : • Visited households.• Interview of community members.• Interview of community leaders.• Observing data registers.

Community leader and CHW

Observations:• Paper based to CommCare system.• Issues with the CommCare system (Syncing

etc.).• Issues with service provider (Airtel).• Few questions in questionnaire were

ambiguous.• Few questions were repetitive.• Sometimes, there was a delay in conduct of

VA.• Only 1 staff was responsible for VA .

Observations:• CommCare system better than paper system.• Staff more comfortable with the digital system.• Staff comfortable with the data entry.• Less chance of leak of information.

Observations:•Mortality analysis showed a spike in the deaths during rainy season.• Few cases of teenage pregnancies.• Incomplete data entry in community registers.•Most of the deaths in Zomba Central Hospital.

Incomplete registers

Recommendations:• Periodic update of the questionnaires.• Better logistics for collection and syncing of data. • Efforts to reduce the website issues.• Better level of access to data on website.• An additional trained staff on standby.

CHW systemGoal: To assess the operational gaps in the CHW system through various methods and to suggest feasible solutions.

Activities:• Interviews of CHW, CHW heads and community members.• Interviews of the health care professionals.• Presentation on M and E and defaulter tracing with Dignitas. • Periodic visits to the health centers.

Activities:• Observing evaluation of CHWs during a household visit.• Observing evaluation of CHW supervisors.• Observing CHW weekly meetings.

Household visit

Supervisor assessing CHW

Activities:• Assisting under 5 clinic for HIV exposed infants.•Wrote a proposal for Monday meetings.• Observation and discussion with the health team.

Under 5 clinic

Training session

Our Friends from Dignitas

Observation:• Lack of availability of funds.• Difficulties of logistics for CHWs (Mobile chargers, bicycles etc).• Confusion regarding future for CHWs post 2015.

Observation:• Issues with the service provider and syncing of data.• Difficulties with the ComCare system (e.g duplication of the data).• Uneven distribution of the households for CHWs.

Recommendations• Better and timely allocation of funds.• Better coordination with the service provider (Airtel).• Clarity for the CHWs for their future post 2015.

Recommendations• Better logistics for newly recruited CHWs. • Speeding up the process of recruitment.• Better coordination with the CommCare system.

Quality of careGoals :

To prepare documents for Diarrhea, malnutrition and Family Planning.

Preparation :

• Visited DHO and collected essential information.• Visited health centers and observed the system.• Collected literature and guides to make the documents.

Activities • Competency assessment documents for diarrhea, malnutrition and family planning.• Audit checklist documents for malnutrition, family planning and diarrhea.• Supportive supervision document for malnutrition, family planning and diarrhea.

Referral system Goals:• Assess community understanding of the referral system. • Identify gaps in the referral system.• Interviews of the members involved in the referral system.

Activities :• Interviews of the healthcare workers.• Interview of the ambulance driver. • Observed few live referrals.• Interviews of the community members.•Wrote a proposal to speed up the process.

Observation:• Only 1 ambulance & 1 driver available for referrals.• Problem of referrals from households to health center.• Delay in referral after 5 PM.

Observation:• Good condition of the ambulance.•Well trained and experienced driver. • Quick referral from health center to Zomba Central Hospital.

Recommendations:• Need one more driver and an ambulance on standby. • Need oxygen cylinder in the ambulance.• Need to keep ambulance near Mwnadama after 5PM.• Need to reduce delay in transfers from home to center.

Beyond but within Observation • Great team to work with.• Good dedication even with paucity of resources.• Qualified for the job.

Observation• Access to internet is a big problem. • Road construction made transport difficult.• Power outages. • Lack of water in toilets.

Recommendations• Internet needs to be the priority.• Timely allotment of the funds.• Power backup.•Water and tissues for toilets.

Great learning experience.

My team at work

My team outside office

It was fun ….

and Malawi does not have Ebola

Thank you MVP.