By Robinson Karuga, Judy Warioko and Maryline Mireku
Bangladesh. Curious name for an urban slum that is sandwiched between Nairobi’s sprawling national park and middle class residential estates in Langata sub-county. Bangladesh slum is home to about 640,000 people who mainly provide casual labour to nearby stone quarries, as touts and as drivers of matatus (public service vehicles) in a nearby peri-urban town called Ongata Rongai. In total, there are about 370 houses made from assorted materials such as mud, wood, and iron sheets.
Despite the lack of social amenities such as piped water, sewerage system and garbage management, Bangladesh slum is impressively clean, compared to other slums in Nairobi. As one walks through the alleys in Bangladesh, they can’t fail to spot healthy and leafy kale growing in black-polythene door step gardens in most of the households. Another interesting observation is the number of water filled “leaky-tins” that are hung on majority of the pit latrines as hand-washing facilities. This place is different from many other slums.
“This is all the work of Community Health Volunteers (CHVs)” said Maryline Mireku. Maryline is a Research Officer in the 5-year multi-country REACHOUT project that has been involved in embedding quality improvement in community health services in Nairobi County. One of the interventions involved building capacity in supportive supervision of CHVs in Bangladesh slum. Bangladesh slum is served by 14 CHVs who make up a cadre of lay health workers that are nominated by fellow community members to provide health education and basic health services (Vitamin A supplementation, growth monitoring, follow up for maternal and child health services) at household level. They are also crucial for referring community members for primary health care services.
What follows is a story that started when I enquired on the effects of this intervention from the Officer in Charge of community health services in Langata sub-county. Her name is Judy Warioko.
“By the way, REACHOUT really contributed to bringing community health in Bangladesh to life”, stated Judy. This response triggered our discussion on how REACHOUT’s had influenced community health services in Bangladesh. According to Judy, Bangladesh slum consistently performed poorly in all the community health indicators before the REACHOUT intervention in 2015, such as community health reporting rates, maternal, newborn and child health (MNCH) indicators, referral and sanitation. This poor performance had been going on since the Ministry of Health established Bangladesh slum as a community unit in 2012. “Things are better now since you people trained on supportive supervision”, she continued. “CHVs now report on time and we have noticed an improvement in the quality of reporting”. According to Judy, CHVs in Bangladesh slum had started submitting their well completed monthly community health reports and were more active in refering community members for primary health care since supervisors were trained on supportive supervision. The 6-day training on supportive supervision focused on the educative, supportive and administrative roles of supervision, different approaches in supervision, problem solving and advocacy. Training was done using a workshop approach and monthly coaching after the workshops.
Being a skeptic, I decided to find out a little more from other sources in Bangladesh slum. My first stop was a conversation with Fredrick Onyango; a CHV who had been nominated as a peer supervisor by CHVs in Bangladesh slum. Fredrick was one of the peer supervisors who participated in the training in supportive supervision.
He confidently started our conversation by saying “Before I did not know anything about group supervision and one-to-one supervision”. The skills in supportive supervision learned during the workshops, subsequent coaching sessions by REACHOUT staff helped him, and other supervisors understand what supervision is and how important it is while delivering health services in the community
According to Fredrick, most of the CHVs could not comprehend the instructions and indicators in the community health reporting tools, which they were required to complete on a regular basis (household service registers and referral forms) before the training. Moreover, CHVs completed these tools incorrectly without supervision. They also constantly ran out of these community health-reporting tools and had to make copies with their own money. This affected the timeliness and quality of reports that they submitted to the health information systems officer at sub-county level.
In addition to training supervisors on supportive supervision, REACHOUT supported Langata sub-county officers to train peer CHV supervisors on how to correctly fill-in the reporting tools. REACHOUT also supported the supervisors by printing and distributing the community health reporting tools. After the training, CHV peer supervisors started using group supervision approaches to coach and support CHVs as they prepare their monthly reports for submission to their supervisor (Community Health Extension Worker -CHEW). CHEWs are primary health worker who supervise CHVs
Accompanied household visits by peer supervisors and CHEWs has improved health services to the community members. Through these approaches in supportive supervision, CHVs are now more rigorous in checking for health services that community members have not received and refer them for primary care such as immunization, antenatal and post-natal care, growth monitoring, among others. Improvement in supervision of CHVs has improved their performance in referral and follow up of community members to take up primary health services.
“Before, CHVs only used to refer community members who came to them. Now they are more keen to look out for health services that a household does not have”, added the CHEW in charge of Bangladesh. They also work with households to ensure that the “leaky-tins” are functional for hand washing purposes and community members are using them.
As I travelled back to the city center, a statement made by Fredrick “After the training, now I know how to do my job” kept ringing in my mind. This effect in Bangladesh slum is a contribution to the bigger universal health coverage picture. I started this series of informal conversations a skeptic. I’m now convinced and proud to say that REACHOUT will be long remembered for starting off places like Bangladesh slum on an exciting journey in improving the quality of community health services. Improvements in referral and reporting in Bangladesh are quick wins to celebrate and share widely.
At the beginning of our conversations, Judy mentioned, “I recommended Bangladesh because it was a low performing unit. Looking back, I think it was a good idea”. I agree with her! REACHOUT’s work in Bangladesh slum was a great place to demonstrate the effect of supportive supervision in improving the quality of community health services.
Robinson Karuga is a Research Fellow at LVCT Health and is part of the REACHOUT team in Kenya. Judy Warioko is now the Community Health Services Coordinators in charge Nairobi County. Special thanks to Neville and Fredrick who work tirelessly to improve the quality of community health services in Bangladesh.The photo is of the Link Facility Nurse (middle) and Peer CHV supervisor (Fredrick in blue shirt) conducting one-on-one supervision on a CHV (in yellow shirt) in Bangladesh slum.
This project is funded by the European Union.