1. 1 The Strength of the Community: A Foundation for Healthcare Delivery Ram Shrestha, D.Sc.(hon) and Rhea Bright, MPH University Research Co., LLC

2. CHW Health Service Structure Health Post CHW Ram Shrestha

3. CHW Approach – Community Health Worker Ram Shrestha

4. Current Situation of Community Health Workers Ram Shrestha

5. S UPPORT TO C OMMUNITY H EALTH W ORKERS Ram Shrestha

6. What is a Community System?

7. Schools Religious Community Women’s Group Local Health Clinic $ Credit & Savings Group Local Government Community Health System Community Committee Ram Shrestha

8. How does a Community System Function?

9. Schools Religious Community Women’ s Group Local Health Clinic $ Savings & Credit Group Local Government Ram Shrestha

10. Schools Religious Community Women’ s Group Local Health Clinic $ Savings & Credit Group Local Government Ram Shrestha

11. Schools Religious Community Women’ s Group Local Health Clinic $ Savings & Credit Group Local Government Ram Shrestha

12. Schools Religious Community Women’ s Group Local Health Clinic $ Savings & Credit Group Local Government Ram Shrestha

13. Schools Religious Community Women’ s Group Local Health Clinic $ Savings & Credit Group Local Government Ram Shrestha

14. Schools Religious Community Women’ s Group Local Health Clinic $ Savings & Credit Group Local Government Ram Shrestha

15. Schools Religious Community Women’ s Group Local Health Clinic $ Savings & Credit Group Local Government Community Health System Community QI Ram Shrestha

16. Name of Group Member # and names of pregnant women identified # and names of postpartum women identified # and names of < 5 children # and names FP user 1. Example Name 1: _____ Name 2: _____ 2. 3. 4. Total Community Group Monthly Health Data Record 2014 Name of Community Group: Women’s Group Village: Luboga Month & Year: February 2014 District: Kishapu

17. Schools Religious Community Women’ s Group Local Health Clinic $ Savings & Credit Group Local Government CHW Community Health System Ram Shrestha

18. What is an Improvement?

19. What is an improvement? Where You are? Where do you want to be in one year? This is a gap 20 pregnant women 200 pregnant women 2% exposed infants receiving HIV test 90% exposed infants tested for HIV

20. Change Ideas for Improvement

21. 10 % of pregnant women participate in ANC services 100% of pregnant women should participate in ANC services QI Team met and discussed Change Idea Proposed- Awareness- TV spots Two weeks later: Measured – 20% women received ANC services Improvement but not 100% QI Team met and discussed Change Idea Proposed- Awareness- TV Spots and individual counseling Two weeks later: Measured – 50% women received ANC services Improvement but not 100% QI Team met and discussed Change Idea Proposed- Awareness- TV Spots, individual counseling and family counseling Two weeks later: Measured – 80% women received ANC services Improvement but not 100% QI Team met and discussed Change Idea Proposed- Awareness- Radio Spots Two weeks later: Measured – 10% women received ANC services No Improvement

22. LSLearning Session LS QI m Situation Analysis Coaching Harvest Dissemination meeting 3 rd month 6 th month 9 th month 12th month 1st month Community QI Implementation Activities Timeline Ram Shrestha Community Group Orientation Coaches Orientation 2-3 months

23. Coaches Orientation: Training facility nurses to serve as community QI coaches, Iringa, Tanzania

24. LSLearning Session LS QI m Situation Analysis Coaching Harvest Dissemination meeting 3 rd month 6 th month 9 th month 12th month 1st month Community QI Implementation Activities Timeline Ram Shrestha Community Group Orientation Coaches Orientation 2-3 months

26. LSLearning Session LS QI m Situation Analysis Coaching Harvest Dissemination meeting 3 rd month 6 th month 9 th month 12th month 1st month Community QI Implementation Activities Timeline Ram Shrestha Community Group Orientation Coaches Orientation 2-3 months

27. Community QI Team, Buikwe, Uganda

28. Changes Tested to identify patients on ART in the community -Home to Home visits. - PHA group reps reach out to membership - Patient to patient linkages - HWs link patients to VHTs - VHTs participate in HF activities - Local Chiefs mobilize community to identify VHTs - Discuss HIV in women group meetings Above Figure shows that the total number of patients on ART identified in the community increased from 15 to 257 patients in June and September 2012 respectively. The improvement was almost two fold when VHTs worked in a system than when working alone. Identification of patients on ART in the community

29. Improved number of pregnant women receiving ANC 86% % of pregnant women tested for HIV increased from 72% in Oct. 2011 to 86% by June 2012

30. Exercise

32. Use of local materials to present Improvement in quality of services