Forming teams at the community level – what I have learned
When the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) began in 2009, URC was beginning to look at how to adapt successful facility-level improvement approaches to the community. Some work had been done on improving social services for orphans and vulnerable children, but generally we were entering uncharted territory. I was a complete novice at community-level work and new to Ethiopia, so I knew I needed to rely heavily on the Ethiopian staff to figure out how to adapt improvement for MaNHEP.
Our initial tasks included orienting community members and leaders and forming quality improvement teams. We provided guidance that team members should include “every person or representative of each group that has a role in each step of the process of care”. We suggested that teams have 12 – 15 members and should consider representatives from women’s groups, families, health committees of the kebele (community) council, community health workers, traditional birth attendants, health extension workers, and religious and influential leaders and elders.
At the facility level, a leader would not necessarily be a member of the improvement team or be a team leader. When my colleagues insisted that the formal kebele leaders and elders not only needed to be on the team, but could also serve as team leaders, I was skeptical. I was concerned that others team members would not be able to speak freely or would agree with the leader. This probably did happen in some places but the benefits of their presence hopefully outweighed the negatives. Against my instincts, I trusted the staff’s knowledge of the local culture. They were right.
I came to understand that the dynamic at a community level is different than at a facility. At a facility, an improvement team could not be formed without the approval and support of the facility or department head. The leader does not need to be part of the team to get the work done. At the community level, the leaders need to be part of the team to give it credibility throughout the community. The facility-level improvement team either consists of all staff in a small facility or represents all key functions and team members can easily reach the rest of the staff to inform them of changes. Community-level improvement requires leaders and team members who can reach hundreds or thousands of people, inform them of the new process and convince them this is a worthwhile effort.
MaNHEP-supported teams consisted of 15-20 people. This is larger than our initial recommendation, but was necessary in order to include all voices and necessary influential leaders. While it is more difficult to conduct team meetings with this number of people, such broad participation allowed the team to reach the entire community using their respective channels.
One correction we needed to make in team composition was that the pregnant women, mothers-in-law and husbands of pregnant women were often drawn from one family. This brought the dynamic of the family into the team, which meant that young first-time pregnant women sat silent, eyes downward. This same dynamic created some of the barriers to seeking care that teams were trying to address. Coaches advised teams to modify composition and use representatives from different families and women with multiple children. This change took the family dynamic out of the team, and they were able to openly discuss how to address family dynamic barriers to care.
Although the same principle underlies forming an improvement team at a facility or community level, some adaptation need to be made such as team size and composition. Ram Shrestha provides a great description of the approach to forming community teams in the short report, Strengthening Community Health Systems to Improve Health Care at the Community Level. Once teams are set up, the next step is training and, of course, improving.
To learn more about the MaNHEP project, see this special issue of the Journal of Midwifery and Women’s Health.