The Better Health Outcome through Mentoring and Assessment (BHOMA) Project: A model for monitoring and strengthening

health systems in Zambia Sarah McGough Introduction Our client is a team of representatives from Catholic Relief Services, the University of Notre Dame Eck Institute for Global Health, and the Churches Health Association of Zambia (CHAZ). Working towards the ultimate goal of improving quality of healthcare delivery amongst the faithbased hospitals in the CHAZ network, Catholic Relief Services has developed a Health Systems Strengthening Initiative (HSSI) based on the World Health Organizations six fundamental building blocks of strong health systems.1 CHAZ has identified improved leadership and governance competencies one of the six WHO building blocks as critical predecessors to good community health. Thus the initial target of the HSSI is to initiate a gap analysis and needs assessment to measure the status of four hospitals in Zambia, the pilot project of the CRS intervention.1,2 In meeting with our client to clarify objectives of the project, we as the Development Advisory Team were instructed to focus on the first link in the chain: analysis of systematic shortcomings in the faith-based hospitals, in particular with regards to 1) weak governance of health facilities and 2) inadequacy of medical supplies and service delivery. The Better Health Outcome through Mentoring and Assessment (BHOMA) in Zambia is a promising model for the CHAZ initiative because, with the goal of strengthening health systems and improving leadership in healthcare, it targets hospital and primary care networks using Zambiaspecific evaluation criteria and metrics. It will be helpful to our client as a model for setting up initial needs assessments of the CHAZ hospitals so that intervention is effective. It also utilizes two features that our client has specifically expressed interest in exploring: the first, mobile technology and electronic records to keep health records efficient and thorough; the second, a balanced scorecard (BSC) system of monitoring and evaluating hospital governance, health workers, and patients. Moreover, the initial results of the BHOMA trials produced helpful baseline knowledge on specific health trends and districts under study, which CHAZ and CRS can replicate and use to inform the first stages of its own monitoring and evaluation.

BHOMA Three-Tiered Strategy The BHOMA project targets health implementation in three Zambian districts: Chongwe, Kafue, and Luangwa. These districts comprise 48 health facilities, of which six are pilot sites for the project. BHOMA operates as a three-tiered model, having developed a unique intervention strategy for each of the three designated levels at which health services function: district, health facility, and community. At the district level, each district is equipped with one Quality Improvement (QI) team that implements intervention in health facilities. The QI team, composed of nurses and a clinical officer, works with local clinic staff to build training capacity and to develop technical and administrative skills. The team members also serve as mentors and consultants for the clinic staff in day-to-day patient consultation. Each QI team is supported by 1) a district-specific clinical care specialist, who represents the Zambian Ministry of Health, and 2) a central Quality Improvement team that offers logistical support to the districts.3 This support system trickles down to the health facility level, at which the BHOMA strategy specifically aims to bolster the capabilities of health clinics. The QI team forms the support structure for clinic staff, administering self-assessment reports and leadership training to improve governance skills. The clinic staff is also helped by community workers designated as Clinic Supporters. The third and final tier is the community health level. This is the level at which the community workers operate and provide clinic support (as Clinic Supporters) as well as serve the wider community outside of the clinic. In this role, all of the community health workers are trained to follow up with patients after appointments as well as record local health data through mobile technology and in-person consultations picking up where the clinics leave off.4 Every level is monitored separately by a BHOMA evaluation team, which is composed of health systems experts, epidemiologists, and anthropologists. Hence the project not only targets each level of health service delivery, but also provides various interlocking support systems to reinforce internal efforts.

BHOMA Monitoring and Evaluation The basic operational strategy is outlined above, but the unique features of healthcare monitoring and evaluation operate within the tiered levels and are also models for CRS replication. The first feature is that of the Balanced Scorecard (BSC), a comprehensive and participatory monitoring device in which health systems are evaluated based on particular indicators that track quality and availability of services. In the BSC used by the BHOMA project, these indicators are differentiated by 6 categorical domains: patients and community, service capacity, service provision, human resources, finance, and governance/overall vision. The balanced scorecard is, in effect, a summary of these diverse domains. To quantify service capacity, health facilities were monitored for 11 service indicators that included bed capacity (no overnight bed/1-3 beds/4-5 beds/etc), phone availability (yes/no/mobile), access to ambulance (no / yes, functional with fuel / yes, not functional), and power working today (yes/not functional) (Table 1, attached).3 Facilities were also evaluated for laboratory capacity, drug availability, and basic equipment. Patients were surveyed to determine service coverage (seeking treatment, treated, and so forth), and patient and staff perspectives were solicited and inputted into the scorecard as criteria for patient satisfaction, service readiness, and service satisfaction. After evaluating each facet of healthcare service provision, performance indices were assigned on a scale of 1-100, and the baseline status of healthcare in each district could be quantified (Table 2, attached).3 The initial results of BHOMA reveal preliminary trends in Zambian healthcare system; rural health workers, for instance, received higher scores with higher patient satisfaction than did health workers in the urban district. This was correlated with higher patient load in urban areas, but all districts exhibited overall low service capacities (i.e. inadequacy of equipment, medicines, and services offered to patients).3 Thus the baseline scorecard results illuminate gaps in the Zambian healthcare services, and direct specific interventions at those gaps towards bolstering service capacity and targeting urban health clinics.3 The second key feature of BHOMA is its use of technology. The project implemented onsite electronic records at all participating clinics and hospitals to measure both clinical care quality and patient outcomes: every patient is assigned a unique ID number, which is synced to a comprehensive database of his or her medical records on a touch screen computer.4 Mobile technology is harnessed

to link all community health worker phones to the electronic facility record system, using a mobile phone software known as CommCare.5 Patients are assigned to CHWs based on geographic location, and CHWs part of the 3-tier strategy conduct patient follow-ups and record health outcomes via mobile phone. All data is organized centrally in the electronic record system, both holding CHWs accountable for completing scheduled house visits and informing health facilities of the outcome of a consultation and/or health service.4

Recommendations to Catholic Relief Services and CHAZ Our client expressed interest in integrating and improving relationships between hospitals, clinics, and health workers, as the latter two are important satellite instruments of healthcare delivery in rural Zambia. The three-tiered strategy designed by BHOMA is one way to facilitate communication between all levels of healthcare providers, as well as implement a support network across the levels such that personnel in one tier provide support in another tier (QI teams, Clinic Supporters, evaluation team). CRS and CHAZ should look to replicate this tiered model to streamline and organize operations in CHAZs hospital network. Our client is primarily concerned with weak leadership within Zambias health system, but has stressed the need to conduct preliminary evaluations of health governance in order to more carefully target an intervention. The Balanced scorecard serves as not only an effective baseline report of the situation prior to intervention, but also as an effective monitoring device to evaluate improvements after interventions have begun. The indicators measure patient and service performance alongside service capacity, making the report truly comprehensive. CRS should borrow criteria and indicators from BHOMAs scorecard, and monitor score reports throughout the duration of the project. Lastly, CRS should consider investing in mobile technology and electronic records systems to centralize health data in the CHAZ pilot hospitals. This would produce a twofold effect: firstly, CRS would be able to monitor the success of its intervention efforts by collecting patient and clinic metrics continuously; secondly, data stored on a central system would keep hospitals and clinics accountable for recorded patient health.

Table 1. Baseline demographic characteristics of the health facilities in the BHOMA study.3

Table 2. Baseline District Performance in Six Health Domains.3

Works Cited 1. The Global Health Systems Strengthening Initiative (HSSI). Catholic Relief Services. 2013. 2. The Zambia Faith-Based Health Systems Strengthening Initiative in Zambia: Implementing Health System Strengthening intervention in Faith Based Institutions in Zambia for better health outcomes. Catholic Relief Services. 11 July 2013. 3. Mutale W, Bond V, Mwanamwenge M, Mlewa S, Balabanova D, Spicer N, Ayles H: Systems thinking in practice: the current status of the six WHO building blocks for health system strengthening in three BHOMA intervention districts of Zambia: a baseline qualitative study. BMC Health Services Research 2013 13(1): 291. 4. Stringer JSA, Chisembele-Taylor A, Chibwesha CJ, Chi HF, Ayles H, Manda H, Mazimba W, Schuttner L, Sindano N, Williams FB, Chintu N, Chilengi R: Protocol-driven primary care and community linkages to improve population health in rural Zambia: the Better Health Outcomes through Mentoring and Assessment (BHOMA) project. BMC Health Services Research 2013, 13(Suppl 2):S7. 5. CommCare Zambia Case Study. CommCare. 2013. http://www.commcarehq.org/users/commcare_zambia/