Similar, but different: Peer learning exchange improves quality of healthcare in Togo and Rwanda

This blog was authored by Pernille Hoej, Maternal and Child Health Program Coordinator at Hope Through Health.

Hope Through Health (HTH) uses an integrated care delivery model to provide high quality care to thousands of individuals living with HIV/AIDS in northern Togo. In January 2017, HTH partnered with Health Builders to participate in the 2017 CHMI Learning Exchange program. You can read more about Hope Through Health on their CHMI profile or website

During our short trip to Rwanda, a phrase we often heard was, “You cannot do that here – that’s illegal.” My colleague from Hope Through Health (HTH), Emile Bobozi, and I were puzzled by this, just as we were puzzled by the cleanliness of the streets and the quiet politeness of the people we met. In Togo, people are loud and agitated and trash finds its way everywhere. Togo and Rwanda are seemingly very similar countries; both with a francophone colonial history, both with poor health outcomes, and both with people primarily living off subsistence farming. However, while we were in Rwanda, it became clear that we had left familiar ground far behind. Luckily, we had our guides – Bertin Gakombe and Tyler Nelson from Health Builders – who enlightened us not only in Rwanda’s complicated history, its recent transition and newer policies, but also in its health system that has many similarities to that of Togo and significant differences at the same time. I won’t go into details about the differences between the health systems of Togo and Rwanda, the point being that having someone else to learn from gives valuable insights that you can’t get from merely studying the situation yourself. In Rwanda, we learned about the work of Health Builders, which has inspired our own work. When they visited us in Togo, their fresh set of eyes gave us a new perspective and helped us see new opportunities in our own context. The learning exchange became a way of disrupting the “business as usual” routines that many organizations suffer from, and engage in new areas of work and new ways of doing things.

At Hope Through Health we value learning – a lot!  In our HIV-clinic and office in Togo, we regularly run trainings and professional development workshops for our close to 100 nurses, physician’s assistants, administrators, community health workers and M&E specialists. These activities ensure ongoing capacity building so employees continue to contribute their best to our patients and beneficiaries. One of HTH’s core models for improving the quality of healthcare in Togo is mentorship. It’s a coaching-like model using peer-to-peer learning, where a nurse employed by HTH mentors nurses and midwives working in rural government clinics. The model facilitates supportive supervision and inclusive, real-time feedback to the clinical staff to improve quality of care of patients in consultations and services, –ultimately improving health outcomes. Using mentorship instead of regular supervision means that one person works continuously and regularly with clinical staff to ensure improvements made are measured and maintained over a long period of time and that quality of care is a constant focus.

In terms of organizational learning, we believe we gain a lot from the outsider peer’s perspective: "HTH has benefited greatly from the learning shared by other implementing organizations, key advisors and funders. HTH aims to contribute to building the collective knowledge base in order to improve effective delivery of community-based healthcare services,” says HTH’s co-founder and chief strategy officer Kevin Fiori. This is why HTH joined Health Builders to participate in CHMI’s collaborative learning exchange. Although Health Builders works in the management of health centers, and at HTH we work more directly with patient-centered care, we  were able to learn from both approaches and how they can improve quality of care. On our site visits with Health Builders in Rwanda and Togo, we learned about how Health Builders is mentoring health center staff on daily management and administration. With this model, health centers are able to improve their economy and hire more staff, and patients are more satisfied causing utilization rates to go up – just to name a few of the benefits. We watched how Health Builders uses their Management Performance Survey to evaluate and track progression in terms of management of health centers. This tool includes critical aspects of management and administration, such as HR, finances, planning and infrastructure.

During this learning exchange, HTH has come to look at strengthening management of health centers in a whole new light. From something that takes too much time and effort – because the local health centers in Togo suffer from a lack of managerial and leadership skills – to something that is attainable, especially if you look at it in smaller sections, like book-keeping or time-schedules.

While the learning exchange has given us the inspiration and tools to engage in quality improvement of care in a new way, it takes time and effort, and you never see the results right away. At HTH, we expect the outcomes of the learning exchange to have long-term benefits that will enhance the quality of care for patients. Concretely, we want to expand our mentoring activities to key areas of management and administration of clinics. For example, mentoring the head nurse in doing book-keeping and in improving the work schedule of employees to reduce waiting time for patients. We will build these new strategies and activities into our existing quality improvement framework. This way we won’t have to reinvent the wheel, but can implement new learnings into existing structures and adapt the learning exchange outcomes to our own indicators to provide quality healthcare.