Role of the community in quality improvement in Ghana: Increasing maternal and child health service coverage

Background: Project Fives Alive! (PFA) utilizes quality improvement (QI) methods to assist Ghana's faith-based and public health services to achieve Millennium Development Goal 4, a 66% reduction in under-5 mortality, by improving the continuum of care from pregnancy through age five. The purpose of this study is to understand factors associated with QI team effectiveness and the role of community relationships in QI team performance. Methods: A qualitative case-study approach (n=12 cases) was taken across 6 regions of Ghana including in-depth interviews with health staff (n=66) and field observations. Analysis entailed developing narrative summaries for each case and systematic topical coding around emergent themes. Results: The achievement of program targets of increased maternal and child health (MCH) service coverage is affected by how QI teams engage with their communities. High achieving QI teams engage communities in relationship building and adapt their work to sociocultural beliefs. Low achieving teams often attribute low achievement to sociocultural norms. The way in which QI teams orient themselves positively or negatively toward community beliefs and how they engage communities in health education, outreach, and promotion of facility health services affects achievement of program goals. Conclusions: Findings indicate that capacity-building of healthcare staff through QI initiatives should include strengthening community engagement skills and address the perceived barrier of sociocultural norms. Working with communities to promote the use of existing MCH services and to address resource constraints contribute to the success of the QI team approach.