by James Dowling, Programme Director
MCHAs provide the backbone of local health serves in Sierra Leone. Their role was created in the 1970s as a stop-gap solution to the chronic lack of qualified midwives and nurses to provide basic health care to pregnant women and children in remote rural areas. Since then, Sierra Leone still lacks adequate numbers of qualified health staff and has continued to develop a staff of now over 3,300 MCHAs working at community-level health facilities. Between 2012-2018, MCHAs managed a total of 850,378 deliveries, which represents 68% of all deliveries across the whole country. MCHA is the lowest level in the health system workforce.
MCHA training is a two-year programme comprising 18 months of theory-based teaching and assessment followed by six months of practical teaching at dedicated MCHA training schools in each of the country’s 14 districts. Following the training, there is a six-month internship at local health centres. The Kambia District training school produces around 58 newly qualified MCHAs every two years. With the new intake at the beginning of 2018, Kambia now has about 233 qualified MCHAs working across the 69 community health facilities, managing over 15,000 deliveries a year.
Once qualified, new MCHAs are absorbed into the health system and are managed by their District Health Management Team – the local devolved department of the Ministry of Health and Sanitation. MCHAs by definition work in remote and inaccessible locations making regular monitoring visits by the district co-ordinators expensive, challenging and infrequent. In a recent review of MCHAs conducted by UNICEF in Sierra Leone, 48% of the MCHAs surveyed in a national sample reported that they had not received any supervision in the last 6 months or longer and 17% reported that they had never received supervision from their DHMT.
The majority of MCHAs work at the lowest level health facilities where there are no other senior staff, such as midwives or nurses or community health officers, and these are the facilities that provide most of the health services to the Sierra Leone population. Without regular assessment, DHMTs cannot know or respond to the level of skill and competency of its MCHAs or the quality of care they provide.
Our MCHA Mentoring Project
This was the set of circumstances that we wanted to address by setting up the first supportive supervision programme for MCHAs in Kambia. We were aware that if we could develop and establish a workable model that delivered cost-effective, one-to-one supervision, assessment and refresher training in Kambia we would be able to demonstrate the benefit of adopting such a model nationally to all MCHAs to improve the quality of maternal and child health services across Sierra Leone. This was the task we set ourselves.
Previously, between 2011 and the Ebola Virus Disease outbreak in 2014, with grants from the UK’s Department for International Development, we had been working with David Holmes and Rebecca Swingler and their teams at Gloucestershire NHS Hospitals Foundation Trust (GHNHSFT) to provide centralised training workshops for up to 60 MCHAs in Kambia via week-long visits by volunteers from Gloucestershire. We knew from our programme of monitoring and evaluation activities that these trainings were improving MCHA knowledge and skills, but we did not have the resources to provide practical assessment ‘on-the-job’ to know if the training was improving MCHA practice back at their health facilities.
In May 2016, we secured a grant of £48,000 from the African Grant Programme to develop the supervision model. We worked with the Kambia DHMT, Gloucestershire Hospitals NHS Foundation Trust and three of our long-term volunteers in Kambia, Alice Fulton, Rob Green and Ridwana Pandor, to create an assessment tool that could be used by local health staff to assess the knowledge and practice of MCHAs across a number of core scenarios, such as the different types of labour, post-partum haemorrhage, eclampsia, care of the sick child and antenatal care. Alice and Ridwana spent a number of months in Kambia testing and refining the tool with MCHAs and midwives at a number of health centres and with input from Rebecca back in the UK. The tool was then validated by the District Medical Officer and the MoH and ready to be rolled out.
The DHMT identified a group of 27 midwives and state enrolled community nurses to be trained as MCHA mentors, and the training, led by Alice, took place over 5 days.
During the training, the mentors were taught how to use the tool and to record scores, as well as how to be effective at providing dynamic, supportive teaching in response to the scores attained. Each mentoring session using the tool would include assessment and training on two scenarios and would last about an hour. The AGP grant enabled us to deliver 2 rounds of mentoring over six months to 104 MCHAs across 29 health facilities, with Alice, Ridwana and Rob observing and supporting the mentoring sessions over that time to monitor the accuracy of score-keeping and to ensure standardisation across the 27 mentors.
The analysis of the results of the assessments showed that 75% of the MCHAs achieved a pass mark of 65% on completion of two scenarios, with the average score obtained being 72%. Analysis also showed a clear correlation between the scenarios for which MCHAs were gaining the lowest scores (and had the weakest knowledge and practice) and the main causes of maternal death in Sierra Leone, namely sepsis, eclampsia and postpartum haemorrhage. These are the scenarios that MCHAs see less frequently at the health centres and so lack the experience to deal with them effectively. While this identifies clearly the topics on which future MCHA training needs to be focused, lack of MCHA knowledge and skills in these areas cannot be seen as the only contributing factor for the high numbers of women dying from sepsis, eclampsia and postpartum haemorrhage in Sierra Leone.
Having completed the development of the mentoring model in phase one, we gained our second grant of £48,000 from the African Grant Programme to roll it out across the district in February 2018. Again with Alice Fulton as lead, we were able to update the MCHA assessment tool to incorporate recent changes made by the Ministry of Health to the MCHA handbook and re-run the mentor training, increasing the number of mentors to 40 and adding 12 Community Health Officers as project monitors responsible for project data collection. Over a period of 16 months, 168 MCHAs received regular supportive supervision from the Kambia Appeal mentors.
Detailed Project Findings
In January 2019, Alice Fulton and Rob Green conducted a monitoring and learning exercise to gain feedback on the project via focus group discussions with MCHAs and Mentors. Overall, participants reported finding the programme overwhelmingly positive, with real enthusiasm voiced in a way that felt encouraging and rewarding. The MCHAs were universally enthusiastic about the mentoring programme and felt it had improved their knowledge. They felt that the mentors were supportive and engaging, facilitating learning in a constructive fashion, not in a critical, intimidating manner that some had experienced in other learning settings.
The MCHA Mentors were also universally positive about the programme. They felt that preparing them for the mentoring sessions made them revise topics and increase their knowledge on the areas they were teaching as they did not want holes in their knowledge exposed when the MCHAs were asking questions. Mentors said the teaching was more enjoyable as it enabled them to form better relationships with the MCHAs.
The MCHA Mentoring project highlighted the need to provide MCHAs with basic medical equipment to enable them to put the knowledge and skills they have learned during the mentoring sessions into practice. To address this directly, and with the agreement of the Tropical Health and Education Trust, we were able to use some of the grant to purchase 200 basic delivery kits and 103 blood pressure units. These will be delivered to Kambia in the coming months, and the DHMT will use the mentoring model to provide additional training to MCHAs on how to use and maintain the equipment. A sample kit and BP machine were taken to Kambia in April (see below) to check they were suitable.
This project was enabled by two consecutive grants from the African Grant Programme managed by the Tropical Health and Education Trust (THET) and funded by Johnson & Johnson.
Where do we go from here?
In October 2018, the MCHA Mentoring project came to the attention of UNICEF, the primary funder for the national MCHA training programme in Sierra Leone. Our project featured as a case study in UNICEF’s national review of the impact and effectiveness of MCHAs in Sierra Leone in March 2019 and was used to illustrate the primary finding of that review – that MCHAs require regular supportive supervision from local mentors managed by their DHMTs. The inclusion of the initial findings from the Kambia Appeal project in UNICEF’s report has increased awareness of our project at national government level, and the UNICEF review is currently being used to assess the feasibility of setting up a national MCHA Mentoring programme across Sierra Leone following the Kambia Appeal model.
While we hope that our model will be picked up by the Ministry of Health to roll out nationally, and that the Kambia Appeal will have some role in helping to achieve that, funding for a nationwide mentoring programme still needs to be found from international donors. So in the meantime, we continue to seek our own funding from trusts and foundations in the UK and from other fundraising activity to ensure that we continue providing mentoring to MCHAs in Kambia in the immediate future. It costs approximately £3,500 for us to provide one monthly cycle of mentoring to all 168 MCHAs via 40 Mentors across Kambia (that’s £26 per MCHA or £87.5 per Mentor each month).