Building Trust in Public Health Clinics in Togo

The primary goal of the CHW Program is to reduce barriers to and improve the quality of patient care services. In weekly meetings, CHWs have the opportunity to share patient concerns directly with program and clinical staff. Data is compiled monthly and shared with all stakeholders. Together, the CHWs, program, and clinic staff work together to make changes that address patient concerns. Once changes are implemented, CHWs follow up with patients to ensure that the new systems are effective. This feedback is again shared in the weekly team meetings and changes are made as necessary.

CHWs serve as a link between patients and clinical staff. During home visits, CHWs not only collect medical data from patients to inform referrals if necessary, but also listen to any concerns or barriers that patients face in accessing or receiving medical care. In weekly supervisory meetings with the CHW Program Director, program and clinic staff, CHWs are able to share patient concerns. The program and clinic staff work together to find solutions to common problems that patients experience. Once appropriate changes are made, CHWs are able to follow up with patients during home visits to learn how the new systems are working and whether or not more modifications are needed. Thus the feedback loop ensures that patients' concerns reach the health care providers and managers who then design and implement programs to better meet patients' needs.

Feedback is collected through standardized paper forms, designed for different types of patients and through anecdotal evidence as told by patients to CHWs on their home visits. Hope Through Health is also in the process of implementing a mobile health data collection system using CommCare. This new program will facilitate easier collection and management of data. CHW-collected data, whether through paper or mobile forms, is transmitted to the CHW Program Director and monitoring, evaluation and quality improvement (MEQ) Director for analysis. The Directors analyze and present trends to CHWs and other clinic staff monthly to generate discussion and solicit feedback. Through the joint processes of weekly meetings to discuss patient challenges and monthly meetings to analyze data trends, health clinic staff are informed of and held accountable to respond to the expressed needs of their patients.

CHWs have effectively lobbied on behalf of patients numerous times. In Togo, the fee-for-hospitalization system is a major barrier to receiving care. This system requires that a patient pay to enter the hospital, and once hospitalized, a patient must have someone to bring them food, fill their prescriptions at the pharmacy and pay for medications in order to receive treatment. Because of the stigma associated with HIV/AIDS, some patients had not disclosed their status to a family member, and upon hospitalization, had no support system, thereby comprising their care. The CHWs brought this issue to the program and clinic staff. To address this problem, the health system provided additional training to CHWs and clinic-based staff on psychosocial support, specifically emphasizing disclosure strategies. As a result, CHWs began to focus more heavily on providing support to patients on how to cope with stigma and how to disclose their status to a trusted confident. The program set a measurable goal to work toward, of having 85% of patients identify a confident with whom she/he shares her/his HIV status. Therefore, should hospitalization occur, the patient has someone to care for them. In the interim, CHWs provide support for hospitalized patients as necessary. Most importantly the efforts to provide disclosure counseling and support have been widely embraced by patients.

A second example is that of nutrition kits. Many patients expressed difficulty meeting expanded nutrition requirements during the first month of beginning antiretroviral therapy (ART). This medication is required to be taken on a full stomach to decrease the likelihood of side effects. CHWs brought this feedback from their patients to the program and clinic staff, who then made a decision to provide nutrition supplementation kits to patients newly initiating ART. The supplemental kits support good nutrition practices, reduce side effects from ART, improve ART adherence and reduce the risk of loss to follow up. This system-level change resulted directly from patient feedback and was widely appreciated by patients.

As a nonprofit organization, HTH has limited funds to implement new programs when patients express concern over current barriers or systems. These resource constraints are even more severe within the public sector. While patient concerns do not usually necessitate large programmatic overhauls, the small costs involved may still prohibit adoption of best practices by the public sector on a larger scale. To increase the impact of the feedback loop, HTH will continue to advocate for greater public funding for essential programs.