Building Trust in Public Health Clinics in Togo

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Building Trust in Public Health Clinics in Togo

Kara Region, TogoKara Region, Togo
Year Founded:
Organization type: 
nonprofit/ngo/citizen sector
Project Stage:
$250,000 - $500,000
Project Summary
Elevator Pitch

Concise Summary: Help us pitch this solution! Provide an explanation within 3-4 short sentences.

In Togo, West Africa, public health clinics go unused in part because patients do not believe they will receive quality care. By using Community Health Workers (CHWs) recruited from the local community, we can build community trust in public clinics and ensure access to quality health care.

WHAT IF - Inspiration: Write one sentence that describes a way that your project dares to ask, "WHAT IF?"

What if health clinics in Togo were so welcoming and patient-centered, they made people WANT to visit them as often as necessary?
About Project

Problem: What problem is this project trying to address?

While 62% of Togo’s population has geographic access (<5km) to public health facilities, only 30% of the population uses these facilities according to the Togolese Ministry of Health. Perceived poor quality of care and mistrust of public clinics contribute to low utilization rates in Togo. Patients lack confidence in the ability of the public clinics to provide quality treatment and therefore do not seek care at the clinics.

Solution: What is the proposed solution? Please be specific!

Hope Through Health’s Community Health Workers (CHWs) are trained members of the community that provide home-based support to patients living with HIV/AIDS. CHWs link clinics and the community. Their role is to establish and maintain strong relationships with patients, including confidentiality, guide them through a continuum of care and reinforce clinic messages in the home. As community members themselves, CHWs are able to build the trust of the community in public health clinics and providers, leading to elimination of perception of poor quality and increased clinic utilization rates. As staff members of public clinics, CHWs have the trust of public clinic staff and providers to extend their impact into the home and community.
Impact: How does it Work

Example: Walk us through a specific example(s) of how this solution makes a difference; include its primary activities.

Consider a patient who stops taking her ARVs when she suffers from negative side effects. If she misses an appointment to refill her prescription, a CHW is immediately notified and sent to the patient's home. The CHW will explain the importance of taking ARVs and how to alleviate negative side effects to the patient. Furthermore, a CHW will communicate to the clinic when structural barriers impede access to care. For example, if a patient can only visit the clinic on market day and ARV refills are not available that day, she cannot receive her life-changing medicine. Program and clinic staff work together to eliminate such barriers, and follow up with patients. CHWs provide an invaluable link between patients and the health system.

Impact: What is the impact of the work to date? Also describe the projected future impact for the coming years.

Thus far, Hope Through Health has relied on the use of Community Health Workers, recruited from the community and trained, to build strong relationships between patients and public health clinics. CHWs also voice the concerns of the patient population they support. While HTH has consistently received positive feedback from our patients, HTH hopes to continue building trust in the public clinics, using patient feedback to further improve clinics and continuing to increase utilization rates. Over 1,666 patients currently receive care through HTH and HTH has plans to scale up over the next few years. Furthermore, less than 1% of our over 800 patients on ART were lost to follow up in 2013, demonstrating the current effectiveness of our CHW program.

Spread Strategies: Moving forward, what are the main strategies for scaling impact?

Moving forward, Hope Through Health wishes to expand from HIV/AIDS to the broader space of maternal and child health. By expanding our patient population, Hope Through Health can use CHWs to provide care to more people in need, thereby reducing poor health outcomes in Togo. Through the use of CHWs, Hope Through Health will maintain its efficiency and effectiveness as we scale up. Ultimately, Hope Through Health aims to collaborate with the Ministry of Health to implement the use of CHWs nationally and improve public clinic utilization rates and quality of care.

Financial Sustainability Plan: What is this solution’s plan to ensure financial sustainability?

The main resources necessary for this project are the people who will be involved, including the CHWs, community leaders, and HTH staff. HTH works with the public sector in Togo to advocate for integration of CHWs into the public health system. This scale up will be completed in conjunction with the One Million Community Health Worker campaign. Ultimately, HTH hopes to work with the Ministry of Health to implement a national CHW program.

Marketplace: Who else is addressing the problem outlined here? How does the proposed project differ from these approaches?

HTH is the only international organization providing health care services in the northern Kara region of Togo. Although other groups use CHWs, our CHWs are specifically recruited from the community that they will serve, trained initially and provided ongoing training sessions, and linked with public health clinics. Because HTH believes that communities can transform the dynamics of health care delivery, we train and support patients and community members to fill key service delivery roles. Their involvement ensures that our programs respond directly to patient priorities.

Founding Story

In 2006, Sadate was 10 years old. Despite being an extremely sick child, he had never received modern medical treatment. Then we helped train a Community Health Worker in Sadate's village. She accompanied Sadate to take a free HIV test. He tested positive and was admitted to the hospital weighing only 20 pounds. Sadate began free antiretroviral therapy and in one month was discharged from the hospital. His Community Health Worker followed Sadate at home. In one year his weight doubled. He started school and ran for the first time in his life. Today he is a successful student and a young community leader. His Community Health Worker is considered a hero by her community.


Hope Through Health currently has 54 staff and a small team of highly qualified volunteers. The Executive Director in the United States supports the team in Togo. Togo Program Director works with the AED-Lidaw executive team, including an Executive Director, Medical Director, Finance Director, and Monitoring, Evaluation and Quality Director. In regards to this specific program, there is a Community Health Worker Supervisor in charge of CHWs.
About You
Hope Through Health
About You
First Name


Last Name


LinkedIn URL
About Your Organization
Organization Name

Hope Through Health

Organization Country

, Kara Region

Country where this project is creating social impact

, Kara Region

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Full Impact Potential: What are the main spread strategies moving forward? (Please consider geographic spread, policy reform, and independent replication/adoption of the idea or other mechanisms.)

Moving forward, Hope Through Health hopes to expand its services from HIV/AIDs to maternal and child health. By offering maternal and child health services, Hope Through Health and its CHWs will be able to provide care for a larger population in the northern Kara region of Togo. We also maintain a close relationship with the Ministry of Health, which is beneficial as we advocate for a national scale up of a CHW program in Togo.

Barriers: What barriers might hinder the success of your project and how do you plan to overcome them?

One of the main barriers is that people may be hesitant to welcome CHWs into their homes for a number of reasons, one being that they are not comfortable disclosing their HIV status to their community. HTH has other programs in place to combat the social stigma of HIV, including educational and support groups. Furthermore, CHWs are specifically trained to deal with difficult situations.

Partnerships: Tell us about your partnerships.

In the US, HTH has established strong partnerships with like-minded NGOs, including Partners In Health and its leadership, individuals including Drs. Paul Farmer, Joia Mukherjee and Lisa Hirschhorn. HTH is a member of Aid for Africa, a unique partnership of 85 charities In Togo, we work very closely with United States Peace Corps, USAID, Population Services International (PSI), UNICEF, UNAIDS and the Ministry of Health.

Closing the Loop
How does your project primarily ensure that feedback delivers results?

Demonstrate how closed feedback loops can make a difference in people’s lives.

Please elaborate on your answer to the above question.

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.

Languages: In what languages are you able to read and write fluently?

English, French.

2nd Round Questions
Thinking about your feedback loop; what information are you trying to get from whom, to whom, and to bring about what change?

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.

What is the purpose of your feedback loop?

Improve quality of programs

If other, please specify
What mediums or mechanisms do you use to collect feedback? (check all that apply)

Paper, Phone or voice.

If other, please specify
Could you briefly describe the way you collect the feedback?

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.

What mechanisms are in place to protect people from retribution?

Option to provide feedback anonymously

If other, please specify
What are the immediate benefits or incentives for people to provide feedback?


If other, please specify

Improved quality of services

How do you ensure new and marginalized voices are heard?

Specific targeted outreach efforts

If other, please specify
What are the incentives for the intended recipient to act on the feedback?

They understand that feedback is necessary

If other, please specify
How does the feedback mechanism close the loop with those who provided feedback in the first place?


If other, please specify

One on one follow up by CHWs and monthly all-patient meetings

How is feedback published/transparent?

Written report

If other, please specify
Give two concrete examples of how feedback loops have brought a program or policy more in line with citizens’ desires.

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.

If there was one thing you could change to increase the impact of your feedback loop, what would it be?

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.

What are your biggest challenges or barriers in “closing the feedback loop”?


If other, please specify

Lack of funding to act on feedback

Are you aware of The Feedback Store?

No, but I would like to be on it

What are the main uses you can envision for the Feedback Store?
What is the one thing you would most like to see changed to improve the competition process?
What are you doing to make sure that feedback providers know that they are empowered by the information they can give and that they know exactly what the information they are providing?