USAID HEALTH CARE IMPROVEMENT PROJECT TASK ORDER 3 · USAID HEALTH CARE IMPROVEMENT PROJECT Task Order 3 FY13 Annual Project Report Contract Number GHN-I-03-07-00003-00 Performance

DECEMBER 2013

This annual project report was prepared by University Research Co., LLC for review by the United States Agency for International Development (USAID). The USAID Health Care Improvement Project is made possible by the American people through USAID’s Bureau for Global Health.

USAID HEALTH CARE IMPROVEMENT PROJECT TASK ORDER 3FY13 ANNUAL PROJECT REPORT

Contract Number GHN-I-03-07-00003-00

Performance Period: October 1, 2012 – September 30, 2013

Front cover (from top):

Regional Child Health Coordinator facilitating a mock Village Health Committee meeting with community groups to prepare them to be able to compare and identify gaps between their community data and facility data. Photo by Rhea Bright, University Research Co., LLC

Using the Framingham Cardiovascular Disease Risk Chart introduced to clinics in Imereti Region by the USAID Health Care Improvement Project, Dr. Berodze and Dr. Liluashvili show Mr. Gabadadze how his risk for a heart attack in the next 10 years has decreased through elimination and control of his risk factors and chronic conditions. Photo by Eka Cherkezishvili, URC.

REPSSI, ANPPCAN and HCI staff planning upcoming activities at a partners meeting in February 2013 in Johannesburg, South Africa. Photo by Charles Kienzle, URC.

An AIMGAPS facility nurse explains the Community Health Systems Strengthening (CHSS) model to her colleagues during a training session in Iringa, Tanzania, where these nurses serve as community QI coaches for their catchment areas. Photo by Rhea Bright, University Research Co., LLC

USAID HEALTH CARE IMPROVEMENT PROJECT

Task Order 3

FY13 Annual Project Report

Contract Number GHN-I-03-07-00003-00

Performance Period: October 1, 2012–September 30, 2013

December 2013

DISCLAIMER

The views expressed in this document do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Acknowledgements: This annual project report was prepared by University Research Co., LLC (URC) for the United States Agency for International Development (USAID) Health Care Improvement Project (HCI) , which is made possible by the generous support of the American people. HCI is managed by URC under the terms of Contract Number GHN-I-03-07-00003-00. URC’s subcontractors for HCI include EnCompass LLC, FHI 360, Health Research, Inc., Initiatives Inc., Institute for Healthcare Improvement, and Johns Hopkins University Center for Communication Programs. For more information on HCI’s work, please visit www.hciproject.org or write [email protected]. Recommended citation: USAID Health Care Improvement Project. 2013. Task Order 3 FY13 Annual Project Report. Bethesda, MD: University Research Co., LLC.

USAID HCI TO3 FY13 Annual Project Report i

Table of Contents List of Tables and Figures ........................................................................................................................................................ ii Abbreviations ............................................................................................................................................................................. iv EXECUTIVE SUMMARY ................................................................................................................................................... VII 1 INTRODUCTION .................................................................................................................................................. 1 2 COUNTRY AND REGIONAL TECHNICAL ASSISTANCE ......................................................................... 3 AFRICA ........................................................................................................................................................................................3 2.1 Botswana ........................................................................................................................................................................3 2.2 Burundi ...........................................................................................................................................................................4 2.3 Cote d’Ivoire .................................................................................................................................................................5 2.4 Kenya ........................................................................................................................................................................... 10 2.5 Madagascar ................................................................................................................................................................. 14 2.6 Malawi .......................................................................................................................................................................... 15 2.7 Mali ............................................................................................................................................................................... 17 2.8 Mozambique ............................................................................................................................................................... 21 2.9 South Africa ................................................................................................................................................................ 23 2.10 Swaziland ..................................................................................................................................................................... 29 ASIA ....................................................................................................................................................................................... 31 2.11 Afghanistan.................................................................................................................................................................. 31 2.12 Indonesia ..................................................................................................................................................................... 37 EUROPE AND EURASIA...................................................................................................................................................... 39 2.13 Georgia ........................................................................................................................................................................ 39 2.14 Ukraine ........................................................................................................................................................................ 44 LATIN AMERICA AND THE CARIBBEAN ..................................................................................................................... 46 2.15 Haiti .............................................................................................................................................................................. 46 2.16 Nicaragua .................................................................................................................................................................... 50 3 USAID GLOBAL HEALTH ELEMENT AND CORE-FUNDED ACTIVITIES ............................................ 52 3.1 Care that Counts Initiative to Improve Quality of Programming for Orphans and Vulnerable

Children ....................................................................................................................................................................... 52 3.2 Community Health ................................................................................................................................................... 55 3.3 Family Planning ........................................................................................................................................................... 57 3.4 Health Workforce Development .......................................................................................................................... 61 3.5 HIV/AIDS .................................................................................................................................................................... 68 3.6 Maternal, Newborn, and Child Health ................................................................................................................. 73 3.7 Nutrition Assessment, Counseling, and Support .............................................................................................. 75 4 COMMON AGENDA ACTIVITIES ................................................................................................................... 79 4.1 Knowledge Management ......................................................................................................................................... 79 4.2 Research and Evaluation .......................................................................................................................................... 81 4.3 Technical Leadership and Communication ......................................................................................................... 95

5 PERFORMANCE TRACKING PLAN ............................................................................................................. 101

ii USAID HCI TO3 FY13 Annual Project Report

List of Tables and Figures

Figure 1. Burundi: Health worker survey on elements of human performance factors, 20 sites, 4 provinces (n=73) (December 2012) .........................................................................................................................................................5 Figure 2. Cote d’Ivoire: Corrective actions implemented to improve CD4 turnaround times (May-December 2012) .............................................................................................................................................................................................8 Figure 3. Cote d’Ivoire: Corrective actions implemented to improve turnaround time for dried blood spots (February-December 2012) ....................................................................................................................................................8 Figure 4. Cote d’Ivoire: Laboratory corrective actions implemented to reduce specimen rejection (April-December 2012) ........................................................................................................................................................................9 Figure 5. Cote d’Ivoire: Increase in laboratory scores, 21 sites (May 2010-August 2013) ......................................9 Figure 6. Mali: AMTSL coverage and postpartum hemorrhage rates, 41 sites (October 2009-March 2013) .. 18 Figure 7. Mali: Kayes and Diema districts, Percent compliance to ENC norms, 41 sites (October 2009-March 2013) .......................................................................................................................................................................................... 18 Figure 8. Mali: Percent compliance to PE/E diagnostic standards, 19 sites, Kayes Region (October 2010-April 2013) .......................................................................................................................................................................................... 19 Figure 9. Mali: Percent compliance to PE/E treatment norms, 19 sites, Kayes Region (October 2011-April 2013) .......................................................................................................................................................................................... 19 Figure 10. Mozambique: Improvement in children’s well-being, moving from “good” to “very good” status in Gaza Province (December 2010-March 2013) ................................................................................................................ 22 Figure 11. South Africa: National PMTCT dashboard (2010-2012) ........................................................................... 26 Figure 12. South Africa: Number of HIV patients on ART, Mpumalanga and Eastern Cape provinces (April 2012-June 2013) ...................................................................................................................................................................... 26 Figure 13. Afghanistan: Percentage of vaginal deliveries for which a partogram was completed (demonstration, Wave 1, and Wave 2 provinces) (June 2009-December 2012) ................................................... 33 Figure 14. Afghanistan: Improvement in compliance with antenatal care counseling standards (demonstration, Wave 1, and Wave 2 provinces) (June 2009-December 2012) ................................................................................... 34 Figure 15. Afghanistan: Improvement in compliance with active management of the third stage of labor (demonstration, Wave 1, and Wave 2 provinces) (June 2009-December 2012) ................................................... 34 Figure 16. Afghanistan: Percentage of births for which 3 AMTSL elements were performed, Maternity hospital collaborative (April 2010-March 2013) .............................................................................................................. 35 Figure 17. Indonesia: Pneumonia medical history recorded in patient’s medical chart ......................................... 38 Figure 18. Indonesia: Proportion of acute myocardial infarction records missing important data in medical history ........................................................................................................................................................................................ 39 Figure 19. Georgia: Calculation of 10-year risk of CVD event, primary and secondary prevention of CVD with high-impact medication bundle, 3 polyclinics and 13 village practices (March 2012 – August 2013) ....... 41 Figure 20: Ethiopia: Percentage of pregnant women who received ANC services at a health post, Illu and Tole districts (July 2011-Feb 2013) .................................................................................................................................... 57 Figure 21: Kabul, Afghanistan: Increase in postpartum counseling and FP (January 2012-May 2013) ................ 58 Figure 22: Kabul, Afghanistan: Postpartum follow-up at 18 months (March 2012-June 2013) ............................ 59 Figure 23. Uganda: Percentage of HIV-positive women receiving family planning counseling at HIV clinics, four sites, Masaka District (November 2011-February 2013) ..................................................................................... 60 Figure 24: Uganda: Percentage of HIV-positive clients counseled for FP at HIV clinics, four sites, Masaka District (November 2011-February 2013) ....................................................................................................................... 61 Figure 25: Decision-Making Tool for CHW Programs .................................................................................................. 65

USAID HCI TO3 FY13 Annual Project Report iii

Figure 26. Tanzania AIMGAPS: Percentage of HIV-exposed infants who received a confirmatory HIV test, Iringa Region (January 2011-February 2013) .................................................................................................................... 70 Figure 27. Tanzania AIMGAPS: Percentage of HIV-positive pregnant women started on or receiving ART (treatment) or ARV prophylaxis, Iringa Region (January 2011-May 2013) ............................................................... 71 Figure 28. Tanzania AIMGAPS: Percentage of HIV-positive pregnant women initiating ARVs during pregnancy compared to male partner testing at ANC (January 2011-July 2013) ....................................................................... 71 Figure 29. Pakistan: Percentage of injections observed being given with a sterile single-use syringe and needle (May 2012-September 2013) ............................................................................................................................................... 73 Figure 30. Malawi: Percentage of clients whose nutritional status was assessed at eight facilities in two districts (January-August 2013) .......................................................................................................................................... 77 Figure 31. Malawi: Number of clients seen, assessed, and categorized as malnourished, eight facilities in two districts (March-July 2013).................................................................................................................................................... 77 Table 1. Contribution of HCI TO3 field activities to the MDGs in FY13 ...................................................................1 Table 2. Cote d’Ivoire: Improvement in targeted indicators, ART/PMTCT spread collaborative (June 2010-September 2012) .................................................................................................................................................................... 10 Table 3. Kenya: Institutionalizing QI at the point of service delivery for 142 QI teams within APHIA/AMPATH plus projects ........................................................................................................................................... 12 Table 4. Malawi: Improvement in targeted OVC indicators ........................................................................................ 16 Table 5. Mali: Improvement in targeted EONC indicators in Diema and Kayes districts ..................................... 20 Table 6. Mali: Improvement in targeted EONC indicators in the three scale-up districts in Kayes Region: Bafoulabé, Nioro, and Yelimané .......................................................................................................................................... 20 Table 7. Mali: Improvement in targeted maternal and child anemia indicators in Bougouni district (Sikasso Region) ...................................................................................................................................................................................... 20 Table 8. Georgia: Percentage of medical charts with best clinical practices for each clinical focus area in 17 project-supported ambulatory sites and 3 hospitals, Imereti Region (April 2012-August 2013) ........................ 41 Table 9. Haiti: Survey on needs of vulnerable children, Nine communities piloting OVC standards ................ 48 Table 10. Nicaragua: Improvement in targeted indicators in FY13 ............................................................................ 52 Table 11. Tanzania: District Health Management improvement indicators, Lindi Region .................................... 67 Table 12. Pakistan: Number of sites complying with safe injection practices (May-September 2013) .............. 73 Table 13. Research and evaluation studies carried out under HCI TO3 in FY13 .................................................. 82 Table 14. Studies about institutionalization completed or in-process under HCI TO3 in FY13 ........................ 83 Table 15. Studies about collaborative improvement either completed or in-process under HCI TO3 in FY13..................................................................................................................................................................................................... 86 Table 16. Spread studies completed or in-process under HCI TO3 in FY13 .......................................................... 88 Table 17. Cost-effectiveness studies completed or in-process under HCI TO3 in FY13 .................................... 89 Table 18. Comparative studies completed or in-process under HCI TO3 in FY13 .............................................. 91 Table 19. Studies on other QI methods completed or in-process under HCI TO3 in FY13 .............................. 93 Table 20. HCI conference and other presentations in FY13 ....................................................................................... 96 Table 21. HCI publications in FY13 .................................................................................................................................... 98 Table 22. HCI TO3 performance tracking plan: Cumulative achievements through FY13 ................................ 101

iv USAID HCI TO3 FY13 Annual Project Report

Abbreviations

AFGA Afghan Family Planning Guidance Association AFSOG Afghan Society of Obstetrics and Gynecologists AMA Afghanistan Midwifery Association AMPATH Academic Model Providing Access to Healthcare (Kenya) AMTSL Active management of the third stage of labor ANC Antenatal care ANPPCAN African Network for the Protection and Prevention of Child Abuse and Neglect APHA American Public Health Association APHIA AIDS, Population and Health Integrated Assistance (Kenya) ART Antiretroviral therapy ARV Antiretroviral ASSIST USAID Applying Science to Strengthen and Improve Systems Project BCT Basic clinical training BPI Brief physician intervention CARMMA Campaign on Accelerated Reduction of Maternal Mortality in Africa CBO Community-based organizations CDC U.S. Centers for Disease Control and Prevention CFW Center for Family Welfare (Indonesia) CHSS Community Health Systems Strengthening CHW AIM CHW Assessment and Improvement Matrix CHV Community health volunteer CHW Community health worker COE Center of Excellence COPD Chronic obstructive pulmonary disease COR Contracting Officer’s Representative COTR Contracting Officer’s Technical Representative CPD Continuous professional development CQI Continuous quality improvement CRS Catholic Relief Services CSI Child Status Index CT Counseling and testing CVD Cardiovascular disease DOH Department of Health (South Africa) eMTCT Elimination of mother-to-child transmission of HIV ENC Essential newborn care EONC Essential obstetric and newborn care FP Family Planning HBB Helping Babies Breathe HBC Home-based care HCI USAID Health Care Improvement Project

USAID HCI TO3 FY13 Annual Project Report v

HCT HIV counseling and testing HPT Human performance technology HR Human resources HQIP Healthcare Quality Improvement Partnership (Afghanistan) HW Health worker IBESR Institute of Social Wellbeing and Research (Haiti) ICAN Infection Control Africa Network IQHC Improving Quality in Health Care (Afghanistan) ISQua International Society for Quality in Health Care IST In-service training IUD Intrauterine device JCI Joint Commission International KARS Indonesian Hospital Accreditation Commission KQMH Kenya Quality Model for Health LDP Leadership Development Program LTFU Loss to follow-up MCWH Maternal, Child, and Women’s Health (South Africa) MDG Millennium Development Goal MDR-TB Multidrug-resistant tuberculosis MMAS Ministry of Women and Social Affairs (Mozambique) MNCH Maternal, newborn, and child health MNH Maternal and newborn health MOGCSW Ministry of Gender, Children, and Social Welfare (Malawi) MOH Ministry of Health MOHSW Ministry of Health and Social Welfare MOLHSA Ministry of Labor, Health, and Social Affairs (Georgia) MOPH Ministry of Public Health (Afghanistan) MR Medical records NB Newborn NCS National Core Standards (South Africa) NGO Non-government organization OHA USAID Office of HIV and AIDS OVC Orphans and vulnerable children PE/E Pre-eclampsia and eclampsia PEPFAR U.S. President’s Emergency Plan for AIDS Relief PHMT Provincial Health Management Team PMI Patient Master Index (Afghanistan) PMTCT Prevention of mother-to-child transmission PN-OEV National OVC Program (Cote d’Ivoire) PNPEC Ministry of Health’s National HIV Care Program (Cote d’Ivoire) PPFP Postpartum family planning

vi USAID HCI TO3 FY13 Annual Project Report

QI Quality improvement QIC Quality improvement collaborative REPSSI Regional Psychosocial Support Initiative for East and Southern Africa RFM Raleigh Fitkin Memorial Hospital (Swaziland) RH Reproductive health RTI Respiratory tract infection SGS Salzburg Global Seminar SLMTA Strengthening Laboratory Management Toward Accreditation SOP Standard operating procedure SOW Scope of work TA Technical assistance TB Tuberculosis TO3 HCI Task Order 3 TWG Technical working group URC University Research Co., LLC USAID United States Agency for International Development USG United States Government VHT Village Health Team VS&L Voluntary savings and loan WHO World Health Organization

USAID HCI TO3 FY13 Annual Project Report vii

Executive Summary University Research Co., LLC (URC) and its subcontractor team completed the fourth year of implementation of the USAID Health Care Improvement (HCI) Project Task Order 3 on September 30, 2013. Year Four was to have been the final year of implementation of HCI Task Order 3. Due to a series of factors beyond URC’s control, including political instability in Mali, the unanticipated close-out of USAID activities in Russia which resulted in a request to move non-communicable disease activities from there to Ukraine, and delays in the award of a bilateral project in Zambia, with which HCI’s planned NACS activity was required to coordinate, USAID issued a one-year, no-cost extension to URC on September 26, 2013 to allow time for completion of a limited number of clearly defined activities. Task Order 3 is the only active task order under the HCI Indefinite Quantity Contract. During FY13, HCI provided technical assistance with field support funding through TO3 in 15 countries: Afghanistan, Botswana, Burundi, Cote d’Ivoire, Georgia, Haiti, Indonesia, Kenya, Madagascar, Mali, Malawi, Mozambique, Nicaragua, South Africa, and Swaziland. HCI assistance in Ethiopia, Lesotho, Pakistan, Senegal, Tanzania, Uganda, and Zambia was supported through core funds from USAID; work in Ukraine was supported with regional funding from the Europe and Eurasia Bureau; and research activities in Niger and Ecuador were supported through the project’s common agenda funds. In all, HCI worked in 25 countries under TO3 in FY13. In FY13, all HCI country assistance programs continued work carried out under TO3 in FY12. At the same time, during the year, activities in most countries were closed down under HCI and transferred to new funding under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, the five-year cooperative agreement awarded to URC by the Office of Health Systems at the end of FY12. In addition to technical assistance to country institutions, we made important progress in the implementation of several key areas in the HCI statement of work. HCI continued to expand its research program and strengthen the evidence base about health care improvement in peer-reviewed health literature and HCI publications, conducting 21 studies and completing nine. Four studies were dropped during the year; the remaining eight will be completed in FY14. Research results were published in peer-reviewed journals on cost-effectiveness of a quality improvement collaborative for obstetric and newborn care in Niger, the accuracy of medical record data in Afghanistan’s maternal health facilities, and the cost-savings of implementing kangaroo mother care in Nicaragua. HCI published 11 technical and research reports, nine short reports/flyers, and one toolkit (the revised version of the “Community Health Worker Assessment and Improvement Matrix”). Three additional technical and research reports were finalized and submitted for approval. Also in FY13, HCI results were shared in 23 presentations made at 10 international and regional conferences. Staff also delivered several briefings to promote awareness of QI approaches and results. As of January 2013, most of URC’s efforts to provide global technical leadership for health care improvement were funded under the new ASSIST Project. Operation of the HCI Portal website continued through all of FY13. In September 2013, migration of all of the resources on the portal to the new ASSIST website was completed. Social media reach during FY13 continued to be sustained through the HCI Facebook page (http://www.facebook.com/HCIProject) and Twitter (@usaidhciproject). During the year, tweets promoted HCI’s work, supporting and forwarding announcements on behalf of several HCI partners. The HCI Twitter handle was referenced the most in April 2013 during the Global Newborn Health Conference, underscoring the significance of using Twitter during events. In September 2013, the HCI Twitter page was transferred to the ASSIST Project and relaunched as @usaidassist. HCI activities in FY14 will be limited to technical assistance to implement quality improvement interventions in Mali, Mozambique, Zambia, Georgia, and Ukraine; close-out of technical assistance in Haiti; support for pre-service training in quality improvement and updating clinical guidelines in Nicaragua; support for the Africa regional partnership in community child protection; and completion of a small number of research studies.

viii USAID HCI TO3 FY13 Annual Project Report

USAID HCI TO3 FY13 Annual Project Report 1

1 Introduction This FY13 Annual Project Report for Task Order 3 (TO3) of the USAID Health Care Improvement Project (HCI) summarizes the project’s key activities and results during the fourth year of implementation: October 1, 2012 through September 30, 2013. The report narrative has four sections: 1. Reports on field support-funded country or regional technical assistance (TA) to improve health

care 2. Core-funded activities and results that supported USAID’s Global Health strategic objectives 3. Activities carried out under the project’s common agenda functions that benefit multiple countries 4. Achievements against the project's Performance Tracking Plan, showing progress made toward

fulfillment of TO3 objectives and performance targets by the end of the contract’s fourth year. During FY13 most HCI-funded activities transitioned to new funding under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. A no-cost extension was granted to URC to continue to implement a limited number of activities until September 29, 2014, as per the contract modification issued by USAID on September 26, 2013. As part of our country work planning and reporting, we consider how improvement activities contribute directly and indirectly to reaching the Millennium Development Goals (MDGs), particularly Goals 46. Our contributions to MDGs 1, 2, 4, 5, and 6 were highlighted in our annual work plan and quarterly reporting to the Contracting Officer’s Representative (COR). Table 1 summarizes how our field activities in FY13 contributed to attainment of each relevant MDG by country.

Table 1. Contribution of HCI TO3 field activities to the MDGs in FY13

MDG How HCI country activities contributed to MDG attainment in FY13

MDG 1: Eradicate Extreme Poverty and Hunger

Haiti: Improve standards for orphans and vulnerable children (OVC) services in all areas: food and nutrition, shelter and care, protection, health, psychosocial well-being, education and household economic strengthening

Kenya: Improve quality of services targeting OVCs in the areas of food and nutrition, shelter and care, and economic strengthening

Malawi: Improve standards for OVC services in all areas: food and nutrition, shelter and care, protection, health, psychosocial well-being, education and household economic strengthening

Mozambique: Improve the quality of OVC services in the areas of food and nutrition, shelter and care, and economic strengthening

Zambia: Increase frequency of nutritional status assessments in HIV patients

MDG 2: Achieve Universal Primary Education

Haiti: Improve standards for OVC services in all areas: food and nutrition, shelter and care, protection, health, psychosocial well-being, education and household economic strengthening

Kenya: Increase school enrollment for vulnerable children affected by HIV through improved quality of coordinated care

Malawi: Improve standards for OVC services in all areas: food and nutrition, shelter and care, protection, health, psychosocial well-being, education and household economic strengthening

Mozambique: Increase school enrollment for vulnerable children affected by HIV through introduction of evidence-based education standards

MDG 4: Reduce Child Mortality

Afghanistan: Reduce neonatal deaths by improving quality of care at public and private health facilities, as well as community-based health services

Georgia: Strengthen the evidence, cost-effectiveness and identify set of “best-buy,” high-impact pediatric services; ensure access to and use of evidence-based clinical guidelines, protocols and pathways, related to priority high-impact pediatric services

Haiti: Improve standards for OVC services in all areas: food and nutrition, shelter and care,

2 USAID HCI TO3 FY13 Annual Project Report

MDG How HCI country activities contributed to MDG attainment in FY13 protection, health, psychosocial well-being, education and household economic strengthening

Kenya: Improve the quality of programs providing health and psychosocial support services for orphans and vulnerable children; improve the quality of antenatal care and prevention of mother-to-child tranmission (PMTCT) services

Madagascar: Assess the functionality of community health worker (CHW) programs in the provision of infant services

Malawi: Improve standards for OVC services in the following areas: food and nutrition, shelter and care, protection, health, psychosocial well-being, education and household economic strengthening

Mali: Improve pediatric anemia prevention and treatment; improve the quality of essential newborn care at facility and community level; improving referral from household to health facility; improving community awareness and care seeking

Mozambique: Improve the quality of programs providing health and psychosocial support services for orphans and vulnerable children

Nicaragua: Reduce neonatal mortality by increasing the competency of medical and nursing students to manage common newborn illnesses and complications

Senegal: improve the quality of community case management of childhood illness

Tanzania: Apply quality improvement (QI) methods to improve the quality of infant feeding and maximize HIV-free survival of children born to HIV-positive mothers through improving the quality of PMTCT

Uganda: Support the spread of evidence-based newborn care at the health facility and community levels

MDG 5: Improve Maternal Health

Afghanistan: Improve the delivery of obstetric care and postpartum family planning at public and private health facilities, as well as community-based health services and birth preparedness

Botswana: Reduce maternal mortality through improved quality of institutional deliveries, reduction in postpartum hemorrhage for vaginal delivery, and improved quality of maternal complications case management

Burundi: Increase the number of pregnant women attending antenatal care (ANC) visits

Georgia: Advocate for integration of priority high-impact “best-buy” medical services for women of reproductive age

Madagascar: Assess the functionality of CHW programs in the provision of maternal care and family planning services

Mali: Increase the percentage of skilled deliveries, reduce postpartum hemorrhage, and improve the quality of obstetric care at the facility and community levels and access to family planning; improve maternal anemia prevention and treatment

Nicaragua: Reduce maternal mortality by increasing the competency of medical and nursing students to prevent and manage maternal complications

South Africa: Improve the quality and availability of modern family planning services

Uganda: Support the spread of evidence-based maternal care at the health facility and community levels and increase the availability of family planning services for women with HIV

MDG 6: Combat HIV and AIDS, Malaria, and Other Diseases

Burundi: Increase the number of pregnant women covered by PMTCT services, increase the number of HIV-positive women receiving care and treatment, increase the number of newborns of positive women tested, and increase the number of positive children receiving care and treatment

Cote d’Ivoire: Develop standards and indicators for peer education programs addressing HIV prevention and harmonize the courses for training peer educators; improve quality of HIV care and treatment services as well as PMTCT; improve quality of programs targeting orphans and vulnerable children; support the laboratory accreditation process to improve the accuracy of testing for HIV, malaria, and other diseases.


MDG How HCI country activities contributed to MDG attainment in FY13

Haiti: Apply QI methods to improve effectiveness of programs to mitigate the impact of HIV and AIDS on children and families.

Kenya: Improve OVC program effectiveness to mitigate the impact of HIV and AIDS on children and families

Mozambique: Improve OVC program effectiveness to mitigate the impact of HIV and AIDS on children and families

Malawi: Improve standards for OVC services in the following areas: food and nutrition, shelter and care, protection, health, psychosocial well-being, education and household economic strengthening

Mali: Reduce transmission of HIV and other blood-borne pathogens through improved injection safety

Nicaragua: Improve outcomes of HIV patients by increasing the competency of medical and nursing students to provide HIV counseling and testing and case management

Pakistan: Reduce transmission of HIV and other blood-borne pathogens through improved injection safety

South Africa: Improve HIV prevention, care, and treatment services; improve PMTCT, counseling and testing, TB/HIV, and ART services

Swaziland: Strengthen provision of multidrug-resistant tuberculosis (MDR-TB) care and treatment services

Tanzania: Prevent mother-to-child transmission of HIV

Uganda: Increase the number of people receiving ART by improving clinic efficiency and strengthening links to other services (PMTCT clinic, HIV counseling and testing services, TB services); improve quality of HIV care services with a focus on retention and clinical outcomes of patients

Zambia: Increase frequency of nutritional status assessments in HIV patients

2 Country and Regional Technical Assistance AFRICA

2.1 Botswana

Overview of HCI’s Program in FY13

Activities What are we trying to accomplish?

Geographic scale

1. National Maternal Mortality Reduction Initiative

2. Contribute to PMTCT through improving maternity care for HIV-positive women and their newborns

Maternal mortality ratio reduced from current 160 deaths/100,000 live births to target, 81 deaths/100,000 live births

Countrywide

Population: 2,098,018

Births per year: 46,000

Estimated # of HIV-positive women is ~19,000

Main Activities and Results In FY12, USAID and CDC Botswana invited HCI to conduct a rapid analysis of existing quality improvement (QI) initiatives being implemented by the Ministry of Health (MOH). Dr. M. Rashad Massoud and URC senior technical staff who visited Botswana found lack of clarity between 1) inputs to improve care and 2) changing how health care service providers work to improve care. They also identified an overemphasis on measurement and reporting, but noted that data from these often do not


align with national level goals, so these measurements are not acted upon. HCI recommended steps for integration and enhancement of existing initiatives in order to garner tangible results that align with the Ministry strategy and identified ways to empower and enhance the participation of MOH senior management in QI activities. Despite these issues with execution, the HCI team found that the building blocks for success are present. The initial visits and interviews found that Botswana has a competent and committed health workforce and a strong desire to identify and fix problems. The staff are forthcoming about problems and weaknesses in a constructive way, looking for ways to improve. During FY13, URC staff visited Botswana several times to work with the Ministry of Health to develop a work plan for the first six months of this initiative to reduce maternal mortality at the national level. They met with the Permanent Secretary of Health, USAID, CDC, and the Ministry of Health Executive Committee. In March 2013, assistance transitioned to new funding under the USAID ASSIST Project.

2.2 Burundi


Activities What are we trying to accomplish? Geographic scale

1. HIV/AIDS services improvement

Contribute to the achievement of PMTCT targets by implementing a PMTCT improvement collaborative approach designed to: 1) Improve uptake of PMTCT services (by mothers, infants, and partners); 2) Improve retention of mothers and infants along the PMTCT cascade; and 3) Improve quality of PMTCT services

The HCI intervention covered 4 out of 17 provinces in the country (Kayanza, Kirundo, Muyinga, and Karuzi)

The target coverage was 1,765,431 inhabitants (out of 10,557,259) in Burundi

Main Activities and Results Activity 1: HIV/AIDS services improvement In FY12, the President’s Emergency Plan for AIDS Relief (PEPFAR) in Burundi requested technical assistance from HCI to ensure that services offered in Burundi relating to PMTCT meet quality requirements. In December 2012, HCI conducted a human performance technology (HPT) assessment—a baseline assessment on five elements of human resource development (clear expectations, attitudes and knowledge, feedback, job environment, and competency). Interviews were held in 20 sites in the four target provinces for the PMTCT improvement collaborative. The assessment showed that only 6.8% of interviewed health workers had job descriptions, that only 53% were trained in PMTCT, that only 55% received good feedback, and that only 9% received recognition for a job well done. In addition, only 61% felt they had a good job environment (Figure 1). In FY13, the PMTCT improvement collaborative became fully operational, covering 70 sites in 12 districts. The following activities were carried out with HCI funding in period October-December 2012:

Developed an initial change package for the peripheral level. Held an experts’ meeting with 30 participants to discuss PMTCT change package, including HPT.

Phase 1 improvement objectives and indicators were defined for quality improvement teams and supervisors, focusing on uptake of PMTCT services in the continuum of antenatal, delivery, and postpartum care. Improvement objectives were identified in three areas: 1) Documentation; 2) Testing and Counseling; and 3) Human Resources.

QI orientation sessions were held for site representatives and district and provincial supervisors. Attending were 32 participants from Kirundo, 18 from Kayanza, 23 from Karusi, and 42 from Muyinga provinces. The main themes were: Introduction to QI, presentation of baseline results of the quality of HIV and AIDS and HR assessment; process mapping; formation of QI teams; and introduction to change package to improve PMTCT services.


Figure 1. Burundi: Health worker survey on elements of human performance factors, 20 sites, 4 provinces (n=73) (December 2012)

Note: HW = health worker.

From January 2013, HCI activities in Burundi continued under the USAID ASSIST Project.

2.3 Cote d’Ivoire



1. ART and PMTCT

Continue the QI project in 80 spread sites

Regionalize the QI project into 10 regions

Improve each community’s link with its site(s)

Institutionalize the improvement process in the Ministry of Health’s National HIV Care Program (PNPEC)

Conduct a national study to define factors impacting patient loss to follow-up (LTFU)

The 80 spread sites (62 PMTCT sites and 79 ART sites) in 40 out of 79 districts in the country and 17 out of 20 regions, serve a population of 17 out of 24 million in the country

Cote d’Ivoire has 633 PMTCT and 477 ART sites.

2. Pharmacy activities for HIV care and treatment

Improve the quality of drug dispensation services in most important pharmacies in Abidjan

13 pharmacies are involved in ART drugs dispensation in Abidjan (out of 95 pharmacies in the city)

3. Orphans and vulnerable children (OVC) care

Improve the quality of programs targeting OVC

Implement the standards in 12 new platforms

Build the capacity of five social centers by integrating QI activities in their work

Build the capacity of the national OVC program to supervise nongovernmental organizations (NGOs) in the implementation of OVC standards

12 platforms out of 30, in 7 of 20 regions

Approximately 140 NGOs are involved in the QI process in the 12 platforms, serving an estimated beneficiary population of 40,000 OVC

The 5 social centers are in three cities: Abidjan, Bouaké, and Bouaflé

6.8

53 55

9

61

0102030405060708090

100

HW with job description

HW trained on PMTCT

HW receives good feedback

HW receives recognition for job well done

HW with good work

environment

% o

f h

ealt

h w

ork

ers

inte

rvie

wed



4. HIV prevention Build MOH capacity to support NGOs in the implementation of peer education standards

Develop QI tools to support the implementation of such standards

Provide technical assistance to PEPFAR implementing partners in QI

The standards are implemented in 10 sites representing 10 cities

About 95 NGOs are engaged in implementing peer education standards

5. Laboratory accreditation

Improve quality of laboratory services in 21 pilot sites

Develop tools for implementing the World Health Organization-Centers for Disease Control and Prevention (WHO-US CDC) accreditation process

The 21 laboratories are located in 10 of the country’s 20 regions and include the regional and central labs; 78 labs in these regions out of 101 in the country are involved in the program

Main Activities and Results HCI assistance in Cote d’Ivoire started in 2008 and initially focused on improving ART and PMTCT services. In 2009, this assistance expanded to include the development of standards of care for orphans and vulnerable children and HIV prevention and laboratory services improvement activities. For the ART/PMTCT and pharmacy improvement activities, HCI worked closely with PNPEC and implementing partners, including Aconda, Health Alliance International, the Elizabeth Glaser Pediatric AIDS Foundation, and the International Center for AIDS Care and Treatment (Columbia University). Starting in April 2013, HCI Cote d’Ivoire activities transitioned to the ASSIST Project. Activity 1: ART and PMTCT

In October 2012, HCI organized the first monitoring meeting for improvement projects with PNPEC and the second coaching visit of FY13. In November 2012, HCI organized the fourth learning session for 80 sites in Abidjan, San Pedro, Daloa, and Bouaké. More than 90% of the facilities participated in the session (72/79 sites), which focused on data collection.

HCI organized a meeting with PNPEC to address gaps in the PMTCT cascade and discuss implementation of the eliminate mother-to-child transmission (eMTCT) national strategic plan. Meeting participants defined indicators to improve the PMTCT cascade to address the objectives of the eMTCT plan.

Loss to Follow-up Study

From February–April 2013, HCI conducted data collection for a study to identify determinants of patient loss to follow-up (LTFU) from HIV care in the HIV care and treatment program. Random sampling was conducted of 40 health facilities in 30 districts and 14 health regions. Community workers were trained to track patients’ LTFU. Survey data collection tools were piloted in three sites, collecting quantitative and qualitative data. Next, a draft strategy to disseminate the study results was developed. Data analysis is underway under ASSIST.

Activity 2: Pharmacy activities for HIV care and treatment In 2011, HCI conducted a pharmacy improvement project with 13 pharmacies in Abidjan as part of the ART/PMTCT improvement work to improve pharmacy record-keeping and supply management to reduce stock-outs. Based on national reports of pharmacies’ activities, we defined improvement objectives and developed tools for pharmacy improvement activities in collaboration with PNPEC, Supply Chain Management System, MEASURE, and the National Pharmacy Warehouse. The first learning session for teams in the pharmacy collaborative took place in December 2011. Participating teams represented the main providers of ART in Abidjan.


The second learning session was conducted in November 2012 with 11 pharmacies. These sessions resulted in several positive changes made to drug dispensation record-keeping procedures, including 1) assigning data management responsibility, 2) informing staff of the need to use the number 0 when the value is null and the use of the term “not applicable” or “N/A” for items not used by the site, and 3) establishing standard operating procedures (SOPs) to check pharmacy reports before sending them to the National Pharmacy Warehouse. Activity 3: OVC Care In FY12, HCI provided training and coaching support to 140 NGOs to pilot standards of care for orphans and vulnerable children in 12 sites countrywide. HCI also worked with the national OVC program to develop the managerial capacity of five government-run social services centers. This capacity building was based on a needs assessment undertaken in April 2012. HCI provided training in QI to the National OVC Program (PN-OEV) to support NGOs in applying the standards. In December 2012, HCI conducted supportive supervision training to 33 coaches at the 12 sites. A workshop was organized in March 2013 to review the results of the OVC program improvement project. The workshop presented a report of program activities carried out and results obtained during the QI process as well as products developed by social centers, master coaches, coaches, and QI teams, including standard operating procedures, job descriptions, and personnel assessment tools. Key achievements of the OVC improvement project include getting all NGOs (61/61) to use the Child Status Index (CSI) tool to assess individual children’s needs and getting almost all (94%) NGOs to update their lists of vulnerable children (reducing the number of children from 20,125 to 13,750) by removing duplicates and ineligible children, resulting in better targeting of and support for the neediest children. Activity 4: HIV Prevention During FY12, HCI provided support to 95 NGOs in 10 cities to apply quality standards for HIV prevention education as well as training in QI for peer education programs for 19 organizations (technical partners, development partners, and national networks) that supervise the NGOs. HCI provided technical assistance to the MOH and PNPEC to organize learning sessions in 10 cities in October and November 2012. In December 2012, HCI organized a supportive supervision visit to the 10 cities for MOH and PNPEC staff. In January 2013 HCI organized a workshop to close out the HIV prevention effort. The workshop provided a set of presentations, including activities carried out and results obtained during the QI process. Activity 5: Laboratory Accreditation HCI has worked since May 2010 with the Regional Center for Health Assessment and Accreditation to implement the WHO-US CDC lab accreditation program in Cote d’Ivoire. HCI collaborated in the development of national guidelines for the accreditation of labs, organized two Strengthening Laboratory Management Toward Accreditation (SLMTA) workshops, conducted on-site coaching for staff of 21 labs, and developed tools, such as procedures manuals and log sheets (for temperature, maintenance, nonconformities, etc.). In FY13, HCI provided technical assistance for lab improvement and performance monitoring to reduce turnaround time from sampling to result delivery, reduce the rejection of specimen delivery, and conduct environmental monitoring of the program (room and equipment temperature control). In March 2013 we organized the first coaching visits to 21 labs involved after the second SLMTA workshop. Corrective actions implemented to improve lab results included: 1) daily work tasks were established and assigned to each staff, 2) new staff were allocated to support the labs’ workloads, 3) a reagents inventory log sheet was established to monitor stock-outs of reagents, and 4) a maintenance register was established to monitor lab equipment to avoid equipment failures. To reduce specimen rejection, HCI developed a sampling guide, created awareness among couriers of the required conditions for transporting samples, and created prescriber awareness to effectively fill out the lab test request form.


Figures 2-4 show that the corrective actions implemented in participating labs resulted in reduced turnaround time for CD4 counts and dried blood spots and reduced specimen rejection in 2012.

Figure 2. Cote d’Ivoire: Corrective actions implemented to improve CD4 turnaround times (May-December 2012)


Key Results: Laboratory - Corrective actions implemented to improve CD4’s Turn Around Time

Source: Laboratory registers. Data were the whole population of each siteImprovement project on CD4 TAT was achieved by 7 laboratories out of 21

May 2012 June 2012 July 2012 Aug.2012 Sept. 2012 Oct. 2012 Nov. 2012 Dec. 2012

TAT ≤ 24H 426 398 2446 2432 3428 3607 3028 3657

TAT > 24H 2488 2182 1567 1109 729 454 1555 1250

0

500

1000

1500

2000

2500

3000

3500

4000

# of tests

Monitoring of CD4 Turn Around Time in 7 laboratories

Beginning of corrective actions implementation

collection and analysis of baseline data

SLMTA I SLMTA II

Corrective Actions to Reduce Turn Around Time 1.Daily work tasks were established and assigned to each staff2. Allocation of new staff to support the workload 3. Establishment of reagents inventory log sheet to monitor reagents’ stock outs

4. Establishment of maintenance register to monitor lab equipment to avoid equipment failure

Figure 3. Cote d’Ivoire: Corrective actions implemented to improve turnaround time for dried

blood spots (February-December 2012)


Key Results: Laboratory – Corrective actions implemented to improve Dried Blood Spots Turn Around Time

Source: Laboratory Registers, Data were the whole population of the siteImprovement project on Dried Blood Spot’s TAT was achieved by 1 laboratory out of 21

Feb.2012 March 2012 April 2012 May 2012 June 2012 July 2012 Augst 2012 Sept. 2012 Oct. 2012 Nov. 2012 Dec. 2012

TAT ≤ 15 days 13 27 20 33 89 136 142 123 205 189 157

TAT > 15 days 267 200 212 198 104 94 88 50 11 17 24

0

50

100

150

200

250

300

# of tests

Monitoring of Dried Blood Spot Turn Around Timecollection and analysis of baseline data


SLMTA II

SLMTA I


Figure 4. Cote d’Ivoire: Laboratory corrective actions implemented to reduce specimen rejection (April-December 2012)


Key Results: Laboratory – Corrective actions implemented to reduce specimen rejection

A M J J A S O N D

Percentage of specimen rejected 1.0% 1.0% 0.50% 1.0% 1.4% 0.8% 1.0% 0.7% 0.6%

Total # of specimen processed 855 4563 5953 5360 4831 5316 5647 5610 5905

1.0%1.0%

0.50%

1.0%

1.4%

0.8%

1.0%

0.7%

0.6%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

Percentage

of rejection

Monitoring of specimen rejectionCorrective Actions To ReduceSpecimenRejection 1. Development of a sampling guide2. Awareness of couriers on the conditions of samples transportation3. Awareness of prescribers to effectively fill lab test request forms

collection and analysis of baseline data


SLMTA I SLMTA II

Source: specimen rejection’s register, Data were the whole population of each siteImprovement project on specimen rejection was achieved by 8 laboratories out of 21

As a result of the improvement activities, average accreditation scores attained by the 21 assessed labs improved from 97 in May 2010 to 198 in April 2013 (maximum score 258) (Figure 5).

Figure 5. Cote d’Ivoire: Increase in laboratory scores, 21 sites (May 2010-August 2013)

US AID HEALTH CARE IMP ROVE ME NT P ROJE CT

Key results: LABORATORYBaseline, second, third & Fourth assessment

97

155

185

198

258

0

50

100

150

200

250

300

Assess. 1 (May 2010) n= 25 sites

Assess. 2 (September 2011) n= 21 sites

Assess. 3(August 2012) n= 21 sites

Assess. 4(April 2013) n= 21 sites

Maximum score

GLOBAL OUTCOME OF ALL LABS INVOLVED

Assess. 1 (May 2010) n= 25 sites Assess. 2 (September 2011) n= 21 sites

Assess. 3(August 2012) n= 21 sites Assess. 4(April 2013) n= 21 sites

Maximum score


Starting in April 2013, all QI work in Cote d’Ivoire transitioned to the ASSIST Project. Due to closure of HCI activities and redesign of the improvement strategy under ASSIST, no additional data were collected after the values reported in FY12. Improvement in targeted indicators for the largest HCI activity in Cote d’Ivoire, the ART/PMTCT spread collaborative, are show in Table 2.

Table 2. Cote d’Ivoire: Improvement in targeted indicators, ART/PMTCT spread collaborative (June 2010-September 2012)

Baseline

(June 2010)

80 spread sites

June 2011

80 spread sites

September 2012

80 spread sites

ART Indicators

Percent of patients with all items filled in the medical record 33% 43% 80%

Percent of HIV-positive patients who did the initial check-up visit 77% 75% 80%

Percent of HIV-positive patients LTFU during ART 16% 13% 8%

Percent of HIV-positive patients LTFU before starting ART treatment

19%

(Oct. 2010) 15% 25%

Survival rate of patient after 12 months 70%

(Dec 2010) 68% 87%

PMTCT Indicators

Percentage of pregnant women counseled and tested in health center (on site)

46% (March 2011) 45% 98%

Percentage of HIV-positive women who received ART to reduce mother-to-child transmission

68% (January 2011)

72% 87%

Percent of infants tested who had been born to HIV-positive women

40% 60% 62%

2.4 Kenya

Overview of HCI Program’s in FY13


1. Disseminate the service standards across the country

Promote the adoption and use of minimum service standards by OVC implementers countrywide

The dissemination effort covered the whole country, targeting the entire population of Kenya, million people

2. Build capacity of the Ministry of Gender, Children, and Social Development and the Department of Children Services on OVC program quality improvement

Improve leadership engagement in promoting quality care in OVC programs countrywide

All 8 provinces

3. Institutionalize QI at the point of service delivery

Ensure improved outcomes for OVC by working with AIDS Population and Health Integrated Assistance (APHIA) and Academic Model Providing Access to Healthcare (AMPATH) plus implementers countrywide

This activity was conducted at the national level.



4. Strengthen the national health system

Support the national health system to institutionalize QI within the sector by developing a national QI policy, partnership framework, accreditation mechanism, and institutionalization of the Kenya Quality Model for Health (KQMH)

National level

Main Activities and Results In FY13, HCI’s main activity in Kenya focused on improving the well-being of orphans and vulnerable children by facilitating QI institutionalization at the point of service delivery through partnership with the APHIA and AMPATH implementing partners, and the Ministry of Gender, Children, and Social Development. HCI continued to work with USAID partners to support 570,000 orphans and vulnerable children. HCI supported the formation of 153 community QI teams spread throughout the country, of which 142 were still active in March 2013. Activity 1: Disseminate the OVC service standards countrywide The OVC service standards were disseminated to the county children’s officers. The project distributed 1200 copies of standards documents in six provinces. The standards were uploaded on the MOH website, enhancing access to them by other partners countrywide. Activity 2: Build capacity of the Ministry of Gender, Children and Social Development and its Department of Children Services on OVC QI HCI continued supporting the QI technical working group at the Ministry by providing secretariat services. During the reporting period, the technical working group held two meetings, reviewing and revising the terms of reference for the group to broaden the scope in driving the improvement agenda beyond the development of the minimum standards and institutionalization of the standards to include child protection. The terms of reference are awaiting endorsement from the Permanent Secretary. By supporting the dissemination of the standards, HCI was also able to link the Ministry to organizations that will support the institutionalization of efforts nationwide, including those of Save the Children International, Kenya Alliance for the Advancement of Children’s Rights, APHIA, and AMPATH plus. Ministry officials were challenged to establish their own site-specific networks that will support their work in the sub-counties and wards. A consultant was identified to perform a situational analysis on psychosocial support services for children. The report highlighted major gaps in the way programs define and implement these services for vulnerable children. A road map for the development of psychosocial support guidelines was adopted by the Ministry. Activity 3: Institutionalize QI at the point of service delivery Work with the APHIA/AMPATH plus implementing partners continued through March 2013. The number of QI teams per project reached a cumulative total of 142 active community teams by March 2013 (see Table 3). Ten teams under APHIA plus Kamili became dormant for various reasons. Interventions by the QI teams led to: 1. Improved service delivery protocols to respond to priority needs of individual children: This has led

to reduced waste and greater efficiency when designing OVC interventions. APHIA plus Kamili is one program that has seen QI teams reduce their programming budget.

2. Appreciation of the role of children, households, and communities in addressing the needs of vulnerable children: Most programs had previously relied on their own perceptions of possible solutions to challenges facing vulnerable children and households without realizing that the


Table 3. Kenya: Institutionalizing QI at the point of service delivery for 142 QI teams within APHIA/AMPATH plus projects

Project Number of QI teams formed (2011-2012)

Active QI teams (March 2013)

APHIA plus Kamili 80 70

APHIA plus Nuru Ya Bonde 16 16

APHIA plus Western Kenya 10 9

AMPATH plus 4 4

APHIA plus Imarisha 8 8

APHIA plus Nairobi Coast 35 35

Total 153 142

communities themselves best understand these challenges and the solutions that could work for them. Child participation, household economic strengthening, and community social action have become very critical interventions in reducing dependency on external support in the communities.

3. Use of data to inform improvement. The teams regularly reviewed their data to find out whether their interventions were making a difference in the children’s lives. Feedback resulted in the initiation of an OVC longitudinal management information system. Once piloted, the system will be adopted by all USAID partners to capture and manage OVC data.

Illustrative OVC QI Team Results The Hakishep community-based organization (CBO) QI team in Kibera, Nairobi, is supported by implementing partner APHIA plus Nairobi – Coast. The CBO provides care and support to 1000 vulnerable children. Their QI team was trained in July 2012 and conducted a baseline CSI assessment on 100 children in August 2012 to help them identify the areas that needed improvement. The CSI results show that shelter and care were the worst performing service, followed by food and nutrition. Further analysis of the results showed that: Most families had not recovered from the effects of the 2007/08 post-election violence in Kenya Lack of child participation in food security initiatives Poverty: caregivers, and most landlords could not afford materials to construct shelter that is

adequate, safe, and dry Low awareness of the importance of locally available food The QI team implemented a number of changes: Training caregivers and formation of Voluntary Savings & Loan (VS&L) groups Training caregivers on selection, planning, and management of income-generating activities Encouraging child participation in food security initiatives Mobilizing OVC caregivers to renovate dilapidated houses in groups rather than individually Involving other stakeholders on specific change ideas to support vulnerable children and their

households Sensitizing the community on child nutrition, maternal health, and immunization Mobilizing the community to distribute food to very needy households These changes were implemented over a six-month period, and a second CSI was administered on the same children in February 2013. The results demonstrated improvement in four of the 11 service areas and no change in the other seven. The proportion of children’s whose well-being was categorized as good or fair rose from 69% to 95% for food security; from 58% to 90% for nutrition; from 53% to 91% for shelter and care; and from 63% to 89% for legal protection.


Activity 4: Strengthen the national health system National policy seminar for QI The ground work was laid for the policy and strategy work in Kenya through the adoption of a roadmap for the work and hosting the national policy seminar for QI in February 2013. The seminar was hosted by the MOH and attended by representatives from USAID (East Africa Regional Office and the Kenya Mission), WHO, Japan International Cooperation Agency, the Deutsche Gesellschaft fuer Internationale Zusammenarbeit, and other improvement stakeholders and experts from Europe and America. Key lessons from the policy seminar included: Multiple and branded improvement approaches provide a challenge to improve quality and safety.

Recognizing and addressing different perceptions of quality among providers, policymakers, and the public requires open dialogue.

Support for system-wide QI and accreditation can only be devised within supportive national policies, goals, objectives, and legal and institutional frameworks that, in turn, enable the development of common strategies for accreditation and certification that can be sustained, institutionalized, country-led, and country-owned to improve quality of health care.

The ideal structure for any accrediting body is an independent third party that represents the interests of the Ministry of Health, insurers, public and private providers, and patients. Its ultimate goal is formal certification through accredited bodies.

Launch and dissemination of the national QI framework (Kenya Quality Model for Health) Work with the Ministry of Health (MOH) revolved around laying the groundwork for the countrywide institutionalization of the Kenya Quality Model for Health (KQMH). In addition, HCI facilitated the MOH to establish a national framework for quality policy and strategy within the Department of Standards and Regulation. HCI assisted the MOH to disseminate the KQMH standards and sensitize members of the Provincial Health Management Teams (PMHTs) in six of the eight provinces in the country. County-specific dissemination plans were developed to guide the process. The project supported the MOH by printing 5000 additional copies of the KQMH standard to be distributed during the county-level dissemination effort. The dissemination targeted members of the Provincial Health Management Teams. The MOH’s main focus was to establish KQMH as the framework for the institutionalization of quality in the health sector with a focus on health facilities at different levels. HCI is supporting the MOH to develop a training manual for QI that will guide trainings targeting different levels of health service providers. The curriculum will be integrated in the several MOH training programs once adopted. National QI training framework HCI supported the Ministry in the development of a national syllabus to be used to train health managers in QI. It will be used on both the in- and pre-service training levels. Support capacity building of county health managers and USAID regional implementing partners (APHIA plus) in rolling out QI One of HCI’s deliverables in FY13 was to build the capacity of counties’ health teams in the implementation of QI. To accomplish this, HCI, the MOH, and APHIA plus identified six initial counties and sub-counties to serve as centers of excellence (COEs) in rolling out QI at the point of service delivery: Nakura, assisted by APHIA plus Nuru Ya Bonde; Meru, assisted by APHIA plus Kamili; Nyamira, assisted by APHIA plus Western Kenya; Isiolo, assisted by APHIA plus Imarisha; and Kilifi and Nairobi counties, assisted by APHIA plus Nairobi Coast. HCI’s work in Kenya was closed out in March 2013, and all assistance transitioned to the ASSIST Project.


2.5 Madagascar


Key activities What are we trying to accomplish? How will we know? Geographic scale

1. Madagascar Community Health Worker (CHW) Assessment

Assess functionality of SanteNet2 and UNICEF CHW programs

Conduct focus groups to review supervision tools

Use HCI’s CHW Assessment and Improvement Matrix (AIM) tool to analyze current CHW services

Build in-country capacity to apply the tool

Triangulate quantitative and qualitative assessment findings to develop a synthesis report

Disseminate findings of the CHW assessment in a stakeholders’ meeting

Through functionality scores, document review, and validation site visits of the CHW programs assessing in each of the 15 components of the CHW Assessment and Improvement Matrix (AIM) tool

Analysis of focus group discussions on supervision tools

Participation of key stakeholders in a training-of-trainers workshop

Participation of key stakeholders in a meeting to disseminate final assessment findings

Two SanteNet2 regions out of 16 supported by SanteNet2/ USAID

One UNICEF region out of 8

Main Activities and Results In FY12, HCI and the Global Health Technical Assistance Project, with technical assistance from CDC, conducted qualitative and cross-sectional studies, respectively, of the program functionality and performance of Madagascar’s national community health volunteer (CHV) system. In FY13, HCI completed the following technical activities:

Finalized and published the qualitative assessment of community health volunteer program functionality (http://www.hciproject.org/publications/assessment-community-health-volunteer-program-functionality-madagascar)

Completed technical review and provided feedback on the CDC-led quantitative assessment of community health volunteer performance (final report: http://www.hciproject.org/publications/evaluation-quality-community-based-integrated-management-childhood-illness-and-reproduc)

Synthesized findings across the qualitative and quantitative assessments and produced a synthesis report (http://www.hciproject.org/publications/community-health-volunteer-program-functionality-and-performance-madagascar-synthesis-q)

Planned, organized, and facilitated a dissemination meeting in Antananarivo on May 22, 2013. The 64 participants represented an array of stakeholders, including UNICEF, NGOs, and the Malagasy Health Ministry. Workshop objectives were to 1) disseminate the key finding and recommendations, 2) facilitate root cause analysis of the gaps identified in the assessment, and 3) facilitate the development of practical strategies to improve CHV activities. Participants reviewed findings, analyzed root causes to identify gaps, and proposed recommendations for improvement on the themes of formative supervision, CHV competence, CHV motivation/incentives, national supervision system and reporting, availability of materials and supplies, linkages between CHVs and the formal health system, and linkages between the CHV and the community.

HCI completed work on this activity in FY13.


2.6 Malawi


Key activities What we are trying to accomplish? Geographic scale

1. Pilot the feasibility and effectiveness of OVC standards in improving outcomes

Develop an evidence-based set of standards that are accepted by the Ministry of Gender, Children and Social Welfare (MOGCSW) and other stakeholders

1,000,000 single and double orphans in Malawi (UNICEF, HIV and AIDS, stock taking reports, 2009)

2. Work with the MOGCSW to build its capacity to implement QI

Facilitate the integration of QI into Ministry systems with senior management involvement

3. Build the capacity of USG implementing partners to apply a quality management approach to enhance OVC service delivery

Work with the Ministry and stakeholders to support communities use the CSI to prioritize improvement areas and use QI methods to apply the standards

Four districts: Lilongwe, Blantyre, Mangochi, and Karonga

Main Activities and Results Activity 1: Pilot the feasibility and effectiveness of OVC standards in improving outcomes for children The Government of Malawi, with support from HCI, started a process in 2009 to standardize the provision of OVC services to ensure that all vulnerable children receive good care. HCI facilitated the development of the draft OVC standards of services and was subsequently asked to support the MOGCSW in piloting the standards and support communities to use QI methods to implement the standards. The project supported MOGCSW to test whether the OVC standards could be used by communities to improve care for children. In early 2012, the project started providing technical support to the four piloting districts to test use of the standards. Until December 2012, the project and Ministry mentored community QI teams on 1) how to use CSI assessments to prioritize areas needing work and 2) how to use evidence in making decisions to improve children’s well-being. Activity 2: Work with MOGCSW to build its capacity to implement improvement work The key FY13 accomplishment was that the government established a QI core group to kick-start the review and finalization process of the OVC standards in October 2012. To achieve this, HCI supported the Ministry to facilitate a QI core group to revise the OVC standards based on the findings from the field test. The core group at national level included MOGCSW, USAID, UNICEF, Catholic Relief Services (CRS), Save the Children, and Every Child Malawi. From October to December 2012, HCI worked with QI teams in seven communities and four districts to pilot the standards. The piloting QI teams were asked to provide feedback on experiences in implementing the standards. Joint learning sessions were conducted for QI teams to present their achievements and lessons learned in the pilot process. Feedback from these meetings was then used by the core group to revise the standards so that they reflected the realities of a diverse set of communities. After finalizing the draft, the standards were presented to the joint OVC and child protection technical working group (TWG) for approval. The national TWG proposed the approval of the OVC standards and recommended the scale-up in implementation of the standards to other districts. Activity 3: Build the capacity of USG implementing partners to apply a quality management approach to enhance OVC service delivery In November 2012, the project started mentoring two USG implementing partners, CRS and Save the Children, in managing improvement activities. These partners and the communities conducted random


CSI assessments of children from existing OVC registers. They analyzed the CSI data to identify priority needs. Table 4 shows progress achieved in the piloting sites with respect to targeted OVC indicators. In January 2013, HCI assistance in Malawi transitioned to the ASSIST Project.

Table 4. Malawi: Improvement in targeted OVC indicators

Indicator Baseline

Last value (December 2012)

Child protection

Number of cases referred to child protection service providers 214† 141

Number of children removed from child labor situations NA 52

Number of children trained in life skills, rights, and responsibilities NA 30

Early childhood development

Percentage of malnutrition cases among the 0-8 year old children †† 36.2% 2.5%

Number of ECD centers established 64 129

Number of children enrolled in ECD centers 2604 6986

Food security and nutrition

Number of OVC households oriented on food production, preparation, utilization, preservation, and processing

NA 108

Number of OVC households linked to food security programs in the area NA 34

Number of demonstration plots established for training farmers NA 0

Education

Number of children enrolled in primary school 9054 12,549

Household economic strengthening

Number of VS&L groups formed 2 30

Number of VS&L groups functional 2 30

Number of households hosting OVC participating in VS&L groups 36 206

Number of community members participating in VS&L groups 70 716

Psychosocial support

Number of children accessing PSS services 246 1312

Number of safe social structures established and strengthened by type NA 26

† This information is from Mangochi, Blantyre, and Lilongwe districts.

†† This information is from Blantyre District.

NA=Data not available.


2.7 Mali


Key activities What are we trying to accomplish? Geographic scale

1. Strengthen essential obstetric and newborn care (EONC) services at the health facility and community levels through the application of collaborative improvement

Apply the collaborative improvement model to improve evidence-based maternal and newborn care at the health facility

Spread the active management of the third stage of labor/essential newborn care (AMTSL/ENC) best practices to 3 new districts in Kayes (Bafoulabe, Nioro, and Yelimane

Introduce the Helping Babies Breathe (HBB) component to the Regional Hospital and Kayes and Diema districts

Strengthen community-based collaborative improvement in 2 communes (26 villages) in Diema

149 facilities (of 164) in 5 districts (of 7) for 1,130,366 inhabitants (of 1,687,116)

The community intervention covered 26 villages surrounding 4 (of 21) peripheral facilities in Diéma

During FY12 HCI supported the bilateral Project “Projet Keneya Ciwara” in spreading best practices of AMTSL/ENC to 4 new districts. This effort continued coaching and monitoring of activities without any direct HCI involvement.

2. Contribute to reducing morbidity among pregnant women and children under five by applying effective QI approaches at the health facility and community levels

Apply the collaborative improvement model to improve the delivery of community and facility evidence-based anemia-control interventions in collaboration with local partners

Sikasso Region (of 9 regions): 1 district (of 7); targeted 525,000 (of 2,625,919) inhabitants in Sikasso

25 of the 37 total health facilities in Bougouni district

Main Activities and Results Activity 1: Strengthen EONC services at the health facility and community levels by applying collaborative improvement

In FY13, HCI’s main focus in Mali was to organize a coaching visit to all 63 sites in Diema and Kayes districts in order to assist QI teams and help them synthesize best practices/proven changes. HCI, through a coaches’ meeting, synthesized a Mali “improved” change package for AMTSL/ENC based on experiences from these districts and the regional hospital and added the AMTSL/ENC training materials. This material was compiled into a dissemination package that was scaled up to 82 more health facilities in three new districts in Kayes (Bafoulabe, Nioro, and Yelimane). In preparation for the dissemination, we provided a training/refresher on this dissemination package to 17 coaches/trainers from former and new districts. We also conducted an orientation on QI and coaching techniques. These coaches/trainers facilitated training sessions for 242 health providers from all 82 sites in the new districts.

In FY13, HCI also reinforced QI teams’ skills in identifying, testing changes, and sustaining gains in the management of pre-eclampsia and eclampsia (PE/E). Of note, only 19 sites with medical doctors were allowed to fully apply evidence-based standards in PE/E treatment using magnesium sulfate.

For the community-based EONC improvement activity, HCI organized a coaching visit to all 26 target villages with community QI teams. HCI assisted them in better implementing their change package, focusing on home visits, the use of ANC services, skilled delivery, and birth preparedness. We also organized a learning session to synthesize best practices and better define roles and responsibilities among key stakeholders, including CHWs, community health committees, peripheral health providers, elected local counselors, and the community in general.


In order to support the sustainability of QI results and ownership, we integrated these topics into regional institutional meeting discussions. Roles and responsibilities at all levels of the regional system and choice of specific topics per district and region were agreed upon.

Figures 6-9 show how, as a result of the improvement work, sites experienced reduced postpartum hemorrhage and dramatic increases in compliance with ENC and PE/E diagnostic and treatment norms.

Figure 6. Mali: AMTSL coverage and postpartum hemorrhage rates, 41 sites (October 2009-March 2013)

Figure 7. Mali: Kayes and Diema districts, Percent compliance to ENC norms, 41 sites (October

2009-March 2013)

Jan 10: Baseline results restitution and orientation in QI

and collaborative

May 10: Coaching visits

Nov 10: LS2 (per district) + key changes sharing

Apr 11: LS3

Jun 11: Coaching visits

Nov 09: Baseline Assessment

Feb-Mar 10: Providers’ training in AMTSL/ENC and

QINiger EONC Collaborative

Experience sharing

Apr 10: Training of coaches; LS1 + Key successful changes

sharing on Niger

Jul 10: Coaching Visits

Feb 11: Coaching visits

Mar 11: Coaches’ meeting

0

10

20

30

40

50

60

70

80

90

100

0.0

1.0

2.0

3.0

4.0

5.0

9-OctN D J10 F M A M J J A S O N D J11 F M A M J J A S O N D J12 F M A M J J A S O N D J13 F M

% B

irth

s co

vere

d b

y A

MT

SL

po

st p

artu

m h

emo

rrh

age

rate

% post partum hemorrhage% births covered by AMTSL

O N D J F M A M J J A S O N DJ12

F M A M J J A S O N DJ13

F M

# of complied criteria to norms 491 502 502 574 597 917 121 124 135 133 138 135 136 133 132 134 139 129 138 137 140 139 139 135 135 132 126 126 123 301

# of criteria 126 126 128 131 127 136 139 142 142 141 142 137 137 133 132 135 139 129 138 137 141 139 140 140 136 133 130 131 125 301

% of compliance to ENC norms 39 40 39 44 47 67 87 88 95 94 97 99 99 100 100 99 100 100 100 100 100 100 100 96 99 99 97 96 98 100

# Sites 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 40 39

0

10

20

30

40

50

60

70

80

90

100

Perc

en

t

% of compliance to ENC norms in EONC Collaborative target sites (Kayes Regional Hospital, Kayes and Diéma districts) from October 2009 to March

2013

Training in AMTSL and QI

LS1 + Key Niger successful changes sharing

Coaching visits

Baseline assessment

Baseline results restitution+ Niger EONC Collaborative Experience sharing

Learning Session 2


Figure 8. Mali: Percent compliance to PE/E diagnostic standards, 19 sites, Kayes Region (October 2010-April 2013)

Figure 9. Mali: Percent compliance to PE/E treatment norms, 19 sites, Kayes Region (October

2011-April 2013)

Tables 5 and 6 report improvement in targeted AMTSL, ENC, and PE/E indicators in FY13 in the original two districts participating in the collaborative improvement intervention in Kayes Region and in the three scale-up districts, respectively.

O N DJ11



F M A M J J A S

Number of Pre Eclampsia/Eclampsia diagnostic standards met 5 7 7 12 10 11 45 39 33 52 71 48 34 21 39 36 42 27 107 74 48 60 57 59 55 78 34 34 41 78 105111113 91 109 24

Number of Pre Eclampsia/Eclampsia diagnostic standards applicable 20 30 30 75 68 75 105 95 77 114248233178169144 41 174 43 118 81 52 71 78 69 63 91 40 42 54 86 114121132131127 24

Compliance with Pre Eclampsia/Eclampsia diagnostic standards 25 23 23 16 15 15 43 41 43 46 29 21 19 12 27 88 24 63 91 91 92 85 73 86 87 86 85 81 76 91 92 92 86 69 86 100

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nta

ge

Compliance with pre-eclampsia and eclampsia diagnostic standards, Kayes Region (19/19 sites in 2 districts) Mali, October 2010-September 2013

Key changes:1. Peer observation on BP monitoring2. Providers’ refresher/on-the-job training

in pre-eclampsia / eclampsia screeningand case management at each coachingvisit

3. Community committee (ASACO) involvement in purchase of essential inputs

4. Treatment standards posted in everydelivery room

O N DJ11



F M A M J J A S

Number of Pre Eclampsia/Eclampsia Treatement standards met 0 0 0 0 0 0 21 42 22 29 66 64 31 25 44 55 39 22 135 81 55 87 53 68 47 87 29 25 52 52 114102 83 125134 19

Number of Pre Eclampsia/Eclampsia Treatement standards applicable

0 0 0 24 20 25 108 85 38 90 116 96 41 34 59 63 48 26 171102 67 101 61 80 66 101 40 37 57 67 121124110180166 19

Compliance with Pre Eclampsia/Eclampsia Treatement standards 0 0 0 0 0 0 19 49 58 32 57 67 76 74 75 87 81 85 79 79 82 86 87 85 71 86 73 68 91 78 94 82 75 69 81 100

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nta

ge

Compliance with pre-eclampsia and eclampsia treatment standards, Kayes Region (19/19 sites in 2 districts) Mali, October 2010-September 2013

Key changes:1. Peer observation on BP monitoring2. Providers’ refresher/on-the-job training

in pre-eclampsia / eclampsia screeningand case management at each coachingvisit

3. Community committee (ASACO) involvement in purchase of essential inputs

4. Treatment standards posted in everydelivery room


Table 5. Mali: Improvement in targeted EONC indicators in Diema and Kayes districts

Indicator Baseline (November 2009, 17 health facilities)

Last value in FY13 (April 2013, 64 facilities under HCI funding)

% of deliveries with AMTSL 48% 100%

% of newborns receiving correct immediate newborn care

56% 100%

% compliance to PE/E diagnostic standards 30% 85%

% compliance to PE/E treatment standards 41% 85%

Table 6. Mali: Improvement in targeted EONC indicators in the three scale-up districts in Kayes Region: Bafoulabé, Nioro, and Yelimané

Indicator Baseline (October 2012, 85 facilities)

Last value in FY13 (April 2013, 85 facilities under HCI funding)

% of deliveries with AMTSL 16% 85%

% of newborns receiving correct immediate newborn care

48% 81%

% compliance with maternal surveillance norms

10% 80%

% compliance with newborn surveillance norms

68% 89%

Activity 2: Contribute to reducing morbidity among pregnant women and children under five by applying effective QI approaches at the health facility and community levels for anemia prevention and control During the first quarter of FY13, at the facility level, HCI defined and adapted the anemia control and prevention intervention package; finalized the initial change package; elaborated training modules and tools; and organized training sessions for trainers. In addition HCI developed behavior change communication messages and materials as well as job aids for providers for anemia control and prevention. At the community level, HCI and the MOH identified 16 satellite villages around four health facilities. Functional community groups were identified from these villages and were organized as QI teams. Initial improvement activities in FY13 demonstrated progress (see Table 7). The work continued with ASSIST funding as of May 2013.

Table 7. Mali: Improvement in targeted maternal and child anemia indicators in Bougouni district (Sikasso Region)

Indicator December 2012 (10 facilities out of 15)

April 2013 (13 facilities)

% of pregnant women for whom conjunctivitis pallor and hemoglobin were checked and documented

37% 45%

% of women 4-8 months pregnant women who received iron, folic acid, malaria treatment, and deworming

48% 58%

% under-5 children for whom pallor was checked and documented during curative care

0% 26%


2.8 Mozambique



Care for Vulnerable Children

1. Gather and communicate evidence on draft service standards for orphans and vulnerable children

Gather evidence that the standards are feasible at the point of service delivery

Gather evidence that implementation of the standards actually makes a difference in children’s lives

Gather evidence that implementation of the standards is within the context of organizational practices

Communicate standards across partners

Develop a dissemination plan

Three regions—Zambézia, Gaza, and Cabo Delgado—with key implementing partners identified by USAID/Mozambique and the Ministry

2. Build capacity of the Ministry of Women and Social Affairs (MMAS) and other stake-holders in 1) developing and implementing minimum OVC care standards and 2) QI principles and methods in OVC programming

Support MMAS to finalize the standards of care as a national document

Provide leadership in improving care quality for programs serving vulnerable children and families

Provide TA to ensure development of standards that are evidence-based

Build constituencies of support for the standards and QI principles

National, cascading to communities

3. Scale up use of the OVC standards

Continued commitment, vision, and allocation of resources toward improvement for OVC services within the QI Task Force, which part of MMAS

Develop a scale-up plan for QI in OVC programs in organizations and regions not reached during the pilot

National, regional, district, community

Home-based Care for People with HIV

4. Plan for QI for home-based care (HBC) programs and creating tension for change

Identify champions in the Government, civil society, and other development partners

Organize a task force to lead the process

Conduct a situation analysis of current HBC programming in Mozambique

Build constituencies of support among HBC stakeholders

National

5. Define quality of HBC using service standards

Develop the capacity of task force members and other stakeholders in the process of developing quality standards

Establish a process for vetting/reviewing the standards

Develop a plan for pilot-testing the standards

National

6. Gather evidence on the implementation of the draft service standards

Gather evidence that the implementation of standards is feasible at the point of service delivery

Gather evidence that implementation of the standards actually makes a difference in people’s

National, cascading to the community level in Gaza, Sofala, and Cabo Delgado



lives and are feasible within the context of organizational practices.

Communicate standards across key USG partners, such as the Strengthening Communities through Integrated Programming projects

7. Develop a plan to help implement national HBC standards in all programs

Incorporate results from the pilot into national policy on HBC standards

Develop a strategy for implementing the standards, including training, procurement, and ongoing QI

National

Main Activities and Results Activity 1: Gather and communicate evidence on draft service standards for OVC HCI funding in Mozambique ended in May 2013. At that point, MMAS, with technical assistance from HCI, had accomplished the following:

Gathered evidence on the piloting of OVC standards in three provinces: Gaza, Cabo Delgado, and Zambezia. In Gaza, the pilot targeted about 2969 orphans and vulnerable children (Figure 10). Food and nutrition, shelter, and economic strengthening were the weakest services before the pilot. All services except economic strengthening recorded 80% and above after the pilot.

Figure 10. Mozambique: Improvement in children’s well-being, moving from “good” to “very good” status in Gaza Province (December 2010-March 2013)

Forty-four delegates from MMAS, civil society, and NGOs attended the OVC standards national

workshop. After two days of thorough discussion and debate, consensus was reached that using the standards helped target services to those children most in need. Through the use of the CSI, communities were able to prioritize which services to improve. Equally important, the group noted that CSI, though an excellent tool for ranking and prioritizing, is not an effective evaluation tool. The group therefore recommended that it should not be recommended for evaluation purposes. The group also noted that communities were able to identify local actors who were able to solve problems locally rather than channeling every problem to social welfare, as happened in the past.

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Food and Nutrition Health Psychosocial Support Education Shelter Protection EconomicStrengthening

Percentage of children with good or very good status in Gaza Province

Dec‐10 Mar‐13


Activity 2: Build capacity of MMAS and other stakeholders Through participatory planning and regular coaching, HCI strengthened the capacity of government staff and partner organizations to apply QI approaches in identifying, prioritizing, and solving prioritized problems using local and/or external resources. Activity 3: Scale up use of the OVC standards This work was not carried out under HCI and will be addressed by the ASSIST Project. Activity 4: Plan for quality improvement for home-based care programs and creating tension for change The drafting of HBC standards took longer to finalize than expected, so the plan for QI for home-based care programs and creating tension for change was not addressed under HCI and will be developed under the ASSIST Project. Activity 5: Define quality of home-based care using service standards By the end of May 2013, the MOH, with HCI technical assistance, managed to accomplish the following:

In December 2012, 18 HBC technical working group members received QI training that was facilitated by URC’s Nigel Livesley.

By February 2013, the TWG had designed and agreed on the community consultation tools and had tested them on a small scale in and around Maputo Province before expanding to Gaza, Sofala, and Cabo Delgado.

By April 2013, community focus group consultations had successfully been carried out in four provinces (Maputo, Gaza, Sofala, and Cabo Delgado). The consultations were held with beneficiaries and providers to describe what they saw as important components of HBC.

In May 2013 HCI in collaboration with the MOH also organized a two-day national workshop where we shared the framework and process for standards development. The draft standards were developed based on Mozambique’s specific context and building on national and international evidence of best practices. The workshop aimed at reaching consensus on desired outcomes per service, drafting a limited number of standards, and developing a work plan for completion of a first draft of service standards.

HCI also organized a process to vet the standards (gathering more inputs) with a larger community of stakeholders than the workshop participants. We worked with the HBC TWG, which led and coordinated the vetting process with several NGOs and their local partners. In addition, we developed a protocol for pilot testing the standards, standard operating procedures, and indicators in a manner that allows all partners to work in a coordinated fashion.

Activity 6: Gather evidence on the implementation of draft service standards and Activity 7: Development of a plan to help implement national HBC standards in all programs will be carried out under ASSIST This work was not carried out under HCI and will be addressed by the ASSIST Project.

2.9 South Africa

Background QAP and its follow-on HCI have worked since 2000 in South Africa, initially improving treatment outcomes in key health areas (TB, maternal and perinatal health) and then focusing on improving quality of HIV and AIDS programs. Beginning in one province, HCI gradually expanded to cover over 214 facilities in five priority provinces: Eastern Cape, KwaZulu-Natal, Limpopo, Mpumalanga, and North West. HCI works closely with the Department of Health (DOH) at all levels (national, provincial, district, and facility) and with other stakeholders, including PEPFAR partners. Working within the HIV prevention, care, and treatment spheres, HCI staff has provided direct medical care and TA to ensure that high-quality health services for people living with HIV and AIDS are available at both health facility and community levels.


Within the context of the PEPFAR realignment process in 2011 in South Africa, HCI’s role was revised to provide TA at the provincial level as a “Specialized Provincial Partner for Quality.” This has necessitated changes in HCI strategic activities, as improvement initiatives are targeted at provincial and district levels rather than at facility and community levels. HCI’s scope of practice has also expanded considerably to include health system strengthening activities such as strategic planning, district development, and supervision.


Key activities What are we trying to accomplish?

How will we know? Geographic scale

1. Increase quality of HIV prevention, care, and treatment services

Increase number of health care providers trained in QI methodology

Increase number of facilities providing high- quality PMTCT services

Increase number of facilities providing high quality counseling and testing (CT) services

Increase number of facilities providing high- quality basic HIV care services for HIV-infected individuals

Increase number of facilities providing high- quality ART services

Increase compliance with guidelines in PMTCT and ART services

Number of health care workers trained in QI methodology

Number districts implementing QI methodology

Percentage compliance with HIV and AIDS guidelines at HCI-supported provinces/districts

Proportion of first ANC clients accessing CT services at HCI-supported provinces/districts

CT uptake at HCI-supported provinces/districts

Percentage adherence with ART at HCI supported provinces/ districts

ART defaulter rate at supported provinces/districts

Provincial distributions: 5 out of 9 provinces District distributions: 31 out of 52 districts

The mid-year population estimate (census 2011) in these 5 provinces was >30 million

2. Health system strengthening

Build capacity at all levels in planning, supervision, program review, improving clinical skills, and developing and implementing improvement plans

Percentage of districts with completed district health plans

Percentage of districts implementing the primary health care supervisor’s manual

Percentage of districts with key program performance data reviewed and documented

Number of DOH managers trained in QI

Proportion of districts assessed utilizing National Core Standards for Health Establishments

At national level and in 5 supported provinces

3. Referrals and linkages

Expand linkages between communities and facilities

Percentage of districts with evidence of functional integrated referral and follow-up networks for HIV care services

Percentage of districts/ provinces introducing joint operational meetings with various directorates

Districts in five supported provinces


4. Policy development

Provide technical support to the DOH for the development of quality guidelines and policies and help document QI efforts

Number of policies and guidelines reviewed / developed

National level

5. Community engagement

Expand linkages between communities, facilities, and districts to ensure integrated programming in a network of services for all HIV-infected clients and their families

Percentage of districts with evidence of functional, integrated linkages between communities, facilities, and districts

Percentage of districts supported/ mentored on administrative and financial managerial capacity for community-based NGOs

Number of care support groups developed/supported

Percentage of districts with functional care support groups for people living with HIV at the facility/ community level

Districts in five supported provinces

Main Activities and Results Activity 1: Increase quality of HIV prevention, care, and treatment services In FY13, HCI worked with national, provincial, and district management teams in the DOH to improve the quality of HIV prevention, care, and treatment services by providing capacity building and mentorship to DOH staff. HCI also provided technical assistance to district management teams with development of quarterly review reports for HIV counseling and testing (HCT), PMTCT, Maternal, Child and Women’s Health (MCWH), and ART. We also participated in quarterly reviews and provided mentorship for QI planning and implementation, which has improved quarterly reports and increased coordination and participation between development partners and DOH staff. HCI staff also provided technical support during various HCT campaign and the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) launches in KwaZulu-Natal, Mpumalanga, and Eastern Cape provinces. Within the Eastern Cape CARMMA launch, HCI was identified as the leading partner, working to involve and coordinate contributions from all partners. The project provided technical support to provincial and district management on quality of HIV data through quarterly review of data quality and feedback, training, and mentorship of DOH staff in Eastern Cape and Mpumalanga provinces. HCI has also worked with National PMTCT/MCWH and other partners to develop National PMTCT QI training modules and provided QI training in partnership with other PEPFAR partners. Staff from HCI are members of the National PMTCT Technical Work Group, which meets at least quarterly to review progress in the program and update national PMTCT improvement plans. There has been significant progress in the national PMTCT program, with maternal-to-child transmission of HIV reduced to <3.5%. Since 2011, all provinces monitor PMTCT dashboard indicators, and all provinces have QI frameworks in place (Figure 11). Initiation of eligible HIV clients on ART has improved significantly. HCI provided support with planning and implementation as well as monitoring of roll-out of fixed-dose combination, which was launched in April 2013. In the last three quarters 96,390 new clients start ART in Mpumalanga and Eastern Cape provinces, bringing the total number of clients on ART there to 466,765. Figure 12 shows the sustained increase achieved in ART initiation.


Figure 11. South Africa: National PMTCT dashboard (2010-2012)

Figure 12. South Africa: Number of HIV patients on ART, Mpumalanga and Eastern Cape

provinces (April 2012-June 2013)


Activity 2: Health System Strengthening Capacity Building: HCI builds capacity in South Africa at provincial and district levels in strategic planning, supervision, program review, training and mentorship, development of clinical skills, and policy development. We trained district program staff and provincial staff on PMTCT QI in North West, Limpopo, Mpumalanga, and Eastern Cape provinces. Training and mentoring were provided to six O.R. Tambo District information officers on cohort reporting and on the use of new ART registers (installed to capture data) in the Eastern Cape. HCI trained 30 individuals (identified as “focal persons”) on home-based care in Sekhukhune District in Limpopo. We also trained 29 data collectors (including 12 field workers) on the use of the primary health care supervision questionnaire for facility managers in Mpumalanga. Lastly, HCI together with DOH staff and PEPFAR partners trained professional nurses in KwaZulu-Natal on the new family planning policy and provided clinical training and mentorship on inserting IUDs. Monitoring and Evaluation and Strategic Information: Over the reporting period, HCI provided technical assistance for monitoring and evaluation and strategic information to DOH staff through quarterly review and provision of feedback on quality of selected HIV and AIDS indicators from the District Health Information System in the Eastern Cape and Mpumalanga provinces. HCI also developed and piloted a follow-up register to record mother and baby pair follow-up of PMTCT care in Limpopo, at the request of the Limpopo provincial managers. Strategic planning: HCI provided support during review of the 2013 District Health Plan performance and provided technical assistance during development of the counterpart plan for 2014-2015 in Eastern Cape. HCI provided mentorship to program and management teams with the development and implementation of QI plans and with the documentation of QI efforts. In Mpumalanga, HCI worked closely with provincial QI managers and provided mentorship for the development of the provincial and district QI operational plans for 2013-2014. HCI also supported the planning and provision of QI training at provincial, district, and sub-district levels and participated in a client satisfaction survey which will be completed in November 2013. There is general evidence of reductions in the number of complaints from clients and improved management of complaints. HCI is the leading partner in Mpumalanga for supporting the implementation of the National Core Standards (NCS) in all facilities and supported the province relative to conducting the provincial NCS workshop where training was provided and plans were developed for implementation of the NCS. The training workshops were also conducted in three districts. HCI supported the districts and sub-districts with the establishment and training of assessment teams in collaboration with other PEPFAR partners. HCI has supported district and provincial teams with facility assessments and provided mentorship in the development of facility QI plans. HCI supported the development and sharing of best practices. In Nkangala, Mammetlake Hospital is being developed as a “model facility” for implementing NCS. HCI also supported the province in conducting training on infection prevention and control, complaints procedures, and supervision. In Limpopo, HCI provided support and mentorship for developed of integrated QI plans to support Sekhukhune District. Strengthening the family planning (FP) program in KwaZulu-Natal as a strategy to prevent maternal and child mortality by preventing unplanned pregnancies In addition to the provincial and district level support for improvement activities, HCI supported a second improvement intervention in FY13 in Uthungulu District of KwaZulu-Natal Province focused in family planning (FP). HCI supported the communication of the FP strategy to all facilities in Uthungulu and to the communities through meetings with community leaders and faith-based organizations. HCI also supported practical training for professional nurses to develop knowledge and skills on intrauterine device (IUD) insertion in three districts in KwaZulu-Natal.


Advocacy for providing IUD services was conducted at facilities, and progress on the availability of IUDs and related services is monitored and reported to the district and province. HCI also provided mentorship on FP to professional nurses. As a result of these efforts, the total number of FP acceptors across all methods and facilities in the province rose by 8%, from 488,788 in April-June 2012 to 528,624 in July-September 2013. The number of IUDs inserted in the province increased from 492 in April-June 2012 to 4,696 in July-September 2013, an almost 10-fold increase. Significant improvement has occurred in awareness of FP services and in the FP knowledge and skills of health care providers. IUD insertion was a skill that had been lost in the service, and the improvement intervention led to the revival of IUD as an FP method. Inputs to National Department of Health In FY13, HCI provided inputs to the DOH district health cluster on competencies required for clinic supervisors and facility managers for the purpose of policy development. We have also worked to develop a National Supervisory Policy Standard Operating Procedures manual and a capacity development framework for primary health care supervisors and facility managers. Inputs have also been provided to the national PMTCT Directorate with regard to revising the PMTCT policy and to the Office of Standards Compliance on progress and challenges in provinces implementing National Core Standards. Activity 3: Referrals and Linkages Over the reporting period, HCI provided support to all five provinces to strengthen linkages between services and communities through community meetings, community dialogues, and meetings with community structures such as “war rooms,” Sukhuma Sakhe, youth groups, women’s groups, men’s groups, religious groups, and faith-based organizations. HCI provided technical assistance to provinces and districts during the development of referral networks and strengthening service integration. HCI was the lead partner in the establishment of comprehensive HIV, AIDS and Sexually Transmitted Diseases meetings in districts in Mpumalanga where HCT, PMTCT, and ART programs have integrated quarterly review and planning meetings. HCI works closely with other development partners within the provinces, and the combined efforts are producing better and more sustainable outcomes. Significant improvement has been seen in the integration and coordination of efforts from different PEPFAR and other development partners. Activity 4: Policy Development In FY13, HCI provided continuous support to the national PMTCT unit on the development of policy updates through the national PMTCT Technical Working Group where other development partners are also represented. HCI also provided inputs to the DOH on the update of the primary health care supervisor’s manual and national supervisory policy. In Mpumalanga Province, HCI provided TA with the development of the monitoring and evaluation guideline, provincial infection control policy, and complaints management policy. Support has also been provided in the communication of the policies and in their monitoring of implementation. Activity 5: Community Engagement As reported above, in FY13 HCI provided support to Mpumalanga and KwaZulu-Natal provinces to strengthen linkages between services and communities through community meetings, community dialogues and meetings with community structures such as “war rooms,” Sukuma Sakhe, youth groups, women’s groups, men’s groups, religious groups, and faith-based organizations. HCI participated in the client satisfaction survey in Mpumalanga, which will be completed in November 2013. As a follow-on to the QAP and HCI projects in the country, ASSIST South Africa started in October 2013. The ASSIST Project’s main objective in South Africa will be to strengthen the health system relative to HIV and AIDS, working in the priority provinces as a specialized PEPFAR Partner for Quality.


2.10 Swaziland



1. Improve the infection control infrastructure of the national TB hospital

Assist in upgrading the functionality of the ventilation system at the TB hospital as part of infection control support

National TB Hospital

2. Improve the diagnostic capacity and infection control infrastructure of TB centre

Assist in upgrading the infrastructure and re-establish laboratory diagnostic capacity to enable rapid diagnosis of TB and fast initiation of TB and HIV treatment

TB Center

3. Improve the diagnostic capacity and infection control infrastructure of Raleigh Fitkin Memorial (RFM) Hospital

Improved infrastructure and install GeneXpert equipment

Redesigned X-ray unit and ventilation system for isolation rooms in the female ward (RFM Hospital)

Increased universal access to TB, TB/HIV, and multi-drug-resistant TB care and treatment

TB Center Manzini: This activity was originally planned for RFM Hospital, but doing so was precluded by funding constraints

Main Activities and Results Activity 1: Improve the infection control infrastructure of the national TB hospital Assist in upgrading of the functionality of the ventilation system at the hospital as part of infection control support HCI installed a new ventilation system at the TB hospital and trained hospital staff to manage it. The hospital required a climate control system for the negative pressure system to work, so a contractor was identified to install it. Following the installation of the mechanical ventilation and the climate control systems, the system was validated and certified and officially transferred to the MOH. In addition, two bio-medical technicians have received onsite, hands-on training to maintain the systems. To ensure that the ventilation system is maintained and used as instructed by the installers, standard operating procedures (SOPs) were developed and implemented. HCI involved the national TB hospital management and MOH through consultative meetings to ensure sustainability and ownership of the maintenance and infection control practices at the hospital. Since 2009, the TB hospital could admit only a maximum of 55 patients. However, from July 2013, the upgraded TB hospital has doubled its capacity to over 100 patients. Activity 2: Improve the diagnostic capacity and infection control infrastructure of the TB center In quarter three of FY13, orientation on the mechanical ventilation and climate control systems was conducted for 42 health care workers. SOPs and protocols on system use have been developed and shared with the health care workers. In addition, 60 health care workers and 40 auxiliary staff were trained on infection prevention and control practices. The curricula covered standard TB infection prevention and control measures as well as general infection control, such as hand hygiene, sharps disposal, and waste management. The infection control committee also implemented its first QI project on surveillance for TB among health care workers at the TB hospital. At the national TB hospital, HCI has continued to support the maintenance of the mechanical ventilation and climate control systems and to ensure provision of surgical masks for all patients and respirators for health care workers. A number of improvements were done including strengthening the administrative control measures; review of IPC SOP; N95 fit testing for 85 health care workers and promoting a safe working environment.


TB Hospital staff attend TB infection control training. Respirator fit testing for TB hospital workers.

Activity 3: Improving the diagnostic capacity and infection control infrastructure of RFM Hospital Infrastructural improvement and installation of GeneXpert at the TB Center The TB Center in Manzini is a specialized clinic offering only TB diagnostic, care, and treatment services. Refurbishment by HCI at the center included creating additional consultation room space, a records/filing room, and a staff lounge. The clinic accommodates the large numbers of patients who access services there. Following the renovations, HCI assisted in adjusting patient flow and conducting baseline risk assessment for infection control. The center and HCI staff worked to address weak areas by revising the infection control plan, designating an infection control focal person, and conducting refresher onsite training for health care workers at the facility. HCI also participated in the development of SOPs for the facility and its standards of care. Patient flow was revised to eliminate patient backtracking and to optimize space utility. The rooms are clearly labelled, and patients can only progress forward from room to room, reducing the risks for cross-infections and confusion. The multi-drug-resistant TB patients are seen in a select area of the clinic and receive priority to access services. Infrastructure refurbishment of the lab and installed equipment at the center was undertaken to ensure efficient use and improved turnaround times for lab results. The lab for TB diagnostics has been supported with a GeneXpert machine and the human resources to run it to reduce the turnaround times for sputum results. Faster diagnoses reduce the risk that patients would become lost to follow-up before initiation on treatment. After infrastructure improvements and GeneXpert installation, HCI helped the facility implement the “FAST strategy,” a component of the comprehensive infection prevention and control measures. All patients with presumptive TB are asked to submit sputum specimens for investigation: The GeneXpert results are received and patients are linked to care the same day as the test. Contacts of patients diagnosed with TB are investigated in the facility. After the TB center refurbishments were completed, the center was commissioned by the Prime Minister and US Ambassador to Swaziland. The center is now a center of excellence for the provision of TB treatment and care services. Redesigned X-ray unit and ventilation system for isolation rooms in the female ward at RFM Hospital At RFM hospital, HCI worked to improve health care worker safety in the radiology department. The previous set-up lacked sufficient protection against repeat radiation for the technician. The area was redesigned to limit radiation exposure and improve infection control in the X-ray rooms and reduce cross-infection risk to the technician. Increased universal access to TB, TB/HIV, and Multi-drug-resistant TB care and treatment To address most-at-risk populations, HCI assisted in establishing a TB clinic in the Matsapha Correctional Institution to offer diagnostic services for both inmates and correctional officers. To do


so, HCI procured a park home to use as a TB clinic and had it installed next to the existing health clinic. The new clinic has three consultation rooms: The first room is used for initiating TB patients into treatment, the second to provide HIV testing and counseling, and the third is reserved in anticipation of GeneXpert equipment, procured with support from CDC. The equipment will process sputum for newly diagnosed TB patients; microscopy will be used to follow up TB cases. The lab now serves as a hub for TB diagnosis for the other 11 correctional institutions in the country. Following installation of the TB clinic, HCI project staff trained 12 nurses from the correctional service on TB/HIV management and the 3 I’s. The nurses, new to TB control, are engaged in a pre-deployment internship at the TB center and work under supervision to gain skills to provide quality TB/HIV services. In addition, the internship is aimed at building the nurses’ capacity to initiate patients on TB treatment and improve documentation. The correctional service TB clinic is operational and provides services to 20-30 clients per day. Improved quality of service delivery by refurbishments of TB clinic Between 2008 and 2010, HCI procured and placed five park homes in various health facilities to be used as TB clinics. During FY13, they were refurbished to improve service delivery. At the Dvokolwako Health Center, the TB clinic has been completed and has improved the service delivery at the health center (previously the clinic was in an operating mini-theater). The new clinic design provides improved ventilation and increased storage for drugs and patient records. Close out and transition activities to the ASSIST Project HCI activities in Swaziland were completed in September 2013. As of October 2013, all support for TB-HIV quality improvement in Swaziland is being provided by the ASSIST Project.

ASIA

2.11 Afghanistan


What are we trying to accomplish?

Key activities Geographic scale

1. Support the Ministry of Public Health and partners in building their capacity to improve quality in health care through use of a harmonized QI approach

Support the development of the Harmonized QI Approach

Support the Improving Quality in Health Care (IQHC) Unit to maintain coordination with other Ministry of Public Health Ministry of Public Health (MOPH) Departments and Ministry partners to facilitate smooth implementation of the IQHC strategy and the unit’s activities

Integrate all quality-related data management systems into a national MOPH data recording and reporting system

National level

Rapid field test of the Harmonized Package in health facilities in 3 districts, Kabul only

2. Phase out direct support to improvement activities in provinces and hospitals

Phase out technical support at the provincial level to the health facility and community QI collaborative, the maternity hospital collaborative, the Helping Babies Breathe Program, and the work to strengthen the medical record system

Kabul, Balkh, Kunduz, Parwan, Bamyan, Herat, Logar, Wardak, Samangan, and Saripul provinces

Main Activities and Results Activity 1: Support the MOPH and partners in building their capacity to improve quality in health care through use of a harmonized QI approach The Afghan MOPH has an established a clear mission “to improve the health of the people through quality health care services provision and the promotion of healthy life styles in an equitable and


sustainable manner.” Previously, attempts to make improvements were not well-coordinated or applied uniformly across the sector. Since 2012, the Improving Quality in Health Care Unit of the MOPH, with financial support from USAID and technical support from its partners, has been working to harmonize the main quality approaches in health at the national level. A core group from the senior leadership of USAID, Health Service Support Project (HSSP), Tech-Serve, HCI, and the IQHC Unit was established on in early January 2012 to provide general guidance and oversight on the process. The IQHC Unit now reviews all proposed MOPH policies and strategies before they are presented for approval by the MOPH Executive Board to ensure that elements of the national strategy are fully included. The programmatic areas of focus of the Harmonized QI Approach are MOPH priority areas, such as maternal and newborn health; child health; communicable diseases; nutrition; and cross-cutting priorities, such as infection prevention, blood transfusion, health promotion, and nursing care. During FY13, in light of new funding realities and the decision to harmonize different QI methodologies, HCI refocused all its support to the MOPH in the development, finalization, and formal approval of the Harmonized QI Approach. HCI supported the IQHC Unit to develop a field implementation guide for the approach and a training package (facilitator’s guide, participants’ handouts, and other reference materials). Throughout FY13, the IQHC Unit led the process, convening core group meetings and task group meetings to review and classify all existing QA standards and fold them into a single Harmonized Package of Standards for 21 service delivery areas for all three basic public health services levels (i.e., district hospitals, comprehensive health centers, and basic health centers). The IQHC Unit and HCI technical staff field-tested the completed package of standards at all three basic services levels in Kabul and Nangarhar provinces in February 2013. The implementation guide and the training package underwent review by the Consultative Group on Health and Nutrition and the Technical Advisory Group of the MOPH – two technical forums that review all MOPH policies and strategic documents before their formal approval by the MOPH Executive Board. The Harmonized Package was translated into Dari and then formally approved in October 2013 by the Executive Board. Translation of the Healthcare Quality Improvement Partnership (HQIP) Field Implementation Guide and HQIP training package into Pashtu is partially completed. Completion is planned during the follow-on support to the IQHC Unit through the Management Sciences for Health Leadership, Management and Governance Project. As a result of these efforts, the Harmonized Package for all Basic Package of Health Services facility levels (i.e., district hospitals, comprehensive health centers, and basic health centers) has been developed and is ready for nationwide launch and implementation. HCI believes that the IQHC Unit now has the capacity and resources to oversee, coordinate, and maintain the approach at the national level and provide technical support and guidance to implementing NGOs on issues surrounding quality of health care in general and the Harmonized Approach in particular. Activity 2: Phase out direct support to improvement activities in provinces and hospitals The following activities which had been directly implemented by HCI in FY12 were phased out by December 2012: implementation of the health facility and community QI collaborative; implementation of the maternity hospital collaborative; the Helping Babies Breathe Program; and efforts to strengthen the medical record system. Implementation of the health facility and community QI collaborative The first improvement activity supported by HCI in Afghanistan, starting in 2009, was the development of the Maternal and Newborn Health Facility Demonstration Improvement Collaborative in Balkh and Kunduz provinces. Within six months of the collaborative’s start, in both provinces, facility QI teams were showing strong gains in a number of quality indicators, particularly second dose tetanus toxoid vaccination of pregnant women, ANC counseling with key messages, and delivery of essential newborn care. The MOPH was keenly interested in spreading the maternal and newborn interventions to additional provinces and selected Bamyan, Parwan, and Herat provinces for the first spread wave. This


was followed by spread to four additional provinces in 2012: Logar, Wardak, Samangan, and Saripul. By the end of 201220, the collaborative’s interventions had reached 85 health facilities in the nine HCI-targeted provinces, achieving measurable gains in quality of maternal and newborn care for an estimated total catchment population of 1,586,084 (about 24% of the total population of the nine provinces). During the last three months that data were collected (Oct-Dec 2012):

Use of the partogram, rose from baseline levels of ~20% to an average of 92% (Figure 13) Compliance with ANC counseling standards rose from baseline levels of under 40% to an average of

92% (Figure 14) The percentage of pregnant women who could cite at least two birth preparedness actions and at

least two pregnancy danger signs rose to an average of 94% and 95%, respectively, up from baseline levels below 50%

The percentage of vaginal births in which all three elements of AMTSL were performed (i.e., oxytocin administered within one minute of delivery, controlled cord traction, and uterine massage), averaged 87%, up from baseline levels of under 50% in Balkh and Kunduz and below 10% in the other provinces (Figure 15)

Compliance with essential newborn care standards (i.e., drying and wrapping the newborn, umbilical cord care, and immediate breastfeeding) averaged 90%, up from baseline levels near 50% in Balkh and Kunduz and below 10% in the other provinces

Compliance with postnatal care standards rose from baseline levels of under 30% to an average of 85%

Percentage of mothers able to cite at least two maternal and newborn danger signs after delivery, rose from baseline levels below 40% to an average of 88%

Figure 13. Afghanistan: Percentage of vaginal deliveries for which a partogram was completed (demonstration, Wave 1, and Wave 2 provinces) (June 2009-December 2012)

AprMayJun Jul AugSepOctNovDecJanFebMarAprMayJun Jul AugSepOctNovDecJanFebMarAprMayJun Jul AugSepOctNovDecJanFebMarAprMayJun Jul AugSepOctNovDec

2009 2010 2011 2012

Demonstration 17 24 33 41 38 36 37 37 43 60 44 63 81 67 56 70 77 80 93 93 89 96 92 94 95 97 98 99 99 100100100 94 100100100100 98 99

Wave 1 24 20 21 33 39 26 64 59 68 70 68 85 90 85 86 89 92 92 94 93 95 96 97 95 99 97 91 96 96 96 93 92 97

Wave 2 15 18 51 52 50 46 47 50 68 92 95 93 96 99 99 100 99 100100 99 100100100

0

20

40

60

80

100

Percentage

Indicator 1: Percentage of vaginal deliveries for which a partogram was completed

Demonstration Wave 1 Wave 2


Figure 14. Afghanistan: Improvement in compliance with antenatal care counseling standards (demonstration, Wave 1, and Wave 2 provinces) (June 2009-December 2012)

Figure 15. Afghanistan: Improvement in compliance with active management of the third stage of

labor (demonstration, Wave 1, and Wave 2 provinces) (June 2009-December 2012)

During the 48 separate learning sessions HCI conducted in the nine provinces, 1175 health workers were trained in evidence-based maternal and newborn care practices and QI methods. In FY13, the USAID Mission in Afghanistan directed HCI to end provincial level support by December 2012; support facility level QI was transferred to provincial MOPH authorities and NGO implementing partners.

AprMayJun Jul AugSep OctNovDec Jan FebMarAprMayJun Jul AugSep OctNovDec Jan FebMarAprMayJun Jul AugSep OctNovDec Jan FebMarAprMayJun Jul AugSep OctNovDec

2009 2010 2011 2012

Demonstration 21 77 86 92 87 77 85 91 77 93 87 90 92 92 84 94 94 93 78 87 89 94 88 90 92 91 94 93 92 92 95 92 94 92 94 93 94 100100

Wave 1 42 39 45 57 67 74 78 86 88 85 90 88 92 92 90 92 92 89 84 84 88 87 91 89 88 92 88 91 94

Wave 2 34 27 30 9 12 18 14 30 50 59 74 84 90 90 91 96 97 98 100100100

0

20

40

60

80

100

Percentage

Indicator 4: Average percentage compliance with ANC counseling standards (birth preparedness, danger signs, routine newborn care


AprMayJunJulAugSepOctNovDecJanFebMarAprMayJunJulAugSepOctNovDecJanFebMarAprMayJunJulAugSepOctNovDecJanFebMarAprMayJunJulAugSepOctNovDec

2009 2010 2011 2012

Demonstration 46 29 41 44 42 52 54 55 57 60 60 67 64 63 42 60 67 68 65 68 73 97 87 95 95 97 97 99 10 10 10 10 94 10 10 10 10 10 99

Wave 1 0 0 0 0 0 7 20 38 47 62 68 73 94 92 87 88 88 91 93 99 97 97 99 94 99 95 92 98 97 98 96 93 99

Wave 2 0 0 7 8 9 11 7 15 23 43 59 66 75 76 79 98 98 10 10 10 10 10 10

0

20

40

60

80

100

Percentage

Indicator 7: Percentage of vaginal births for which 3 AMTSL elements were performed (oxytocin within 1st minute after delivery, cord traction,

uterine massage)



Implementation of the maternity hospital collaborative In parallel with the provincial level facility and community maternal newborn health improvement collaboratives, HCI also developed a hospital maternity care collaborative for several large public and private hospitals in Kabul. to improve the prevention and treatment of the major causes of direct maternal and neonatal mortality. Figure 16 shows the improvement achieved in the Kabul hospitals compared with the provincial hospitals for the percentage of births for which all three AMTSL elements were performed. Average compliance rose to 97% in the last three months that the data were collected (January-March 2013).

Figure 16. Afghanistan: Percentage of births for which 3 AMTSL elements were performed, Maternity hospital collaborative (April 2010-March 2013)

During FY13, the maternity hospital interventions were developed in close coordination with the MOPH based on MOPH priorities; the interventions emphasized preventive and curative case management of maternal and newborn sepsis through the implementation and monitoring of evidence-based interventions and infection prevention standards. HCI first modified and tailored for Afghan hospitals international infection prevention standards and then conducted infection prevention baseline assessments addressing four areas (waste management, all services, surgery, and safe injection) in Kabul and in Wave 1 and 2 provinces (Herat, Bamyan, Balkh, Parwan, Logar, Wardak, Samangan and Saripul). HCI trained about 160 first-line providers on infection prevention standards in HCI-assisted hospitals in Kabul and 69 providers in Balkh, Parwan, Herat, and Bamyan regional hospitals. Maternal and newborn sepsis work was begun only in Kabul hospitals. All HCI support for maternity hospital improvement in the provincial hospitals ended in December 2012. In Kabul, HCI staff continued to provide technical support to Kabul maternity hospitals through June 2013, when all assistance ended as part of the close-out of HCI assistance in Afghanistan. As part of the technical handover of the project, a change package of evidence-based practices (lessons learned throughout the HCI Project) was submitted to the IQHC Unit in early September 2013.

0

20

40

60

80

100

A‐10

M‐10

J‐10

J‐10

A‐10

S‐10

O‐10

N‐10

D‐10

J‐11

F‐11

M‐11

A‐11

M‐11

J‐11

J‐11

A‐11

S‐11

O‐11

N‐11

D‐11

J‐12

F‐12

M‐12

A‐12

M‐12

J‐12

J‐12

A‐12

S‐12

O‐12

N‐12

D‐12

J‐13

F‐13

M‐13

Percentage

A-10

M-10

J-10

J-10

A-10

S-10

O-10

N-10

D-10

J-11

F-11

M-11

A-11

M-11

J-11

J-11

A-11

S-11

O-11

N-11

D-11

J-12

F-12

M-12

A-12

M-12

J-12

J-12

A-12

S-12

O-12

N-12

D-12

J-13

F-13

M-13

Kabul Collaborative 20 31 41 58 48 57 82 84 89 88 88 87 86 82 85 94 94100100100100100100100100100100100100100100100100100100100

Provincial Collaborative 0 0 81 43 23 16 22 84 85 78 91 96 95 89 90 9810093 9810010091 96 9810010091 96 9810097100100

Wardak & Logar 60 65 95 95 95 95100100100

Maternity Hospital Collaborative Indicator 5: Percentage of births for which 3 AMTSL elements performed (Oxytocin given at 1st minute after

delivery, Cord traction, Uterine fundal massage)

Kabul Collaborative Provincial Collaborative Wardak & Logar


Alongside this, the gradual transfer of HCI technical staff to the IQHC Unit took place from mid-August. By mid-September, all three technical HCI staff members were based at the IQHC Unit. They are considered MOPH employees on and after October 1, 2013. This measure is expected to ensure sustainability of QI activities. Hospital Medical Records The MOPH and Medical Record (MR) committee approved the medical record revised package as a national tool to be used in all hospital maternity wards countrywide. Presently, the medical information of all visiting patients is regularly recorded. If they are outpatients, they are registered in the out-patient department logbook. If they are inpatients, they are referred to the MR department and their information is recorded in the Patient Master Index (PMI) of MR computers. By establishing this new MR system and use of the new MR package, remarkable changes and improvements are expected to be observed in the patient recording, in the filing system, in the retrieval of patient files, and in archiving and data quality. To institutionalize the use of medical record data, HCI reviewed, revised, and finalized the Medical Record Policy as requested by the MR committee and MOPH Health Management Information System Department. In addition, the development of the PMI in a new platform was finalized during the second quarter of FY13. The new PMI is installed on a number of MR computers at Malalai hospital for quick referral and on all computers of the MR departments of the hospitals where PMI was piloted. Postpartum family planning (PPFP) improvement HCI had started the PPFP demonstration improvement collaborative at Malalai, Isteqlal, Afghan, Shinozada, and Mehdi (two public and three private) hospitals in Kabul in October 2011 to improve the quality of PPFP services and establish a system that includes good quality counseling, accessibility to FP methods, and the empowerment women to select a FP method during the postpartum period. HCI reviewed and redesigned PPFP counseling tools (registration book, indicators, questionnaire, and client cards) and recruited female counselors to provide systematic peer counseling. To ensure privacy during peer counseling (husbands and wives and in some cases involving the wives’ mothers-in-law), the counseling rooms in Malalai and Isteqlal hospitals were redesigned. Data collected to evaluate the intervention found follow-up at three, six, 12, and 18 months revealed postpartum women in the intervention group had markedly fewer pregnancies than those in the non-intervention group. To institutionalize the PPFP program and facilitate smooth handover, HCI built the capacity of the MOPH Reproductive Health (RH) Directorate staff and gradually ended its involvement in the PPFP program. HCI conducted training sessions and made joint coaching visits with RH staff to PPFP-targeted hospitals in Kabul. Eventually, PPFP collaborative activities were handed over to RH staff in June 2013. HCI provided PPFP counseling to 41,355 clients from October 2011 to June 2013. Helping Babies Breathe (HBB) Program HCI supported Afghanistan’s roll-out of HBB. During FY13 the HBB training of trainers was conducted for 10 US military medical personnel in Kabul in February. The US military medical team replicated the HBB training and so far has trained 179 first-line providers on how to resuscitate babies during the golden minutes of life in two insecure provinces of Afghanistan (Paktika and Baghlan). HCI donated eight mannequin sets with a number of resuscitation sets along with training materials in local languages to the military medical team ensure that the HBB trainings would be conducted precisely correctly. HBB activities were handed over to stakeholders and Provincial Public Health Offices in HCI-targeted provinces on December 31, 2012. However, HBB activities continued in HCI-targeted hospitals in Kabul till their handover in June 2013. To institutionalize HBB within the health system and ensure its sustainability, HCI conducted an HBB training of trainers workshop at Malalai Hospital in May 2013. Thirty-two participants from the Reproductive Health Directorate, the Afghanistan Midwifery Association, the Ghazanfer Institute of Health Services, and Malalai Maternity and Isteqlal hospitals were trained. In addition, an HBB training


was conducted by the newly trained HBB trainers in June 2013 for 22 front-line providers, including a doctor and midwives from Malalai and Isteqlal hospitals, on how to resuscitate asphyxiated newborns during the first minute of life. HCI staff also supported the RH Directorate to include the HBB initiative in the RH Learning Resource Package to ensure future sustainability. The HBB training package, which includes soft and hard copies and 120 mannequin and 120 resuscitation sets, 120 HBB trainer and participants’ book, pelvic model, and HBB flip charts, were provided to Malalai and Isteqlal hospitals, the Afghanistan Midwifery Association, the Ghazanfer Institute of Health Services, and the MOPH. End-of-project conference To officially hand over all technical deliverables and close the four-year program of HCI assistance to the MOPH, HCI convened a one-day conference in Kabul on July 7, 2013. Key participants in the conference were the Deputy Minister of Public Health, the USAID Health Team Leader, the IQHC Unit Coordinator, and representatives from the WHO, UNICEF, and Management Sciences for Health (which will continue to provide technical support to the IQHC Unit for the coming year through the Leadership, Management and Governance Project). The conference included presentations on achievements, lessons learned, and recommendations for the MOPH and partners. It also had an interactive session with speakers at small tables demonstrating the results that had been achieved and tools developed in the project’s focus areas: facility-based improvements in maternal and newborn care, HBB, postpartum family planning, medical records, and community health promotion. The event concluded with a panel discussion on the way forward for QI in the Afghan health sector. The Deputy Minister publically acknowledged his appreciation for HCI’s contribution and requested USAID to continue its support for QI. He expressed appreciation for the 2013-2014 transition plan and the 2014-17 improvement plan that HCI had drafted. The WHO representative recognized the excellent collaboration that WHO had enjoyed with HCI on various policy-level initiatives and thanked project staff for their strategic support to the MOPH. Each participant received a flash drive with the electronic copies of all QI materials and training guides developed by HCI as well as a hard copy of The Improvement Guide.

2.12 Indonesia




1. Hospital Accreditation Process Impact Evaluation: Evaluating the quality of care provided in hospitals undergoing Joint Commission International (JCI) and Indonesian Hospital Accreditation Commission (KARS) accreditation

Quantitative and qualitative evaluation of the effect that implementing a new hospital accreditation system has on process and outcomes measures in 9 Indonesian hospitals

This is evaluation is not intended to directly improve processes in Indonesia. However, results will be fed back to stakeholders along with recommendations on actions to take to address deficiencies

Nine hospitals have been selected in three provinces:

3: JCI accreditation

2: KARS accreditation

4: 2015 renewal of KARS accreditation

Main Activities and Results In 2012, the USAID HCI Project was engaged to begin an evaluation of the quality of care and patient outcomes in Class A Indonesian hospitals in a study know as HAPIE, the Hospital Accreditation Process Impact Evaluation. This longitudinal comparison study is examining changes in quality and safety

Most of the projects, when it finishes there is no follow up and most of the cases it collapses. But HCI prepared a long term plan for the MOPH to build on what HCI achieved.

--WHO Representative, End-of-Project Conference, July 7, 2013


performance in nine hospitals: three undergoing the JCI accreditation process, two undergoing the new KARS accreditation process and four that are not due to have any accreditation until 2015. The HAPIE study will be conducted in three phases: baseline, mid-term (18 months after baseline), and endline (36 months after the baseline). The baseline was completed in FY13 by URC and our partner, the Center for Family Welfare (CFW) – Universitas Indonesia, under the HCI Project. The mid-term and endline evaluations will be conducted through the ASSIST Project.

Activity 1: Hospital accreditation process impact evaluation: evaluating the quality of care provided in hospitals undergoing JCI and KARS accreditation The study was divided into four parts. The hospital review captured data in 10 domains of organization-wide quality management. An organizational audit was conducted to describe the quality of care at the unit/department level within a hospital related to the four diagnoses (normal delivery, acute myocardial infarction, pediatric pneumonia, and hip fracture). A questionnaire captured patients' experiences with their care during an inpatient stay. Twenty key informants, mostly from hospital accreditation teams, were interviewed: two from each hospital except four from one hospital. Data were collected in the nine hospitals in October and November by the CFW team. Dr. Edward Broughton travelled to Jakarta twice during the year to analyze data collected in the baseline period, draft the report of results, identify implications for improving data capture at 18 and 36 months, report back pooled results to administrators from a selection of the nine hospitals, and meet with WHO for an update on progress with KARS reforms. He was also involved in directing the data collection and developing the capacity of the CFW team in data collection, analysis, and report writing. Along with Dr. Anhari Achadi of CFW, he was also involved in two of the feedback meetings where the general results were presented separately in two of the nine participating hospitals. The following are selected data collected during the baseline evaluation and presented at the hospital feedback meetings. Figure 17 shows the proportion of pneumonia case records from each of the nine hospitals in which the medical history was completely recorded: It was lower than 50% in all hospitals. Figure 18 shows the proportion of charts from acute myocardial infarction cases that were missing important information in the medical history. These figures represent the general pattern of inadequate recording of medical histories of patients and the results of their physical examinations, two important indicators of performance quality in a hospital.

Figure 17. Indonesia: Pneumonia medical history recorded in patient’s medical chart


Figure 18. Indonesia: Proportion of acute myocardial infarction records missing important data in medical history

EUROPE AND EURASIA

2.13 Georgia



1. Improve quality, consistency, and continuity of medical care in Georgia in a demonstration region

Improve timeliness, continuity, effectiveness, efficiency, and patient-centeredness of services and their consistency with clinical guidelines through the improvement collaborative approach

Strengthen the capacity of medical providers to provide safe, timely, continuous, effective, and efficient medical care

Strengthen the capacity of local partners (medical associations, training centers, teaching hospitals, and medical schools) to deliver continuous learning opportunities

Improve awareness on quality improvement experiences countrywide

Strengthen health information systems to support development of evidence-based decisions on improvement quality of medical care

Ensure equitable access to priority “best-buy” high impact medical services in the demonstration region

Improve the quality, consistency, and continuity of medical care in a demonstration region

2. Improve access and use of evidence-based medical information by Georgian physicians and enhance the

Improve access to evidence-based medical literature (guidelines, manuals, pathways, protocols) of Georgian physicians

Enhance the use of evidence-based clinical guidelines, protocols, and pathways in clinical practice

Strengthen the capacity of professional associations in developing and adapting international guidelines and evidence-based literature to the Georgian context

Provide TA to hospital and insurance company executives on

Dissemination of evidence for priority conditions to all physicians countrywide, Demonstration intervention to improve the



availability of modern evidence- based treatments

planning and introduction of new essential medical technologies quality, consistency, and continuity of care in one region with 294 health facilities

Main Activities and Results The HCI Project in Georgia was officially launched in February 2012 and was initially scheduled to end on September 30, 2013. To ensure a minimum 18-month period of full-scale implementation and achieve maximum project impact in line with the project objectives and scope-of-work (SOW), the project applied for and received approval from USAID for a no-cost extension until September 29, 2014. HCI in Georgia has achieved significant gains in its first two full years of implementation and is well on its way to meeting the objectives identified in its original SOW. Activity 1: Improve quality, consistency, and continuity of medical care in a demonstration region During FY13, the Georgia HCI team conducted four learning sessions; 34 field trips; and 5766 provider-hour trainings, including:

1668 provider-hours in QI methodology (including principles of evidence-based medical practice) 980 provider-hours in cardiovascular disease (CVD) risk factor screening and modification 578 provider-hours in acute coronary syndrome management 2029 provider-hours in pediatric pneumonia/ acute respiratory tract infection (RTI) management 702 provider-hours in asthma/chronic obstructive pulmonary disease (COPD) management 214 medical providers trained in evidence-based medical guidelines After 18 months from the start of regional collaborative improvement activities, the project witnessed significant improvement in all project priority clinical areas:

Average compliance with evidence-based best practices on screening, prevention, and management of CVD risk-factors increased by 72% from baseline

Average compliance with management of acute coronary syndrome best practices improved by 31% Average compliance with RTI management best practices in ambulatories and hospitals of

improvement intervention facilities improved by 51% and 36%, respectively Average compliance with asthma and COPD management best practices in ambulatories and

hospitals improved on average by 74% and 65%, respectively Figure 19 provides an illustrative example of compliance with the most difficult indicators in one of the project’s priority clinical areas as well as project interventions to address identified gaps in care, specifically: calculation of global CVD risk, which can be reduced dramatically with a low-cost “bundle” of medications like aspirin and blood pressure and cholesterol drugs (primary prevention) and secondary prevention of heart attack. Figure 19 shows that despite constant and reliable improvement in risk calculation, compliance with best practices in primary and secondary prevention of CVD vary significantly. These variations could also be caused by following: 1) both indicators are composite measures and counted as positive only if all relevant medications are prescribed or counter-indications noted; 2) small sample size (in August only five charts were eligible for primary prevention). After 18 months of implementation in Georgia, HCI-supported facilities achieved reliable, consistent delivery of essential, high-impact, cost-effective prevention and treatment services of high-burden non-communicable diseases considered “best buys” by WHO (Table 8).


Figure 19. Georgia: Calculation of 10-year risk of CVD event, primary and secondary prevention of CVD with high-impact medication bundle, 3 polyclinics and 13 village practices (March 2012 –

August 2013)

Table 8. Georgia: Percentage of medical charts with best clinical practices for each clinical focus area in 17 project-supported ambulatory sites and 3 hospitals, Imereti Region (April 2012-August

2013)

Clinical Focus Area Baseline April 2012

Aug 2013

Primary and secondary prevention of CVD (average compliance with best practices) (17 sites)

23% 95%

Body Mass Index documentation and counseling on diet and physical activity during last 12 months

6% 98%

Smoking status documentation and tobacco cessation intervention at last visit 8% 97% Anti-hypertension treatment prescribed/adjusted at last visit if hypertensive 72% 99% Acute coronary syndrome management (average compliance with best practices) (3 sites)

27% 58%

EKG and interpretation in 10 minutes at presentation 27% 89% Evidence-based initial treatment bundle (opioid analgesic, oxygen if indicated, nitrate, and aspirin)

2% 45%

Lipids measured prior to discharge - 43%

Screened for tobacco and, if smoker, received tobacco cessation intervention - 26%

Discharged on post-myocardial Infarction high-impact treatment bundle 9% 34%

Ambulatory management of asthma and COPD (average compliance with best practices) (3 sites) 15% 94%

Classification/severity status updated at last visit 0 100% Average number of non-evidence-based medications 4.20 0 Trigger (pets, viral infections, dust, smokers at home) assessed and modification plan recorded 0 100%

Hospital management of asthma and COPD (average compliance) (2 sites) 20% 85%

Distribution of job‐aids

Training in dislipidemia

Training in CVD risk management

State insurancefor age>60‐65

Initiation of state "Universal Health Care"

program

EB project presented at training questioning

aspirin prescription for

patients with diabetes

LS1

LS2

LS3

LS4 LS5

LS6

0

10

20

30

40

50

60

70

80

90

100

Mar‐12

Apr‐12

May‐12

Jun‐12

Jul‐12

Aug‐12

Sep‐12

Oct‐12

Nov‐12

Dec‐12

Jan‐13

Feb‐13

Mar‐13

Apr‐13

May‐13

Jun‐13

Jul‐13

Aug‐13

Calculation of estimated 10 year risk of heart disease and stroke (N=70)

high impact treatment bundle prescribed if 10 year risk of CVD event >20% or

diabetes (primary prevention N=20)


Clinical Focus Area Baseline April 2012

Aug 2013

Average number of nebulizer treatments during the first two days of admission in patients discharged for asthma/COPD last month 0 6.0

Spirometry results documented prior to discharge 0 100% Bronchodilator prescribed at discharge 0 50% Controller prescribed at discharge 0 50% Ambulatory management of respiratory tract infection in children (15 sites) 15% 94% % of medical charts of children diagnosed with acute RTI for whom diagnosis is supported by medical chart documentation

37% 100%

% of medical charts of children diagnosed with respiratory tract infection for whom vital signs were recorded in medical record

60% 97%

% of medical charts of children treated with antibiotic for RTI for whom chart documentation supports antibiotic use 14% 100%

% of medical charts of children treated with antibiotic for RTI for whom first-line antibiotic was used 15% 100%

Hospital management of respiratory tract infection in children (2 sites) 20% 85% % of charts of children hospitalized for RTI with diagnosis justified by chart documentation

49% 100%

% of charts of children hospitalized for RTI treated with evidence-based, first-line antibiotic (if antibiotics used)

32% 82%

Average # of non-evidence-based medications prescribed per RTI hospitalization 5.95 0.04 % of charts of children hospitalized for RTI for whom unnecessary diagnostic tests were ordered

76% 38%

Clinical and geographic spread of the QI activities As the project scope is limited to a few health care facilities and the desire to join the quality improvement activity is very high, partners and HCI signed a Memorandum of Understanding that provides that the partners will use resources developed within the project to improve quality of care, receive minimal external technical assistance, and share results with the project. Thus far, two health corporations (including My Family Clinic, a network of 32 hospitals and several ambulatory sites throughout Georgia), two professional medical associations, and four ambulatory health care clinics in the region and in Tbilisi have joined the partnership. As an example of such a partnership, My Family Clinic started implementing a standardized ANC chart the project had developed in collaboration with the Mother and Child Department of the National Center of Disease Control and Public Health. Along with routine services provided according to the state program, the chart also has a standard place for screening and modification of behavioral and physiological risk factors of major non-communicable diseases at various points of the existing system (e.g., screening for diabetes in high-risk populations at the first visit, universal screening of gestational diabetes at 24th week of pregnancy at the second visit, and calculation of 10-year CVD risk at the planned visit to internist etc.). The integration of CVD risk factor screening and modification practices in standard ANC is crucially important given the fact that NCDs increasingly play major role in morbidity and mortality of women of reproductive age and ANC visits are often the only opportunity to reach this population. The project also provided limited support to collaborative improvement facilities in their independent attempts to replicate QI in other clinical areas (clinical spread). Examples of such support are:

The head of the Internal Medicine Department at Regional Clinical Hospital in Kutaisi has led efforts in her facility to improve the quality of medical care for patients with stroke. The project helped her to review international evidence, choose adequate indicators, and perform a rapid baseline


assessment. Also, in September 2013 she had a one month internship in Germany that result from HCI’s efforts to strengthen organizational and personal linkages between the Georgian medical diaspora and their Georgian counterparts. After her return, she developed flow sheets and is planning to implement revascularization procedure (fibrinolysis) for stroke patients at the hospital.

The Second Adult Polyclinic in Kutaisi decided to spread a successful methodology on diabetes. They conducted chart review to understand the baseline situation, set the targets, and developed indicators to monitor progress in the management of diabetic patients. The clinic also started to develop a patient registry and adapted a flow sheet to support the generation, collection, analysis, and use of high-quality data for improving yjr quality of diabetes screening and management.

Activity 2: Improve access to and the use of evidence-based medical information by Georgian physicians and increase the availability of modern evidence-based treatments National Protocols The HCI team was deeply involved in the translation and adaptation of national protocols in the project’s clinical focus areas to standardize diagnostic/treatment interventions at specific levels of care, provide standard audit criteria to evaluate quality of medical services, enable making evidence-based decisions at each level of the health system, and enable billing and reimbursement by different payers (including state purchaser, insurance companies, etc.). During FY13, together with national experts, the project continued to work begun in FY12 on nine national protocols. Final versions of these protocols include all best evidence adapted to Georgia’s context. They have also undergone all stages for formal adoption by the state and have been adopted by the Guidelines Council at the Ministry of Labor, Health, and Social Affairs (MOLHSA) and will be institutionalized by ministerial decree in the near future. Continuous Professional Development Modules In FY13, to support sustainability and institutionalization of training modules, HCI, the Georgian Respiratory Association, and Tbilisi State Medical University, submitted several continuous professional development (CPD) modules to the Council of Continuous Professional Development at the health ministry. Four modules have been approved and registered by the council including: 1) Smoking status screening and tobacco cessation interventions; 2) Theoretical and practical aspects of spirometry : 3) Modern recommendations on assessment and treatment of asthma; and 4) Modern recommendations on assessment and treatment of chronic obstructive pulmonary disease. According to the agreement with professional medical associations and the university, after completion of the HCI Project, project participants will continue to implement the modules together: Professional associations will conduct the modules while the university will organize trainings and provide administrative support. Four additional modules have been developed. Together with the Professional Association of Family Doctors, the project prepared a module on dislipidemia screening and management. In addition, in collaboration with the Medical Association for Health Quality, the project developed draft continuous medical education modules: 1) CVD Risk-factor Screening and Modification, 2) Translating Research into Evidence-based Medical Practice, and 3) Quality Improvement in Medical Care. The modules will be submitted to the Council of Continuous Professional Development at the MOLHSA. Building evidence search and appraisal capacity To support medical doctors in their access to and use of modern evidence-based medical information, the HCI team conducted a training of medical personnel from CI facilities in the practical use of searching and reviewing evidence-based medical literature. With HCI support, providers in improvement intervention facilities also practiced evidence review. After the training, six doctors expressed interest in searching for evidence-based modern information on their own clinical cases and questions they have in their daily practice. The project technical team provided assistance in forming clinical questions and relevant keywords, searching the PubMed database, evaluating and choosing relevant articles, and making better treatment decision for their patients based on the latest research.


The results of their work were presented during a learning session and a summarized on the project web-page (http://healthquality.ge/). Together with New York University the project organized a five-day workshop in Kutaisi for health care professionals focused on evidence-based practice. HCI supported faculty members’ travel in the Imereti Region and the translation and reproduction of the training materials. Course topics included: 1) principles of research and evidence-based practice, 2) health research designs, 3) review of clinical practice guidelines, 4) literature search and review, and 5) critical thinking and research critique. Forty-eight doctors and managers of various medical facilities from western Georgia as well as top and mid-level managers from the central offices of Geo-Hospitals and My Family Clinic (health corporations owning a network of hospitals and ambulatory centers in different Georgian regions) attended the week-long training. During the training, participants worked in groups on clinical topics of interest and developed evidence-based practice projects to facilitate organizational change aimed at improving patient care outcomes and efficiency. HCI helped organize the training and contributed technically by providing examples and practical implications of the topics covered in relevance to participants’ routine clinical practice. Web and Facebook Pages To support wider access to and use of evidence-based medical information, the project developed a web-page for the Georgia Health Quality Forum: www.healthquality.ge. While building a culture of quality improvement in health care, the website facilitates dialogue and collaboration between/among interested parties, including the health ministry, the National Center for Disease Control and Public Health, professional medical associations, academics, the Georgian US medical diaspora, health care facilities, providers, and patients. To increase awareness of the project and the concepts and methods of improving health care quality and access to evidence-based medical information, the project runs a Facebook page, http://www.facebook.com/USAIDGeorgiaHealthCareImprovementProject. After its launch, the Georgia HCI team posted about 220 links to the up-to-date resources on best clinical and QI practices and provided translation of the summary evidence updates in Georgian. For the first week of October 2013, the page reached 2120 users and had 891 likes, mostly from medical personnel and health care facilities/ organizations.

Directions for FY14 Current activities in Georgia are expected to continue under HCI funding through December 2013 and then transition to ASSIST Project funding.

2.14 Ukraine




1. Training of trainers on an evidence-based brief physician intervention (BPI) for tobacco and alcohol quitting.

2. Training of health care providers on the use of BPI and FP counseling

3. Two learning sessions for participating providers to facilitate shared learning from the implementation of BPI

To achieve at least 80% tobacco- and alcohol-free pregnancies in selected facilities in two oblasts by September 2014

To achieve at least 90% coverage with BPI and FP counseling of reproductive age

Number of health care providers using BPI protocols

Percentage of pregnant women appropriately counseled on tobacco and alcohol at participating clinics

Percentage of non-pregnant women visiting participating clinics appropriately counseled on tobacco and alcohol and FP

Oblasts: Luhanks and Poltava

Facilities: women’s consultations, FP centers, ambulatory clinic, youth-friendly clinics (estimated total: 20)

Health care providers

(estimated total:


4. Development of a clinical/ organizational protocol (guideline) for BPI implementation nationwide

5. Development of a training curriculum for BPI and facilitation to incorporate the curriculum into post-graduate medical education in one or two medical education institutions

women and teenagers 15-17 years old

Percentage of teens age 15-17 appropriately counseled on tobacco and alcohol

Percentage change in tobacco use among pregnant women counseled

Percentage change in alcohol use among pregnant women counseled

100 )

Target populations: pregnant women (primary), teenage girls, women of reproductive age (Total # not yet estimated)

Main Activities and Results The project activity’s scope of work was approved by the USAID Europe and Eurasia Bureau and USAID Mission in Ukraine on February 11, 2013. In March, URC hired Dr. Elena Novichkova, Country Resident Advisor, and Ms. Katerina Bazayants, Administrative and Financial Officer, to initiate project activities and secure the project’s registration with the Government of Ukraine. Registration of the activity with the Government of Ukraine was approved in August 2013. In April 2013, two oblasts were selected for the intervention based on guidance from the Mission and MOH: Poltava and Luhansk. A Memorandum of Understanding with MOH as the project’s beneficiary was signed in May 2013. HCI signed three more memoranda of understanding with: the Ukrainian Medical Monitoring Center on Alcohol and Drug by the MOH, the Poltava Oblast Health Care Department, and the Luhansk Oblast Health Care Department. In April, Dr. Novichkova presented on the activity during the round table “Stop alcohol-related mortality: Government and society unite for saving lives,” organized by the Ukrainian Information Center for Alcohol and Drugs Problems. Attended by approximately 25 participants representing Verhovna Rada, the WHO office in Ukraine, civil society organizations, and anti-alcohol movements, the event received positive reviews. On June 11, 2013, HCI convened a formal launch for the Ukraine improvement program jointly with USAID and the MOH. The event brought stakeholders to present and discuss key findings on alcohol and tobacco use among pregnant women and women of reproductive age in Ukraine, the activity’s goal and objectives, key technical assistance activities, expected results, the implementation strategy, and approaches to results evaluation. Preparations for improvement activities in the pilot regions

The Resident Advisor held technical meetings in the Ukraine with local partners to secure their participation in the activity. Scopes of work and draft consultant agreements for the US experts were developed.

Sixteen health facilities will be involved in the activity from two Oblasts; eight in Poltava Oblast (in the cities of Poltava, Kremenchuk, Komsomolsk, and Lubny), and eight in Luhansk Oblast (in the cities of Luhansk, Alchevsk, Severodonetsk, Lysichansk, Krasnyi Luch, and Sverdlovsk). The participating facilities will include women’s consultations and ambulatory clinics (primary health care level).

During September 2013, preparatory work was conducted to set up a technical two-day meeting early in October 2013 in Kyiv jointly with US-based experts (Drs. Tatiana Balachova and Richard Windsor), local experts, and representatives of participating facilities in the two oblasts to discuss BPI protocols for alcohol use reduction and smoking cessation, the plan for a baseline assessment, the process of BPI implementation, and activity evaluation.

Also during September, preparations were made to organize an international experts’ trip to Poltava Oblast to meet the Director of Oblast Health Care Department and visit participating women’s


health care centers. The visit will introduce international experts to the department managers and women’s health care center staff who will participate and enable the experts to become familiar with the primary health care system for pregnant women/women of reproductive. The implementation protocol may be revised if the experts have recommendations to do so after the visit.

Directions for FY14 QI teams will be organized in the intervention facilities in the two oblasts and trained in the alcohol and tobacco BPI and baseline data collection will be completed in the second quarter of FY14. Activities will transition to ASSIST Project funding in the third quarter of FY13.

LATIN AMERICA AND THE CARIBBEAN

2.15 Haiti



1. Build capacity of the Ministry of Social Affairs/Institute of Social Well Being and Research and other stakeholders in: 1) the development and implementation of minimum standards for services to vulnerable children; and 2) QI principles and methods in OVC programming

Provide leadership in improving care by programs serving vulnerable children and families

Provide TA to ensure the development of standards that are evidence-based

Build constituencies of support for the standards and for the principles of QI

3 geographic departments cascaded to 9 communities

2. Integrate OVC minimum standards of care within a national strategy

Strengthen integration of OVC standards within a national strategy response

Ensure country ownership of the standards

Ensure participation that reflects all levels of stakeholders from the government to the children and families served

North, Artibonite, and West departments

3. Gather and communicate evidence on draft service standards

Hold learning sessions where stakeholders will share experiences, challenges, and lessons learned

Gather evidence that the standards are feasible at the point of service delivery

Gather evidence that implementation of the standards actually makes a difference in children’s lives

Gather evidence that implementation of the standards is within the context of organizational practices

Communicate standards across partners

Support stakeholders to share evidence of QI programming on the HCI Portal

3 departments with 3 key implementing partners: Catholic Medical Mission Board (CMMB) Management Sciences for Health, and Partners in Health (PIH). Standards will be piloted in 9 communities

4. Develop QI tools Develop job aids to support implementation of standards at the point of service delivery

Develop tool to rate essential actions and guidelines on dimensions of quality

Develop tools used to gather evidence of QI

North, Artibonite, and West departments

5. Scale up the standards Develop a scale-up plan for QI in OVC programs in organizations and regions not reached during the pilot

West, Artibonite, North, South,



Northeast, Central Plateau

6. Institutionalize QI Create a community of learning across OVC stakeholders

Sharing at level of 6 geographic departments and cascaded to 12 communities

Main Activities and Results HCI was invited by USAID Haiti in 2010 to provide technical assistance to the Ministry of Social Affairs and its Institute of Social Wellbeing and Research and implementing partners to improve the quality of services offered to vulnerable children and families affected by HIV. In FY13, the project focused on building consensus among stakeholders on a set of minimum service standards for vulnerable children at the point of service delivery. The guiding principle was to have stakeholders reflect on the essential question: What measurable differences do our programs make in the lives of vulnerable children, and how do we know that our programs are making a difference? Activity 1: Build capacity of the Ministry and other stakeholders In FY13 HCI activities in Haiti supported the Ministry-led development of a minimum set of OVC service standards to be employed at the point of service delivery. Simultaneously, HCI aimed to increase the capacity of stakeholders in applying QI methods and practices to improve services for vulnerable children and families in three departments. HCI established a positive working relationship with the Ministry’s Institute of Social Wellbeing and Research, which holds a key leadership role in overseeing child policies in Haiti. QI Task Team meetings Three QI Task Team sessions were organized at the national level on the process of the standards development. HCI identified implementing organizations in each department that were interested in participating in the QI initiative and created a partnership that included stakeholders from the government, implementing partners, and community leaders. The initial NGOs that were chosen to pilot standards in these geographical departments were CMMB in North Department; Partners in Health/Zanmi Lasante and Catholic Relief Services in Artibonite Department; and World Concern Haiti/ACLAM, Save the Children, and AVSI Foundation in West Department. During the QI Task Team Meetings, OVC stakeholders finalized the selection of three pilot departments (North, Artibonite, and West), including 20 points of community services delivery in 19 communities. However, the selection was modified due to closure of the Community Health and AIDS Mitigation Project and two other NGOs that declined to continue the process. Therefore, CMMB and PIH implemented the standards in North and Artibonite departments and MSH in the West Department. Thus, only nine communities were ultimately selected to pilot standards. QI Departmental Committee Four work sessions were held in the departments of Artibonite, North, and West where local government and OVC partners participated in the three QI departmental committees. All local stakeholders involved in this process attended the discussion about difficulties, methodology, and new strategies to get best practices by applying standards through services provided for vulnerable children. Through the four QI departmental meetings, HCI tried to increase the capacity of local stakeholders and community actors to conduct the piloting phase of OVC standards in their communities. Technical assistance on QI and evidence-based standards HCI provided technical assistance to the CMMB, PIH, and MSH and trained 39 coaches in the three departments (15 in North, 15 in Artibonite, and 9 in West). Topics included the principles and science


of QI, systems and processes, measurement, teamwork, improving quality in Haiti, OVC standards, tools, work plans, coaching, and use of the Child Status Index. The coaches subsequently supported the standards communication and piloting process in their respective departments. Training Sessions on CSI HCI collaborated with CRS, which provided the CSI trainers. Thirty-three field agents were trained in Artibonite, 22 in Cap Haitian, and 38 others in West. Activity 2: Integrate OVC minimum standards within a national strategy HCI’s goal in Haiti was to integrate the OVC Minimum Standards of Care within the National Plan of Child Protection and among involved stakeholders. The standards were developed based on the Haiti-specific context and national and international evidence of best practices. To ensure coordination of a national strategy for OVC care and support, it was important that the standards under development build on policies and guidelines that already existed. Two standards revision sessions were held in October and November 2012. Fifteen OVC stakeholder representatives worked together to vet and refine the standards. Participants were divided into seven groups to each revise one of the seven standard-related services (health, education and vocational training, food and nutrition, economical strengthening, protection, housing and care, psychosocial support). Each group discussed and modified the draft version of its standards before presenting them to a plenary session. The next draft version of the standards was circulated to all partners of the QI task team in Port-au-Prince and to local partners and communities via coaches training sessions held in three departments. Activity 3: Gather and Communicate Evidence on Draft Service Standards To gather and communicate evidence on the draft OVC standards, HCI developed a performance self-assessment tool that the NGOs used to describe the OVC services they provided in the nine piloting sites. In May, April, and September 2013, the NGOs self-assessed their performance related to psychosocial support, protection, and household economic strengthening. This information served as the baseline data for the project. Eighty field agents were trained on the CSI and assessed the needs of 2,384 children in the nine communities. Table 9 shows the results. The nine sites then worked to apply the standards in the care of these children, during the period April through September 2013.

Table 9. Haiti: Survey on needs of vulnerable children, Nine communities piloting OVC standards

Department Funds NGO # Field agents

Points of service delivery site Children reached

North

PEPFAR CMMB 10 Hospital of St Jean of Limbe 360

5 Hospital of Sacre-Coeur of Milot 180 5 Hospital Esperance of Pilate 180

Artibonite PEPFAR- CDC

PIH 10 POZ-Montrouis 300 10 St Nicolas Hospital of Saint Marc 300 11 Health Center, First Echelon 330

West PEPFAR MSH 9 SADA-Matheux- Arcahaie 230 10 FONDEF-Martissant/Port-au-Prince 300 10 Grace Children-Delmas 204

80 2384

Piloting Phase Information sessions on standards An information session on the standards was held in each department for implementing partners’ staff, community field agents, and QI departmental committee members during March, April, and June 2013.


During the sessions, the standards were shared, and discussions were held to explain how to apply the standards, how to disseminate them, and strategies for reaching families. Guidance during the piloting phase In addition to the draft standards distributed to each site, HCI provided and discussed a piloting protocol with all site managers of the three implementing partners. Piloting committee At each site, a piloting committee was formed to ensure implementation of the draft standards and to analyze the implementation process in light of the local situation. Each of the nine piloting committees had community leaders and implementing partner staff involved in the piloting process. During field visits, coaches provided support to the site managers and piloting committees on how to conduct the pilot and use the QI tools (see Activity 4 below). Learning sessions Three learning sessions were held for each site. Some discussions were conducted based on the input of the analysis forms. Some strategies were modified to overcome piloting difficulties and to test guidelines of the essential actions related to the seven service areas (psychosocial support, education, food security and nutrition, protection, shelter, household economic strengthening, and health). Activity 4: Develop QI Tools For the piloting phase, HCI developed several QI tools to facilitate the work of applying the standards. Preliminary survey tool This preliminary survey allowed HCI to collect situational information on each NGO that was going to implement the standards. It revealed the areas covered by the NGO partners, the number of children enrolled and served by their project, the level of involvement of the community members with their activities, and the number of community agents working with them. Information gathered through this tool helped prepare the baseline survey and the start-up of the standards piloting. Performance assessment tool HCI also created a performance self-assessment tool to assess whether the NGOs were implementing key activities related to the standards. All nine piloting sites conducted this self-assessment at the beginning of the piloting and again in September 2013, to self-identify areas where they need to focus their efforts. Data analysis form The analysis form is a tool that the team of each piloting site completes as the process moves forward. It clarifies understanding of each of the essential OVC actions and key activities that are difficult to implement or non-applicable. For each gap, suggestions or justification are proposed in order to adapt the standards to meet the site’s needs. Two sessions were held for their coordinators and their assistants in Milot, Limbe, Pilate, Saint Marc, Montrouis, Delams, Martissant, and Sada-Matheux to facilitate their use of this tool. QI journal The QI journal was adapted to the national context to guide the improvement efforts at each site. Each team met at least monthly to help bridge the gap in OVC service delivery and develop strategies that would improve the lives of children and their families. Two training sessions were held for the piloting committees in Milot, Limbe, Pilate, Saint Marc, Montrouis, Delmas, Martissant, and Sada-Matheux to show them how use the QI journal and generate a monthly report. Activity 5: Scale-up the Standards A plan to scale up the best practices and lessons learned from the piloting phase is being designed. Standards implementation will be expanded by the Ministry of Health to additional departments in FY14. Activity 6: Institutionalize QI


The planning of the institutionalization of QI was started in North and Artibonite departments in FY13. Two meetings at the department level were held to exchange and share each site’s piloting experiences. Site managers and piloting committees talked and shared best practices and strategies to overcome some of the barriers revealed by the pilot.

Directions for FY14 HCI will close out its activities in Haiti at the end of December 2013. A national learning session, revision of the standards draft, endorsement day, scale-up planning and dissemination of the standards are among key activities that will be completed in the first quarter of FY14.

2.16 Nicaragua



1. Introduce the collaborative improvement model in universities

Implement continuous QI actions in academic planning, evaluation, and educational processes in nursing and medicine in universities

8 universities (out of 12)

Student population: 5157; teacher population: 506

2. Strengthen the transfer of methodological approaches

Promote the use of the teaching package and its incorporation into medical and nursing curricula

3. Address the HIV/AIDS quality of care needs of the transgender and transsexual populations

Design and implement an improvement plan that includes mechanisms for quality assurance

Main Activities and Results Activity 1: Introduce the collaborative improvement model in universities In the HCI FY13 annual work plan, HCI proposed working with the six largest public and private universities conducting nursing and medical training in Nicaragua: Universidad Nacional Autonoma de Nicaragua (UNAN Managua), Universidad Nacional Autonoma de Nicaragua (UNAN León), Universidad Americana (UAM), Politécnico de la Salud (POLISAL), Universidad Politécnica de Nicaragua (UPOLI), and the Bluefields Indian & Caribbean University (BICU). At the request of the USAID Mission, HCI also included Universidad de las Regiones Autónomas de la Costa Caribe Nicaragüense (URACCAN) as well as Universidad Cristiana Autónoma de Nicaragua (UCAN), a private university, in this work. Thus, in total, eight universities received HCI’s technical assistance during FY13. HCI introduced the collaborative improvement model to teaching processes in these universities. Through the collaborative, gaps or improvement opportunities were identified, scopes of work developed, change packages proposed, and learning sessions conducted. Changes implemented by teams were comprised of: including the teaching package contents in each university’s study plans; standardizing methodologies for implementing the package; applying teaching package tools to corresponding modules; redefining competencies; and installing a DVD containing the teaching package in the labor and delivery area computer, virtual laboratory, and university libraries. Results achieved through this work include: updating medical and nursing curricula according to the teaching package; including teaching and learning assessment methodologies in teaching processes; using the rapid cycles methodology to provide timely responses to gaps identified in the teaching-learning process; developing checklists for other processes in the curriculum; strengthening teachers’ competencies; improving the quality of student education; and scaling up training to other universities. Activity 2: Strengthen the transfer of methodological approaches To achieve the sustainability of tools implemented and to promote continuous quality improvement in the teaching of basic MCH and HIV care processes in compliance with MOH standards, HCI conducted a transfer process to universities centered on: 1) implementation of the teaching package to develop


human resources’ competencies to provide care for FP, maternal-child health, and HIV/AIDS. The teaching package is a training tool containing hard copies of documents and an interactive DVD. Each topic package includes information on clearly defined competencies, learning objectives, methodologies, support materials—including learning assessment guides—as well as the number of hours needed and organizational competencies to develop the topic. The methodological design content was a selection of topics prioritized based on: 1) the most frequent difficulties medical and nursing graduates face in health facilities; 2) applying the continuous QI methodology; 3) and knowledge management as an important factor for institutionalization and sustainability of technical assistance. In some of the universities (e.g., UNAN Managua, UNAN Leon, BICU, and POLISAL), the transfer experiences had started in FY12. In FY13 HCI continued strengthening this process to UAM, UPOLI, UCAN, and URACCAN. For these universities, HCI conducted work sessions to present the elements of the teaching package and raised awareness of its importance. To enable teachers to use the teaching package, trainings were conducted on each of the four modules: family planning, maternal health, child health, and HIV/AIDS. Additional trainings were conducted for fourth, fifth, and sixth year medical students and third and fourth year nursing students. These additional trainings enabled these students to develop their competencies to address health problems during their mandatory social service in MOH facilities. Faculty were trained on the application of the continuous QI methodology. Teachers also learned by observing HCI advisors to apply the teaching package’s methodology. Some topics were taught by advisors and teachers, which enabled advisors to verify correct the application of the package by teachers. Another improvement activity implemented by universities was completing performance evaluations of teachers (BICU and POLISAL), monitoring and follow-up of their graduate students to know about their work force insertion (POLISAL), systematic monitoring of teachers to measure progress in implementing the teaching package (UNAN Managua), defining performance and learning objectives on the topics they are teaching, and making effective presentations that favor learning (BICU). In FY13 HCI reproduced and delivered the following materials to the universities: 1000 FP care rapid guides; 1000 obstetric complications rapid guides; 1000 medical eligibility criteria and 50 Helping Babies Breathe (HBB) flipcharts; 76 notebooks with HBB, AMTSL, lifesaving maneuvers, IUD insertion, and HIV counseling checklists; and 331 teaching packages. HCI also provided to the universities 22 fabric models for HBB training, four pelvic models, four newborn models, two projectors, and two desktop computers. By the end of FY13, seven of the eight universities had included the teaching package in their curriculum. Teachers have the necessary competencies to implement methodological designs and continuous QI in their teaching, and students are graduating with better competencies to respond to Nicaragua’s health problems. Achievement in meeting targets for key performance indicators is show in Table 10.

Activity 3: Address the HIV/AIDS quality of care needs of transgender and transsexual population In FY13, using all available information from previous research conducted by different USAID projects among sexually diverse populations, especially the female transgender population, HCI drafted a national strategic plan to provide integrated care to the female transgender population in Nicaragua. HCI provided support to participating organizations to draft a Family and Mutual Help Groups Manual. It is used to work with family members of this population to reduce stigma and discrimination within families and to contribute to improving the quality of life. In addition, HCI drafted the first clinical guide for a comprehensive approach for female transgender population.


Table 10. Nicaragua: Improvement in targeted indicators in FY13

Indicator 2013

Target Q1 Q2 Q3 Q4 Total

Number of new health care workers graduated from pre-service institution 145 430 254 - 829 500

Number of men 41 186 66 - 293

Number of women 104 244 188 - 536

Number of health care workers who successfully completed an in-service training program within the reporting period

37 141 150 - 328 300

Number of men 7 48 60 - 115

Number of women 30 93 90 - 213

Number of medical and para-medical practitioners trained in evidence-based clinical guidelines

170 105 163 - 438 50

Number of people trained in maternal/newborn health through USG-supported programs

220 1,206 232 - 1658 1,000

Number of men 36 506 47 - 589 250

Number of women 184 700 185 - 1069 750

Closing out the HCI maternal-child health (MCH) component As planned in FY13, HCI celebrated in FY13 the graduation of the USAID Health Program in Nicaragua. The USAID Mission’s health office conducted its evaluation and celebrated the fully implemented health program in Nicaragua. HCI actively participated in both.

Directions for FY14 In FY14, through the USAID ASSIST Project, URC will continue to work with universities to strengthen the implementation of the teaching package, continuous improvement of quality in teaching, and measuring competencies of medical graduates for obstetrics and neonatal complications and HIV. ASSIST will also work with medical associations to share scientific evidence to reduce neonatal mortality.

3 USAID Global Health Element and Core-funded Activities 3.1 Care that Counts Initiative to Improve Quality of Programming for Orphans

and Vulnerable Children



1. Partnerships in Community Child Protection

Create a partnership between existing African organizations that will provide technical leadership in the area of child protection and safety

Africa


2. Technical capacity of Partnership members

Increase in technical capacity of African organizations in areas of child protection, family strengthening, and the science of improvement, including research and evaluation

Increase in organizational capacity of African organizations in areas of creating and maintaining partnerships, governance, knowledge management, and communications

Build the QI capacity of champions, government and other stakeholders, through various mediums

Alliance develops an integrated quality approach towards protection and safety of children, one that aligns national policies and community practices, and ensures a protective environment for children, through prevention, response, and advocacy.

Africa

3. Qualitative study Gather evidence on the impact of partnering and strengthening organizations

Africa

4. E-modules Dissemination of the e-learning modules on Quality Improvement in Vulnerable Children programs

Global

Main Activities and Results Activity 1: Partnerships in Community Child Protection During FY13, HCI facilitated the development of a collaboration between two regional African organizations working in the area of support and protection of most at risk children.

Regional Psychosocial Support Initiative (REPSSI) Africa Network for Protection and Prevention of Child Abuse and Neglect (ANPPCAN) The first meeting of the organizations was held in Kampala, Uganda, September 25-28, 2012, the second meeting February 5-7, 2013, in Johannesburg, South Africa. The group discussed the details of an improvement project aimed at the community/district level in protection of vulnerable children. HCI posted an RFP in February 2013 with the objective to strengthen the capacity, effectiveness, and reach of Africa’s response to vulnerable children and families through formal and informal systems at the district level. The primary activities consisted of: 1. Organize a regional action-oriented community of learning around standards-based and evidence-

based child and family protection systems. The community of learning is expected to cross national boundaries. Bidders are invited to propose locations depending on their presence in countries. Bidders should demonstrate a presence in multiple African countries or consider proposing a teaming arrangement that works across countries.

2. Implement improvement activities as agreed to by URC, including district level technical support (guidelines, trainings, workshops, coaching, technical support to government and civil society, etc).

3. Prepare periodic reports and end-of-project report and recommendations. Both REPSSI and ANPPCAN submitted proposals in response to the RFP in February and were awarded the contracts in June 2013. To launch the Partnerships in Community Child Protection project, HCI facilitated a regional meeting in August 2013 of 16 representatives from government, REPSSI, ANPPCAN, and URC in four countries, Kenya, Tanzania, Swaziland, and Uganda. The meeting began with a presentation on the history of the partnership project and the current activities in the four countries. HCI also took the opportunity to give a brief overview of improvement. John Njoka, a consultant from University of Nairobi, presented on the situation analysis he conducted for this project. The second day of the meeting was spent primarily on work planning for each of the four countries and reporting the status of their plans.


National meetings were held the 4th quarter in Tanzania, Kenya and Uganda. The objectives of the meetings were to present and discuss the situational analysis that was developed and to discuss a strategy for moving to the district and community levels. Activity 2: Technical capacity of Partnership members REPSSI and ANPPCAN were offered the opportunity to receive three capacity building workshops. Based on each organizations self-assessment, the following trainings were conducted: 1) REPSSI: Quality Improvement, January 2013, and Qualitative Research, March 2013; 2) ANPPCAN: Quality Improvement, June 2013, and Research and Evaluation, July 2013. In addition, both organizations sent a staff person to a Knowledge Management workshop conducted by HCI in Durban, March 2013. The third workshop on Leadership and Strategic Communications was conducted in October 2013 and led by global staff of EnCompass LLC. Activity 3: Qualitative study Dr. Sarah Smith of the HCI research team has been involved with the partnership activities from the inception of the project. She has periodically interviewed the staff on aspects of the partnering experience from REPSSI and ANPPCAN. She will report on the partnering aspects of the project at the conclusion of the activities in February 2014. Activity 4: E-modules Over the years, many lessons have been learned about the process of improving quality of care for vulnerable children, and these lessons have been compiled in the interactive USAID Care that Counts e-Learning Course for Quality Improvement in Programs for Vulnerable Children. The e-modules were launched in February 2013 and can be accessed at www.hciproject.org/elearning/care-that-counts This English e-Learning course is designed for anyone who has an interest in learning more about how to use quality improvement principles in programs for vulnerable children, including in-country Ministry personnel, international non-governmental organizations, national NGOs, community organizations, and donor agencies. This course can also be used to educate and advocate for quality improvement in programming for vulnerable children. The course is separated in two parts and learners can pause and come back to the course as needed. Module 1 is an “Introduction to Quality Improvement” and takes about 30 minutes to complete. The module begins with a pre-assessment test for learners to see what they know about quality and what they can learn more about. It then introduces the principles of quality improvement and explains how these are used in improving the quality of programming for vulnerable children. These principles are: commitment to change, client centeredness, multidisciplinary team work, process analysis, data-based decision-making, and shared learning. Module 2 covers “Best Practices in Improving Quality of Care for Vulnerable Children: The QI Road Map.” This self-directed module can take one to three hours to complete. Learners are guided along the steps in the quality improvement road map, which includes creating awareness at the country level, building commitment of multiple stakeholders, developing standards of care at the point of service delivery, piloting and implementing standards, and taking stock. The course ends with a posttest to assess information learners have gained through the course and provides the option of printing a certificate of course completion.


3.2 Community Health



1. Community of Excellence (COE) Study Ethiopia

Develop a conceptual framework of community competencies to care for vulnerable children and families

Develop a tool to measure community competencies

Pilot study the tool to validate it

Develop and test a tool to measure community competencies to provide OVC services to children and their families in Ethiopia

Ethiopia: Two districts (woredas) out of 550 in the country: Dire Dawa and Debre Zeit

2. Community Health Worker Improvement Collaborative

Explore various community groups and their networks (local government networks, CHWs, and volunteers)

Form a QI team from the representation of the various groups mentioned above

Apply QI methods to implement a community-level change package targeting identified causes of weak performance of CHWs (health extension workers)

Apply QI methods to improve the performance of community health workers

Ethiopia: 18 health posts and their catchment communities in two Woreda districts): Illu and Tole

(2 of 180 Woreda) Total population of Illu = 70,784 and of Tole = 72,922

Prevalence of HIV in Oromia Region is estimated to be 1.6% (2010)

Six health centers and 18 health posts and their surrounding communities are involved in the collaborative.

3. Community support for people living with HIV in Uganda

Improve the performance of CHWs and the CHW program by strengthening the community health system

Strengthen community support for CHWs by establishing a functional community health system formed by the community groups, local government, and community networks

Uganda: Buikwe District (one of 112 districts), involving

1 (of 16) health facilities, 10 (of 475) 475 villages, and 20 (of 950) village health teams

Main Activities and Results Activity 1: Communities of Excellence Study in Ethiopia In FY13 two NGOs, Ratson and Propride, continued testing the Community of Excellence tool to measure the capacity of CBOs to provide comprehensive care to vulnerable children and families in Debre Zeit and Dire Dawa. The project gathered evidence from testing the tool, revised the core competencies tool, and developed guidelines for establishing a COE. A monthly meeting was conducted with community working groups, and technical support by the Research Institute of the School of Social Work, Addis Ababa University, was provided during the testing process. The technical support ensured that the commitment to the process was sustained and sufficient mechanisms for feedback were provided. Accordingly, the content of the tool was reduced to 41 capacity indicators for the 15 capacity dimensions, 205 definitions of the capacity indicators, and scoring/points for each capacity definition. The institute developed a guide for administering and the scoring of the COE tool. The guide explains who can use the tool; summarizes its content; and lists the steps for conducting the self-assessment, reviewing evidence for scores given, calculating the scores, and categorizing the CBOs for capacity building. The tool categorizes CBOs into three groups, depending on the aggregated average in the self-assessment score. The lowest score means the CBO is being established the middle score means it is an emerging association, and highest score means that the CBO is a community of excellence.


The COE tool was implemented in the CBOs of Debre Zeit and Dire Dawa, which started with HCI and the institute providing orientation. In the beginning, HCI and institute staff did most of the coaching, often in conjunction with the two implementing partners’ capacity-building officers in the two regions. Thereafter, the two local NGOs continued in a supervisory role and were available for coaching and QI or team supervision. The review meetings were organized with pilot communities to better understand how user friendly the tool is and whether it is measuring capacity and change over time. Participants of the review meeting have highlighted the relevance of the tool to measure capacity. The CBOs reported that the tool was important to check program performance, build well-organized office management systems and documentation, plan program implementation, and strengthen relationships with stakeholders. All sites mobilized local resources, revisited their program plan, and reaffirmed their commitment to serving highly vulnerable children and their guardians. For example, in using the Governance and Legality dimension, CBOs in Debre Zeit realized that they needed to renew their registrations or obtain one for the first time. In using the Monitoring, Evaluation and Coordinating dimension, CBOs in Debre Zeit realized that they had no monitoring system, and they put one into place. After using the Volunteer Management dimension, CBOs were able to create and follow a volunteer management guide. In using the Resource Mobilization Sustainability dimension, CBOs realized that they no longer needed to rely solely on international development organizations for resources: They are now looking within their own communities for support. In using the Networking dimension, the CBOs have increased their participation in Kebele and Iddir in order to access a marketing outlet in the center of the town and received training from their new partners like Mekdin Ethiopia (NGO). The USAID activity manager for the COE study visited the four communities that are piloting the standards in Dire Dawa town. The CBOs emphasized that the tool enabled them to see the status of their CBOs in delivering services to OVCs. They were critical in assessing their CBOs, as there was no material benefit from HCI attached to it. They also mentioned that they are covering all basic costs to provide coordinated care for the children, including school materials, health care, and food. A case mentioned included how they mobilized the barbers and beauty salons to care for the children for a year. This was small but significant step in creating community ownership of care and support services as per the country ownership strategy of USAID. Two meetings were held with the senior management team of the Yekokeb Berhan project, the biggest OVC care and support project in Ethiopia, receiving a $100 million grant from USAID/ Ethiopia to provide care and support for 500,000 highly vulnerable children throughout the country. The first meeting was held in February 2013 with 12 project leaders drawn from the three partner international NGOs of Pact, Child Fund U.S.A., and Family Health International. The second meeting was held with the project’s lead partner, Pact. Included were the senior technical advisor, Deputy Chief of Party, the senior program manager, and the capacity-building manager. The QI advisor held a meeting with USAID officials, including the Prevention team leader, OVC AOTR, COE activity manager, and Pact senior manager. Participants discussed the way forward of the COE. An agreement was reached to expand the COE to all sites under the Pact program. Activity 2: Community Health Worker Improvement Collaborative in Ethiopia In October 2012 the technical support under HCI provided to the CHW collaborative project in Ethiopia ended. Toward the end of the project, a transition meeting was organized by the zonal office to discuss how the districts and health centers would continue the CHW collaborative activities. The work plan provides that the coaches from the health centers and health extension workers were responsible for organizing QI team meetings and continuing improvement activities. The zonal and district health officials decided that they would discuss with other health centers how to spread community QI activities through their health posts. Despite the project’s ending, the community QI teams continued activities to improve the performance of these workers. Data reported by the health center showed that the proportion of pregnant women who had been identified by QI team members


and who received ANC services from the health post had been maintained at 90%, even after the technical support from HCI ended (see Figure 20).

Figure 20: Ethiopia: Percentage of pregnant women who received ANC services at a health post, Illu and Tole districts (July 2011-Feb 2013)

Both community health activities in Ethiopia were completed under HCI funding in FY13.

Activity 3: Community Support for People with HIV in Uganda During the first quarter of FY13, HCI supported visits by district coaches, HCI staff, and MOH staff to 10 communities. The visits focused on supporting teams in identifying HIV patients and in supporting HIV/AIDS patients to self-manage. The QI teams continued to collect data on HIV patients, assess them for clinical improvement, goal setting, and achievement. A learning session was held for two days to 1) share and learn community approaches on how to identify HIV patients, 2) equip community teams with skills and knowledge on how to help patients self-manage, 3) discuss with teams data collection techniques and using data to make effective changes. Three or four participants were invited from the 10 villages in the collaborative, and 32 came (11 men and 21 women). Of them, 17 were Village Health Team (VHT) members (12 women and 5 men); others were local leaders, religious leaders, and members of community-based groups. The session’s facilitation methods involved group discussions, case studies, and presentations. Each QI team shared changes that led to improvement and data on identifying patients with HIV. The facilitator assisted all 10 teams to prepare monthly work plans for the coming quarter. Data shared showed that VHTs who worked in a community-based system were nearly twice as successful at bringing in patients for ART as VHTs who worked independently of other community groups. Funding for this activity transitioned to the USAID ASSIST Project in March 2013.

3.3 Family Planning



1. Integrate FP counseling and services with postpartum services in Afghanistan

Address a high unmet need for postpartum FP by improving the provision of FP counseling and services to postpartum women in one district

5 maternities in Kabul district, Afghanistan; population 3,449,800


2. Improve integration of FP counseling and services with HIV services in one district in Uganda

Address unmet need for FP services for HIV-positive women by improving integrated service delivery of FP and HIV services in one district

4 clinics in Masaka District, Uganda, population 250,000

Major Activities and Results Activity 1: Integrate FP counseling and services with postpartum services in one district in Afghanistan through the application of modern QI approaches From January to June 2013, HCI continued support to a Postpartum Family Planning (PPFP) improvement collaborative in five maternity hospitals (2 public and 3 private) in Kabul. These hospitals register approximately 46,920 deliveries annually. The primary collaborative aim was to build the capacity of hospital managers, providers, and the MOPH officials to use QI approaches to integrate FP into routine postpartum care to address the unmet need for FP among many postpartum women. QI team-introduced changes included: 1) training the postpartum hospital staff in PPFP; 2) creating a PPFP checklist for use by providers and PPFP counselors on the postpartum ward; 3) conducting group FP counseling among recently delivered women on the postpartum ward; 4) establishing a private FP counseling space where husbands and wives could be counseled together; and 5) involving the mothers-in-law of recently delivered women when the mother-in-law was known to be the decision makers relative to FP. To increase access to a full range of contraceptive methods in public hospitals (where supplies are often lacking), front-line QI teams of providers and managers from public hospital maternities and postpartum wards forged links with the Afghan Family Planning Guidance Association (AFGA), a non-profit organization providing FP services in the public hospitals participating in the PPFP collaborative. After PPFP counseling was provided to women in these two hospitals (as part of group counseling and in private counseling rooms established by the hospitals with project support), women who chose to begin a modern FP method, such as the IUD were referred to the AFGA unit located on the hospital grounds near the postpartum ward. As can be seen in Figure 21, the aggregate percentage of postpartum women across the five hospitals discharged after birth with a modern FP method of choice rose from 12% (180 women) in January 2012 to 95% (2153) in May 2013.

Figure 21: Kabul, Afghanistan: Increase in postpartum counseling and FP (January 2012-May 2013)

10

20

30

40

50

60

70

80

90

100

Per

cen

tag

e le

avin

g w

ith

FP

met

ho

d

Jan-12 Feb-12 Mar-12 Apr-12 May-12Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13N 180 624 763 853 1575 1658 2340 1766 2033 1718 1700 2232 1694 2342 3434 2859 2153

D 1497 1740 1575 1543 1952 2159 2934 2163 2363 1876 1863 2351 1875 2501 3680 3133 2268

% 12 36 48 55 81 77 80 82 86 92 91 95 91 94 93 91 95

Proportion of post partum women leaving hospitals with preferred method of FP in 5 hospitals, Kabul, Afghanistan, Jan 2012-May 2013

Change: Group counseling

Change: Individual counseling, providing PPFP related information to the husband through mobile if husband isn’t present at the time of counseling

Change: Counseling with mother in law

Nominator: Number of postpartum women who received the preferred FP method from the hospitalDenominator: Total number of postpartum women who received FP counselingPercentage: Proportion of post partum women leaving the hospital with their preferred method of FPSource: 5 maternity Hospitals in Kabul City


Follow-up done at 3, 6, 12, and 18 months found that postpartum women in the intervention group had markedly fewer pregnancies than those in the non-intervention group (Figure 22).

Figure 22: Kabul, Afghanistan: Postpartum follow-up at 18 months (March 2012-June 2013)

Note: “Suspected” = Believed to be pregnant

HCI support for the PPFP improvement work in Kabul ended in June 2013. The MOPH Department of Reproductive Health and hospital leadership are committed to continuing this work, and the United Nations Population Fund has committed to providing support to Malalai and Isteqlal hospitals for at least one more year. In addition, the Swedish Committee for Afghanistan has begun supporting PPFP in maternities in three provinces (Wardak, Jalalabad, and Lagman), applying the collaborative improvement model and change ideas. Activity 2: Integrate FP counseling and services into routine HIV services in Masaka district in Uganda through the application of modern QI approaches With a total fertility rate of 6.4, 26% of women of reproductive age in Uganda use a modern FP method, and 34% report an unmet need for FP. HIV prevalence is 7.3% among adults of reproductive age with 10% of HIV infections transmitted from mother to child. Reducing unmet need for FP among HIV-positive women is important for reducing vertical HIV transmission and for improving their health outcomes by reducing unwanted pregnancies and promoting healthy birth spacing. In FY13, HCI supported a multi-faceted QI intervention to improve integration of FP services into routine HIV/AIDS services in four clinics in Uganda’s Masaka district. Key activities included:

Baseline survey to identify critical constraints and measure baseline indicator values Review of national FP policy, guidelines, and routine RH indicators, prioritizing three national FP

indicators for routine program monitoring Integrating onsite technical and QI training of providers and managers focused on FP counseling and

methods administration (including long-acting methods) and use of QI methods to improve the delivery and distribution of MOH FP counseling job aids

Forming facility QI teams and fostering monthly supportive supervision to help them build QI competence to test changes to HIV care processes and to measure, using data they (the teams) generate, whether changes resulted in improved FP service delivery indicators

study participants contacted pregnant suspected sample contacted pregnant suspected

Intervention Control3 Months 643 303 0 0 681 380 10 0

6 Months 303 217 2 4 380 235 20 14

12 Months 217 207 9 3 235 196 34 9

18 Months 207 149 16 5 196 167 45 13

643

303

0 0

681

380

10 0

303

217

2 4

380

235

20 14

217 207

9 3

235196

349

207

149

16 5

196167

4513

0

100

200

300

400

500

600

700

800

Nu

mb

ers

of

wo

me

n

3, 6, 12, and 18 months follow-up of post partum women seen in all five intervention hospitals (March 2012--June 2013)


Conducting learning sessions for the clinics and district officers to share learning and accelerate uptake of best practices. The first learning session was in January 2012 and the second the following June.

Conducting a final harvest meeting in April 2013 to synthesize best practices and lessons learned Convening a dissemination meeting in September 2013 to share the results of the FP-HIV work in

Masaka District Improvement efforts focused on improving delivery of integrated FP and HIV/ART services in the four facilities in the Masaka District that provide ART services for females living with HIV. An average of 901 HIV-positive clients of reproductive age was seen per month in the four clinics over the 16-month intervention period. Figures 23 and 24, respectively, show that the percentage of HIV-positive clients counseled for FP in the previous month rose from 29% to 84% and that the percentage of HIV-positive clients given a modern FP method rose from 16% to 60% over the intervention period (data from November 2011 to February 2013, aggregated across the four clinics). Providers in targeted facilities introduced several changes to integrate and strengthen FP services as a routine part of ARV services, including:

• FP counseling in every HIV group health education • Dispensing short-acting FP methods with ARV medications • Aligning FP and HIV clinic schedules • Adding a tick box for FP counseling to ART patient registers and the patient ART card • Sharing FP commodities among clinics • Regularly coordinating with FP implementing partners for service continuity for women

choosing short-acting FP methods • Organizing routine HIV testing in FP clinics

This activity was concluded in September 2013. No further family planning activities will be carried out under HCI in FY14.

Figure 23. Uganda: Percentage of HIV-positive women receiving family planning counseling at HIV clinics, four sites, Masaka District (November 2011-February 2013)


Figure 24: Uganda: Percentage of HIV-positive clients counseled for FP at HIV clinics, four sites, Masaka District (November 2011-February 2013)

3.4 Health Workforce Development



HIV-funded activities

1. Uganda CHW* Productivity and Performance Study

Note that CHWs in Uganda are referred to as “Village Health Team” members. They are usually volunteers.

Develop a standardized methodology for quantifying and defining CHW productivity

Identify factors influencing productivity and performance

Explore the relationship between CHW productivity and performance

160 VHT members from two sub-counties in the Busia district (sample size adjusted for actual number of VHTs in the randomly selected sub-counties)

2. Team-Based Performance Management: Case Study with Tools

Synthesize the experiences used in applying human performance technology (HPT) to the quality approach used in Niger and Tanzania

Present the tools and processes with two country case studies to allow the team-based approach to performance management to be applied by others in different contexts

Case studies: Niger and Tanzania

Global application

3. Tanzania Health Worker Engagement Study

Publish study findings with validated tool

Finalize and disseminate activity report 1330 health workers from 183 health facilities in 6 regions of Tanzania

4. Decision-making tool for CHW programs

Develop an evidence-based tool for national level decision makers to support and guide them as they progress through CHW

Experts and researchers from 13 countries



program design, planning, and/or scale-up

5. In-Service Training Improvement Framework and Study

Develop an improvement framework, in collaboration with international development and implementing partners, for developing an effective national in-service training program for health workers

Survey in-service training programs to identify opportunities for improvement

International improvement framework developed through consultation and consensus-building with international development partners

National survey of in-service training program providers in Ethiopia

6. Strengthening district health management performance in Tanzania

Strengthen district health management performance to support the establishment and management of QI principles and practices throughout the district’s service delivery system

Strengthen district health management team competencies and processes to improve ART/PMTCT services

1/ (of 30) regions: population 0.8 million

1 (of 1) regional health management team

6/6 Council health management teams in all districts.

192 health facilities

7. Ethiopia CHW performance improvement collaborative

In 2013 HCI and then the follow-on ASSIST projects provided remote technical support to spread the community QI

Two (Illu and Tole) out of 180 woredas in the Oromia Region. The population of Illu and Tole is 12,600 (2008 data). HIV prevalence in Oromia is estimated to be 2.4% 6 (of 192) health centers, 18 (of 80) health posts and community QI teams in Tole and Illu

MCH Funding

8. CHW Regional Meeting Follow-up

Follow-up with countries that participated in the 2012 CHW Regional Meeting in Ethiopia with TA as requested to those countries that would like support in applying CHW AIM assessments and interventions to address gaps in CHW performance Report on progress made in six participating countries toward the objectives and plans made during the meeting

Uganda, Zambia, Rwanda, Mali, Kenya, and Ethiopia

9. CHW Central website, a global resource promoting and engaging CHWs

Continue to manage the CHW Central website until Spring 2013, raising awareness of its resources and benefits and increasing its membership Develop a strategy and operational plan that will sustain the resource so that it will meet priority needs of stakeholders and ASSIST partners, in addition to the wider CHW community of government representatives, donors, implementers, and contributors

Global

10. CHW Assessment and Improvement Matrix (CHW AIM) Revision

Revise CHW AIM based on feedback from field work and the regional meeting; update intervention lists and additional tools

Global


Major Activities and Results Activity 1: Uganda CHW (VHT) Productivity and Performance Study This study is being undertaken to examine village health team (VHT) productivity and performance in two sub-counties of Busia District with a minimum sample size of 260 VHT members. With support from PEPFAR and in collaboration with World Vision, Uganda’s MOH, the Busia District Health Office, and other partners, HCI proposed to undertake a cross-sectional observational and retrospective quantitative study between July to October 2013 to: 1. Develop an aggregate measure of VHT productivity and performance; 2. Develop, validate, and publish a reliable method by which to quantify VHT productivity and

performance; 3. Explore the factors that influence VHT productivity and performance; and 4. Explore the nature of the relationship between VHT productivity and performance. The study protocol and tools were submitted to the Makerere University College of Health Sciences Institutional Review Board (IRB) and the Uganda National Council for Science and Technology for approval, and approvals were granted by both. Field manuals for data collection have been drafted. Data collectors and supervisors have been identified and contracted. Data collectors have been trained and data collection has begun. URC is currently seeking an extension to the HCI contract so that the project will be able to continue and complete this activity as planned. Activity 2: Team-Based Performance Management: Case Study with Tools To understand how health worker performance might be improved so that improvements in care delivery can be further enhanced, HCI initiated two health worker performance activities in the Mtwara Region in Tanzania in 2010 and in the Tahoua Region in Niger in 2009. These activities sought to explore: what human factors might impact performance, what interventions would address those factors to affect improved health worker performance, and what progress toward better health outcomes might be further advanced by implementing these interventions. In Tanzania, improvement indicators tracked HIV services, and in Niger the indicators focused on MCH improvements. QI collaboratives in both countries pursued seven performance factor areas that are part of Human Performance Technology (HPT). These seven areas had been shown to impact staff performance and outcomes in other sectors of private industry and were expected to have the same or similar impact in the public health sector, and specifically at the primary care level. The process of addressing each area was labeled by HCI advisors a “human resources performance cycle.” In FY13, HCI presented the activities in these two countries as case studies, which synthesized the technical report of each country experience and shared the highlights of the processes followed, tools used, and lessons learned from the collective experiences. The report combining the two case studies also includes examples of the tools used during the different steps of the human resources performance cycle so that these tools will be available to others seeking to adapt and apply them in similar health workforce performance improvement activities. The case studies will be finalized and published on the ASSIST website in FY14. Activity 3: Tanzania Health Worker Engagement Study This cross-sectional study is being undertaken in Tanzania in collaboration with the Ministry of Health and Social Welfare and Muhimbili University of Health and Allied Sciences. It employs mixed quantitative and qualitative methods to study engagement among health workers providing HIV services and the relationships among engagement, performance, and retention. In FY13, the health worker engagement study research team completed the qualitative analysis, which aimed to explain how and why engagement characteristics are influenced by factors identified from the quantitative part of the study.


Highlights from the qualitative analysis that are especially relevant to improvement work are:

Engaged health workers are change agents who go beyond routine clinic work to actively facilitate improvement. They are health workers who stimulate improvement by designing and implementing ideas to respond to health delivery challenges. This type of engagement is especially important to reduce loss-to-follow up. Quantitative cluster analysis found that health facilities with health workers who had above average engagement scores had only 10-13% of HIV clients that were lost to follow-up compared to 35% in health facilities with workers with lower engagement scores. The implication is that to facilitate improvement, it is important that improvement activities seek to build the knowledge, skills, attitudes, and behaviors of health workers to be change agents in their workplaces.

Team work and co-worker support enhances job satisfaction. Health workers who feel that they are valued by their co-workers and that their work contributes significantly to the rest of the team seem to be more satisfied with their jobs. Staff cooperation was also described by one staff member to encourage health workers to work hard in delivering HIV services. The implication for improvement work is that strengthening team work through improvement teams and collaborative team problem-solving may improve job satisfaction and enhance efforts at work.

Data analysis has been completed with preparation of findings for publication in peer-reviewed journals. Activity 4: Decision-Making Tool for CHW Programs The working group discussions during the USAID Evidence Summit on CHW Performance of 2012 revealed a need for a centralized resource of publications, examples, and guidelines that country decision makers can use to harvest lessons learned when they are developing or scaling up their own CHW programs. HCI developed, in 2013, the Decision-Making Tool for CHW Program Support is a functional, user-friendly, web-based tool created to provide practical decision-making support on the design, development, implementation and scale-up of CHW programs. The tool provides a step-by-step guide for policy makers, taking them through the process of instituting, improving, or scaling up a CHW program. It provides access to key informational resources and shared country experiences. It can be used by national and sub-national decision makers (including policy makers and program implementers) as they progress through designing, planning, implementing, and sustaining a CHW program. The tool can be used as a follow-on support resource to managers, implementers, and government leaders who apply the CHW AIM tool to evaluate the functionality of their CHW programs and identify the areas that need improvement. Likewise, the Decision Making Tool complements the guidelines proposed by the CHW Frameworks for Partners Harmonization and Monitoring and Accountability by empowering governments to strengthen their leadership role in guiding partners to align their program development with national objectives. Figure 25 shows the Decision Making Tool's decision sections, with each decision area highlighted in a different color and with each decision step noted within those areas. Available at every step, as noted in the orange block, will be links to publications and resources, as well as country examples, plus a short discussion of considerations that are important for the decision maker to address before going onto the next step. In addition, stakeholders who will be important in the process of advancing the program’s development and scale-up will be suggested in the list of “Key Stakeholders” for each step in the tool. The tool is available on the K4Health toolkit website (http://www.k4health.org) and a link featured on the CHW Central website (http://www.chwcentral.org/). An advisory group of representatives from 13 countries contributed information and lessons learned from their own countries, and a review committee, led Drs. Henry Perry and Steve Hodgins, contributed content for the tool. The Decision Making Tool is complimented by a USAID-funded series of technical articles that provide comprehensive analyses on the decision areas that each step addresses. The authors of the articles formed a review committee, led by Drs. Perry and Hodgins, and provided additional contributions to the content of the online tool. Likewise, the ASSIST team, led by Allison Annette Foster, Dr. Ram Shrestha, and Anya Guyer, provided content for the technical articles.


Figure 25: Decision-Making Tool for CHW Programs

Activity 5: In-Service Training Improvement Framework and Study This activity was initiated in FY12 under HCI and supported by PEPFAR with the goal of developing guidance in the form of a global in-service training improvement (IST) framework. IST has been a major strategy for the rapid scale-up of HIV services, with over 3.7 million training encounters supported by PEPFAR alone between 2003 and 2008. IST programs are rarely evaluated and the demand is growing for more sustainable, effective, and efficient health worker training to strengthen the health workforce and health systems. Recognizing the lack of consolidated guidance and the global need to bring together expertise, experience, and evidence, HCI facilitated a modified Delphi process to define practices to improve IST effectiveness, efficiency, and sustainability. This led to the development of the first global improvement framework for IST, which was applied in FY12 by HCI, CapacityPlus, and Jhpiego to facilitate assessments of the national IST situation in Ethiopia, Nigeria, and Afghanistan. HCI worked with the Federal Ministry of Health, key stakeholders, and the USAID Mission in Ethiopia to design and undertake a national IST assessment. HCI also facilitated 35 representatives of key stakeholders to develop the basis of a national IST strategy. During FY13, the IST framework was presented to the global community through different venues. Jhpiego sponsored a presentation and formal discussion at USAID headquarters in Washington in November 2012. In addition, the framework was presented at the USAID State of the Art (SOTA) meeting. In August 2013, the IST framework was presented again at the CDC African Regulatory Collaborative Congress in Kenya. Activity 6: Strengthening District Health Management Performance in Tanzania This demonstration collaborative sought to apply quality improvement approaches and performance management methods to strengthen the support and coordination of QI at regional and district levels, while also improving the execution of management functions in the Lindi Region of Tanzania. This activity supported all six Council Health Management Teams (CHMT) at the district level and the Lindi Regional Health Management Team (RHMT) to develop and test changes to improve management


performance in the four core functions of management teams: quality improvement, human resources for health, health information systems, and supplies and logistics. A rapid situational analysis was conducted in February 2012 with the participation of all six CHMTs and the RHMT, followed by a design workshop in March where participants identified weaknesses in joint district and regional management processes, and areas and priorities for improvement. CHMTs and the RHMT established QI teams and defined specific improvement aims to address priority needs. All teams also planned changes to facilitate the scale up of improvements to other health facilities which are not supported by HCI or other donors in applying improvements to HIV services. Lack of clarity on individual tasks and expectations for joint management roles and responsibilities was identified to be a major contributor to the gap in performance observed in Lindi Region of Tanzania. In the last quarter of FY12, including six RHMT members and 36 CHMT members from all six Lindi districts participated in a two-day learning session in Mtwara for the Tandahimba HR collaborative where they learned about changes tested in Tandahimba to improve supportive supervision, retention of new staff, the flow of supplies and logistics, the recording, management and reporting of district health information, and the implementation of activities in their annual plans. Using some carry-over funds from HCI while waiting for approval of ASSIST funding to continue the core project research, the second coaching sessions were undertaken in all six districts in December 2012, with the objective of supporting QI teams to support the implementation of ideas tested in Tandahimba and gather data on results to date. It took time for the District Managers to embrace the concept of performance improvement and applying improvement methods to these issues. HCI coaches worked with the managers to identify the primary roles of the CHMTs and define indicators that would demonstrate how well they were performing those roles. Most of these indicators were process indicators rather than outcome indicators because the district management level has very little influence on the outcomes of many of their tasks and responsibilities. Data collected during the coaching visits showed that the districts were able to submit their supply orders and other reports to the region on time. The Kilwa district has improved staff appraisal completion by 25% since 2011 by training staff on how to properly fill out Ministry of Health Performance Appraisal System forms. Some staff have already been appraised, and high performers have been recommended for promotion. The district is currently providing orientation to new employees as soon as they report, which is expected to result in higher rates of staff retention. Out of 38 new staff recruited in last quarter, 34 (89%) received technical orientation within two weeks. This is improvement compared to 58% (16/28) observed last year. The same improvement was observed in Liwale district where new staff is now given technical orientation within two weeks of their arrival. Table 11 summarizes results across the key indicators. While support for the Tanzania District Management Collaborative transitioned to the USAID ASSIST Project in March 2013, results reported under ASSIST for September 2013 can also be attributed to the initial technical support provided under HCI.

The exercise of creating job descriptions among the district’s council health management team through HCI and ASSIST has been helpful in streamlining and rationalizing tasks. The % of management team members with clear and rationalized job descriptions increased from 0% in December 2010 to 100 % in June 2013. To improve the availability of medicines and supplies in the health facilities the district management teams (CHMTs) aimed to raise the percent of on-time supply order submissions. With assistance from HCI and ASSIST, training on how to correctly fill out the Requesting and Reporting forms minimized unnecessary errors and reduced back and forth communications to correct and re-submit requisitions. Another change made in the process was that a clerk assigned with the responsibility for collecting all the reports and orders now calls the facilities approximately one week in advance of submission date to remind them of the coming deadline and offer any support for problems with completing the documents. The percentage of facilities that submitted supply orders on time increased from 76% in March 2011 to 96% in September 2013. The % of district level reports that were


processed and submitted to the region within two weeks of receipt from the facilities moved from 71% in March 2011 to 91% in September 2013; and the % of requisitions that were processed and submitted to the RHMT within two weeks of receipt also rose slightly from 91% in March 2011 to 96% in September 2013.

Table 11. Tanzania: District Health Management improvement indicators, Lindi Region

Indicator: Baseline (March 2011)

October 2011

October 2012

Sept. 2013

INDICATORS COLLECTED QUARTERLY

% of facilities that submitted supply orders on time to the CHMT

76% 85% 95% 96%

% of district level reports that were processed and submitted to the region within two weeks of receipt from the facilities 71% 94% 98% 91%

% of supply orders which were processed by the CHMT within two weeks of receipt and sent to the RHMT

91% 73% 91% 98%

% of management team members that have clear and rationalized job descriptions

0% 7% 5% 100%

INDICATORS COLLECTED SEMI-ANNUALLY

% of newly recruited staff that received a technical orientation within two weeks of reporting

53% 25% 44% 69%

% of newly recruited staff that are retained at 6 months 69% 98% 78% 97%

% of CHMTs that have QI competencies (self-reported) according to an 11-point questionnaire.

0% 0% 49% 75%

INDICATORS COLLECTED ANNUALLY

% of health facilities applying improvement approaches to improve quality of health services (out of 192 facilities)

3% 3% 5% 13%

% of staff at district hospital that have undergone and annual performance appraisal 0% 2% 5% 55%

To address staff retention, one of the interventions that proved effective was what the CHMTs labeled as “Orientation Packages.” With this package, the CHMTs arranged for a process of welcoming staff was established so that whenever staff arrived, a member of the CHMT had assigned someone to introduce them to the facilities staff, orient them to the facilities processes and procedures, and help them to meet the district officers. In addition, the districts set aside money from the budget to keep an apartment ready with essential necessities provided so new staff could immediately have a place to live. Finally, the districts also set aside a small stipend to allow the new arrivals to have spending money until their payroll status was confirmed, at which time they reimburse the advance from their pay-checks. After implementing these orientation packages the percentage of new staff that was still remaining at the facilities at six months after arriving went from 69% in March 2011 to 97% in September 2013. The Tanzania district management collaborative will be completed in early 2014 under ASSIST funding. Activity 7: Ethiopia CHW Performance Improvement Collaborative See section 3.2 Community Health. Activity 8: CHW Regional Meeting Follow-up The USAID-sponsored Community Health Worker Regional Meeting was held in Addis Ababa from June 19 to 21, 2012. The meeting was designed and led by HCI partner Initiatives Inc. The meeting sought to demonstrate and discuss tools and strategies to strengthen the functionality, scale-up, and sustainability of government- and NGO-managed CHW programs, using findings from the application of the CHW AIM tool that had been used in the participating countries. Near the meeting’s end, country participants developed action plans to guide their post-meeting activities. Six countries were


represented with over 60 government, NGO, and international partner participants. The country CHW activities represented at the meeting were from Ethiopia, Kenya, Rwanda, Uganda, Zambia, and Mali. The resulting meeting report, “CHW Regional Meeting: Country Follow Up Plans and Actions” describes the progress each country has made over the last year in addressing the action plans that the country teams developed during the meeting’s working groups. Activity 9: CHW Central Website CHW Central is an online community of practice bringing together program managers, experts, practitioners, researchers, and supporters of CHW programs. The website is a virtual meeting place for sharing resources and experiences, learning through expert panels, and participating in conversations through online dialogue. This site is available to all, but to participate in conversations, one needs to register for a free membership. The site is designed to respond to the growing need for a central data repository of information, topic discussions, professional networking, and research that impact and involve global development issues around CHWs. It fosters the exchange of ideas, best practices, and promising strategies that will help improve the effectiveness and efficiency of CHW programs worldwide. In FY13, the site, which had been hosted solely on the HCI Project portal (http://www.hciproject.org/), was successfully migrated to the Initiatives Inc. website (http://www.chwcentral.org/), where it will be managed by that firm and supported by member partners. The design and content of the new, updated site builds on the strength of the USAID investment through HCI and adds features that were suggested during consultations and focal group discussions online and discussions at the CORE Group 2013 Spring meeting. During that meeting, four sessions of roundtable discussions enabled Initiatives Inc. and HCI representatives to describe the new website concepts, announce its new location and hosting structure, and collect feedback and suggestions. The new website, independent of HCI, was launched in August 2013. Activity 10: CHW Assessment and Improvement Matrix (CHW AIM) Revision The CHW AIM is a guided self-assessment that allows a diverse group of stakeholders to score their programs against 15 programmatic components and four levels of functionality. Technical partners, government managers, and other program implementers and managers use the results to develop action plans to address weaknesses or gaps in their CHW program functionality. After the USAID-sponsored regional meeting on CHWs in Ethiopia with six country representatives, along with implementing partners and NGOs who had applied the tool, input was collected from CHW AIM users and implementers on improvements and updates that would make the assessments more user-friendly. These and other recommendations provided by implementing partners who were using the tool guided the updates and revisions made in 2013. Improvements to CHW AIM included the addition of a guide explaining how to use the tool and a set of more-streamlined worksheets and tables that will be more appropriate for field application. The updated CHW AIM tool is available on the ASSIST website and was announced on CHW Central.

3.5 HIV/AIDS


Activities What are we trying to accomplish? How will we know? Geographic scale

1. Addressing barriers to implementation of the WHO PMTCT and Infant

Apply QI principles to strengthen the global effort to maximize HIV-free survival of children and the health of their mothers by:

Establishing best practices and guidance for implementation of the

Mothers and infants will receive appropriate PMTCT and infant feeding services and guidance.

Mother-baby follow-up and adherence to recommended

3 sites (1 district, hospital, 1 health center, and 1 dispensary) in Njombe Town Council (1 of 4 districts in Njombe


Feeding Guidelines

latest WHO PMTCT and infant feeding guidelines

Improving uptake and retention of women and infants along the PMTCT continuum

Improving uptake of ANC services

Improving family planning for HIV-infected couples

Enhancing linkage of PMTCT to social services, especially OVC programs

feeding and ARV regimens will improve.

Facilities will be able to track mothers and infants along the PMTCT continuum.

Uptake of services at key “gaps” along the PMTCT continuum will improve.

Region) in Tanzania

2. PMTCT Assuring Infants and Mothers Get All PMTCT Services (AIMGAPS)

11 sites and 11 villages in 4 districts of Iringa, Tanzania: (176 PMTCT programs in 4 of 129 districts)

3. Injection Safety

Apply QI principles to improve safe injection practices and reduce the incidence of unnecessary medical injections to reduce the transmission of HIV/AIDS, Hepatitis B & C, and other blood-borne pathogens

Increased adherence to safe injection practices

Increased adherence to safe waste disposal practices

Increased availability of post- exposure prophylaxis

Decreased incidence of unnecessary medical injections

Mali: 25 sites (21 public and 4 private facilities)

By region: Sikasso region: 9 public facilities (of 25) and 2 private facilities Bamako region: 12 public facilities (of 55) and 2 private facilities Pakistan, Sindh Province:– 25 sites (22 private, 3 public)

Swaziland, TBD

Main Activities and Results Activity 1: Addressing barriers to implementation of the WHO PMTCT and Infant Feeding Guidelines In FY13, carryover funds were used to prepare a technical report on this activity; the report is in final review. Results were also presented at the 141st APHA Annual Meeting in November 2013 (https://apha.confex.com/apha/141am/webprogram/Paper280558.html). Activity 2: Assuring Infants and Mothers Get All PMTCT Services (AIMGAPS) While Mission-funded improvement activities in Tanzania transitioned to the ASSIST Project as of October 1, 2012, HCI continued to support one improvement intervention in Tanzania with OHA funding: Assuring Infants and Mothers Get All PMTCT Services (AIMGAPS). HCI has been working with the Ministry of Health and Social Welfare (MOHSW) and EngenderHealth in the Iringa Region of Tanzania to improve uptake, retention, and quality of prevention of mother-to-child transmission of HIV services across the continuum of care from the antenatal period through the entire breastfeeding period until the HIV status of the exposed infant is definitively determined. Initially, the AIMGAPS activity began at the facility level but later expanded to include a community component. During the reporting period, HCI continued to provide coaching and mentoring to eight sites in Iringa Municipal and District councils. All QI teams continued to collect and update data for monitoring progress. The proportion of HIV-positive pregnant women started on or receiving ART or ARVs continued to improve. HCI QI advisors worked with facility staff to improve data quality to prevent over reporting. Improvements were also achieved in relation to tracking mother-baby pairs. Changes in documentation (i.e., encouraging providers to record mothers’ ANC and Care and Treatment Center


[CTC] registration numbers together) enabled providers to determine whether mothers who bring their HIV-exposed infants for follow-up care are enrolled in care and treatment. If providers found that a mother had not enrolled in the CTC, they were then able to enroll the mothers at the CTC during the infant’s follow-up visit. Figure 26 present gains achieved in FY13 in infant testing.

Figure 26. Tanzania AIMGAPS: Percentage of HIV-exposed infants who received a confirmatory HIV test, Iringa Region (January 2011-February 2013)

After testing changes and monitoring indicators for two years, it became apparent that increasing uptake and retention of PMTCT services requires community support. For a few indicators, facility-level changes of care processes alone were leading to little or no improvement. For example, data on enrollment of HIV-exposed infants into PMTCT follow-up care and male involvement in ANC lagged behind other improvement indicators where clear progress was made, such as, pregnant women initiating ARVs during pregnancy (see Figures 27 and 28). In August 2012, the Community Health Systems Strengthening (CHSS) model, developed by HCI’s Senior Advisor for Community Health, Ram Shrestha, was implemented to strengthen the linkage between the community and facility to increase uptake and retention of PMTCT services. The CHSS model was implemented in three AIMGAPS health centers and their surrounding villages (11 villages in total) to strengthen the community component of AIMGAPS. In FY13, coaching continued and improvements were observed in male partner testing at antenatal care at the three sites with the strong community component, where male partner testing increased from 50% in October 2012 to 86% in August 2013, while the overall male partner testing rate across all participating sites increased only from 17% in January 2011 to 31% in July 2013 (see Figure 28). Under the ASSIST Project in FY14, best practices from the CHSS model are being spread to the remaining AIMGAPS sites.

J-11 F-11M-11

A-11M-11

J-11 J-11 A-11 S-11O-11

N-11D-11 J-12 F-12M-12

A-12M-12

J-12 J-12 A-12 S-12O-12

N-12D-12 J-13 F-13

# HIV exposed infants who receive a confirmatory HIV

test (PCR/Serology)1 3 5 7 7 5 11 17 19 20 14 26 42 37 40 10 44 43 27 55 33 29 33 19 33 27

Total # HIV exposed infants attending the clinic who were

weaned > 6 weeks ago 13 14 25 28 47 48 72 78 55 53 42 56 63 68 59 51 112 135 64 96 77 59 55 30 50 34

% HIV exposed infants receiving a confirmatory HIV test

8 21 20 25 15 10 15 22 35 38 33 46 67 54 68 20 39 32 42 57 43 49 60 63 66 79

# of Sites Reporting 5 5 5 6 6 6 6 7 7 6 5 7 9 9 9 8 9 10 10 10 10 10 9 9 9 8

8% May 2011: Learning Session 1

Aug. 2011: Learning Session 2

Jan. 2012: Learning Session 3

Mar. 2012: Shortage of rapid test kits led to limited HIV

testing

Apr. 2012: Reagents obtained, testing resumed.

Jun. 2012: Learning Session 4; Providers agreed to remind mothers one month prior to

actual test date about conf irmatory test.

Sept: 2012: Redistribution of dried blood spot test kits

between facilities. Facilites with large amouts of stocks

sent supplies to facilities with less stock.

79%

0

10

20

30

40

50

60

70

80

90

100

% H

IV e

xpos

ed in

fant

s re

ceiv

ing

a co

nfirm

ator

y H

IV te

st% HIV exposed infants receiving a confirmatory HIV test in 10 sites

in Iringa Region, Tanzania, Jan 2011 – Feb 2013

Changes:•Introduced an early infant diagnosis (EID) focal person at the regional hospital

•EID focal person made sure that blood sample results were dispatched to the right facilities

•Improved documentation of test results

•Sent messages or called mothers of exposed infants who were either 18 months old or had completely stopped breastfeeding to request those mothers to bring their infants the hospital


Figure 27. Tanzania AIMGAPS: Percentage of HIV-positive pregnant women started on or receiving ART (treatment) or ARV prophylaxis, Iringa Region (January 2011-May 2013)

Figure 28. Tanzania AIMGAPS: Percentage of HIV-positive pregnant women initiating ARVs during pregnancy compared to male partner testing at ANC (January 2011-July 2013)

Changes introduced: a) May 2011: Learning Session 1, Providers trained on QI principles, QI teams formed followed by coaching and mentoring; b) Aug. 2011: CD4 count threshold was increased meaning more women became eligible for triple therapy with HAART; c) Nov. 2011: Increased stocks of ARVs at Reproductive and Child Health clinics to meet increased demand; d) Mar. 2012: Shortage of ARVs; e) Jan. 2012: Started community component; f) Aug. 2012: Implemented Community Health Systems Strengthening model.

e)

f)

a)

b)

c)

d)

0

10

20

30

40

50

60

70

80

90

100

Percen

tage

Jan‐11

Feb‐11

Mar‐11

Apr‐11

May‐11

Jun‐11

Jul‐11

Aug‐11

Sep‐11

Oct‐11

Nov‐11

Dec‐11

Jan‐12

Feb‐12

Mar‐12

Apr‐12

May‐12

Jun‐12

Jul‐12

Aug‐12

Sep‐12

Oct‐12

Nov‐12

Dec‐12

Jan‐13

Feb‐13

Mar‐13

Apr‐13

May‐13

Jun‐13

Jul‐13

% of male partners testing for HIV at ANC 17 21 24 16 18 17 24 17 24 20 19 25 18 21 22 16 21 24 10 23 36 22 24 33 28 27 27 25 28 24 31

% HIV+ pregnant women started on or receiving ART (treatment) or ARV prophylaxis

43 49 44 43 26 32 43 36 52 59 50 45 64 74 77 59 45 80 81 85 76 85 85 90 96 85 93 86 91 91 85

% of HIV‐positive pregnant women initiating ARVs during pregnancy versus % of male partners testing for HIV at ANC in 11 sites, Iringa, Tanzania, January 2011‐July 2013

% of male partners testing for HIV at ANC % HIV+ pregnant women started on or receiving ART (treatment) or ARV prophylaxis

J-11 F-11 M-11 A-11 M-11 J-11 J-11 A-11 S-11 O-11 N-11 D-11 J-12 F-12 M-12 A-12 M-12 J-12 J-12 A-12 S-12 O-12 N-12 D-12 J-13 F-13 M-13 A-13 M-13

#HIV+ pregnant women started or receiving ARV prophylaxis or ART during pregnancy (new

and follow up)35 42 42 42 30 40 71 42 60 58 71 61 92 120 117 84 70 90 118 174 167 194 168 107 167 120 114 110 100

Total # HIV+ pregnant women who are eligible for ART and those eligible for ARV prophylaxis

(gestational age ≥14 weeks)82 85 96 97 115 126 167 118 115 98 143 137 144 162 151 142 155 112 146 197 210 229 197 119 174 142 110 121 111

% HIV+ pregnant women started on or receiving ART (treatment)

or ARV prophylaxis 43 49 44 43 26 32 43 36 52 59 50 45 64 74 77 59 45 80 81 88 80 85 85 90 96 85 104 91 90

# of Sites Reporting 11 11 11 10 11 11 11 11 11 11 11 10 11 11 11 11 11 10 11 11 11 11 11 9 10 10 10 10 9

43%

May 2011: Providers trained on QI principles, QI teams formed,

documentation stressed followed by coaching and mentoring

Aug. 2011: New WHO 2010 PMTCT guidelines introduced,

ARV prophylaxis eligibility changed f rom CD4 >200 to >350, resulting in

an increase in total number of clients eligible to receive ARVs

Dec.2011: Increased stocks of ARV at RCH to meet increased demand

Mar. 2012: Enrollment to PMTCT care reduced as testing was

restricted due to shortage of test kits

90%

0

10

20

30

40

50

60

70

80

90

100

% H

IV+

pre

gn

an

t wo

me

n s

tart

ed

o

n o

r re

ceiv

ing

AR

T (t

rea

tme

nt)

o

r AR

V p

rop

hyl

axi

s % HIV+ pregnant women started on or receiving ART (treatment) or ARV prophylaxis in 11 sites in

IRINGA REGION, TANZANIA, January 2011 – May 2013


Activity 3: Injection Safety Mali This improvement collaborative began in March 2013; it incorporates 24 health facilities from the capital city of Bamako and the rural district of Bougouni. During FY13 HCI advisors oriented the participating health facilities on improvement science and initiated coaching visits to the sites. Results Safe injection procedures: To ensure safe injection procedures and adequate infection control, sites

have made available adequate arrangements for hand washing and infection control including gloves, water, alcohol, and bleach. Compliance with standards for safe injections increased from 88% in June to 91% in September 2013.

Waste Management: Sites have also tried to ensure adequate availability of color-coded bins for waste segregation and safety boxes. Adherence to waste management norms improved from 74% to 80% during the June to September 2013 period.

Post-exposure prophylaxis: Effective management of sharps injuries requires as least: 1) a qualified person responsible for assessing sharps injuries, 2) a register for recording injuries, 3) a post-exposure prophylaxis medicine kit, and 4) a flowchart/guidelines on sharps management. In June 2013, only 17 of the sites had these basic components in place. By September 2013 all 24 sites reporting had done so.

The injection safety activity in Mali will be completed in January 2014, under HCI funding. Pakistan In FY13, HCI completed work with a local organization, Bridge Consultants, to improve safe injection practices and waste management in Karachi, Sindh Province, Pakistan. The activity was carried out in three union councils in Karachi: Memon Goth, Gujro, and Darsanna Channa. In Pakistan, the majority of medical care is provided in the private sector, thus a total of 25 sites were included in the activity, including 23 private facilities and two government facilities. Of the 23 private facilities, 14 are staffed by trained medical doctors, and nine are staffed by unlicensed providers. The sites were supported by coaches from Bridge Consultants, who received training from HCI. In FY13, the activity focused on improving injection safety and infection control at the health facilities, advocacy for stronger policy support for safe injection practices, and strengthening community awareness about injection safety. By the end of the activity in September 2013, all sites had reminders and job aids displayed promoting safe injection practices. All injections that were performed and observed throughout the last five months of the activity used a sterile needle and syringe (see Figure 29). Several other practices showed improvement; Table 12 shows improvement in targeted injection safety indicators in Pakistan in FY13.

In addition, advocacy meetings were held with the Hepatitis Control Program of Sindh and several ministers of Sindh cabinet on injection safety. On World Hepatitis Day (July 28, 2013) several articles were published in leading English and Urdu dailies regarding injection practices. A detailed dossier highlighting the gaps in injection practices and policies was shared with the provincial law minister. HCI also supported the preparation of a commentary on injection safety policies in Sindh that was published in the November 2013 issue of the Journal of the Pakistan Medical Association. Injection Safety Swaziland Protocol and tools for a baseline assessment of injection safety practices were drafted in FY13. Ethics approval has been obtained for the assessment from the URC Institutional Review Board and the Swaziland Ethics Committee. The baseline assessment, which is expected to be completed in the second quarter of FY14 under HCI funding, will inform the subsequent improvement activity to be supported under the ASSIST Project.


Figure 29. Pakistan: Percentage of injections observed being given with a sterile single-use syringe and needle (May 2012-September 2013)

Table 12. Pakistan: Number of sites complying with safe injection practices (May-September 2013)

Number of sites complying with safe injection practices

Indicator (12 sites total) Baseline – May-13 Endline- Sept-13

Medications drawn immediately prior to use. 9 sites 11 sites

No needles are left in multi-dose vials 11 sites 12 sites

Bottles of intravenous fluids are not used as a common source for multiple patients

10 sites 12 sites

Injections performed using a sterile needle and syringe 12 sites

3.6 Maternal, Newborn, and Child Health



1. Contribute to maternal, newborn, and child (MNC) mortality reduction through the application of improvement approaches at the health facility and community levels in selected USAID priority countries

Apply the collaborative improvement model to improve evidence-based child survival interventions care at community levels (health huts) in Senegal

Senegal: Mbour District, population 300,000 and Tivaouane District, population 200,000

Apply the collaborative improvement model to improve evidence-based maternal and newborn care at the health facility and community levels in Uganda

Uganda: Luwero District, population 416,000 and Masaka District, population 250,000

Apply the collaborative improvement model to improve evidence-based ANC and PMTCT services at facility and community levels in Kenya

Kenya: Kwale District, population 161,000

31%

71%73% 73%

100% 100% 100% 100%

0%

20%

40%

60%

80%

100%

May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13

May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13

% observations with sterile single‐use needle and syringe.

31% 71% 73% 73% 100% 100% 100% 100%

Number of observations observed being given with sterile syringe and needle.

4 15 11 8 12 12 12 12

Total number of observations 13 21 15 11 12 12 12 12

% of injections observed being given with a sterile single‐use syringe and needle (observed to be taken from a new unopened packet).

Phase one (May‐12 to Nov‐12)

‐ Coaching support to providers‐ Training in infection control

and injection safety‐ Intensive community

awareness through TV spots and door to door campaign.

Data collection not done since the activity was on hold due to subcontract renewal.

Phase two( May‐13 to Sep‐13)‐ Coaching support to providers‐ Formation of community health committess ‐Hep B vaccination of 30 providers

‐Intensive advocacy work with the provincial leadership


Improve outcomes for newborns by addressing the major causes of neonatal mortality in Afghanistan

Afghanistan: Five provinces: Jalabad (Nagarhar), Kandahar, Paktia, Khost, and Kabul

Support LAC Regional Newborn Alliance

Cross-cutting regional technical leadership targeting five LAC countries

2. Support Global Technical Leadership in USAID priority maternal, newborn, and child health (MNCH) areas

Development of Basic Newborn Resuscitation Quality Framework

Global

Main Activities and Results Activity 1: Contribute to maternal, newborn and child mortality reduction through the application of improvement approaches at the health facility and community levels in selected USAID priority countries Senegal HCI’s partnership with ChildFund on improving community case management of childhood illness in 30 health huts in two districts in Senegal ended in December 2012. A final dissemination meeting shared and synthesized best practices. International and country partners will continue to support spread of successful changes. Uganda HCI maternal and newborn health (MNH) collaborative improvement work in 34 facilities in 24 villages in the Masaka and Luwero districts culminated in a final Harvest Meeting in September 2012. The meeting convened MNCH care providers, VHT members, and community and health facility coaches who discussed the changes they had made, how they had made them, and whether they had yielded improved results based on time series charts and data. Teams of participants then summarized changes that were found to be most effective and feasible across teams and generated a common “change package” of innovative changes that led to improvement in priority MNH indicators at both the facility and community levels. A final Dissemination Meeting was held in November 2012 to share the “change package” with stakeholders at all levels of the health system, including representatives of the MOH, National Newborn Steering Committee, professional associations, funders, development/implementing partners, civil society, training institutions/academia, media, and MNCH care providers. Plans were made for scaling up the change package to other districts in Uganda, especially districts participating in the “Saving Mothers Giving Life” initiative. In addition to synthesizing and disseminating the results of MNH improvement work in the Masaka and Luwero districts, HCI played an active role in FY13 in assisting Uganda’s MOH to coordinate the scale up of improved newborn care practices, including HBB. Among other activities, HCI supported the MOH in a national mapping exercise of HBB-plus activities and supporting partners. Kenya In October 2012, the HCI team in Kenya convened a harvest meeting to synthesize best practices learned during implementation in 2011 and 2012 of an ANC improvement collaborative in 21 facilities in Kenya’s Kwale district. The demonstration project resulted in increased utilization of ANC services and an increasing number of institutional deliveries over the life of the improvement work. Increasing utilization of ANC and institutional delivery services was largely due to a strong focus on strengthening community and facility linkages, including community referrals of pregnant women for facility ANC and delivery services.


Afghanistan In 2012, HCI continued to support intensive newborn resuscitation capacity-building activities for providers as it phased out provincial service delivery newborn improvement work at the Mission’s request. Among other capacity-building activities, HCI led a Helping Babies Breathe (HBB) training of trainers for 10 members of the US Military Medical team in February 2013. Trainees subsequently trained 179 first-line providers in two Afghan provinces using HCI-provided equipment and training materials. Over the course of 2012, HCI began to hand HBB activities over to the MOPH. In May 2013, HCI supported an HBB training of trainers for 31 female doctors and midwives, including representatives from the MOPH Reproductive Health Depepartment, Afghan Society of Obstetrics and Gynecologists, Afghan Midwifery Association (AMA), Ghazanifar Institute of Health Sciences, and the Malalai and Isteqlal maternity hospitals. The newly trained trainers then conducted follow-on HBB training for to first-line providers in June 2013. HCI donated 120 mannequin sets, 120 resuscitation sets, 120 training packages (facilitators’ guide and participants’ books) to the MOPH and the organizations and hospitals listed here. HBB has now been integrated into the curricula of the Community Midwifery Education and Community Nursing Education programs and is being integrated into the curriculum of the Ghazanfar Institute. HCI’s HBB project was officially handed over to the MOPH on June 30, 2013. However, in the final months of HCI, the team is providing support to the Ministry to develop an HBB national roll-out strategy and is working on a case study of HCI-supported HBB improvement work to synthesize and disseminate lessons learned. LAC Regional Neonatal Alliance Modest HCI core MNCH funds were used in FY13 to support LAC Regional Newborn Kangaroo Mother Care and Newborn Resuscitation activities focused on transitioning LAC regional activities to the HCI follow-on ASSIST Project. Activity 2: Support Global Technical Leadership in USAID priority MNCH areas Development of the HBB Quality Framework by the HBB QI Cluster, led by HCI: A complete first draft of the Basic Newborn Resuscitation Quality Framework was circulated among partners at HCI’s closure in September 2013. Final revisions and future dissemination of the framework will be supported by the ASSIST Project. Participation of HCI/ASSIST technical staff in the 2013 Global Newborn Conference, the global Every Newborn Action Plan working group, the Newborn Indicators Technical Working Group, and the UN Commission for Life-saving Commodities Resuscitation working group has helped promote a regular focus on quality in these groups and ensure that the framework is responds to and reflects current global technical directions in newborn health.

3.7 Nutrition Assessment, Counseling, and Support

Background To support the continued adoption, adaptation, and scale-up of nutrition assessment, counseling, and support (NACS) as a standard of care in national HIV/AIDS programs, USAID supports improving the health and quality of life for people living with HIV, their families, and vulnerable children by improving their nutrition status, increasing HIV-free survival of infants born to women in PMTCT programs, reducing household food insecurity among families affected by HIV, and strengthening the integration of nutrition support with health systems at the clinic and community levels. Building on HCI’s experience supporting nutrition services for HIV clients in Uganda and Kenya, the project supported NACS in FY13 and the implementation and scale-up of Partnership for HIV-Free Survival (PHFS) by applying modern QI methods to strengthen health systems to deliver nutrition services for people living with HIV, with particular attention to mothers and their exposed infants.





1. Integrate NACS into HIV clinics to improve nutritional status of HIV clients

Improve the nutritional status of malnourished HIV clients

Improve nutritional status by tracking HIV clients who are assessed for nutritional status and properly categorized, counseled, treated, and supported

Malawi: 2 districts (Balaka and Karonga) in 8 facilities

Zambia: Kitwe District in 8 facilities

Democratic Republic of the Congo: TBD

2. QI technical assistance for PHFS

Reduce HIV transmission to exposed infants and reduce infant mortality by ensuring care is provided in line with 2010 WHO PMTCT guidelines

Increase the number of pregnant women receiving ARVs for treatment or prevention in line with national guidelines

Increase the numbers of new mothers exclusively breast feeding for the first six months, complementary feeding for the first 12 months, and number of breast-fed infants protected by ARVs.

Lesotho: 12 sites in 3 districts

Tanzania: 30 sites in 3 districts

Uganda: 22 sites in 6 districts

Kenya: 17 sites in 4 districts

Mozambique: 8 communities in 3 provinces

Main Activities and Results Activity 1: Integrate NACS into HIV clinics to improve nutritional status of HIV clients Malawi Nutrition accounts for 50% of deaths in Malawi. The MOH with HCI support worked in eight facilities in two districts in FY13 to integrate nutrition services into HIV, TB, and PMTCT care and into the health care system. The major challenges with integrating nutrition into routine health care in Malawi are: 1) health facilities lack therapeutic food, leaving little incentive to assess patients since no treatment is available and 2) data are generally lacking at the central level, so the MOH cannot quantify each facility’s needs or support the argument that funds are needed to procure therapeutic food. HCI’s goal with respect to these challenges is to support the MOH to make facility-level changes to obtain more data on malnutrition, integrate key indicators from the Nutrition, Care, Support, and Treatment Programme (NCST) into the Health Management Information System, and build a national level team to address nutrition issues. In FY13, at the national level, HCI has assisted in producing training materials by holding a workshop to develop guidelines and a training manual for the NCST program. The purpose of HCI’s participation in developing this material is to ensure that QI indicators are incorporated into the NCST guidelines. HCI continues to collaborate with the MOH monitoring and evaluation staff and the WHO to ensure that these indicators are integrated into the NCST programme. In FY13, at the facility level, HCI Malawi staff continued to provide support to health facility QI teams to assess, categorize, and prescribe therapeutic food. Figure 30 shows that the proportion of clients assessed for their nutritional status in August 2013 was 90% of the patient population who received care from eight facilities in Karonga and Balaka, a substantial increase from 68% eight months earlier. In addition to the growing number of clients seen at the clinic and the increasing proportion of such clients assessed, Figure 31 shows the number who were categorized as malnourished. The data depicted in these figures resulted from of a number of changes tested at the facility, including:

Using different types of staff to carry out the nutrition assessment: For example, all eight QI teams incorporated either expert clients and/or different types of hospital support staff to assist in assessing clients in ART, TB, and PMTCT clinics.


Figure 30. Malawi: Percentage of clients whose nutritional status was assessed at eight facilities in two districts (January-August 2013)

Figure 31. Malawi: Number of clients seen, assessed, and categorized as malnourished, eight

facilities in two districts (March-July 2013)

Assessing clients during registration: All eight teams established points for registration in the ART,

TB, and PMTCT clinics when the client arrives at the clinic but before clinic registration. Developing a schedule for facility staff: Two out of eight health facilities introduced rosters where

staff were allocated times to conduct assessments.

1100888

5340

6311

78737589

8528

75 109

3621

4718

62895752

6264

21 36

353 471 548 381 351

Jan Feb March April May June July

# of clients seen # of clients assessed # malnourished


Using electronic medical records: One of the eight teams use an electronic medical record system to help enforce nutritional assessment by precluding a client from advancing to the next treatment stage after his or her weight and height have been entered into the system.

Introducing registers to capture client assessment information: One out of eight QI teams introduced these registers, which improved the organization of nutrition data

HCI support for the NACS work in Malawi was concluded in FY13. In FY14, further scale-up of this work will be supported with Mission funding under the ASSIST Project. Zambia NACS After repeated postponements by the USAID Mission, discussions were held in late FY13 concerning the start-up of HCI-supported NACS work in Zambia. In October 2013, Dr. Victor Boguslavsky, HCI Regional Director, attended a NACS acceleration planning meeting in Kitwe, Zambia organized by FANTA (the Food and Nutrition Technical Assistance Project III). In FY14, HCI will work with FANTA III, Thrive Project, Project Concern International, Livelihoods and Technical Assistance II Project (Lift II), the Ministry of Community Development, and the Maternal and Child Health Department of Kitwe District in Zambia to introduce NACS standards in 34 health facilities of the district. Activity 2: Quality Improvement technical assistance for the Partnership for HIV-Free Survival (PHFS) Mozambique PHFS HCI staff in Mozambique and Bethesda worked closely with the USAID Mission and the many partners contributing to PHFS efforts to define our role and activities in the eight communities and how we will coordinate with HealthQUAL and other partners. A PHFS launch meeting was held in Sofala Province on Oct 1, 2013. Participants included the Mozambique MOH and staff from ASSIST, FANTA, and HealthQUAL. Lesotho PHFS In preparation for the PHFS activities in Lesotho, HCI staff designed a training on QI and coaching for new district coaches. The two-day training was held in October 2013 in the Mohale's Hoek District; participants were nurses, nutritionist, and doctors who focus on PMTCT, HIV, and nutrition. HCI’s objective is to support the MOHSW to kick-start QI activities for the PHFS Initiative. PHFS assistance in Lesotho will continue in FY14 with Mission funding under the ASSIST Project. PHFS Global Learning In FY13, HCI launched a new PHFS page on the internal URC intranet page to facilitate shared learning across countries participating in the PHFS work.

Directions in FY14 During FY14, HCI will support NACS activities in eight sites in Kitwe District, Zambia, and PHFS activities in eight communities distributed over three provinces in Mozambique.


4 Common Agenda Activities 4.1 Knowledge Management



1. Achieve a smooth transition of all content and the redirection of visitors to the HCI Portal to the new ASSIST web portal

Complete analysis of user statistics of the HCI Portal to inform the development of user profiles for the new ASSIST web portal

Move HCI Portal content to the new ASSIST web portal

Continue to operate both sites for a period to facilitate use of the ASSIST web portal

Transition HCI’s social media pages (Facebook and Twitter) to new ASSIST social media pages

Global

2. Share learning from HCI’s knowledge management (KM) experience

Prepare a paper summarizing the experience of the HCI KM system and submit the paper to a peer-reviewed journal

Global

Main Activities and Results Activity 1: Achieve a smooth transition of all content and the redirection of visitors to the HCI Portal to the new ASSIST web portal HCI Portal Operation of the HCI Portal continued through all of FY13, since the ASSIST Project website was not launched in FY13 as expected. Traffic to the HCI Portal did see a decline in the second half of FY13 due to reduced emphasis on adding and promoting new content on the portal and because of the removal of CHW Central from the portal in August 2013. Overall, there were 83,215 visits to the HCI Portal in FY13, down about 13% from visits in FY12. In November 2012, the HCI Knowledge Management Director met with the full web support team at the Johns Hopkins University Center for Communication Programs in Baltimore to discuss the transition from the HCI Portal to the new ASSIST Portal. In September 2013, migration of all of the resources on the HCI Portal to the development server for the ASSIST Portal was completed. CHW Central Community of Practice USAID, through its Office of HIV and AIDS Health Workforce team, had signalled at the start of FY13 that no further OHA funding would be provided for operation of the CHW Central virtual community of practice beyond the funds given to HCI in previous years. The MCH group at USAID has also declined to provide further funding for CHW Central. Funds remaining in the HCI TO3 contract supported the maintenance costs of Initiatives Inc. for management of the site through June 2013. After exploring several alternatives, Initiatives Inc. proposed to take over operation of the site as a private activity, outside the mechanism of the HCI Project. This proposal was discussed with the HCI Contracting Officer’s Representative (COR), who approved the devolution of the URL and site content to Initiatives Inc. The redesigned, independent CHW Central website went live in August 2013 at www.chwcentral.org, and all CHW Central community of practice content was removed from the HCI Portal. Initiatives Inc. agreed to retain language on the redesigned site indicating that USAID and the HCI Project supported the development of the CHW Central site. Under the ASSIST Project, the health workforce team will continue to participate in the CHW Central community of practice, but the site will not be affiliated with ASSIST.


HCI Social Media During FY13, HCI continued to sustain its social media reach and gained new followers. Visitors to the HCI Facebook page frequented the following tabs: Timeline, Photos, About Section, Likes, and Vimeo. The HCI Portal and maternoinfantil.org continued to be the top external referrers to the HCI Facebook page. The top countries represented in terms of “reach,” excluding USA, were Georgia, Nigeria, Cambodia, Jordan, Bangladesh, and Kyrgyzstan. Top new “likes” were acquired from visiting the page itself and from Facebook Recommendations. Photos highlighting project activities and updates about CHW Central continued to reach the most followers. Throughout the year, the HCI Facebook page also supported posts made on the HCI Georgia Facebook page. As the HCI Twitter page was synched to the HCI Facebook Timeline, our Facebook followers that do not use Twitter were still privy to knowledge (i.e., live tweets) we shared via Twitter specifically. The HCI Facebook page ended FY13 with 519 likes. The HCI Twitter page closed the third quarter of FY13 with 344 followers. In addition, Dr. Massoud, the HCI Project Director, joined Twitter in February 2013 and complemented our efforts in sharing our work and approaches. During the year, tweets promoted HCI’s OVC e-learning module, the HCI Uganda maternal health video posted on our Vimeo account, and the relaunch of the CHW Central website as an independent community of practice. The @usaidhciproject Twitter handle was referenced the most in April 2013 during the Global Newborn Health Conference, which further emphasizes the significance of using Twitter during events. Throughout the year, the HCI Twitter page supported and promoted announcements on behalf of partners such as REPSSI and CHW Central. In September 2013, the HCI Twitter page was transferred to the USAID ASSIST Project and relaunched as @usaidassist. Activity 2: Share learning from HCI’s knowledge management experience A manuscript describing HCI’s experience with knowledge management and the lessons drawn from the operation of the HCI Portal was drafted. It will be finalized and submitted to the COR for review in the first quarter of FY14. Key lessons addressed in the article include: Knowledge is created through conversation: Using KM techniques like storytelling and knowledge

cafés in learning session’s results in more effective engagement of participants and generates new insights about which changes tested resulted in improvement.

Learn in small groups; integrate knowledge in large groups: To bring together the collective knowledge of a group, people need to learn and process ideas in small group conversation and then integrate that knowledge in large groups. Following on small group work, deliberate activities need to be carried out in learning sessions to synthesize the collective knowledge of the assembled improvement team representatives.

Create knowledge products that convey advice to others: Compilations of tested changes are useful reference documents, but increasingly we recognize that additional guidance products are needed to effectively convey what we have learned about how to improve services in specific care areas. Moreover, such learning is best conveyed as recommendations and advice to others, rather than documentation of what we did. The advice should be expressed as what we would recommend to others to do in the future based on what we now know from our implementation experience

Create communication products that provide examples and stories of what is possible: In addition to products that convey key learning from improvement, we also recognize the value of communication products that can help to persuade others to adopt new practices. Such communication products would include case studies and stories on how a particular facility or community achieved a specific result. These stories may be thought of as testimonials of how QI is possible. Video clips of individuals telling their improvement stories are an especially effective format for such testimonials. Photographs of individuals or teams are also helpful to create a sense of connection among implementers.


Use deliberate processes to connect implementers to spread learning: While well-designed and field-tested knowledge products are important tools for conveying learning about how to improve care, we also recognize that written products and tools need to be complemented with opportunities for dialogue and exchange among implementers. Designing deliberate handover activities, where those who have actually implemented care improvements can share the details of their key lessons, answer the particular questions of other implementers, and help them plan how they will improve care in the same topic area, are especially useful as part of scaling up tested interventions to new sites.

Organize knowledge, make it readily available, and connect it to interested users through social media: An effective strategy for stimulating the uptake of knowledge products that are posted on web pages is through the use of social media, particularly Facebook and Twitter, which are used extensively by health workers and health care organizations in Africa for professional communication. Connecting through social media with individuals and organizations who are interested in improving health care creates ready channels for promoting content posted on web portals.

Directions for FY14 The HCI Facebook page continues to promote HCI results; it will be transitioned into the ASSIST Facebook page by the end of 2013, when the ASSIST website will be up and running. Once the ASSIST website has been operational for a few months and we have actively promoted the new site, the HCI Portal will be removed as a stand-alone web site; at that time, visitors to the URL www.hciproject.org will be redirected to www.usaidassist.org. All content previously available on the HCI Portal will still be available in the Resources section of the ASSIST website. We will finalize the manuscript describing the experience with and lessons learned from the HCI knowledge management system and submit it to the COR for approval.

4.2 Research and Evaluation




1. Institutionalization of modern QI approaches and QI results

Advance learning globally on status and drivers of institutionalization of results and QI implementation

Complete at least five field studies evaluating QI programs or activities after external assistance has ended and other research and evaluation studies addressing institutionalization

Ecuador

Niger

2. Methods and approaches for effective design/ implementation of improvement collaboratives

Advance learning globally on design and implementation of improvement collaboratives, especially related to application of QI at the community level

Complete at least six studies on improvement collaborative

Georgia

Guatemala

3. Methods and approaches for effective design/ implementation of spread activities

Advance learning globally on shared learning and spread of effective changes (better care practices)

Complete at least 18 studies on spread activities

Afghanistan

Mali

4. Cost-effectiveness of QI approaches and strategies (including

Advance global learning on comparative advantage and economic efficiency of QI

Complete at least 15 studies on cost-effectiveness

Complete at least two comparative

Cote d’Ivoire

Mali




comparative studies) activities studies Uganda

5. Other QI methodologies, distinct from the improvement collaborative approach

Advance learning globally on QI methodologies distinct from the improvement collaborative approach

Complete at least 15 studies on QI methodology distinct from the improvement collaborative approach

Tanzania

Uganda

6. Mission-requested studies on barriers to implementation of HCI improvement activities

Advance knowledge on barriers to improvement

Complete mission-requested studies on barriers to implementation of HCI improvement activities

Cote d’Ivoire

Main Activities and Results Studies Table 13 lists all research and evaluation studies carried out under HCI TO3 in FY13. During the year, HCI completed the following studies:

Cost-effectiveness analysis of improving the quality of care in maternity hospitals in Kabul, Afghanistan

Qualitative evaluation of community-based improvement for EON Care in Balkh Province, Afghanistan

Comparative study to assess the impact of collaborative improvement on customer satisfaction, provider satisfaction, and services for people living with HIV/AIDS, Cote d'Ivoire

Evaluation of a CHW improvement collaborative in Ethiopia Institutionalization of improvement activities in three regions of Niger: facilitators and barriers Spread of better care practices and quality improvement for EONC services from Niger to Mali Patient and provider perspectives on improving the linkage of HIV-positive pregnant women to HIV

care in eastern Uganda What has HCI done to institutionalize improvement? A report from 17 countries

Table 13. Research and evaluation studies carried out under HCI TO3 in FY13

Country Study Technical Area Clinical Area

Status

Afghanistan Hospital QI improvements in Kabul CEA MNCH Complete

Afghanistan Balkh household surveys 2010 – 2012 Community MNCH Complete

Afghanistan Validity of patient records Data Validity MNCH Complete

Cote d’Ivoire Prevention dissemination strategies Spread/CEA HIV/AIDS Dropped

Cote d’Ivoire Factors influencing loss to follow up Barriers HIV/AIDS Analysis/Writing

Cote d’Ivoire Client satisfaction Collaboratives HIV/AIDS Complete

Cote d’Ivoire Cost-effectiveness of HIV/AIDS Quality Improvement interventions

CEA HIV/AIDS Complete

Ecuador Process of institutionalizing QI Institutionalization MNCH Continuing

Ethiopia Community QI Model evaluation Community MNCH Complete

Georgia Evaluation of QI intervention Collaboratives MNCH Analysis/Data Collection


Country Study Technical Area Clinical Area

Status

Mali Pre-eclampsia/eclampsia evaluation CEA MNCH Data Collection completed

Mali Spread of best practices from Niger to Mali

Spread/CEA MNCH Complete

Mali Evaluation of community collaborative Community MNCH Dropped

Niger Institutionalization of improvement activities in three regions of Niger: facilitators and barriers

Institutionalization MNCH Finalizing for Review

Russia Facility-based mechanisms for sustainability

Institutional. MNCH Complete

Tanzania Evaluation of QI training on OVC implementation

Other QI OVC Finalizing for Review

Uganda Comparative evaluation of MNCH collaborative

Coll./CEA MNCH Finalizing for Review

Uganda Evaluation of CHW productivity

(Study originally planned for Mali but changed to Uganda due to unrest in Mali)

HR MNCH Dropped

Uganda Enrollment of HIV-positive pregnant women

Other QI HIV/AIDS Complete

Uganda Patient involvement study Other QI HIV/AIDS Analysis/Writing

Uganda Evaluation of chronic care model CEA HIV/AIDS Dropped

Publications Manuscripts describing results of HCI-supported research that were published in FY13:

Cost-effectiveness of a quality improvement collaborative for obstetric and newborn care in Niger: International Journal of Health Care Quality Assurance http://www.emeraldinsight.com/journals.htm?articleid=17084063&show=abstract

How accurate are medical record data in Afghanistan’s maternal health facilities? BMJ Open http://www.ncbi.nlm.nih.gov/pubmed/23619087

The cost-savings of implementing kangaroo mother care in Nicaragua: Rev Panam Salud Publica http://www.ncbi.nlm.nih.gov/pubmed/24233110

Activity 1: Institutionalization of modern QI approaches and QI results HCI completed three studies on institutionalization in FY13 (see Table 14). One ongoing study will be completed in FY14.

Table 14. Studies about institutionalization completed or in-process under HCI TO3 in FY13

Institutionalization of improvement activities in three regions of Niger: Facilitators and barriers

Completed in FY13. This observational cross-sectional study examined the level of institutionalization of improvement activities and compared facilitators and barriers of such institutionalization in three regional health systems in Niger (Tahoua, Tillaberi, and Maradi). Quantitative and qualitative data were collected on the extent of institutionalization and factors that promote or inhibit institutionalization from the regions, covering 9 districts and 47 facilities, including 36 integrated health centers, eight district hospitals, two regional hospitals, and one regional maternity hospital. Interviews were conducted with facility-level, district-level, and region-level respondents. The HCI Institutionalization Framework was adapted to include questions relevant to the Nigerien context. Two


measures for institutionalization were explored: expansion of improvement activities to new services or professional groups and expansion to new technical domains not previously supported by implementation partners.

The study found that all health facilities in Tahoua and Tillaberi and 17 of 18 facilities in Maradi reported receiving support from various partners in implementing improvement activities. Health facilities, including those not previously supported by HCI, reported implementing improvement activities in several areas and involving a wide range of staff from health personnel to social workers. Some 41% of facilities expanded improvement activities initiated by partners to additional units or categories of personnel, and 68% reported having applied QI to new clinical domains not previously initiated by partners. Key informants reported observing improvements in key indicators, client access to services, and satisfaction following the implementation of improvement in new domains. Leadership, shared responsibilities and engaged health personnel and community stakeholders, and financial, material and personnel support were reported as key to the facilities’ success in implementing improvement in new domains. Analysis and interpretation of data and personnel shortage and resistance were reported as important inhibitors to implementing activities in new domains.

The most encouraging signs of institutionalization were reported in Tahoua. At the facility-level, a higher proportion of health facilities in the region reported positively on institutionalization measures in several domains, including political will/leadership, roles and responsibilities for improvement, data monitoring, and communication. Tahoua performed better than Maradi and Tillaberi in terms of roles and responsibilities for improvement. All districts in Tahoua reported positively on all proxies of institutionalization except in terms of the orientation of new region-level staff to improvement. No region reported positively on this.

Less than a third of all health facilities in three study regions reported receiving support from their district for implementing improvement activities in domains other than those initiated by partners in the facility or expanding improvement activities to other facilities (27.7% and 21.3%, respectively).

Perception of institutionalization was highest in Tahoua. Facilitators of institutionalization reported by facility- and district-level respondents included material and financial support, supervision through coaching visits, leadership from health facility management team, continuous trainings in improvement methods, and engagement of health personnel and the community. Regional level respondents stressed the importance of having a variety of partners assisting the MOH. Reported barriers included shortages and turnover of health personnel, lack of supervision, and insufficient documentation of improvement changes implemented at the facility level, resistance to change, and lack of engagement by key stakeholders. At the regional level, lack of teamwork, weak leadership, and an insufficient number of partners intervening at the health facility level were reported as barriers to institutionalizing improvement work.

Recommendations by key informants to promote institutionalization include conducting on-going training in improvement for health personnel, documenting improvement activities and monitoring indicators to sustain and institutionalize improvement, shared leadership and creating a position or team dedicated to improvement, regular supervision, developing an improvement competency framework for use in the field, evaluating improvement activities implemented throughout the region, instituting a system for improvement teams to exchange best practices, and instituting training of all health personnel in improvement as part of their regular educational training.

Institutionalization of QI approaches and results in former HCI-assisted regions in Russia

HCI finalized this report in FY13. The objectives of the survey were to identify and evaluate evidence of QI institutionalization in former HCI/QAP-assisted regions of Russia, including creation of culture of quality, initiation of QI in areas different from QAP/HCI focus areas, and incorporation of QI into training curricula of health care education facilities. Data were collected by survey from participants of three collaboratives implemented by HCI/QAP in Russia from 1998-2010:

Improving care for Respiratory Distress Syndrome and Pregnancy-Induced Hypertension in Tver Oblast (1998-2002)

Treatment, Care, and Support for HIV Patients in Togliatti (2004-2006), Novotroitsk (2006-2008), and St. Petersburg (2004-2010)

Social support for HIV-affected families in St. Petersburg (2007-2010) as part of Treatment, Care and Support for HIV Patients

The survey found:


All improved practices developed and institutionalized under the QAP/HCI in Tver Oblast, Togliatti, St. Petersburg, and Novotroitsk were still is place.

QI institutionalization were evidenced to different degrees in St. Petersburg, Togliatti, and Tver Oblast at the level of facility/unit/department or individual care providers.

All QI work is currently done by specialists who were active participants of QAP/HCI collaboratives; in general, it is not materially rewarded and is driven mainly by professional and personal incentives.

Barriers to expanding QI were a lack of officially assigned responsibilities for QI; insufficient rewards for quality; insufficient funds for study tours, trainings, and literature; and insufficient education on QI, including a lack of local QI trainers.

There was significant demand for a separate QI position at the facility and regional levels to design, coordinate, and evaluate QI work across the facility and region or demand for vesting QI functions in deputy heads at the facility and regional levels.

What has HCI done to institutionalize improvement? A report from 17 countries

This report was published in FY13. This assessment of the ways HCI has supported 17 host countries to institutionalize QI at the national level collected data using semi-structured interviews with HCI Chiefs of Party (COPs) either in-person or by phone. HCI COPs described such institutionalization as a process in which the health sector incorporates improvement methodologies as a routine and sustained component of daily work and integrates improvement into the health sector’s functional structure. There was also acknowledgement that institutional investment is needed to ensure that QI “will not operate as just a one-time, limited vertical program” but is “performed on a regular basis as part of the work” (Davis Rumisha, COP, HCI-Tanzania).

The Role of HCI

COPs reported HCI’s playing an important role in the institutionalization of improvement at the national level. This role often involved bringing together key government, non-governmental, and, sometimes, private stakeholders to address QI. Key to institutionalizing improvement methodologies was raising awareness and knowledge of these methodologies and approaches. HCI, in all countries, has trained health workers at multiple levels of the health system in improvement methods and their application to a diverse range of health areas, including but not limited to maternal and neonatal health, HIV/AIDS, infection prevention, and TB. Many HCI COPs reported using data, particularly evidence regarding the impact of adopting improvement approaches, to influence key stakeholders at the national level to integrate improvement into the health care system.

Integrating QI into the structure and function of the health system is central to its institutionalization. Such integration at the national level is particularly pertinent in countries where the health system is highly centralized. At the national level, indicators of integration of Qi include the development of standards of care, guidelines, and policies related to improvement; incorporation of QI into pre- and in-service training of all levels of health workers; and provision of resources that support health facilities across the health system to integrate and sustain QI. Most HCI COPs described providing technical assistance at the national level in developing guidelines, standards of care, and national policies and strategies for QI. HCI has also advocated at the national level for government commitment to providing necessary resources for QI institutionalization.

This assessment of HCI’s work in promoting QI institutionalization at the national level indicates that close collaboration with national stakeholders is invaluable. Using data and allowing key stakeholders to see the impact of improvement approaches at the point of service delivery can be effective in gaining support for institutionalizing improvement methodologies. This should be coupled with effective advocacy.

The process of institutionalizing QI in the public health system in Ecuador: An anecdotal qualitative assessment

This study will be finalized in FY14. HCI prepared a draft of this study that will provide anecdotal evidence to characterize the MOH QI process and experiences over the past 10 years, when QAP and HCI assisted Ecuador’s MOH to create a model of continuous QI in its health services. The study will characterize the process and achievements of QI institutionalization, define as “the means by which a health organization progressively establishes QI as an integral and sustainable part of its daily work routine.” The research questions/objectives are: 1) How and to what extent have QI management and its management structure become institutionalized (at the central, provincial, and county hospital levels)? 2) In what principal functions (management, regulation, assurance, service provision)


has QI become institutionalized, in what tangible ways, and attaining what level of institutionalization? 3) How far has the status of institutionalization actually advanced? What have been the benefits, successes, failures? How much more improvement is still needed? What are the suggestions for achieving this?

Activity 2: Methods and approaches for effective design and implementation of and improvement collaborative During the year, HCI completed four studies on improvement collaborative (see Table 15). One study will continue into FY14.

Table 15. Studies about collaborative improvement either completed or in-process under HCI TO3 in FY13

Improvements in maternal and neonatal health in Balkh province: Results from household surveys 2010-12

HCI completed this study in FY13 and seeks to publish it in a peer-reviewed journal in FY14. HCI implemented a community-based intervention to improve maternal services, pregnancy and newborn care counseling, management of perinatal complications, and postpartum FP services in Balkh Province, Afghanistan. This pre/post intervention study used household surveys at intervention and control sites. We tested for differences in outcomes between intervention and control groups from before to after the intervention, controlling for confounders and overall differences between baseline and intervention periods.

Results: We found significant improvement associated with the intervention in six of eight indicators (percentage of women who received four ANC visits, percentage who received two tetanus injections, percentage who received iron supplements, mean number of birth preparedness actions cited by pregnant women, percentage of women currently using any FP method, and percentage of women reporting their husband was currently using any FP method) from baseline to endline periods. A decrease was associated with the intervention for two indicators (percentage of women who received community health workers visits and percentage of births attended by a skilled birth attendant), although the percentage of births attended by skilled birth attendants increased in both the intervention and control groups.

Conclusion: Improvements attributable to the intervention were seen in three-quarters of the indicators for quality of care in the intervention group, while there was a decrease in most of the same indicators in the control group during the same period. The results suggest that there would be value in implementing the improvement intervention elsewhere in Afghanistan.

Qualitative evaluation of community-based improvement for EONC in Balkh Province, Afghanistan

HCI completed this evaluation in FY13. This evaluation examined CHWs’ and other key informants’ perspectives on community-based EONC in general and the changes that were tested and implemented through HCI’s community-based EONC improvement activity in Balkh Province. Focus group discussions (FGDs) were held with male and female CHWs, separately, in June 2011 and March 2012. Qualitative interviews were conducted with key informants (community health supervisors, midwives, reproductive health officer, and community-based health center officer) in June 2011 and March 2012. FGDs and interviews were conducted in Dari, recorded, transcribed, and translated. Content analyses were then performed.

At baseline, CHWs expressed pride in their work providing their communities with a service and linking community members with facility-based health care. Challenges mentioned at baseline included insufficient medication stores, limited transportation for both the CHWs and their patients, and insufficient referral sheets. CHWs expressed some concern that their role was not adequately recognized by the health facility staff and, to a lesser extent, by community members. Male CHWs also faced challenges in providing female community members with services, including ANC; female CHWs, on the other hand, had difficulties traveling to the houses of patients if not accompanied by a male family member. While the policy dictates that male and female CHWs (ideally a married couple) should be paired, this was not always the case in practice.

According to respondents, changes that yielded the greatest impact included facility staff prioritizing CHW referrals, counter-referrals whereby CHWs followed up on pregnant women who had dropped out of ANC, and the establishment or reactivation of the community shura (health committee). CHWs felt that shuras provided them with the legitimacy they needed to be respected in the community while also offering a venue for conducting group counseling or education, thus increasing the CHWs reach within the community. Availability of


medications was not impacted throughout the implementation period and continued to be a challenge for CHWs.

Findings from this study suggest that reorganization of both facility- and community-based support structures can positively impact CHWs perception of their role in community-based obstetric and newborn care. While there are study limitations, this research provides insight into how a community collaborative approach can support CHWs and strengthen linkages between the community, CHW, and facility.

Comparative study to assess the impact of collaborative improvement on customer satisfaction, provider satisfaction, and services for people living with HIV/AIDS in Cote d'Ivoire

HCI completed this study in FY13. This French-language study is titled, “Evaluation des activités du collaboratif HCI sur l’offre des soins, l’expérience et la satisfaction des prestataires et des patients dans les sites de prise en charge du VIH/sida en Cote d’Ivoire.“ The National HIV care program (PNPEC), the Ministry of Health, HCI, and several other partners have been implementing a collaborative approach to improve the quality of HIV services in Cote d'Ivoire since 2009. This intervention was conducted in two phases: a demonstration phase from January 2009 to March 2010 in 41 sites and an expansion phase which added 79 sites and began in May 2010. Before the introduction of the HCI collaborative, a baseline assessment revealed significant opportunities to improve different components of HIV care, including in the areas of client and provider satisfaction. The overall objective of this post-only, cross-sectional study was to explore the effect of the HCI-supported collaborative on HIV services and provider and client experience and satisfaction. Fifteen pilot sites that participated in the HCI collaborative were selected as the exposed group, and 15 sites that received no quality intervention were selected as the non-exposed group. Data were collected from 148 providers (74 in HCI sites and 74 in non-HCI sites) and 311 clients (150 in HCI sites and 161 in non-HCI sites). Two sets of comparisons groups were used: 1) responses from patients and providers from HCI sites were compared to those from non-HCI sites using chi-square tests and 2) providers from HCI sites were asked about their experiences at the site before and after implementation of the intervention. Differences in providers’ responses were assessed using Mc Nemar chi-square tests.

We found that providers from HCI sites were more likely to report efficient patient flow and having mechanisms to receive patients’ feedback than providers from non-HCI sites. Clinical care equipment and supplies such as the PTMCT, pre-ARV, and ARV registers were also more likely to be available at HCI sites than non-HCI sites. In addition, QI processes such as regular meetings, use of process diagrams, collection of data on quality of care indicators, and use of data for decision-making were more frequently reported by providers at HCI sites. Responses from providers at HCI sites confirmed that the use of these practices were higher following the HCI intervention than before it at their sites (p<0.05). In addition, most providers at HCI sites reported improvement at their site following the intervention in areas such as communications with other providers and task sharing. Although overall there were no differences between patients from HCI and non-HCI sites in terms of satisfaction, patients from HCI sites reported higher satisfaction with the cleanliness and comfort of the sites than patients from non-HCI sites (p<0.05). This evaluation shows that in addition to improving the quality of HIV services, the HCI collaborative is also associated with higher provider satisfaction overall. The higher supplies and services at HCI sites might reflect the fact that providers exposed to improvement have become more resourceful in terms of obtaining needed supplies and equipment. The lack of differences in terms of client satisfaction may be attributed to the fact that baseline satisfaction may have been high in the selected sites. A longitudinal study with baseline and follow-up measures of HIV services and provider and client satisfaction would strengthen the conclusions of this evaluation.

Improving a community health system in Ethiopia: A pilot study

This study was completed in FY13. Access to community health services is a challenge in Ethiopia due to limited human resources and infrastructure. The MOH Health Extension Program seeks to improve access to and use of services, particularly in the areas of maternal and child health and hygiene and sanitation. One strategy has been to train and deploy health extension workers (HEWs) to rural kebeles to provide health education, prevention, and basic curative services. HCI implemented a community-based improvement collaborative by establishing improvement teams to strengthen the linkages between the community and health system and improve the capacity of existing community groups and their networks to manage their health. This paper documents the findings from a qualitative evaluation of the intervention.

The improvement teams brought key community stakeholders together to form the foundation of a community health system and support HEWs in service delivery. Participation on a team raised members’ awareness of and


respect for the services HEWs provided, which was seen as positively impacting the coverage of services and referral of those in need to HEWs for care. The teams also offered a venue for HEWs to raise concerns or challenges with service delivery and receive support and guidance. While more needs to be done to improve access to and the quality of community-based health services, this pilot study demonstrated that supporting the community health system can positively impact the work of HEWs.

Effectiveness and cost-effectiveness of improving hospital and ambulatory care for chronic diseases in Imereti Region, Georgia

Data collection for this study began in FY13. The study will be completed in FY14. A regional demonstration QI intervention is being implemented by HCI in Georgia with the goal of improving quality, continuity, consistency, and coordination of ambulatory and hospital services for prioritized clinical conditions in a demonstration region in Imereti in western Georgia. The intervention is being implemented in eight facilities (four hospitals and four policlinics) and 13 solo clinical practices. The intervention focuses on improving the quality of care of adults seeking care for cardiovascular and/or COPD and asthma as well as pediatric patients seeking care for asthma or pneumonia. This evaluation seeks to assess the quality of screening and management services of project priority diseases/clinical conditions, assess the effectiveness of the quality improvement intervention in the facilities and solo practices, and determine the efficiency of the intervention where inputs are costs per patient and outcomes are process and/or outcome indicators of service performance. The specific questions are:

What change in quality of care indicators is seen from before implementation of the improvement intervention to 12 months after the beginning in the clinical areas of cardiovascular, asthma, and COPD care for adults and of asthma and pneumonia care for children?

What is the cost of the HCI intervention from the perspective of the intervention funders (HCI and who pays for the time of clinicians involved in improvement, etc.?) and the health care expense payers (patients and insurers)?

What is the incremental cost-effectiveness of the HCI intervention in terms of resources expended per additional process/outcome indicator achieved in the intervention group compared to the control group.

Activity 3: Methods and approaches for effective design and implementation of spread activities HCI completed one study on spread in FY13 (see Table 16).

Table 16. Spread studies completed or in-process under HCI TO3 in FY13

Dissemination strategies for prevention of HIV/AIDS in Cote d’Ivoire

The objective of this study was to compare the effectiveness of different spread strategies. Due to changes in planned implementation, this study was dropped. Spread of better care practices and quality improvement for EONC services from Niger to Mali

This study was completed in FY13. While spread of improvement interventions within one country has been studied, little research has studyed spread from one country to another. HCI initiated a study on the transfer of an EONC collaborative and best practices from Niger to Mali. This cross-sectional study includes quantitative measures as well as a qualitative approach designed to better understand the context in which the improvement of clinical indicators occurred. Fifteen community health centers in two districts in the Kayes region were included.

Results: The study found that implementation of the EONC collaborative and best practices led to significant improvements in clinical indicators in Mali. Adherence to AMTSL increased from 24% to 100% in eight months. Postpartum hemorrhage decreased significantly, although unlike AMTSL, this indicator did not maintain its optimal value over time.

In-depth interviews revealed that the clinical content of the EONC intervention and some best practices from the collaborative were successfully spread from Niger in Mali. In addition to the clinical content of the intervention and practices related to QI such as data monitoring and regular meetings, respondents implemented best practices derived from Niger, such as building the capacity of providers and addressing medicine supplies, equipment, materials, and support needs in facilities. Respondents also reported having implemented practices to improve adherence to norms of care and to strengthen the organization of services.

Changes to intervention: Most respondents reported that they had not made any changes to the best practices


originating from Niger. However, two facilities reported having added a community awareness component to the intervention to 1) address the high proportion of births that occur in homes and 2) encourage pregnant women to deliver in health centers.

Hindering and facilitating factors: QI teams reported facing numerous obstacles during the implementation of intervention, including staff shortages, lack of equipment and materials, poor state of health facilities, preferences for home births, non-functional QI teams, and numerous issues related to data collection activities. On the other hand, support from the community including the financial support from community health associations, teamwork and provider commitment were seen by respondents as enabling the intervention’s successful implementation.

QI team members’ communication: Providers reported that communication was key to successful implementation of the intervention. In addition to learning sessions and staff meetings, other methods of communication were used to share experiences and lessons learned with colleagues from other health facilities in the district, such as visiting other health facilities in the district to share ideas on QI and making phone calls to coaches between coaching visits for additional support.

Coaches’ experiences: Coaches supporting QI teams reported that they acquired important skills during their training and learning sessions not only in the areas of QI, clinical care, and use of data to identify problems and make decisions but also in the areas of human resource management and coaching. QI empowered them to make improvements despite limited finances. On the other hand, factors that limited their support to QI teams included time constraints, lack of transportation, lack of availability of QI teams at times, staff turnover, lack of financial incentives, gaps in knowledge and skills in clinical areas, insufficient documentation and data collection tools (specifically, QI team journals), and lack of computer equipment. To improve their work, coaches called for more time and freedom in terms of how and when they conduct coaching visits. Some coaches advocated for attending QI team meetings, for example.

Conclusion and recommendations: The perceived value of the intervention was unanimous among QI teams and coaches and was confirmed by the improvement in clinical indicators. Taking initiative, the perception of the importance of data, teamwork, and provider commitment during the intervention’s implementation are particularly encouraging as they contribute to the overall performance of health centers beyond the improvement areas targeted by the EONC collaborative. The findings suggest consideration of the following recommendations:

• Increase time for coaching visits: Coaches and QI teams noted that the time allocated for coaching visits did not allow adequate support.

• Address time constraints of coaches: Coaches reported juggling multiple responsibilities given the time required to perform their coaching tasks in addition to their regular clinical duties.

• Strengthen the competence of coaches and QI teams: Coaches reported that they need to strengthen their ability to fill in documentation and data collection tools, such as QI team journals. For QI Teams, in addition to filling QI journals, there are also gaps in areas such as data collection and clinical competence.

• Continue to emphasize the importance of data: Coaches and QI team members highlighted the importance of data.

• Streamline data collection tools and reporting: QI teams reported that filling data collection tools is time-consuming and has an impact on their clinical duties. It is important to look into how to avoid the duplication of data collection tools and reporting.

Activity 4: Cost-effectiveness of QI approaches and strategies (including comparative studies) HCI completed one cost-effectiveness study in FY13. One study, being conducted in partnership with Harvard University, will be completed in FY14 (see Table 17).

Table 17. Cost-effectiveness studies completed or in-process under HCI TO3 in FY13

Cost-effectiveness of the improvement collaborative approach in the context of hospital-level maternity services in Kabul, Afghanistan

HCI completed this study in FY13. HCI introduced an intervention, beginning in 2010, to improve maternal and neonatal care in three private and three public maternity hospitals in Kabul. Specific improvement areas were case identification and management of postpartum hemorrhage, pre/eclampsia, obstructed labor, newborn asphyxia and other childbirth complications, establishing a triage system to minimize delays in urgent care, establishing routine uses of partograms, reorganizing care to ensure compliance with national evidence-based standards during delivery and immediately postpartum,


and restructuring discharge care to promote exclusive breastfeeding, thermal protection, regular surveillance for danger signs, and postpartum FP. This study examined the effectiveness, costs, and cost-effectiveness of the HCI intervention. It sought to determine the effectiveness of the Kabul maternity hospital intervention in terms of QI process indicators and an outcome indicator, estimate the cost from the perspective of the program funders (the Afghan MOPH and HCI) of implementing the maternity hospital intervention in the six hospitals, and determine the cost-effectiveness from the funders’ perspective of the intervention compared to performance and efficiency prior to implementation.

This pre/post-intervention evaluation measured changes in indicators of partographs correctly completed, patients monitored according to standards, infants treated with essential newborn care, breastfeeding in the first postpartum hour, resuscitation conducted to standards, mother’s knowledge of newborn and maternal danger signs, and occurrence of adverse events such as postpartum hemorrhage. Program costs included staff salaries, transportation, office equipment, consultant fees, security, and accommodation and the support costs of convening QI teams for learning sessions and other meetings. Decision tree models were run for the seven outcome variables then all were pooled for an estimate of the impact of the program on all the indicators of interest. The strategy of implementing the improvement intervention was compared to the situation existing prior to implementation, considered business-as-usual.

The pre-intervention baseline was the average of three months’ data collected for each hospital before the initiation of the intervention (from March to May 2010). Post intervention data collection was conducted from June 2010 to February 2011. We used Fisher’s exact tests to determine differences between the pre- and post-intervention periods. A deterministic model was used to calculate the point estimate for the cost-effectiveness of improvement intervention as measured in dollars per outcome under consideration (e.g., $ X /mother receiving the three elements of AMTSL according to standards).

The study estimated that 56,000 deliveries were attended in the 13 months of the intervention in the six facilities. There were statistically significant increases in all process indicators for quality of care as a weighted average of all facilities. The greatest improvement in compliance was for the proportion of partographs completed (66% increase; P<0.001) while the smallest was for compliance with essential newborn care (16.2% increase; P<0.001). There was a decrease of 18.4% (P=0.005) in the proportion of women with postpartum hemorrhage among those who present to the hospital for readmission following delivery. All other outcome indicators showed either no statistically significant change or slight increases in adverse outcomes.

The total additional expenditure for the whole cohort was $273,000 or $4.87 per woman receiving services. Of this total, only $4,000 ($0.072 per woman receiving services) was due to increases in clinical costs as a result of the intervention. The majority was for implementation of the intervention itself, of which technical staff costs contributed the most. For a cost of $10,000, we can expect 1370 more partographs correctly completed, 641 more mothers monitored in compliance with norms, 334 neonates given essential newborn care according to standards, 787 more women breastfeeding their infants in the first hour after delivery, 971 more mothers receiving AMTSL according to standards, 474 more newborns given resuscitation according to standards, 862 more mothers knowledgeable about newborn danger signs, and 380 fewer cases of postpartum hemorrhage.

The study concluded that there were substantive improvements in compliance to all clinical norms targeted for this intervention, indicating that the quality of care for mothers receiving services was much better after the HCI activities than before. The cost of the intervention itself, at about 50% of total public per capita health spending in Afghanistan, is likely too high for the public health finance system to absorb alone. Therefore, we recommend implementing this intervention in other facilities in Kabul that were not part of the initial implementation if full or partial non-government support can be obtained.

Cost-effectiveness of HIV/AIDS quality improvement interventions in Côte d’Ivoire

HCI is partnering with Harvard University on this study, which was approved by the Cote d’Ivoire IRB in FY13. It will be completed in FY14. Since 2007, HCI has been implementing QI interventions in facilities that provide HIV treatment services in Cote d’Ivoire. While previous HCI studies have linked the effect of those interventions to supply-side health outputs—such as improvements in patient chart documentation—and some patient-level process outcomes—such as reductions in patient loss to follow-up—the potential impact of HCI QI interventions on patient health outcomes has not been explored. Further, the costs of such quality of care improvements from HCI interventions remain unknown. Given the resource constraints on providing HIV services in Côte d’Ivoire, understanding the budget impact of QI interventions and/or their cost-effectiveness remains an important area of research. This study


seeks to fill that gap to inform MOH policies toward HIV treatment. The study’s primary research question is: What is the cost-effectiveness of HCI-implemented QI interventions to improve quality of HIV-related care in Cote d’Ivoire? This research question can be broken down into three distinct sub-questions: 1) What improvements in quality of HIV care and health outcomes are attributable to HCI QI interventions? 2) What are the costs of those QI interventions? 3) What is the incremental cost-effectiveness of those QI interventions compared to the status quo?

Comparative Research on Cost-effectiveness of QI Approaches Several reports, including an HCI evaluation summarizing the results of collaborative improvement in 12 countries by over 1300 teams during 1998-2008, have shown that teams were able to achieve large increases in compliance with health care standards and, in some cases, in health outcomes across all care areas addressed, regardless of the baseline level of quality. However, due to operational restrictions, most assessments of quality improvement collaboratives have been uncontrolled, pretest/post-test designs that cannot rule out other plausible causes for observed improvements, such as secular trends. The two studies described in Table 18 were designed to address this issue.

Table 18. Comparative studies completed or in-process under HCI TO3 in FY13

A comparative evaluation and cost- effectiveness analysis of an improvement collaborative for maternal and newborn care services in Uganda

This report is being finalized in early FY14. This cluster-randomized, controlled study evaluated the impact and cost-effectiveness of a maternal and newborn care collaborative improvement effort in Uganda, comparing pre- and post-implementation quality of care indicators on samples of patients from both participating and non-participating sites. In non-participating sites, clinical content training was provided without the collaborative improvement intervention.

This evaluation sought to determine whether there was added value, above clinical content training alone, of a quality improvement collaborative intervention in improving maternal and newborn health care quality by comparing pre- and post-implementation quality of care indicators. It also measured the relative efficiency of the two interventions. The study analysis was complicated by a considerable amount of missing data in control group sites. When missing data were considered as indicating non-compliance with the performance indicators, there is strong support for the conclusion that significant improvements in at least five of the indicators of maternal and newborn care were attributable to the intervention (see below).

Results for the difference between baseline and endline in intervention and control groups on 10 performance indicators

Variable

Baseline Post‐intervention

Change associated

with intervention

(%) P‐value

Change associated

with intervention

(OR)

P‐Value Control Intervention Control Intervention

AMTSL 19.7% 17.1% 6.9% 68.0% 62.8% <0.001** 30.20 0.010*

Breastfeeding 1st hour

19.7% 24.0% 33.5% 77.5% 36.9% 0.094 4.58 0.216

Dry and wrap infant

19.7% 24.0% 33.5% 89.2% 50.2% 0.023* 13.60 0.031*

Sterile cord care

27.6% 24.0% 33.5% 88.7% 58.4% 0.010* 22.10 0.004**

Neonatal eye care

19.7% 15.4% 33.5% 88.7% 57.9% 0.007** 23.08 0.014*

Knows importance of breastfeeding

19.1% 30.3% 30.7% 87.9% 45.0% 0.040* 8.97 0.065

Knows 17.8% 28.0% 30.3% 86.1% 43.9% 0.044* 7.20 0.119


neonatal danger signs

Examined in 1st 24 hours postpartum

19.7% 26.3% 34.4% 86.1% 45.0% 0.042* 8.99 0.064

Examined 2‐3 days post‐partum

15.8% 10.9% 11.9% 51.9% 47.6% 0.004** 15.52 0.049*

Examined 4‐7 days post‐partum

14.5% 8.6% 12.4% 36.4% 31.6% 0.046* 9.67 0.119

* Statistically significant at p<0.05 ** Statistically significant at p<0.01

The overall cost of the program was $6.39 per delivery attended during the intervention. Considering the entire expenditure for the program ($193,000), approximately 18,907 more women receive care during childbirth compliant with AMTSL, 11,150 more infants receive breast-feeding within the first hour after delivery, 15,173 more infants are wrapped and dried appropriately according to evidence-based recommendations, 17,498 more infants are provided with sterile umbilical cord care, 17,642 more infants receive appropriate eye care after delivery, 13,601 more mothers are able to articulate their knowledge on the importance of breastfeeding the infant, 13,265 more mothers can articulate the danger signs that indicate health problems with the infant that require attention, 14,382 more infants attended the clinic for a health check in the first 24 hours of life, 14,382 more infants received a health check in the first three days, and 9550 more infants received a health check within four to seven days. These numbers are based on the very conservative assumption that improvements in the intervention sites would last for the 24-month duration of the intervention and no longer.

An evaluation and cost-effectiveness analysis of an improvement collaborative for eclampsia/pre-eclampsia services in Mali

Data were collected for this study in FY13; it will be completed in FY14. This study will compare costs and outcomes for clinical management of eclampsia and pre-eclampsia in quality improvement collaborative facilities (first six months of implementation) to the costs and outcomes in facilities with no collaborative improvement intervention. Following the initial six months, the collaborative improvement methodology was introduced to the control sites and changes in quality performance monitored over that time. HCI implementation of interventions to improve maternal and newborn health services, including AMTSL and essential newborn care, has been ongoing in 41 facilities in two health districts (Diema and Kayes) in the Kayes region since early 2010. Most facilities are above 80% compliance in AMTSL and essential and newborn care quality indicators and are working on maintaining or improving performance.

The HCI Mali/Niger team started implementing a second quality improvement collaborative (QIC) phase to improve clinical practice for pre-eclampsia and eclampsia care at the end of February, 2011. This study will determine the costs and effects of this QIC intervention and compare them to those of a basic clinical training (BCT) in the same type of health facilities in Mali that are not part of the collaborative.

This study will determine whether a QIC intervention has an added value in improving pre-eclampsia and eclampsia care quality above BCT alone. It will also measure the relative efficiency of the two interventions. The research questions are: 1) Do pregnant and delivering women in QIC intervention facilities receive better care (screening/diagnosis and treatment of pre-eclampsia/eclampsia) than those in BCT-only facilities? 2) Do pregnant and delivering women in QIC intervention facilities have better clinical outcomes, in terms of eclampsia incidence than those in BCT-only facilities? 3) What is the incremental cost-effectiveness of the QIC intervention compared to the BCT-only intervention in terms of process and outcome indicators for mothers? 4) Does adherence to eclampsia/pre-eclampsia norms become higher in BCT-only sites when clinicians are trained on the QIC methodology? 5) Does adherence to eclampsia/pre-eclampsia norms in the QIC intervention facilities change in the six months following the active intervention period?

This longitudinal study uses a controlled pre- and post-intervention design. The QIC sites will be those participating in the QIC intervention and the control sites will receive BCT only. BCT is also part of the QIC intervention. The implementation of this study was delayed by the political situation in Mali.


Activity 5: Other QI methodologies, distinct from the improvement collaborative approach HCI completed two studies on other QI methods in FY13. Two continuing studies will be completed in FY14 (see Table 19).

Table 19. Studies on other QI methods completed or in-process under HCI TO3 in FY13

Perceived impact of QI trainings on the care and support of most vulnerable children and their households in Tanzania

HCI completed a draft of this study in FY13; it will be finalized in FY14.

The purpose of this assessment was to determine the perceived impact of the most vulnerable children (MVC) QI trainings on service provision to MVC and their households. Specific objectives were to investigate 1) the extent to which various MVC stakeholders (both governmental, non-governmental, and community-level structures like Most Vulnerable Children’s Committee [MVCC] use and communicate information on the National MVC QI Gguidelines, 2) the perceived impact of QI trainings and knowledge of the National MVC QI Guidelines on providers’ skills and the way they work, and 3) the perceived impact of QI trainings on vulnerable children and their households. Interviews were conducted in Swahili with five respondents at the national level, 11 at the regional level, 27 at the council or local government level, 160 at the MVCC ward and village level and 27 service delivery volunteers and 525 children and caregivers/ parents.

The study found that familiarity with the MVC QI guidelines was much higher among stakeholders at the national, regional, and council/local government authority levels compared to MVCCs and volunteers. Respondents from the MOHSW and national level implementing partners reported that the MVC QI training improved the coordination and involvement of different stakeholders in supporting MVCs. MVC and their caregivers noted that implementing partners, MVCCs, and volunteers are providing better support for them than before the training. On the other hand, despite widespread recognition that the identification process of most vulnerable children based on established criteria is a critical step before initiating services, respondents in some areas reported that identification criteria are sometimes not followed. Some community members present incorrect information on children’s status in order to classify them as MVC, and some MVC households are double-counted due to relocation and use of different names. As a result, services are provided to ineligible children and households, which increases need and ultimately reduces the capacity to provide prompt and appropriate support.

Overall, this assessment found that the MVC QI guidelines and associated trainings have facilitated different stakeholders to understand and apply the guidelines in planning and implementing MVC interventions that are more likely to improve the welfare of MVC and their households but that the perceived impact of the training strategy was stronger at higher levels of the health system. More efforts are needed to enable service providers at the ward and village levels to be familiar with the guidelines and be knowledgeable about their application to improve services provided to MVC and their households. The capacity of MVCCs and volunteers to understand and use of the MVC QI guidelines should be strengthened through regular coaching and mentoring.

Assessment of the introduction of the Chronic Care Model for HIV care in Uganda

HCI dropped this economic evaluation of the chronic care model in Uganda, having determined that it would be duplicative. It has been replaced by a more comprehensive ASSIST evaluation of the chronic care model in Uganda, currently underway. Patient and provider perspectives on improving the linkage of HIV-positive pregnant women to HIV care in eastern Uganda

HCI has submitted this study for publication in the African Journal of AIDS Research. This study examined barriers and facilitators to the linkage of HIV-positive pregnant women from antenatal care to HIV care from patient and provider perspectives and solicited recommendations for improving such linkages. Despite strong evidence that ART the risk of mother-to-child transmission of HIV and improves the health of HIV-positive mothers, many HIV-positive pregnant women do not enroll into HIV care. Semi-structured interviews were conducted with 11 health providers and 48 HIV-positive mothers currently enrolled in HIV care in eastern Uganda. Identified facilitators to linking HIV-positive pregnant women to HIV care included support from expert clients, active referrals, same day HIV care registration, physical accompaniment to HIV clinics, and coordination between ANC and HIV services. Reported barriers included shortages in HIV testing kits and fear of social, physical, and medical consequences. Participants recommended integrating ANC and HIV services, reducing waiting times, HIV counseling by expert clients, and establishing community-based approaches for improving linkages to HIV care. Linking HIV-positive pregnant women to HIV care can be improved through


deliberate implementation of QI interventions at facilities, engagement of male partners, and mobilization of communities.

Engaging clients in quality improvement at HIV clinics in Uganda: A mechanism for making care more client-centered?

HCI has completed data collection and analysis for this report and will prepare a manuscript to submit for peer review in FY14. QI is becoming an important component of health care world over, with growing recognition in the literature of the contribution patients can make to improving health outcomes. The increasing prevalence of chronic illnesses calls for having patients play an active role in their health care. This study will examine the extent to which selected interventions successfully engaged clients and providers together in QI activities (problem identification, problem analysis, solution identification, and testing and implementing changes) in Ugandan HIV/AIDS care clinics (with comparison to control clinics) and what health care providers’ and clients perceptions are of clients’ active participation in the process.

Since 2007 HCI and Uganda’s MOH have been implementing collaborative QI activities to improve the quality of services offered to clients attending HIV care clinics. Findings from a preliminary assessment revealed that clients are minimally involved in QI activities at the facility-level, so HCI is supporting an intervention to promote client involvement.

This pre/post qualitative evaluation will include six intervention and six control sites. HCI coaches will provide feedback to the intervention sites, providing a selection of interventions to increase client involvement. Sites will be invited to select the interventions that best suit their needs and resources.

Activity 6: Mission-requested studies on barriers to implementation of HCI improvement activities This study on “Identifying factors influencing lost-to-follow-up rates in ART programs in Cote d’Ivoire” was funded by the USAID Mission and sought to identify factors that promote or inhibit loss to follow-up among patients who have initiated ARVs in Cote d’Ivoire based on information gathered from patients, providers, and members of organizations supporting people living with HIV/AIDS. This case-control study identified patients from 40 ARV sites in 14 regions. Intervention cases were defined as patients lost to follow-up (n=626) and control cases as those still under ARV treatment (n=626). Interviews included closed- and open-ended questions. Data on social, individual, clinical/biological and interpersonal factors were also collected. In addition, in-depth interviews were conducted with a subsample of patients (n=40). This study is being conducted in partnership with the National Program for Care and Treatment. HCI completed data collection in FY13 and developed a preliminary draft report. This study will be finalized in FY14. Activity 7. Capacity building and support to country programs Dr. Broughton traveled to Kenya to deliver training on program monitoring and evaluation to members of 11 chapters of the African Network for the Protection and Prevention of Child Abuse and Neglect from Ethiopia, Tanzania, Zambia, Sierra Leone, Mozambique, Uganda, Mauritius, Somalia, Liberia, and Kenya. Dr. Sarah Smith traveled to Uganda to conduct a training for mentors of the Regional Psychosocial Support Initiative (REPSSI) from four countries (Malawi, Lesotho, Uganda, and Zimbabwe) in qualitative research methods. REPSSI is a non-profit working to lessen the psychosocial impact of poverty, conflict, HIV and AIDS among children and youth across East and Southern Africa.

Directions for FY14 In FY14, the R&E unit will finalize all remaining HCI studies begun in previous years, which includes 12 studies (see tables above). The unit will also provide support to all HCI countries to report on remaining activities to make the culture of improvement sustainable beyond HCI’s involvement.


4.3 Technical Leadership and Communication



1. Provide global technical leadership for USAID’s worldwide efforts to improve health care in developing countries

Expand the use of modern QI approaches in USAID-assisted health care systems and by USAID cooperating agencies

Demonstrate the results of USAID’s investment in health care QI

Global

2. Advocate for adoption of QI approaches, policies, and programs by international, regional, and national health care organizations

Expand the use of QI approaches in USAID-assisted health care systems

Expand awareness of the evidence for modern QI approaches through presentations at regional and international events

Global

3. Produce technical reports and submit articles to peer-reviewed journals both of which describe QI interventions and measure their impact

Develop and disseminate evidence for the results, cost-effectiveness, and benefits of applying modern QI approaches in USAID-assisted health care systems

Global

4. Support the development of new graduate training programs in QI as applied in low- and middle-income countries

Develop QI capacity in the next generation of health care providers and help to standardize the teaching of modern QI approaches

National and global levels

5. Increase understanding of the role of integration in health systems strengthening

Develop an e-learning module on gender issues in service delivery as part of the CapacityPlus Health Systems Strengthening e-Learning course

Global

Main Activities and Results Activity 1: Provide global technical leadership for USAID’s worldwide efforts to improve health care Conference and other presentations In FY13, HCI results were shared in 24 presentations made at 11 international and regional conferences (Table 20). As of January 2013, most of URC’s efforts to provide global technical leadership for health care improvement were funded under the new USAID ASSIST Project. In the second quarter of FY13, former HCI Health Workforce Senior Advisor Lauren Crigler made three presentations on improvement approaches applied to health workforce at the annual conference of the International Society for Performance Improvement in April. At the International Forum on Quality and Safety in Healthcare, Dr. Tamar Chitashvili, Chief of Party of the Georgia HCI project, presented a poster on the non-communicable disease improvement work in Georgia and also facilitated a mini-course on chronic conditions care. HCI staff from Afghanistan and South Africa also participated in the Forum. Slides on HCI’s kangaroo mother care work, including the cost-effectiveness results from Nicaragua, were presented by Dr. Goldy Mazia of the Maternal and Child Health Integrated Project at the November 2012 International Kangaroo Mother Care Conference in India.


Table 20. HCI conference and other presentations in FY13

Conference HCI Participation CORE Group Fall Meeting October 11-12, 2012 Washington, DC

Lani Marquez, HCI/ASSIST Knowledge Management Director, with Lenette Golding, CARE, led the interactive session, “InKnowvation: Simple techniques for tapping into all the knowledge in the room”

Feza Kikaya, HCI/ASSIST Communications and Social Media Coordinator, staffed an HCI table with CHW AIM toolkits and other publications

APHA Annual Meeting Oct. 27-31, 2012 San Francisco, CA

Annie Clark, HCI/ASSIST Senior QI Advisor for MNCH, made the oral presentation, “Improving newborn resuscitation in Uganda”

International Society for Quality in Health Care (ISQua) Conference October 21-24, 2012 Geneva, Switzerland

Dr. Massoud led the 45-minute panel, “Making Health Care Better in Low and Middle Economies” (panelists included: Ed Kelley, Sir Liam Donaldson, Jean Nguessan, Sylvia Sax, Bruce Agins, and Ezequiel García-Elorrio)

Maina Boucar, HCI/ASSIST Regional Director for West Africa, made the oral presentation, “Spread of better care practices and quality improvement for maternal and newborn services from Niger to Mali”

Donna Jacobs, Director of URC South Africa, made the oral presentation, “Sustaining the gains : Quality improvement of HIV and AIDS programs in South Africa (2007 – 2011)”

Dr. Broughton made the oral presentation, “Maternal health service improvements in Kunduz Province, Afghanistan”

Dr. Massoud led the oral presentation, “Managing knowledge for improvement: Why knowledge management approaches are new and essential tools for improving health systems” together with Tim Shaw of the University of Sydney

Mabel Namwabira, HCI/ASSIST QI Advisor in Uganda, made the short oral presentation, “Engaging clients in quality improvement (QI): A pre and post assessment of a client engagement intervention at 12 HIV facilities in Western Uganda”

Dr. Broughton presented the poster, “Applying modern QI concepts to improve maternal care in low resource settings” on behalf of Youssef Tawfik, former HCI/ASSIST Senior QI Advisor for MNCH

Global Symposium on Health Systems Research October 31-November 3, 2012 Beijing, China

Dr. Broughton led the satellite session, “How do we learn in order to strengthen health systems?” as a 45-minute interactive talk followed by two small-group discussions. The presentation had three sections: 1) using real-time data for learning; 2) cost-effectiveness analysis, and 3) the use of qualitative research in improving health systems. It was attended by about 30 people, including Tim Evans, chair of the conference organizing committee. (Planned participation of Dr. Massoud and other HCI/ASSIST staff Sarah Smith, Ram Shrestha, and Tana Wuliji was precluded by hurricane-related flight cancellations.) The poster, “Utilization of the in-service training (IST) improvement framework to guide country IST strategy development - Ethiopian case study” developed by HCI was presented by Ms. Rahima Shikur of Ethiopia’s MOH.

World Conference on Lung Health, Nov. 13-17, 2012, Kuala Lumpur, Malaysia

Alisha Smith-Arthur presented the poster, “Expanding continuing medical education for TB through online training in Indonesia” on the Indonesia TB CD-ROM training activity (her participation was funded from outside HCI)

Infection Control Africa Network (ICAN) November 27-29, 2012, Cape Town, South Africa

Dr. and Ms. Jacobs facilitated a Knowledge Café at the ICAN conference to engage participants in brainstorming about next steps for operationalizing the Salzburg Global Seminar statement, “Better Care for All, Every Time: A Call to Action.”

International Conference of African Society for

Dr. Jean Nguessan presented the poster, “Implementation of Laboratory Quality Improvement Process Towards Accreditation of 21 Laboratories in Cote d’Ivoire:


Conference HCI Participation Laboratory Medicine December 1-7, 2012 Cape Town, South Africa

Lessons Learned and Way Forward”

Global Maternal Health Conference 2013 January 15-17, 2013 Arusha, Tanzania

Drs. Kathleen Hill, HCI/ASSIST MNCH/FP Lead, and Jorge Hermida, Regional Director for Programs in Latin America and the Caribbean, presented on the panel, “Measuring quality of maternal care for what purpose in the post-MDG world: global, national, district and institutional needs,” organized by MCHIP and WHO and moderated by Deborah Armbruster, Senior Maternal Health Advisor at USAID.

Dr. Hill presented the paper, “Financial incentives to improve quality of maternal care: Current evidence and future needs.” She also participated in a plenary panel session on “Respectful maternal health care.”

Paul Isabirye from Uganda made an oral presentation on the Mission-funded Saving Mothers Giving Life work under HCI: “Empowering health care providers to improve the quality of maternal health care using low cost, high impact QI interventions in two districts of western Uganda”

The Performance Improvement Conference 2013 (International Society for Performance Improvement) April 14-17, 2013, Reno, Nevada USA

Ms. Crigler presented a 90-minute session on the HR collaborative work in Niger and Tanzania, “Improving health care through team-based performance management.”

She also presented in a 20-minute roundtable, “Closing the space between workers,” on the use of the Cross Functional Matrix Tool, which HCI has used in Niger, Tanzania, and Zambia.

Ms. Crigler also presented in another 20-minute roundtable, with Initiative’s Becky Furth as co-presenter, on CHW AIM: Strengthening community health worker programs.”

International Forum on Quality and Safety in Healthcare

April 16-19, 2013, London, UK

Dr. Chitashvili, Mirwais Rahimzai, Najia Tareq, and Tina Maartens attended the conference.

Dr. Chitashvili presented the poster “Improving quality of prevention, screening and treatment services of cardiovascular diseases in Georgia” and participated in the full-day course on chronic conditions care.

Global Mental Health Forum September 27-28, 2013 King’s College, London, UK

Dr. Diana Chamrad presented on the results of the HCI four-country assessment of non-communicable disease screening and treatment practices in the oral presentation, “Integration of depression and alcohol abuse screening and care practices in primary care settings for women in Albania, Armenia, Georgia, and Russia.” A new HCI flyer was created to summarize the mental health results of the HCI-led four-country assessment. Dr. Chamrad’s travel and time were covered by URC.

Briefings On October 26, 2012, Dr. Sonali Vaid, HCI/ASSIST Quality Improvement Advisor, participated in the Plexus Institute Board meeting. She represented HCI before this non-profit dedicated to advancing understanding and applications of complexity science. HCI Director Dr. Massoud and Senior Advisor for Health Workforce Ms. Allison Annette Foster participated in the November 12, 2012 Office of HIV/AIDS (OHA) Partners Meeting. At the information table assigned to HCI, they distributed lists of HCI HIV publications and displayed copies of the Uganda NuLife-HCI nutrition improvement intervention final report, the research report on the spread of ART and PMTCT best practices in Tanzania, the Kenya OVC case study, the Uganda expert patient/ task shifting report, and the collection of HCI flyers that had been developed for the 2012 International AIDS Conference. HCI staff participated in a day-long seminar organized by Jhpiego on December. 4, 2012, at USAID entitled “Making Smart Investments in Supporting Health Care Provider Performance: What Does the


Evidence Support?” Together with Diana Frymus of USAID/OHA HCI/ASSIST Senior QI Advisor Tana Wuliji presented on “Improving health worker competencies: Applying consensus-based methods to develop recommendations and strategies for in-service training improvement.” Activity 2: Advocate for adoption of QI approaches, policies, and programs by international, regional, and national health care organizations Operationalizing the Salzburg Global Seminar Statement During the first quarter of FY13, HCI Director Dr. Massoud led activities at two international conferences to highlight the statement of the Salzburg Global Seminar (SGS), “Better Care for All, Every Time: A Call to Action.” The statement was developed by 58 global health leaders from 33 countries who participated in the SGS on “Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?” in April 2012. The following October, Dr. Massoud led a panel session at the ISQua conference in Geneva with the participation of Dr. Ed Kelley and Sir Liam Donaldson of the WHO Patient Safety Programme; Dr. Jean Nguessan of HCI; Dr. Sylvia Sax of Heidelberg University; Dr. Bruce Agins of HEALTHQUAL International, and Dr. Ezequiel García-Elorrio of the International Journal of Quality in Health editorial board, all SGS participants; the panel discussed the implications of the SGS Call to Action. In November 2012, Dr. Massoud and Dr. Jacobs facilitated a Knowledge Café at the Infection Control African Network conference in Cape Town. The session enabled participants to brainstorm next steps for operationalizing the SGS statement. The conference’s final full day consisted of eight small-group discussions where participants were tasked with developing actions they can conduct in their workplaces to improve infection control through reviewing the SGS Statement. Community Partnerships for Child Protection in Africa Under the Care that Counts Initiative, HCI continued to develop its partnership for Child Protection in Africa with the Regional Psychosocial Support Initiative (REPPSI) for East and Southern Africa and the African Network for the Protection and Prevention of Child Abuse and Neglect (ANPPCAN), headquartered in Nairobi. Both organizations worked with HCI throughout FY13 to develop their capacity to support QI activities in the region. Both are actively engaged in applying QI as a strategy for achieving better outcomes for vulnerable children. Throughout the year, Dr. Diana Chamrad mentored REPSSI and ANPPCAN staff in the application of improvement methods to child protection services and in developing their capacity to lead and support improvement in child protection services in the region. Activity 3: Produce technical reports and submit articles to peer-reviewed journals both of which describe QI interventions and measure their impact During FY13, seven articles describing HCI results were published or accepted for publication in peer-reviewed journals, and another five manuscripts were prepared and submitted for publication in such journals. HCI published 13 technical and research reports, nine short reports/flyers, and one toolkit (Table 21). Three other technical and research reports were finalized and submitted for COR approval.

Table 21. HCI publications in FY13

Articles Published or Accepted for Publication in Peer-reviewed Journals

Massoud MR, Mensah-Abrampah N, Sax S, Leatherman S, Agins B, Barker P, Kelley E, Heiby JR, Lotherington J. Charting the way forward to better quality health care: How do we get there and what are the next steps? Recommendations from the Salzburg Global Seminar on making health care better in low- and middle-income economies. 2012 Dec;24(6):558-63. Int J Qual Health Care. doi: 10.1093/intqhc/mzs062. Epub 2012 Oct 16.

Broughton E, Ikram AN, Sahak I. How accurate are medical record data in Afghanistan’s maternal health facilities? Accepted for publication March 21, 2013 in BMJ Open. Manuscript ID bmjopen-2013-002554.

Rahimzai M, Amiri M, Burhani N, Leatherman S, Hiltebeitel S. Rahmanzai A. Afghanistan’s National Strategy for Improving Quality in Health Care. Int J Qual Health Care 2013; 25(3):270-276. Available at: http://intqhc.oxfordjournals.org/content/early/2013/03/12/intqhc.mzt013.full.


Broughton E, Saley Z, Boucar M, Alagane D, Hill K, Marafa A, Asma Y, Sani K. Cost-effectiveness of collaborative improvement for essential obstetric care. International Journal of Health Care Quality Assurance 2013;26(3):pp. 250-261. Abstract available at: http://www.emeraldinsight.com/journals.htm?issn=0952-6862&volume=26&issue=3&articleid=17084063&show=abstract

Lopez S, Wong Y, Gomez I, Escobar F, Tinoco B, Parrales A. Quality in practice: Preventing and managing neonatal sepsis in Nicaragua. Int J Quality in Health Care 2013;25(5):599-605. Online version published 20 August 2013.

Broughton E, Gomez I, Sanchez N, Vindell C. The cost-savings of implementing kangaroo mother care in Nicaragua. Rev Panam Salud Publica 34(3), 2013. Accepted for publication 5 September 2013.

Altaf A, Vaid S. The Sindh Disposable Syringe Act: Putting the act together. Approved by COR in August 2013 and submitted to the Journal of the Pakistan Medical Association. Accepted by JPMA on August 25 for publication in November 2013 issue.

Articles Submitted for Publication in Peer-reviewed Journals

Smith S, Kaba M, Shrestha R. Improving a community health system in Ethiopia: A pilot study.

Submitted as 1000-word letter to the Journal of Primary Care and Community Health on May 21, 2013. Manuscript ID JPC-13-0034.

Mwaniki MK, Vaid S, Chome IM, Amolo D, Tawfik Y. Improving service uptake and quality of care of integrated maternal health services: The Kenya Kwale District Improvement Collaborative. Submitted 27 June 2013 to BMC Public Health. Manuscript number: 1816331002102671

Tawfik Y, Rahimzai M, Ahmadzai M, Clark A, Kamgang E. Integrating family planning in postpartum care through quality improvement: experience from Afghanistan. Approved by the COR in August 2013 and submitted to Global Health: Science and Practice on September 30, 2013. Provisionally accepted for publication in October, pending revisions. Revisions submitted November 10. Sahak I, Amiri M, Broughton E, Hiltebeitel S, Anwari MK, Ikram AN. Changes in maternal and neonatal health in Balkh province, Afghanistan: Results from household surveys 2010–2012. To be submitted to the Pakistan Journal of Public Health. Submitted to the COR for approval in September 2013. Saleem H, Kyeyagalire R, Lunsford SS. Patient and provider perspectives on improving the linkage of HIV-positive pregnant women to HIV care and treatment in eastern Uganda” Submitted September 9, 2013, to AIDS Patient Care and STDs, Manuscript ID is APC-2013-0282. Rejected September 13, 2013. Resubmitted October 2 to the Africa Journal of AIDS research, Manuscript ID: RAAR-2013-0111.

Short Reports and Flyers (Date Published)

Improving health care and averting deaths from cardiovascular disease in georgia (4-page flyer) (October 2012)

Applying improvement methods to increase coverage and quality of family planning services (4-page flyer) (November 2012)

Quality improvement approaches for newborn care services in uganda (4-page flyer) (January 2013)

Care that Counts E-Learning Course for Quality Improvement in Programs for Vulnerable Children (2-page flyer) (February 2013)

FY13 Activities of the USAID Health Care Improvement Project (4-page flyer) (February 2013)

Improving injection safety and waste management in peri-urban Karachi, Pakistan (2-page flyer) (April 2013) Community partnerships for child protection in Africa (4-page flyer) (July 2013) Birth egistration results from improvement activities in care for vulnerable children (4-page flyer) (July 2013) Integration of depression and alcohol abuse screening and care practices in primary care settings for women in Albania, Armenia, Georgia and Russia (4-page flyer) (September 2013)

Technical and Research Reports (Month Published)

Namibia integrated health care waste management plan. Final Project Report. (October 2012)

Institutionalization of quality improvement approaches and results in former USAID-assisted regions in Russia. Research and Evaluation Report. (December 2012)

An assessment of community health volunteer program functionality in Madagascar. Technical Report. (January 2013)

Development of minimum care standards for orphans and vulnerable children in Zambia. Final Report. (March


2013)

Integrating palliative care with HIV care in two Ugandan districts using a collaborative quality improvement approach. Technical Report. (March 2013)

What has HCI done to institutionalization improvement? A report from 17 countries. Research and Evaluation Report. (March 2013)

Spread of EONC best practices from Niger to Mali. Research Report Summary. (April 2013)

Dissémination du Niger au Mali du collaboratif d’amélioration des soins obstétricaux et néonataux essentiels et des meilleures pratiques du collaboratif: expériences, perceptions et efficacité. Rapport de la Recherche et Evaluation [Spread of EONC best practices from Niger to Mali. Research Report]. (April 2013)

Community health volunteer program functionality and performance in Madagascar: A synthesis of qualitative and quantitative assessments. Research and Evaluation Report. (April 2013)

Fonctionnalité et performance du programme des agents de santé communautaires à Madagascar Une synthèse d’évaluations qualitative et quantitative. Rapport de la Recherche et Evaluation [Community health volunteer program functionality and performance in Madagascar: A synthesis of qualitative and quantitative assessments. Research and Evaluation Report. (April 2013)

Une évaluation de la fonctionnalité du programme des volontaires de santé communautaires à Madagascar. Rapport Technique Evaluation of the functionality programs of community health workers. Technical Report]. (April 2013)

CHW regional meeting: Country follow-up plans and actions. Technical Report. (June 2013)

Improving quality of HIV services and health worker performance in Tandahimba District, Tanzania: An evaluation. Research and Evaluation Report. (July 2013) Cost-effectiveness analysis of improving maternity hospital care in Kabul, Afghanistan. Research and Evaluation Report. (Submitted for COR approval in September) Ikram AN, Sahak I, Anwari MK, Majeedi AJ, Saleem H, Smith S. September 2013. Evaluating the spread of the maternal and newborn health care collaborative to Bamyan, Herat, and Parwan provinces in Afghanistan. Research and Evaluation Report. (Submitted for COR approval in September) Rahimzai M, Yaqubi E. September 2013. Technical assistance in health care improvement to the Ministry of Public Health of the Islamic Republic of Afghanistan. Final Report. (Submitted when? to the Ministry of Public Health for final approval)

Toolkit (Month Published)

Community Health Worker Assessment and Improvement Matrix (CHW AIM) Toolkit. (Revised September 2013)

Activity 4: Support the development of new graduate training programs in QI as applied to low- and middle-income countries HCI worked with the People’s Open Access Education Initiative (Peoples-Uni) in supporting the development of a module on patient safety and health care QI. Peoples-uni (http://www.peoples-uni.org/) is an initiative to build public health capacity in low- and middle- income countries via e-learning. During FY13, HCI’s Dr. Vaid contributed to the course materials. The course was conducted from March 3-June 16, 2013, with 24 students enrolled from Afghanistan, India, Zambia, Swaziland, Switzerland, Sudan, Cameroon, Nigeria, and South Africa. Nine students were affiliated with URC/HCI. Activity 5: Increase understanding of the role of integration in health systems strengthening Working with the USAID Gender team and Capacity Plus, HCI contributed to the development of the e-learning course, “Gender and Health Systems Strengthening.” We assisted in planning the course outline and developed its module on gender integration and service delivery. A case study on the HCI experience on Kangaroo Mother Care was also drafted for the course.

Directions for FY14 We will continue to publish articles and reports on completed HCI activities.


5 Performance Tracking Plan Table 22 shows HCI TO3 cumulative achievements against performance targets through the end of FY13 and activities planned through FY14 to achieve remaining targets.

Table 22. HCI TO3 performance tracking plan: Cumulative achievements through FY13

HCI TO3 Performance Target How the target has been by the end of FY13 or will be met in FY14

Objective 1: Document the interventions supported by this task order to improve the quality of health care, how quality was measured, and the impact of these interventions

Performance target 1.1: Within the first year of Task Order #3, the contractor is required to complete field-testing and analysis of results in the six countries from Task Order #1, finalize the design of the SES and implement the system for all major improvement activities supported by the contract.

Target has been met:

The Systematic Evaluation System (SES) Endline Evaluation report was completed and submitted to the Contracting Officer’s Representative (COR) on September 30, 2010.

The learning system standards were communicated to all HCI country teams through guidance issued by the HCI Director in September 2010; all HCI country offices reported on their application of the learning system standards for the FY10, FY11 and FY12 TO3 self-evaluation reports.

Performance target 1.2: Within the first year of Task Order #3, the contractor must submit to the COTR a comprehensive report summarizing the development and ongoing implementation of the SES.


A report summarizing the learning system standards and how they are implemented in all countries was submitted to the COR on September 30, 2010.

Performance target 1.3: Within the first year of Task Order #3, the contractor must submit for COTR approval a detailed plan for the analysis and dissemination of the content of the SES, including a quantitative summary of results in terms of % improvement of all indicators, specification of interventions and duration of observations of indicators


A plan for ongoing analysis and synthesis of quantitative results from the learning system was submitted to the COR on September 30, 2010.

Beginning in FY11, HCI country and technical teams have placed more emphasis on developing knowledge products that convey key learning derived from improvement activities, including specification of effective interventions. Technical reports on HCI-supported work in Tanzania, Cote d’Ivoire, Nicaragua, Guatemala, Bolivia, Honduras, Uganda, and Niger have summarized such learning and provided follow-on recommendations.

Comparisons of improvement in key indicators by country were reported in the HCI TO3 FY10, FY11 and FY13 TO3 self-evaluation reports.

Performance target 1.4: Beginning with the submission of the Year One annual report for Task Order #3, the contractor will provide a comprehensive summary of supported QI activities and the quantitative results of these activities, including analysis with follow-on recommendations.


The TO3 FY10, FY11 and FY12 Annual Project Reports included a comprehensive summary of supported QI activities and quantitative results with analysis and next steps for implementation. At the country level, HCI teams present recommendations for follow-on actions to host country officials through regular briefings and at workshops and conferences marking the conclusion of specific improvement activities. Recommendations for follow-on actions are also presented to each funding Mission and USAID Washington office through country- and activity-specific end-of-year reporting, Country Operational Plans, and Headquarters Operational Plans.

Objective 2: Institutionalize modern quality improvement approaches as an integral part of health care in USAID-assisted countries

Performance target 2.1: Starting Target has been met:



with the Year Two annual report for Task Order #3 (due December 2011), the contractor’s annual report will include, for each major country program, a summary of steps taken to support or measure the institutionalization of QI.

Drawing on project-supported studies of institutionalization, in FY11 HCI developed a framework with the key elements that contribute to the institutionalization of QI at the national, regional, and service delivery levels. To determine the level and type of institutionalization that has occurred, data were collected in the last quarter of FY11 from 15 countries that had been receiving HCI assistance for at least 12 months prior to data collection: Afghanistan, Bolivia, Cote d’Ivoire, Ecuador, Guatemala, Honduras, Mali, Namibia, Nicaragua, Niger, Russia, South Africa, Swaziland, Tanzania, and Uganda. HCI country teams interviewed individuals involved in improvement activities at each level (national, regional, district, and facility). The summary results of this assessment of progress to date in institutionalizing QI approaches were summarized in the HCI TO1 FY11 and TO3 FY11 self-evaluation reports in sections addressing “Progress toward Achieving Task Order Objective 2, Institutionalization” and reported in a separate research report, available at http://www.hciproject.org/publications/institutionalization-improvement-15-hci-supported-countries.

In FY12, to complement the FY11 findings about level and type of institutionalization, HCI conducted a qualitative study to better understand the activities and support HCI field offices provided to 17 HCI-assisted countries to facilitate the institutionalization of improvement at the national level. We also explored the facilitating factors and barriers to institutionalization. A review of quarterly and annual reports from each participating country was conducted. Based on these reports, tailored guides were developed for interviewing HCI Chiefs of Party. The findings from this study were summarized in the FY12 and FY13 HCI TO3 self-evaluation reports.

Objective 3: Expand the evidence base for the application of QI to human resources (HR) planning and management

Performance target 3.I: The contractor will support the Niger HR collaborative, including introduction of the standardized evaluation system, and provide USAID with detailed progress reports at six-month intervals beginning six months from the beginning of Task Order #3.


Six-month progress reports on the Niger HR collaborative were submitted to the COTR on March 31, 2010; September 30, 2010; June 10, 2011; September 29, 2011; and March 30, 2012.

This collaborative was completed in December 2011; the final report was published in September 2012 (available at: http://www.hciproject.org/publications/human-resources-collaborativeimproving-maternal-and-child-care-niger-final-report)

Performance target 3.2: During the first year of Task Order #3, the contractor will complete field-testing the current tool for monitoring community health worker performance in maternal-child health services in at least two programs. On the basis of these field tests, the contractor will make indicated revisions to the tool.


The FY10 TO3 Self-Evaluation Report included (in section 2.2.3.2) a discussion of the formal field testing of the CHW Assessment and Improvement Matrix (AIM) tool in Nepal, Benin, Ethiopia, and Zambia in FY09 and FY10. A revised version of the tool was published in April 2010 on the HCI Portal and disseminated among members of the CORE Group. Further revisions were made to the tool following its fourth application in Zambia in September 2010; the final version of the tool was published on the HCI Portal in March 2011 and disseminated at CORE Group meetings in May and October 2011 and at the GHC Conference in June 2011, where it was disseminated in conjunction with the launch of the CHW Central community of practice website.

The French version of the CHW AIM toolkit, Matrice d’évaluation et d’amélioration de la performance des agents de santé communautaires (MEAP



ASC): Une boîte à outils pour l’amélioration des programmes et services des agents de santé communautaires, was published by HCI in September 2012.

The Spanish version of the CHW AIM toolkit, Matriz de Evaluación y Mejoramiento para Trabajadores de Salud Comunitaria (MEM TSC): Un Kit de Herramientas para mejorar los Programas y Servicios de Trabajadores de Salud Comunitaria, was published by HCI in September 2012.

In FY13, staff from Initiatives Inc. updated the CHW AIM Tookit in English. The revised toolkit was published in September 2013 and distributed at the CORE Group Fall Meeting in October 2013.

Performance target 3.3: During the first year of the Task Order, the contractor will develop a plan for introducing the community health worker performance evaluation tool into participating USAID mission programs, including a strategy for providing distance technical support for implementing partners.


During FY10, the CHW AIM tool was disseminated widely, and HCI was advised by the MCH Group at USAID that they no longer want a plan for introducing the tool to Missions.

Performance target 3.4: During the course of Task Order #3, the contractor will develop at least three additional human resources collaboratives in high-burden AIDS countries, incorporating findings from the Niger HR collaborative cited above.


Under TO3, HCI carried out four human resources collaboratives in three high-burden AIDS countries, drawing tools and lessons developed in Niger:

1) HR Collaborative in Tandahimba District, Mtwara Region, Tanzania

2) CHW Collaborative in Oromia, Ethiopia

3) District health management performance collaborative in Lindi Region, Tanzania (with all six Council Health Management Teams and the Regional Health Management Team)

4) Pharmaceutical workforce management collaborative in Uganda

Performance target 3.5: During the course of Task Order #3, the contractor will carry out at least five field studies addressing the impact of human resources interventions on the quality of care, including the task-shifting strategy.


By the end of FY13, under TO3, HCI completed five studies on the impact of human resources interventions on quality of care:

1) Evaluation of the Scale-up of the PMTCT Infant Feeding Counseling Training Program in Tanzania. HIV Training Evaluation. This study was completed in FY10 and its final report published in September 2010: http://www.hciproject.org/node/1769.

2) The findings of the Uganda expert patient study were published in November 2011 in the report, Task Shifting in HIV/AIDS Service Delivery: An Exploratory Study of Expert Patients in Uganda, available at: http://www.hciproject.org/publications/task-shifting-hivaids-service-delivery-exploratory-study-expert-patients-uganda.

3) The findings of the assessment of the effectiveness of the CHW AIM tool for improving CHW program functionality in Zambia was published as the technical report, Improving CHW Program Functionality, Performance, and Engagement: Operations Research Results from Zambia, in June 2012. Available at: http://www.hciproject.org/publications/improving-chw-program-functionality-performance-and-engagement-operations-research-resu.

4) Documentation of the Niger HR collaborative’s impact on quality of care is described in the final report, The Human Resources Collaborative: Improving Maternal and Child Care in Niger, published in September 2012. Available at:



http://www.hciproject.org/publications/human-resources-collaborativeimproving-maternal-and-child-care-niger-final-report.

5) Documentation of the Tanzania HR collaborative’s impact on quality of care in described in the final report, Improving quality of HIV services and health worker performance in Tandahimba District, Tanzania: An evaluation, was published in July 2013. Available at: http://www.hciproject.org/publications/improving-quality-hiv-services-and-health-worker-performance-tandahimba-district-tanzan.

Objective 4: Expand experience with the improvement collaborative approach in USAID-assisted countries

Performance target 4.1: During the course of Task Order #3, the contractor will develop and support 20 Phase I (improvement) collaboratives, including those begun under Task Order #1, for an average of two and a half years. These collaboratives will document an average level of improvement in the selected quality indicators of greater than 10% within 18 months.


This performance target was exceeded in FY10: 33 phase 1 improvement collaboratives were launched or completed under TO1 by the end of FY11. By the end of FY12, 23 additional Phase I improvement collaboratives were launched under TO3, for a total of 56 phase I collaboratives supported under HCI. The phase 1 collaboratives supported under HCI TO3 are:

1. Afghanistan maternal and newborn health community demonstration collaborative in Balkh and Kunduz provinces

2. Afghanistan Kabul maternity hospital demonstration collaborative

3. Uganda maternal-newborn care demonstration collaborative

4. Uganda palliative care demonstration collaborative

5. Uganda chronic care demonstration collaborative

6. Uganda maternal-newborn care community demonstration collaborative

7. Senegal community case management demonstration collaborative with ChildFund

8. Human resources collaborative in Tandahimba District, Mtwara Region, Tanzania

9. Tanzania Most Vulnerable Children Programs demonstration collaborative in Bagamoyo District in Pwani Region

10. Russia TB demonstration collaborative in Bryansk and Saratov oblasts

11. Kenya antenatal care-PMTCT demonstration collaborative (Kwale District)

12. Ethiopia CHW demonstration collaborative in Oromia

13. Afghanistan postpartum family planning demonstration collaborative

14. Mali postpartum family planning demonstration collaborative (Kayes province)

15. Honduras obstetric referrals demonstration collaborative (Comayagua Region)

16. District Health Management Collaborative in Lindi, Tanzania

17. Pharmaceutical workforce management collaborative in Uganda

18. Georgia Imereti Region NCD collaborative

19. Uganda FP-HIV collaborative in 1 district

20. Manyara, Tanzania PMTCT-RCH integration demonstration collaborative

21. Cote d’Ivoire Pharmacy Collaborative in 15 sites

22. Community Support to CHWs Collaborative in Uganda

23. Mali anemia prevention and control demonstration collaborative (Bougouni District, Sikasso Region)



Level of improvement achieved in these collaboratives through the end of FY12 was presented in the TO3 FY12 self-evaluation report. Collaborative profiles on these phase I collaboratives were posted on the HCI Portal.

Performance target 4.2: The collaboratives supported under Task Order #3 will include at least one that addresses the current management processes of the district health team (or the local equivalent).


The human resources collaborative launched in Tandahimba District of Morogoro Region in Tanzania at the end of FY10 with TO3 funding addressed district-level health program management. The Regional and District Health Management Team collaborative started in Lindi, Tanzania in FY12 also focuses on improving health management processes at the district level.

Performance target 4.3: At least four of the 20 collaboratives developed under Task Order #3 will be implemented by a partner organization, with the role of the contractor limited to providing training and support to the partner organization.


Four of the demonstration collaboratives supported under TO3 are implemented by a partner organization:

1) Tanzania AIDS Relief Tanga Region ART/PMTCT collaborative

2) Tanzania Clinton Foundation/EGPAF Mtwara ART/PMTCT collaborative

3) Tanzania FHI 360 Morogoro ART/PMTCT collaborative

4) Tanzania EngenderHealth Infant Feeding Collaborative in Iringa

Performance target 4.4: At least four of the collaboratives developed under Task Order #3 will address the chronic care of HIV/AIDS across the continuum of care, from the level of self-care to referral hospital care. At least three of these collaboratives will be in Africa. Before the end of Task Order #3, the contractor will submit a report summarizing the improvement of the application of the chronic care model to AIDS in African countries.


Four collaboratives developed under TO3 address the chronic care of HIV across the continuum of care, three of which are in Africa:

1) Nicaragua ART

2) Uganda palliative care

3) Uganda chronic care

4) Tanzania patient-self management activity with the Morogoro ART/PMTCT collaborative

HCI prepared a report summarizing the application of the chronic care model to AIDS in African countries and submitted it to the COR on December 2, 2013 for review and approval.

Performance target 4.5: During the course of Task Order #3, the contractor will carry out at least six descriptive or intervention studies focused on the design and implementation of improvement collaboratives.


Seven studies were completed by the end of FY13:

1) Tanzania: Evaluation of the Partnership for Quality Improvement (partner collaborative) strategy was completed in FY10 and the report, The Partnership for Quality Improvement to Improve PMTCT and ART Services in Tanzania: Assessment of Results, Capacity, and Potential for Institutionalization, was published in June 2011.

2) Ecuador: Sustainable scale-up of AMTSL (completed in FY11 and published in Int J Gyn Obst in June 2012.

3) Uganda: Effectiveness of different coaching strategies on QI team performance (study completed in FY11; the report, Comparison of Coaching Strategies for Improvement Collaboratives in Ugandan HIV/AIDS Health Centers, was published in March 2012)

4) Guatemala: Descriptive study of QI team performance (completed in FY11 and the summary report, Quality improvement team performance in Guatemala, was published in September 2011 along with the full study report in Spanish)



5) Afghanistan: Qualitative assessment of community-based services for EONC in Kunduz Province (published in June 2012)

6) Afghanistan: Changes in maternal and neonatal health in Kunduz Province as a result of a community-based collaborative improvement intervention (report was prepared as a manuscript and submitted for peer-reviewed publication)

7) Afghanistan: Changes in maternal and neonatal health in Balkh province, Afghanistan: Results from household surveys 2010 – 2012 discussing the impact of quality improvement methods to community level services in Balkh Province, Afghanistan was submitted to the COR for approval in September 2013. The manuscript will be submitted to the Pakistan Journal of Public Health.

Objective 5: Expand experience with the spread collaborative approach in USAID-assisted countries

Performance target 5.1: The contractor will develop 20 spread collaboratives adapted to the needs of the involved health system, including those developed under Task Order #I, and support them for an average of two and a half years. In reporting on these collaboratives, the contractor will provide an estimate of the total population in catchment area of the participating facilities, with a target of at least 100,000 for the average population served. The contractor will also provide a count of the number of facilities reached by the spread collaborative, with a target average number of facilities of at least 50. Reports will also summarize the level of quality attained for each collaborative indicator, with comparison values from the corresponding Phase I (improvement) collaborative.


HCI supported 10 phase II spread collaboratives under TO1; 11 new phase II (spread) improvement collaboratives were initiated under TO3 through the end of FY12:

1. Bolivia TB DOTS spread collaborative in El Alto, La Paz Province, including 46 facilities and 19 laboratories serving a population of 900,000

2. Bolivia TB spread collaborative in the city of Cochabamba, including 38 facilities and 16 laboratories serving a population of 620,000

3. Afghanistan maternal and newborn health facility spread collaborative in Parwan, Bamyan and Herat provinces, involving 26 facilities serving a population of over 570,000

4. Uganda HIV spread collaborative (96 sites, serving a population of 14 million)

5. Russia prevention of hypothermia among newborns spread collaborative in I29 facilities in Kostroma, Yaroslavl, Ivanovo, Tambov, Tula, and Tver oblasts

6. Russia breastfeeding spread collaborative in 16 facilities in Ivanovo, Tula, Tambov, and Kostroma oblasts

7. Russia spread collaborative on optimizing labor management through use of the partograph in 21 facilities in Kostroma, Yaroslavl, Ivanovo, Tambov, and Tula oblasts

8. Russia spread collaborative on prevention of unwanted pregnancies, abortions, and sexually transmitted diseases among teenagers in10 facilities in Kostroma, Tambov, Ivanovo, and Tula oblasts

9. Russia spread collaborative on primary neonatal resuscitation in 19 facilities in Ivanovo, Tver, Tula, Tambov, Yaroslavl, and Kostroma oblasts

10. Afghanistan maternal and newborn health facility spread collaborative in Samangan, Sari Pul, Wardak, and Logar provinces, including 28 facilities serving a population of over 330,000

11. Partner PMTCT spread collaborative in EGPAF-supported Kilimanjaro Region in Tanzania (EGPAF demonstration region: Mtwara), including 13 facilities serving an estimated population of over 100,000

The facility essential obstetric and newborn care spread collaborative in Segou and Koulikoro regions of Mali was unable to be implemented due to the suspension of technical assistance activities in Mali from March-August 2012 as a result of the civil unrest. When activities resumed in FY13, HCI was unable to resume work in Segou and Koulikoro regions and instead was directed to



focus on EONC activities in additional districts of Kayes region.

Performance target 5.2: The contractor will conduct at least 18 descriptive or intervention studies addressing the design or implementation of spread activities, including those developed under Task Order #I. Studies of the spread process within improvement collaboratives may be counted toward achievement of this target.

Target was been met:

HCI supported 6 studies on spread under TO1 and completed 12 more under TO3 through FY13:

1) Tanzania: Evaluation of the Partnership for Quality Improvement, the strategy for developing regional partner collaboratives (completed in FY10)

2) Towards more effective spread of improvement methods (completed in FY11)

3) Ecuador: Spread of EONC better care practices and CQI in 51 sites (completed in FY12)

4) Russia: Spread of innovations in MCH collaboratives through a web portal (completed in FY12)

5) Uganda: Spread of better care practices to improve coverage, retention, and outcomes of patients receiving ART (completed in FY12)

6) Guatemala: Spread of ProCONE best practices from health centers to health posts in San Marcos (completed in FY12)

7) Guatemala: Case study of spread from San Lorenzo health center to three peripheral facilities (completed in FY12)

8) Nicaragua: Spread of innovations in MNCH to new teams (completed in FY12)

9) Bolivia: Evaluation of methods used to spread learning from the El Alto TB collaborative to new sites in Cochabamba (completed in FY12)

10) Uganda: Diffusion and adaptation of innovations to improve care for HIV/AIDS patients in 14 health facilities in Uganda (completed in FY12)

11) Afghanistan: Evaluating spread of an MNCH improvement collaborative to Bamiyan, Herat, and Parwan provinces (completed in FY13)

12) Evaluation of the spread of EONC best practices from Niger to Mali (completed in FY13)

Performance target 5.3: By the end of the second year of Task Order #3 (September 2011), the contractor will submit a report summarizing the status of spread activities to date, including the findings of studies and evaluations and major knowledge gaps


Drawing on the findings of the spread studies carried out by HCI, we commissioned an analytical report synthesizing our findings on spread by Dr. John Ovretveit. The final report was submitted to the COTR on September 29, 2011 and approved for publication on November 7, 2011.

Objective 6: Expand the experience base for other specific QI approaches

Performance target 6.1: Under Task Order #3, the contractor will carry out 15 descriptive or intervention studies of QI methodologies distinct from the overall collaborative approach, including those begun under Task Order #1. These studies may address well-defined QI methodologies used within the framework of an improvement or


Seven applications or evaluations of other QI approaches were completed by the end of FY10 under TO1; 11 additional studies and applications were completed under TO3 by the end of FY13, reaching a total of 18 studies. The studies of other QI methodologies than collaborative improvement that were carried out under HCI TO3 are:

1) Field testing of the Framework for improving care and outcomes of patients on ART led to the development in FY11 of an instructional manual on how to apply the framework. The tool was published on the HCI Portal in August 2011.



spread collaborative. 2) Malawi HIV/AIDS quality of care assessment (report published in FY11)

3) Documentation of impact of OVC standards in Strengthening Community Safety Nets Project in Ethiopia with ChildFund (report published in November 2011)

4) Assessment of selected maternal newborn care practices in women of reproductive age in the Europe and Eurasia Region: This four-country assessment (data were collected in Albania, Armenia, Georgia, and Russia) was new in HCI’s FY11 scope of work and was completed in September 2011. The final report was published in June 2012.

5) Assessment of the non-communicable disease screening and care practices in women of reproductive age in the Europe and Eurasia Region: This four-country assessment (data were collected in Albania, Armenia, Georgia, and Russia), implemented in conjunction with the maternal newborn care practices study, was designed and completed in FY11. The final report was published in April 2012.

6) Application of the Community Health Worker Assessment and Improvement Matrix (CHW AIM) in Madagascar: Data were collected in August 2011. The written report on the qualitative assessment conducted by HCI was published in November 2012.

7) Documentation of the ISO 9001:2008 certification for administrative, financial, and clinical services in Guatemala: A technical report describing the application of ISO 9001:2008 standards in the Ministry of Health of Guatemala was drafted and approved by the USAID Mission and the COTR. However, as a result of new certifications of compliance with ISO standards that took place in September, the Mission has request that HCI revise the report to include the new certification results. The revised report was published in September 2012.

8) Cost-effectiveness analysis of ISO 9001:2008 certification vs. collaboratives in Guatemala: Data collection for this study was completed in FY11, and the final report was published in June 2012.

9) Cost-effectiveness analysis of OVC standards development and piloting in Kenya: This study was carried out in FY11, and the final report was published in November 2011.

10) Application of the CHW Assessment and Improvement Matrix (CHW AIM) in Zambia: This application of the CHW AIM tool began in September 2010, with the participation of four NGOs and the Ministry of Health. Endline data collection took place in the first quarter of FY12. The report was published in June 2012.

11) Case Study on Piloting Standards in Kenya. Published in March 2012.

Performance target 6.2: Under Task Order #3, the contractor will carry out at least two comparative evaluations of the performance of providers participating in a collaborative, and that of a similar group, receiving traditional supervision for the same quality indicators.

Target will be met in FY14:

Two comparative evaluations were carried out under HCI TO3:

1) Mali comparison study for eclampsia / pre-eclampsia, comparing cost-effectiveness of a quality improvement collaborative with training alone

2) Comparison study on effects of a QI intervention on maternal and newborn outcomes in collaborative and non-collaborative sites in Uganda

The Uganda study was completed in FY13. The Mali study will be completed in FY14 (completion of the Mali study was one of the activities specifically authorized under HCI TO3 no-cost extension through September 2014).

Objective 7: Improve the cost-effectiveness of QI in USAID-assisted countries



Performance target 7.1: During the first year of Task Order #3, the contractor will submit to the USAID COTR a report summarizing the design of the knowledge management system, addressing at a minimum, certain features and capabilities.


A report summarizing the design, features, and capabilities of the HCI KM system was submitted to the COTR on 30 September 30, 2010.

Performance target 7.2: During the course of Task Order #3, the contractor will carry out 20 evaluations and studies addressing the design of the knowledge management system, user applications of system content for QI and validation of submissions, including those carried out under Task Order #I.


In addition to the 15 KM studies that were completed under TO1, five additional KM studies were completed in FY12:

1) Bolivia: Evaluation of methods used to spread learning from the El Alto TB collaborative to new sites in Cochabamba (study completed in FY12; final report is in editing)

2) Survey of users of the CHW Central site (completed by Initiatives Inc. in November 2011)

3) Design of a Spanish-language community of practice for implementers of Kangaroo Mother Care (completed in June 2012)

4) Evaluation of a links to and referring websites for the HCI Portal, completed by CCP in June 2012

5) Best improvement report contest to increase outside submissions to HCI Improvement Database held in February 2012. Interviews with finalists were conducted in April 2012 to validate their submissions.

Performance target 7.3: During the course of Task Order #3, the contractor will carry out 15 studies and evaluations related to improving the cost-effectiveness of specific QI approaches or methodologies, including those carried out under Task Order #I.

Target has been met.

Ten cost-effectiveness studies were carried out under TO1; ten more studies have been completed through the end of FY13 under TO3, and two more studies will be completed in FY14: 1) Cost-effectiveness of the conditional cash transfer intervention in Guatemala (completed in FY11)

2) Kenya: CEA of piloting OVC standards (completed in FY11 and report published in November 2011)

3) Uganda: Cost-effectiveness of central level vs. District coaching strategy (completed and report published in March 2012)

4) Ecuador: Spreading Evidence-Based Maternal and Newborn Care Practices and Continuous Quality Improvement in Ecuador: A Temporal Comparison (study completed in FY13; report in editing)

5) Guatemala CEA of ISO versus collaboratives (report published in June 2012)

6) Nicaragua: The cost-savings of implementing Kangaroo mother care in Nicaragua. A manuscript describing these findings was submitted to the Pan American Journal of Public Health in October 2012 and accepted for publication in September 2013: Rev Panam Salud Pública 2013 Sep;34(3):176-82.

7) Cost-effectiveness of improving services to people with HIV in Nicaragua. A manuscript describing the findings of this study was submitted to the Journal of the International AIDS Society in September 2012 but was not accepted for publication. The Spanish version of the report was published in March 2012 and disseminated in Nicaragua.



8) Cost-effectiveness of the improvement collaborative approach in the context of hospital-level maternity services in Kabul | Afghanistan. The final report of this study was submitted to the COR for approval in September 2013.

9) How accurate are medical record data in Afghanistan’s maternal health facilities? A manuscript describing the findings of this study was accepted for publication in BMJ Open in March 2013 and is accessible at: http://bmjopen.bmj.com/content/3/4/e002554.full.

10) A comparative evaluation and cost-effectiveness analysis of collaborative improvement for maternal and newborn care services in Uganda. The study was completed in FY13. The report is in editing.

11) Cote d’Ivoire: Evaluating the cost of poor quality. This study seeks determine, What is the cost-effectiveness of HCI-implemented QI interventions to improve quality of HIV-related care in Cote d’Ivoire? HCI is partnering with Harvard University to conduct this study, which will be completed in FY14.

12) An evaluation and cost-effectiveness analysis of an improvement collaborative for eclampsia /pre-eclampsia services in Mali. The cost-effectiveness analysis of the Mali comparison study will also be completed by the third quarter of FY14.

Performance target 7.4: By the end of Task Order #3, the KM system has been accessed by at least 2000 users, 75 acceptable submissions from outside the Task Order have been received and posted and the contractor has responded to 400 requests for information or assistance.

Target has been:

By the end of FY12, the HCI Portal had been accessed by 140,579 unique visitors, with an average daily visit of about 200.

The Spanish maternal and child health web site (www.maternoinfantil.org) has had over 200,000 visits since its launch in FY09, with an average over 400 daily visits in 2012.

As of the end of FY12, the KM system has received 122 acceptable submissions from outside the Task Order that have been posted in the Improvement Database.

By the end of FY12, HCI had received and responded to 288 substantive requests for assistance through the various knowledge management websites supported by the project (excluding requests for password or login help). The target of 400 requests was not reached in FY12 due to lack of spontaneous requests. Because this last target was demand-driven, the USAID COR determined in April 2013 that this particular component of Performance Target 7.4 of HCI TO3 had indeed been satisfactorily met by HCI’s response rate at or near 100% of received requests.

Performance target 7.5: By the end of Task Order #3, the contractor has prepared a paper summarizing the KM system and its performance and submitted the paper to a peer-reviewed professional journal.

Target will be met in FY14:

An article summarizing the experience of the HCI KM system has been drafted and is currently in review.

Objective 8: Provide global technical leadership for QI in USAID-assisted countries

Performance target 8.1: By the end of Task Order #3 received written confirmation from no

Target will be met in FY14. By the end of FY12 under TO3, we had written confirmation from three international organization:

1) The Directors' Joint Consultative and East, Central, and Southern Africa



fewer than five international organizations with objectives in health systems strengthening that they will incorporate language that explicitly endorses QI as a strategy for achieving these objectives.

Community (ECSA) Health Ministers' mechanisms (the highest technical and policy making organs of ECSA countries).

2) International Society for Quality in Health Care, which has signed a written agreement with URC to collaborative on promotion of quality and patient safety approaches through regional workshops and other events

3) Salzburg Global Seminar, which convened the Salzburg Seminar “Making Health Care Better in Low and Middle Income Economies” in April 2012. The Salzburg Statement issued by the participants in the seminar explicitly endorses QI as a strategy, and representatives from some 25 government ministries and international organizations signed it.

In FY12 and FY13, we worked with two new organizations:

4) Regional Psychosocial Support Initiative (REPSSI) headquarted in South Africa

5) African Network for the Prevention and Protection against Child Abuse and Neglect (ANPPCAN), headquartered in Nairobi, Kenya

HCI has established a regional Child Protection Alliance with these two organizations, aimed at spreading the adoption of improvement methods to improve outcomes for vulnerable children. As a result of activities that will be completed in FY14, we will fully meet this performance target in FY14.

Performance target 8.2: By the end of Task Order #3, the contractor will produce 20 technical reports and papers related to describing QI interventions and measuring their results, including seven papers published in peer-reviewed journals, as well as those produced under Task Order # 1.


By the end of FY11, under TO1, HCI had published seven articles in peer-reviewed journals and 15 technical reports describing QI interventions and results. Under TO3 through FY13, HCI has published seven more articles in peer-reviewed journals and 35 additional technical and research reports describing the interventions and results of QI:

Technical and research reports:

1) A Rapid Evaluation of the Uganda MoH Training Program on Use of HIV Monitoring Tools (June 2010)

2) Evaluation of the Scale-up of the PMTCT Infant Feeding Counseling Program in Tanzania (September 2010)

3) A Summary of Results and Lessons from HIV Training Evaluations (September 2010)

4) Sustaining Better Maternal and Newborn Care and Quality Improvement in Niger: Challenges and Successes (March 2011)

5) Sustainability of Improvements in Maternal and Child Care and Institutionalization of Continuous Quality Improvement in Nicaragua (May 2011)

6) Institutionalization of Continuous Quality Improvement in AMOCSA, a Private Health Care Provider in Chinandega, Nicaragua (May 2011)

7) The Partnership for Quality Improvement to Improve PMTCT and ART Services in Tanzania: Assessment of Results, Capacity, and Potential for Institutionalization (June 2011)

8) Aligning and Clarifying Health Worker Tasks to Improve Maternal Care in Niger (August 2011)

9) Postpartum Family Planning Intervention for At-risk Women in Masaya and Rivas, Nicaragua (August 2011)

10) Results from the Pilot Phase of an ART/PMTCT Improvement Collaborative in Cote d’Ivoire (September 2011)



11) Expanding TB-HIV Integration and Public-Private Mix Interventions to Nam Dinh and Hai Duong Provinces, Vietnam (September 2011)

12) How do quality improvement teams function after an improvement intervention ends? A description of team performance after the end of an obstetric and newborn care QI initiative in Niger (September 2011)

13) Institutionalization of continuous quality improvement interventions on maternal and child health in Honduras (September 2011)

14) Spreading best practices in maternal and newborn care in Guatemala (September 2011)

15) Implementing Standards-based Quality Improvement Processes at the Community Level for Orphans and Vulnerable Children: The Strengthening Community Safety Nets (SCSN) Project, Ethiopia (October 2011)

16) Implementation of Standards of Service Delivery for Orphans and Vulnerable Children in Kenya: A Prospective Evaluation of Performance, Costs, and Equity (November 2011)

17) USAID's Legacy of Family Planning Technical Assistance to the Guatemalan Public Health Sector: Over a decade of success through USAID's Calidad en Salud and Health Care Improvement Projects (January 2012)

18) Improving Care for Vulnerable Children in Kenya: Results from Piloting Service Standards (March 2012)

19) Integrating Nutrition Interventions into Routine HIV/AIDS Care: Challenges, Solutions, and Lessons Learned from Uganda (May 2012)

20) Taking Every Opportunity to Save Lives: The Role of Modern Quality Improvement in Enhancing Maternal, Newborn, and Child Health Programs. A Synthesis of USAID Health Care Improvement Project Field Experience (June 2012)

21) Comparative Evaluation of Collaborative Improvement and ISO Certification to Improve Quality of Maternal and Neonatal Care in Guatemala (June 2012)

22) The Human Resources Collaborative: Improving Maternal and Child Care in Niger (September 2012)

23) Improving the Health System through Certification: Implementing ISO 9001:2008 in Guatemala (September 2012)

24) Integrating palliative care with HIV care in two Ugandan districts using a collaborative quality improvement approach (March 2013)

25) Improving quality of HIV services and health worker performance in Tandahimba District, Tanzania: An evaluation (July 2013)

26) Namibia Integrated Health Care Waste Management Plan. Final Project Report. (October 2012)

27) Integrating palliative care with HIV care in two Ugandan districts using a collaborative quality improvement approach. Technical Report. (March 2013)

28) Rahimzai M, Yaqubi E. September 2013. Technical Assistance in Health Care Improvement to the Ministry of Public Health of the Islamic Republic of Afghanistan. Final Report. (Submitted it to the Ministry of Public Health for final approval.)

29) Institutionalization of Quality Improvement Approaches and Results in Former USAID-assisted Regions in Russia. Research and Evaluation Report. (December 2012)

30) What has HCI done to institutionalization improvement? A report from



17 countries. Research and Evaluation Report. (March 2013)

31) Spread of EONC Best Practices from Niger to Mali. Research Report Summary. (April 2013)

32) Dissémination du Niger au Mali du collaboratif d’amélioration des soins obstétricaux et néonataux essentiels et des meilleures pratiques du collaboratif: expériences, perceptions et efficacité. Rapport de la Recherche et Evaluation. (April 2013)

33) Improving quality of HIV services and health worker performance in Tandahimba District, Tanzania: An evaluation. Research and Evaluation Report. (July 2013)

34) Cost-effectiveness analysis of improving maternity hospital care in Kabul, Afghanistan. Research and Evaluation Report. (Submitted to the COR in September for approval.)

35) Ikram AN, Sahak I, Anwari MK, Majeedi AJ, Saleem H, Smith S. September 2013. Evaluating the spread of the maternal and newborn health care collaborative to Bamyan, Herat, and Parwan provinces in Afghanistan. Research and Evaluation Report. (Submitted to the COR in September for approval.)

Seven articles on QI results have been published in peer-reviewed journals under TO3:

1) Broughton E. How & Why of CEA. Published in Int J Clinical Pathways in September 2011.

2) Hermida J et al. Sustainable scale-up of AMTSL in Ecuador. Published in Int J Gyn. Obs. in June 2012.

3) Rahimzai M, Amiri M, Burhani N, Leatherman S, Hiltebeitel S, Rahimzai A. Afghanistan’s National Strategy for Improving Quality in Health Care. Published 12 March 2013 in International Journal for Quality in Health Care pp. 1–7 10.1093/intqhc/mzt013.

4) Lopez S. Wong Y. Gomez I. Escobar F. Tinoco B. Parrales A. Quality in Practice: Preventing and managing neonatal sepsis in Nicaragua. Published 20 August 2013 in Int J Quality in Health Care pp. 1-7 10.1093/intqhc/mzt060.

5) Broughton E, Ikram AN, Sahak I. How Accurate Are Medical Record Data in Afghanistan’s Maternal Health Facilities? Accepted for publication March 21, 2013 in BMJ Open.

6) Edward Broughton E, López SR, Aguilar MN, Somarriba MM, Pérez M, Nieves S. Economic analysis of a pediatric ventilator-associated pneumonia prevention initiative in Nicaragua. Published 2012 in the International Journal of Pediatrics. doi:10.1155/2012/359430.

7) Altaf A, Vaid S. The Sindh Disposable Syringe Act: putting the act together. Journal of the Pakistan Medical Association. Accepted on 8/25/13 for publication in the November 2013 issue.

Performance target 8.3: By the end of Task Order #3, the contractor will facilitate at least 15 articles or broadcasts in mass media that address the nature of QI activities and their results, including those facilitated under Task Order #1.


HCI facilitated nine articles and broadcasts in mass media addressing the nature of QI activities and their results under TO1 by the end of FY11. By the end of FY12, we had facilitated 17 new mass media articles and broadcasts under TO3: 1. Article in the Guatemalan newspaper Prensa Libre on Helping Babies Breathe (February 2011) 2. Article in the Tver newsweekly Rzhevsky Vestnik on QI in obstetric care supported by HCI (February 2011)



3. In March 2011, a conversation between the CSIS panel moderator (Judyth Twigg), Victor Boguslavsky, and former Senator Bill Frist was posted on the CSIS website, at: http://csis.org/multimedia/interview-senator-bill-frist-and-dr-victor-boguslavsky-us-russia-collaboration-health. 4. In Afghanistan, three episodes of the “Families Health” television show highlighted quality improvement efforts supported by HCI (episodes aired in May, August, and September 2011) 5. HCI’s Health Workforce team contributed a short piece on applying QI to human resources management and a Niger case for the State of the World’s Midwifery Report, which was launched in June 2011in Johannesburg. The piece on application of QI to human resources for health is on p. 116 of the main report. The Niger country profile prepared by HCI is available at: http://www.unfpa.org/sowmy/resources/docs/country_info/short_summary/Niger_SoWMyShortSummary.PDF. 6. HCI/Russia staff and project federal-level experts were interviewed by the Ren-TV Bryansk regional channel, a local TV channel, about tuberculosis project activities in Bryansk oblast, in July 2011. 7. Many Afghani television stations highlighted the launch ceremony of the National Strategy for Improving Quality in Health Care in news segments on August 8, 2011. 8. ISQua Talk, “Heal Me But Don’t Kill My Culture” delivered by Dr. Jorge Hermida and videotaped at the ISQua conference in Hong Kong in September 2011 and posted on the ISQua Knowledge web portal at: http://www.isquaknowledge.org/activities/isqua-talks/jorge-hermida.html. 9. TV broadcast on Moscow station of First Lady of Russia touring hospital with newborn resuscitation equipment provided by HCI (October 11, 2011) 10. On Jan. 27, 2012, HCI staff member Emily Treleaven posted a blog on the Healthy Newborn Network website about HCI’s work to scale up Kangaroo Mother Care in Central America, “Connecting Across Borders to Improve Kangaroo Mother Care”, at: http://www.healthynewbornnetwork.org/blog/connecting-across-borders-improve-kangaroo-mother-care 11. On March 14, 2012, “Meditsinskaya Gazette” (Medical Gazette) published a full page article “Green light to discussions: crucial issues of quality and safety in healthcare in Russia” to feature the International Forum Remote Participation Session and highlight its role in disseminating modern approaches to quality improvement to the Russian healthcare community. 12. Article “When Patients Become Experts” about patient self-management improvement work in Morogoro, Tanzania published on the web magazine, Global, on 19 April 2012. 13. Salzburg discussion forum and daily updates from Salzburg Global Seminar, “Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?”, posted on the ISQua Knowledge website 20 March –30 April 2012 14. On April 15, 2012, a story was posted on the USAID Afghanistan website about HCI’s work to improve care for newborns in respiratory distress: http://afghanistan.usaid.gov/en/USAID/Article/2677/Helping_Afghan_Babies_Breathe 15. Blog about Salzburg posted on the K4Health website on 22 May 2012 at: http://www.k4health.org/blog/post/we‐can‐make‐health‐care‐better‐salzburg‐call‐action. 16. On June 18, 2012,the Women Deliver website featured a story about HCI’s support for the scale-up of AMTSL in Ecuador: http://www.womendeliver.org/updates/entry/celebrate-solutions-ecuadors-



health-system-model-reduces-maternal-mortality. 17. On June 21, 2012, the second learning session of the Georgia non-communicable disease improvement collaborative was featured on three national and 1 regional TV channels in Georgia, highlighting the USAID-support for improving quality of care in Georgia. One of the clips can be viewed at: http://www.youtube.com/watch?v=QoWX6NvN9Lw&feature=share.

Performance target 8.4: By the end of Task Order #3, the contractor will support the development of new graduate-level training programs in QI as applied in low- and middle-income countries, or the revision of established programs in three training institutions located in these countries.


Through the end of FY13 under TO3, we developed four graduate level training programs in QI 1) QI curriculum developed by Dr. Stephen Kinoti for the new medical

school in Kenya: the Kenya Methodist University Medical School. This new medical school opened in 2011.

2) In Nicaragua, the HCI team developed in FY12 a national curriculum for pre-service and in-service training with the Ministry of Health and with the National Universities in Managua and Leon. During FY13, HCI will support the expansion of the curriculum to six public and private universities.

3) In South Africa, Dr. Donna Jacobs developed a one-week QI course with the School of Public Health of the University of Witwatersrand in Johannesburg. The course, aimed at MPH students, is offered annually. It was first offered in August 2010 and again in August 2011, with instruction led by HCI staff and with support from the Director of the Quality Assurance Department of the National Department of Health.

4) Dr. Sonali Vaid developed an online QI module for the People’s Uni in FY13.

USAID HEALTH CARE IMPROVEMENT PROJECTUniversity Research Co., LLC

7200 Wisconsin Avenue, Suite 600Bethesda, MD 20814

Tel: (301) 654-8338Fax: (301) 941-8427www.hciproject.org

Documents

USAID HEALTH CARE IMPROVEMENT PROJECT TASK ORDER 3 · USAID HEALTH CARE IMPROVEMENT PROJECT Task Order 3 FY13 Annual Project Report Contract Number GHN-I-03-07-00003-00 Performance