This short report summarizes the ways in which the USAID Health Care Improvement Project (HCI) is working with local groups and partners to apply quality improvement (QI) methods within the Community Health System in order to strengthen the impact of CHWs and other service providers at the community level, while at the same time increasing sustainability of programmatic impacts. Currently carrying out activities in more than 30 countries globally, HCI seeks to develop the capacity of health systems to apply modern QI approaches to make essential services better meet the needs of underserved populations; improve efficiency and outcomes; reduce costs from poor quality; and improve health worker capacity, engagement, and performance.

An evaluation of job aids to improve the diagnosis and treatment of malaria in Kenya and Malawi.
A presentation from the Job Aids Symposium.

The Quality Assurance Project (QAP), initiated in 1990, provides technical assistance to developing countries in designing and implementing effective strategies for monitoring the quality of health care. This fourth report in QAP's Quality Assurance Methodology Refinement Series compared the level of statistical agreement between four quality assessment methods used at Under Five clinics in 14 health facilities in Malawi's Lilongwe district. These methods included 436 observations of provider-patient encounters, 426 exit interviews with caretakers, reviews of 362 records, and interviews with 30 providers. The consistency of provider behavior varied according to the child's primary symptom (highest for diarrhea and lowest for cough). Agreement between observation and record review was poor for both general assessment of the child and management of specific conditions; provider interview data had only fair agreement with observation data on a limited number of items. Exit interview data had fair to good agreement with observation data for many items, especially tasks related to fever or diarrhea and concrete activities caretakers could see or hear. Record reviews involved the least time, while provider interviews were least expensive. Overall, these findings suggest that supervisors should first conduct provider interviews to ensure those supervised have the requisite knowledge for proper case management and record reviews to assess whether they use the correct drugs and dosages for the conditions diagnosed. Once supervisors are confident of their employees' knowledge, skills can be assessed through direct observation of performance. When skills have been confirmed, occasional unscheduled exit interviews can be conducted.

Cholera is a serious, infectious disease with a high case fatality rate. In 1998 in Mangochi district, Malawi, 100 cases of cholera were treated by the Kapire Health Center (HC). As part of the Community Health Partnerships (CHAPS) project, the health center formed a quality improvement (QI) team to improve the services the center provides to the community. The QI team identified 17 opportunities to improve the quality of patient care. Using a decision matrix, the team chose cholera outbreaks in the health center catchment area as the first problem it would address. In addition to the 100 cholera cases the center treated in 1998 (10 resulted in death), another 20 cases were treated in 1999. In addition to the human loss and suffering, the HC experienced crowded treatment facilities, a shortage of drugs, and increased staff workload. The team established the goal of eliminating cholera cases in the catchment area by the end of the Year 2000 rainy season. Because the cholera problem affected not only health center staff, but also the entire community, Village Headmen, Village Health Committee (VHCs), and community members from the 12 villages surrounding Kapire HC were asked to participate in addressing the problem. (excerpt)

The Case Study series presents real applications of Quality Assurance (QA) methodologies in developing countries at various health system levels, from national to community. The series focuses on QA applications in maternal and reproductive health, child survival, and infectious diseases. Each case study focuses on a major QA activity area, such as quality design, quality improvement, communication and development of standards, and quality assessment. In some cases, more than one QA activity is presented. Quality assessment is the measurement of the quality of healthcare services. A quality assessment measures the difference between expected and actual performance to identify opportunities for improvement. Performance standards can be established for most dimensions of quality, such as technical competence, effectiveness, efficiency, safety, and coverage. Where standards are established, a quality assessment measures the level of compliance with standards. For dimensions of quality where standards are more difficult to identify, such as continuity of care or accessibility, a quality assessment describes the current level of performance with the objective of improving it. A quality assessment frequently combines various data collection methods to overcome the intrinsic biases of each method alone. These methods include direct observation of patient provider encounters, staff interview, patient focus group, record review, and facility inspection. The assessment is often the initial step in a larger process which may include providing feedback to health workers on performance, training and motivating staff to undertake quality improvements, and designing solutions to bridge the quality gap. This case study describes how local staff in Malawi collected, analyzed and interpreted quality assessment data to identify opportunities to improve family planning services. (excerpt)