This paper summarizes 10 years of evidence of the effectiveness of collaborative improvement in improving health outcomes and compliance with health care standards. The collaborative improvement approach was designed by the Institute for Healthcare Improvement (IHI) in the United States to produce rapid, significant improvements in a targeted area of health care. The paper was commissioned by USAID and analyzes the results achieved by over 1,300 teams of health care providers who participated in 27 improvement collaboratives supported by USAID during 1998-2008.   Data analyzed consisted of 135 time-series charts representing pooled data from groups of teams from 12 countries. All together, the data covered 81 distinct measures of compliance with standards and outcomes for maternal, newborn and child health, HIV/AIDS care, family planning, and malaria and tuberculosis diagnosis and treatment.

In response to concerns that stigma and discrimination pose barriers to access to healthcare services for patients with HIV or AIDS, the Quality Assurance Project surveyed 110 healthcare providers in six health facilities in Kenya in late 2003–early 2004. Structured interviews assessed provider beliefs, attitudes, practices, and fears toward providing care to these patients. Findings indicate that all providers expressed negative attitudes and fear, and most reported being aware of discriminatory practices by providers and facilities toward these patients. The report concludes that as long as providers feel unsafe in providing services to these patients, discrimination will persist. The report discusses the implication of these fidings for stigma reduction strategies to ensure high quality health services for people with HIV/AIDS. Appendices provide informed consent text and the four instruments used for the interviews.

Trained clinical observers used a structured checklist at referral and district/regional hospitals in four developing countries to monitor care provided to 245 women during labor, delivery, and postpartum and their newborns during postpartum. The countries were Benin, Ecuador, Jamaica, and Rwanda. Observation periods were either continuous and lasted 72 hours or noncontinuous and lasted 12 hours over 4--6 days; all such periods included a weekend day and night. Observers marked the checklist to record the times when healthcare providers performed certain tasks and whether each had been done according to standard. Certain circumstances--such as a woman giving birth before arrival--required rigorous data cleaning. The quality of care for the different tasks is reported here by country, by hospital type, and overall. The frequency of labor monitoring was well below the rates recommended in all four countries, regardless of hospital type. Fetal heart rate (FHR) was monitored the most frequently at 1.3 times per hour, although its recommended rate in all countries is twice an hour. Other labor indicators recommended at twice per hour were checked less often: maternal pulse was taken 0.43 times per hour, contraction intervals 0.38 times per hour, and contraction duration 0.37 times per hour. The two indicators recommended at the rate of once every four hours (0.25 times per hour) were performed more frequently: maternal blood pressure at 0.63 times per hour and vaginal exam at 1.1 times per hour. On average, in 26% of the cases, no labor indicator was monitored at all. In the three study countries where partograph use is recommended, incorrect use was observed in more than half the case observations, varying substantially by country. Correct partograph use was associated with more frequent labor monitoring. (author's)

This report presents findings from Phase 2 of the Rwanda Human Resources Assessment for HIV/AIDS Services Scale-up. The study aimed to review the existing staffing situation in the country, document practices and levels of effort in providing HIV/AIDS services, and calculate staffing needs for planned expansion of antiretroviral treatment. Phase 2 of this study describes current systems of HIV/AIDS services in Rwanda by documenting categories of staff and the specific HIV/AIDS services they perform, comparing performance to national standards, and analyzing the time required to provide these different services. The study also looks at the adequacy of current management and supervision of personnel providing HIV/AIDS services and the country's HIV/AIDS training capacity. Information on which the Phase 2 analysis was based was derived from 283 observations of providers with HIV/AIDS clients, record reviews, and interviews with District Health Management Teams, site managers, training coordinators, and 93 service providers at 20 sample sites. The sample sites examined in Phase 2 included both public facilities managed by the Ministry of Health and agree sites (those managed by religious institutions but that are considered to be part of the public health system). Fifteen of the sites yielded information on voluntary counseling and testing (VCT) services, 12 sites on prevention of mother-to-child transmission (PMTCT) services, and eight sites on antiretroviral therapy. (excerpt)

This report presents findings from Phase 1 of an assessment of the human resources implications of HIV/AIDS services scale-up in Rwanda. Phase 1 of the study sought to document the number and type of staff currently employed at public and private sites in Rwanda, estimate those currently providing HIV/AIDS services, and identify employment practices that could facilitate or hinder human resources scale-up for HIV/AIDS service delivery. To estimate the number of health workers providing health services and the employment mechanisms through which they are contracted, the research team gleaned data from Ministry of Health reports. The study found that out of Rwanda's 4,889 active health service providers, 4.2% are doctors, 52.2% are nurses, and 23.5% are nurse aides or other auxiliary staff. Hospitals absorb 44% of the health workforce, and half of the country's doctors are posted at the three national referral hospitals. The Ministry of Health employs 43% of the health workforce through the civil service. The largest share (55%) of the workforce is employed through contracts with a health facility (38%) or through NGOs, donor organizations, or district contracts (17%). Salaries for staff contracted by health facilities are usually paid from funds accumulated from user fees and occasionally from contracts the facilities have with a supporting institution. Reliance on user fees constrains the ability of health centers, especially those in rural areas, to meet their staffing needs. (excerpt)

Each year, more than 500,000 women worldwide die from complications related to childbirth. With good quality obstetric care, approximately 90% of these deaths could be averted. The assistance of a skilled birth attendant during labor, delivery, and the immediate postpartum period is one important component of quality obstetric care. An enabling environment for skilled attendance at delivery and prompt attention for women arriving at a medical facility with an obstetric complication are also key factors. However, little is known about the competence of skilled birth attendants (SBAs), the elements that contribute to an enabling environment, and the causes of what is commonly known as the "third delay": the delay in receiving medical attention after a woman arrives at a healthcare facility. Through its Safe Motherhood Research Program, the Quality Assurance Project carried out three studies to explore these issues in countries with high maternal mortality ratios. The first study examined the competency of SBAs. The second measured SBA performance and the relative contribution to performance of different enabling factors in the work environment. The last examined causes of in-hospital delays in receiving obstetric care. All three studies occurred between September 2001 and July 2002 in Benin, Rwanda, Ecuador, and Jamaica. This report presents the results from Rwanda, where three hospitals participated: a tertiary care referral hospital with an active maternity department and two regional hospitals. The competency study measured knowledge with a 58-question test covering six subject areas. We also tested skills in several key areas, including ability to use a partograph, neonatal resuscitation, manual removal of placenta, bimanual uterine compression, and insertion of an intravenous needle. Finally, we asked participants to assess their own ability to carry out common obstetric procedures. Results show low competency levels with a mean score of 47% correct. Active management of third stage labor merits specific mention, as the mean score was only 7%. The overall test scores for doctors, professional nurses, and midwives were quite similar, while scores for technical nurses were significantly lower. There were too few doctors and midwives to compare skills scores in a statistically reliable way; however, professional nurses scored significantly higher than technical nurses overall, for mouth-to-mouth and nose resuscitation, and asepsia. There was no correlation between providers' self-assessment and their competency as measured by the knowledge and skills tests. The enabling environment study addressed the contribution of enabling factors and essential elements to health worker performance. We used an observation checklist to evaluate performance during labor, delivery, and the immediate postpartum period. We reviewed medical records to evaluate performance in managing obstetric complications. We also surveyed providers in each facility about supervision, training, and motivation. Finally, we inventoried the availability of essential drugs, equipment, and supplies in each study hospital. Labor monitoring, including checking fetal heart rate and the mother's blood pressure, was inadequate in most observed cases. Providers used a partograph only about a third of the time. Few washed their hands before assisting at delivery, and only about half cleaned the perineum before birth; most administered oxytocin to the mother after delivery. The third delay study used direct observation to analyze patient flow in all three study hospitals. In addition, three physicians reviewed medical records to reveal any delays at different points in patient care: Most of the delays they found occurred during diagnosis, especially for obstructed labor. Waiting times after arrival at the hospital or the OB department were short, averaging 13 minutes, with one regional hospital averaging only 3 minutes. The mean time from decision to operate and start of a cesarean section at the tertiary hospital was about two hours. Antibiotics were administered only 44 minutes on average after an order at the tertiary hospital. (author's)