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.

The purpose of the Performance-based Incentives Pilot Study was to develop and test a process for motivating staff and increasing performance by offering rewards for position contributions within the healthcare facility. The study was framed by three primary objectives:

• To test the effects of both financial and non-financial rewards on healthcare worker motivation
• To examine the impact of performance-based rewards on overall health center performance
• To analyze the effectiveness of selected health indicators.

The study was broken down into the following three phases:

• Phase One or Study Preparation
  • Consisted of developing the study design, defining indicators, creating guidelines for receiving rewards, performing district, orientations and collecting baseline data
• Phase Two or Implementation
  • Spanned the time during which districts implemented the performance-based incentives program
• Phase Three or Analysis and Reporting
  • Included the analysis of staff motivation surveys and health center indicators.

In 1997, Zambia became one of the first countries in sub-Saharan Africa to launch a national hospital accreditation program. In mid-2000, a team of researchers was organized to assess the milestones and successes of the Zambian accreditation program and document the challenges it faces. This documentation included reviewing relevant documents and budgets, interviewing key policy-makers and stakeholders, and examining accreditation survey data. To assess the performance of the program, the report referred to a framework of seven vital elements for an accreditation program's success. The research team compiled 10 milestones of the Zambia program: 1) recognizing the need to improve quality; 2) choosing the right accreditation model; 3) setting up the formal structure; 4) developing and testing standards; 5) training surveyors; 6) conducting consultative surveys; 7) refining policies and procedures; 8) developing the database; 9) conducting full accreditation surveys; and 10) interpreting findings and making accreditation decisions. They also noted that the program is at a critical juncture and urgently needs to resolve some important issues. Most important of these is to finalize the accreditation manual for hospitals, to achieve legal status and an administrative structure for the Zambia Health Accreditation Council, to communicate the results of the first round of accreditation surveys, and to determine how to assist hospitals that do not achieve accreditation status.

This document reports on an evaluation of the Quality Assurance Program (QAP) in Zambia. The evaluation took place in the fall of 1998, during the QAP's fifth year. The QAP's strategy was to build quality assurance (QA) capacity at the district and health center levels by training health providers and their managers in setting standards for health services, monitoring indicators of achievement, and team-based problem solving. Problem-solving teams are expected to identify quality of care problems from both users' and providers' perspectives, document the root causes, design and implement solutions, and use indicators to monitor progress in solving problems. In addition, a network of coaches and link facilitators was created to support and guide the teamwork and monitor performance and achievements. This report presents the findings, lessons learned, and recommendations developed by the evaluation team. Key recommendations relate to the importance of communicating standards in a way that will be accepted by users, ensuring that standards are consistent in all communications (training, job aids, etc.), improving performance by having supervisors observe staff while they are providing healthcare, and addressing the failure of teams to form or remain active in small health centers. Important successes detailed in the report relate to significant improvements to healthcare quality where teams formed successfully and the development of teamwork. Several recommendations are made for further research that would help improve the quality of healthcare in Zambia and beyond. (author's)

In cooperation with the Zambian Central Board of Health, the Quality Assurance Project investigated the way in which job aids could increase compliance with IMCI regulations throughout the country. Zambia was one of the first countries to train providers in IMCI, which resulted in a significantly higher number of health care workers already equipped with these skills and knowledge. As a result, the country was a logical choice for this initiative. In fact, several WHO-developed IMCI job aids, including chartbooks, wall charts, recording forms, and mother cards were already being used in Zambia at the beginning of our analysis. Chartbooks provide the official definition of IMCI guidelines and include recommended drugs and dosages. As a result, other African countries began to realize the importance of improved job materials, which would enable providers to implement IMCI.

The study, which was comprised of three stages, focused upon collecting information about provider opinions and their use of the IMCI job aids. This helped in developing and testing materials according to scientfic design principles. The initial stage consisted of assessing the effectiveness and usage of existing IMCI job aids. Thereafter, the new IMCI job materials were both developed and introduced. Finally, following the introduction of the NOPD book, the effectiveness and usage of the updated job aids were reassessed. The following document outlines the methods and results from the three individual stages.