This presentation was given by Dr. Mirwais Rahimzai, Country Director for HCI Afghanistan, and Dr. Ghulam Sarwar Hemati, Director of the Grants and Contracts Management Unit in Aghanistan,  at the 28th International Conference of the International Society for Quality in Health Care, Ltd. (ISQua), which took place in Hong Kong, China from September 14-17, 2011. The conference theme was, “Patient Safety: Sustaining the Global Momentum.”

The Uganda Ministry of Health (MoH) Quality Improvement Strategy Meeting was convened in Kampala, Uganda, on March 21–22, 2011. The meeting provided a forum for various departments within the MoH, selected partners, and international improvement experts to share experiences, clarify the role of Government partners, and discuss lessons learned from implementing health care quality improvement initiatives at national and local levels. The MoH Quality Assurance Department (QAD) together with the United States Agency for International Development Health Care Improvement Project (HCI) organized and supported this meeting. 

Dr. Henry Mwebesa, Commissioner of QAD, chaired the meeting. Dr. M. Rashad Massoud, Director of HCI and Senior Vice President of the Quality & Performance Institute, University Research Co., LLC, designed and facilitated for the meeting.

Throughout the two days, participants shared their experiences with quality improvement (QI) efforts across multiple levels of the health sector, identified challenges and interventions while implementing QI, and made recommendations for harmonizing and sustaining QI efforts in Uganda. Examples discussed were from Uganda, Afghanistan, Sweden, Niger, South Africa, Ethiopia, Russia, and Palestine. 

This report summarizes the key discussions during the meeting.

The collaborative model of quality improvement aims at testing and implementing Quality Improvement (QI) interventions on a small scale, synthesizing the most robust and effective changes, and spreading them at scale. Collaborative improvement not only generates improvements in the quality of care delivered in these initial sites, but also develops organizational learning. However, there still exist knowledge gaps on how to successfully spread evidence practices and ensure up-take and continuous application of these practices in resource-limited settings.

The study examines the process of spread of improvements from the demonstration phase of the MNCH Facilities Collaborative in Balkh and Kunduz to three new provinces: Parwan, Herat, and Bamiyan.  In the demonstration phase, different change ideas are tested and an intervention package composing of these change ideas and interventions that yield high outcomes will be prepared and used for scale up to the three new provinces. The aim of the spread study is to evaluate the uptake and implementation of a package of changes—which originated in the demonstration phase—in Bamyan, Parwan and Herat.

• How sites in new provinces react to and take up improvements coming from the demonstration phase
• How the applicability and effectiveness of QI methodology in improving quality of health care differs in new settings

• Which ‘change ideas’ were adopted, modified or rejected by health facilities in the three new provinces
• How were the ‘change ideas’ communicated to the sites, and what were the reasons behind the uptake of each ‘change idea’?
• Were there specific reasons that facilitated or hindered the uptake of change ideas? What were they and what are QI participants perspectives on them?
• What were the most successful means of spreading of quality improvement changes?

 In November 2009, the HCI Project began a Demonstration Collaborative in the northern Afghan provinces of Kunduz and Balkh (K&B). The goal of the intervention is to improve birth outcomes by reducing maternal and infant mortality and morbidity. There is significant interest in understanding the cost implications and the cost effectiveness of this approach along the continuum of care – from community, to health center, to hospital. This study is an economic analysis of the intervention – using an improvement collaborative to improve the quality of care provided to clients and improve patient outcomes.

• household survey (in households in which a child was born in the previous two years) to collect data on knowledge and practices related to essential newborn and maternal care practices and demographic information.
• facility-based data collection on indicators such as tetanus injection coverage, the presence of birth preparation plans, application of AMTSL, post-partum counseling, mothers’ knowledge, compliance with ENC standards, availability of soap and water in delivery rooms, newborn mortality rate, stillbirth rate, maternal mortality rate and post-partum hemorrhage rate.

Data on programmatic costs will be collected, including those incurred by HCI (staff salaries, consultants, local transportation, apportioned office equipment, participant per diems, etc) and incremental clinical costs resulting from improved practice and paid by the MoPH (additional medicines such as oxytocin, additional sterile supplies and delivery kits and durable equipment such as a medication refrigerator). For cost variables that are difficult to obtain precisely, estimates based on direct observation or expert opinions may the only feasible way to provide this input.