Between March 2007 and September 2008, the USAID-funded Calidad en Salud Project, implemented by University Research Co. LLC (URC) carried out an initiative to improve the quality of essential obstetric and newborn care services (Promoción y Cuidados Obstétricos Neonatales Essenciales, known by its Spanish acronym, ProCONE). Implementation began in 25 health centers in the San Marcos Health Area in the highlands of Western Guatemala, and in 2009 was expanded to an additional 79 health posts and 56 primary care units in San Marcos and in eight other health areas. USAID | Calidad en Salud supported these efforts until the project ended in September 2008, when support for ProCONE continued under the USAID Health Care Improvement Project (HCI), also implemented by URC. ProCONE emphasized compliance with norms for prenatal, postnatal, and neonatal care. In addition, counseling, and selected interventions for children under 24 months (growth monitoring, breastfeeding, complementary feeding, micronutrient supplementation, and vaccination) were monitored.

1. How did the health facilities included in the spread phase learn about change ideas and best practices?
2. How did the facilities select and adapt the best practices they implemented? Why were adaptations necessary?
3. What perceptions does facility staff have of these changes and of the process of spreading “best practices” tested by other health facilities?

This study has been submitted for publication in a peer-reviewed journal. The full text will be available when published.

This short report describes how the USAID Health Care Improvement (HCI) project provided training to physicians on cultural sensitivity in birthing services in Guatemala, which resulted in increased patient satisfaction. In 2009, HCI and the Guatemalan Ministry of Health began a process of continuous quality improvement of care in the Todos Santos Cuchumatán’s Permanent Health Care Center.

As a component of its work to address neonatal mortality, the USAID Health Care Improvement Project (HCI) is working with Ministries of Health to implement national Kangaroo Mother Care (KMC) programs in five Latin American countries: Guatemala, El Salvador, Honduras, Nicaragua and Ecuador. This short report describes the technical assistance that HCI is providing to support the implementation and scale-up of the KMC program throughout all phases.

The ProCONE Maternal and Neonatal Health Care Improvement Collaborative was developed by the Guatemalan Ministry of Public Health and Social Assistance (MSPAS) and focuses improving prenatal, delivery, postpartum, and neonatal care. From March 2007 to September 2008, ProCONE (Promoción y Cuidados Obstétricos Neonatales Esenciales) was implemented using a collaborative improvement approach in 22 health centers, 1 Centro de Atencion Inmediata Materno-Infantil (CAIMI), and 2 hospitals in the San Pedro District of San Marcos Department, in western Guatemala. After this successful demonstration phase, ProCONE best practices and quality improvement processes (documentation of changes implemented, monitoring of key quality of care indicators, and periodic sharing of QI team learning) were spread to 122 additional health facilities in seven high-priority regions of Guatemala, starting in January 2009. The success of this spread phase led to plans to spread these best practices and QI process to new regions of Guatemala and to lower levels of the health system (health posts) in active regions.

1. 1.      Have the ProCONE demonstration and initial spread phases maintained the quality of care (QOC) gains for clients over time (between the end of the active collaborative phase and 6 months after the end of the initial spread phase)?
2. 2.      To what extent are key QI activities still being implemented at the point of service delivery? What QI activities facilitated, impeded or altered the QOC gains? Is there a culture of quality at the site/facility that supports QI implementation and evolution? What activities after the collaborative phase facilitated, impeded or altered this culture over time?

1. 3.      To what extent are key maternal-neonatal QI activities being implemented at the supportive (district, health area, central) levels of the health system? What is the status of the 8 elements of institutionalization in relation to QI? For example, are policies created that encourage a culture of quality, leadership, basic values, allocation of resources, evaluation and strengthening of infrastructure, communications and information, recognition at the district, health area and central levels of the health system? Are regular support and QI coaching, essential inputs, accountability, recognition for QOC and for monitoring of indicators being provided? What factors do or do not facilitate providing this support? Has the QI process been applied to clinical domains and services (other than maternal-neonatal health care)? How and why, or why not?

Various complementary quantitative and qualitative methodologies will be used to evaluate the research questions using a controlled pre-post (quasi-experimental) design. The sample frame includes all of the ProCONE demonstration and initial spread phase facilities and facilities that were unexposed to the ProCONE interventions with similar socio-demographic characteristics for which health service statistics data are available for the same time period.

Conditional cash transfer (CCT) programs seek to improve health outcomes for the poor by providing incentives for specific target groups to seek care. However, if the quality of care provided at facilities where CCT program beneficiaries seeking services is poor, a CCT program may have limited impact overall. This study provides information to decision makers regarding the effectiveness and cost-effectiveness of combining a specific quality improvement intervention known as collaborative improvement with a CCT program in Guatemala. The CCT program, Mi Familia Progresa, or “My Family is Making Progress”, was launched in April 2008 to provide economic incentives to the poorest of the poor, especially those living in communities located in the highlands of Guatemala, to use preventive maternal and child health services.  

Because CCT is a demand-side program in which beneficiaries are required to use maternal and child preventive health services in order to obtain the cash benefit, the supply side must meet the increased demand for services for the program’s effects to be realized. Also beginning in 2008, the USAID Health Care Improvement Project (HCI) initiated with the Ministry of Health a maternal and newborn care improvement collaborative which has operated at facility and community levels to introduce changes to increase compliance with clinical norms and improve maternal and newborn outcomes. 

A quasi-experimental design was used to test the effect on compliance with clinical norms of implementing the quality improvement (QI) collaborative at centers covered by the CCT program. The analysis compared differences in compliance between 38 centers covered by both the QI collaborative and the CCT program and 12 centers covered only by the CCT program. Data were obtained through direct observations of provider-client interactions while providing prenatal care and child health services, using checklists completed by trained observers who were also health professionals. Multivariate linear regression was applied to test the statistical significance of differences in compliance between the two study groups while controlling for confounding factors, such as number and type health center staff and socio-economic status of the client population. The study found that for six out of 13 prenatal care process criteria, compliance was statistically significantly higher in CCT+collaborative sites compared to CCT-only sites. The percent of compliance with prenatal care norms was 10 percentage points higher in the CCT+collaborative group (94%) compared to CCT-only facilities (84%). Full compliance, defined as when all 10 technical criteria (excluding the three counseling criteria) were performed in a clinical visit, was 58% at CCT+collaborative sites and 0% of the CCT-only sites. 

Compliance with preventive child health care norms was also measured and compared between collaborative and non-collaborative health facilities. Collaborative sites showed statistically significantly higher levels of compliance with norms for child health consultations than the other non-collaborative sites within the CCT. Most non-collaborative facilities scored very low, demonstrating the need for major improvements in child health service quality in those sites. The proportion of cumulative compliance with child health criteria, based on nine criteria, was 36 percentage points higher in the CCT+collaborative group (86%) compared to CCT-only facilities (50%). Considering full compliance as performance of all eight technical criteria for a child health visit (excluding the counseling criterion), CCT+collaborative sites achieved 60% full compliance, compared to 12% in CCT-only sites.

The total cost of the QI collaborative from January 2009 to June 2010 was $293,385. The number of prenatal and child health visits provided in the sites during that period was over 375,000, giving a per-patient cost of the collaborative at $0.78. The highest cost item for the collaborative, at 29% of the total, was travel, including transportation and accommodation for the learning session participants and for the coaching visits to individual sites. For the total expenditure, there were 60,102 additional prenatal care consultations done to full compliance with clinical norms and 122,900 additional child health consultations done to full compliance. This is an additional cost per prenatal visit delivered in full compliance with norms of $1.25 and an additional cost of $1.78 per child health visit in full compliance with norms. These are conservative estimates given that the collaborative addressed neonatal and delivery visits as well as prenatal care and child health.

Given the modest cost and the high level of effectiveness in improving compliance with clinical norms for prenatal and child health services, the study concluded that expansion of the essential obstetric and newborn care improvement collaborative to other health facilities in areas where the CCT program is operating is a cost-effective strategy for improving maternal and child health in Guatemala.   

• 1) To assess performance of QI teams at several levels in the health system: national, health area, and  health facilities
• 2) To document the QI activities teams performed, including documenting best practices and changes, monitoring and analyzing data, and sharing successful experiences between teams in the collaborative
• 3) Provide information on results achieved by QI teams in the indicators reported during 17 consecutive months measured as absolute improvement in indicators, speed of the improvement and maintenance of the improvement over time.