Since 2009, the United States Agency for International Development (USAID) has supported the development and strengthening of Kangaroo Mother Care (KMC) activities in ten countries through the USAID Maternal and Child Health Integrated Program (MCHIP) and the USAID Health Care Improvement Project (HCI). In order to facilitate discussion and collaboration between country programs, MCHIP, with the support of USAID and HCI, hosted the first annual regional conference on KMC programs in Santo Domingo, Dominican Republic, in December 2011. Because of the diversity of experiences in developing and implementing KMC programs and similarity of contexts, a regional conference allowed countries to make important connections with other program implementers and exchange valuable information about strategies for success. This short report details the conference goals and objectives, and discusses country advances in KMC programs.

Volante sobre los avances del proyecto HCI en la aplicación del Método Madre Canguro en cinco países de América Latina.

In 2005, the Quality Assurance Project (QAP) pilot tested in one province of Ecuador a method for improving the cultural acceptability of obstetric care in public facilities—an important barrier to increasing skilled attendance in many countries. EOC providers, representatives of health facility users’ committees, traditional midwives, and local government officials were brought together in three one-day workshops to analyze the barriers to cultural acceptability of obstetric care and then propose and monitor changes to how care is provided at local health facilities. Following the workshops, facilities began introducing changes, such as delivery in a squatting position, allowing visits by family members, and allowing birthing women to use herbal teas.

This HCI research study sought to measure the impact of these changes.  The final study report in Spanish is linked below.

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.

This study describes and evaluates the strategies developed and implemented by the Ministry of Public Health in Ecuador to spread continuous quality improvement (CQI) and best care practices for essential obstetric and neonatal care (EONC) throughout the country. The first phase of this initiative began in 2003 with 14 health care facilities ranging from health centers to hospitals; new facilities were added over time. Drawing on these experiences, the Ministry of Health with technical support from HCI compiled and published conclusions on best care practices in 2007-2008 in preparation a spread phase to 51 facilities with no prior formal involvement beginning in 2009. The study compares the demonstration and spread phases; and presents data collected to monitor, evaluate and stimulate improvement. This study investigated three questions:

La Dirección Provincial de Salud de Tungurahua, Ecuador, con el apoyo de Family Care International (FCI) y el Proyecto de Garantía de la Calidad (QAP), ha desarrollado una experiencia piloto de humanización y adecuación cultural de los servicios de salud de atención del parto, como estrategia para reducir las barreras culturales que impiden el acceso a la atención calificada durante el parto. La iniciativa se encuadra dentro de la estrategia de reducción de la mortalidad y morbilidad maternal recomendada y promovida por el Grupo de Trabajo Interagencial Regional para la Reducción de la Mortalidad Materna en América Latina y el Caribe. Esta publicación pone a disposición de los trabajadores de salud la metodología aplicada en este proceso piloto, que aspira a humanizar el proceso del parto y nacimiento de manera de que responda a las expectativas de las mujeres; sobretodo, a las expectativas de aquellas mujeres que presentan complicaciones relacionadas con el embarazo y el parto.

This report presents the results from of the Quality Assurance Project’s three Safe Motherhood Studies: competence of skilled birth attendants, the enabling environment for skilled attendance at birth, and the causes of the "third delay"—the delay in receiving medical attention after a woman arrives at a healthcare facility. The studies included five hospitals: a tertiary care referral hospital in the capital, two secondary care provincial hospitals, and two small district hospitals.

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)

The Quality Assurance Project (QAP) investigated strategies for increasing efficiency in hospital laboratory services, an area of hospital operations that is frequently identified as high cost. The study developed measurement methodologies for seven separate sources of economic waste in hospital laboratories (unneeded tests, unclaimed tests, resource use inefficiency, staffing inefficiency, expired reagents, poor quality control, and inefficient procurement) and tested them in three public hospitals in Ecuador. The methodologies were intended to provide rapid assessments of the economic waste in each source and so relied on data from existing hospital records and relatively short turnaround surveys. Estimates of economic waste were made for each source by comparing actual measured costs to what the costs would have been if standards were met. The application found that the measurement methodologies were useable, in the sense that they could be applied and the requested data obtained. We found thateconomic waste from unneeded tests and staffing inefficiency may be very large. Findings on a sample of unneeded tests in six disease categories (acute diarrhea in children and adults, pneumonia in children and adults, appendicitis, cholecistitis) indicated that roughly half were unneeded and may represent economic waste. This result is based on clinical standards for lab tests developed through consensus by each hospital and may not apply to other disease categories. The economic waste of staffing inefficiency was estimated to range from 15% to 25% of the total laboratory budget across the three hospitals. However, these figures probably overstate the actual economic waste due to over-staffing because they do not account for staff time spent on indirect and other productive tasks. Economic waste from inefficient procurement of reagents and materials was estimated to be very high at one of the three hospitals due to lack of systematic competitive bidding. Additional refinement of the measurement methodologies is needed to obtain information that is valid and useful. This report identifies the areas that need to be strengthened in each methodology. Some examples: the need to develop clinical standards for lab tests was not originally envisioned, and the successful development of standards for six disease categories needs to be extended to other categories to ensure a representative selection that can be generalized to all test. Poor record keeping and erratic discard practices for unclaimed tests and expired reagents suggest that improved ongoing monitoring and reporting of these problems may be necessary to acquire valid data. Information on the cost of benefits and other payroll costs should be incorporated into the staffing inefficiency methodology, along with information on all productive tasks carried out by laboratory staff. These and other refinements would improve the validity of the methodologies. Finally the issue of double counting needs to be addressed as such information is incorporated into management decision making. (author's)