At the request of the Office of the Global AIDS Coordinator (OGAC), the United States Agency for International Development (USAID) and the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (Global Fund), the USAID Health Care Improvement Project (HCI) developed an approach to yield meaningful information about the quality of HIV services for users at multiple levels of the health system. The approach proposes 16 quality criteria (QC) that were assessed through 25 existing indicators. The indicators were based on measures previously required or recommended by funders and other stakeholders, such as the Global Fund, PEPFAR, and the World Health Organization. This report presents the findings from a field test of the approach in five countries in three world regions: Africa, Eurasia, and Southeast Asia.

This short report describes assistance that the USAID Health Care Improvement Project (HCI) is providing to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and to the Office of the Global AIDS Coordinator (OGAC) to develop an approach that can be used to harmonize global reporting and improve the quality of HIV services and health outcomes. This study details HCI’s approach that employs 16 quality criteria for 5 HIV service delivery areas: testing and counseling, care and treatment, PMTCT, TB/HIV, and harm reduction. Field tests were conducted in five selected countries: 3 in Africa, 1 in Eurasia and 1 in Southeast Asia.  

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.

Arterial hypertension (AH) is a major cause of mortality in Tula Oblast, Russia, where 27 percent of the population is believed to have the condition but only 10 percent have been diagnosed. In addition to the human suffering and loss, the toll on the healthcare system was burdensome. A US-Russia team of oblast leaders, healthcare providers, and quality assurance experts examined the then-current system, proposed evidence-based changes that were introduced gradually and monitored for their effect, and revised the system so that AH could be identified early and people with AH could learn healthy behaviors. This report presents the guideline that serves as part of that system; results are included in the Report Improving the System of Hypertension Care in Tula Oblast.

The fall of the Soviet Union in 1991 signaled a turning point for the region. Scores of weapons factories closed, and the network of work site polyclinics or medsanchasti had to be integrated into the remaining system of clinics and hospitals. In addition, the entire healthcare and insurance system underwent massive restructuring. Since hypertension care had been largely the responsibility of these work site polyclinics, management of care for individuals with hypertension was disrupted during this period. Many patients simply continued to take previously prescribed medications; others were apparently untreated and even undiagnosed. The region began witnessing a marked increase in the prevalence of complications of uncontrolled hypertension, in the form of myocardial infarctions, strokes, hypertensive crises, and uncontrolled blood pressure. In fact, by 1998, the main cause of adult mortality in Tula was cardiovascular disease, primarily from complications of hypertension. This has been a countrywide pattern; unrecognized and untreated hypertension in Russia has been cited as a major contributor to cardiovascular disease. In turn, cardiovascular disease is estimated to be responsible for one-half of the excess mortality in the Russian Federation, where mortality rates have steadily increased since the 1960s, largely affecting adult males in their most productive years. (excerpt)