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.

Throughout Africa, the human resources crisis in the public health system has become one of the biggest challenges in attaining the Millennium Development Goals (MDGs). In the face of difficult working environments and inadequate support, health workers are often unprepared and unable to meet the high demands placed on them; they lose motivation, become disengaged, or vacate their posts altogether.   This report describes pioneering work in Niger by the USAID Health Care Improvement Project (HCI) to apply quality improvement methods to strengthen human resources management and performance at the facility- and district-management level to improve maternal care in the Tahoua Region.   

Since May 2009, 15 health facility and 11 district management quality improvement (QI) teams have worked together with the support of the Ministry of Public Health (MOPH) in Niger and the USAID HCI Project. This work uses the QI Collaborative approach to develop, test, implement, and spread feasible strategies targeting specific human resources improvement objectives to improve maternal care services. As part of this strategic human resources management process to improve maternal care, teams aligned maternal health goals and objectives from the central to facility levels, and clarified and defined tasks and competencies for clinical staff in maternity units. Regional and district health teams continue to implement system changes while facility teams focus on improving performance and providing support to engage health workers.

Collaborative improvement is a QI strategy to improve the quality of care and facilitate the emergence of a culture of quality in a network of participating sites, by bringing together the energy and creativity of different sites to address key quality issues in an efficient and effective manner. Little research has been done to document the extent of institutionalization achieved at the end of formal collaborative improvement activities. This evaluation examines the extent of institutionalization of quality improvement after the end of technical assistance to an essential obstetric and newborn care (EONC) improvement collaborative in Niger. This quality improvement initiative was launched by USAID’s Quality Assurance Project in 2006 and aimed to improve the quality of maternal and newborn care services according to evidence-based standards. When external technical support for the learning sessions and coaching visits ended in December 2008, this afforded an opportunity to study whether the gains achieved during the program could be sustained.

The experiences of Niger and other countries in quality improvement over the years indicate that QI cannot simply “taught” in a generic workshop setting, nor can it flourish without technical support and the integration of QI initiatives into the micro and macro aspects of the health system. Sustaining gains in quality of care and institutionalizing QI into the fabric of health care requires simultaneous efforts at both the strategic policy level and in the priority activities of the system.
The experience of Niger offers some key lessons and some key insights into the institutionalization process. The 20 sites included in the study had benefitted significantly from the EONC improvement collaborative activities, which provided both clinical and QI skills, coaching support, and opportunities to share results and effective changes. These benefits are reflected in the consistently high levels of compliance with EONC standards (verified through external chart review and direct observation of care) at these 20 sites.
While this study did not have the power to test hypotheses, the study has shed some light on certain assumptions about collaborative improvement and its contribution to institutionalization. While the collaborative itself is not a permanent activity or structure to be institutionalized, participation in collaborative activities can facilitate institutionalization of gains and sustainability of results.

This is an evaluation of teamwork in the context of the Essential Obstetric and Newborn Care (EONC) Quality Improvement Collaborative in Niger. It focuses on what quality improvement performance looks like after the end of technical assistance for the quality improvement initiative. The quality improvement collaborative had been launched by USAID’s Quality Assurance Project in 2006 and aimed to improve the quality of maternal and newborn care services according to evidence-based standards. The external technical support for the learning sessions and coaching visits ended in December 2008, and this afforded an opportunity to study whether the gains achieved during the program could be sustained. This evaluation aims to understand the team dynamics (team stability and collaboration) that influence sustainability of quality improvement initiatives.   

This study presents results of a costing and cost-effectiveness analysis conducted retrospectively of the 2006-2008 Niger Essential Obstetric and Newborn Care (EONC) Collaborative, which was implemented in 33 facilities in Niger to improve maternal and newborn care oucomes by increasing compliance with evidence-based care standards. This study used outcomes data from routine program monitoring and costs from a number of sources including Health Care Improvement Project (HCI) accounting records and surveys of clinical managers. It compares the costs of attended vaginal delivery and immediate neonatal care in the six months before the QI collaborative started with the average of the last three months of the intervention. The four measures of effectiveness used were compliance with AMTSL, rates of post-partum hemorrhage, compliance with essential neonatal care and compliance with breastfeeding within the hour following delivery. Calculating the incremental cost-effectiveness using HCI and MOH costs including development and demonstration gave low, positive incremental cost-effectiveness ratios.

This study has been accepted for publication in the International Journal of Health Care Quality Assurance, and will be available when published.

In 2008, the USAID Health Care Improvement Project (HCI) took on the challenge of improving the learning system for health care improvement. This learning system includes the processes of harvesting, analyzing, and synthesizing knowledge about what teams do to improve health care and the process of sharing what they learn with other QI teams. Using experience to date and some innovations, HCI developed a set of four tools—collectively known as the “Standard Evaluation System” (SES) tools—for teams and their coaches to use to facilitate these knowledge management processes. The SES tools include a QI team-level Journal, a QI team-level Synthesis Form, and two databases for results indicator data—one for QI teams and the other for the collaborative level. These tools were created to help support the collaborative learning system by which teams examine which of their changes were most effective and sharing this learning with other teams in the collaborative. This report summarizes the results of testing these SES tools to strengthen documentation, analysis, and sharing of QI team efforts to improve care through testing of changes.

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.

Little research has been done to characterize or describe the level of institutionalization achieved at the end of formal collaborative improvement activities. Beginning in 2006, the Ministry of Health (MOH) of Niger, with support from the USAID Health Care Improvement Project (HCI) initiated efforts to reduce maternal and newborn mortality with an integrated package of evidence-based practices in essential obstetric and newborn care (EONC), introduced with a collaborative improvement strategy. These efforts led to significant gains in quality of services, and when external technical support for these activities ended in December 2008, it presented the opportunity to study whether the gains achieved during the program could be sustained.

The development and effectiveness of job aids to improve caretaker compliance with antibiotic regimens for the treatment of pneumonia in children and the development and effectiveness of a case management map in Uganda.
A presentation from the Job Aids Symposium.