Due to an increase in the number of children affected by HIV and AIDS in Kenya, efforts to provide services for orphans and vulnerable children have expanded quickly in recent years. Lately, stakeholders have realized more attention should be given to outcomes and service quality. To address this, seven implementing organizations were identified to participate in the piloting of standards for services to vulnerable children in four districts. This study evaluates the effectiveness, efficiency and equity of implementation of standards of service to vulnerable children, which are of particular interest to USAID and the government of Kenya.

1. 1) Was there a difference in the welfare of children receiving services from participating community-based organizations as measured by the difference between baseline and end line CSI scores?
2. 2) What was the incremental cost to the implementing partners and USAID / HCI of implementing the new standards?
3. 3) What was the proportion of girls and boys enrolled in vulnerable children care in the participating sites?
4. 4) Were there differences in the effectiveness of the service delivery in improving child welfare between boys and girls and between younger and older children?
5. 5) As reported by coaches and QI team members, what were key activities, the progress seen, the challenges and the role of stakeholders in implementing the new standards of vulnerable children care?

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.

Lessons learned from programs serving orphans and vulnerable children (OVC) affected by HIV/AIDS have revealed the need to improve quality in OVC services and to strengthen harmonization across partners around the questions: How can our programs make a measurable difference in children’s well-being? What are the range of essential actions that we all agree need to be part of a service to best to mitigate the impact of HIV/AIDS on children and families, in the pursuit of efficiency, effectiveness and sustainability?

Several countries in sub-Saharan Africa have joined together in the quest for improving quality of services, through the USAID-funded Care that Counts Initiative, implemented by the USAID Health Care Improvement Project. These countries are engaged in applying the “science of improvement” to OVC services by 1) defining quality using service standards, 2) organizing for improvement at the point of service delivery; 3) and gathering evidence on the draft service standards that can be shared across countries. This case study highlights how Save the Children, as the leading organization of the USAID-funded Positive Change, Children, Communities and Care Program, together with local non-governmental organizations, and community-based organizations in Dire Dawa, Ethiopia, applied the science of improvement to pilot test the draft service standards.  The case study describes the design and organization of the pilot of draft service standards and the tools used to document and measure results from community level improvement activities. This case study has a “sister” case study developed by Save the Children that concretely details the actual results of implementing the standards, entitled "Communities in Action: Improving Quality in Service Delivery for Enhanced Wellbeing of Children in Ethiopia."

During the week of November 18-21, 2008, representatives from more than 16 countries came together to share experiences and enhance their understanding of Quality Improvement (QI) for programming and services targeting orphaned and vulnerable children (OVC). The African Regional Training and Exchange Event, “Care That Counts: Quality Improvement in OVC Programming” was held in Adama, Ethiopia. The team of 14 facilitators for the event included representatives from international organizations (INGOs), local non-governmental organizations (NGOs), and donors from the United States, Kenya, Tanzania, Zimbabwe, Namibia and Ethiopia. The training built upon concepts and priorities highlighted in the first meeting of OVC experts which was held in Tanzania in 2007.

The centerpiece of the training was a proposed “Roadmap for Quality Improvement for OVC Programs,” a conceptual framework to guide the process of developing and implementing OVC standards. Facilitators highlighted the fact that the Roadmap is a work in progress and that this training would provide important opportunities for feedback from participants in an effort to improve the Roadmap. The Roadmap highlights the overall partnership and work of key stakeholders, including government, INGOs, NGOs, beneficiaries, etc. It also highlights processes and activities at the organizational level, frequently referred to as the “point of service delivery.”  To achieve a measurable difference when working on behalf of orphans and vulnerable children there needs to be a comprehensive understanding of their needs and providing services which are effective, efficient and equitable.

The creation of service standards through consensus is a key element of the QI process. Stakeholders are involved in defining in operational terms what OVC services at the point of delivery should look like and what outcomes they should bring. The idea of “minimal essential actions” is a key component of a service standard; it is necessary to define what is “good enough.” Service standards are also developed incorporating evidence and best practice and consensus among stakeholders. Once service standards are developed they need to be communicated, piloted, evaluated, and improved.

Other materials presented at the training event addressing principles of quality improvement, dimension of quality, developing consensus-based standards, steps to vetting and gathering evidence to refine draft standards, steps in communicating standards, and a vignette about measuring quality improvement based on experiences in Ethiopia.

Link below to the final report about the Training and Exchange Event and to materials developed by the HCI Project for the event.

Pact Tanzania has implemented a comprehensive approach to improve quality of the service provision for OVC. Standards and related guidelines have been drafted and have been used by volunteers in five regions (Mbeya, Mtwara, Kagera, Tabora, and Mara) under the Jali Watoto programme. Pact Tanzania’s Jali Watoto programme is working with the USAID Health Care Improvement Project to implement learning groups in two districts: Nzega and Kyela.