The Uganda Ministry of Health (MoH) Quality Improvement Strategy Meeting was convened in Kampala, Uganda, on March 21–22, 2011. The meeting provided a forum for various departments within the MoH, selected partners, and international improvement experts to share experiences, clarify the role of Government partners, and discuss lessons learned from implementing health care quality improvement initiatives at national and local levels. The MoH Quality Assurance Department (QAD) together with the United States Agency for International Development Health Care Improvement Project (HCI) organized and supported this meeting. 

Dr. Henry Mwebesa, Commissioner of QAD, chaired the meeting. Dr. M. Rashad Massoud, Director of HCI and Senior Vice President of the Quality & Performance Institute, University Research Co., LLC, designed and facilitated for the meeting.

Throughout the two days, participants shared their experiences with quality improvement (QI) efforts across multiple levels of the health sector, identified challenges and interventions while implementing QI, and made recommendations for harmonizing and sustaining QI efforts in Uganda. Examples discussed were from Uganda, Afghanistan, Sweden, Niger, South Africa, Ethiopia, Russia, and Palestine. 

This report summarizes the key discussions during the meeting.

USAID has supported the introduction and implementation of Continuous Quality Improvement (CQI) activities in Nicaragua since the year 2000, first through the Quality Improvement Project (QAP) and most recently through the Health Care Improvement (HCI) Project. These quality improvement activities focused primarily on Ministry of Health (MINSA) facilities. However, private health care facilities were invited to participate. The Medical Association of the West (La Asociacion Medica de Occidente, S.A.) (AMOCSA) was one of these private health care facilities and has participated in CQI activities since 2004. AMOCSA, through this collaboration with QAP/HCI/USAID, participated in a series of improvement activities in order to improve the quality of services offered to clients with a specific focus on maternal and infant health, family planning, and prevention of infections. Assistance was provided for: standardization of the care process, monitoring the compliance with care standards using relevant indicators, guaranteeing the right to proper care for newborns including breast feeding, strengthening the team approach, and measuring the satisfaction of patients in the facilities. In 2007, through technical assistance from HCI/USAID, a Quality Management Program was developed for AMOCSA in order to ensure sustainability of continued quality improvement activities into the future.

This study is a qualitative cross sectional study where a sample of heath care professionals working in AMOCSA facilities in Chinandega are surveyed on their exposure to different aspects of continuous quality improvement (CQI). Most of the survey questions refer to CQI activities that are currently being implemented in AMOCSA, while some survey questions refer to activities that may have happened over a longer period of time. Responses from the study participants are used to measure the level of institutionalization achieved in AMOCSA facilities. A convenience sample of 27 study participants was selected. Each of the participants answered a self-administered questionnaire that included questions on the development process for CQI, the enabling environment for CQI, evidence of institutionalization of CQI and other external factors.

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.