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.

From March 23-24, 2011, the USAID Health Care Improvement Project (HCI) convened a two-day workshop in Nairobi, Kenya to orient AIDS Population and Health Integrated Assistance Plus (APHIA-Plus) implementing partners providing orphan and vulnerable children (OVC) services to Quality Improvement (QI) tools and how these tools can be implemented in their work to increase the impact of their efforts in improving children’s lives. The APHIA-Plus implementing partners also developed annual work plans that included QI techniques, receiving support and feedback from HCI and USAID personnel who were present. The report below summarizes the proceedings of this workshop.

Lessons Lessons learned from OVC programs have revealed the need to improve service quality 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 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, equity, reach, and scale and sustainability? In response to the observed need to improve the quality of services provided to orphans and vulnerable children, in 2007, PEPFAR, through the United States Agency for International Development (USAID), sought to create a regional initiative to support countries and implementing partners in improving the quality of OVC programming. With support from the USAID Health Care Improvement Project (HCI), a regional OVC quality improvement initiative was organized. The initiative, which has come to be known as Care that Counts, has engaged national stakeholders, program implementers, and donor agencies throughout sub-Saharan Africa in improving the quality of OVC programming. 

This short report describes the efforts of the Care that Counts Initiative to support to implementers at the country level to:
1) Build constituencies and commitment for quality in OVC programming,
2) Develop OVC service standards through consensus processes involving key stakeholders, including children and their families,
3) Undertake quality improvement activities at the point of service delivery with community-based volunteers and organizations, and
4) Gather evidence that standards and other quality improvement approaches have a measurable impact.

An evaluation of job aids to improve the diagnosis and treatment of malaria in Kenya and Malawi.
A presentation from the Job Aids Symposium.

Quality assessment is the measurement of the quality of healthcare services. A quality assessment measures the difference between expected and actual performance to identify opportunities for improvement. Performance standards can be established for most dimensions of quality, such as technical competence, effectiveness, efficiency, safety, and coverage. Where standards are established, a quality assessment measures the level of compliance with standards. For dimensions of quality where standards are more difficult to identify, such as continuity of care or accessibility, a quality assessment describes the current level of performance with the objective of improving it. A quality assessment frequently combines various data collection methods to overcome the intrinsic biases of each method alone. These methods include direct observation of patient-provider encounters, staff interview, patient focus group, record review, and facility inspection, among others. The assessment is often the initial step in a larger process, which may include providing feedback to health workers on performance, training and motivating staff to undertake quality improvements, and designing solutions to bridge the quality gap. This case study describes how five Integrated Management of Childhood Illness (IMOI) trainers and supervisors conducted an assessment of provider knowledge and skill, to carry out IMCI at 38 facilities in two districts in Kenya. (excerpt)

Private drug outlets have grown increasingly important as the main source of malaria treatment for residents of malaria endemic areas. Unfortunately, the quality of information and the quantity and quality of drugs provided is often deficient. The World Health Organization has included the private sector in its Roll Back Malaria strategy, but has noted that it is notoriously difficult to change private sector practices without burdening the governments of developing countries. In the Bungoma district of Kenya, the Quality Assurance Project (USA) teamed up with the Bungoma District Health Management Team and African Medical and Research Foundation to test an innovative, low-cost approach for improving the prescribing practices of private drug outlets. The intervention, called Vendor-to-Vendor Education, involved training and equipping wholesale counter attendants and mobile vendors with customized job aids for distribution to small rural and peri-urban retailers. The job aids consisted of: (a) a shopkeeper poster that described the new malaria guidelines, provided a treatment schedule, and gave advice on the appropriate actions to take in various scenarios; and (b) a client poster that depicted the five approved malaria drugs and advised clients to ask for them. The training of wholesalers began in April 2000. (author's)