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  • Community Health Worker Programs: A Review of Recent Literature | Community Resource

    This paper reviews recently published literature on community health worker programs, primarily focusing on maternal and newborn child health. Eighteen CHW programs and eleven relevant articles were included. It identifies key components of successful CHWs programs, reviews past successes and failures of CHW program implementation and summarizes important lessons learned.

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  • Malaria Rapid Testing by Community Health Workers is Effective and Safe for Targeting Malaria Treatment: Randomised Cross-Over Trial in Tanzania | Community Resource

    This study assessed the impacts of use of rapid malaria diagnostic tests (RDTs) by CHWs on the provision of artemisinin-based combination therapy (ACT) and health outcome in fever patients in Tanzania. The authors found that RDTs administered by CHWs may improve early and well-targeted ACT treatment in malaria patients at community level. However, the effect and impact of RDT, including cost effectiveness, will depend on the local context, including malaria endemicity and the appropriateness of the type of RDT being used.

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  • Strengthening Community Health Systems to Improve Health Care at the Community Level | Publications

    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.

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  • Implementing the HMC Resolution on Task Shifting- Focus on Injectables. Evidence Review and Development of Country Workplans | Community Resource

    The East, Central and Southern Africa Health Community (ECSA-HC) in collaboration with Family Health International (FHI), held a regional workshop on expanding community-based access to family planning- focus on injectable contraception.  

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  • Sequential Validity of Quality Improvement Team Self-assessments in Tanzania | Publications

     

    Emerging evidence indicates that collaborative improvement is a cost-effective way to improve health care quality in diverse cultures. Such improvement generally relies on data from quality improvement (QI) teams’ own assessment of their facility’s performance and results. The validity of self-assessment data is important to both the teams themselves and to the collaborative as a whole: These data provide QI teams with the information they need to identify quality problems and to learn whether their actions actually improved quality. 
    This report presents the results of an investigation of sequential validity of self-assessment by service providers in an improvement collaborative in the Mtwara Region of Tanzania. Study objectives were to determine the validity of self-assessments by the QI teams and whether validity improved during the first year of the collaborative.
    The study was carried out in nine health care facilities participating in an improvement collaborative in Mtwara Region of Tanzania, during its first 10 months of activity. The collaborative is addressing HIV/AIDS care, particularly as it relates to antiretroviral therapy (ART) and the prevention of mother-to-child transmission of HIV (PMTCT). 
    The research team defined eight activities in the self-assessment process that can influence the validity of the information that results: 1) writing the records, 2) storing and retrieving records, 3) selecting records from which to abstract data, 4) abstracting data from the selected records, 5) summarizing the abstractions, 6) the agreement of computer and written records, 7) the quality and use of computer records, and 8) communicating the summary data (results related to improving the quality of care) to other members of the QI team and the clinical staff. The team then developed and tested forms and procedures for measuring the validity of the information each activity produced.   
    The study found significant upward trends in measurement scores occurred for the tasks of writing the record, selecting the sample, the use of computer results, and communicating results. No significant change in validity occurred in storing and retrieving records, abstracting or summarizing selected records, or agreement of written records with computer records. However, some of these activities started high and remained high throughout the study: For retrieving records, validity was close to 100% in the first and last two measurements for most cases; for abstracting records, a small increase occurred in validity during the study for all three indicators but was significant for only one of them; and for summarizing abstracts, errors were zero or close to it throughout the study. Changes in validity were roughly the same for all three indicators.
    Over the course of the study, validity either improved or started and remained high for most self-assessment activities; none decreased. The communication activity, which differs from the others in that it does not contribute directly to the validity of the performance scores reported by the QI teams, had a very low end-of-study score across all sites, suggesting limited use of data for QI activities. With few exceptions, this study shows that self-assessment as part of Mtwara improvement collaborative provided valid data and improved as the collaborative matured. This finding—coupled with the result that some steps in the self-assessment process, such as storing and retrieving records and communicating results, are not always done well—suggests the need to address these activities early in a collaborative. The finding that the validity of abstracted data between QI teams and the gold standard set by the expert reviewers was not statistically different is especially encouraging.
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  • Spread of PMTCT and ART Better Care Practices through Collaborative Learning in Tanzania | Publications

    The Tanzania National AIDS Control Program (NACP) and PEPFAR initiated the Partnership for Quality Improvement (PQI) in 2007 to develop and promote a harmonized quality improvement (QI) plan for antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) services countrywide. The partnership included PEPFAR’s HIV/AIDS care and treatment implementing partners, with technical leadership from the USAID Health Care Improvement Project (HCI), implemented by University Research Co., LLC (URC), and PharmAccess International (PAI).

    The PQI introduced the “Improvement Collaborative” strategy to generate better care practices to improve care provided to those needing HIV and AIDS services and has developed improvement collaboratives in four regions. Collaborative improvement is built on multiple teams working on a common aim and sharing learning about what works to achieve results more rapidly.  This study evaluates peer-to-peer learning among health workers and the spread of better care practices within regions and across regions in the PQI ART/PMTCT collaboratives in Tanzania.
    This cross-sectional evaluation used quantitative and qualitative methods to measure use of mechanisms for exposure and sharing of change ideas, changes implemented, and factors that facilitated or hindered sharing and uptake of change ideas. Data were collected in three regions (Tanga, Morogoro, and Mtwara) in a total of 25 sites. URC/Tanzania staff collected data through interviews and focus group discussions with team members, Council Health Management Teams, Regional Health Management Teams, implementing partners, and the NACP during the period of February to May 2010.
    The evaluation found that across the three regions, the great majority of ideas were “borrowed” from other teams, indicating that ideas of other teams are the main sources of adopted changes. The most commonly used (and also the most favored methods) of presenting information about changes were oral presentations with visuals, written descriptions, provision of tool/materials, evidence on effectiveness and warnings to avoid failures. Simplicity of the change idea was most frequently listed as the most important factor to try an idea, while a perceived lack of necessity was the top reason not to try. External support was the most important factor favoring implementation, while lack of technical support was the top hindering factor.
    The results of the study indicate that shared learning and spread of better care practices or effective changes is taking place both within and across the three regional collaboratives studied. Teams desired relatively detailed information about “how to do” the changes they were exposed to. Results also show that not all changes were equally spreadable; spread depended on how straight-forward was their implementation and whether it required authority or resources beyond the purview of the facility. Additional mechanisms for sharing learning across regions are needed, as well as mechanisms within regions that build on existing structures and meeting opportunities.
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  • The Partnership for Quality Improvement to Improve PMTCT and ART Services in Tanzania: Assessment of Results, Capacity, and Potential for Institutionalization | Publications

    The USAID Health Care Improvement Project was asked by USAID in 2007 to assist the Tanzanian Ministry of Health and Social Work (MoHSW), regional and district level stakeholders, and implementing partners to set up a national Quality Improvement (QI) program for ART/PMTCT services in line with the Tanzania National Quality Improvement Framework. The QI program soon became known as the Partnership for Quality Improvement (PQI). The main aims of the PQI were to: 1) Build capacity for a harmonized QI approach among the many implementing partner organizations working this area, thereby accelerating the speed of and increasing the resource pool for QI in Tanzania; 2) Strengthen capacity for QI at national, regional, district and health facility levels (particularly in light of recent health care reforms to decentralize health services); and 3) Demonstrate the effectiveness of QI collaborative methods in improving patient outcomes in a limited number of regions (a prototype prior to spreading to additional regions). 

    HCI worked with the National AIDS Control Program (NACP) and the Dutch NGO PharmAccess to develop and implement the PQI. PQI was first launched in Tanga in May 2008 in partnership with AIDS Relief; the second region, Morogoro was included in February 2009, with Family Health International (FHI); and the third region, Mtwara, was added in June 2009 with The Clinton Health Access Initiative (CHAI) and Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). CHAI and EGPAF also committed their own funding and began to replicate PQI in late 2009 to the Lindi region.

    The evaluation study examined how well the PQI has worked in the three first regions (Tanga, Morogoro, and Mtwara) and identified how the approach could be further strengthened or modified for spread to other regions in Tanzania in the future.

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  • Improving Care for People with Chronic Conditions in East Africa | Publications

    Until recently, malaria and other acute infectious diseases were the leading causes of mortality and morbidity in East Africa, and the health systems in the region were generally designed to manage acute conditions. Now with the advent of the HIV pandemic and increasing prevalence of non-communicable diseases, health systems are struggling to manage people with chronic conditions. Helping health systems change from the acute care model to one which has structures and processes in place to help people living with chronic conditions manage their condition at home will require transformation at many levels.  HCI is working with the Ministries of Health in Uganda and Tanzania to make these changes.   This flyer describes current efforts supported by HCI to promote the use of the Chronic Care Model, an evidence-based set of principles for improving chronic condition care that has been endorsed by the World Health Organization.

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  • Baseline Assessment of HIV Service Provider Productivity and Efficiency in Tanzania | Publications

    Tanzania, like many other countries in Africa, is facing a severe shortage of qualified health professionals. Only 35% of positions in government health facilities have been filled, leaving Tanzania in the wake of burgeoning human resources for health crisis. According to the Annual Health Statistical Abstract from 2008, the national average of the population per medical officer was 64,000, 31,000 per assistant medical officer, and 7,000 per clinical officer. The shortage of health professionals has been exacerbated by the HIV/AIDS pandemic and other communicable diseases such as malaria and TB.

    In an effort to improve the quality of care of HIV services delivered in Tanzania, the USAID Health Care Improvement Project (HCI) and the Ministry of Health and Social Welfare (MOHSW) began implementing a partner improvement collaborative in the Mtwara region in nine care and treatment centers in June of 2009. The aim of the collaborative is to apply QI methods to ART and PMTCT services in order to ensure a high quality of care is being delivered to clients. The collaborative is now looking to integrate HR interventions into its work in order to improve efficiency of service delivery, and strengthen health worker performance and engagement. Health worker productivity and engagement are integral to improving efficiency as they determine what tasks health workers perform and how engaged and motivated they are to perform at a high level.
     
    In collaboration with the Government of Tanzania, HCI designed a baseline assessment of HIV/AIDS service providers to gather information on productivity and engagement. The information gathered from this baseline assessment will be used to develop a set of HR improvement packages based on best practices that will be integrated into the ongoing ART collaborative. The baseline was conducted in six sites in the region of Mtwara from June 30th- July 6th, 2010. 
     
    The assessment identified several areas where human resource management systems can be improved to strengthen provider efficiency and productivity and improve the quality of HIV/AIDS service delivery. All health workers should be provided with written job descriptions that clearly align their tasks and goals. Without written job descriptions, it is impossible to implement strong performance management. Recognition and reward systems can be improved to ensure that health workers get the acknowledgement and praise they deserve when they perform well. The process for performance evaluations needs to be communicated clearly with lower level facilities. Facility managers and providers should also learn how to set performance objectives.    Promotion and career advancement opportunities are somewhat rare, which may affect worker motivation. The majority of employees are moderately engaged, regardless of the type of facility or the position they hold, but specific areas of engagement, such as recognition and materials, could be improved. Productivity appears to vary throughout the day with providers being very productive in the morning when patients arrive and productivity levels decreasing dramatically in the afternoon when client loads are low. Client flow does not appear to be a problem, but is something that should continue to be monitored since client loads can vary dramatically by day.
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  • Health Workforce Competency and Facility Readiness for Safe Deliveries in Tanzania | Publications

    Tanzania, like many East, Central and Southern African Countries, is facing high maternal and newborn mortality and morbidity rates. The percentage of women delivering at health facility under care of a skilled attendant in Tanzania is estimated to be 46%.

    Recognizing the value of studies of the competency of healthcare providers and their working environment, the East, Central and Southern Africa Health Community (ECSA-HC) in collaboration with Ministry of Health and Social Welfare (MOHSW) Tanzania conducted this study aiming at determining the competency levels of health providers, and enabling factors provided by the facility and the health system.

    The study was conducted in 2008 in eight districts within four regions of Tanzania Mainland: Kisarawe and Bagamoyo (Coast Region), Singida Rural and Manyoni (Singida Region), Njombe and Mufindi (Iringa Region), and Muheza and Korogwe (Tanga Region). The assessment comprised of two parts to which each participant was subjected: (1) A knowledge test consisting of 50 multiple choice and true/false questions covering several topics mainly infection prevention, uncomplicated labor and delivery, prevention and management of hemorrhage, immediate care of the newborn including newborn resuscitation and prevention and management of sepsis. The test was scored using a predetermined answer key; (2) Assessment of five skill areas - (i) active management of the third stage of labor (AMTSL), (ii) manual removal of placenta, (iii) bimanual uterine compression (iv) immediate newborn care, and v) neonatal resuscitation by observing participant performance of each procedure on an anatomical model. Each participant was assessed in these five areas by trained observers. 

    The findings indicated that providers performed average in several areas (1) the average score for knowledge test was 56%, with the scores progressively improving with ranking of facility category from 50% for dispensaries to 58% for district hospitals and also with increasing qualifications from 45% among medical attendants to 62% among Medical Officers and AMOs. (2) The average score for skills of active management of the third stage of labor skill and manual removal of the placenta were 55.3% and 54.5% respectively. Bimanual uterine compression, immediate newborn care (36%) and neonatal resuscitation (25%) were generally poorly performed compared to the others. There were no statistically significant differences between different facility and cadre levels: Nonetheless, it was realized that providers appreciated feedback and performance was observed to improve immediately on some of infection prevention steps.

    Regarding facility readiness, some key medicines such as antibiotics and haematenics were available in most health facilities. However, lives saving medicines such as oxytocin and magnesium sulphate were not in stock in more than 60% of the facilities. Organization and sustainability of referral/counter-referral systems and use of maternal and neonatal health standards were also poor.

    It is concluded that gaps to provision of quality maternal and newborn services exist with regard to competency of health personnel, infrastructure and referral systems. There is also indication that minimal investment in training on specific approaches for prevention and management of life-threatening complications will significantly contribute to the reduction of maternal and neonatal mortality and morbidity. It is recommended that the MOHSW and stakeholders design and implement strategies to ensure sustained improvement of service providers’ capacity, the support systems at health facilities including infrastructure, supplies and equipment, as well as strengthening referral and counter-referral systems, to ensure safe deliveries in health facilities.

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  • Spread of PMTCT and ART Better Care Practices through collaborative learning in Tanzania | Publications

     

    This evaluation takes place in the context of the “Partnership for Quality Improvement” (PQI) initiative in Tanzania. The partnership was initiated in 2007 by the Tanzania National AIDS Control Program (NACP) and PEPFAR to improve the quality of ART/PMTCT services in Tanzania through the implementation of a harmonized approach to modern quality improvement.   At the time of this report, the Health Care Improvement Project (HCI) and PharmAccess International (PAI) are providing technical leadership to facilitate shared learning among ART/PMTCT collaboratives managed by implementing partners (FHI, CHAI. EGPAF, AIDS Relief etc.) and regional health management teams in Tanga, Morogoro, Mtwara and Lindi. 
     
    Within the partnership, learning developed within one partner’s collaborative should lead to rapid uptake of effective changes by other teams, leading to desired level of results for all teams. Sharing this learning should not be limited just within that region or that implementing partner, but spread to other regions supported by other partners as well. This ability to build on learning within regions, within partners, across regions and across partners is important for efficient achievement of better care and better outcomes for people affected by HIV and AIDS. 
     
    Research questions/objectives:
    This evaluation seeks to study the mechanisms and results of the spread of better care practices in the Partnership for Quality Improvement. Identifying facilitating and hindering factors for shared learning and spread will help determine how learning among peers and spread of better care practices can be strengthened within the PQI context. The specific objectives of this evaluation are:
     
    1.    To describe the various steps involved in the change process including the origin of ideas, their testing and implementation and their subsequent spread to other teams.
    2.    To determine the various internal and external factors influencing the change process and identify means to augment the effects of favorable factors and remove barriers.
    3.    To explore the role of the higher levels of the health system and collaboratives in catalyzing the spread of best practices and their scale up.
     
    The lessons learnt from this evaluation will provide guidance to quality improvement programs in other countries for strengthening learning among peers and improving spread within a collaborative approach or in other quality improvement efforts.
     
    Methodology:
    This is a cross-sectional evaluation which involves both quantitative and qualitative methods of data collection. All sites in the 3 regions (Tanga, Morogoro and Mtwara) whose collaboratives have been operative for more than 6 months were included in this evaluation (total of 29 facilities). Data was collected by interviewing the quality improvement focal person of facility teams and through focus group discussions with QI team members. 
     
    Results:
    Results of the evaluation showed that the improvement collaborative is indeed facilitating sharing of ideas. Across the three regions, the great majority of ideas are “borrowed “from other teams, managers and coaches; with Tanga and Morogoro borrowing almost 70% of ideas, while in Mtwara 40% of the ideas had been borrowed. This indicates that ideas gained from participating in the collaborative are the main sources of adopted changes. The HCI/Tanzania project team composed a list of 16 effective changes (as of January 2010. Of these 16 effective change ideas teams had tried an average 12.6 changes per facility. Four of these 16 changes were tried by all facilities: issuing a 2 month supply for clients living far away; reorganizing patient charts for easy retrieval, establishing a mother-child register to link children to their HIV+ mother; and issuing Co-trimoxazole in the Reproductive Health Clinics.
     
    Learning sessions and coaching were the primary mechanisms for being exposed to or sharing changes with other teams, but other meetings, site visits, and phone calls were also used. Teams desired detailed information about “how to carry out” the changes they are being exposed to. Not all changes were found to be equally spreadable – spread of ‘better care practices” depended upon how straight-forward their implementation is and whether teams possessed the authority or resources to implement the activity. Staff engagement and staff resistance were cited as important factors impacting the implementation of a change. Implementation also depended upon external technical support, facility leadership and capacity for change. At present, the sharing across collaboratives has been mainly dependent on the role of the HCI/PAI team to create the linkages across collaboratives and regions. Additional mechanisms for sharing learning across a network of regions are needed, as well as mechanisms for sharing learning within a region that build on existing structures and opportunities.

     

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  • Sustainabilitiy of the Effectiveness of a PMTCT Counselor Training Program during National Scale-up | Tanzania | Publications

    This study evaluated whether a PMTCT Infant Feeding Counseling Program that includes training of counselors, facility supervisors and facility staff, counselor job aids, and mother take-home brochures was fully implemented in program facilities and yields healthier, better nourished infants at 6 months of age than a PMTCT program without it, comparing program exposure, nutritional status and heath history of 190 infants at 6 months of age from 4 intervention facilities and 4 matched control sites. Home visits using in-depth, semi-structured interviews, weight measurement and direct observation were done with 190 mothers (and their children) who received PMTCT antenatal counseling at one of the 8 study facilities and who recently delivered. Program exposure was measured by the mother’s report of receiving a take-home brochure at the antenatal counseling session; health history in terms of infants’ infectious disease episodes from birth to six months, and nutritional status based on weight-for age at 6 months adjusted for birthweight.  Read more in the final report.

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  • Health Workforce Competency and Facility Readiness for Safe Deliveries | Tanzania | Publications

    The maternal mortality ratio in Tanzania is estimated to be 578/100,000.1  A great majority of these deaths are due to obstetric complications, 90% of which can be avoided. Some obstetric complications can be predicted and most are treatable if women receive high quality care when needed.2 Care provided by a competent Skilled Birth Attendant (SBA) during labor, delivery and in the immediate postpartum period is a key component of quality obstetric care. The percentage of deliveries assisted by a SBA has become a proxy indicator for reducing maternal mortality.3

    Despite the wide coverage of training service providers on Basic and Advanced Life Saving Skills in Tanzania since 2003, there is limited information on maternal and newborn care provider competency or the impact of these trainings. Therefore, the need to determine the competency levels of the service providers and functionality of the health systems was urgent. 
     
    Research questions/objectives
    The research objectives of this study were three-fold:
    1.To determine the current competency levels of the workforce attending to women and newborn during labor, delivery and the immediate postpartum period (first 24 hours)
    2. To determine the facility readiness for provision of care during labour, delivery and immediate postpartum period.
    3. To provide recommendations for quality improvement in the delivery facilities.
     
    Methodology
    The study was conducted in eight districts within four regions of Tanzania Mainland,  namely Kisarawe and Bagamoyo (Coast Region), Singida Rural and Manyoni (Singida Region), Njombe and Mufindi (Iringa Region), and Muheza and Korogwe (Tanga Region).  The assessment comprised two parts: (1) a knowledge test consisting of 50 multiple choice and true/false questions covering several topics inlcuding infection prevention, uncomplicated labor and delivery, prevention and management of hemorrhage, immediate care of the newborn including newborn resuscitation and prevention and management of sepsis. The test was scored using a predetermined answer key. And (2) assessment of five skill areas - (i) active management of the third stage of labor (AMTSL), (ii) manual removal of placenta, (iii) bimanual uterine compression (iv) immediate newborn care, and v) neonatal resuscitation by observing participant performance of each procedure on an anatomical model. A total of 194 service providers from these facilities participated. Each participant was assessed in these five areas by trained observers. 
     
    Health facilities were evaluated using a checklist for the existence of the essential and enabling factors. These included: human resource, medical waste management, availability of water and source of light, essential medicines, equipment and supplies, functionality of referral system, and availability and use of maternal and newborn guidelines standards.  
     
    Results/Findings
    The average score for the knowledge test was 56%, with the scores progressively improving with ranking of facility category from 50% for dispensaries to 58% for district hospitals and also with increasing qualifications from 45% among medical attendants to 62% among Medical Officers and AMOs. The average score for active management of the third stage of labor and manual removal of the placenta were 55.3% and 54.5% respectively. Bimanual uterine compression, immediate newborn care (36%) and neonatal resuscitation (25%) were generally poorly performed compared to the others. There were no statistically significant differences between different facility and cadre levels.
     
    Regarding facility readiness, some key medicines such as antibiotics and haematenics were available in most health facilities. However, live-saving medicines such as oxytocin and magnesium sulphate were not in stock in more than 60% of the facilities. Organization and sustainability of referral/counter-referral systems and use of maternal and neonatal health standards were also poor. 
     
    These findings indicate that gaps to provision of quality maternal and newborn services exist with regard to competency of health personnel, infrastructure and referral systems. There is also indication that minimal investment in training on specific approaches for prevention and management of life-threatening complications will significantly contribute to the reduction of maternal and neonatal mortality and morbidity. 
     
     
    1. World Health Organization 2006. Making a Difference in Countries: Strategic Approach
    to Improving Maternal and Newborn Survival and Health. Department of Making
    Pregnancy Safer. WHO: Geneva, Switzerland. 
    http://www.who.int/making_pregnancy_safer/documents/wa3102006ma/en/index.html
     
    2. World Health Organization, 2004. Maternal Mortality in 2000: Estimates developed by
    WHO, UNICEF and UNFPA). WHO: Geneva, Switzerland. 
     
    3. National Bureau of Statistics (NBS) [Tanzania] and ORC Macro. 2005. Tanzania
    Demographic and Health Survey, 2004-5. Dar es Salaam, Tanzania. National Bureau of
    Statistics and ORC Macro.
     

     

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  • Investigation of the Sequential Validity of QI Team Self-Assessments in a Health Facility HIV Improvement Collaborative in Tanzania | Publications

    This is a study of the validity of the QI Teams’ self-assessment of their own performance as part of the ART/PMTCT improvement  collaborative in Mtwara region, considering all the steps in the self-assessment process. Data collection began in August 2009 with baseline data collection by new QI teams as part of their QI work.  Four rounds of data collection evaluated improvements in: completeness of case recording, record storage and retrieval, sample selection for abstraction, abstraction, summary, and communication of findings. The study found that validity of self-assessment data generally improved over the life of the collaborative.

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  • Evaluation of the Scale-up of the PMTCT Infant Feeding Counseling Training Program in Tanzania | Publications

    From 2003-2006, University Research Co., LLC (URC), through the USAID-funded Quality Assurance Project, partnered with the Ministry of Health and Social Welfare (MOHSW), the Tanzania Nutrition and Food Center (TNFC), and the Kilimanjaro Christian Medical Center (KCMC) to develop an infant feeding counseling program based on the World Health Organization’s guidelines on infant feeding in the context of HIV. In 2007, the MOHSW and National AIDS Control Program (NACP) formally endorsed the infant feeding counseling materials and the training program in their use that had been developed and tested by URC. The infant feeding (IF) counseling training program was officially incorporated into the national program for the prevention of mother-to-child transmission of HIV (PMTCT). In addition, the MOHSW requested that URC, through the USAID Health Care Improvement Project (HCI), assist in planning and monitoring the scale-up of the infant feeding counseling training program.

    The scale-up of the PMTCT IF counseling program began in 2008 and is still ongoing. This evaluation focuses on the PMTCT IF counseling training program, which consists of a five-day training of regional trainers-of-trainers (TOT), a five-day training of PMTCT counselors, a one-day orientation of health facility staff, and a three-hour sensitization of the site director, senior managers and supervisors. Job aids developed by URC for the PMTCT counselors were also introduced during the training. These include: a question and answer guide, counseling cards, and brochures for mothers to take home with information on exclusive breastfeeding and infant feeding options, how to feed a baby after six months, and maternal health during pregnancy.
     
    This evaluation sought to determine the extent of training actually conducted in a sample of health facilities in one region (Iringa), the completeness of the training provided, whether any training had been conducted for new or replacement staff, and availability of the counseling job aids and mother take-home brochures developed for the program.
     

    Twenty facilities in Iringa Region of Tanzania were visited for this evaluation. Data collection occurred in two rounds with two different teams. Data were collected through a structured questionnaire. Informal interviews were also conducted with MOHSW district level staff as well as EngenderHealth staff.

    The evaluation found that only a small proportion of sites in the region (11%) had staff who had received training in infant feeding counseling. Of the 18 facilities studied, a total of 69 staff in 13 (72%) facilities had received the five-day counselor training. The majority of those trained as counselors were nurses (56%). Out of the 18 facilities that had staff trained in infant feeding counseling, 33% had a complete set of job aids, 61% had a partial set, and 6% had no job aids in their facility. Take-home brochures to be disseminated among pregnant women were currently completely out of stock in 75% of facilities. Almost all facilities reported that they did not have a procedure to order more materials.

    This evaluation found that training of infant feeding counselors is not keeping pace with the scale-up of the PMTCT program.   There is a great need to speed up the implementation of IF counselor training, especially among non-nurse cadres, such as doctors and clinicians. Clear guidance needs to be provided during training of counselors on how to order replenishment materials. Additionally, facilities need to be encouraged and assisted to put in place a system for the replenishment of materials.

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  • Synthesis of Findings and Learning from the Field Testing of Learning System Tools: The Standard Evaluation System (SES) Team Documentation Journal, Team Synthesis Form, and Excel Results Databases | Publications

    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.

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  • PEPFAR | Care that Counts: Improving the Quality of Programs for Orphans and Vulnerable Children | Publications

    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.

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  • Results of Collaborative Improvement: Effects on Health Outcomes and Compliance with Evidence-based Standards in 27 Applications in 12 Countries | Publications

    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.

    The study found that improvement collaboratives were able to achieve large increases in compliance with health care standards and in some cases, in health outcomes, across all care areas addressed, regardless of the baseline level of quality. Of the 135 analyzed time-series charts, 88% attained performance levels of at least 80%, and 76% reached at least 90%, even though more than half had baseline levels at 50% or below. The data provide compelling evidence that collaborative improvement can achieve large increases in performance, regardless of baseline level, and that results can be achieved relatively rapidly.  Across collaboratives, time series charts showed average increases of 52%.  Teams reached performance levels of 80% in about 13 months on average when baselines levels were below 50% and in about 6 months when baselines were above 50%. 

    The analysis also suggests that moving beyond 80% performance requires different efforts (system redesign) to make high quality the routine and that deliberate spread reduces time required to raise performance of new sites.

    The strength of a health system is measured in its ability to deliver good health outcomes. By achieving significant, sustained improvements in compliance with standards and outcomes, collaborative improvement is a viable tool for health systems strengthening in developing countries.
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  • Pact Tanzania tools for working with OVC volunteers | Publications

    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.

    Tools developed for use with volunteer OVC service providers are linked below. For more information on Pact’s work in Tanzania, visit www.pactworld.org.
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  • Counseling Cards | Publications

    Counseling Cards
    The counseling cards are intended for health workers to use during sessions with HIV-positive prenatal and postpartum women. Published in English and Swahili, the cards are tools that health workers can use to explain: the risk of transmission of HIV from mother to child when no preventive actions are taken; infant feeding options for HIV-positive mothers; the concept of acceptable, feasible, affordable, sustainable and safe (AFASS) replacement feeding; and how to safely practice their chosen infant feeding method.

    Risk of Passing HIV from Mother to Baby
    Using this counseling card as a guide, the health worker can show the client a graphic depiction of the risk of passing HIV from HIV-positive women to their babies when NO preventive actions are taken. The card shows that most babies are infected with HIV during pregnancy and birth (approximately 20%). It also depicts the rate of babies who become infected with HIV through breastfeeding (approximately 15%) The health worker can use the card to illustrate that the majority of babies (approximately 65%) are not infected with HIV, but should be protected through the use of ARVs and safer infant feeding.

    Infant Feeding Options
    This counseling card is intended to assist healthcare providers counsel women who have tested HIV-positive. It offers graphic depictions of three of the most common methods being actively promoted for feeding infants of HIV-positive women in Tanzania so that the healthcare worker can guide the mother in determining the safest option for feeding her baby.

    Infant Formula or Modified Cow's Milk as a Safe Option
    This counseling card is directed to women who have tested HIV-positive and who are exploring their infant feeding options.This graphic job aid enables counselors to discuss whether using infant formula or modified cow’s milk presents a safe and secure alternative to breastfeeding, following AFASS criteria.

    Risk of HIV passing from mother to baby if mother and baby take Nevirapine
    Using this counseling card as a guide, the health worker can show the client that the risk of mother passing HIV to baby decreases the mother practices exclusive breastfeeding and mother and baby take Nevirapine.

    How to Breastfeed
    This job aid is intended to assist the counselor to give clear instructions to pregnant women on how to breastfeed. Illustrated, step-by-step instructions are presented to promote good positioning of the baby to prevent breast problems which can increase the transition of HIV through breastfeeding.

    How to Hand Express Breast Milk
    This counseling card graphically depicts the steps for the mother to follow to hand express breast milk, an important skill for all mothers to have, no matter what their status. It encourages the use of a cup rather than a bottle for feeding the baby.

    Many Ways to Position and Attach Baby
    Using this counseling card as a guide, the healthcare worker can show the mother a range of ways to position and attach the baby.

    During the first 6 months, baby needs only breast milk
    This card illustrates that during the first six months, the baby should be given only breast milk.The mother should avoid giving water, glucose water, and all other foods and drinks.

    Danger Signs
    Danger signs indicating that the baby should be immediately taken to the nearest health facility are illustrated.

     

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