Using Collaborative Improvement to Achieve Quality Care for Vulnerable Children in Ethiopia
Topics: Building QI capacity in OVC implementers, Coordination of OVC care, Developing OVC service standards, Orphans and vulnerable children, OVC services
Region and Country: Ethiopia
Ethiopia has been greatly impacted by the devastating effects of HIV and AIDS. Estimates indicate that Ethiopia has over five million orphans and vulnerable children (OVC), with nearly 900,000 of them directly affected by HIV and AIDS. While numerous organizations in Ethiopia provide services to these children, most have focused on increasing access to services to reach as many children as possible. A situational analysis in 2007 found that OVC service providers offered widely varying services, and there was little evidence to show that these services were making a measurable difference in the lives of those being served. While OVC service standards were drafted in 2006, it was not clear to what extent service providers throughout the country were aware of or applying the standards. The National OVC Task Force, led by the Ministry of Women’s Affairs and the HIV/AIDS Prevention and Control Office (HAPCO), decided that the standards should be field tested and data collected to answer four main questions:
1) Are the service standards understandable and “do-able” at the point of service delivery?
2) What are the best practices that facilitate the ability of implementing organizations to meet the service standards?
3) Do the service standards (when implemented) lead to measurable improvements in the quality of services and programming?
4) Do the service standards (when implemented) lead to measurable improvements in the lives of children?
Save the Children, which managed the largest OVC program in Ethiopia at the time and which had the capacity to gather the evidence and resources to integrate quality improvement activities into its ongoing project activities, was tasked with organizing the piloting of the OVC service standards. Through the PEPFAR | Care that Counts Initiative, the USAID Health Care Improvement Project was asked to work with Save the Children to design and evaluate the pilot. The improvement collaborative approach was selected as the way of organizing the piloting of standards because of the need to learn from service providers at the community level about how to best operationalize the standards. Save the Children worked with its local implementing partner, the Ethiopian NGO ProPride, to organize the pilot in the Dire Dawa region.
The intervention was to apply the draft Ethiopia National OVC Service Standards, which listed “Critical Minimum Activities”—actions which OVC stakeholders in Ethiopia had decided defined what would be considered “good enough” care for vulnerable children, or the minimum requirements necessary for providing a quality service—within the following six service areas: education, health and nutrition, economic strengthening, psychosocial care and support, legal protection, and coordinated care. Implementing partners also drafted guidelines on how best to meet these essential actions in the conditions in which most OVC programs were operating on the Ethiopian context (see Volunteer guide of actions during home visits below under “Related documents”).
The pilot began with a baseline survey of participating CBOs enabling them to assess their current level and quality of service delivery. The assessment surveyed 543 children and 89 caregivers. Gaps in the provision of services and barriers were identified using an assessment checklist administered by Save the Children and ProPride staff (see Ethiopia OVC Service Supervisory Checklist under “Related documents”). In addition, the Child Status Index was used to measure the well-being of a representative sample of children at the beginning and end of the pilot. These children were linked to the CBOs who participated in the improvement efforts.
While the work was only conducted in one region, it was intended that the findings of the pilot would inform the communication and promotion of the OVC standards nationally. Following a national workshop in April 2009 to review the results of the piloting, the Government of Ethiopia led a period of inter-ministerial review and revision of the draft standards. In February 2010, the Ministry of Women’s Affairs (MoWA) published and formally launched the “Standard Service Delivery Guidelines for Orphans and Vulnerable Children’s Care and Support Programs” with all stakeholders within the country, including UNICEF, UNAIDS, and other agencies supporting programs for children (see “Ethiopia OVC Quality Standards_Feb2010” below under “Related documents”. The MoWA has taken the lead and ownership for monitoring the implementation of the service standards by all OVC implementing partners.
Six community-based organizations (CBOs) working with ProPride in Dire Dawa were selected to pilot the OVC services: Goro Mahiberat Hibert, Genede Dippo Meredaja Iddir, Edeget Begara Mahiberat Hibert, Keyro Meredaja Iddir, Kebele 20 Meredaja Iddir, and Andinet Meredaja Iddir. Initially, it was envisioned that all CBOs would test ALL the draft service standards, but the CBOs preferred to pilot test only one service at a time. Each CBO felt more comfortable testing a standard for a service for which it felt it had expertise. This reality also demonstrated how much work needed to be done to build the capacity of local implementers to provide a coordinated care approach. Each CBO was assigned a different service component to the pilot standards, such that across the six CBOs, standards were piloted for seven service components (one CBO piloted both health and nutrition standards). The CBOs, which each worked with between 19 and 45 volunteers, each constituted one QI team. The six CBOs together provided services to over 3300 vulnerable children.
Coaches are essential in promoting QI and supporting teams engaged in improvement. It was agreed during the design of the pilot that there would be two sets of coaches. The first were external coaches based in Addis, who were technical specialists from Save the Children. These coaches were expert in the service itself (psychosocial support, food and nutrition, protection, health service, etc.). In addition, there were internal coaches: the OVC officers from ProPride who were expected to visit the local CBOs at least once a week. The coaches’ responsibilities included organizing meetings, facilitating discussions, identifying gaps, generating improvement objectives and indicators, and measuring how proposed changes made a difference in the delivery of services. The coaches continuously mentored the QI teams, holding meetings every two weeks.
It became clear over time that the internal coaches, the ones closest to the QI teams, were best placed to provide ongoing support. The international NGO coaches could not visit the teams as regularly as planned due to distances, limited resources, and, in some cases, limited understanding of the team’s processes. The local coaches were able to establish rapport with the teams as they lived in the same area, closer to the point of service delivery and the team processes. This facilitated greater understanding and more constructive engagement.
The six teams in the collaborative were comprised of CBO volunteers who provide home visits, CBO leadership, representatives of the children and their guardians, and village-level representatives of the MOH (i.e., the Kebele HIV/AIDS desk officer). At the first learning session in July 2008, representatives of all six teams met to share the results of their self-assessments, their own improvement objectives to improve quality of OVC services, and their proposed changes. At the second learning session (held in November 2008), representatives of QI teams met and shared actual changes tested to meet improvement objectives. At this session, teams were encouraged to start documenting rigorously the organizational changes that were needed to enable implementation of the standards and make suggestions to revise the standards to make them more feasible. Following the second learning session, teams did not meet as a group again, but staff of the six CBOs, ProPride, and Save the Children met to review results emerging from the teams. In February 2009, an endline assessment was carried out by Save the Children and ProPride staff.
While the quantitative evidence from this six-month pilot is limited, the results suggest that the standards have led to measurable improvements in children’s lives. For instance, the Education QI Team documented increased school attendance; fewer dropouts; and more links with tutorial and food support. Furthermore, the Health and Nutrition QI team reduced the period from requesting health care to receiving it from five to three days for all beneficiaries and OVC and their families; these beneficiaries are also now receiving a waiver from the Kebele to receive free health care services. The table below compares findings of the baseline and endline assessments.
Service Area - Indicator Measured (Baseline Assessment) (Endline Assessment)
Education - % of children enrolled in school (87%) (100%)
Education - % of children who dropped out (7%) (0%)
Education - % of children in need of tutorial support receiving it (30%) (42%)
Nutrition - % of children in need of food support receiving it (44%) (58%)
Health - % of children receiving medical treatment within 3 days (15%) (100%)
Protection - % of cases referred resolved in the court system (unknown) (77%)
Beyond these quantitative results, the pilot produced valuable learning about how to practically implement the OVC standards. Although coordinated care was originally seen as its own service component, the pilot revealed that this service should serve as an overarching guide for the delivery of all services.
The pilot indicated that the Coordinated Care QI Team actually delivered the best and most comprehensive range of services. This team made several changes to achieve its desired outcomes. For example, it emphasized regular assessments of a child’s status and referred each to other services based on need. In addition, volunteers were given clear job descriptions, and this team also recruited new volunteers to enhance the follow-up activities for each service component. In addition, the team emphasized not only assessing the children but the household situation, enabling more holistic care and support to families.
Volunteers visited OVC regularly and had the primary responsibility of coordinating their care. While a volunteer may be trained in one technical area, he or she should also have the skills to recognize the needs of the entire child and refer, if necessary, to additional services. For example, a health care-oriented CBO should learn during home visits if a client is skipping school and refer him or her to the education CBO.
At the pilot’s conclusion, noticeable changes were apparent in the teams’ ability to assess, refer, and follow-up on children receiving support. The CBOs’ introduction of the standards to the volunteers allowed them to better understand their roles and responsibilities and to change the way they perceived their role as service providers—from providing material support to providing an actual service (with its attendant needs assessment, referral, and follow-up) to the children. The CBOs formed critical linkages with other service providers within their community and with the local Kebele Government Administration, which aided in the facilitation of referrals for OVC. This process of engagement enhanced the volunteers’ ability to quickly and appropriately respond to the needs of the children and their households. Moreover, a regular and more thorough follow-up system was implemented by all of the CBOs. Volunteers are now responsible for conducting regular home visits to provide follow-up support to children and ensure children actually have received the services. More regular follow-up has led to quicker resolution of problems, especially in the cases of abuse and health care issues.
