USAID HEALTH CARE IMPROVEMENT PROJECT TASK ......Bureau for Global Health, Office of Health, Infectious Diseases and Nutrition. USAID HEALTH CARE IMPROVEMENT PROJECT TASK ORDER 1 FY11

DECEMBER 8, 2011

This annual project report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID). The USAID Health Care Improvement Project is made possible by the American people through USAID’s Bureau for Global Health, Office of Health, Infectious Diseases and Nutrition.

USAID HEALTH CARE IMPROVEMENT PROJECT TASK ORDER 1FY11 ANNUAL PROJECT REPORT

Contract Number GHN-I-01-07-00003-00

Performance Period: October 1, 2010 – September 18, 2011

Front cover (from top):

Health worker attending the National Symposium on Antimicrobial Resistance in Jakarta, Indonesia explores the computer-based training program on tuberculosis diagnosis and treatment developed by HCI with the National TB Program. Photo by Nurfina Bachtiar, URC.

Data collection at the Europe & Eurasia Region site for the field test of a set of performance criteria to measure the quality of HIV services. During FY11, HCI completed the field testing of the proposed quality critieria and presented the findings to the Global Fund and Office of the Global AIDS Coordinator. Photo by Rhea Bright, URC.

In October 2010, HCI and our Russian partner, the Federal Research Institute for Health Care Organization and Information of the Ministry of Health and Social Development, launched the public portion of the www.healthquality.ru website to provide resources in Russian on improving the quality of health care. The site features a distance learning course on quality improvement methods, with a certificate issued by the Institute upon successful completion of the course.

Patient files grouped by appointment day—one change introduced by a team led by Mr. Stephen Okiror of Bukedea Health Center in Uganda that helped to greatly improve retention of HIV patients in care. Mr. Okiror’s story, “Improving Patients’ Retention in HIV Care Through Adherence to Scheduled Appointments at Bukedea Health Center IV, Eastern Uganda”, was judged as the “Best Improvement Report” submitted in a contest sponsored by the project to encourage submissions to the HCI Portal’s Improvement Database. Mr. Okiror’s story was presented in a poster at the 2011 Global Health Council annual conference in Washington, DC. Photo by Robert Kyeyagalire, URC.

USAID HEALTH CARE IMPROVEMENT PROJECT

Task Order 1

FY11 Annual Project Report Contract Number GHN-I-01-07-00003-00 Performance Period: October 1, 2010–September 18, 2011

December 8, 2011

DISCLAIMER

The views expressed in this document do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

USAID HCI TO1 FY11 Annual Project Report i

Table of Contents LIST OF TABLES AND FIGURES ..................................................................................................................................................... i ABBREVIATIONS ........................................................................................................................................................................... ii

EXECUTIVE SUMMARY................................................................................................................... iii

1 INTRODUCTION ........................................................................................................................ 1

2 COUNTRY TECHNICAL ASSISTANCE .................................................................................. 2

ASIA ...............................................................................................................................................................................................2 2.1 INDONESIA ......................................................................................................................................................................2 EUROPE AND EURASIA ................................................................................................................................................................3 2.2 RUSSIA .............................................................................................................................................................................3

3 USAID GLOBAL HEALTH ELEMENTS ................................................................................. 11

3.1 OGAC-GLOBAL FUND HIV QUALITY CRITERIA ................................................................................................... 11 3.2 CARE THAT COUNTS QUALITY IMPROVEMENT INITIATIVE FOR OVC PROGRAMS .......................................... 13

4 COMMON AGENDA ACTIVITIES ......................................................................................... 14

4.1 PROJECT MANAGEMENT ............................................................................................................................................ 14 4.2 KNOWLEDGE MANAGEMENT ................................................................................................................................... 15 4.3 TECHNICAL LEADERSHIP AND COMMUNICATION................................................................................................. 18

5 PERFORMANCE TRACKING PLAN ...................................................................................... 20

LIST OF TABLES AND FIGURES

Table 1. Contribution of HCI TO1 FY11 field activities to relevant Millennium Development Goals ......... 1 Table 2. HIV/AIDS service quality criteria field tested by HCI for the Global Fund in FY11 ......................... 6 Table 3. Fifteen HCI Task Order 1 knowledge management studies ................................................................. 15 Table 4. HCI TO1 journal articles and technical reports published in FY11 .................................................... 18 Table 5. HCI TO1 cumulative achievement of performance targets, FY08-FY11 ........................................... 20 Figure 1. Content of the Indonesia TB computer-based training program ......................................................... 2 Figure 2. Patient information card included with the TB training package .......................................................... 3 Figure 3. Russia: Early neonatal mortality rate in project regions and Russian Federation as a whole, 2005-2010 ...................................................................................................................................................................................... 6 Figure 4. Russia: Number of neonatal deaths from asphyxia and intrauterine hypoxia, Kostroma Oblast, 2005-2010 ............................................................................................................................................................................ 6 Figure 5. Russia: Percent of newborns experiencing intrauterine hypoxia or asphyxia, 2005-20100 ........... 7 Figure 6. Russia: Teen birth and abortion rate per 1000 girls age 15-17, Kostroma Oblast, 2007-2010 ... 8 Figure 7. Russia: Abortion rate among girls 15-17 years of age, 2007-2010 ....................................................... 8 Figure 8. Russia: Percent of babies breastfed by age, Sharya Hospital, Kostroma Oblast, 2008-2010 ......... 9 Figure 9. Russia: Percent of premature of births from 22-27 weeks gestation taking place at level 1 maternity hospitals .......................................................................................................................................................... 10 Figure 10. Russia: Monthly use of web portal www.healthquality.ru .................................................................. 10 Figure 11. Five steps in the OVC quality improvement process addressed by the OVC QI E-Learning Module 2 ............................................................................................................................................................................ 13

http://www.healthquality.ru/�

ii USAID HCI TO1 FY11 Annual Project Report

Abbreviations ART Antiretroviral therapy ARV Antiretroviral CBT Computer-based training CD4 Human T helper cells expressing CD4 antigen (T helper cell) CD-ROM Compact disk, read-only memory COTR Contracting Officer’s Technical Representative EONC Essential obstetric and newborn care FY Fiscal year HCI USAID Health Care Improvement Project HIV/AIDS Human immunodeficiency virus/acquired immunodeficiency syndrome IBI Indonesian Midwife Association IDI Indonesian Medical Association (Ikatan Dokter Indonesia) KM Knowledge management MCH Maternal and child health MDG Millennium Development Goal MNC Maternal newborn care NICRA Negotiated Indirect Cost Recovery Agreement NTP National Tuberculosis Program OGAC Office of the Global AIDS Coordinator (Department of State) OHA Office of HIV/AIDS (USAID) OVC Orphans and vulnerable children PEPFAR U.S. President’s Emergency Plan for AIDS Relief PMTCT Prevention of mother-to-child transmission of HIV PPNI Indonesian National Nurses Association QAP Quality Assurance Project QC Quality criteria QI Quality improvement QRM Quarterly Review Meeting RH Reproductive health STD Sexually transmitted diseases TB Tuberculosis TO1 Task Order 1 TO3 Task Order 3 UNAIDS Joint United Nations Program on AIDS UNGASS United Nations General Assembly Special Session URC University Research Co., LLC USAID United States Agency for International Development USG United States Government WHO World Health Organization

USAID HCI TO1 FY11 Annual Project Report iii

Executive Summary University Research Co., LLC (URC) and its subcontractor team completed the fourth and final year of implementation of the USAID Health Care Improvement (HCI) Project Task Order 1 on September 18, 2011. The original task order completion date of September 19, 2010 had been extended by 12 months at no cost by the USAID Contracting Officer.

The HCI Task Order 1 (TO1) contract is one of two global HCI Task Orders implemented by URC during FY11: HCI Task Order 3, the other global task order with identical objectives as HCI Task Order 1, ran concurrently with HCI TO1 throughout the year. Most of the activities and country-level technical assistance provided under the HCI Project in FY11 were carried out under HCI Task Order 3 (TO3).

As proposed in the FY11 Work Plan for HCI Task Order 1, only a few narrowly defined activities were implemented under TO1 in FY11. The major and most far-reaching activity was the completion of field testing of criteria to measure the quality of HIV and AIDS services, in partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Office of the Global AIDS Coordinator. During FY11, HCI completed the final field test in the Europe and Eurasia region, finalized all five country reports and a synthesis report summarizing the findings from all five field tests, and presented the findings at a Global Partner’s Meeting at the Global Fund in Geneva in June 2011.

The other activities implemented under HCI TO1 in FY11 included completion of a computer-based training package on tuberculosis diagnosis and treatment for physicians, nurses, and midwives in Indonesia and support during the first quarter of FY11 for the “Improving Care for Mothers and Babies” initiative in Russia. The first version of a two-module E-learning product on quality improvement in programs serving orphans and vulnerable children was also completed and submitted to USAID for review.

Fourteen studies to inform the design and improvement of the project’s knowledge management system were completed during the year and results reported to USAID. Finally, URC completed all TO1 technical reporting, including two technical reports, 18 research and evaluation reports, and one short report describing QI interventions and results implemented under Task Order 1.

Technical and administrative close-out of the TO1 contract was completed, as well as close-out of all TO1 subcontracts. HCI global task order activities will continue under Task Order 3 in FY12.

USAID HCI TO1 FY11 Annual Project Report 1

1 Introduction University Research Co., LLC (URC) completed the fourth and final year of implementation of the USAID Health Care Improvement Project Indefinite Quantity Contract (IQC) Task Order 1 (TO1) on September 18, 2011. This document summarizes the project’s activities and results under TO1 funding for the fourth year of project implementation, the period corresponding to October 1, 2010 through September 18, 2011 (FY11).

This report is organized in four sections: 1) reports on the two TO1 field-support country activities in Indonesia and Russia; 2) results from USAID core-funded activities for the OGAC-Global Fund HIV quality criteria field test and Care that Counts Initiative for quality improvement in programming for orphans and vulnerable children (OVC); 3) activities carried out under the project’s common agenda functions, including studies to enhance the project’s knowledge management system, completion of reports on TO1-supported research, and overall management of Task Order 1; and 4) the final Performance Tracking Plan for TO1, showing how all TO1 objectives and performance targets were met by the completion of the contract.

It should be noted that HCI Task Order 3 (TO3), the other global task order with identical objectives as HCI Task Order 1, ran concurrently with HCI TO1 during FY11 and that the vast majority of HCI field activities were implemented under TO3 during FY11.

The specific activities implemented by the project under TO1 funding in FY11 consisted of technical assistance in Russia to support maternal, newborn and reproductive health collaboratives in six regions of the Central Federal District during the first quarter of the fiscal year; the development and field testing of quality indicators for HIV/AIDS services on behalf of the Global Fund and Office of the Global AIDS Coordinators; short-term technical assistance in Indonesia to complete a computer-based training product on tuberculosis case management; and completion of studies to inform the design and operation of the project’s global knowledge management system.

Table 1 summarizes how our TO1 field activities in FY11 contributed to the attainment of the Millennium Development Goals.

Table 1. Contribution of HCI TO1 FY11 field activities to relevant Millennium Development Goals

MDG How HCI country activities contribute to MDG attainment MDG 4: Reduce Child Mortality

Russia: Reduce infant mortality by improving quality of obstetric and newborn care, especially care for preterm and low birthweight infants and neonates with respiratory difficulties

MDG 5: Improve Maternal Health

Russia: Reduce maternal morbidity and abortion rates through improved quality of obstetric care and expanded access to family planning counseling and modern contraceptive methods

MDG 6: Combat HIV/AIDS, Malaria and Other Diseases

Indonesia: Improve diagnosis, management, and referral of TB patients by developing computer-based training for physicians, nurses, and midwives

2 USAID HCI TO1 FY11 Annual Project Report

2 Country Technical Assistance Asia 2.1 Indonesia Overview of HCI’s Program in FY11 Main QI interventions/ activities

What are we trying to accomplish? Scale of intervention

Tuberculosis computer-based training

Develop updated tuberculosis (TB) CD-ROM and computer-based training (CBT) package in Bahasa Indonesia for medical practitioners in Indonesia, especially in the private sector

Support the Indonesian National Tuberculosis Program in disseminating the CD-ROM

Nationwide; CBT is aimed at the approximately 65,000 private sector doctors practicing in Indonesia

Main Activities and Results To support the National TB Program (NTP) in Indonesia in its efforts to train health practitioners, especially private providers, in FY09 the USAID Mission in Indonesia requested that HCI update and adapt for Indonesia a computer-based training (CBT) product that had previously been developed for Bolivia by the Quality Assurance Project. During FY10, the content for the training program was developed, based on the the NTP’s guidelines and the recently updated International Standards for Tuberculosis Care. In FY11, the content of the CD-ROM was finalized after approval by the NTP and other key stakeholders in Indonesia, including the Indonesian Medical Association (IDI), the Indonesian Midwife Association (IBI), and the Indonesian National Nurses Association (PPNI). The topics covered in the nine modules of the CBT program are listed in Figure 1.

To gain a better understanding of weak areas in current provider knowledge that should be reinforced through the training package, during FY11, HCI conducted focus group discussions with both physicians and nurses in Indonesia. The focus groups were particularly valuable for informing changes in the training content for TB service delivery by private midwives and nurses, who are important frontline providers in rural areas. Members of the Indonesia Midwife Association and Indonesian National Nurses Association helped HCI to expand the content of the training product to address the midwife’s role in TB services.

Working with a local media company (One Comm) in Jakarta, HCI developed the content and formatting of the CD-ROM and accompanying materials. The training package includes the following pieces, in the Bahasa Indonesia language:

• TB computer-based training CD-ROM covering nine modules for doctors and six modules for nurses and midwives

• Job aids such as the Fact Sheet for Health Professionals on TB and MDR TB: Infection and Transmission and an information card for patients, adapted from one developed in South African by the TASC II Tuberculosis Project

Figure 1. Content of the Indonesia TB computer-based training program

1. Introduction, history, and epidemiology of TB 2. Pathogenesis of TB infection and tuberculosis

disease 3. Diagnosis of TB infection and TB disease 4. Treatment of TB infection and TB disease 5. Treatment of TB in children 6. Adherence to TB treatment 7. TB and HIV infection 8. Multi-drug resistant TB diagnosis and

management 9. TB infection prevention and control


• A manual developed by IDI on tuberculosis case management using directly observed treatment

• A pocket guide on the International Standards for Tuberculosis Care

Two computer-based training packages were created, one for doctors and the other for nurses and midwives, following the structure of the training modules already in use by IDI and the NTP of Indonesia.

The physician version of the CD-ROM was completed in July 2011 and demonstrated and disseminated at the National Symposium of Indonesia Antimicrobial Resistance Watch, held in Jakarta in July 2011. The training package for nurses and midwives, including the job aids and patient information card, was completed in August 2011.

Directions for FY12 Copies of the CD-ROM were delivered to the National TB Program in Indonesia. The training modules will be uploaded to the IDI and PPNI websites, where members passing the course will receive accreditation. Other professional associations are also anticipated to have the training package available on their websites. The training is anticipated to reach approximately 65,000 public and private doctors and other health workers in country. Under separate funding, URC will explore opportunities to document the uptake of the CD-ROM. The English translation of the Indonesian TB CBT has been made available on the HCI Portal at: http://www.hciproject.org/idn_tb_course.

Europe and Eurasia 2.2 Russia Overview of HCI’s Program in FY11 HCI’s TO1-funded program in Russia in FY11 focused on sustaining gains in maternal and newborn care and reproductive health services achieved in FY10 in three oblasts of the Central District surrounding Moscow (Kostroma, Tambov and Yaroslavl) and spreading the best practices developed to two new oblasts: Tver and Ivanovo. (A third oblast, Tula, was added to the program after completion of TO1.) In Russia, HCI is implementing the initiative “Improving Care for Mothers and Babies” in collaboration with the Ministry of Health and Social Development’s Central Scientific Research Institute for Health Care Organization and Information (formerly known as the Federal Public Health Institute), the Kulakov Scientific Research Center for Obstetrics, Gynecology and Perinatology, and the Ivanovo Scientific Research Institute for Motherhood and Childhood. As requested by USAID/Moscow, a number of project activities were designed to support priorities of the US-Russia Bilateral Presidential Commission’s Working Group on Health related to maternal and child health.

The improvement effort encompasses six distinct regional improvement collaboratives, each with participation of facility-based teams from all three oblasts:1) prevention of newborn hypothermia and respiratory disorders, 2) optimizing labor management using the partograph, 3) prevention of unwanted pregnancies and sexually transmitted diseases (STDs) among teenagers, 4) breastfeeding promotion, 5) primary neonatal resuscitation, and 6) regionalization of perinatal care. The last collaborative was newly started in FY11.

Figure 2. Patient information card included with the TB training package

http://www.hciproject.org/idn_tb_course�


Activities What are we trying to accomplish? Scale of intervention Manage the Regional Project on “Improving Care for Mothers and Babies”

Train providers of maternal and infant care and reproductive health care and leadership at the oblast level in basic quality improvement methods and move them toward completion of graduate-level courses in quality improvement

Complete adaptation of our Russian “Communicator” web portal, to the real-time reporting, collection and monitoring of data on reproductive health and maternal and child health care processes and outcomes, and to provide a public, Russian-language library of key materials for quality improvement in these areas

Test methods of institutionalizing quality improvement methodology within Russian institutes, regions and health care facilities

Direct, onsite assistance to six regions (Kostroma, Tambov, Tver, Ivanovo, Ryazan and Tula) out of 84 Regions in Russia, with a total population of women of reproductive age of 1.8 million, including approximately 1 million women in service areas of facilities where we will provide intensive assistance. Facilitate virtual technical support through the internet and telemedicine conferences, to facilities and regions expressing interest in the project, including Yaroslavl oblast, where we worked in FY09 and FY10.

Prevention of hypothermia and respiratory disorders among newborns spread collaborative

Decrease hypothermia among newborns Measurably improve care for prevention of

hypothermia among newborns

17 individual facilities in Kostroma, Tambov, Yaroslavl and Ivanovo oblasts

Optimizing labor management spread collaborative

Increase use of the WHO partograph to manage birth

Decrease incidence of neonatal hypoxia/asphyxia

All Kostroma oblast 14 individual facilities from Kostroma, Yaroslavl, Tambov and Ivanovo oblasts (including 2 new facilities from Ivanovo)

Spread collaborative to prevent unwanted pregnancies, abortion and sexually transmitted diseases among teenagers

Decrease unwanted pregnancies, abortions and births among teens

Increase STD screening among teens Increase pre- and post-abortion counseling

Entire Kostroma oblast 6 facilities in Kostroma, Tambov and Ivanovo oblasts

Breastfeeding spread collaborative

Increase exclusive breastfeeding at discharge from the maternity ward and 3 and 6 months of age

Tambov, Tver, Ivanovo (9 facilities)

Improvement of primary neonatal resuscitation spread collaborative

Support implementation of new national protocol for primary neonatal resuscitation

Develop regional training programs on primary neonatal resuscitation

Entire oblasts of Ivanovo, Tver, Tambov, Kostroma and Yaroslavl; 18 pilot facilities from these oblasts

Demonstration collaborative on regionalization of perinatal care

Support the effective organization of perinatal care on a regional level

Improve management and prevention of preterm birth

Develop definitions of indicators of quality regionalized perinatal care

Entire oblasts of Tver, Kostroma and Tambov; 15 facility improvement teams

Main Activities and Results Learning session five of the original five collaboratives was held in October 2010 to formally present the results of the first phase of “Improving Care for Mothers and Babies”: the phase 1 improvement collaboratives in Tambov, Kostroma and Yaroslavl oblasts, and to formally initiate the second phase of the project. It was explained that the second phase included spread of four improvement objectives


(prevention of hypothermia, expansion of breastfeeding, use of the partograph and teen reproductive health) to new oblasts in the central region, including use of experienced health facilities as partners and mentors for new facilities. Draft written change package toolkits in these areas were distributed to assist in implementation. The second phase would also include continuation and expansion of work on primary neonatal resuscitation and regionalization of care, on which new Russian federal regulations had just been issued and which had therefore not yet shown results. The learning session had 92 participants from eight central Russian oblasts and two maternal and child health institutes. Participants from Ivanovo, Ryazan and Tula oblasts stated their enthusiasm for starting work under the project. The representative attending from Vladimir oblast stated that she was disseminating the change packages for independent implementation in her region. Six Yaroslavl region facilities sent representatives to the learning session and expressed interest in continuing collaboration with the project on a long-distance basis.

In November and December, 2010, orientation and training sessions were begun for regional and facility improvement teams in Ivanovo and Tver oblasts. Tver Oblast expressed a firm intent of working on improvements in regionalization of perinatal care and primary neonatal resuscitation region-wide, on the basis of its newly opened oblast perinatal center. Six pilot health facilities, including the perinatal center, were selected to participate inthese two collaboratives. Tver State Medical Academy, a long-time partner of HCI and its predecessor, the Quality Assurance Project (QAP), joined the oblast improvement team and agreed to assist in supporting improvement activities. Ivanovo oblast also selected six facilities to participate in various spread collaborative. Three facilities agreed to implement hypothermia prevention, one to pursue breastfeeding expansion, two to implement the partograph and two to implement teen reproductive health. The oblast as a whole agreed to develop a regional training program in primary neonatal resuscitation. The Ivanovo Institute for Motherhood and Childhood and the Ivanovo State Medical Academy agreed to participate in the oblast improvement team and to provide expertise. Workplans were developed to spread success in Kostroma and Tambov oblasts oblast wide and to continue intensive work on regionalization of care.

In a significant step toward institutionalization of quality improvement methodology, “Improving Care for Mothers and Babies” conducted a three-day quality improvement training session for 21 participants from the Kulakov Center, with the strong support of the Center’s chief doctor. Two potential QI projects were developed, including one on improving patient satisfaction through expanding maternity visiting hours.

Collaborative on prevention of hypothermia and respiratory disorders among newborns

According to preliminary official data, only 19 infants died during the first week of life among 7,917 live births in Kostroma Oblast in 2010. The resulting early neonatal mortality rate of 2.4 per 1000 live births represented more than a 60% reduction from the level of 6.2 per 1000 in 2008, a level that had led to this region being targeted for improvement by both the project and the Ministry of Health and Social Development (see Figure 3). These results can be attributed in part to training and improvements in care practices and protocols achieved in the collaborative on hypothermia prevention (which has been shown to reduce neonatal mortality); the collaborative on regionalization of care, which included transport of high-risk mothers (preterm births in utero) and extremely low birth weight neonates to the Ivanovo Institute’s perinatal center; the collaborative on use of the partograph, which helped to prevented asphyxia and hypoxia during labor by timely identification of fetal distress; and the collaborative on primary neonatal resuscitation, which prevented death from asphyxia and hypoxia.

Figure 4 demonstrates the impact of the latter two factors. The number of neonatal deaths from asphyxia and hypoxia fell from 19 in 2008 to 7 in 2010. Also critical in reducing neonatal mortality was the Russian Government’s health care modernization program, under which Kostroma Oblast purchased 150 separate items of equipment for neonatal resuscitation, as well as two specially equipped ambulances, in 2010.


As Figure 3 also shows, results were not as dramatic in the project’s two other intervention regions. After an upward blip in 2009, Tambov Oblast returned to its role leading Russian regions in terms of low early neonatal mortality. Although it is impossible to know to what degree project interventions, such as prevention of hypothermia and oblast-wide training on primary neonatal resuscitation, contributed to these results, they were clearly supportive of larger efforts. In Yaroslavl Oblast, early

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sFigure 3. Russia: Early neonatal mortality rate in project regions and Russian Federation as a whole, 2005-2010

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Figure 4. Russia: Number of neonatal deaths from asphyxia and intrauterine hypoxia, Kostroma Oblast, 2005 - 2010


neonatal mortality rates rose for the second year in a row, despite strong regionalization and referral of high-risk mothers to tertiary level care. These problems may be related to disorganization of care at the tertiary level due to delays in opening the new oblast perinatal center.

Collaborative on optimizing labor management through the use of the partograph

In the first quarter of FY11, this collaborative expanded to include all facilities in Kostroma Oblast and two new facilities in Ivanovo Oblast. With technical support from the project, Kostroma Oblast issued an executive order directing expansion of use of the partograph oblast-wide. Figure 5 shows that rates of intrauterine hypoxia and asphyxia decreased dramatically in the project regions of Tambov and Kostroma oblasts during 2010, compared to all regions of the Central Federal District of Russia. Hypoxia and asphyxia were stable in Yaroslavl Oblast, where they were already extremely low.

Collaborative on prevention of unwanted pregnancies, abortion, and sexually transmitted diseases among teenagers

Six facilities were officially participating in this collaborative as of the end of TO1. In addition, the Kostroma Center for Family Planning and Reproduction continued to work to spread this collaborative improvement activity oblast-wide, conducting several education and training sessions for the public and health professionals. A significant development during the first quarter of FY10 was the incorporation of representatives of the local Russian Orthodox Church into the improvement team in Sharya Hospital in Kostroma Oblast. The Church is actively involved in anti-abortion activities, including voluntary “spiritual” pre-abortion counseling, at the hospital’s women’s consultation. In return for being allowed to provide voluntary counseling at the clinic, the Church agreed not to interfere with the provision of contraceptives or provider-patient counseling.

Figure 6 shows the results of region-wide spread in government facilities in Kostroma Oblast. The rate of both births and abortions has continued to fall, indicating that prevention is occurring at the level of pregnancy prevention, rather than pregnancy preservation. Figure 7 shows abortion reduction in all three phase 1 project regions. While the government anti-abortion campaign is showing results all over

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Figure 5. Russia: Percent of newborns experiencing intrauterine hypoxia or asphyxia, 2005 - 2010

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Russia, with a 33% national reduction in the teen abortion rate, the results are more dramatic in the project regions, with a 50% reduction.

Breastfeeding collaborative With support of the project to improve their adherence to the UNICEF Baby-Friendly Hospital standards, Tambov Oblast Children’s Hospital and Torzhok Central District Hospital, Tver Oblast, were

2007 2008 2009 2010Number of births 128 148 124 96Number of abortions 202 273 139 90Number of girls age 15-17 14448 12730 11171 10201Number of births per 1000 girls 8.9 11.6 11.1 9.4Number of abortions per 1000 girls 14.0 21.4 12.4 8.8

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Figure 6. Russia: Teen birth and abortion rateper 1000 girls age 15-17, Kostroma Oblast, 2007-2010

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Figure 7. Russia: Abortion rate among girls 15-17 years of age, 2007-2010

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awarded the status of “Baby-Friendly Hospitals” during the first quarter of FY11. Tambov Oblast Children’s Hospital is one of the first Russian hospitals providing only intensive and second-level care for sick infants to be awarded this status. It agreed to take a leadership role in spreading these practices oblast-wide and to other children’s hospitals in project regions. With the addition of Ivanovo City Maternity Hospital #4, the collaborative expanded to nine participating facilities in three regions. Figure 8 shows annual improvements in breastfeeding at the level of the children’s polyclinic at one participating facility, Sharya Hospital.

Collaborative on regionalization of perinatal care Primary neonatal resuscitation and regionalization of perinatal care required oblast-wide efforts, with participation from both pilot health facilities and the oblast health department. Oblast-level clinical trainings on primary neonatal resuscitation took place during the first quarter of FY11 in Tambov and Yaroslavl. The Yaroslavl Medical Academy reported having trained 50 health facility staff from November 2009-December 2010. The training center at Tambov Oblast Children’s Hospital reported having trained 137, or 33% of the required delivery room and emergency personnel in the region during 2010. Trainees included 54 physicians and 83 nurses. Improvements in test scores were significant. The collaborative on regionalization of perinatal care, launched in the first quarter of FY11, involved the oblast-level perinatal care authorities in Kostroma, Tambov and Tver oblasts and 15 pilot facilities in the three regions. HCI supported the piloting of a computerized perinatal information system in Kostroma oblast to support monitoring and regionalization of care during pregnancy and perinatal care, on the basis of software developed by the Ivanovo Institute. On the basis of data entered at the woman’s first four antenatal care visits, the computer system develops a care plan for the woman, recommending referral for consultation and delivery at the level 2 hospital (Kostroma Oblast Hospital) or the level 3 hospital (the Ivanovo Institute) based on the level of risk. Project partners agreed that the indicator of success of regionalization would be to reduce to near zero the percent of women in early preterm labor (22-33 weeks gestation) delivered at maternity facilities designated as level 1, with the goal of reducing these figures to near zero. Figure 9 shows the percent of women with very early preterm labor (22-27 weeks) for 2010 for the three oblasts, plus comparison data for 2009 for Tver. These data show that project oblasts achieved some improvement in 2010 after the publication of the federal regulation requiring regionalization, but there is still a great deal of room for further improvement.

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Figure 8. Russia: Percent of babies breastfed by age, Sharya Hospital, Kostroma Oblast, 2008-2010

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Development of the Russian Web Portal on MCH and QI

At the very end of FY10, the project launched a public side to its web portal, www.healthquality.ru. The first quarter of FY11 was its first operating quarter. The public site of the portal is intended to provide access to information on both the methodology of quality improvement and on clinical topics to which improvement methodology has been applied in Russia. The portal operates under the slogan “Improving Care—Assuring Health. Accessibility, Safety, Effectiveness, Efficiency” and is the official site of the Federal Methodological Center for Quality Assurance in Healthcare, part of the project partner Federal Research Institute for Health Care Organization and Information. The public portion of the site includes an expanded library of Russian-language reference materials related to improvement methodology and clinical topics, including, but not limited, to those produced by HCI and its predecessor, QAP. In November 2010, access was provided through the portal to a video and text distance learning course on QI methods and to a news feed, which can be subscribed to through a listserv. While the content of the site is in Russian, a toggle switch displays section headings in English, to facilitate navigation of the site by non-Russian speakers. Figure 10 shows usage figures for the public portion of the site during the period of TO1 funding.

26%

19%

8%10%

0%

5%

10%

15%

20%

25%

30%

Tver 2009 Tver 2010 Tambov 2010 Kostroma 2010*

Figure 9. Russia: Percent of premature of births from 22-27 weeks gestation taking place at level 1 maternity hospitals

*Does not include transfers to Ivanovo Institute

320

995795

568

13811493

600

1675

2257

0

500

1000

1500

2000

2500

Unique visitors Visits Document downloads

Figure 10. Russia: Monthly use of web portal www.healthquality.ru

Oct 2010Nov 2010Dec 2010



Directions for FY12 Implementation of the six maternal and child health collaboratives in Russia continued with HCI support under Task Order 3 for the rest of FY11, and the collaboratives will be completed in the first quarter of FY12. A final conference on the results was convened in Moscow in November 2011.

3 USAID Global Health Elements 3.1 OGAC-Global Fund HIV Quality Criteria Overview of HCI’s Program in FY11 QI interventions and other activities

What are we trying to accomplish? Scale of intervention

Field tested a set of quality criteria using existing indicators (i.e., UNGASS, PEPFAR, Global Fund, etc.) to assess the feasibility and relevance of countries using the quality criteria to monitor and improve HIV/AIDS services at multiple levels of the health system.

Develop a set of globally agreed upon quality criteria with corresponding indicators to monitor and improve HIV/AIDS services.

Field test the proposed quality criteria and measurement mechanisms to assess their feasibility and relevance and their relationship to existing in-country indicators in five countries with varying HIV epidemics

Determine whether the quality criteria approach yields meaningful information that can be used to improve HIV services and strengthen country capacity at the national, regional, and facility levels to measure the quality of services.

Share and disseminate field test results with key partners and the global community

Five countries representing different types of HIV epidemics: three in Africa (East Africa, West Africa, and Southern Africa) one country each in Eurasia and Southeast Asia.

Main Activities and Results In FY11, HCI continued collaboration with the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Office of the Global AIDS Coordinator (OGAC) to develop an approach that would yield information that could be used to improve HIV services and strengthen country capacity at the national, regional, and facility levels to measure the quality of those services. During FY10, the Global Fund, OGAC, and technical partner organizations, such as the Joint United Nations Programme on HIV and AIDS (UNAIDS) and the World Health Organization (WHO), participated with HCI in defining 16 quality criteria and in identifying existing mechanisms to measure those criteria. The quality criteria, listed in Table 2, relate to five HIV service delivery areas: HIV testing and counseling, HIV care and treatment, prevention of mother-to-child transmission (PMTCT), tuberculosis/HIV, and harm reduction (needle and syringe and opioid substitution programs).

The quality criteria were designed to be general enough to allow country programs flexibility in evaluating the quality of program performance for reporting and improvement purposes at national, regional, and facility levels without restricting countries to indicators that may not be applicable or feasible in their context. It was envisioned that the criteria would better inform national planning and ensure that national HIV reporting requirements would also enable data analysis and use for quality improvement at the point of service delivery, so that facilities could use the same data to routinely identify and address gaps in their HIV services and improve care. The criteria were also intended to help donors know the impact of the programs they fund and have greater insight into program effectiveness.

During FY10, HCI worked with the Global Fund, WHO, and other partners to develop and establish consensus on the quality criteria and began field testing of the proposed quality criteria and corresponding indicators in five countries representing different types of HIV epidemics: three in Africa,


one in Southeast Asia, and one in Europe and Eurasia. The field tests assessed the feasibility and relevance of the proposed criteria and measurement mechanisms and their relationship to existing in-country indicators. Four of the five field tests were conducted in FY10.

During FY11, HCI completed the final field test in Europe and Eurasia, conducted an analysis of all five country results, and prepared a synthesis report summarizing the findings from all five field tests. HCI presented the findings at a Global Partner’s Meeting at the Global Fund in Geneva in June 2011.

Analysis of the field test results showed that all of the quality criteria for HIV counseling and testing and HIV care and treatment were feasible, with the exception of tracking patient enrollment into care and treatment services. However, in the three African countries, the field tests revealed significant gaps in tracking and coordination of PMTCT services for both mothers and exposed infants. The field tests showed that it was very difficult and often impossible to track whether or not pregnant women received the cascade of PMTCT services and if their exposed infants received follow-up care. In addition, the data collected based on the quality criteria revealed that a very high proportion of both pre-ART and ART patients are lost to follow-up. The field tests found that the mechanisms for linking patients between service areas were generally weak in all countries (for example, from testing to treatment, from PMTCT to HIV treatment, and from delivery to follow-up of exposed infants).

The Global Fund used the findings of the field tests to inform monitoring and evaluation reporting requirements in their Round 11 call for proposals.

Table 2. HIV/AIDS service quality criteria field tested by HCI for the Global Fund in FY11


Directions for FY12 HCI is currently awaiting funding notification to determine whether work on the quality criteria will continue in FY12. A proposal was submitted to implement the quality criteria in three countries over an 18-month period, with a focus on strengthening country capacity at national, regional, and facility levels and putting in place sustainable mechanisms to collect and analyze data on the quality criteria and use the information for local decision-making.

3.2 Care that Counts Quality Improvement Initiative for OVC Programs Overview of HCI’s Program in FY11 Activities What are we trying to accomplish? Scale Finalize the two modules of the OVC quality improvement E-Learning course

Develop an E-Learning product that will guide key stakeholders when engaging in the QI process and guide implementers in implementing OVC quality standards at the point of service delivery, including tools that can be adapted to each country’s context

E-Learning course will be disseminated in Africa and made available on the HCI Portal

Main Activities and Results The two modules of the E-Learning course were finalized by URC’s subcontractor, EnCompass LLC, in November 2010. Module 1 of the course covers the introduction to the quality improvement (QI) process and rationale for efforts to improve OVC programming. Module 2 takes the user through five steps in the quality improvement process as applied to OVC program (see Figure 11).

Figure 11. Five steps in the OVC quality improvement process addressed by the OVC QI E-Learning Module 2

In February 2011, HCI presented the two OVC quality improvement (QI) E-Learning modules that had been developed by URC subcontractor EnCompass LLC to Gretchen Bachman and Sarah Berk of the USAID Office of HIV/AIDS (OHA). Ms. Bachman requested that HCI cost out a series of changes to the product, primarily to simplify the language in some places and add a running example in Module 2 to help illustrate the five steps to quality improvement of OVC Programs. The expected cost for making the requested changes was conveyed to OHA and is under consideration.

Directions for FY12 HCI is currently awaiting final instructions from USAID on what further revisions are desired for the E-Learning modules. It was agreed that any further changes to the two modules will be made under Task Order 3.


4 Common Agenda Activities 4.1 Project Management Activity What we are trying to accomplish Ensure efficient technical coordination among project activities and timely reporting to the COTR

Hold weekly meetings of Project Director and COTR Conduct quarterly review meetings with COTR and invited guests presenting

results on all project activities Conduct monthly senior management meetings, headquarters staff meetings, and

technical seminars Submit contract deliverables

Ensure timely submission of deliverable and approval requests, including Year Three Annual Project Report and Self-Evaluation Report and Year Four Work Plan

Ensure efficient close-out of TO1

Ensure that all financial and technical reporting obligations are met

Main Activities and Results Coordination of technical activities

Progress on all TO1 activities was formally reviewed each quarter with the Contracting Officer’s Technical Representative (COTR) for the HCI Project. During FY11, we held four Quarterly Review Meetings (QRM) with the COTR: on October 21, 2010; January 20-21, 2011; April 27-28, 2011; and July 27-28, 2011. Because of the expansion in the number of technical and country activities being implemented by HCI, beginning in January, the QRM was expanded to take place on two consecutive days.

In addition, the HCI Director and COTR held weekly coordination meetings throughout the year.

Reporting and deliverables

All TO1 required deliverables were submitted on time to the COTR, including the TO1 FY11 consolidated work plan, the HCI TO1 FY10 annual project report and self-evaluation report, and the quarterly Performance Monitoring Reports for the HCI Indefinite Quality Contract.

Close-out of Task Order 1

Throughout FY11, close-out actions on TO1 were conducted on a rolling basis to ensure smooth transition of resources from completed activities under TO1 to new activities currently being conducted under TO3.

Administrative close-out, including employment contracts, office leases, and equipment handover, was started during previous years as some activities transitioned to TO3 earlier than others. A global request for disposition of equipment, also submitted in a prior year, facilitated the continued use of equipment throughout this transition while also reducing the need to purchase many new items for TO3 activities. Contractual close-out focused on meeting final reporting requirements and the close-out of TO1 subcontracts early in the year, allowing for timely submission of deliverables as well as Negotiated Indirect Cost Recovery Agreement (NICRA) rate adjustments from subcontractors. Financial close-out, including the final invoicing, is underway as final expenses and URC NICRA rate adjustments are being calculated along with the end of fiscal year internal audits.

Directions for FY12 HCI global task order activities will continue under Task Order 3 in FY12.


4.2 Knowledge Management Overview of HCI’s Activities in FY11 What we are trying to accomplish Scope Conduct studies to inform ongoing enhancements to the HCI KM system

Get user feedback to improve the usefulness and acceptability of the HCI KM site; and understand how users are using site content to improve the site and make it more useful and user-friendly Drawing on findings from KM studies, carry out small tests of

interventions to increase use of the HCI Portal and engage implementers outside the project in contributing to the Improvement Database Conduct small studies to validate submissions to assure that

accurate information is posted by users outside HCI

Main Activities and Results Under TO1, USAID tasked HCI with developing a global knowledge base about what can be done to improve the quality of health care in USAID-assisted countries and to make that knowledge widely available using Internet technology. Consequently, a major core-funded task was the design of a knowledge management system to create, capture, synthesize (analyze, summarize, and distill), and share knowledge about how to improve health care with a focus on the priorities of USAID-assisted countries. The Health Care Improvement Portal (www.hciproject.org) is the hub of the project’s knowledge management (KM) system. The HCI Portal was designed under TO1 during the first two years of project implementation and launched at the end of FY09.

Other elements of the HCI KM system include region- and topic-specific web sites with the similar mission of gathering and spreading learning about how to improve health care or other related services, including the Spanish language maternal and newborn care web site (www.materoinfantil.org) and the Russian language maternal and child health site (www.healthquality.ru). In addition, another tool in the HCI KM system is a private Intranet (http://intranet.hciproject.org) created to enable HCI staff and partners to share emerging approaches, ideas, and preliminary versions of tools and methods that, when finalized, would be added to the HCI Portal.

While these web sites have all benefited from iterative adjustments made in response to usage data, user comments, and staff feedback, the project has made use of specific studies to provide inputs for design changes and to test strategies for encouraging greater user participation in the HCI Portal’s Improvement Database. Specifically, we have sought ways of encouraging organizations and projects outside URC and HCI partners to submit improvement reports to the HCI Portal Improvement Database. Because increasing outside submissions to the Improvement Database was viewed as a key barrier to conducting further studies to validate submissions or evaluate applications of system content, the studies conducted under TO1 focused on the design and increasing usage of the KM system.

During FY11, HCI completed 14 of the 15 studies requested by USAID under HCI TO1 to inform the design and refinement of features of the HCI KM system and to test strategies for increasing submissions to the HCI Portal from outside the project. These studies met Performance Target 7.2 of the HCI Task Order 1 contract and are summarized in Table 3. The final report on the 15 KM studies carried out under Task Order 1 was submitted to the COTR on September 19, 2011.

Table 3. Fifteen HCI Task Order 1 knowledge management studies

TO1 KM Study Purpose of the study Sample/number of

respondents When

completed 1 Interviews with members

of the HBB Advisory Committee about

Discern the opinions of leaders in the HBB initiative about needs and functionality

10 members of the HBB Advisory Committee, from 7 different organizations

May 2010

http://www.hciproject.org/�

http://www.materoinfantil.org/�


http://intranet.hciproject.org/�


TO1 KM Study Purpose of the study

Sample/number of respondents

When completed

specifications for a Helping Babies Breathe Community of Practice website

for the design of community of practice to support implementation of the HBB Initiative

2 Review of best practices in designing web-based Communities of Practice

Review of literature and web resources on Communities of Practice

N/A December 2010

3 Survey of potential users of the CHW Central community of practice

Gather information from people working with community health worker programs to inform the design and content of the CHW Central web site

199 people took the online survey, but because of incomplete responses, only 177 responses were usable. The link for the online survey was sent to 68 key informants and also sent out to the CORE Group and other listservs

January 2011

4 Intervention to test a contest for best improvement report as a means for increasing postings on the HCI Portal

To test whether a material incentive (prize of presentation at an international conference) would stimulate entries to the Health Care Improvement Database

30 eligible entries were received: % from Africa, % from Asia, and % from Latin America

April 2011

5 Test of intervention to personally invite selected poster presenters from the International Forum in Nice, France in April 2010 to submit an improvement report to the HCI Portal

Test whether personal invitations to post an improvement report about previously presented content would result in submission of an improvement report to the HCI Portal

23 posters were identified as appropriate; valid contact information could only be obtained for 11 authors

May 2011

6 Test of intervention to make a personal connection and invite participants of the International AIDS Conference in Vienna in July 2010 to submit to the HCI Portal

Test whether personal invitations to post an improvement report about previously presented content would result in submission of an improvement report to the HCI Portal

75 abstracts were identified as appropriate, but valid email addresses could only be obtained for 61 of the 75

May 2011

7 Test of intervention to make a personal connection and invite poster presenters and other participants at the 2011 International Forum in Amsterdam to submit to the HCI Portal

Test whether personal invitations to post an improvement report about previously presented content would results in submission of an improvement report to the HCI Portal

35 appropriate posters (12 before and 23 during the conference) and one oral presentation were identified, but valid email addresses were only obtained for 15 of the 36

May 2011

8 HCI staff survey regarding the HCI Portal

Obtain structured but anonymous feedback from HCI staff about their use of and preferences for the content and features of the HCI Portal

Survey sent to over 400 HCI HQ and field staff; 65 staff responded (41% based in the US; 36% in Latin America, 22% based in Africa; and 2% based in Asia/Europe)

June 2011


TO1 KM Study Purpose of the study

Sample/number of respondents

When completed

9 HCI staff survey regarding the test HCI Intranet

Obtain structured but anonymous feedback from HCI staff about their use of and preferences for the structure, content and features of the HCI Intranet

Survey sent to over 400 HCI HQ and field staff; 65 staff responded (41% based in the US; 36% in Latin America, 22% based in Africa; and 2% based in Asia/Europe)

June 2011

10 HCI partner survey regarding the HCI Portal

Obtain structured but anonymous feedback from HCI partners about their use of and preferences for the content and features of the HCI Portal and preferences for a new HCI Intranet

Survey was emailed to 29 individuals from 8 partner organizations; 6 respondents, all based in the US

June 2011

11 Survey of users who registered at the Kampala conference regarding the HCI Portal

Gain feedback on the use of the HCI Portal by a group of users who were introduced to the Portal at a 2009 conference in Kampala

The survey link was emailed to 68 individuals; 11 respondents, all based in Africa

June 2011

12 Survey of recently registered users from outside the project regarding the HCI Portal

Obtain feedback on the use and content of the HCI Portal from recent users, including those who submitted for the best improvement report contest

The survey link was emailed to 78 individuals who had registered on the site in the previous six months; 19 responded (74% based in Africa, 16% based in Asia/Europe, 11% based in Latin America)

June 2011

13 Intervention to encourage colleagues at HEALTHQUAL to submit improvement stories to the HCI Portal

Test whether enlisting the HQ staff of an HCI partner would increase contributions to the HCI Portal by its field staff

Two emails and two telephone calls with the HEALTHQUAL coordinator

July 2011

14 Survey (in Spanish) of users of the maternoinfantil.org site

Obtain feedback on the use of the maternoinfantil.org website from registered users and on preferences for new features to be developed on the site

Survey link was emailed to approximately 900 persons on the Materno Infantil listserv; 94 respondents (99% based in Latin America)

September 2011

15 Review of Social Media options for the HCI KM system

Identify options for HCI in the realm of social media, describing use by other organizations and projects and analyzing the appropriateness of each option

N/A September 2011

Directions for FY12 Conclusions from these 15 studies will continue to inform our KM strategy under Task Order 3. We will continue to make personal invitations to individuals, especially following a face-to-face contact, to solicit contributions to the Improvement Database on the HCI Portal. We will also continue to make use of Zoomerang surveys as an inexpensive means of polling users or target groups about HCI-affiliated websites and communities of practice. Under TO3, HCI will launch a Facebook page in FY12. We will repeat the Best Improvement Report contest in FY12, with the prize of presentation at the GHC


Conference in Washington in July 2012. We will use the suggestions of survey respondents to develop new content areas on the HCI Portal and create more filters and search options for Portal users. We will also begin providing a more in-depth and systematic orientation for HCI staff and partners about the resources on the HCI Portal and on a re-designed HCI Intranet and send out periodic reminders to staff, partners and other users about updates and new content available on the site.

4.3 Technical Leadership and Communication Overview of HCI’s Activities in FY11 What we are trying to accomplish (global) How and with whom Develop and disseminate evidence of the effectiveness of applying modern QI approaches in USAID-assisted health care systems

Write and publish technical reports and publish articles in peer-reviewed journals

Main Activities and Results Develop and disseminate evidence of the effectiveness of applying modern QI approaches in USAID-assisted health care systems

During FY11, four articles on HCI TO1 results were published or accepted for publication in peer-reviewed journals. In addition, we published two technical reports, 18 research and evaluation reports, and one short report describing QI interventions and their results from work implemented under Task Order 1. These publications are listed in Table 4.

Table 4. HCI TO1 journal articles and technical reports published in FY11

Articles Published or Accepted for Publication in Peer-reviewed Journals Franco LM and Marquez L. Effectiveness of collaborative improvement: evidence from 27 applications in 12 less developed and middle-income countries. Published in BMJ Quality & Safety Online First on 11 February 2011 as 10.1136/bmjqs.2010.044388. Broughton E, Gomez I, Nuñez O, Wong J. Cost-effectiveness of a pediatric care improvement intervention in Nicaragua. Accepted for publication 13 May 2011 by Revista Panamericana de Salud Pública/Pan American Journal of Public Health. Broughton E, Saley Z, Boucar M, Alagane D, Hill K, Marafa A, Asma Y, Sani K. Cost-effectiveness of collaborative improvement for essential obstetric care. Accepted for publication 30 May 2011 by the International Journal of Health Care Quality Assurance. Hermida J, Broughton E, Franco LM. Validity of quality performance indicator self-evaluation for maternal and newborn health in Ecuador. Accepted for publication 18 July 2011 by the International Journal for Quality in Health Care. Technical Reports (Date Published) Wittcoff A, Crigler L, Mbago P, Moshi E, Furth R. Baseline Assessment of HIV Service Provider Productivity and Efficiency in Tanzania. Technical Report. (March 2011) Crigler L, Djibrina S, Wittcoff A, Boucar M, Saley Z, Lin Y-S. Assessment of the Human Resources System in Niger. Technical Report. (June 2011) Research and Evaluation Reports (Date Published) Stephen N. Kinoti SN, Burkhalter B, Rumisha D, Hizza E, Ngonyani M, Broughton E, Gondwe T. Sequential Validity of Quality Improvement Team Self-assessments in Tanzania. Research and Evaluation Report. (November 2010) Tanzania Spread Study Team. 2011. Spread of PMTCT and ART Better Care Practices through Collaborative Learning in Tanzania. Research and Evaluation Report. (June 2011) Semakula R, Kasule K, Hiltebeitel S. 2011. The Validity of Self-assessment Data in a Ugandan Quality Improvement Program. Research and Evaluation Report. (June 2011) Nabwire J, Southgate R, Broughton E, Livesley N, Karamagi E. 2011. Evaluation of the Costs and Benefits of an HIV Care Coverage Improvement Collaborative in Uganda. Research and Evaluation Report. (June 2011)


Kyeyagalire R, Southgate R, Broughton E, Livesley N, Karamagi E. 2011. The Data Management Improvement Collaborative in Uganda. Research and Evaluation Report. (June 2011) Hurtado E, Richardson P, Broughton E. 2011. Analysis of Effectiveness and Cost-effectiveness of Adding Collaborative Improvement to a Conditional Cash Transfer Program in Guatemala. Research & Evaluation Report. (August 2011) Nguessan J, Jennings L, Ackah A, Franco L, Kouassi V. 2011. Assessing Quality Improvement Team Performance in the HIV/AIDS Improvement Collaborative in Cote d’Ivoire. Research Report Summary. (September 2011) Nguessan J, Jennings L, Ackah A, Franco L, Kouassi V. 2011. L’appréciation de la performance des Equipes d’amélioration de la qualité (EAQ) participant dans le collaboratif d’amélioration des services VIH/SIDA en Côte d’Ivoire. Rapport de la Recherche et Evaluation. (September 2011) Franco L, Nguessan J, Ackah A, Gondwe T, Kouassi V. 2011. Etude Sur L’apprentissage Partage en Cote d’Ivoire: La Diffusion des Changements Parmi les EAQ. Rapport de la Recherche et Evaluation. (September 2011) Franco L, Nguessan J, Ackah A, Gondwe T, Kouassi V. Effects of participating in collaborative improvement on the quality of HIV/AIDS care in facilities in Cote d’Ivoire: a comparison of intervention and control sites. Research and Evaluation Report. (September 2011) Mohan D, Franco LM, Sabou D, Boucar M, Saley Z, Broughton E. 2011. Validity of Quality Improvement Team Self-assessment in Monitoring Maternal and Newborn Indicators in Niger. Research and Evaluation Report. (September 2011) Boucar M, Franco LM, Jennings L, Mohan D, Sabou D, Saley Z. 2011. How Do Quality Improvement Teams Function after an Improvement Intervention Ends? A Description of Team Performance after the End of an Obstetric and Newborn QI Initiative in Niger. Research and Evaluation Report. (September 2011) Hurtado E, Insua M, Franco LM. 2011. Strengthening QI team performance through shared learning and coaching in Guatemala. Research Report Summary. (September 2011) Hurtado E, Insua M, Franco LM. 2011. Monitoreo del Desempeño de los Equipos de Mejoramiento Continuo de la Calidad en Guatemala a través del aprendizaje compartido y la tutoría. Informe de Investigación. (September 2011) Hurtado E, Insua M, Franco LM. 2011. Como se replicaron los cambios de mejoramiento de la calidad: Estudio de la diseminación de las mejores prácticas en la atención materno neonatal en Guatemala. Informe de Investigación. (September 2011) Hurtado E, Insua M, Franco LM. 2011. Estudio de la diseminación de las mejores prácticas en la atención materno neonatal en Guatemala. Resumen Ejecutivo. (September 2011) Hurtado E, Insua M, Franco LM. 2011. How Proven Improvements are Adopted by Other Health Centers: A Study on the Spread of Best Practices for Maternal and Newborn Care in Guatemala. Research Report Summary. (September 2011) Bright R, Stern A. Feasibility of Proposed Quality Criteria for Monitoring and Improving HIV Services. Technical Report. (September 2011) Short Report and Flyers (Date Published) Feasibility of Using Quality Criteria to Monitor and Improve the Quality of HIV Services (4 page flyer) (September 2011)

Directions for FY12

Under TO3, HCI will continue to emphasize publishing project results and approaches in peer-reviewed journals.


5 Performance Tracking Plan Table 5 summarizes the full achievement of TO1 performance targets as of the end of FY11.

Table 5. HCI TO1 cumulative achievement of performance targets, FY08-FY11 HCI TO1 Performance

Target Cumulative Achievement of Performance Targets by the End of FY11 Objective 1: Document the interventions supported by this task order to improve the quality of health care, how quality was measured, and the impact of these interventions Performance target 1.1: 100% of QI interventions are documented in a consistent format, which includes description of the intervention and quantitative measures of the success of the intervention over a defined time period, including a baseline measure.

All QI interventions supported by HCI TO1 were documented in the following manner: 1) information archived at the country level and in URC’s headquarters, 2) Collaborative Profiles posted on the HCI Portal about HCI-supported QI interventions that were improvement collaboratives, 3) Improvement Reports or other technical or research reports posted on the HCI Portal for QI interventions that were not collaboratives, and 4) written and verbal reports on results and key findings were presented each quarter to the COTR. Documentation standards and tools, drawing on the lessons learned from the field testing of the project’s Standard Evaluation System, were developed and disseminated to all HCI teams in FY10 in the form of Learning System Standards for improvement interventions and team-level QI activities. These standards encourage and support compliance with seven standards: three standards for the QI team level and four standards for the collaborative or QI program level which address not only consistent documentation of improvement interventions and results at the individual team and program levels, but also the analysis and synthesis of this information to identify effective changes that can be spread to other teams. These standards represent a set of “simple rules” that can be applied in any setting or context in which we work, affording the necessary flexibility to define them more specifically in the specific contexts in which they are being applied. Quantitative measures of the success of each QI intervention carried out under TO1 were reported annually in the HCI TO1 self-evaluation reports fro FY08-FY11.

Objective 2: Institutionalize modern quality improvement approaches as an integral part of health care in USAID-assisted countries Performance target 2.1: Of health systems receiving technical assistance under task order #1 for more than 12 months, 75% have documented implementation of QI interventions independent of contractor assistance.

Twenty-two country health systems received TA for more than 12 months under HCI TO1: Africa: Cote d’Ivoire, Ethiopia, Kenya, Lesotho, Mali, Mozambique, Namibia, Niger, South Africa, Swaziland, Tanzania, Uganda. Asia: Afghanistan, India, Indonesia, Vietnam. Europe: Russia. Latin America: Bolivia, Ecuador, Guatemala, Honduras, Nicaragua. HCI country teams all began reporting on evidence of institutionalization as part of FY09 annual reporting; this evidence was catalogued in the FY09 and FY10 HCI TO1 Self-Evaluation Reports. By the end of FY11, 20 of the 22 countries (91%) had documented evidence of supporting QI interventions independent of URC assistance. (This evidence was presented in the HCI TO1 FY11 self-evaluation report.) The two countries lacking such evidence remain: India, where HCI provided intermittent technical assistance to a small-scale project, and Lesotho, where HCI ceased activities in October 2009. We do know that the TB-HIV improvement strategies that HCI helped to develop in Lesotho were integrated into the bilateral project implemented by the International Center for AIDS Care and Treatment Program at Columbia University.


HCI TO1 Performance Target Cumulative Achievement of Performance Targets by the End of FY11

Objective 3: Expand the evidence base for the application of QI to human resources (HR) planning and management Performance Target 3.1: In at least two African countries, develop improvement collaboratives on HR management processes, including quantitative improvement goals, and achieving an average improvement over baseline performance of at least 10%

Under HCI TO1, we developed three collaboratives in Africa addressing HR management processes: 1. The Niger HR Collaborative 2. The Uganda District Health Management Collaborative 3. The Uganda Coverage/Efficiency Collaborative Documentation of these collaboratives is available on the HCI Portal. A report on the first phase of the Niger HR collaborative, published in August 2011, shows that changes made by these teams resulted in significant clinical, performance, and efficiency gains between May 2009 and December 2010: six of Tahoua’s eight districts have met the national target for the percentage of births delivered in a health facility (i.e., more than 25%); postpartum hemorrhage fell by half in participating sites; adherence to essential newborn care standards rose from 72% to 98%; and the average waiting time for pre-natal consultations was reduced by 50–98%. When the Tahoua Human Resources Collaborative started, none of the health workers had job descriptions, whereas now, almost all health workers have specific, written job descriptions and clear roles and responsibilities outlined for their work. A report on the cost-effectiveness of the Uganda coverage/efficiency intervention published in June 2011 presented data on five of the 14 sites. At Kabuyanda Health Center, average waiting times decreased for all HIV clinic services; the facility experienced a two-thirds decrease in patient waiting time, from 198 minutes to 61 minutes (p<0.001). In Maddu Health Center, waiting times decreased significantly for registration, increased for dispensing, but overall there was no statistically significant change (p=0.65). In Ntwetwe Health Center, the average total time spent at the clinic decreased from 253 minutes at baseline to 136 minutes at follow-up. For staff productivity in Maddu, there was an increase in productive time from 57% at baseline to 81% at follow-up (p=0.02). For the Uganda district management collaborative, data presented in the FY10 TO1 Self-evaluation report showed that the % of districts independently conducting coaching visits increased from 33% in Dec. 2009 to 91% by May 2011.

Performance Target 3.2: Develop and evaluate 15 applications of QI methods to HR policy issues, of which at least three directly address the efficiency of health care processes or the productivity of providers

Sixteen applications of QI methods to HR policy issues were completed under TO1 by the end of FY10. Four address efficiency and productivity. The 16 applications are: 1. Aligned national health goals and objectives to local level in Tahoua, Niger 2. Written job descriptions in Niger 3. OVC volunteer engagement assessment in Ethiopia 4. HR systems assessment in Niger 5. Health worker engagement survey to improve retention in Niger 6. Assessed time utilization of health workers to improve productivity in Niger 7. Assessed client flow in maternity services to improve services delivery in

Niger (efficiency) 8. Nicaragua Organizational Climate Assessment 9. Developed assessment tool and process to evaluate and count functional

CHWs 10. Assessed CHWs in Nepal 11. Assessed CHWs in Benin 12. Uganda baseline assessment for client flow (efficiency) 13. Uganda baseline assessment of time utilization of health workers

(productivity) 14. Uganda baseline assessment of health worker engagement 15. Task-shifting in MNC Counseling: Evaluation of the Quality and Impact of



counseling by skilled and unskilled health care workers in Benin 16. Assessment of compliance with maternal health standards by skilled birth

attendants in Tanzania Objective 4: Expand experience with the improvement collaborative approach in USAID-assisted countries Performance Target 4.1: Support the development of 7 phase I improvement collaboratives, including improvement goals expressed as quantitative indicators, and achieving an average improvement over baseline performance of at least 10% within 18 months after the beginning of the collaborative. Collaboratives with specified topics listed elsewhere in this statement of work contribute to the achievement of this target

By the end of FY10, HCI had launched or completed 33 phase 1 improvement collaboratives under TO1, far surpassing the performance target of 7. Phase 1 collaboratives supported under TO1: Benin (1): EONC Aplahoue-Dogbo-Djakotome District Cote d’Ivoire (1): ART/PMTCT in 41 sites Mali (2): Facility EONC collaborative and Mali Community EONC collaborative Niger (2): Phase II EONC pre-eclampsia demonstration collaborative and HR Collaborative in Tahoua Tanzania (4): Tanga Region ART-PMTCT collaborative (AIDS Relief); Morogoro Region ART-PMTCT collaborative (FHI); Mtwara Region ART-PMTCT collaborative (Clinton Foundation); Infant Feeding Collaborative in Iringa Uganda (8): District health management demonstration collaborative; Coverage collaborative; Retention collaborative; Clinical outcomes collaborative; Laboratory collaborative; Data management collaborative; Nutrition collaborative; Private sector collaborative Afghanistan (1): EONC facility collaborative in Kunduz and Balkh provinces Vietnam (1): TB-HIV collaborative in Thai Binh Russia: (7): Demonstration collaborative on social services for families affected by HIV (St. Petersburg); Prevention of newborn hypothermia and respiratory disorders (Tambov, Yaroslavl, and Kostroma oblasts); Breastfeeding promotion (Tambov, Yaroslavl, and Kostroma oblasts); Optimizing labor management using the partograph (Tambov, Yaroslavl, and Kostroma oblasts); Prevention of unwanted pregnancies and STIs among teenagers (Tambov, Yaroslavl, and Kostroma oblasts); Primary neonatal resuscitation (Tambov, Yaroslavl, and Kostroma oblasts); Regionalization of perinatal care (Tambov. Kostroma, and Tver oblasts) Guatemala (2): Community ProCONE demonstration collaborative in San Marcos; Complications ProCONE demonstration collaborative Honduras (1): La Paz region pneumonia and diarrheal disease case management collaborative Nicaragua (3): VCT-STI demonstration collaborative; ART demonstration collaborative in 5 SILAIS; Post-obstetric event family planning demonstration collaborative Quantitative improvement over baseline exceeded 10% for multiple indicators in all of the demonstration collaboratives.

Performance Target 4.1a: Support the development of at least one phase I improvement collaborative addressing district level health program management in Africa.

Under HCI TO1, we developed two phase I collaboratives addressing district level health program management in Africa: 1. Niger HR collaborative 2. Uganda District Health Management collaborative

Performance Target 4.1b: Support the development of two phase I improvement collaboratives addressing the chronic care of HIV/AIDS patients across the continuum of care, from the level of self

Under HCI TO1, we developed six phase I collaboratives (including five in Africa) addressing gaps in coverage, retention, and improved clinical outcomes by applying the project’s ART Framework: 1. Nicaragua ART collaborative 2. Cote d’Ivoire ART/PMTCT demonstration collaborative 3. Uganda HIV coverage/efficiency collaborative 4. Uganda HIV retention collaborative



care to referral hospital care. At least one of these collaboratives must be in Africa.

5. Uganda HIV clinical outcomes collaborative 6. Uganda nutrition collaborative

Performance Target 4.2: Conduct at least three descriptive and intervention studies.

Under HCI TO1, we conducted five descriptive and intervention studies: 1. Ecuador: Humanization, cultural adequacy and demand generation for quality

maternal care 2. Ethiopia: Applying the science of improvement to achieving quality care for

vulnerable children 3. Results of collaborative improvement: Effects on health outcomes and

compliance with evidence-based standards in 27 applications in 12 countries 4. Niger: Descriptive study of factors associated with QI team performance 5. Cote d’Ivoire: Descriptive study of QI team performance in the ART/PMTCT

demonstration collaborative Objective 5: Expand experience with the spread collaborative approach in USAID-assisted countries Performance Target 5.1: Support the development of 7 phase II spread collaboratives which extend improved practices to an average population of at least 100,000 beneficiaries and achieve levels of improvement of 75% that of the original phase I collaborative within 18 months. Contract activities listed elsewhere in this statement of work which extend improvements on this scale also contribute to fulfilling this target.

Under HCI TO1, we developed 10 phase II spread collaboratives that extended improved care practices to populations greater than 100,000: 1. Uganda first wave spread collaborative (32 new sites) in HIV/AIDS Quality of

Care Initiative 2. Uganda second wave spread collaborative (31 sites) in HIV/AIDS Quality of

Care Initiative 3. St. Petersburg, Russia spread collaborative on HIV treatment, care and

support and TB-HIV co-infection management (all 18 districts of St. Petersburg)

4. St. Petersburg, Russia spread collaborative on social services for families affected by HIV (all 18 districts of St. Petersburg)

5. Guatemala Basic ProCONE spread collaborative (8 health areas) 6. Guatemala Community ProCONE spread (8 health areas) 7. Nicaragua maternal and newborn complications spread collaborative, 9

hospitals 8. Nicaragua post-obstetric event family planning collaborative 9. Cote d’Ivoire spread collaborative on ART/PMTCT (80 new sites) 10. Lindi Region ART-PMTCT collaborative (Clinton Foundation/EGPAF) (spread

from Mtwara) Performance Target 5.2: Conduct at least 6 studies of the process by which one facility team implements improvements developed by another team, including consideration of the role of documentation, direct exchanges between teams, and facilitation by experts.

HCI completed six studies on the process of spread of improvements from one team to another under TO1: 1. Results of collaborative improvement: results of 27 applications in 12

countries 2. Options for spread of simple high impact interventions 3. Cote d’Ivoire: Shared learning 4. Tanzania: Shared learning and spread related to the Tanga collaborative 5. Nicaragua: Shared learning and spread 6. Guatemala: Spread of best practices from demonstration phase

Objective 6: Expand the experience base for other specific QI approaches Performance Target 6.1: Apply and/or evaluate at least 6 QI tools, methodologies, or approaches in addition to those listed elsewhere in this statement of work.

Under TO1, HCI completed seven applications and evaluations of QI approaches other than collaborative improvement: 1. Uganda private-for-profit HIV quality of care assessment 2. Cote d’Ivoire HIV quality of care assessment 3. Evaluation of the impact of job aids on counseling for maternal and newborn

care in Benin 4. Evaluation of ART training in Uganda 5. Evaluation of HIV patient monitoring tools training in Uganda 6. Evaluation of infant feeding counseling training in Iringa, Tanzania



7. Development of a TB computer-based training CD-ROM in Indonesia Performance Target 6.2: In conjunction with at least two of the QI evaluations listed in this statement of objectives, incorporate a comparative analysis of established supervisory practices on the same topic, in facilities not participating in the QI initiative.

HCI completed two comparative analyses of the results of QI teams versus teams receiving regular supervisory practices: 1. Guatemala: Evaluating the contribution of QI on effectiveness of a conditional

cash transfer program 2. Cote d’Ivoire: Study comparing demonstration sites and baseline for

expansion sites Both reports were published in FY11.

Objective 7: Improve the cost-effectiveness of QI in USAID-assisted countries Performance Target 7.1: By the second year of the task order, develop a functioning global knowledge management (KM) system for improvement information.

The Health Care Improvement Portal was launched in September 2009, at the end of FY09, completing the global knowledge management system for HCI. In addition to the main HCI Portal, the project: • Launched in FY09 an Intranet for the project team to facilitate technical

sharing among country and headquarters teams and partners • Launched in March 2009 a Spanish language knowledge management web site

for sharing evidence-based practices and improvement experiences in maternal and newborn care: www.maternoinfantil.org

• Launched in FY09 a private web portal, www.healthquality.ru, to support knowledge management in the MCH/RH collaboratives in Russia; a public section of this portal was launched in September 2010

• Launched in the last quarter of FY10 an information-sharing web site in Spanish and English for the Latin American Regional Newborn Health Alliance, www.alianzaneonatal.org.

Performance Target 7.2: Conduct at least 15 studies and evaluations to (1) support the design of the KM system; (2) evaluate field applications of system content; and (3) validate selected submissions.

Fifteen studies in support of the design and enhancement of the KM system were carried out under TO1: 1. Interviews with members of the HBB Advisory Committee about

specifications for a Helping Babies Breathe Community of Practice website 2. Review of best practices in designing web-based Communities of Practice 3. Survey of potential users of the CHW Central community of practice 4. Intervention to test a contest for best improvement report as a means for

increasing postings on the HCI Portal 5. Test of intervention to personally invite selected poster presenters from the

International Forum in Nice, France in April 2010 to submit an improvement report to the HCI Portal

6. Test of intervention to make a personal connection and invite participants of the International AIDS Conference in Vienna in July 2010 to submit to the HCI Portal

7. Test of intervention to make a personal connection and invite poster presenters and other participants at the 2011 International Forum in Amsterdam to submit to the HCI Portal

8. HCI staff survey regarding the HCI Portal 9. HCI staff survey regarding the test HCI Intranet 10. HCI partner survey regarding the HCI Portal 11. Survey of users who registered at the Kampala conference regarding the HCI

Portal 12. Survey of recently registered users from outside the project regarding the

HCI Portal 13. Intervention to encourage colleagues at HEALTHQUAL to submit

improvement stories to the HCI Portal 14. Survey (in Spanish) of users of the maternoinfantil.org site

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15. Review of Social Media options for the HCI KM system The results of these studies were written up in a summary report submitted to the COTR in September 2011.

Performance Target 7.3: Carry out 10 studies related to improving the cost-effectiveness of specific QI approaches or methodologies.

By the end of FY10, HCI had completed 10 studies related to improving the cost-effectiveness of specific QI approaches or applications: 1. Ecuador: Validity of self-assessment in EONC Collaborative 2. Guatemala: Analysis of the effectiveness and cost-effectiveness of adding QI to

a conditional cash transfer program 3. Nicaragua: Cost analysis of an intervention to prevent ventilator-associated

pneumonia 4. Nicaragua: Cost-effectiveness of pediatric hospital improvement interventions 5. Niger: Cost effectiveness of collaborative improvement for EONC 6. Niger: Validity of QI team self-assessment in monitoring maternal and

newborn indicators 7. Tanzania: Sequential validity of self-assessment for ART/PMTCT services 8. Uganda: Cost-effectiveness of the data management collaborative 9. Uganda: Evaluation of the costs and benefits of the HIV services coverage

collaborative 10. Uganda: Validity of self-assessment data

Performance Target 7.4: By the end of the task order, the KM system has been accessed by at least 1000 users, 50 acceptable submissions from outside the task order have been received and posted, and the contractor has responded to 200 requests for information or assistance.

By the end of FY11, usage of the HCI knowledge management system, encompassing the HCI Portal, the CHW Central Community, and the Spanish Maternal and Child Health and Russian Health Russia websites, has exceeded all the usage targets set in the TO1 contract. Total visits to these sites through the end of FY11 exceeded 138,000 users. Analysis of the usage of just the Improvement Database on the HCI Portal, which is the core resource of the project’s knowledge management system, shows that during the FY10-FY11the database of improvement reports and collaborative profiles received 2,060 unique visitors who came to the database 3,116 times, surpassing the target of 1000 users accessing the KM system. The total number of outside submissions to the KM system through FY11 was 56, and the number of requests for assistance submitted through the KM system totaled 207.

Performance Target 7.5: Within three months of the award, the contractor will arrange for the uninterrupted global availability of all USAID-supported documents, reports, and other products on the web site www.qaproject.org.

HCI met this requirement in FY08 by making all reports and technical materials that had been available on the www.qaproject.org web site available on the temporary project site at www.hciproject.org while the HCI Portal site was being developed. All of the publications and technical content on QI methods from the Quality Assurance Project web site are available on the HCI Portal, both through the HCI Publications page and as highlighted technical resources on improvement tool and improvement topics pages.

Objective 8: Provide global technical leadership for QI in USAID-assisted countries Performance Target 8.1: The policy and program documents of three international organizations incorporate language explicitly endorsing an organized QI program as an integral component of the health services which they support.

HCI had achieved four endorsements of QI methods by the end of FY10: 1. HCI assisted the International AIDS Alliance to add a section on Quality

Improvement to its Toolkit for OVC Programs in FY08. 2. OGAC endorsed the facilitators’ guide for quality in OVC programs in FY09. 3. The HCI Director and COTR collaborated with WHO, the New York State

AIDS Institute, CDC, and other cooperating agencies to develop the content on quality improvement of HIV/AIDS care in a manual for PEPFAR implementers distributed at the HIV Implementers’ meeting in Kampala in June 2008.

4. HCI collaborated with WHO, Harvard University, and the World Alliance for Patient Safety to develop a position paper on the application of QI methods to the large-scale spread of care checklists (published in September 2010).

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Performance Target 8.2: Contractor staff and its collaborators will produce 10 technical reports and papers related to describing QI interventions and measuring their impact, including 5 papers published in peer-reviewed journals.

By the end of FY11, HCI had published 15 technical reports and seven peer-reviewed journal articles describing QI interventions and measuring their impact, totaling 22 publications that meet this performance target: 1. Evaluating Health Care Collaboratives: The Experience of the Quality

Assurance Project (June 2008) 2. Collaborative Evaluation Series: Russia Site Visit Report (August 2008) 3. Expanding TB and TB/HIV Integrated Services in Thai Binh Province, Vietnam

(January 2009) 4. Applying the Science of Improvement to Achieving Quality Care for

Vulnerable Children in Ethiopia (October 2009) 5. Results of Collaborative Improvement: Effects on Health Outcomes and

Compliance with Evidence-based Standards in 27 Applications in 12 Countries (December 2009)

6. Integrating Nutrition into HIV/AIDS Care, Treatment, and Support Using a Quality Improvement Approach: Results from Uganda (co-published with the NuLife Project) (April 2010)

7. Options for Large-scale Spread of Simple, High-impact Interventions (September 2010)

8. Spread of PMTCT and ART Better Care Practices through Collaborative Learning in Tanzania (June 2011)

9. Evaluation of the Costs and Benefits of an HIV Care Coverage Improvement Collaborative in Uganda (June 2011)

10. The Data Management Improvement Collaborative in Uganda (June 2011) 11. Analysis of Effectiveness and Cost-effectiveness of Adding Collaborative

Improvement to a Conditional Cash Transfer Program in Guatemala (August 2011)

12. Assessing Quality Improvement Team Performance in the HIV/AIDS Improvement Collaborative in Cote d’Ivoire (September 2011)

13. Effects of participating in collaborative improvement on the quality of HIV/AIDS care in facilities in Cote d’Ivoire: a comparison of intervention and control sites (September 2011)

14. How Do Quality Improvement Teams Function after an Improvement Intervention Ends? A Description of Team Performance after the End of an Obstetric and Newborn QI Initiative in Niger (September 2011)

15. How Proven Improvements are Adopted by Other Health Centers: A Study on the Spread of Best Practices for Maternal and Newborn Care in Guatemala (September 2011)

Peer-reviewed journal articles describing QI interventions and their impact: 16. Harvey SA, Jennings L, Chinyama M, Masaninga F, Mulholland K, and Bell DR.

2008. Improving community health worker use of malaria rapid diagnostic tests in Zambia: package instructions, job aid and job aid-plus-training. Malaria Journal 7:160. Published 22 August 2008.

17. Jennings L, Yebadokpo A, Affo J, Agbogbe M. Antenatal counseling in maternal and newborn care: use of job aids to improve health worker performance and maternal understanding in Benin. 2010. BMC Pregnancy and Childbirth 10:75. Published 22 November 2010.

18. Jennings L, Yebadokpo A, Affo J, Agbogbe M. Task shifting in maternal and newborn care: a non-inferiority study examining delegation of antenatal counseling to lay nurse aides supported by job aids in Benin. BMC Implementation Science. Published 6 January 2011.

19. Franco LM, Marquez L. Effectiveness of collaborative improvement: evidence from 27 applications in 12 less developed and middle-income countries. Published in BMJ Quality & Safety Online First on 11 February 2011.



20. Broughton E, Gomez I, Nuñez O, Wong J. Cost-effectiveness of a pediatric care improvement intervention in Nicaragua. Accepted for publication 13 May 2011 by Revista Panamericana de Salud Pública/Pan American Journal of Public Health.

21. Broughton E, Saley Z, Boucar M, Alagane D, Hill K, Marafa A, Asma Y, Sani K. Cost-effectiveness of collaborative improvement for essential obstetric care. Accepted for publication 30 May 2011 by the International Journal of Health Care Quality Assurance.

22. Hermida J, Broughton E, Franco LM. Validity of quality performance indicator self-evaluation for maternal and newborn health in Ecuador. Accepted for publication 18 July 2011 by the International Journal for Quality in Health Care.

Performance Target 8.3: The contractor will facilitate at least five articles or broadcasts in mass media which address the nature of QI activities and their results.

By the end of FY10, HCI had facilitated seven articles and broadcasts in mass media addressing the nature of QI activities and their results: 1. In July 2008, the AIDSMAP web site published an article on HCI’s QI efforts

to introduce HIV testing and counseling into TB clinics in Lesotho 2. Dr. Refiloe Matji, HCI’s Regional Director for Southern Africa, was

interviewed in March 2009 on the News Hour with Jim Lehrer on the Public Broadcast System in the United States

3. Articles on improving HIV care were published in FY08 and FY09 in two issues of the magazine AIDS Sex Health in Russia

4. An article was published in October 2009 in the ECSA Bulletin describing QI interventions and their role in helping countries meet the MDGs, based on Dr. Stephen Kinoti’s presentation at a regional ECSA meeting in September 2009.

5. The local newspaper “GalichIzvestiya” in Kostroma Oblast in Russia published an article on June 10, 2010, featuring the improvement activities and results in Galich rayon hospital, one of the leader sites participating in the MCH collaboratives. The team leader of the Galich team was quoted discussing how the hospital had benefited from participation in the MCH collaborative, listing improvements achieved and new services that are now available to mothers and babies. The article is titled “Deliver a-la Russian” by I. Kozyr.

6. An article on the results of the Niger HR Collaborative was published in Le Sahel, a leading newspaper in Niamey, on July 26, 2010.

7. A blog post by Dr. Massoud on the role of QI in reaching the MDGs was published on the Global Health Magazine website in September 2010.

Performance Target 8.4: At least once during the period of performance, the contractor will convene an external technical advisory group (TAG), consisting of experts in fields pertinent to the statement of work.

This performance target was met in FY09. The Technical Advisory Group convened at USAID in May 2009; the panel consisted of six world-class experts in improvement who had been approved by the COTR.

Performance Target 8.5: The contractor will support the development of new graduate-level training programs in QI as applied in low- and middle- income countries or the revision of established programs, in two training institutions, such as schools of public health, or ministry of health training institutes.

HCI supported the development of two new post-graduate training programs in QI by the end of FY10: 1. A mini-course on QI for medical students was delivered in January 2010

through the Afghanistan Public Health Institute; based on this experience, a one-week QI course was developed with the Institute in 2010.

2. HCI developed a distance learning QI course with the Methodological Center for Quality of the Ministry of Health and Social Development in Russia. The course was made available on the public side of the Web Communicator in FY11. The Center award a certificate in Health Care Organization to those who successfully complete the course.

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Documents

USAID HEALTH CARE IMPROVEMENT PROJECT TASK ......Bureau for Global Health, Office of Health, Infectious Diseases and Nutrition. USAID HEALTH CARE IMPROVEMENT PROJECT TASK ORDER 1 FY11