USAID 
FROM THE AMERICAN PEOPLE 
SEPTEMBER 30, 2006 
This publication was produced for review by the United States Agency 
for International Development by the Quality Assurance Project. 
QUALITY 06 ASSURANCE 
PROJECT 
Front cover: This child was severely malnourished and experiencing 
several complications when he arrived at the national children's hospital 
in Nicaragua months before this picture was taken. Responding to the 
needs of such children, during Year Four, QAP focused on improving 
care for severely ill and malnourished children in hospitals in Nicaragua, 
Niger, and Tanzania. Photo by Oscar Nunez, QAP/Nicaragua. 
QUALITY ASSURANCE AND 
WORKFORCE DEVELOPMENT 
PROJECT: YEAR FOUR 
SELF EVALUATION 
Performance Period: July 1, 2005-June 30, 2006 
Contract Number GPH-C-00-02-00004-00 
September 30, 2006 
DISCLAIMER 
The views expressed in this publication do not necessarily reflect the views of the United States Agency 
for International Development or the United States Government. 

Table of Contents 
EXECUTIVE SUMMARY ........................................................................................................................... V 
ABBREVIATIONS .................................................................................................................................. VIII 
1 INTRODUCTION .................................................................................................................................... 1 
2 RESULTS-DEVELOPMENTAL IMPACT ..................................................................................... 1 
2.1 ADVANCES IN ADAPTING THE IMPROVEMENT COLLABORATIVE MODEL TO DEVELOPING 
COUNTRIES ................................................................................................................................................... 3 
Documentation, Evaluation, and Research on Collaboratives ................................................................ 5 
2.2 COUNTRY PROGRAMS ...................................................................................................................... 6 
AFRICA .......................................................................................................................................................... 6 
Niger ........................................................................................................................................................... 6 
Rwanda ................................................................................................................................................... 10 
South Africa ...... : .................................................................................................................................... 17 
Tanzania ···· ··········· ···-···· ·~· ··· ······· ············· ········· ···· ··--·············· ··············· ········ ················ ···· ··· ····._ ............ 21 
Benin ........................................................................................................................... , ........................... 24 
Uganda ................................................. , .................................................................................................. 26 
Lesotho ............................................................. : ..................................................................................... 28 
Swaziland ............................................................................ , .................................................................. 28 
EASTERN EUROPE ....................................................................................................................................... 29 
Russia ...................................................................................................................................................... 29 
LATIN AMERICA AND THE CARIBBEAN ..................................................................................................... 34 
Nicaragua ................................................................................................................................................ ~4 
Ecuador ................................................................................................................................................... 40 
Honduras ................................................................................................................................................ 42 
2.3 SHORT-TERM TECHNICAL ASSISTANCE ........................... ., ........................................................... 47 
Bangladesh: Improving Quality of TB Case Management through Supervision ................................. 47 
Cambodia: Developing Public-Private Partnerships for TB Control .................................................. .48 
Peru: Institutionalizing QA in a Private Healthcare Delivery Organization ....................................... .48 
Uganda and Zimbabwe: Adapting Jobs Aids to Improve Infant Feeding Counseling for HIV-positive 
Women ............................................................................................................ : ...................................... 49 
Zambia: Job Aid and Orientation for Malaria Rapid Diagnostic Test.. ............................................... .49 
2.4 GLOBAL AND REGIONAL ACTIVITIES ............................................................................................ 50 
Health Systems Strengthening/Mainstreaming ..................................................................................... 50 
Newborn Care Initiative ......................................................................................................................... 50 
Improving the Care of Orphans and Vulnerable Children .................................................................... 51 
Operations Research ............................................................................................................................... 51 
Computer-Based Training ....................................................................................................................... 55 
Technical Leadership ............................................................................................................................. 55 
3 MONITORING - TRACKING OF PERFORMANCE .................................................................. 58 
Improving Validity of Self-Reported Data ............................................................................................ 59 
Institutionalizing Monitoring of Compliance with Standards .............................................................. 60 
4 QUALITY - ON-TIME DELIVERY AND LACK OF DEFECTIVE SERVICES AND 
PRODUCTS .................................................................................................................................................. 61 
QAP Year Four Self Evaluation 
Quality of Technical Assistance, Research, and Written Reports ........................................................ 61 
Responsiveness and Timeliness ............................................................................................................. 62 
5 MANAGEMENT- EFFECTIVE AND EFFICIENT MANAGEMENT OF RESOURCES ..... 63 
Effective Coordination of Technical Activities ..................................................................................... 63 
Increasing Efficiency ............................................................................................................................. 63 
Use and Effective Integration of Subcontractors .................................................................................. 63 
Cost Control ........................................................................................................................................... 64 
6 COLLABORATION - EFFECTIVE COLLABORATION AND COORDINATION ............... 64 
7 OPPORTUNITIES FOR IMPROVEMENT AND NEW DIRECTIONS ..................................... 65 
List of Tables, Boxes, and Figures 
Table 1. Scale-up in QAP Country Activities as of June 2006 ................................................................... vi 
Table 2. Achievement of Performance Criteria for Results in the Project's Fourth Year ............ : .............. 1 
Table 3. Status of QAP Improvement Collaboratives as of June 2006 ....................................................... .4 
Table 4. Niger: Technical Content and Timing of EONC Collaborative Cycles ......................................... 8 
Table 5. Rwanda: Best Practices for Improving PMTCT Services Implemented through the 
Collaborative .................................................................................................................................. 13 
Table 6. Rwanda: Best Practices for Improving Pediatric Malaria Services Implemented through the 
Collaborative .................................................................................................................................. 14 
Table 7. Rwanda: Changes Introduced through the Collaborative to Improve ART Services .................. 17 
Table 8. South Africa: QAP's HNI AIDS Service Targets and Achievements, Oct. 2006-Sept. ............. 19 
Table 9. Nicaragua: Compliance with KeyEOC Process Standards in 14 SILAIS, 2003-2005 ............... 36 
TablelO. Nicaragua: Compliance with Key EOC Process Standards in Four Empresas Medicas 
Previsionales, 2004-2005 .............................................................................................................. 38 
Table 11. Ecuador: Expansion of CQI Activities .......................................................................................... 41 
Table 12. Ecuador: Selected Indicators from the EOC Collaborative, July 2003-June 2005 ..................... .41 
Table 13. Honduras: Coverage of Decentralized Provider Networks Assisted by QAP, 2006 .................. .43 
Table 14. Honduras: Quality Ratings Achieved by Decentralized Provider Networks Assisted by QAP, 
2005-2006 ............................ ,, ........................................................................................................ 44 
Table 15. Honduras: Quality Assurance Structure in the Five Departmental Regions Assisted by QAP, 
2006 ................................................................................................................................................ 45 
Table 16. Honduras: Results of the First Quality Monitoring of the Five Departmental Hospitals Assisted 
by QAP, July.2006 ............................................................ : ............................................................ 45 
Table 17. Honduras: Compliance with Quality Standards in the Five Departmental Hospitals Assisted by 
QAP, July 2006 ............................................................................................................................... 46 
Table 18. Status of Operations Research Studies as of June 30, 2006 ......................................................... 51 
Table 19. QAP Technical Publications, 7/1/05-6/30/06 ............................................................................... 55 
Table 20. QAP Technical Presentations at Briefings and Conferences, 7 /1/05-6/30/06 ............................. 57 
Box 1. Facility Results in South Africa: Driefontein Health Center in Mpumalanga Province ............. 18 
Box 2. Feedback from USAID Mission Staff on the Quality of QAP Assistance and Products ............ 61 
ii QAP Year Four Self Evaluation 
Figure 1. Niger: Proportion of Malaria and Pneumonia Cases Meeting > 80% of Case Management 
Standard ........................................................................................................................................... 7 
Figure 2. Niger: Proportion of Providers Able to Demonstrate Sequential Steps of AMTSL per 
Standard ........................................................................................................................................... 9 
Figure 3. Rwanda: Percentage of Partners of Women Tested for HIV who Are Also Tested .................... 11 
Figure 4. Rwanda: Percentage of HIV-positive Pregnant Women Given Nevirapine to Take Home in 
Case of Home Delivery ................................................................................................................. 12 
Figure 5. Rwanda: Percentage of Children Born of HIV-positive Women Tested at 15-18 Months ......... 12 
Figure 6. Rwanda: Percentage of Children 0-5 Years with Fever that Were Taken to a Health Center in 
the First 24 Hours, May 2003-June 2006 ...................................................................................... 14 
Figure 7. Rwanda: Percentage of Children 0-5 Years Treated at Health Centers According to Malaria 
Case Management Standards, January 2004-June 2006 ............................................................... 15 
Figure 8. Rwanda: Percentage of Patients with CD4>350 who Adhere to their Appointments (5 Sites), 
July 2005-July 2006 ....................................................................................................................... 16 
Figure 9. Rwanda: Percentage of Patient on ARVs at Least 12 Months Showing CD4 Increase (5 Sites) 16 
Figure 10. South Africa: Number of People Provided with Counseling and Testing in Limpopo, 2006 (12 
Facilities) ........................................................................................................................................... 19 
Figure 11. South Africa: Number of HIV-positive Persons Receiving Ongoing Counseling and Support, 
Eastern Cape, 2006 ........................................................................................................................ 20 
Figure 12. South Africa: Referral of TB Patients for HIV Testing, KwaZulu-Natal, 2006 ......................... 20 
Figure 13. Tanzania: Compliance with Case Management Standards, Four PHI Hospitals, April-August 
2006 ................................................................................................................................................ 22 
Figure 14. Tanzania: Screening of Pediatric Patients for HIV in Five PHI Hospitals (July 2005-June 2006) 
........................................................................................................................................................ 23 
Figure 15. Tanzania: Reduction in Stock-outs of Contraceptives in Collaborative Sites, Dec. 2004-May 
2006 ................................................................................................................................................ 24 
Figure 16. Benin: Completion of the Partograph According to Standards in 10 Peripheral Facilities, 
October 2004-March 2006 ............................................................................................................ 25 
Figure 17. Benin: Practice of AMT SL in 10 Peripheral Facilities, October 2004-March 2006 .................. 25 
Figure 18. Uganda: Percentage of Patients with Valid Contact Information, Four Sites, June 2005-April 
2006 ................................................................................................................................................ 27 
Figure 19. Uganda: Percentage of Eligible Patients Started on ART, Nine Facilities, June 2005-May 2006 
.................................................................................................... ,.~ ..................... ~········· ~··•·•! ••• ... '··········27 
Figure 20. Russia: Number of HIV-positive Individuals who Received Counseling on TB-HIV Co￾infection, Togliatti, Samara Oblast, April 2005-April 2006 ........................................................ 30 
Figure 21. Russia: Active Screening of HIV-positive Patients for TB in Engels, Saratov Ob last, 2005 .... 31 
Figure 22. Russia: Number of TB Patients Receiving HIV Counseling and Test in TB Clinic #5, St. 
Petersburg City, January 2005-July 2006 ..................................................................................... 31 
Figure 23. Nicaragua: Pneumonia Case Fatality. Comparison of Year Three and Year Four Data ............ 35 
Figure 24. Nicaragua: Diarrhea Case Fatality. Comparison of Year Three and Year Four Data ................ 36 
Figure 25. Nicaragua: Trends in Compliance with BOC Standards. Boaco, Chinandega, Madriz, RAAN, 
and Rio San Juan SILAIS, July 2005-June 2006 .......................................................................... 37 
Figure 26. Nicaragua: Incorporation of Routine Use of the Partograph in the EMP AMOCSA, 
Chinandega SILAIS, September 2004-August 2006 ................................................... :.: .............. 38 
QAP Year Four Self Evaluation iii 
Figure 27. Nicaragua: Improvement in Case Management of Sexually Transmitted Infections, 
ProMujer ........................................................................................................................................ 39 
Figure 28. Nicaragua: Percentage of Pregnant Women who Received Counseling on STI/HIV/AIDS, 
March-August 2006 ....................................................................................................................... 39 
Figure 29. Ecuador: Percentage of Deliveries in Which Oxytocin Was Administered to Prevent 
Hemorrhage in Health Facilities Participating in the EOC Collaborative, July 2003-June 2006 
........................................................................................................................................................ 42 
Figure 30. Honduras: Trends in Number of Maternal Deaths by Priority Department, 1999 to 2005 ....... .47 
Figure 31. Bangladesh: Provider Compliance(%) with NTP Standards for DOTS Observed in Round 1 
Supervision Visits .......................................................................................................................... 48 
Figure 32. Zambia: CHW Performance with Paracheck PfMalaria RDT .................................................. .49 
iv QAP Year Four Self Evaluation 
Executive Summary 
The Quality Assurance and Workforce Development Project (QAP) sees as its overall mandate to assure 
that funds provided by USAID, other donors, and host country governments are used most effectively to 
achieve quality care and optimized health outcomes. QAP's fourth year of implementation was marked by 
continued scale-up of improvement activities and expansion of their technical scope. Field work 
expanded to additional sites in Ecuador, Honduras, Nicaragua, Niger, Russia, South Africa and Tanzania, 
and new field programs were launched in Lesotho, Swaziland, and Uganda. New technical work was 
initiated related to: expanding newborn care and better integrating it within maternal care, incorporating 
nutritional interventions in acute pediatric care in Niger, mainstreaming quality improvement tools and 
approaches for health systems strengthening within USAID's health portfolio, and applying QA methods 
to strengthen programming for orphans and vulnerable children. 
The improvement collaborative continued as the dominant technical approach applied in QAP-supported 
field activities, largely due to the results it produces and its effectiveness for systematic scale-up of best 
practices. QAP has implemented 20 collaboratives in 13 countries in four years and extended 10 into 
Year Four. Collaboratives in Nicaragua, Niger, and Uganda are being implemented at national scale, with 
participating sites in almost all districts or regions. The extent of the scale-up of improvement activities 
in each QAP-assisted country by the end of Year Four are summarized in Table 1. 
We continued to refine the collaborative approach, with new "spread" collaboratives started in Tanzania 
and Ecuador and new operations research on the validity of self-assessment. To capture the project's rich 
experience implementing collaboratives, we brought staff together for a "Collaboratives Leaming Week" 
in June 2006 to share experiences across countries addressing common areas of care and to plan the field 
evaluations that began in August. 
Our key achievements in institutionalizing improvements in quality of care this year included: 
• 
• 
• 
• 
• 
• 
• 
• 
Launch of Niger's essential obstetric and newborn care (EONC) collaborative, which is leveraging 
the pre-existing pediatric hospital improvement (PHI) collaborative to integrate maternal aud 
newborn care best practices into routine care at 88 % of national and regional maternity hospitals and 
64% of all district hospitals 
Development of a new quality healthcare policy for Rwanda that integrates strategies for quality 
assurance, performance-based financing, and expanding coverage of mutual health organizations 
Spread of pediatric AIDS and hospital improvement activities to 12 new hospitals_in northern 
regions of Tanzania and the roll-out of job aids and stronger training programs for PMTCT 
counselors in five regions, reaching 600 providers in over 300 sites 
Launch of a national ART collaborative with Uganda's MOH in 57 sites in 91 % of districts 
Institutionalization of improvements in HIV/AIDS services in Russia through policy direc"tives, 
allocation of local budgets, creation of new official positions, and initiation of a new collaborative to 
improve family planning services for people with HIV I AIDS 
Declines registered in case fatality rates for pneumonia and diarrhea in Nicaraguan hospitals 
participating in the PHI collaborative, and the application of standards-based care, client-focused 
counseling, and continuous quality improvement to a new clinical area: HIV/AIDS services 
Implementation of new contracting arrangements between Honduran health authorities and 
hospitals/facility networks that incorporate explicit indicators of quality of care linked to pay for 
performance and provide financial incentives for quality care 
Formal adoption o(active management of the third stage of labor as part of Ecuador's official norms 
and start-up of a national spread collaborative to extend such management to all facilities in the nine 
provinces where it had not been introduced through the original BOC collaborative 
QAP Year Four Self Evaluation v 
New operations research was carried out in Zambia to develop and field test job aids to improve health 
worker performance with rapid diagnostic tests for malaria. Work progressed on 20 other OR studies 
during the year: four were completed and results published; another six have final reports in editing. In 
all, QAP published eight research and technical reports and presented findings at ten international 
and regional conferences in Year Four. Our results have sparked interest in the collaborative approach 
among other USAID cooperating agencies, and we have begun plans for new collaboratives next year that 
will be implemented by other organizations with limited QAP technical assistance. 
Recognizing the value added by QAP to their country portfolios, USAID Missions in Honduras, 
Nicaragua, and Russia increased funding to QAP this year. The project continued to demonstrate its field 
orientation by increasing the use of host country national (HCN) personnel. In Year Four, HCN labor and 
benefit costs exceeded headquarters staff costs by 2 percentage points: 17% versus 15%. 
Priorities for next year include completing and disseminating results of field evaluations and cross￾country analyses of QAP-supported collaboratives, including evidence for sustainability of collaborative 
results and institutionalization of QA activities; mainstreaming the collaborative approach by completing 
and disseminating collaborative evaluations, guidelines, tools, and training materials and by mentoring 
new organizations to conduct collaboratives; and expanding work to increase client and community 
involvement in improvement activities and strengthen community linkages to enhance the continuum of 
care for children and adults with HIV/AIDS. 
Table 1: Scale-up in OAP Country Activities as of June 2006 
Country- Scope of Initial 
Clinical Improvement Activities Extent of Scale-up of % of Facilities or Areas Covered 
Focus** (Start Date) Activities as of June 2006 as of June 2006 
Benin- 15 facilities in 2 sanitary Expansion to include stronger 40% of regional hospitals (2/5) 
EOC** districts (out of 34 districts newborn care and linkages 9% of district hospitals (2/23) 
in the country) (February with PMTCT planned for 2% of health centers/posts (10/616) 
2005) 2007 
Ecuador- All (7) health areas in 1 76 health areas in 13 provinces 45% of all MOH health areas in 
EOC** province (August 2003) (out of 22 in country) the country (76/168) 
Honduras- 1 health region out of7 in 62 facilities in 5 departmental 100% of hospitals and MCH 
EOC** the country (November areas (out of 20 in country) clinics and 82% of health centers 
2003) in the 5 departmental areas 
Lesotho 5 Health Service Areas out 5 out of 18 Health Service 28 % of the country's Health 
TB-HIV of 18 in the country Areas Service Areas 
(October 2005) 
Nicaragua- 3 local health systems 14 out of 17 SILAIS in the 80% of the country's 
EOC** (SILAIS) out of 17 in the country municipalities 
country (September 2003) 
Nicaragua- 6 out of 22 maternal and 14 of22 maternal and child 64% of the country's hospitals that 
PHI** child care hospitals in the care hospitals in the country treat children 
country (October 2003) 
Niger- 6 out of 10 national/ 8 out of 10 national/regional 80% of national/regional pediatric 
PHI** regional pediatric hospitals, pediatric hospitals; 3 out of 3 hospitals 
all 3 national maternity national maternity hospitals; 100% of national maternity 
hospitals, and 8 out of 33 21 out of33 district hospitals hospitals 
district hospitals in the 64% of the country's district 
country (August 2003) hospitals 
Niger- 3 out of 3 national maternity 3 out of 3 national maternity 88% of national/regional maternity 
EONC** hospitals, 4 our of 5 regional hospitals; 4 out of 5 regional hospitals 
maternity hospitals, and 21 maternity hospitals; 21 out of 64% of the country's district 
out of 33 district hospitals in 33 district hospitals hospitals 
the country (January 2006) 
vi QAP Year Four Self Evaluation 
Russia- Pilot sites in 4 of 89 19 facilities in 1 out of 19 1.8 million population are served 
HIV/AIDS territories in the country districts in St. Petersburg; 17 by the facilities assisted by QAP 
treatment, (November 2004) facilities in Samara Oblast; 11 
care, and facilities in Orenburg Oblast, 
support** including Oblast AIDS Center; 
23 facilities in Saratov Oblast, 
including Oblast AIDS Center 
Russia- Pilot sites in 4 cities (in St. 15 health institutions in 494,000 women of reproductive 
Family Petersburg, Saratov Oblast, Krasnogvardeiski District in age are served by the institutions 
planning** and Samara Oblast (January St. Petersburg; 26 health assisted by QAP 
2006) organization in Saratov City 
and Engels, Saratov Oblast; 9 
health institutions in Togliatti, 
Samara Oblast 
Rwanda- 18 sites, at least 1 in each of 17 original sites (1 original 4 hospitals (12% of the country's 
PMTCT** the country's 12 provinces, site became inactive) + 19 district hospitals) 
representing 100% of the expansion sites = 36 sites 32 health centers (9% of the 
PMTCT facilities at that country's health centers) 
time (July 2003) 
Rwanda- 60 health centers and Reduced to 23 sites by July 3 district hospitals (100% of 
Malaria** hospitals in 4 of the 2004 (3 district hospitals and district hospitals in the 4 districts) 
country's 39 districts 20 health centers) and 51 health centers (85% of health 
(January 2003) expanded to 31 more health centers in the 4 districts) 
centers in September 2005 
Rwanda- 16 sites covering all 12 16 original sites + 14 5 hospitals (15% of district 
ART** provinces, representing expansion sites = 30 sites hospitals) 
100% of the ART facilities 25 health centers (7% of health 
at that time (August 2004) centers in the country) 
South 10 hospitals and 50 clinics 33 facilities in Mpumalanga These facilities: counseled 64,853 
Africa- in Mpumalanga Province Province clients post-HIV test; tested 21,438 
VCT, (July 2002) 25 facilities in KwaZulu-Natal pregnant women; delivered NVP to 
PMTCT, Province 8,687 pregnant women and 9,046 
ART, 27 facilities in Eastern Cape infants; provided palliative care to 
palliative Province 24,391 PL WHA; and served 7 ,095 
care 11 facilities in Limpopo clients with TB and HIV services 
Province and 9,820 clients with ART 
Swaziland 3 TB diagnostic units and 25 facilities in Manzini 22 out of 162 clinics (14%) in the 
- TB-HIV 22 clinics in Manzini, 1 of 4 Region country 
regions (August 2005) 
Tanzania- 7 hospitals in 3 regions (out 19 facilities in 7 regions: Participating hospitals in 28% 
Pediatric of 25 mainland regions in 3 hospitals in Dar es Salaam; (7 /25) of mainland regions 
AIDS** the country) (October 2004) 1 hospital in Kilimanjaro; 1 
hospital in Kibaba; 4 hospitals 
and 2 health centers in Arusha; 
1 hospital in Morogoro; 6 
hospitals in Tanga; 1 hospital 
in Manyara 
Tanzania- 9 facilities in all (3) districts Collaborative concluded in 100% of district hospitals and 
Family in one region (capital), out July2006 health centers in Dar es Salaam 
planning** of 25 mainland regions in region 
the country (October 2004) 
Uganda- 57 sites in 51 of the 56 Incorporation of 30 additional Pilot sites in 91 % of districts in the 
ART** districts in the country sites is planned in 2007 country 
(January 2006) 
** Designates improvement activities using the collaborative methodology. 
QAP Year Four Self Evaluation vii 
Abbreviations 
ADD 
AMT SL 
ANC 
ART 
ARV 
BCG 
CBO 
CBT 
CCP 
CD-ROM 
CDC 
CHW 
CORE 
COUNSENUTH 
CQI 
DOTS 
DRSP 
DSR 
EGPAF 
EMP 
BOC 
EONC 
ETAT 
FCI 
FP 
GFATM 
HCN 
HIV/AIDS 
HSS 
IDU 
IHI 
IMCI 
IMNCI 
IUD 
LISEM 
MAFE 
MANCORSARIC 
MCH 
MDR 
MIFAMILIA 
MINS A 
MIS 
MOH 
MOHSW 
NDOH 
NGO 
NTP 
NVP 
OFDA 
viii 
Aplahoue-Dogbo-Djakotome (Benin) 
Active Management of Third Stage of Labor 
Antenatal Care 
Antiretroviral Therapy 
Antiretro viral 
Bacillus Calmette-Guerin 
Community-based Organization 
Computer-Based Training 
Critical Care Pathway 
Compact Disc-Read Only Memory 
Centers for Disease Control 
Community Health Worker 
Child Survival Collaborations and Resources 
The Centre for Counselling, Nutrition and Health Care (Tanzania) 
Continuous Quality Improvement 
Directly Observed Therapy, Short-course 
Regional Public Health Directorate (Direction de Regionale de la Sante Publique) 
Reproductive Health Directorate (Direction de la Sante de la Reproduction) (Niger) 
Elizabeth Glaser Pediatric AIDS Foundation 
Private Medical Provider (Empresa Medica Previsional) (Nicaragua) 
Essential Obstetric Care 
Essential Obstetric and Newborn Care 
Emergency Triage Assessment and Treatment 
Family Care International 
Family Planning 
Global Fund for AIDS, Tuberculosis and Malaria 
Host Country National 
Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome 
Health Systems Strengthening 
Intravenous drug user 
Institute for Healthcare Improvement 
Integrated Management of Childhood illness 
Integrated Management of Newborn and Childhood Illness 
Intrauterine Device 
List of Pregnant Women (Listado de Mujeres Embarazadas) (Honduras) 
Madres Felices (Honduras) 
Municipality of Santa Rita of Copan (Honduras) 
Maternal and Child Health 
Multi-drug-resistant 
Ministry of the Family (Nicaragua) 
Ministry of Health (Nicaragua) 
Management Information System 
Ministry of Health 
Ministry of Health and Social Welfare 
National Department of Health (South Africa) 
Nongovernmental Organization 
National Tuberculosis Program 
Nevirapine 
Office of U.S. Foreign Disaster Assistance 
QAP Year Four Self Evaluation 
OGAC 
OPV 
OR 
ovc 
PAHO 
PAK 
PEPFAR 
PHI 
PLWHA 
PMTCT 
PNLP 
POPP HI 
PRSS 
QA 
QAP 
QI 
QoC 
QSM 
RAAN 
RAAS 
ROT 
RHINO 
SBA 
SEDES 
SILAIS 
SSH 
STI 
TB 
TRAC 
UNFPA 
UNGC 
UNICEF 
URC 
USAID 
USG 
VCT 
WHO 
WHO/AFRO 
XOR 
Office of the Global AIDS Coordinator 
Oral Polio Virus 
Operations Research 
Orphans and Vulnerable Children 
Pan American Health Organization 
Pobe-Adja-Ouere-Ketou (Benin) 
President's Emergency Plan for AIDS Relief 
Pediatric Hospital Improvement 
Persons Living With HIV/AIDS 
Prevention of Mother-to-Child Transmission of HIV 
Programme National Integre de Lutte contre le Paludisme (National Malaria Control 
Program) (Rwanda) 
Prevention of Postpartum Hemorrhage Initiative 
Health Sector Reform Project (Honduras) 
Quality Assurance 
Quality Assurance Project 
Quality Improvement 
Quality of Care 
Quality Supervision and Monitoring 
North Atlantic Autonomous Region 
South Atlantic Autonomous Region 
Rapid Diagnostic Test 
Routine Health Information Network 
Skilled Birth Attendant 
Departmental Secretariats of Health (Bolivia) 
Local Integrated Health Care System (Nicaragua) 
Secretariat of Health of Honduras 
Sexually Transmitted Infection 
Tuberculosis 
Treatment and Research AIDS Center (Rwanda) 
United Nations Fund for Population Activities 
National Quality Assurance Unit (Honduras) 
United Nations Children's Emergency Fund 
University Research Co., LLC 
United States Agency for International Development 
United States Government 
Voluntary Counseling and Testing 
World Health Organization 
Regional Office for Africa of the World Health Organization 
Extreme Drug-resistant 
QAP Year Four Self Evaluation ix 

1 Introduction 
This Self Evaluation Report of the Quality Assurance and Workforce Development Project (referred to 
hereafter as QAP) describes the key results of work performed under the contract during the fourth year 
of project implementation, July 1, 2005, to June 30, 2006. This document does not attempt to describe all 
activities performed by the project but rather focus on key results and developmental impact. The USAID 
evaluation panel is urged to review the project's Year Four Annual Report, published July 31, 2006, for 
more details about any country or core technical activity. 
The structure of this report follows the performance criteria defined by US AID for the contract in Year 
One and updated in Year Two, as well as technical directives issued by the CTO with respect to the use of 
the improvement collaborative methodology. Section 2 presents our analysis of the key results achieved 
in Year Four to institutionalize quality assurance activities (QA) in USAID-assisted health programs. 
Sections 3-6 address the project's performance with respect to monitoring, quality of services and 
products, management and efficiency, and collaboration with Missions and USAID cooperating agencies 
and partners. The final section identifies opportunities for improvement and new directions for Year Five. 
2 RESULTS - Developmental Impact 
The project's achievements vis-a-vis the contract's performance criteria are summarized in Table 2 , 
focusing primarily on the results achieved through improvement collaboratives and long-term assistance 
to scale up national QA activities or programs. Results are then reported for each country where QAP has 
a significant field program. Thereafter are summaries of results from the project's global, regional, and 
core technical activities. 
Table 2: Achievement of Performance Criteria for Results in the Project's Fourth Year 
Performance Criteria Countries/ Activities Meeting Criteria (Bold 
Indicates Addition in Year Four) 
Improvement Collaboratives 20 collaboratives initiated since start of project in 12 
End-of-Project Target: 10 collaboratives implemented countries (3 new collaboratives in Year Four) 
Institutionalization of Quality Assurance 11 programs/countries: Ecuador, Eritrea, Honduras, 
End-of-Project Target: Develop and implement large-scale Malawi, Nicaragua, Niger, Russia, Rwanda, South 
QA programs in at least 10 countries Africa, Tanzania, Uganda 
QA policy level commitment 10 programs/countries: Ecuador, Honduras, Malawi, 
End-of-Project Target: At least 8 programs develop written Nicaragua, Peru, Russia, Rwanda, Jamaica, South 
policies addressing QA activities Africa, Uganda 
Organization of QA as an accountable program 9 programs/countries: Honduras, Ecuador, 
End-of-Project Target: At least 7 QA programs have Nicaragua, Niger, Russia, Rwanda, South Africa, 
comprehensive documentation of the organization of QA Tanzania, Uganda 
activities .. Training in QA methods 10 programs/countries: Ecuador, Honduras, 
End-of-Project Target: At least 7 QA programs have Nicaragua, Niger, Peru, Russia, Rwanda, South 
training strategy and use related materials/methods to Africa, Tanzania, Uganda 
sustain skills and knowledg;e of QA 
Quality of care monitoring 10 programs/countries: Benin, Ecuador, Honduras, 
End-of-Project Target: At least 8 programs produce Nicaragua, Niger, Russia, Rwanda, South Africa, 
monitoring data with multiple measurements over time Tanzania, Uganda 
Development of quality standards 14 programs/countries: Benin, Ecuador, Eritrea, 
End-of-Project Target: At least 7 programs develop or Honduras, Jamaica, Lesotho, Nicaragua, Peru, 
revise evidence-based clinical standards and corresponding Russia, Rwanda, Swaziland, Tanzania, Uganda, 
clinical guidelines Vietnam 
Promotion of compliance with clinical standards 13 prog;rams/countries: Bangladesh, Benin, 
QAP Year Four Self Evaluation 1 
II - - Countries/Activities Meeting Criteria (Bold Performance Criteria Indicates Addition in Year Four) 
End-of-Project Target: At least 9 programs have Ecuador, Eritrea, Honduras, Nicaragua, Niger, Peru, 
documented methodologies to promote compliance with Russia, Rwanda, South Africa, Tanzania, Uganda 
clinical guidelines 
Quality improvement 10 programs/countries: Ecuador, Honduras, Jamaica, 
End-of-Project Target: At least 9 programs document Nicaragua, Peru, Russia, Rwanda, South Africa, 
results of quality improvement interventions Tanzania, Uganda 
Benchmarking of best practices 12 countries: Improvement collaboratives initiated in 
· End-of-Project Target: At least 5 programs introduce a Benin, Ecuador, Eritrea, Honduras, Jamaica, Malawi, 
standardized approach to documenting, introducing, Nicaragua, Niger, Russia, Rwanda, Tanzania, 
evaluating, and spreading best practices Uganda 
Quality design/re-design of systems of care HIV/AIDS: 8 programs/countries: Lesotho, 
End-of-Project Target: In at least 7 programs initiate Nicaragua, Russia, Rwanda, South Africa, 
design of HIV I AIDS or other systems of care Swaziland, Tanzania, Uganda 
Other systems of care: 5 programs/countries: 
Vietnam, Peru, Ecuador, Honduras, Niger 
Documentation and dissemination of QA activities 11 programs/countries: Benin, Ecuador, Honduras, 
End-of-Project Target: At least 10 programs consistently Malawi, Nicaragua, Niger, Russia, Rwanda, South 
document QA activities and systematically disseminate Africa, Tanzania, Uganda 
them to providers 
Incentives for peiformance 4 programs/countries: Ecuador, Honduras, 
End-of-Project Target: At least 6 programs introduce Nicaragua, Zambia (OR studies) 
performance-based incentives 
Community demand for quality 5 programs/countries: Benin, Ecuador, Honduras, 
End-of-Project Target: At least 4 programs have ongoing Nicaragua, Peru 
monitoring of patient opinion/satisfaction and/or 
implement mechanisms to include community 
participation in the governance of health services .. 
Monitoring and evaluation of QA programs 6 c,ountries/programs: Bangladesh, Ecuador, 
End-of-Project Target: At least 8 programs support the Nicaragua, Honduras, Russia, Rwanda, South Africa 
design 
activities 
and implementation of a large-scale MIS for QA ~ 
Regulatory-strategies for QA 5 programs: Bangladesh, Eritrea, Jamaica, 
End-of-Project Target: Support the development of an Honduras, Nicaragua 
external, standards-based QA system in 5 programs • 
Operations research 3 new studies initiated in Year Four, and 3 approved 
End-of-Project Target: Conduct 50 operations research studies were cancelled, bringing to 37 the total of 
studies approved OR studies that are completed or 
underway. Two more studies are in the concept paper 
stage. 
Short-term technical assistance 7 international consultations: World Bank 
End-of-Project Targets: Provide 10 consultations related to (Honduras); WHO Polio Eradication Initiative; 
international bank or Global Fund projects and 15 WHO Chronic Care Model; UNICEF/WHO HIV and 
consultations in support of USAID cooperating agencies or Infant Feeding; WHO Child and Adolescent_ Health; 
other international organizations WHO 3x5; WHO malaria RDT development and 
testing 
10 CA consultations: ORBIS; CRS; Russia (other 
CAs working in Russia); Linkages regarding Infant 
Feeding in PMTCT; assistance to CARE, Society for 
Women and AIDS in Africa, and Salvation Army to 
develop intervention for community-based case 
management of HIV I AIDS; CORE Group on 
improvement collaboratives; develop framework 
for quality in OVC programming; RHINO 
2 QAP Year Four Self Evaluation 
Performance Criteria Countries/ Activities Meeting Criteria (Bold 
Indicates Addition in Year Four) 
Technical leadership Participated in 22 major international and 14 regional 
End-of-Project Targets: Participate in at least 10 major conferences. Published 14 articles in peer-reviewed 
technical meetings; produce at least 8 technical reviews; journals, 44 operations research and technical 
publish at least 5 articles in peer-reviewed journal, reports, 1 monograph, 4 case studies 
pruticipate in at least 10 technical collaborations with other Participated in 8 technical collaborations (P AHO on 
international health organizations; conduct at least 10 prenatal care and skilled attendance at birth; 
briefings; and conduct at least two state-of-the-art training UNICEF on HIV and Infant Feeding; WHO Polio; 
courses for staff WHO Chronic Care Model; International Coalition 
for Treatment, Access and Care for HIV; WHO 
Making Pregnancy Safer; Roll Back Malaria 
Conducted 1 staff training on collaborative 
improvement; Collaboratives Learning Week held 
for field and home office technical staff 
2.1 Advances in Adapting the Improvement Collaborative Model to 
Developing Countries 
Four years ago, QAP embarked on a major methodological challenge: adapt the core improvement 
mechanisms of collaboratives to the complex realities of developing countries. During Year Four, QAP 
continued to manage 10 collaboratives in nine countries and launched new collaboratives in Uganda, 
Niger, and Russia, bringing to 20 the number of collaboratives initiated during the contract (see Table 3). 
Collaborative work in these countries is proving to be effective both in significantly increasing the quality 
of care in diverse programs and in accelerating the scale-up of the improvements from initial facilities to 
much larger portions of the health system. · 
Moreover, in several countries (Niger, Nicaragua, Honduras, Ecuador, Tanzania, and Uganda), 
"prototype" process improvements-evidence-based practices introduced through a collaborative, an'd in 
some cases, improvement methods themselves-have been or are being institutionalized into national 
policies. For example, Tanzania's the pediatric hospital improvement (PHI) collaborative developed 
effective emergency triage assessment and treatment methods and tools, as well as mechanisms to provide 
quality urgent care to sick children as soon as they arrive at an outpatient unit. On its own initiative, the 
Ministry of Health began this year to spread these mechanisms to 13 new facilities in Tanzania's northern 
region. The essential obstetric care (EOC) collaborative in Nicaragua, Ecuador, and Honduras has served 
as a mechanism for spreading evidence-based EOC practices, such as the correct use of the partograph, 
active management of the third stage of labor, and post-partum monitoring, to large portions of those 
countries in relatively short periods. ill N~ger, we leveraged the quality improvement capacity developed 
through the PHI collaborative to launch a new essential obstetric and newborn care (EONC) collaborative 
at scale from the very beginning, reaching 68% of the country's hospitals that attend deliveries. We 
also began this year to test new and adapted concepts, methods, and tools that will guide the international 
community in the successful application of the collaborative approach to developing countries, including 
training materials and new forms of collaboratives, such as "spread" collaboratives that even more rapidly 
scale up proven best practices. 
Throughout the experience of working with hundreds of managers and country teams on three continents, 
QAP has demonstrated several advantages in the collaborative approach: 
• Leadership of national institutions (usually the Ministry of Health) is established from the beginning 
of the collaborative and fostered at all levels: national, regional/provincial, and facility. This instills 
ownership by the national institutions and paves the way for institutionalization of improved 
processe~ and evidence-based interventions. 
• Scale-up is an explicit objective planned from the start of the collaborative. I 
QAP Year Four Self Evaluation 3 
• Sharing of improvement experiences and innovations among collaborative teams is a powerful way to 
collectively develop "prototype interventions" to overcome operational obstacles to evidence-based 
practices and increase quality. 
Table 3. Status of QAP Improvement Collaboratives as of June 2006 
Area Country Status as of June 2006 Number of Sites 
1. PMTCT Rwanda 351
h month 17 original sites + 19 expansion sites = 36 sites 
2. Malaria Rwanda 361
" month 23 original+ 31 expansion sites in 4 districts 
(out of 39 health districts in the country) 
3. Latin Ecuador, 341
" month Ecuador: 13 provinces (out of 22 in country) 
American EOC Honduras, Honduras: 5 depa1tmental areas (out of20 in 
Nicaragua country) 
Nicaragua: 14 SILAIS (out of 17 in country) 
4. Infection Tanzania Completed 4 hospitals 
prevention 
5. Multiple Russia (5 QAP suppmt ended in December 23 oblasts 
topics collaboratives) 2004 
6. PHI Elitrea QAP suppmt ended in September 10 oliginal hospitals + 10 new hospitals added 
2005 due to USAID program in June 2005 
closure 
7. PHI Niger 33'0 month 32 facilities (out of 46 pediatric hospitals in 
country) 
8. PHI Nicaragua 33'0 month 14 hospitals (out of 22 MCH hospitals in 
country) 
9.PHI Malawi QAP suppmt ended in Dec. 2005; 8 district hospitals (out of 27 districts in the 
supp01t for PHI was folded into country) 
bilateral assistance for OA 
10. PHI Guatemala Terminated after 6 months in Dec. 13 distlict, regional, and departmental hospitals 
2004 due to changes in MOH and 
USAID priorities 
11. PHI and Tanzania 20th month 20 hospitals in 6 regions (out of25 mainland 
HIV/AIDS regions) 
Care 
12.Adolescent Jamaica Ended in May 2005 due to end of 4 sites 
health QAP funding; improvement 
activities resumed under the 
bilateral adolescent reproductive 
health program in 2006 
13.ART Rwanda 23'0 month 5 district hospitals and 25 health centers 
14. HIV/AIDS Russia 19th month Pilot facilities in 4 territories (out of 89 
treatment, care territories in the country) 
and support 
collaborative 
15.EOC Eritrea QAP support ended in September 17 facilities in 2 districts in 1 of 6 zones in 
2005 due to USAID program country 
closure 
16. Family Tanzania 2om month 9 facilities in all 3 dist1icts of Dar es Salaam 
Planning region (1 of 25 mainland regions) 
17. EOC Benin 16m month 15 facilities in 2 sanitary districts (out of 34 
districts in the country) 
18.ART Uganda 5" month 57 sites in 91 % of districts 
19. EONC Niger 5th month 28 facilities (out of 41 hospitals attending births 
in country) 
20. Family Russia 5th month Pilot sites in 4 cities (3 territories) involving 50 
Planning for health institutions 
PLWHA 
4 QAP Year Four Self Evaluation 
• The emphasis that collaboratives place on monitoring an intervention's results makes teams and 
managers particularly aware of their potential to modify quality of care. The collaborative approach 
allows for an increased pace of expansion of improvements and implementation of best practices 
much faster and more efficiently than other improvement approaches. 
• The combination of mechanisms to increase clinical competence and process improvement skills in 
collaborative learning sessions is proving to be effective in empowering teams to analyze and change 
care processes. 
The three-country Latin American EOC Collaborative continues to use information technology to 
promote sharing among teams and managers. In the past year, the website (www.mortalidadmaterna.org) 
continued as a viable vehicle for sharing results among the now more than 200 teams participating in 
Ecuador, Honduras, and Nicaragua. In addition, the low-cost email technical forum supported 
discussions of five new topics across teams and countries, including individuals not participating in 
collaboratives. 
Documentation, Evaluation, and Research on Collaboratives 
An evaluation protocol for conducting field evaluations of collaboratives was developed through 
discussions among QAP, subcontractor Encompass, and USAID. The field visits will compare 
collaboratives' plans to their implementation and document outcomes. Evaluation data will be obtained 
from collaboratives' records, direct observation, interviews, and other data collection methods involving 
team leaders, team members, national and district level MOH staff, donor organizations, NGOs, 
healthcare facilities and providers, community members, coaches, country managers, and QAP staff. 
Each evaluation team will include a senior QAP staff member who has not been directly involved in the 
collaborative being evaluated (to avoid potential bias), an evaluation expert from EnCompass, and a local 
consultant. Evaluation field work began in Tanzania in August 2006 and will continue in Year Five to 
cover six countries: Tanzania, Niger, Uganda, Nicaragua, Ecuador, and Russia. 
A "Collaboratives Learning Week" was organized by EnCompass and held in Bethesda, MD, June 19-23, 
2006. QAP field staff from nine countries joined headquarters staff for an intensive meeting to share 
experiences and insights about implementing collaboratives. Small group and plenary session discussions 
illuminated the similarities and differences in implementing collaboratives and provided an opportunity to 
document in-depth information on issues raised and lessons learned from implementation. Meeting notes 
are being used to inform the field evaluations. 
Data collection continued in Niger on OR initiated in Year Three to evaluate the effectiveness of the PHI 
collaborative for improving malaria and pneumonia case management in district hospitals and to compare 
the collaborative approach to traditional clinical training for improving quality of malaria and pneumonia 
care. The baseline data report was used to inform the design of pediat1ic malaria and pneumonia case￾management training conducted in the spring of 2006 for the PHI intervention group and in the training￾only control group, per the study protocol. Final data collection will begin this fall with a final report 
anticipated in early 2007. 
We initiated a new OR study in Year Four to quantify the validity of self-assessment of compliance with 
standards by facility-based quality improvement teams in Ecuador. The study will identify factors 
associated with higher validity of self-assessments (team experience, training, facility size, etc.) and 
identify ways to improve such validity. The study also seeks to develop a practical method and tools that 
provincial MOH quality facilitators can apply for ongoing supervision of the validity of CQI teams' self￾assessments. 
QAP Year Four Self Evaluation 5 
2.2 Country Programs 
Africa 
Niger 
QAP's primary achievements in Niger in year four have included the start-up of an essential obstetric and 
newborn care (EONC) collaborative at scale, the consolidation of the pediatric hospital improvement 
(PHI) collaborative gains in 73% of Nigerien first-referral health centers, and the introduction of intensive 
recuperation services in 15 of 32 PHI sites in the aftermath of the 2005 Nigerien food crisis. The PHI and 
EONC collaboratives reinforce a maternal-newborn-child health and nutrition continuum at scale in 
shared sites in a country with some of the highest maternal (700/100,000), newborn (44/1000), early 
childhood (276/1000) mortality rates and childhood malnutrition rates (50%) in the world (UNICEF 
2005). 
The PHI collaborative, which works to improve integrated management of childhood illness (IMCI) at the 
first referral level, continues to be implemented in close collaboration with the national MOH IMCI 
program. Likewise, the EONC collaborative is being implemented in close collaboration with the MOH 
Direction de la Sante de la Reproduction (DSR), charged with overseeing all reproductive health 
activities in Niger, including safe motherhood and newborn health. The EONC collaborative is 
introducing improved newborn services at scale for the first time in Niger, including advocacy for a 
national newborn policy to promote low-cost evidence-based standards for reducing newborn mortality. 
Regional MOH pediatrics, obstetrics, and midwifery experts play a vital role in day-to-day activities of 
both collaboratives (i.e., training, on-site coaching, learning sessions). Day-to-day management of the 
collaboratives is led by regional MOH authorities (Direction Regionale de la Sante Publique, DRSP) 
employing a uniform set of tools, training resources, and standards. Year Four innovations to strengthen 
local leadership and support in Niger have included the placement of regional QAP "coordinators", the 
training of local MOH "on-site internal" coaches, and ongoing support of MOH "PHI regional external 
coaches" (MOH and hospital staff) to direct regional collaborative management, with close support by 
QAP staff. 
Pediatric Hospital Improvement Collaborative 
Officially launched in 2003 in 17 first referral level hospitals, the PHI collaborative went to scale in 
March 2005, increasing from 14 to 29 sites and achieving coverage of 73% of first referral level pediatric 
care facilities in Niger. Data for 2005 demonstrate that after an initial dip in performance during scale-up, 
gains have been achieved at scale in all 29 sites by the end of Year Four for improved pediatric 
emergency triage assessment and treatment (ET AT) and case management of pneumonia, malaria, and 
diarrheal disease, leading causes of early childhood mortality in Niger. As can be seen in Figure 1, the 
proportion of cases meeting 80% of WHO standards for malaria and pneumonia case management in PHI 
facilities as measured by validated self-assessment improved from January 2004 to December 2005 
during the pre-scale-up "phase l" of PHI, and then again from January to August 2006 during "phase 2" 
to achieve results at scale comparable to those prior to scale-up. As has been demonstrated by QAP 
collaboratives elsewhere and as can be seen in Figure 1, the rate of improvement after scale-up has been 
quicker than during the pre-scale-up phase. We believe this is a direct result of deliberate efforts to 
rapidly disseminate at the start of phase II the best practices and lessons that emerged from phase I. 
Examples of collaborative interventions and local changes implemented to improve pediatric pneumonia, 
malaria, diarrheal, and ET AT care include: regular clinical training and on-site coaching of providers 
(reinforced by dissemination of standards in simple job-aid formats, morning rounds led by physician 
staff, etc.); reorganization of care flow processes and hospital staffing; regular monitoring and efforts to 
ensure availability of stock of laboratory, drug, and equipment inputs; development of site-specific 
monthly action plans; regular audits of pediatric deaths by the pediatric team; and monthly collection and 
review of site-specific performance by PHI teams supervised by regional MOH and QAP coaches for 
6 QAP Year Four Self Evaluation 
Figure 1. Niger: Proportion of Malaria and Pneumonia Cases Meeting> 80°1o'of Case 
Management Standards 
en 
c: 
·31 
E 
c: Ill 
~ 'E Q) C1l 
gi -g c: C1l 
C1l Ui 
E ~ Q) b Ill 00 
~ " c: 
0 
'f 
0 
c. 
e 
Cl. 
14 PHI sites 2004-2005 (pre-scale-up); 29 PHI sites 2006 (after scale-up) 
(Avg. # monthly cases analyzed per illness= 124) 
scale-up 100 --,--~~~~~~~~~~~~~~~~---~~~-. 
90 -t-~~~~~~~-=--:- -...--~----=-=~~~~~~---1 , 80 -t-~~~~~~~..--..--......-....----'--4<----10'-T-~~~~-----T"l 
?O-t-~~~~~----t------1,__~~-----~~-+-~~-------j,__, 
60 -l-~~~~~ -._,_~~------v-~~--~~~,,__________, 
50-t-~~__,-- ------t-+-~~~~~~---+-"~-----+~------< 
40 +-~---~~~---"'--~----¥-~~~~~~~----h"1=-'"--/-~~----j 
30 -+-~---1-----==------~~~~~~~~~~~~~~~~----1 
20 -+--"""""-,1-~~~~~~~~~~~~~~~~~~~------l 
10 -t-~~~~~~~~~~ ~~~~--------1 
0 -+-~~~~~~~~~~~~~~~~~~~~~~~-.----< 
---Malaria 
• Pneumonia 
continuous quality improvement at the local level. A specific example of the changes made is making 
sure each facility took steps to ensure 24-hour availability in urgent care areas of working oxygen 
concentrators and pediatric dosages of antibiotics, quinine, and anti-convulsants, which prior to the 
collaborative were routinely unavailable unless purchased by a child's family. 
PHI' s countrywide introduction of ET AT services into 73 % of Nigerien district hospitals has been an 
important collaborative achievement that is widely recognized by the Nigerien MOH and child health 
partners. The PHI 2003 baseline assessment demonstrated that prior to PHI there was no system of triage 
or priority care in district or regional hospitals for children with IMCI danger signs referred to these 
l;iospitals from surrounding primary health centers, despite very high mortality rates for these most 
vulnerable children. Since 2004 the PHI collaborative has conducted regular ETAT training sessions 
(with supplemental UNICEF and WHO funding) to ensure that all PHI sites at scale are formally trained 
in ET AT. The acquisition of ET AT skills is a tremendous gain for pediatric providers and the children 
for whom they care. For Year Five, the MOH has invited QAP to finalize an integrated national "ET AT 
training and implementation package" to be institutionalized as a routine part of MOH pediatric services 
in Niger. Niger's accumulated ETAT expertise will extend also beyond the country level: the IMCI 
Director of WHO/ AFRO for West and Central Africa has requested that QAP/Niger provide technical 
assistance for WHO-sponsored ET AT training in francophone Africa in 2007. 
Quality monitoring has presented a formidable challenge for the PHI collaborative in Niger, given the 
very rudimentary health information systems and low quality of medical records in most facilities. 
MOH/QAP coaches routinely verify the validity of self-collected data against the medical record during 
coaching visits. To ease the monitoring burden on collaborative participants and improve quality of 
monitoring, in 2006, the PHI monitoring framework and tools were simplified to measure ongoing 
improvement through calculation of average adherence with WHO case management standards (among a 
sampfo of randomly selected cases) in addition to existent measurement of proportion of cases treated 
according to standards, an "all or nothing measure" a:dopted at the outset of the collaborative. Average 
% compliance with pneumonia, malaria, and ETAT standards has ranged above 65% for the first half of 
2006, finishing at over 80% for all conditions by the end of Year Four. These results stand in sharp 
contrast to the 2003 PHI pre-assessment, in which proportion of cases meeting standards was less than 
15% for malaria and pneumonia and less than 5% for ETAT. It is hoped that the simplified monitoring 
tools will facilitate higher quality data collection. 
QAP Year Four Self Evaluation 7 
Recuperation of malnourished children as an integral part of PHI: 
In the wake of the 2005 food crisis, the PHI collaborative has rapidly 
expanded care for severely malnourished children in 50% of its sites 
(15 of 32 district hospitals) with supplemental funding from the Office 
of U.S. Foreign Disaster Assistance (OFDA) and UNICEF. 
Recuperation centers for moderately to severely malnourished children 
have been established in 15 PHI sites and rely heavily on PHI 
collaborative gains, infrastructure, and participant staff. At the end of 
the first quarter of the new PHI program, the 15 participating sites have 
demonstrated an average 58% compliance with WHO malnutrition 
recuperation standards, which represents solid progress in these district 
hospitals where recuperation services have traditionally been non￾existent and in which the PHI baseline survey demonstrated a less than 
5% compliance with WHO recuperation standards. In the spting of 
2006, malnutrition case-fatality rates averaged 14% in the 15 PHI sites 
Child recovering from 
malnutrition being weighed 
newly targeted for intensive recuperation services, as compared with case fatality rates over 40% in PHI 
sites without such services. In Year Five, UNICEF will provide supplemental funding to extend the 
malnuttition services to an additional six district hospitals, to reach 21 of the 32 PHI sites. 
Essential Obstetric and Newborn Care Collaborative 
The EONC collaborative was launched in January 2006 in 21 out of 33 district hospitals, four out of five 
regional maternity hospitals, and all three national maternity hospitals-facilities that cover seven of 
Niger's eight administrative regions. The EONC collaborative is being implemented in close 
collaboration with the MOH DSR as a series of phased cycles, with each cycle building upon the previous 
cycle. Table 4 summatizes the technical content and timing of the EONC cycles. 
Table 4. Niger: Technical Content and Timing of EONC Collaborative Cycles 
Phase I (current) Phase II 
Cycle I - Active management of the third stage of - Focused antenatal care (birth preparation 
(Approx. 12- 15 labor and risk factor identification; intermittent 
months) - Immediate and essential newborn care preventive therapy and malaria 
(thermal protection, eye care, early and treatment; tetanus vaccination) 
exclusive breastfeeding, BCG/oral polio - Correct use of the partograph 
virus, umbilical care) - Infection prevention II (sharps, waste 
- Infection prevention I (handwashing, disposal, high level sterilization) 
gloves, instrument decontamination) 
- Client satisfaction 
Cycle II - Improved management of obstetric complications (eclampsia, sepsis, hemorrhage) 
(Approx. 15 -18 - Improved management of newborn complications (asphyxia, sepsis, management of months) low-birth weight newborn) 
In the spring of 2006, a baseline survey was conducted in 15 new EONC district and regional level 
maternity hospital sites to identify critical gaps in maternal-newborn health service delivery and to guide 
EONC program planning and monitoring. Direct observation of 48 antenatal care sessions found low 
compliance with basic antenatal care services known to reduce maternal and neonatal morbidity and 
mortality: birth preparedness counseling, including recommendation for delivery at a skilled facility (2% ); 
screening and counseling for pregnancy danger signs, such as bleeding and pre-eclampsia symptoms 
(0% ); counseling for bednet use (0%) and treatment/counseling for anti-malarial intermittent preventive 
therapy (0%); routine hematocrit screening (20%) and prescribing of iron (46%); syphilis screening 
(10% ); and systematic screening of blood pressure (77%) for early detection of pre-eclampsia/eclampsia. 
8 QAP Year Four Self Evaluation 
The ability of 26 providers (five doctors, 20 midwives, and one nurse) to carry out active management of 
the third stage of labor (AMTSL) was assessed as part of a simulated case study using a pelvic mannequin 
in four regional maternity hospitals (MIG, MCZ, Magaria, and Maradi). As shown in Figure 2, only 35% 
of providers demonstrated immediate post-partum administration of oxytocin during a simulated case 
study and even fewer were able to demonstrate the elements of controlled cord traction, stabilization of 
the uterus, and appropriate removal of the placenta. Less than 15% of providers demonstrated appropriate 
hand washing and less than 42% demonstrated appropriate initial disinfection of scarce gloves in chlorine 
solution. Taken together these findings suggest that AMTSL and basic infection prevention measures are 
not routinely being practiced in Niger. 
Ill 
... 
Cl) 
80 
~ 60 
> 0 
~40 0 
<f!. 20 
Figure 2. Niger: Proportion of Providers Able to Demonstrate Sequential Steps 
of AMTSL per Standard 
0 
27 
In a simulated case study to assess essential newborn care among 18 doctors and 35 midwives randomly 
sampled from study facilities, 0% of doctors or midwives demonstrated all five elements of essential 
immediate newborn care (delivery onto abdomen, immediate drying with clean cloth, checking 
respiration, cutting cord with sterile blade, and establishing skin-to-skin contact before delivery of 
placenta), and only 50% of providers demonstrated all essential post-partum newborn care elements (eye 
care, vitamin k, examination and weighing of newborn, temperature verification, support for 
breastfeeding, BCG/OPV vaccination), despite solid evidence that low cost basic newborn measures can 
have a dramatic impact on newborn mortality in limited resource settings. 
Given the low quality of basic EONC services in even the higher level Nigerien facilities and the absence 
of quality training facilities for EONC anywhere in the country, one of the greatest challenges for the 
collaborative is the low number of EONC-trained providers. In the last quarter of Year Four, the EONC 
collaborative started the first stage of an aggressive, two -pronged training campaign: 1) formal training 
sessions for EONC providers from collaborative sites, held in two large regional maternity hospitals in 
the west and eastern extremes of the country (Niamey and Zinder) using expert clinician trainers, 
followed by 2) on-site continuous training and coaching to reinforce skills in the real-life settings in 
which providers work. The EONC collaborative is working closely with national experts and regional 
DSR officials to develop the Niamey and Zinder maternity hospitals as national EONC training centers. 
Following the sequence of topics shown in Table 4, training in the last quarter of Year Four (phase 1 of 
collaborative) targeted AMTSL and essential newborn care. Training sessions use mannequins and QAP￾produced job aids. EONC indicators tracked in the collaborative reflect current USAID core maternal and 
newborn health facility indicators, including the most recent AMTSL indicators recommended by 
USAID's Prevention of Postpartum Hemorrhage Initiative (POPPHI). To facilitate compliance with 
QAP Year Four Self Evaluation 9 
and monitoring of targeted EONC standards, 
QAP introduced locally produced ink stamps to 
add into partograph and antenatal records small 
boxes to record performance of essential 
elements of AMTSL and newborn care. A 
behavior change communication component for 
promotion of early and exclusive breastfeeding 
(currently< 1 %) is being introduced through a 
series of counseling posters targeting the 
antenatal and immediate post-partum periods. 
As of September 2006, 36 national EONC 
trainers (10 obstetricians, two pediatricians, and 
24 midwives) have participated in a training of 
trainers to prepare them as national expert 
trainers. These 36 EONC expert trainers have 
La mise au Sein Immediate Dans l'heure qui suit la naissance 
Counseling poster demonstrates immediate postpartum 
breastfeeding 
in tum trained 121 EONC providers from all 28 collaborative sites in seven of Niger's eight regions. 
QAP's Value-Added in Niger 
QAP has been working in Niger since the founding of the Tahoua Quality Assurance Project in 1993. 
The Niger QAP program has grown substantially in both technical breadth and geographic coverage over 
the past ten years to now cover over 60% of Niger's first referral facilities. QAP's sustained presence in 
Niger has fostered strong MOH institutional QA capacity at national and regional levels over the last 
decade, essential for scaling up improved maternal, newborn, and child health services in a country with 
very limited resources and among the highest mortality rates in the world. QAP gains are increasingly 
being institutionalized as part of routine MOH services (e.g., ETAT, AMTSL, essential newborn care), 
and full MOH leadership and ownership of collaborative achievements represents a leading goal for QAP 
in Niger. With its added focus on EONC and malnutrition in 2006, QAP's Niger program is now 
applying its extensive QA and in-country expertise to three of Niger's most pressing areas of need￾nutrition, maternal health, and newborn-child health. 
Rwanda 
During Year Four, QAP continued to support the Government of Rwanda in improving quality of care for 
HIV/AIDS and malaria services through a PMTCT-VCT collaborative in 37 sites (16 original+ 21 
expansion sites), a pediatric malaria care collaborative in 23 sites, and an antiretroviral therapy (ART) 
collaborative in 16 sites. In September 2005, the malaria collaborative was expanded to 31 additional 
health centers in the same four districts, raising the number of participating sites to 54. 
Because this was the final year of USAID field support for QAP in Rwanda, the project's efforts were 
also directed at institutionalizing the quality improvement methods applied and at identifying lessons and 
best practices emanating from these collaboratives. QAP provided technical assistance to the Ministry of 
Health to develop a written policy on quality management of healthcare and a national program for 
quality assurance. In September 2005, QAP trained a team of 25 local experts-staff from the original 
sites in the PMTCT and malaria collaboratives who best mastered the QA process and methods-to serve 
as coaches/mentors to two or three new sites. These local experts were asked to visit newer sites at least 
once or twice a month to provide encouragement and technical guidance in quality improvement. QAP 
also conducted three major QA trainings for MOH staff during the year. In October 2005, 27 staff 
members from the Central Hospital of Kigali, the Treatment and Research AIDS Center (TRAC), selected 
district management teams, and facilities were trained as quality improvement coaches for their respective 
institutions. In March 2006, QAP held a training of trainers for 10 national MOH staff and then another 
series of trainings during June-August 2006 for 45 MOH staff at the district level. In a separate effort, in 
10 QAP Year Four Self Evaluation 
April 2006 QAP responded to a request from Kigali Health Institute, which provides in-service training 
for doctors and nurses, for assistance in the revision of a training module on basic QA. These trained 
personnel will enable the sustained application of quality assurance approaches in Rwanda's newly 
decentralized health system. 
QAP's assistance to the Ministry of Health in conducting three national improvement collaboratives 
culminated in August 2006 with a one-day national conference on the results and lessons learned of the 
three improvement initiatives. Summarized below are the key results and changes introduced by sites 
participating in each collaborative to improve case management at the hospital and health center levels. 
PMTCT-VCT Collaborative 
Figures 3, 4, and 5 show the progression of key indicators that have been monitored by teams, with data 
pooled for the original sites (old sites) and for the expansion sites (new sites) which joined the 
collaborative at the end of 2004. Solid lines refer to percentages and are read on the left hand axis, while 
dotted lines are the corresponding denominators, graphed on the right hand axis of each graph. Generally, 
the new sites have shown very good results, with 2006 data for all indicators reaching levels comparable 
to levels achieved by the original sites after a longer period of intervention. Though old sites and new 
sites did not start out at the same level for all indicators, in many cases, new sites have achieved 
improvement in less time by implementing best practices developed by the original sites. In some cases, 
collaborative data compare very favorably with countrywide TRAC data. For instance, the TRAC 2005 
Annual Report noted that 47% of HIV-positive women deliver at health facilities, while original 
collaborative sites reported 69% in 2005 and 80% in 2006 (60% for new sites). In addition, the 
percentage of HIV-positive women who took nevirapine (NVP) during labor reached 98 % in original 
collaborative sites (new sites reached a level of 96%) in 2005 and 92% in 2006. This compares favorably 
to the 58% reported in TRAC's 2005 report. 
Figure 3. Rwanda: Percentage of Partners of Women Tested for HIV who Are Also Tested 
--Old sites:% of partners tested --New sites: % of partners tested 
•Old sites:# of women registered in ANG and tested •New sites:# of women registered in ANG and tested 
100 -,-------------------------------------~ 2,500 
90 
80 '# • 70 
'"•, •'· ---, ... ----------~----.~-.-----~-,~---~----- ',__ __.'-,,-.__~----+ 2,000 
, ' # 
• .. 
60 ' # +------;;-,-,--.-..--::-..,----,,.---------------- -"-------;.---~--'-. -/.;'1l"-:;,.....;1<---==---t 1,500 
50 " 
40 
30 
20 
10 
JFMAMJJASONDJFMAMJJASONDJFMAMJJASONDJFMAMJ 
The key improvement changes made by teams to expand uptake of HIV testing and improve PMTCT 
services are summarized in Table 5. A number of the changes that collaborative teams successfully 
tested have been adopted nationally. For example, the national norm is now for health facilities to 
provide HIV test results on the same day as the test, to give NVP at first contact (the same day as an HIV￾positive test result is given), and to give written invitations to partners to be tested (a change developed by 
the collaborative's Kabgayi site that was then replicated in other sites through the collaborative structure). 
Other changes, such as systematic invitation to partners to accompany the woman on her first prenatal 
visit and making a list of HIV-positive women expected at the facility's delivery room, are currently in 
the process of being accepted nationally. 
QAP Year Four Self Evaluation 11 
Figure 4. Rwanda: Percentage of HIV-positive Pregnant Women Given Nevaripine to Take Home in 
Case of Home Delivery, Jan. 2003-June 2006 
100 
90 
80 
70 
60 
50 
40 
30 
20 
10 
100 
90 
80 
70 
60 
50 
40 
30 
20 
10 
I 
-Old sites:% of HIV-positive pregnant women given NVP to take # ., I I 
home --New sites :% of HIV-positive pregnant women given NVP to take ' 
home ~~~~~~~~~~~~~~~~--J 
• • •Old sites:# of HIV-positive pregnant women seen 
• • • New sites:# of HIV-positive pregnant women seen 
JFMAMJJASONDJFMAMJJASONDJFMAMJJASONDJFMAMJ 
2003 2004 2005 2006 
Figure 5. Rwanda: Percentage of Children Born of HIV-positive Mothers Tested at 15-18 
Months 
- Old sites: % of infants of HN-positive mothers tested at 1 5-18 months 
- New sites:% of infants of HN-positive mothers tested at 15-18 months 
80 
60 
40 
AMJ J ASONDJ FMAMJJA SO ND MAMJJA SON M A M J J 
200 200 2005 200 
The strategy of using an extranet site for sharing data among teams was initiated in August 2005 at the 
demonstration phase (old) sites. Eight sites began to share their indicator data through the Extranet site 
regularly within a few months. Dependence on the Extranet for data sharing was discontinued in 
February 2006, due to factors including turnover in information technology support at QAP's Rwanda 
office, inefficiency of slow connections, and frequent electricity blackouts. 
Malaria Collaborative 
Based on the results presented by teams at the fifth learning session of this collaborative in May-June 
2005, the National Malaria Control Program (PNLP) of the MOH decided to extend the collaborative to 
most of the health centers in the four districts. Best practices implemented by the initial sites were 
identified and discussed at the fifth learning session, to serve as the focused technical content for new 
sites (see Table 6). 
12 QAP Year Four Self Evaluation 
Table 5. Rwanda: Best Practices for Improving PMTCT Services Implemented through the 
Collaborative 
Objective Changes Introduced 
Increase HIV - Increase# of ANC sessions per week to receive fewer clients per session so as to 
testing of women increase length of counseling session per client 
in prenatal care - Send HIV test blood samples to lab as they are taken rather than in batches 
- Analyze HIV test blood samples as they arrive in lab rather than in batches 
- Reduce staff lunch tirne to snack break (so that all clients receive post-test counseling 
the sarne day) 
Increase partner - Counsel pregnant women on importance of partner testing and the issue of discordant 
testing HIV test results in a couple 
- Make partner testing available 7 days a week 
- Deliver written invitations to partners 
- Horne visits to sensitize partners 
- Reorganization ofreception (priority testing given to partners) 
- Add partner code on liaison form to identify women whose partners have not yet tested 
in order to reinforce sensitization 
- Participation of a health center agent at community meetings to talk about importance 
of HIV testing and need to accompany women to the first ANC visit 
- Keeping ANC carnet and/or liaison card at health center and inviting partners to 
retrieve thern, using this as an opportunity for sensitization 
- Meeting and sensitization ofrnen/partners after umuganda (community work) 
Increase % of - Instructive meetings to remind staff of their role in assuring that women be given NVP 
pregnant women Reinforcement of staff skills and capacity in PMTCT counseling, delivery norms and 
who take procedures, lactation, and feeding of newborns of HIV-positive mothers 
nevirapine at - Posting of job aids in the delivery roorn 
delivery - Add columns to HIV-positive ANC register to add information on patient address, 
appointment date, date NVP received 
- Improve appointment system for HIV-positive women to keep track of and follow-up 
on women who rniss appointments 
- Give NVP at first contact and confirm possession of NVP during following visits 
Improve follow- - identification of children born of HIV-positive mothers for follow up, 
up of children - Systematic request for liaison card of mothers who corne for vaccinations 
born to HIV- - Improve tracking system to identify all children who need to be tested 
positive women - Horne visits and active search of children lost to follow-up 
- Use ofrneetings of associations of parents adhering to the program as opportunity to 
sensitize families and to test the child 
The district medical officer and supervisor in each of the four districts worked with QAP to identify 17 
local experts from among the initial teams. These collaborative experts were then trained in coaching 
techniques in September and October 2005 and made visits to the new sites, accompanied by QAP staff, 
in November and December 2005, to collect baseline data, orient new teams to the best practices to be 
introduced, and show new teams how to monitor the indicators used in the collaborative. The sixth 
learning session of the malaria collaborative was held separately in each district in April and May 2006. 
Bringing together the district hospital team and old and new teams from most of the health centers in each 
district helped participants to better understand problems in the continuum of care. For instance, the 
presenter from Ruhengeri district hospital observed, when showing data on case fatality due to severe 
malaria, that patients referred from health centers were typically arriving in a very severe condition, 
which then led to discussions with health center staff on why referrals were given so late. Such 
discussion helped providers at both levels of care to understand how to work together more effectively. 
QAP Year Four Self Evaluation 13 
Table 6. Rwanda: Best Practices for Improving Pediatric Malaria Services Implemented through 
the Collaborative 
Objective Changes Introduced 
Increase timely - Health center staff take advantage of windows of opportunity such as well child check￾care-seeking for ups, treatment visits, and vaccinations to reinforce importance of taking children to the 
children with health facility within 24 hours of fever 
fever - Information/education through faith organizations and places of worship 
- Promotion of community-based health insurance schemes 
Improve malaria - Reinforcement of malaria case management norms through staff refresher training 
case meetings and collaborative learning sessions 
management at - Re-assignment of skilled staff to patient consultations 
facilities - Posting of flowcharts and job aids in consultation rooms 
- Improvements to the patient visit registration system 
- Designation of a staff person to supervise each child's intravenous therapy and take 
vital signs every 6 hours 
Reduce case - Introduction of triage system and giving priority to children 0-5 years old 
fatality through - Work schedules and task assignments reviewed regularly and reorganized to assure the 
prompt triage presence of skilled personnel and availability of lab services on weekends and holidays 
and treatment 
Figures 6 and 7 show the final data related to two key objectives of the collaborative: improving timely 
care-seeking by mothers and malaria case management. The final learning session, held in July 2006, 
brought together representatives from the four districts to review the monitoring data and best practices 
emerging from the improvements that teams tested. 
At the final collaboratives conference in August 2006, the MOH publicly acknowledged the contributions 
of the malaria collaborative. The PNLP has integrated one of the indicators that was first tested in the 
collaborative into the national health information system: % of children 0-5 years old who were taken to 
the health center within 24 hours of presenting with fever. In addition, beginning in October 2005, the 
PNLP itself started to provide basic QA and collaborative training in other districts, with technical 
support from QAP. Training participants have included health center providers and district health 
management teams in 13 of Rwanda's 39 districts. The PNLP hopes to attract new donor funds to 
support continued quality improvement activities for malaria care in these districts. 
Figure 6. Rwanda: Percentage of Children 0-5 Years with Fever that Were Taken to a Health Center 
in the First 24 Hours, May 2003-June 2006 
-old sites 
- new sites 
-- •old sites:# cases analysed in the month 
100% - - • new sites:# cases analysed in the month 
-- 120( 
90% 
80% ~ 100( 
/ ,''./ 70% / .. rJ. 800 
60% .~ I I 
I I ~ I ' I,' ' 50% ' - . 600 
~ . ' - -- fi' -- • • 40% - . ' - ~ • - ./_ • -- 'II. -:. ~ . - 400 - - -- - - .. - - - - . - - - -- . -.. . ' 30% .. 20% 
____,, - / 
200 
10% 
0% 0 
J F M A M J J A s 0 N D J F M A M J J A s 0 N D J F M A M J 
14 QAP Year Four Self Evaluation 
Figure 7. Rwanda: Percentage of Children 0-5 Treated at Health Centers According to Malaria 
Case Management Standards, January 2004-June 2006 
100% 
90% 
80% 
70% 
60% 
50% 
40% 
30% 
20% 
10% 
0% . -.... • . • 
-old sites 
- new sites 
• • • new sites:# children 0-5 yrs admitted with malaria 
•#children 0-5 yrs admitted with malaria 
MJ J ASONDJ FMAM J J ASON D J F MAMJ JASON D J FMAM J J 
2003 2004 2005 2006 
ART Collaborative 
500 
Fourteen sites continued participating in the ART collaborative during the year. A problem for the 
collaborative last year was the lack of physician participation on the improvement teams. In August 
2005, in preparation for the fourth learning session, QAP staff visited sites attempting to sensitize doctors 
to become more involved in the collaborative. During the fourth learning session, held in September 
2005, teams confirmed problems with lack of commitment to QI work. Many teams reported that they 
were not meeting regularly and only four out of 16 initial sites were able to collect indicator data Only 
three doctors participated (among 27 participants), and all were from the same hospital. 
To address these obstacles, QAP staff asked sites to assemble a list of problems they had with ART. Each 
site decided which problems they wanted to work on (e.g., waiting time, home visits) and formulated 
objectives and indicators. Sites monitored three common indicators as well. Teams found that sharing 
information helped to identify system problems. For instance, sites noticed that the indicator for increase 
in CD4 count had decreased in all sites. After inquiring at the national laboratory, they found out that the 
sole CD4 machine had malfunctioned and was giving false results. 
By learning session five in February 2006, three sites were represented by doctors, and by the sixth 
learning session in July 2006, doctors represented four sites. Sites found that they were able to reach 
some of the targets defined at the fourth learning session. Sites also shared their experiences with dealing 
with site specific issues. For instance, the Masaka health center team noted after reorganizing their 
services that they were missing some patients whose CD4 counts were still above 350/mm3 (i.e., not yet 
eligible for ARV treatment). These patients were not coming in for appointments to monitor their CD4 
count levels, and as a result some came when they were in advanced stages of AIDS. The team began 
monitoring more carefully the percentage of such patients that showed up to their appointments and 
improved counseling to HIV-positive patients not yet eligible for ART. After they shared their results, 
other sites started implementing the same changes, and by the sixth learning session, five sites were 
reporting on this indicator (see Figure 8). 
QAP Year Four Self Evaluation 15 
Figure 8. Rwanda: Percentage of Patients with CD4 >350 who Adhere to their Appointments (5 
Sites), July 2005-July 2006 
100% --% of patients with CD4 >350 who adhere to their appointments 
90% -- •#of patients with CD4 > 350 - - / 
/ .. - 80% 
- / - .. 
"" /·-.. .. .. .. ... - --- .. I 
- - . -
70% 
60% 
50% I 
40% ' • 
30% • 
I 
20% I .. -.. .. - - - - - - - - 10% 
0% 
Jul-05 Aug-05 Sep-05 Ocl-05 Nov-05 Dec-05 Jan-06 Feb-06 l\/ar-06 Apr-06 l\/ay-06 Jun-06 Jul-06 
300 
250 
200 
150 
100 
50 
0 
However, not all indicators showed improvement. Two objectives in particular were not easy to improve: 
"100% of patients on ARVs for 12 months had (any) increase in CD4 count" and "100% of patients on 
ARVs for 12 months had increase in body weight." As seen in Figure 9, sites found that their ability to 
influence this outcome was affected by factors that are beyond their influence, such as stage of infection, 
nutrition (not all sites have nutritional support), and drug resistance. During the final learning session, 
teams discussed what successful changes they had introduced to improve ART services. These are 
summarized in Table 7. 
Figure 9. Rwanda: Percentage of Patients on ARVs at Least 12 Months Showing CD4 Increase, 5 
Sites 
100% .- ~~~~~~~----1 --% of patients on ARVs for at least 12 months with an increase in CD4 count 250 - - • # of patients on ARVs at least 12 months 
90~o -+-~14-~~~~~-a-~~--1-----~~-f-I-~~~~~~~~~~~~~~~~~~~~~----< 
so% +---1-+~~~~~1-+-~~--1-~-\-~f-'1----1-\-~__,,~~~-"-~~~~~~~~''-"-~~~~-+-200 
70% -+----o-~..---.r--..-~---.-+~----jf--~--+-----f~-t--1---+-~f--~~~~-.-~---~~~------..-tt-~~~ .. ~~--; 
60% +--f-~~~-\-~-l---+-~-1-~~-\--l---+-f- -\-1-~~~~~-+~-l----lL'~~__,_-+ ~~---=---t- 150 
50% +--+-~~~~-\--+-~+--1--~~~H-~--\-;J--~~~~~~~~+-Jlr--~~~~~---\-~~-----j 
40% -+--+-~~~~.._._~__,__,,__~~~~~~~~~~~~~~~~~~~~~~~~~~100 
30% -+--1-~~~~----'0--~~~~~~~~~~~~~~~~~~---~~~~~~~~~~----< 
' 20% -+-+-~~~~~~~~~~~~~~~~~~~~~~~-.~~~~~~~~~~~~-+-50 
0 
Technical Assistance in QA Policy Development 
In 2005, the Ministry of Health requested QAP assistance to develop a written policy on quality 
assurance, a document laying out a national QA program, and a strategic plan for assuring quality 
throughout the health system. In 2006, the Ministry's needs changed from a document focused 
exclusively on QA to one focused on quality of care and including quality assurance, performance-based 
16 QAP Year Four Self Evaluation 
Table 7. Rwanda: Changes Introduced through the Collaborative to Improve ART Services 
Objective Changes Introduced 
Improve - . Staff trained to expand topics on which ARV patients are counseled to include 
quality of care importance of adherence to ARV regimen, CD4 testing, keeping appointments, 
forPLWHA maintaining health, secondary effects of ART, and information about associations of 
people living with HIV/AIDS 
- Increase the number of rooms where ARVs are distributed to reduce waiting time 
- Reduce frequency of appointments for patients who have been on ARVs for> 1 year and 
adhere to treatment very well 
- Completion of files during patient's consultation 
Improve - Monitoring of medical records for completeness 
patient follow- - ARV distribution schedule explained to clients 
up (for CD4 - Scheduling ARV distribution and CD4 testing on the same day 
testing and - Enrolling patients in ARV program the same day as HIV-positive test results given 
ARV - Schedule monthly meetings of HIV-positive community-based supporters (guardiens) adherence) with patients 
- Home visits to patients who miss appointments, one week after appointment 
financing, and mutual health organizations. QAP worked with the Promotion of Quality Care Department 
and other stakeholders to develop a single, comprehensive policy on quality management, which allows 
for integrated efforts to improve and sustain the quality of care for the people of Rwanda. The policy 
document has been officially accepted by the Ministry of Health (May 2006), and the Quality 
Management Program document is nearly completed. The latter outlines strategic directions and specific 
results, strategies, and activities and specifies roles and responsibilities of all key health system actors 
related to quality management. The fact that quality of care is viewed by the Ministry as the 
responsibility of all health system actors paves the way for more sustained efforts to improve and 
maintain quality. In Year Five, QAP will assist the Government of Rwanda to develop a detailed, five￾year strategic plan for quality management. 
QAP's Value-Added in Rwanda 
Rwanda has changed by leaps and bounds in the last decade in nearly every arena--notjust in health. This 
is due to the will of the Rwandan leadership to build the country after the genocide, supported by a great 
number of multilateral and bilateral aid organizations. As aid dollars continue to pour into this stable 
country with competent leadership, visible improvement in all arenas should be expected. Against this 
backdrop, QAP has contributed in several important ways. Early on, QAP demonstrated that teams of 
facility staff could be trained and orga.nized to institute measurable improvements in healthcare, and tI!at 
this process empowered teams. In the last few years, QAP has demonstrated that the collaborative 
methodology can extend quality improvement at large scale in a relatively short period of time, with I 
measurable results. In the last 18 months, QAP had an all-Rwandan technical staff, trained and supported 
a cadre of district-level local experts to support teams, trained QA trainers and coaches at key institutions, 
helped to incorporate QA into in-service training, and assisted the MOH to formulate a written policy and 
implementation plan to support quality assurance. Spreading QA is ultimately about teaching health 
personnel at all levels to improve on their own performance. While this may not have been the optimal 
moment to end the three collaboratives, QAP has passed on the experience, knowledge and demonstrated 
value of quality assurance to all levels of the Rwandan health system. 
South Africa 
Between October 2005 and September 2006, QAP continued to help the National Department of Health 
(NDOH) of the Republic of South Africa to expand the provision and improve quality of HIV I AIDS 
services in four provinces: Mpumalanga, KwaZulu-Natal, Limpopo, and the Eastern Cape. Due to 
PEPFAR reporting requirements and provincial rezoning, fewer facilities were supported by QAP during 
QAP Year Four Self Evaluation 17 
Year Four. QAP staff provided direct assistance to 96 health facilities in the four provinces: 33 facilities 
in three districts (Gert Sibande, Ehlanzeni and Nkangala) in Mpumalanga; 25 facilities in two districts 
(Uthungulu and Sisonke) in KwaZulu-Natal; 11 facilities in two districts (Greater Sekhukhune and 
Bohlabela) in Limpopo; and 27 facilities in two districts (Chris Hani and the Nelson Mandela 
Metropolitan Area) in the Eastern Cape. Discussions with provincial staff have culminated in agreements 
to expand QAP assistance to additional facilities within the next year. With the appointment of a new 
provincial QA coordinator in April 2006, QAP resumed its program of assistance in Bopherima district of 
the North West province; 14 facilities in two sub-districts have been targeted for QAP support. 
In response to USAID directives, QAP's technical assistance has focused on increasing the uptake of 
services related to HIV counseling and testing, the prevention of mother-to-child transmission of HIV 
(PMTCT), HIV and tuberculosis (TB) service integration, antiretroviral (ARV) treatment, and palliative 
care and support activities for persons living with HIV/AIDS (PLWHA). This is being achieved through 
the provision of technical support and assistance to health facility staff in operationalizing national 
guidelines and protocols for specific HIV programs. QAP staff train and mentor district managers, 
facility-based health staff, and community-based organization (CBO) staff to use data to review the 
performance of current systems (case management, laboratory, pharmaceutical, information systems, 
planning and evaluation, etc.), identify gaps, and develop strategies to improve performance. QAP staff 
makes monthly or quarterly visits to all facilities and Local Service Areas participating in the program. 
Box 1 illustrates the kind of support that QAP provides to the assisted facilities. 
Box 1. Facility Results in South Africa: Driefontein Health Center in Mpumalanga Province 
Driefontein Health Center is situated in the Gert Sibande district, within Mpumalanga province, serving a 
community of approximately 50,000 people. Within the province, the HIV sero-prevalence rate amongst 
pregnant women is 30.8%, indicating a dire need for improvement and strengthening of the PMTCT 
program. Through the leadership of Mrs. Maria Fakude, the provincial QAP Coordinator, in 
collaboration with the Department of Health QA Coordinator, the quality of the PMTCT program has 
improved significantly. By promoting HIV counseling and testing for all pregnant women at their first 
antenatal visit, the HIV testing rate has improved from 23% in October 2005 to 78% in March 2006. In 
addition, the emphasis on compliance with guidelines for facility staff has led to an increase in the 
administration of Nevirapine to all HIV-infected pregnant women and their babies from 151to207 in the 
first two quarters of 2006, a 25% increase. According to data collected from registers and from patient 
record audits, all babies born to HIV-infected mothers are now receiving Nevirapine prophylaxis at the 
health center. 
In line with the national PMTCT guidelines, facility staff has been educated about the need to perform 
clinical staging and CD4 counts on all HIV-infected pregnant women and to refer for ART when 
appropriate. Through ongoing support and mentoring, the compliance with clinical staging of HIV 
infected pregnant women has increased from zero at the end of 2005 to 67% in the 2nd quarter of 2006. 
CD4 count testing has increased from 33% to 100% in the same time period. Facility staff has also been 
educated about the need to provide opportunistic infection prophylaxis to all HIV-exposed babies at six 
weeks and to inform mothers about PCR testing of their babies. The initiation of this service has shown 
some improvement from eight to 28 infants in the first two quarters of 2006. 
During a recent assessment of the value added by QAP, the Driefontein Health Center manager said, 
"Through the monthly support visits QAP has provided guidance, information, and training on national 
guidelines. This has resulted in improved record keeping, improved compliance with national guidelines, 
improved management and care of mothers and children and better insight into the care of HIV/AIDS 
clients and the correlation between TB and HIV. QAP has also influenced improvement in all programs 
at the facility such as chronic care, family planning and minor ailments." 
18 QAP Year Four Self Evaluation 
QAP's results with respect to planned targets are summarized in Table 8. QAP far exceeded the set 
targets in all five HIV/AIDS programmatic areas, making particular gains in the areas of TB-HIV, 
PMTCT, and ART services (areas where targets were not met in Year Three). 
Table 8. South Africa: QAP's HIV/AIDS Service Targets and Achievements, Oct. 2006-Sept. 2006 
Planned Targets Accomplished Targets 
HIV/ AIDS Service Area (Oct 2005-Sept. 2006) as of Sept. 2006 
Counseling and Testing 
# service outlets 100 96 
# clients pretest counseled - 85,676 
#clients tested and post-test counseled 18,000 - 64,853 
# clients tested HIV-positive - 27,997 
PMTCT 
# service outlets 100 88 
# pregnant women pretest counseled - 22,424 
#pregnant women tested and post-test counseled 20,000 21,438 
# pregnant women tested HIV-positive - 9,907 
# women provided with NVP 5,000 8,687 
#babies provided with NVP - 9,046 
Basic Health Care and Support 
# service outlets - 85 
#clients provided with basic health care and support - 24,391 
#clients on ART readiness program - 25,301 
HIV-TB ' 
# service outlets - 89 
#clients provided with HIV-TB services - 7,095 
ART 
# service outlets 5 23 
#clients on ART 1500 ~1 • 9,820 
#clients screened for TB before ART initiation - 5,496 
Counseling and Testing 
QAP is working with the local health 
departments to ensure that appropriate 
systems are in place to increase the 
availability of high quality counseling 
and testing services. In the past year, 
QAP supported 96 facilities that 
counseled over 85,676 individuals, a 
29% increase over last year's level. On 
average, 76% of those who received pre￾test counseling accepted an HIV test and 
received post-test counseling. Of those 
tested, 43% were found to be HIV￾positive. Figure 10 shows increased 
uptake of counseling and testing in the 
QAP-assisted facilities in Limpopo 
Province. 
Figure 1 O. South Africa: Number of People Provided with Counseling 
and Testing in Limpopo, 2006 (12 Facilities) 
QAP Year Four Self Evaluation 
1st Qtr 
o Pretest counselled 
• Post test counselled 
2nd Qtr 3rd Qtr 
• Tested for HIV 
DHIV+ 
19 
PMTCT 
QAP is covering 88 facilities in the country to provide quality PMTCT services. Some 21,438 pregnant 
women received an HIV test and post-test counseling, out of which 9,907 (46%) tested positive. Of these 
women, Nevirapine was provided to 88%, demonstrating a marked improvement in compliance with 
national guidelines among facility staff. The compliance rates with screening for sexually transmitted 
infections (STis) and counseling for infant feeding options have increased significantly in participating 
facilities. Also, the proportion of antenatal care (ANC) clinic attendees accepting counseling and testing 
is also rising, as is follow-up of babies born to HIV-positive mothers at community health centers. 
Palliative Care - Basic Health 
Care and Support 
QAP assisted 85 facilities in 
improving quality of basic health care 
and support services to PL WHA. The 
focus has been to improve the early 
detection and treatment of 
opportunistic infections, nutritional 
support systems, and palliative care 
and to increase home-based treatment 
of diarrhea and use of prophylaxis. 
Over 24,391 individuals have received 
support through these facilities. 
During the past year, facilities in the 
Eastern Cape made particular gains in 
provision of support to PLWHA (see 
Figure 11). 
Figure 11. South Africa: Number of HIV-positive Persons Receiving 
Ongoing Counseling and Support, Eastern Cape, 2006 
20000 
15000 
10000 
5000 
1st Qtr 06 2nd Qtr 06 3rd Qtr 06 
During this reporting period, QAP also supported two community-based organizations (CBOs) that 
provide home-based care in two provinces in order to improve the continuum of care for PL WHA. While 
this has been a challenging process, key issues such as communication, integration of services and referral 
of clients between different levels of care have shown improvement. Ongoing support and mentoring is 
being provided by QAP staff, both to individual facilities and to the two CBOs. 
Palliative Care -TB-HIV 
QAP is working with health 
facilities to improve operational 
policies and guidelines to increase 
cross-referrals between HN and TB 
facilities. A major challenge to 
improving TB services for HN￾positive patients is lack of national 
guidelines and directives to support 
this program. QAP staff worked in 
89 facilities in the past year and 
supported over 7 ,095 RN-positive 
Figure 12. South Africa: Referrals of TB Patients for HIV 
Testing, KwaZulu-Natal, 2006 
1800 ,--------------------, 
1600 +-------------
1400 +-------------
1200 +--------
1000 
800 
600 
400 
200 
0 
patients for TB screening, treatment, F--:7-i:i'=':.::;;~::::::.::~"'-:::-:::';~=~:~T-=·~.'-"'~:;,;,~~7-iv-"' 10
="u"""-f------'::':'~--+---==51=----1----':7:11:=----1 
and follow-up. QAP is also 
promoting wider HIV screening of 
TB patients. Figure 12 shows the increase achieved this year in the number of TB patients referred and 
tested for HIV in KwaZulu-Natal. The proportion of TB clients referred who actually were tested 
increased slightly over last year, to 56%. 
20 QAP Year Four Self Evaluation 
ARV Services 
QAP is helping the NDOH, local health departments, and other stakeholders in operationalizing national 
protocols on ARV treatment. We are assisting stakeholders in developing a continuum of care model to 
ensure that ARV clients receive optimal care at all levels of care. We are assisting facilities to utilize 
patient records and information systems to ensure that each patient receives quality care. We are also 
helping facilities develop linkages with CBOs to provide community-based support to ensure patient 
adherence with ARV treatment regimens. In the past year, QAP worked with 23 facilities that served 
9,820 people on AR Vs, a 142% increase over the number of patients provided with ART in QAP-assisted 
facilities last year. 
QAP's Value-Added in South Africa 
QAP has continued to work closely with the National Department of Health in South Africa to develop 
and adapt a large number of standards, guidelines, and protocols for various HNI AIDS comprehensive 
treatment, care, and support services. QAP staff work closely with the provincial and district staff to 
provide ongoing mentoring support to ensure that HIV I AIDS services are integrated with the regular 
health services at the facility level. QAP continues to add value by helping the NDOH make health 
services at the facility level and health systems at the district level, functional. District level supervision 
and inf01mation systems are being greatly improved to provide ongoing mentoring and support to facility 1 
staff. Integration of services at the facility level has also improved, ensming that PL WHA receive high 
quality services at different stages of disease and at different levels of the health system. 
Tanzania 
In Year Four, QAP implemented three major activities in Tanzania: 1) continuing the pediatric AIDS 
hospital improvement collaborative in the six original hospitals and assisting the Ministry of Health and 
Social Welfare (MOHSW) to expand the collaborative to 12 new sites in northern regions, 2) concluding 
the family planning collaborative in 15 facilities in Dar es Salaam region, and 3) supporting the training 
of PMTCT staff in five regions to use the HIV-infant feeding job aids developed by QAP in Year Three. 
Pediatric Hospital Improvement and AIDS Care Collaborative 
During the past year, QAP's technical support focused on strengthening the capacity of the six hospitals 
participating (Amana, Temeke and Mwananyamala Municipal Hospitals, Morogoro Regional Hospital, 
Tumbi Special Hospital, and Kilimanjaro Medical Center) to use the WHO HIV screening algorithm 
which was adapted for Tanzania in Year Three and to routinely place HIV-exposed children on 
cotrimoxazole prophylaxis. 
The HIV screening algorithm enables health providers to more readily identify, test, and refer HIV￾infected children to HIV Counseling and Treatment Centers. Emphasis was placed on reaching more 
children by including outpatient, PMTCT clinics, and reproductive and child health clinics as entry points 
where the HIV screening algorithm could be used. QAP also worked with hospital staff to map 
community-based organizations providing HIV/AIDS care in order to foster stronger links with such 
groups for follow-up of HIV-infected children diagnosed and treated in the hospitals. 
The collaborative also introduced at the November 2005 learning session, a pediatric admission job aid 
and critical care pathway for hospitalized children, both adapted from QAP's work in Malawi. The 
critical care pathway (CCP), a form that tracks each child's care over the duration of hospitalization, and 
accompanying forms to monitor completion of CCPs in each hospital, were introduced in the fourth 
learning session in November 2005. The CCP serves as a job aid and case management record, 
prompting hospital staff to record, each day, medications and therapy administered, physical condition of 
the child, vital signs, and lab results. QAP worked with the participating hospitals to put in place 
procedures for routinely monitoring a sample of CCPs for compliance with case management guidelines. 
By the fifth learning session in April 2006, sites began reporting compliance data (see Figure 13). 
QAP Year Four Self Evaluation 21 
Based on the positive results of the PHI 
collaborative in these hospitals, the 
MOHSW asked QAP for assistance in 
extending the pediatric AIDS and hospital 
improvement work to 12 hospitals in the 
Arusha and Tanga regions of northern 
Tanzania. In their first learning session, led 
by the MOHSW with support from QAP in 
December 2005, the new teams were 
oriented to the Referral Care Manual, ET AT 
and QI concepts, how to apply the baseline 
facility assessment tool, and improvements 
in pediatric patient flow that were developed 
in the original sites. During their first action 
period, these sites implemented ET AT 
training for pediatric staff and made 
infrastructure changes to facilitate new 
patient flow patterns and create suitable 
spaces for care of pediatric emergencies. 
Pl P2P31iA.YiE. ... _, -- ··-·· -··· -··~ 0..tutt.i1h I I AG E..-... I.Of Ottu rAdtriu ion I I H~n ~.io. •• _________ • PAECtATRlCCCP wor.-n...d DD ,.., , c-A O-""S 
lllU: 6 tv - I 10 : 2" IQ 10 2 I 
l lG.\V 
1ar..:.rnZlhcin Yl1f 
~ ~ Utte ·~..., ..,. 
:.l:ld''" tt~..,,..-.H tu 
YM 
le YI/I 
PfO 
Critical care pathway introduced in Tanzania in Year Four. 
en 
"'C "'C .. Q) co 
Figure 13. Tanzania: Compliance with Case Management Standards, 
Four PHI Hospitals, April-August 2006 
Q) == "'C c ·-> co 
.... a> en '".t::: 
U) .~ 
3l == co Ol 0 c: 
'O~ 
~ 0. o E 
0 
0 
Apr-06 May-06 Jun-06 
Month 
Jul-06 
_._ Malaria 
Aug-06 
QAP and MOHSW IMCI staff strengthened facility QI teams through training and on-site coaching as 
well as monitoring the progress of implementation of improvement activities. The initial sites continued 
to strengthen their triage process and management of children with emergency conditions, and over the 
year reduced to 6% the proportion of admitted children not triaged according to guidelines. Quality 
improvement changes made by these hospitals included introducing pediatric side laboratories for 
children to take care of basic laboratory tests, meetings between PHI teams and AIDS treatment center 
staff to improve coordination of care, and stronger advocacy with hospitals' Health Management Teams 
to take into account pediatric care needs in main budgets and procurement plans. The latter efforts have 
enabled the procurement of oxygen concentrators, oxygen cylinders, laboratory supplies, drugs and other 
medical supplies needed to care for critically ill children. 
The introduction of the HIV screening algorithm has contributed to improvements in the detection of HIV 
infection and improved management of children with HIV infection. At a national level, out of the 
approximately 50,000 clients commenced on ARV treatment, 12% are estimated to be pediatric, a bit 
short of the 20% target set by the MOHSW. Data collected from five original collaborative sites 
(presented in Figure 14) show a total of 1508 children were suspected to have HIV infection based on the 
22 QAP Year Four Self Evaluation 
screening algorithm. Of these, 1190 were tested, 553 were found to be HIV-positive, and 527 (95 % of 
those HIV-positive) were referred to treatment centers for ART and cotrimoxazole prophylaxis, subject to 
eligibility. Irregular supply of HIV testing reagents contributed to fluctuations in the numbers of children 
tested from month to month. 
"' 250 .... 
c: 
Cl) 200 ·~ 
0.. 150 
-0 
... 100 Cl) 
.c 
E 50 
:l 
z 0 
Figure 14. Tanzania: Screening of Pediatric Patients for HIV in Five PHI 
Hospitals (July 2005 - June 2006) 
Jul-05 Aug Sep Oct Nov Dec Jan,06 Feb Mar Apr May June 
Months 
Suspected - Tested Positive 
Family Planning Collaborative 
Initiated in Year Three with core funding, the family planning (FP) collaborative expanded in Year Four 
with field support to include six new facilities, raising to 15 the total number of facilities participating in 
Dar es Salaam region. Three learning sessions were held at which old and new teams shared ideas for 
addressing quality aspects of family planning services, including increasing client privacy; reducing stock 
outs and increasing method mix; improving knowledge and skills of service providers; improving client 
counseling and screening for medical eligibility; and reducing missed opportunities for FP and HIV 
services within each facility. To address the problem of lack of FP job aids and counseling materials, 
QAP worked with the MOHSW to develop and field test an All Methods Brochure. Other FP 
stakeholders were involved in the review stages of the brochure, which the MOHSW has now adopted. 
The collaborative held its final learning session in July 2006, at which teams developed plans for 
continued advocacy and resource mobilization for FP capacity development, monitoring of compliance 
with FP standards, and sharing of lessons learned and experiences. Major achievements of the 
collaborative included: reduction of FP commodities stock-outs through tracking of FP methods 
dispensed and timely requisition of supplies (see Figure 15); improved client counseling and screening 
for medical eligibility using WHO criteria; increase in client access to preferred method of FP; increase in 
the number of referrals from the under five clinic attendees; improved patient privacy; improved record 
management; and a slight increase in the number of new users of FP in the facilities. Despite the 
improvements made, some constraints within the service provision environment made it impossible to 
achieve the objective of reducing missed opportunities for FP services. The proportion of total 
Reproductive and Child Health Services clients who were new or continued FP users remained stagnant. 
During the final learning session of the collaborative, attended by senior officials of the MOHSW and the 
Dar es Salaam Regional Health Office, all tools developed in the collaborative for baseline FP services 
assessment, monitoring of compliance with standards, health talks, exit interviews, and data collection 
and consolidation were shared, along with the results achieved by the participating teams. 
QAP Year Four Self Evaluation 23 
Figure 15. Tanzania: Reduction in Stock-outs of Contraceptives in Collaborative Sites, 
Dec. 2004-May 2006 
All Facilities: - Number of Days of Stock-Outs 
35~-- -- ------------ --~ 
3•~--=~..-""""'------...,.!1\.,-------~----~~~~~~~~---1 ~~~~~~~~~1 
-1-- -- ~..,,:.._------ ---------1 -+-Depo 
,,I+-__ __,,..__ ________ ___ _ -------< ..._ Microgynon 
Microval 
1- "= --"""".,....-..;;::::=-:/---""'---- --'~•;;;;;;~- --- Male condoms 
0 ' --'-r-J\..ooi--.......-c==t'-- ~,,r;,,..oli.-l 
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 
Month 
-+- Female condoms 
Infant Feeding Counseling in the Context of HIV/AIDS: Job Aids and Training Program 
Building on the strong reception to the HIV and infant feeding job aids and counseling materials produced 
in Year Three, in Year Four, QAP collaborated with national PMTCT partners, sub-contractor 
COUNSENUTH, USG cooperating agencies, and other donors to support training of trainers and 
implementation of whole-site training of service providers on appropriate counseling for the prevention of 
mother-to-child transmission of HIV. QAP supported activities in five regions that have resulted in the 
training of more than 600 providers who care for pregnant women, mothers, and infants in over 300 sites. 
To date, QAP has made available more than one million print materials for use in PMTCT services and 
pre- and post-natal units in Tanzania. The infant feeding job aids and counseling materials have 
contributed to reducing HIV transmission by more effective counseling of women about safer feeding 
practices, including exclusive breastfeeding, reduction in mixed feeding, and use of appropriate 
complementary foods. In Year Four, the MOHSW made the decision to officially adopt the counseling 
job aids and the corresponding training package for management, mid-level, and frontline service 
providers involved in PMTCT and infant feeding. The materials will be reissued in 2007 with the 
branding of the National AIDS Control Programme. 
QAP'S Value-Added in Tanzania 
QAP has worked very closely and in collaboration with existing MOHSW systems and processes in 
Tanzania, adding value to the ministry's efforts to improve the quality of care for children with HIV 
infection, improve access to and quality of family planning services, and prevent mother-to-child 
transmission of HIV. Empowering hospital and health center quality improvement teams to document, 
analyze, and take actions based on data about performance according to standards, and the strong 
involvement of the IMCI and Quality Assurance units of the MOHSW and collaboration with other 
MOHSW partners (EngenderHealth, EGP AF, and COUNSENUTH) in planning and implementing QI 
activities are important building blocks for sustaining quality assurance in the Tanzanian health system. 
Ultimately, the focus of QAP's work in Tanzania has been on strengthening health systems, which will 
lead to improved health services utilization for targeted health problems, in line with MOHSW and 
USAID Mission strategic objectives. 
Benin 
QAP has worked with the Ministry of Health of Benin since February 2005 to support an essential 
obstetric care collaborative in two 'Zone Sanitaires, Pobe-Adja Ouere-Ketou (PAK) and Aplahoue-Dogbo￾Djakotome (ADD). Fifteen facilities participate in the collaborative: three regional hospitals (Zou 
24 QAP Year Four Self Evaluation 
Collines, Mono-Couffo and Oume/Plateau), two district hospitals (Pobe and Aplahoue-Djakotomey￾Dogbo ), and ten peripheral facilities (CSC/CSA), five from each zone. 
In the second half of 2005, QAP assisted the MOH to conduct two rounds of supportive supervision and 
to hold the third learning session in January 2006. The main focus of the learning session was to review 
progress in the four technical focus areas of the collaborative: compliance with ANC norms, adequate 
completion of the partograph, active management of the third stage of labor, and selected aspects of 
routine newborn care. Key partners, notably UNFP A, UNICEF and the ACQUIRE Project (IntraHealth), 
participated in the learning sessions and provided support to both districts in areas of need identified by 
the collaborative. IntraHealth trained providers in AMSTL, and UNFP A provided selected items of 
equipment. 
Throughout the year, the 10 peripheral facilities reported increases in most of the process indicators being 
monitored. Notable improvements were seen in the proportion of partographs adequately completed and 
the proportion of deliveries with AMTSL (see Figures 16 and 17). Improvements were also evident in 
facilities. Staff put up screens or curtains in consultation rooms and delivery wards to improve client 
privacy and posted job aids to remind providers how to manage post-partum hemorrhage and AMTSL. 
Figure 16. Benin: Completion of the 
Partograph According to Standards in 
10 Peripheral Facilities, Oct. 2004-Mar. 
2006 
100....-~~~~~~~~~---,~~~~~--. 
80+-~~~~~~---,--,,, ....... -&:--~~~--j 
60 1-;;;,A.i;~~,,......~~~~~~~~--i 
~ 40-+-~~~~~~~~~~~~~~~--j 
20-+-~~~~~~~~~~~~~~~--t 
0-+-...-~.....-,...-.--.-..--.--.--r-......-......--.-...-~........,r-t 
ONDJFMAMJJASONDJFM 
Month 
Figure 17. Benin: Practice of AMTSL in 
10 Peripheral Facilities, Oct. 2004-Mar. 
2006 
100....-~~~~~~~~~~~~~~---. 
ao+-~~~~~___.,,. k:iil~~~~ 
60+-~~~~~--. ~~~~~~~---l 
40+-~~~~--.IF-~~~~~~~~----I 
20-t-~~--.--...,....,.--~~~~~~~~~-----t 
0 i'llll~TA1.-r--r--r--..--.-.-,...,,,---r-.--r-.-i 
ONDJFMAMJJASONDJFM 
Month 
Although considerable progress was made in the first year of the project, there were a number of ongoing 
management challenges. The project coordinator who had been located in Cotonou in order to work 
closely with the MOH Family Health Directorate (and at their request) found that the counterpart was 
available for supervisory visits only infrequently. A lack of transport too1 made supervision difficult, and 
site visits were conducted much less often than had been originally planned. In the first six months of 
2006, the QAP project coordinator left, and it took several months to find a suitable replacement. During 
that time, few formal collaborative activities were conducted, although some teams continued to monitor 
their activities independently. In June 2006, QAP staff visited the collaborative sites to assess progress 
and assess the feasibility of investing additional core funds to strengthen newborn health and linking 
community and facility care. This visit confirmed some progress in maternal health, but rev_iews of a 
number of records highlighted the need to regularly audit self-reported data to verify the validity of results 
reported. A decision was made to continue work in the two same districts but to focus more on ADD 
district, where the presence of other NGOs, such as Plan International, provides the possibility of 
leveraging resources in order to achieve greater impact at the community level. 
1 A vehicle for which the procurement was initiated over a year ago is still awaited. 
QAP Year Four Self Evaluation 25 
- -
QAP's Value-Added in Benin 
Throughout the past year QAP has worked closely with the.MOH in developing the collaborative 
activities. Although there have been some weaknesses as described above, there is now widespread 
recognition of the importance of addressing quality in the delivery of EONC services in Benin. In the 
national strategy for the reduction of maternal and neonatal mortality, published this year, the need to 
improve service quality features as one of the key priorities. Benin has achieved considerable progress in 
developing a wider range of policies and protocols to address EONC but much less has been achieved in 
terms of program implementation. The collaborative model, with its potential for scale-up and rapid 
improvement, is ideally suited to the current environment. The national strategy identifies the 
collaborative approach as one of the effective strategies for achieving quality improvement at scale, and 
the MOH has asked that QAP build national capacity to conduct collaboratives before project completion. 
The new national strategy highlights the importance of addressing newborn health and of linking facility 
and community c;are. These are major preoccupations for the MOH and are key themes which will be 
addressed by the collaborative in the corning ye~. 
Uganda 
For the past year, the Quality Assurance Project has provided technical assistance to the Ugandan 
Ministry of Health's Quality of Care (QoC) Initiative, launched in November 2005. The main objective 
of this Initiative is to develop a sustainable quality improvement system for HIV I AIDS service delivery 
using the continuous quality improvement (CQI) model. Under the overall aegis of the QoC Initiative, 57 
health facilities, including national and regional referral hospitals, district hospitals, and health centers, 
were selected for participation in an antiretroviral treatment improvement collaborative. The 
collaborative was developed with the intention of increasing the number of sites in subsequent years, until 
all facilities providing antiretroviral medicines are included. Sites were selected from all over the 
country, with more than 90% of Uganda's old 56 districts represented. All activities of the collaborative 
are coordinated and directed by the MOH. QAP's role is to help strengthen the capacity of existing MOH 
structures at the national and sub-national levels and provide technical assistance in implementing 
HIV/AIDS quality improvement programs at participating health facilities. 
Much of QAP's efforts this first year were devoted to facilitating the creation of a leadership and 
technical structure to support quality improvement activities in the districts. A Steering Committee for 
the Initiative was established and has met several times this past year. This committee, made up of 
members from the MOH, USAID, the Regional Center for Quality in Health Care (RCQHC), and QAP, 
provides strategic leadership to all QoC activities. The committee has helped to strengthen coordination 
and collaboration between MOH partners and stakeholders, including WHO, CDC, USAID, RCQHC, 
John Snow Inc.' s DELIVER Project, Joint Clinical Research Center, and Elizabeth Glaser Pediatric AIDS 
Foundation (EGPAF), among others. A core technical team made up of technical staff from the MOH, 
the private sector, other HIV/AIDS providers, and QAP/Uganda was created and received quality 
improvement training to be able to provide technical leadership for the QoC Initiative. This team 
developed key monitoring indicators to be used in the collaborative and has been also been responsible 
for building capacity of regional coordination teams and supporting them in coaching facility teams. The 
regional coordination teams are made up of providers with experience in ART who have received further 
training in quality improvement. Members of the regional teams work together with core team members 
to plan and facilitate learning sessions and conduct monthly site visits. 
The first learning session was held as a series of regional sessions in January 2006. The second round of 
learning sessions was held in April 2006. Through June 2006, more than 280 coaching visits were made 
to the facilities. All participating health facilities have established quality improvement teams that work 
to improve key monitoring indicators, identify areas for improvement, test ways of improving these areas 
using the CQI model, and track improvements over time. After the first learning session, teams collected 
and analyzed baseline data and carried out systems analysis of patient flow. These data were presented by 
sites during the second learning session. This exercise alone has led to palpable improvements, including 
26 QAP Year Four Self Evaluation 
reduced congestion by spreading clinic days from 1 to 5 days in some cases, increased use of patient 
records, improved documentation and storage of patient records, and better logistics management. In 
some instances, site teams have reorganized existing human resources for better efficiency. 
Baseline data were collected retrospectively for the six months prior to site involvement in the Initiative. 
The core team developed 27 improvement objectives divided into five categories: patient assessment and 
screening; patient treatment with ART; prevention of opportunistic infections, referral and follow-up of 
patients; and health facility preparedness. To reduce the burden on staff, sites were asked to monitor only 
one indicator per category. Members of the core and regional teams visited teams to reinforce indicator · 
definitions and validate data collected. While many weaknesses were revealed, data showed that the 
majority of patients on ART actually met eligibility criteria (98%) and there has been drop in death rates, 
from 5% to about 1 % of patients on ART. Improvements have been noted in two indicators: the average 
percentage of valid patient contact information rose from 19.8% in the June-December 2005 period to an 
average of 51.3% in January-April 2006 (see Figure 18), and the percentage of eligible patients who were 
actually started on ART rose from 38.4% in June-December 2005 to 60% in January-April 2006 (see 
Figure 19). While these results are preliminary, the trends are encouraging. 
100% 
Figure 18. Uganda: Percentage of Patients with Valid Contact Information, 
Four Sites, June 2005-April 2006 
90% 
80% 
I I 
I Start ol QoC Initiative I 
I f--..-...._ 
, I -.......--
j I 
/ -- ~ I 
/ ~ 
70% 
60% 
50% 
40% 
30% 
20% 
10o/o 
0% 
Jun-OS Jul-OS Aug-OS Sep-OS Oct-OS Nov-OS Dec-OS Jan-06 Feb-06 Mar-06 Apr￾06 
Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-OS Dec-05 Jan-06 Feb-06 Mar-OS Apr-06 
-+-%of Patients 7 .6% 8.4% 30.8% 30.5% 24.4% 24.1% 12.9% 57.7% 46.1% 50.6% 50.9% 
Figure 19. Uganda: Percentage of Eligible Patients Started on ART, Nine Facilities, 
June 2005-May 2006 
100% 
90% 
80% 
70% 
60% 
50% 
40% 
30% 
20% 
10% 
0% 
·~ 
%o1E iNIPaflntl 33 ~ 
...... 
QAP Year Four Self Evaluation 
Sep-05 
38.1% 
I QoC Initiative Started I 
I 
j ../ 
Nov-05 "''"' 33.1% 
__.. 
./ ....... .-
/ 
Jan-0& ...... Apr-OS May.(MJ 
!57.3% 58.8% 65.K 
27 
QAP's Value-Added in Uganda 
With the introduction of ARV medication, HIV I AIDS becomes a chronic disease requiring treatment for 
life. Best practices for care and treatment have been developed or are currently in the process of being 
developed. In Uganda, rapid implementation of these practices at all health facilities is a recognizable 
challenge. Ensuring that all HIV/AIDS patients on ART are given care in accordance with these best 
practices is even more challenging. QAP began providing technical support to the MOH after training 
had already been conducted to provide accreditation to at least one site in every health district to allow 
them to provide ARV s. However, no funds were available for follow-up support after training, or even 
regular supervision by the AIDS Control Programme, despite the recognized need to ensure that quality is 
maintained during the process of scaling up ART treatment. The QoC Initiative is responding to the need 
for continual, on-the-job support and supervision of MOH personnel at participat-ing-sites. In addition, 
quality improvement has never been implemented on such a large scale before in Uganda, nor in this 
manner that seeks to build capacity at all levels within the MOH to sustain quality assurance activities. 
The real value of QAP in Uganda is its focus on creating a sustainable culture of quality improvement in 1 
healthcare, where personnel from national to health center levels feel inspired and have the tools to 
identify areas for improvement, initiate changes, and demonstrate improvement, not just in the area of 
HIV I AIDS, but potentially in other high burden disease areas as well. 
Lesotho 
QAP has been working on improving the quality of TB services in Lesotho since April 2005. During 
Year Four, the project worked in five Health Service Areas (out of 18 in the country) to strengthen TB 
and TB-HIV case management, focusing on: development of treatment and care guidelines; training of 
health care providers in TB and TB-HIV screening, treatment and follow-up; development of referral 
mechanisms to ensure follow-up care and treatment of co-infected patients; and increasing the 
involvement of the private sector in TB and TB-HIV service provision. The key accomplishments during 
the past year include: 
• 
• 
• 
• 
• 
Introduced new TB-HIV recording and reporting tools. New registers have been adapted, printed, 
and circulated to all public health care facilities. 
Developed curricula for the PMTCT partnership on TB treatment of pregnant women and neonates . 
Trained 19 TB coordinators on counseling and testing . 
Trained 35 public and private practitioners on TB-HIV management. 
Trained 16 private doctors who are currently participating in the TB program. More than 700 patients 
have been put on treatment through these providers. The private providers are receiving free drugs 
and other support from the National Tuberculosis Program. 
QAP also assisted the Government of Lesotho along with other partners to draft a response to the Global 
Fund for AIDS, Tuberculosis and Malaria ( GF A TM) on ,poor utilization of funds in Lesotho. 
Swaziland 
During the past year, QAP worked in three TB diagnostic units and 22 clinics in the Manzini Region (one 
of four regions in the country) to improve early detection of TB cases. QAP has worked with National 
TB Program (NTP) to update TB guidelines covering both children and adults. Training of health care 
workers has been a key component to improve TB case finding, TB case management, as well as ensuring 
that TB-HIV co-infected patients receive appropriate treatment and care. QAP has also provided support 
to the NTP to develop systems for monitoring multi-drug-resistant (MDR) TB and management of MDR￾TB. The key accomplishments in the past year include: 
• 
28 
Provided technical support to the NTP on preparing a response to the GFATM about issues related to 
management of resources. 
QAP Year Four Self Evaluation 
• Assisted the Ministry of Health and Social Welfare in restructuring the NTP program. The new NTP 
management structure has been better able to respond to the growing TB epidemic in the kingdom. 
• Assisted the NTP to revise its national guidelines for TB. In addition, QAP helped the NTP to 
establish joint TB-HIV working committees at the central and regional levels, to improve access to 
counseling and testing among TB patients and to strengthen diagnosis, treatment, and follow-up of 
HIV patients with TB co-infection. 
• Provided support to the NTP in improving access to quality microscopy services. 
• Worked with the NTP to revise TB registers to better monitor co-infected patients. 
• Trained over 30 healthcare workers on TB case management. 
QAF!:s Value-Added in Lesotho and Swaziland 
The TB programs in both Lesotho and Swaziland are quite weak, and TB-HIV coordinated activities are 
almost non-existent. QAP is helping the two countries to develop operational strategies, based on our 
experiences in Russia, South Africa, and Cambodia strengthening TB and TB-HIV programs, including 
laboratory services, record keeping and reporting, provider compliance with national guidelines, and 
patient adherence with treatment regimens. QAP is also assisting the two programs to improve infection 
prevention and control strategies to reduce secondary TB/MDR TB infections in facilities. This is critical 
in light of the emergence of extreme drug-resistant (XDR) TB in Southern African. 
Eastern Europe 
Russia 
In Year Four, QAP continued technical assistance for a demonstration HIV/AIDS treatment, care, and 
support improvement collaborative involving multiple teams in four territories of Russia: 
Krasnogvardeiski Raion in St. Petersburg, Engels City in Saratov, Togliatti City in Samara, and Orenburg 
City in Orenburg. The HIV/AIDS collaborative includes a special focus on HIV-TB detection and 
treatment. In January 2006, QAP began a new collaborative to improve family planning information and 
services for PL WHA in four Russian cities. 
Treatment, Care, and Support for PL WHA 
During Year Four, interdisciplinary teams in each region continued to test, implement, institutionalize, 
and scale-up improvements as well as identify new priorities, such as developing and implementing 
regional ARV treatment readiness plans. The key results achieved with QAP assistance are summarized 
below by focus area of the collaborative. 
Improvement of Services for HIV and TB Co-infection 
In Year Four, following two round tables on HIV-TB co-infection that QAP held in October 2005 and 
March 2006, project teams made TB screening more accessible for HIV-positive clients, increased 
counseling on HIV-TB co-infection, developed and implemented algorithms for TB preventive treatment 
in HIV clients, and spread the improvements made in screening and preventive treatment of TB among 
HIV-positives to additional facilities in St. Petersburg, Orenburg Oblast, Saratov Oblast, and Samara 
Ob last. 
• Based on the work of the QI team in Orenburg, the Orenburg AIDS Center determined that a new 
position for a TB specialist was necessary. The team worked with the AIDS Center and oblast 
authorities to find financing for the position. The AIDS Center has allocated, renovated, and 
equipped offices for tuberculin testing and sputum collection. An algorithm of information exchange 
between the AIDS Center, City TB Dispensary, and Oblast TB Hospital was developed by the HIV￾TB team and approved by the Steering Committee. Since starting work in December 2005, the TB 
specialist is now seeing over 120 patients per month at the AIDS Center. 
QAP Year Four Self Evaluation 29 
• In December 2005, the AIDS Center in Togliatti set up an office for tuberculin testing and trained 
nurses to execute TB testing and interpret results. To further promote TB screening among the target 
group, the AIDS Center is working with the NGO "Parents Against Drugs" for their outreach workers 
to refer patients for TB screening at the AIDS Center. 
• Larger numbers of HIV-positive individuals are also receiving counseling about HIV-TB co￾infection. Following VCT training for staff, on average, 250 patients a month are now counseled 
about HIV-TB co-infection in Togliatti (see Figure 20). 
350 
Figure 20. Russia: Number of HIV-positive Individuals who Received Counseling 
on TB-HIV Co-infection, Togliatti, Samara Oblast, April 2005-April 2006 
1st Learning 
session focused on 
150 VCT and TB/HIV 
Apr 05 May- OS June 05 July- 05 Aug 05 Sep 05 Oct 05 Nov 05 Dec 05 Jan 06 Feb 06 Mar 06 Apr 06 
• Specialized HIV-TB wards have been introduced to deliver more comprehensive care to co-infected 
patients. In 2005, the HIV-TB team in Engels proposed that specialized wards be allocated for 
patients with HIV-TB co-infection, based on their analysis of epidemiological data. The team 
developed an algorithm of information exchange between TB and AIDS services. These suggestions 
were approved by the Coordinating Committee and institutionalized by Order #109 issued by the 
Saratov Oblast Ministry of Health in January 2006. This order obligates all TB dispensaries in 
Saratov Oblast to allocate four to six beds for in-patient treatment of patients with HIV-TB co￾infection. In Orenburg, a separate ward was created at the Oblast TB hospital in July 2006 to treat 
patients with co-infection. 
• The HIV -TB coordination organized and tested by the collaborative team in Engels was evaluated · 
and finalized by oblast officials to serve as the basis for Order #128 on Improving TB care delivery to 
HIV clients issued by the Saratov Oblast Ministry of Health in February 2006. This order effectively 
extends the HIV-TB care delivery model (which includes yearly TB testing for HIV-positive patients) 
developed by the Engels team to all municipalities in the oblast and is a good example of an 
intentional spread initiated by local authorities. Figure 21 charts the increase achieved in Engels in 
2005 in screening HIV-positive patients for TB. 
• The use of Isoniazid Preventive Therapy in HIV-positive patients who have not tested positive for TB 
is also beginning to spread. Three HIV-positive patients in Togliatti and 19 in Engels were started on 
TB preventive treatment in the first half of 2006. 
30 QAP Year Four Self Evaluation 
Figure 21. Russia: Active Screening of HIV-positive Patients for TB in Engels, Saratov Oblast, 2005 
90% 
80% 
70% 
80% 
50% 
"""' 
30% 
20% 
10% 
0% 
HIV+ Screened for TB at Least Once as Percent of the Total Number of Patients 
Registered and Receiving AIDS Services, Engels, 2005 
(By quarter, gender, IDU status) 
Males Females IDUs 
!quarter 
• II quarter 
D Ill quarter 
ON uarter 
• _fu August 2004, only 12 patients with HIV-TB co-infection were registered at St. Petersburg TB 
Dispensary #5, and none was receiving ART. Due to improved detection, counseling practices, and 
trainings facilitated by QAP and the collaborative HIV-TB team, 31 patients with HIV-TB co￾infection are now registered at TB Dispensary #5 and 22 of them are receiving ART. Figure 22 
shows increases in the number of TB patients receiving HIV counseling and testing in Dispensary #5. 
Figure 22. Russia: Number of TB Patients Receiving HIV Counseling and 
Test in TB Clinic #5, St. Petersburg City, January 2005 - July 2006 
40 Monthly average 
Jan - Sept 05: 
16 patients 
O Jan Feb Mar Apr May 
05 05 05 05 05 
June 
05 
38 
Monthly average 1----
0ct 05 - Jul 06: 
40 patients 
tested 
July Aug Sep Ocl Nov Doc Jan Feb Mar Apr May June July 
~ ~ ~ ~ ~ ~ 00 00 00 00 00 00 00 
-+-Series1 28 24 15 11 18 15 11 14 12 41 22 · 34 48 52 39 31 46 52 38 
QAP Year Four Self Evaluation 31 
Improved Access and Better Coordination of Care 
• 
• 
• 
• 
• 
• 
• 
A major technical intervention supported by QAP this year was a series of regional trainings to 
improve the quality of HIV counseling and testing. Following a training of trainers in VCT led by the 
Healthy Russia Foundation, collaborative teams in each region integrated schedules for VCT training 
into local health plans and budgets, including determining which specialists needed priority training. 
From May to September 2006 each region conducted four VCT trainings for local health providers. 
In total, 67 providers were trained in St. Petersburg, 57 in Engels, 34 in Togliatti, and 80 in Orenburg. 
In Orenburg, following VCT trainings and official informational letters on standard pre- and post-test 
counseling and data collection, the number of patients receiving voluntary counseling and testing for 
HIV at the Oblast Drug Rehabilitation Hospital has been steadily increasing, with an average of 450-
470 patients per month now receiving voluntary testing for HIV. 
Sites have also reduced HIV test tum-around-time. In less than one year, the tum-around time of HIV 
tests in Engels has been reduced from 8-10 to 3-4 days. In Orenburg, tum-around time for HIV tests 
at the Oblast Drug Rehabilitation Hospital has also been steadily reduced; now at least 50% of tests 
are returned within 48-96 hours. 
HIV-TB services are being decentralized to improve access for patients. In St. Petersburg, the HIV￾TB team decided to introduce services at the primary care level. The team developed a scope of work 
for a TB Specialist at the TB Dispensary to work with HIV-positive clients and an algorithm of 
information exchange and referrals which were approved by an order of the Health Department of the 
Krasnogvardeiski District Administration in September 2005. Under this order, the AIDS Center 
Infectious Disease Specialist sees HIV clients in Polyclinic # 17 once a month, while the TB 
Dispensary Specialists receives patients in Polyclinic #103 every other week. In Togliatti, the new 
model of HIV-TB care includes X-ray screening at the primary care level; on average, 200 HIV￾positive patients are now screened for TB each month. 
The role of primary care in follow-up of HIV patients has also been further developed. In Engels, the 
collaborative team worked with AIDS Center staff to redesign the system to deploy a mobile team of 
an AIDS Center Infectious Disease Specialist and nurse to receive patients at Polyclinics# 1 and #2 
once a month to provide consultations and collect blood samples for routine follow-up testing (e.g., 
CD4, viral load, and blood biochemistry). Blood samples for HIV follow-up testing are now drawn 
in all polyclinics of Engels five days a week. 
The case management model implemented in Engels of Saratov Oblast was adapted to St. Petersburg 
and Orenburg, and case manager positions created by local authorities and funded by municipal 
budgets. In Orenburg, this model was modified to create a social worker position at the AIDS Center 
beginning in January 2006. The new services have proven popular, with 370 patients signing up for 
the social worker's services as of August 31, 2006. In St. Petersburg, two case managers started to 
receive patients in July 2006 at the Youth Drug Rehabilitation Center. 
Following on learning sessions in December 2005 and in June 2006 that addressed ART scale-up, 
health officials, lead specialists, and providers from all project sites reviewed the status of 
preparedness for large-scale provision of ART, further elaborated regional plans utilizing inputs from 
colleagues and various experts, and agreed on measures to track progress on patient enrollment into 
ART. All sites have developed algorithms to enroll patients into ART that also outline mechanisms 
of data transfer and care coordination. 
Institutionalization and Scale-up of Improvements 
An important result of the work of teams in all four regions has been the development of normative 
documents (prikazy), allocation of local budgets, and creation of new official positions to support and 
spread the improvements generated through the collaborative. 
• In Orenburg, the care coordination team prepared documents justifying a social worker position at the 
AIDS Center to improve coordination between medical and social services and NGOs. In November 
32 QAP Year Four Self Evaluation 
2005, the Oblast Ministry of Health signed Order #725 on improving medical and social services for 
PL WHA. In January 2006, the AIDS Center filled the position for a social worker with its own 
budget. 
• Following testing at pilot facilities, the Orenburg Oblast Ministry of Health institutionalized new 
practices for pre- and post-test counseling, algorithms of care delivery to PLWHA, and information 
exchange through Order #76, which regulates HIV/AIDS care provided at the AIDS Center, Oblast 
Drug Rehabilitation Hospital, Oblast TB hospital, City TB Dispensary, Pirogov Clinical Hospital, 
City Clinical Hospital #4, City Perinatology Center, and City Infectious Disease Hospital. 
• In June 2006, the Head of the Krasnogvardeiski Raion (St. Petersburg) administration approved an 
Action Plan to combat HIV infection in the raion. The plan was developed by joint efforts of medical 
and social services of the raion and is funded out of the municipal budget. 
• The ART organizational model developed and tested by Saratov/Engels teams has been replicated in 
five cities of Saratov Oblast at the initiative of the Oblast Ministry of Health. Subsequent to the 
regional order, similar municipal orders to organize ART for PL WHA in Engels, Balakovo, Balashov, 
and Saratov were developed and approved. The orders stipulate rules and criteria for ART 
administration and ARV drug provision, list facilities authorized to provide ART, and outline the 
algorithm of ARV drug provision by authorized facilities. 
Integration of Family Planning and HIV Services 
This new activity was launched in January 2006 as an improvement collaborative aimed at serving the 
needs of HIV-positive families by improving access to and quality of family planning services for 
PLWHA in four sites (Krasnogvardeiski District, St. Petersburg; Saratov City and Balakovo City, Saratov 
Oblast; and Togliatti, Samara Oblast). The primary participating organizations are centers for 
reproductive health and family planning, maternity houses, and women's consultation clinics, but the 
collaborative will also strengthen ties with polyclinics, social services, drug rehabilitation services, AIDS 
Centers, and NGOs. QAP is drawing on training materials and best practices from the USAID-funded 
Maternal and Child Health Initiative. 
Building upon initial QA trainings, teams in all sites have analyzed current systems for provision of 
contraceptive services to HIV-positive women. Areas that teams identified for improvement include 
insufficient knowledge of family planning counseling, underdeveloped referral systems, lack of 
confidentiality, low quality of HIV pre- and post-test counseling, and limited access to health care for 
most-at-risk populations. Improvements introduced to date by the collaborative include: 
• Trainings on modem family planning methods were held in Saratov and Balakovo, with trainings to 
follow in the other sites. 
• In Balakovo, the collaborative team convinced city health authorities to procure intrauterine devices 
(IUDs) and offer them free of charge to HIV-infected women at the City Maternity House. In 
addition, the city health committee has directed city women's clinics to secure resources to make 
IUDs available for free for HIV-positive women. 
• In St. Petersburg, the Youth Drug Rehabilitation Center has started to refer adolescents, via its 
helpline, for youth-friendly family planning services at the Youth Consultation "Rzhevka". Along 
with free family planning services and counseling, "Rzhevka" offers HIV testing and free condoms. 
QAP's Value-Added in Russia 
QAP is the leading organization in Russia working on organizing the system of HIV I AIDS treatment, 
care, and support. While many other programs, including federal programs, Global Fund, UN AIDS, and 
others are working on inputs of ART, equipment, and training of personnel, QAP's efforts have been 
focused on coordination between vertical services such as TB clinics, AIDS Centers, and drug treatment 
clinics and on improving access to care by increasing the role of primary care in testing and medical 
follow-up for HIV-positives. QAP is complementing the efforts of the Global Fund and regional 
QAP Year Four Self Evaluation 33 
programs through support for teams that are developing practical plans for large-scale provision of ART. 
Over the past year, ART has become widely available in the regions where QAP is working, yet HIV￾positive persons are not coming in for regular medical follow-up or to be put on ART. We have initiated 
operations research to identify factors constraining the demand for ART; its results will assist not only 
QAP-supported teams but other programs as well. Finally, the success of QAP-supported demonstrations 
has led regional governments to request QAP assistance in scaling up improvements in the system of 
HIV/AIDS treatment, care, and support and TB-HN services throughout St. Petersburg City and 
Orenburg Ob last. QAP' s work in Year Four has established a solid foundation for more integrated and 
higher quality HIV I AIDS services in the four project regions and set the stage for transitioning from this 
demonstration collaborative to spread collaboratives in Year Five which will scale up the improvements 
developed in the demonstration to the entire region. 
Latin America and the Caribbean 
Nicaragua 
In Year Four, QAP technical assistance to the Ministry of Health (MINSA) expanded to a new local 
integrated health system (SILAIS), Rivas, and more significantly, to a new technical area, HIV/AIDS. In 
2005, MINSA requested QAP assistance in the development of quality standards for HIV/AIDS 
prevention, diagnostic, and treatment services and to help integrate voluntary counseling and testing for 
HIV within the family planning program, emphasizing PMTCT. The addition of Rivas brought coverage 
of QAP assistance to a total of 15 of the 17 SILAIS in Nicaragua. In the past year, QAP also began 
working with ProMujer, an NGO that provides low-interest loans for microenterprise development and 
offers gynecological services, family planning, and utero-cervical cancer prevention to its 14,000 clients. 
QAP also continued providing technical support to 10 Empresas Medicas Previsionales (EMPs) that 
deliver health services financed through the Social Security system. 
While quality assurance processes for essential obstetric and newborn care and acute pediatric care have 
become well institutionalized in the SILAIS and individual facilities assisted by QAP, results in 
Nicaragua this year were affected by a national strike of physicians which lasted from November 2005 
through May 2006. Monthly monitoring of quality indicators was disrupted in a number of facilities, 
particularly in hospitals. Quality monitoring and improvement activities were reinitiated beginning in 
June 2006, but in some facilities, residual bitterness over the strike has diminished enthusiasm for QA 
activities. QAP staff is working to overcome these obstacles. 
Pediatric Hospital Improvement 
The pediatric hospital care improvement collaborative initiated in 2003 continued in 14 SILAIS hospitals 
(out of the 22 maternal and child hospitals in Nicaragua). Participating hospitals include: Bluefields, 
Chinandega, Estelf/San Juan de Dias, Jinotega, Madriz, Matagalpa (September 2003); Boaco, Puerto 
Cabezas, Granada, Leon, Nueva Segovia (August 2004); and Juigalpa, Masaya, and Estelf/La Trinidad 
(January 2005). In early 2006, the private provider (EMP) AMOCSA, which operates five clinics 
providing health services in the Social Security system, joined the collaborative. Clinical areas 
emphasized in the collaborative include care of the newborn (both with and without complications), 
management of the severely malnourished child, nutritional recuperation, perinatal mortality surveillance, 
and pediatric emergency care. 
During the physicians' strike, monitoring of compliance with standards was carried out less frequently in 
some hospitals. Monitoring data for compliance with pediatric care standards that have been reinforced 
through the collaborative during the past year did not show improvement. The indicators that have been 
the least stable are those related to management of diarrhea, meningitis and severe malnutrition. Key 
problem areas for health personnel include inadequate patient monitoring during rapid rehydration, 
monitoring intake and output, taking vital signs at the correct frequency, nutritional counseling, and 
34 QAP Year Four Self Evaluation 
nutritional support for severely ill children. A shortage of human resources and lack of oversight by 
managers have also been obstacles to achieving further improvement, factors exacerbated by the 
physicians' strike. Nevertheless, progress was made in the past year in the standardization of antibiotic 
use and classification of severity in the management of meningitis. In the area of nutritional 
rehabilitatiori, QAP assistance in the past year focused on training and helping hospital staff to apply the 
PROCOSAN nutritional counseling approach and provide more individualized counseling to mothers and 
caretakers of sick children, including appropriate use of nutritional rehabilitation formulas. QAP staff 
adapted a pediatric emergency care job aid used in emergency wards in the U.S. to Nicaraguan treatment 
protocols. QAP assistance has also focused on improving client focus in pediatric care, including 
improving interpersonal treatment and creating play areas for hospitalized children. Four hospitals 
(Madriz, Chinandega, RAAS, and Esteli) have organized play areas for children and psychosocial 
support. 
Two in-service training centers were created and are functioning very well in the Chinandega and Esteli 
hospitals to build staff competency in management of acute pediatric illnesses through short rotations. 
UNICEF and PAHO have designated funds to support MINSA in establishing such training centers in all 
hospitals in the country, with QAP technical support. 
In general, there is some evidence of impact of the PHI collaborative in standardizing case management 
of the most common childhood illnesses treated in hospitals. As may be seen in Figure 23, case fatality 
rates for pneumonia have declined in PHI hospitals between the July 2005-June 2006 period and the July 
2004-June 2005. Some hospitals (Madriz and Esteli/San Juan de Dias) have actually seen no pediatric 
deaths from pneumonia in the latter period. Declines in case fatality have also been seen in diarrhea, as 
shown in Figure 24. Four hospitals (Estell, Madriz, Chinandega, and Granada) saw no deaths from 
diarrhea in the July 2005-June 2006 period. 
16.00 
14.00 
Cf) 
c: 12.00 0 
~ 
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0 
0 
0 
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.... 
Cl> 
c. 
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.. 
co 
Cl> 
Q 
4.00 
2.00 
0.00 
14.16 
Figure 23. Nicaragua: Pneumonia Case Fatality 
Comparison of Year Three and Year Four Data 
0.000.00 
Jinotega MatagaJpa Granada Madriz 
Hospital 
Le6n Chinandega Estelf 
QAP Year Four Self Evaluation 
9.35 
Pooled 
CJ 2004-2005 
• 2005-2006 
35 
UI 
c: 
0 
'iii 
UI .E 
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0 
0 
0 
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Q) 
c 
40.00 
35.00 
30.00 
25.00 
20.00 
15.00 
10.00 
5.00 
0.00 
Figure 24. Nicaragua: Diarrhea Case Fatality 
Comparison of Year Three and Year Four 
34.1 1 
Jinotega Matagalpa Granada Madriz Leon Chinandega Esteli Pooled 
Hospital 
Essential Obstetric and Newborn Care 
During the past year, all 14 QAP-assisted SILAIS participated in the EOC Collaborative, including 127 
health center teams and 15 hospital teams. Technical support from QAP for collaborative team~ included 
technical training in the management of obstetrical complications for primary and secondary level 
providers in five SILAIS and the development and dissemination of a job aid on the management of 
obstetrical complications. Three EOC clinical training centers have now been established (in 
Chinandega, Madriz, and Leon) to provide in-service, competency-based training for medical and nursing 
personnel from the municipal health centers in their respective SILAIS. 
The quality standards and indicators for antenatal care, delivery care, and immediate care of the newborn 
that have been promoted through the collaborative have been officially incorporated into the new MINSA 
perinatal clinical record, are part of required reporting for hospitals, and have been included within the 
management agreements with municipal health centers and hospitals. 
Table 9 documents the substantial gains achieved in the quality of essential obstetric care across the 
participating SILAIS, as evidenced by pooled compliance with key process standards. For each year, 
values shown are averages of monthly values for compliance with standards across the SILAIS reporting 
data. 
Table 9. Nicaragua: Compliance with Key EOC Process Standards in 14 SILAIS, 2003-2005 
Indicator ( % ) 2003 2004 2005 
Use of partograph for labor monitoring 40 77 87 
Administration of oxytocin as part of active management of the third 69 99 100 
stage of labor 
Postpartum monitoring according to standards 44 75 85 
Appropriate management of obstetric complications 56 82 87 
During July and August 2005, simplified measurement methods to assess the competence of skilled birth 
attendants were field tested in all 20 hospitals in the country that attend births and in 44 health centers, 
covering a total of 1,358 medical and nursing personnel. The results of the study, reported to the Ministry 
36 QAP Year Four Self Evaluation 
of Health in early 2006 and formally published in June, calculated a global competency score across all 
types of personnel and technical areas of 62%. The primary areas of knowledge deficiency identified 
were labor monitoring, use and interpretation of the partograph, management of the newborn (both with 
and without complications), management of pregnancy-induced hypertension, and prevention of sepsis. 
The weakest skill areas identified were manual extraction of the placenta, bimanual uterine compression, 
and neonatal resuscitation. These skill and knowledge gaps will be the focus of in-service training 
activities in the coming year and will be reinforced by the creation of clinical training centers in 
additional SILAIS, with support from UNICEF, PAHO, and UNFP A. 
The physicians' strike also affected monitoring of EOC indicators and results in the first half of 2006. 
Some SILAIS (such as the five whose results are shown in Figure 25) were able to maintain gains made 
in prior years, while others saw declines in performance of tasks such as labor and post-partum 
monitoring. 
Figure 25. Nicaragua: Trends in Compliance with EOC Standards 
Boaco, Chinandega, Madriz, RAAN, and Rio San Juan SILAIS 
July 2005-June 2006 
100.0% 
o:'l"'. - .. ' - -
~ - r-- ~ \.. 90.0% 
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Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mu-06 Apr-06 May-06 Jun-06 
Jl.1·06 Ai.g-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-OB Apr-06 May·06 JUfl-06 
Percentage of warren in labor with p31lograph 80.1% 83.0% 76.4% 74.1% 74 .5% 74.1% 75.2% 78.1% 74.flb n.m 81.3% 83.1% 
corrpletOO a.rd interpreted correctly 
- • Percentage of delivering warren given appropriate 94 .6% 99.0% 92.0% 90.6% n.0% 89.5% 98.0% 97.8% 80.2% 97.8% 98.6% 99.0% 
dosage of oxytocfnto prBYent post-partum 
ham>rr~e 
-• • Percea~e ol woffl3!fl adequatety m:inllored in the 94.6% 93.2% 910% 88.5% 87.9% 87.6% 83.6% 90.2% 872% 88.0% 90.5% 93.7% 
immdiale oost-oart umoeriod 
Month 
In addition to support to public facilities, QAP also worked with MINSA authorities in seven SILAIS to 
provide technical support in quality assurance and improvement to 10 private medical care organizations 
(EMPs) providing services in their respective catchment areas. This assistance has the dual objective of 
strengthening the governance role of SILAIS authorities and improving quality of BOC in the private 
sector. As is seen in Table 10, improvements in care have been achieved in the initial EMPs assisted. 
The main EMPs in Chinandega-AMOCSA, Sacuanjoche, and La Consulta-have maintained high 
levels of quality with respect to the application of oxytocin to prevent hemorrhage and post-partum . 
monitoring but experienced difficulties in sustaining routine use of the partograph during the physicians' 
strike. AMOCSA has been successful in sustaining use of the partograph, as seen in Figure 26. The 
QAP Year Four Self Evaluation 37 
EMP Esmensa in Nueva Segovia has not demonstrated improvements in quality of essential obstetric care 
despite its participation in monitoring quality indicators since August 2005. SILAIS authorities are 
working with the departmental office of the Social Security Institute to bring pressure on this EMP to 
improve its performance. 
Table 1 O. Nicaragua: Compliance with Key EOC Process Standards in Four Empresas Medicas 
Previsionales, 2004-2005 
Indicator(%) 2004 2005 
Use of partograph for labor monitoring 52 81 
Administration of oxytocin as part of active management of the third stage 38 83 
of labor 
Postpartum monitoring according to standards 35 66 
Appropriate management of obstetric complications 88 98 
Figure 26. Nicaragua: Incorporation of Routine Use of the Partograph in the 
"C EMP AMOCSA, Chinandega SILAIS, September 2004-August 2006 Cll 
Qi 
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Sep· Oct- Nov- Dec- Jan- Feb- Mar- Apr- May Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May Jun· Jul- Aug￾M M M M ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 00 00 00 00 00 00 00 00 
---5 11 .1 55.6 11 .1 60.0 33.3 66.7 80.0 80.0 85 .7 80.0 75.0 100. 80.0 77.8 66.7 80.0 83.3 85 .7 87.5 85 .7 87.5 90.0 85.7 87.5 
Assistance to the NGO ProMujer 
In the past year, QAP worked with ProMujer, a member of the USAID.-supported Nicasalud Federation of 
NGOs, to establish quality standards, update its gynecological and obstetric care clinical protocols, and 
introduce mechanisms for measuring client satisfaction. Quality improvement teams were established in 
ProMujer's four clinics in Managua, Le6n; Chinandega, and Masaya, and ProMujer has created a position 
of national quality supervisor. Quarterly monitoring of quality indicators by these teams have already 
begun to show solid gains in compliance with the new standards (see Figure 27 for STI care) and in client 
satisfaction. Two new clinics are scheduled to open in the second half of 2006, and QAP will work with 
those facilities from the outset to establish quality improvement activities. 
38 QAP Year Four Self Evaluation 
100% 
Figure 27. Nicaragua: Improvement in Case Management of 
Sexually Transmitted Infections, ProMujer 
63.6% 
60% +------------------
July2005 (Baseline) March 2006 June 2006 
I Percentage of STI cases managed according to the clinical protocol I 
HIV/AIDS and PMTCT 
During 2005, MINSA, working with a 
series of USAID implementing partners 
(QAP, PASMO, PASCA, DELIVER, 
Nicasalud, IRH) and UNICEF, identified 
the need for integrating counseling 
related to HIV/AIDS and other sexually 
transmitted infections (STI) in the 
Ministry's existing program for family 
planning counseling, with the goal of 
increasing voluntary counseling and 
testing (VCT) among pregnant women in 
order to improve the identification of 
pregnant women who are RN-positive and to reinforce HIV preventive behaviors. Following on this 
process, MINSA, through its Directorate for Quality Control and Assurance, which has assumed 
leadership for the organization of STI-HIV/AIDS services as of 2006, requested that QAP intensify and 
focus its technical assistance on developing a model of care that incorporates strategies for the prevention 
of vertical transmission from mother to child at both the primary and secondary levels of care. 
To design this technical assistance, QAP conducted a rapid assessment of existing HIV/AIDS services, 
including integrated FP-STI-HIV/AIDS counseling, referral for HIV testing and ART, and PMTCT. 
Based on the findings, QAP supported MINSA to design quality services to identify, treat, and follow-up 
persons infected with HN and develop a network of laboratory services to support HIV testing. An HN 
testing algorithm was developed, and beginning in April 2006, QAP began working directly with six 
SILAIS to train personnel to process HN lab tests and to introduce testing and counseling of pregnant 
women to prevent vertical transmission of HN. Discussions to reduce stigma and discrimination towards 
PLWHA were held with personnel in 11 hospitals, and multi-disciplinary teams to support HN 
counseling and testing were created in 10 hospitals. As of September 2006, QAP is supporting the roll￾out of PMTCT services in eight hospitals and 59 health centers in eight SILAIS: Estelf, Madriz, Nueva 
Segovia, Leon, Chinandega, Rivas, RAAN, and RAAS. Figure 28 shows initial results in seven SILAIS. 
Figure 28. Nicaragua: Percentage of Pregnant Women who Received 
Counseling on STl/HIV/AIDS, March-August 2006 100 ~---------------------------------~ 
90 
BO 
70 
60 
50 
40 
3 0 
20 
10 
July August 
--.Esteli 0 34 85.7 94 
---Madriz 0 2 1 .7 66.7 88.3 95 
- N .Se ovia 0 0 2 0 85 75 
"""*""Le6n 0 0 37.5 55 85 85 
-M--Chinande a 0 0 30 65 73.6 93 
_.,_Ma sa a 0 0 0 0 50 7 1.3 
--+-Rivas 0 0 0 8.2 34.8 33.9 
Avera e 0 5.4 43.7 35.5 71.7 78.2 
QAP Year Four Self Evaluation 39 
QAP's Value-Added in Nicaragua 
QAP' s team in Nicaragua is well recognized by its counterparts for its professionalism and technical 
leadership. The learning methodologies and job aids developed by QAP have helped to develop service 1 
provider capacity in clinical areas that are a priority for the Ministry of Health. The concepts QAP has 
promoted in Nicaragua, of defining quality, monitoring compliance, and undertaking ongoing I 
improvement activities, have become accepted at the national level and in SILAIS throughout the country,, 
as a routine part of health services management and delivery. The QA results that have been widely 
disseminated in Nicaragua have helped to engage numerous technical cooperation agencies in co￾financing quality assurance activities. Finally, the project's work with EMPs has served to promote the 
integration of the private sector in local health systems and bolstered the steering role of SILAIS 
authorities. 
Ecuador 
QAP' s assistance in Ecuador during Year Four contributed to three main results: 1) strengthening the 
institutionalization of continuous quality improvement in obstetric and child care in over half of the 
provincial health systems in the country; 2) expanding the practice of active management of the third 
stage of labor, and 3) planning for a new collaborative of provincial referral hospitals to improve the 
quality of care for obstetrical complications. 
With QAP assistance, the Ministry of Health of Ecuador has entered a stage of maturity in the 
institutionalization of quality assurance, integrating it into its regular organization and functions. A 
continuous quality improvement program for maternal and child health services has been firmly 
established in 13 (65 % ) of the country's 22 provinces; the 13th province, Esmeraldas, began improvement 
activities in Year Four. At the central level of the MOH, the chief of the maternal health program plays a 
leadership role fostering QA throughout the organization, and several senior officials participate in a 
Steering Group for the EOC Collaborative, including one full-time staff member who maintains and 
updates a national data base of quality of care indicators. Within each participating province, the official 
in charge of the MCH program is the provincial QA facilitator who also coaches CQI teams and liaises on 
QA with the central level. 
Some 114 teams in 45% of the country's health areas (76 out of 169) are now participating in the EOC 
improvement collaborative, measuring and periodically reporting data on 18 quality indicators 
encompassing prenatal, delivery, and post-partum care, immediate newborn care, management of 
obstetrical complications, and integrated management of childhood illness. Even though only one new 
province joined the collaborative in Year Four, the number of CQI teams expanded considerably (by 
63 % ), signaling a stronger degree of engagement of health facilities and areas in ongoing improvement 
activities. (See Table 11.) 
While the extent of development of the various components of the EOC model (i.e., improvement of 
clinical care processes, clinical training, cultural adaptation, community promotion) varies among 
provinces, most have achieved over the period of the collaborative a minimum level of performance in 
non-complicated deliveries (see Table 12). Evidence-based EOC practices, such as antenatal care 
screening, use of the partograph, active management of third stage of labor, immediate post-partum and 
immediate newborn care, are now widely practiced in the collaborative's participating facilities with 
levels of compliance with standards that consistently exceed eighty percent in regular monthly 
monitoring. 
A critical area of best practice scale-up this past year was the institutionalization of active management of 
the third stage of labor in Ecuador. According to the Ministry's maternal mortality epidemiological 
surveillance system, post-partum hemorrhage was the leading cause of maternal deaths in 2005, 
accounting for 31.8% of maternal deaths. Active management has been effectively spread at the 
operational level in Ecuador through the EOC collaborative. When the collaborative started, AMTSL was 
40 QAP Year Four Self Evaluation 
Table 11. Ecuador: Expansion of CQI Activities 
# Facilities with 
#CQI #CQI #CQI #CQI CQITeams 
Province Teams Teams Teams Teams Hospitals Health Other health 
Year One Year Two Year Three Year Four Center services 
Azuay 2 6 6 5 5 
El Oro 2 10 10 11 8 3 
Bolivar 2 4 4 7 5 2 
Tungurahua 2 8 8 11 7 4 
Cotopaxi 1 6 6 6 3 3 
Imbabura 2 4 4 4 3 1 
Morona 1 7 7 7 6 1 
Santiago 
Guayas 2 0 0 0 0 0 
Carchi 5 5 3 2 
Loia 10 14 8 6 
Orellana 3 3 19 2 2 15 
Chimborazo 6 7 9 7 2 
Mana bi 16 11 5 
Total 14 54 70 114 68 31 15 
Table 12: Selected Indicators from the EOC Collaborative, July 2003-June 2005 
(Pooled Data from All Provinces and Facilities Reporting) 
July Jun 
Percenfaf(e of reviewed cases that complied with quality standards 2003 2005 
Percentage of prenatal consultations in which all standard tasks were performed 0% 72% 
Percentage of deliveries in which the partograph was correctly used 44% 85% 
Percentage of normal deliveries in which oxytocin was administered to prevent 17% 68% 
postpartum hemorrhage 
Percentage of newborns for whom the standard tasks were performed 25% 84% 
Percentage of normal deliveries in which standard, immediate postpartum tasks 21% 82% 
were performed 
Source: Quality of care database of the Ministry of Health, 2006 
Jun 
2006 
75% 
88% 
82% 
82% 
85% 
rarely practiced in MOH hospitals; by the end of Year Three (June 2005), the collaborative has elevated 
its practice to 63% of normal deliveries in the participating provinces. By June 2006, this level rose to 
82% of deliveries in the facilities participating in the collaborative (see Figure 29). The positive 
experience of hospitals in half the country in applying active management served as a "bottom-up" force 
for policy change which culminated in April 2006 in the official publication of an Addendum to the 
National MOH Norms to incorporate active management of third stage of labor into the country's official 
norms and to update its guidelines on the use of oxytocin, immediate procedures in case of post-partum 
hemorrhage, and laboratory tests based on international evidence. QAP is now working with the MOH to 
build on this momentum with a focused "spread" collaborative to introduce active management in the 
other 11 provinces where it is not being routinely practiced, including Ecuador's two largest cities. 
While the results for correct management of normal deliveries are very encouraging, quality of care for 
obstetric and newborn complications continues to challenge public hospitals in Ecuador, where attending 
staff are often medical interns. Because a large share (69%) of maternal deaths occur in hospitals, the 
MOH launched in July 2006, with QAP assistance, a new demonstration collaborative in six provincial 
hospitals, to identify best practices for standardizing care for obstetrical and newborn complications. 
Progress was also made in developing sustainable mechanisms for building competency of public sector 
personnel in essential obstetric and newborn care. QAP worked with the MOH to develop 8 training 
QAP Year Four Self Evaluation 41 
Figure 29. Ecuador: Percentage of Deliveries in Which Oxytocin Was Administered to Prevent 
Hemorrhage in Health Facilities Participating in the EOC Collaborative, July 2003-June 2006 
I 
INDICADOR # 4: Partos vaginales atendldos en los H. del Pafs en los que se 
admlntstr6 a la parturienta 10UI. de Oxltoclna intramuscular dentro del m inuto 
despues del nacimiento del bebe y se registr6 en la HCP. Jullo/03 a Junlo/06 
vo ~~~~~~~~~~~~~~~~~~~~~~~~~~~ 
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modules (total training time of 32 hours) and establish teaching centers in provincial hospitals, to support 
in-service training to upgrade the skills of personnel who manage obstetrical complications in public 
hospitals. Two centers have been established to date, and with funding from the United Nations Fund for 
Population Activities (UNFP A), training of trainers has begun to establish centers in the coming year in 
six more provincial hospitals. QAP has also signed an agreement with the Central University of Ecuador 
to work with faculty to introduce competency-based training in management of obstetrical complications 
and the essential obstetric care system concept in pre-service training for professional midwives. 
Finally, the MOH has adopted the "Manual for humanization and cultural adaptation of delivery care" as 
an official strategy for public facilities that attend births. This manual was developed by QAP, Family 
Care International (FCI), and the MOH Provincial Health Office of Tungurahua based on the cultural 
adaptation interventions piloted last year in Tungurahua. QAP has begun a new operations research study 
to measure the impact of adapting delivery practices to users' preferences on user satisfaction and demand 
for institutional deliveries in four provinces with indigenous and Afro-Ecuadorian populations. 
QAP's Value-Added in Ecuador 
QAP is an active participant in national policy discussions related to maternal health and has been a 
driving force behind the adoption of evidence-based maternal health policies and standards in Ecuador. 
The maturity and expansion of continuous quality improvement processes within MOH facilities in over 
half of the country has led the MOH to transform them into national policies, which further ensures their 
institutionalization and sustainability beyond the life of the EOC collaborative itself. A good indicator of . 
the extent of institutionalization of QA activities in Ecuador is the fact that QAP maintains only two full￾time staff members in its Quito office, and a few part-time occasional consultants in provinces. Most of 
the QA activities are run by the Ministry of Health institution itself. QAP also works very effectively with 
other technical cooperation agencies, including the United Nations Development Program, UNFP A, and 
FCI to undertake joint activities at the provincial level related to essential obstetric care. 
Honduras 
Over the past several years, QAP has provided technical support to the Secretariat of Health of Honduras 
(SSH) to develop and institutionalize CQI processes aimed at maternal and child health services, first in 
two health regions and then expanding to five of the 20 departmental health regions created under the 
2004 health sector reorganization. At the same time as the reorganization, QAP was invited by USAID to 
become part of its health sector reform program, to work with new decentralized healthcare networks that 
were managed by municipal and non-governmental entities in selected municipalities in Copan, Lempira, 
42 QAP Year Four Self Evaluation 
and Comayagua, as part of the Government's effort to reform the health sector by separating payer and 
provider functions. At that time, QAP was given the mandate was to support the networks in establishing 
CQI systems that would ensure high quality services that were responsive to users' needs, as well as to 
help the departmental health offices of the SSH to provide effective oversight to the networks to assure 
quality. Based on positive results this year in both areas of work, in January 2006, USAID expanded 
QAP's scope of work to encompass broader technical support for health sector reform activities and for 
strengthening reproductive, child, environmental, and community-based health services, including 
incorporating quality improvement activities within these components of USAID's health sector 
assistance to Honduras. The geographic scope of QAP assistance has also expanded to include technical 
activities in all 20 departmental health regions. 
Support for Health Sector Reform Initiatives 
QAP assistance to decentralized providers in the past year has been concentrated in four of the poorest 
departmental health regions. Support was provided for the organization and the training of two new 
decentralized providers: "Inmaculada Concepcion" which manages the emergency clinic in San Manuel 
Colohete in the departmental region of Lempira, and the Communal Association "Madres Felices" 
(MAFE) that manages the clinic of Taulabe in the departmental region of Comayagua. QAP also 
continued to provide assistance to the Municipality of Santa Rita de Copan (MANCORSARIC), the 
provider that manages the emergency clinic of El Jaral in the departmental region of Copan. 
MANCORSARIC is now preparing to extend its network to include an additional nine facilities in its area 
of influence. Table 13 details the reach and number of beneficiaries of these decentralized providers. 
Table 13. Honduras: Coverage of Decentralized Provider Networks Assisted by OAP, 2006 
Department Municipality/ #Health Beneficiary Type of Provider Payment Total 
Communities Facilities population Mechanism Funding 
(Lemviras) 
Copan Santa Rita/Otuta, 6 75,000 Commonwealth Production 6,945,787 
Rio Amarillo MANCORSARIC and Per 
Copan Ruinas/ capita 
Virginia, Las 
Flores, Cabanas/ 
Rio Negro 
Comayagua Taulabe 3 25,444 Communal Civil Production 4,618,709 
Association and per 
"Madres felices" capita 
(MAFE) 
Lempira Colohete 4 12,230 Comunal Civil Production 3,525,044 
Association and per 
"Inmaculada capita 
Concepcion de 
Colohete" 
Totals: 10 18 132,136 15,089,540 
At the national level, QAP worked with the SSH' s Extension of Coverage Unit to develop the quality 
indicators to be included in contracts between the departmental health regions and decentralized providers 
and to develop a system for monitoring quality of services provided by these entities. At the local level, 
QAP has helped to strengthen the capacity of these decentralized providers for managing their networks 
and for implementing continuous quality improvement processes focused on maternal and child care. 
Interventions that the providers have introduced to increase coverage and quality include payment of 
incentives to traditional birth attendants for referrals, creation of clubs of pregnant women clubs, design 
of training and supervision tools for both clinical and preventive services, and providing additional 
services like dental care and lab work in the same facility. In this effort, QAP has worked closely with 
the World Bank-funded Health Sector Reform Program (PRSS). This year, MAFE and Inmaculada 
QAP Year Four Self Evaluation 43 
Concepcion signed contracts with the SSH that specify expectations for quality and the indicators that 
will be used to measure compliance with quality standards. 
Under the decentralized service delivery scheme, every two months the Extension of Coverage Unit of the 
Departmental Health Regions carries out a measurement of compliance with quality standards and makes 
the corresponding payment to the decentralized provider, based on the percentage compliance and 
according to contract stipulations. Table 14 shows the results of the first four measurements for these 
two new decentralized providers. The results thus far are very encouraging to the SSH and suggest that 
these decentralized providers are achieving the objectives established in the health sector reform: 
increasing access and quality. 
Table 14. Honduras: Quality Ratings Achieved by Decentralized Provider Networks Assisted by 
QAP, 2005-2006 
Monitoring by the Extension of Coverage Unit 
1st measurement 2"d measurement 3rd measurement 4th measurement 
Quality Overall Quality Overall Quality Overall Quality Overall 
Provider 
MAFE 80 66.6 79.2 71.2 98 91 100 93.2 
Inmaculada 68 79 76.35 86.25 75.6 81 93 88.44 
Concepcion 
Quality Assurance Institutionalization 
Technical support to the Secretariat of Health's National Quality Assurance Unit (UNGC) and assistance 
to the five priority Departmental Health Areas for the institutionalization of CQI in maternal and child 
health (MCH) services continued to be the core of QAP's technical assistance program in Honduras 
during Year Four. QAP worked closely with the head of the UNGC, Dr. Rosario Cabafias, to monitor 
implementation of quality improvement plans and provide supportive supervision to the SSH quality 
improvement coordinators in the departmental health offices in Comayagua, La Paz, Lempira, Intibuca, 
and Copan. The departmental coordinators, in turn, provided training and support to facility-based 
improvement teams, except in the region of Lempira, where there is no coordinator and the process relies 
greatly on QAP's local consultant. QAP also supported the UNGC in organizing the first National 
Congress on Quality Assurance in August 2006. The congress was attended by more than 100 delegates 
from facility-based quality improvement teams, decentralized healthcare providers, universities, and other 
technical cooperation agencies. 
In the five regions, there are now five hospitals, eight maternal and child health clinics, and 49 health 
centers with a doctor that are regularly monitoring and reporting on quality indicators. The hospitals and 
maternal clinics monitor 16 quality indicators on childbirth care, prenatal care, and care for children under 
five years. In the five regions, there is a now a total of 70 SSH supervisors who have been trained in 
quality improvement methods who support and advise improvement teams. Table 15 shows this QA 
structure by region. 
QAP also worked with the SSH and USAID to create a mechanism for direct funding of QA activities in 
the five departmental hospitals through formal management agreements between the hospitals and the 
departmental health office. Under these agreements, the departmental region agreed to finance plans for 
the improvement of each hospital, in an amount of up to US$ 21,000 for the two referral hospitals (West 
and Comayagua) and up to US$ 18,000 for the other hospitals (La Paz, La Esperanza, and Gracias). The 
hospitals, through their quality committees and improvement teams, have agreed to comply with a set of 
16 quality indicators in childbirth care, management of obstetrical complications, newborn care, family 
planning, and case management of pneumonia and diarrhea in children under five years. The 
improvement teams of the hospitals have prepared two quarterly improvement plans to date. 
44 QAP Year Four Self Evaluation 
Table 15. Honduras: Quality Assurance Structure in the Five Departmental Regions Assisted by 
OAP, 2006 
Departmental #of SSH # of Facilities Reporting #of Quality #of Users 
Region Supervisors Quality Data Improvement Teams Committees 
Trained in CQI 
Copan 11 H=l; CMI=l; CM0=12 19 9 
Comayagua . 20 H=l; CMl=4; CMO=ll 20 1 
Lempira 14 H=l; CMI=2; CMO=ll 19 7 
Inti bu ca 16 H=l 1 
La Paz 9 H=l; CMI=l; CM0=15 21 1 
Total 70 60 (H=100%; CM1=100%; 80 18 
CM0=82%) 
H =Hospital; CMI = MCH Clinic; CMO =Health Center with Physician 
The amount of funds actually provided to each hospital is determined based on the results of quality 
monitoring carried out quarterly by the departmental region. The first external quality monitoring of the 
hospitals' performance, conducted in July 2006, produced the ratings and award amounts shown in Table 
16. 
Table 16. Honduras: Results of the First Quality Monitoring of the Five Departmental Hospitals 
Assisted by OAP, July 2006 
Hospital Results from the Results from the Budget Total Budget 
Monitoring Plan Monitoring of Assigned Earned 
Indicators 
Comayagua 100% 64.48% 80,000.00 57,700.00 
Lempira 89% 68.00% 60,000.00 43,320.00 
Intibuca 95% 76.30% 60,000.00 48,024.00 
Copan 64% 78.80% 80,000.00 60,640.00 
La Paz 95% 67.8% 60,000.00 43,944.00 
Teams are gradually improving their performance on the quality indicators, although improvement in the 
management of obstetrical complications and case management of severely ill children continues to lag 
behind other services, as may be seen in Table 17. 
In response to these results, the hospitals have prepared new improvement plans oriented towards 
weaknesses, particularly management of sepsis in pregnant women and diarrhea in children. 
Improvements that are being carried out in the hospitals include: the redesign of intake forms for 
emergency care, regular monitoring of key drugs in pharmacies, procurement of equipment, 
standardization in the taking of vital signs, workshops to reinforce the use of norms when handling . 
complications, enhancements to physical plant, improvement of the supervision process, and design of 
orientation plans for new personnel. To improve the care process, the teams have developed various tools 
to guide the management of emergency cases. This experience led the UNGC to call for a national 
meeting of all departmental hospitals to redesign a unique and standardized format to be used at the 
national level. The five hospitals are also implementing a "Client Service" strategy that has improved 
orientation of the client in the hospital, provided better information, and created a better channel for 
handling complaints and requests. The success to date of the hospital agreements as a mechanism for 
spurring focused improvements in service quality has motivated the SSH and USAID to extend them to 
the nine maternal and child clinics in the five health regions beginning in January 2007. 
QAP Year Four Self Evaluation 45 
Table 17. Honduras: Compliance with Quality Standards in the Five Departmental Hospitals 
Assisted by QAP, July 2006 
Monitoring Results by Hospital 
Indicator Comavagua Lemoira Intibuca Copan La Paz 
Inputs for care 100 100 100 90 90.5 
Use of the partograph 44.8 100 43 30 89 
Active management of the 100 100 100 100 100 
third stage of labor 
User satisfaction 100 100 93.3 66.6 100 
Immediate post-partum care 88.4 100 40 93 93 
Family planning counseling 100 100 93 30 89.65 
Management of obstetrical 100 0 71.4 22 62.5 
hemorrhage 
Management of pre-eclampsia 50 0 50 50 66.6 
Management of puerperal 0 0 0 0 
sepsis 
Immediate care of the newborn 42.3 100 93 70 0 
Management of newborn with 95.7 100 100 80 100 
asphyxia 
Management of child under 5 20 0 44 10 0 
years with pneumonia 
Management of child under 5 0 100 0 0 10 
years with diarrhea 
Referrals 100 100 100 82 
Total 64 68 76.3 74.12 67.8 
Progress was also made in improving quality at the level of ambulatory care facilities (health centers with 
physician), particularly for prenatal care. Use of the LISEM instrument (a form which accompanies the 
woman throughout her pregnancy up through the post-partum period) to guide key activities that should 
be performed at each visit has reached 93% of prenatal consultations in ambulatory facilities in the five 
regions by June 2006. One of the innovations introduced in these facilities to increase the proportion of 
pregnant women for whom all key services are provided is to hold monthly "circles of pregnant women", 
meetings in the facilities during which additional services (e.g., dental exams, lab tests) are provided that 
are not always offered during routine prenatal care visits. 
In facilities that attend deliveries, correct use of the partograph reached 81 % of deliveries in May 2006, 
active management of the third stage of labor was practiced in 100% of deliveries, compliance with post￾partum monitoring was 87%, and immediate evaluation and care of the newborn met standards in 88% of 
cases. Management of obstetrical complications has been more difficult to improve. Correct 
management of hemorrhage was at 0% when the year started and has reached 38% of cases in June 2006. 
Pre-eclampsia was managed according to standards in 75% of cases in June 2006, and endometritis was 
correctly managed in 80% of cases. Diarrhea and pneumonia in children under five years were managed 
correctly in 81 % of cases in June 2006. 
Figure 30 shows data on maternal mortality in the areas of focus. Data from 1990 and 1997 are from 
studies on maternal mortality. Data from 2005 and 2006 come from the SSH maternal mortality 
surveillance system. Even though the two data sources are not directly comparable, they do indicate that 
there is a progressive reduction of maternal deaths in the country. 
46 QAP Year Four Self Evaluation 
Figure 30. Honduras: Trends in Number of Maternal Deaths by Priority Department, 1990 to 2005 
Numero de muertes maternas IMMER y SVM par Departamento. Honduras. 
Copna Lempira lntibuca La Paz 
1990 31 25 26 19 
• 1997 14 12 10 7 
0 2004 5 9 7 7 
0 2006 3 5 3 
QAP's Value-Added in Honduras 
QAP's effectiveness in Honduras contributed to the decision by USAID to expand QAP's program to four 
new components in 2006, adding work in support for health sector reform efforts of the SSH; community￾based maternal and child health; family planning; and environmental health. USAID and the SSH have 
asked that QAP integrate the continuous quality improvement process in all of these program areas. The 
QA structures and processes that have been incorporated into the routine operations of the five focus 
departmental health regions and their facilities have created a model that can be replicated in the remained 
of the country. QAP's close working relationship with the SSH National Quality Unit and the health 
sector reform program of the World Bank have extended the impact of QA strategies beyond the five 
USAID-assisted regions. 
2.3 Short-Term Technical Assistance 
Bangladesh: Improving Quality of TB Case Management through 
Supervision 
Based on findings from a 2004 OR study responding to a request from the National TB Program (NTP), 
QAP developed a Quality Supervision and Monitoring (QSM) strategy for expanding access to and 
improving the quality of directly observed treatment. QAP organized a three-day training in late 2005 on 
quality of care and its integration with supervision and monitoring for 148 district supervisors/managers 
(both government and NGO) from across the country. The course was facilitated by NTP, WHO, and 
QAP and included a manual, Improving Quality and Strengthening Monitoring and Supervision of DOTS: 
A Curriculum for District-Level Supervisors. 
The QSM strategy is now piloted in four sub-districts (thanas) in each of the six districts, reaching 24 
service delivery facilities. A day-long orientation was conducted for the district- and sub-district-level 
supervisors along with administrative heads of the 24 QSM pilot sites. For evaluation purposes, QAP 
conducted a baseline assessment in January-May 2006 (prior to implementation) of the QSM intervention 
facilities and six comparison facilities. The baseline showed that while a gap existed between provider 
knowledge and skills/practice (the overall knowledge score was 84%, versus a skills score of 76%), the 
intervention and comparison sites were roughly comparable in terms of provider assessments and TB 
service. 
QAP Year Four Self Evaluation 47 
Supervisors began implementing the QSM intervention in June 2006. They conducted Round 1 visits 
between June 18 and July 20, reviewing the status of key DOTS indicators in each facility, including case 
detection rate, proportion of TB cases that are smear-positive, sputum conversion rate, and treatment 
success rate. They found virtually the same levels for all DOTS indicators as were found in the baseline. 
Importantly, they also observed provider compliance with service delivery and found that provider 
counseling skills were the greatest weakness (Figure 31). The findings prompted district supervisors to 
address some of the gaps, including filling vacant positions, developing community mobilization 
activities, training laboratory technicians, orienting staff on appropriate infection prevention practices and 
equipment maintenance, and strengthening counseling and communication with patients. 
100 
BO 
60 
40 
20 
0 
Figure 31. Bangladesh: Provider Compliance(%) with NTP 
Standards for DOTS Observed in Round 1 Supervision Visits 
96 
-
TB Case 
Classification 
79 
-
TB Diagnostic 
Categories 
79 
-
Treatment 
Regimen 
63 
-
Counseling 
Cambodia: Developing Public-Private Partnerships for TB Control 
QAP support for TB activities in Cambodia began in 2004 with an OR study to document the quality and 
extent of TB services provided by private sector providers. The findings sparked national policy change 
to allow greater private sector involvement in TB control and prevention. In Year Four, QAP assisted the 
USAID bilateral Health Systems Strengthening Project to design and implement, on a pilot basis in one 
operational district in Battembang Province, a public-private partnership (PPP) model for TB prevention 
and control. In the last year, over 94 private providers signed Memoranda of Understanding with the 
National TB Program to refer TB suspects to public TB DOTS facilities. Under the program, both public 
and private providers received training and communication materials to ensure availability of quality TB 
screening, treatment, and follow-up services. The number of TB suspects referred from private providers 
to public facilities is rising, and based on the PPP model is being scaled up to four new provinces. 
Peru: Institutionalizing QA in a Private Healthcare Delivery Organization 
QAP continued to provide short-term technical assistance to private, non-profit provider Max Salud to 
develop a CQI system in its four-clinic network in Chiclayo. In late 2005, USAID/Peru announced the 
close-out of support for Max Salud, so in February 2006 QAP and the Max Salud QA managerial group 
planned the transition to a completely self-managed QA program. A new Max Salud QA Coordinator, 
Dr. Luis Castaneda, worked with QAP to ensure a smooth internal transition. By the end of Year Four, 
QAP was providing technical assistance entirely by email and phone, while the Max Salud QA program 
continued, enthusiastically managed by Dr. Castaneda and the QA managerial team and with strong 
support from Max Salud' s Executive Director. In July 2006, Max Salud launched the QA program in its 
new clinic in Cajamarca. 
48 QAP Year Four Self Evaluation 
Uganda and Zimbabwe: Adapting Jobs Aids to Improve Infant Feeding 
Counseling for HIV-positive Women 
Our HIV and infant feeding training and counseling materials program in Tanzania attracted continued 
international interest during Year Four. Having shared results and materials with international 
organizations and donors through meetings and email, QAP was invited to provide technical assistance to 
PMTCT and infant and young child feeding programs in Uganda (with PEPFAR funding) and Zimbabwe 
(with EGPAF and UNICEF support). In each country, QAP worked with local partners to review 
national policy in light of the updated UNICEF-WHO guidelines on HIV and infant feeding and to adapt 
the Tanzanian job aids for local use. We helped organize local technical review of the messages and 
illustrations in the Tanzanian materials and then worked with MOH nutritionists, PMTCT specialists, 
health communication specialists, and graphic artists to craft locally appropriate versions. We trained 
graphic artists in Uganda and in Zimbabwe in the techniques needed to create attractive and effective 
illustrations and designs. We helped local teams finalize the draft sets of materials and provided guidance 
in field testing. As a result, the MOH in each country worked with local PMTCT partners and other 
stakeholders to: 1) develop the job aids in other languages (seven in Uganda and three in Zimbabwe), 2) 
develop additional complementary materials, and 3) identify funding to support several initial training 
activities. In Uganda, QAP funded the printing of 1000 copies of each of five materials (Question and 
Answer Guide and four infant feeding options brochures), which are being used to train local health 
workers in the new national guidelines. 
Zambia: Job Aid and Orientation for Malaria Rapid Diagnostic Test 
Building on earlier work with WHO, QAP collaborated in 2006 with WHO and the Zambia National 
Malaria Control Center to develop a job aid and orientation for use with malaria rapid diagnostic tests 
(RDTs). The objective was to enable volunteer community health workers (CHWs) to use RDTs safely 
and effectively. QAP led formative research comprising interviews and focus groups with 33 CHWs in 
Luangwa District in January and February. Based on that research, we developed and pilot-tested a draft 
job aid. In late June-early July, we systematically tested the job aid in Chongwe and Chibombo Districts. 
This test compared CHW performance in using an RDT under three levels ("rounds") of preparation: In 
round 1 CHWs used only the manufacturer's instructions (translated into the local language); in round 2 
they used only the job aid; and in round 3 they used the job aid and had a three-hour orientation. Sample 
size calculations recommended observing 23 CHWs per round (69 total) to detect a difference of+/- 20% 
in performance between rounds. The actual test observed 32 CHWs in round 1, 23 in round 2, and 26 in 
round 3. Between rounds 1 and 2, the percentage of steps performed correctly increased from 61 % 
(9.8/16) to 81 % (13/16). Performance increased to 90% (14.4/16) in round 3 (Figure 32).· Improvements 
were statistically significant for rounds 1 vs. 
2 and rounds 1 vs. 3 (pS0.01), but not for 
rounds 2 vs. 3 (p=0.23), probably because 
the sample was too small to detect a 9% 
difference. These initial results suggest that 
the job aid with a short orientation can 
enable CHWs to perform RDTs safely and 
correctly. Tests are planned in 2007 to 
determine whether improved performance 
lasts after six and 12 months. QAP plans to 
work with WHO to make the job aid plus 
orientation package available on the Internet 
for malaria control programs that employ 
CHW s as part of implementing artemisinin 
combination therapy. 
QAP Year Four Self Evaluation 
100% 
80% 
Percent c 
60% 
40% 
20% 
0% 
Figure 32. Zambia: CHW performance with 
Paracheck Pf Malaria ROT 
(Percent of steps performed correctly by round) 
90% 
81% 
prrect 
61% 
1. Package 
instructions only 
2. Job aid only 3. Job aid + 3 hour 
orientation 
Round 
49 
2.4 Global and Regional Activities 
Health Systems Strengthening/Mainstreaming 
The Health Systems Strengthening (HSS)/Mainstreaming Initiative puts the combined knowledge and 
experience of USAID's health system strengthening projects at the service of USAID's large bilateral 
projects and improves their capacity to achieve US AID' s health impact objectives. QAP is one of three 
Global Health projects chosen to take part in this initiative because of its ability to improve 
implementation at the local level and help countries achieve and demonstrate health impact results. In the 
past 18 months, QAP has participated with the other two HSS partners in developing and testing new 
Health System Assessment instruments in Angola and Benin, contributing to the.quality assurance and 
other modules of the assessment methodology. QAP also participated in the Routine Health Information 
Network (RHINO) Third International Workshop in Chiang Rai, Thailand, providing perspectives on 
monitoring quality of care at community and primary care facilities. QAP again provided assistance to 
the Child Survival and Health Grants Program (CSHGP) Mini-University and in the review of Detailed 
Implementation Plans. 
As part of efforts to expand the use of the improvement collaborative approach by program implementers 
worldwide, QAP began collaboration in Year Four with the CORE Group to plan a community-based 
maternal and child health collaborative; it will be implemented in FY07 by a CORE member organization 
with QAP technical assistance. This will be the first community-focused collaborative and also the first 
implemented by a CORE member. 
Newborn Care Initiative 
Newborn care is increasingly an integral component of QAP's PHI and BOC collaboratives, with 
newborn care activities underway to varying degrees in five African and Latin American countries. In 
Nicaragua and Niger, newborn care activities are being integrated into EONC and PHI collaboratives, 
while in Benin they are also being integrated with PMTCT services. Although collaboratives have 
emphasized the quality of care for mothers and older children under five years, with increasing awareness 
of the importance of newborn health, countries have begun to increase the range and complexity of 
newborn activities. Teams in the BOC collaborative in Honduras, Ecuador, and Nicaragua monitor 
readiness (the availability of equipment and supplies) to provide newborn care and compliance with 
routine newborn care standards. Nicaragua has also integrated PHI standards (including care for the sick 
newborn) into the Mother and Baby Friendly Health Units certification process and adapted the perinatal 
record to include monitoring of newborn care. 
In view of collaborative successes in Latin America, USAID allocated additional core funds to QAP to 
determine whether the collaborative approach might also be used for strengthening newborn care. 
USAID requested that the funds be used in Africa, which has the highest rates of stillbirth and neonatal 
death, and in a context where PMTCT services were also available. The funds were also assigned for the 
strengthening of the home-hospital continuum and for the development of an integrated model of 
EONC/PMTCT care. 
Responding to these criteria, QAP allocated most of the additional funding to revitalize and strengthen the 
newborn health component of the Benin BOC collaborative and build in a strong newborn component in 
the nascent Niger EONC collaborative. Benin was chosen as the major recipient of the funds because its 
collaborative was already active at primary and secondary levels and because of an extant national 
PMTCT service. By funding two geographically close programs with the same management structure, 
QAP was able to leverage both countries' resources. For example, Benin staff has provided training 
support to Niger teams, while the Niger team provided QA and collaborative training to Benin staff. 
These countries are also sharing training and monitoring tools and provider job aids. 
50 QAP Year Four Self Evaluation 
This year in Niger, essential newborn care (ENC) has been one of two main technical priorities. 
Consensus on national standards was achieved in March 2006, and these standards were then used to 
develop provider job aids, training curricula, and monitoring and evaluation tools. Regional teams were 
trained and coached in ENC. Care for newborn complications will be introduced next year. In Benin, 
progress has been slower owing to delays caused by loss of the project coordinator. Plans were 
developed, however, to strengthen quality of essential maternal and newborn care at the facility level. In 
addition, the Benin EONC collaborative will have a major community component that will be carried out 
in collaboration with Plan International. 
Improving the Care of Orphans and Vulnerable Children 
Countries and organizations receiving PEPFAR funds have raised concerns about the quality of services 
provided to orphans and vulnerable children (OVC). The USG has begun to develop strategies to ensure 
quality OVC care and has requested QAP assistance. In FY06, QAP provided assistance to OGAC in 
developing a process and tools for achieving standards of care and quality improvement in programming 
for this particularly vulnerable population. This effort began with participation in a series of meetings 
with interested OGAC and partner representatives and then a presentation by the QAP Director at a global 
USG staff meeting in March 2006 in Namibia. Further assistance was provided for the development by 
PATH of a facilitation guide for this process. QAP involvement will continue in FY07 as the process and 
tool are tested and implemented in PEPFAR-supported countries. QAP will pursue this collaboration 
energetically, convinced this in an area susceptible to significant improvements through QA. 
Following on the success of its study of the program evidence base for the feeding of infants of HIV￾positive women, QAP started plans to study the evidence base for issues and programs for OVC in low￾prevalence (but highly concentrated) HIV-epidemic countries. 
Operations Research 
Operations research studies completed, in process, or under consideration by the end of Year Four are 
listed in Table 18. Highlighted numbers indicate studies completed in Year Four. For those completed 
studies whose results were not presented in last year's Self Evaluation, key results are summarized below. 
Table 18. Status of Operations Research Studies as of June 30, 2006 
Location Study Name Status (Yr Done) 
OR Studies Completed or In-Process during Year Four 
1 Global HIV and infant feeding: Compilation of program evidence Completed (Yr 3) 
2 Multi-country Collaboratives documentation and evaluation Underway 
3 Benin Safe motherhood studies: Results from Benin Completed (Yr 2) ,._.. 
4 Ecuador Safe motherhood studies: Results from Ecuador Completed (Yr2) 
- 5 Jamaica Safe motherhood studies: Results from Jamaica Completed (Yr 2) ,._.. 
6 Rwanda Safe motherhood studies: Results from Rwanda Completed (Yr 2) - 7 Measuring the competence of SB As Completed (Yr 2) -
8 Timeliness of hospital care for obstetric emergencies Completed (Yr 4) - Benin, Ecuador, 9 Jamaica, Rwanda Quality of obstetric care in 14 hospitals Completed (Yr 4) 
rn Comparing methods to identify hospital birth attendants Completed (Yr4) -
11 Factors predicting partograph performance Data analysis 
12 Bangladesh Rapid assessment of tuberculosis system Completed (Yr 3) 
13 Cambodia Treating TB in the Private Sector Completed (Yr 3) 
14 Ecuador Scale-up of CQI in Free Maternity Program Completed (Yr 3) 
QAP Year Four Self Evaluation 51 
15 Ecuador Develop maternal health questions for ENDEMAIN national Completed (Yr 4) health survey 
16 Ecuador Generating demand for quality of maternal care Underway 
17 Ecuador Validity of self-assessments in EOC collaborative Underway 
18 Jamaica Impact of PMTCT mother-child pairs program Completed (Yr 3) 
19 Jamaica Improving process of maternal mortality surveillance Completed (Yr 4) 
20 Kenya Evaluation of cost and effect ofIMCI CBT Completed (Yr 4) 
21 Laos, Philippines Proper application of malaria Rapid Diagnostic Tests Completed (Yr 3) 
22 Nicaragua Mother and baby friendly program as focused accreditation Report in 
success preparation 
23 Nicaragua Improved measures of SBA competency Completed (Yr 4) 
24 Niger Evaluation of PHI malaria collaborative Underway 
25 Russia Situational analysis of TB-HIV co-infection Completed (Yr 4) 
26 Rwanda HIV stigma study Data analysis 
27 Rwanda ARV adherence study Data analysis 
28 Rwanda Human resources assessment to scale-up HIV I AIDS care Summary report in 
preparation 
29 South Africa Effectiveness of TB DOTS supporters Completed (Yr 3) 
30 South Africa Accreditation and regulatory options Completed (Yr 3) 
31 South Africa Functional analysis of Soweto PMTCT programs 
Draft report in 
review 
32 South Africa Rapid assessment of ART Report in editing 
33 Tanzania Counseling job aids and take-home materials on infant feeding for Report in 
PMTCT preparation 
34 Tanzania HIV stigma study Data analysis 
35 Zambia HIV/AIDS workforce study Completed (Yr 2) 
36 Zambia Health worker performance-based incentives study Report in editing 
37 Zambia Development and testing of malaria RDT job aids Underway 
Potential OR Studies under Consideration 
1 Global Review of evidence on protecting HIV orphans and vulnerable 
children in low and concentrated HIV-prevalence areas 
2 Tanzania Evaluation of national scale-up of infant feeding counseling 
materials 
3 Tanzania Validity of sequential self-assessments in PHI collaborative 
Dropped Studies 
1 Multi-Country Quality of TB care and lab services Dropped 
2 Eritrea Nurse motivation and appreciative inquiry Dropped 
3 Eritrea, Jamaica Low-cost measures of quality of care for maternal complications Dropped 
4 Jamaica Community follow-up of obstetric emergencies Phase 2 not funded 
5 Kenya Improving client purchases of anti-malarials Dropped 
6 Zambia HIV health worker training study Dropped 
• 
52 QAP Year Four Self Evaluation 
10. Multi-Country: Comparing methods to identify hospital birth attendants. This methodological 
analysis took advantage of the data collection instrument used to record provider performance during 
labor and delivery (OR study #9). The individual providers attending each observed case were recorded 
using two methods. In theory, both methods should have identified the same providers for any case, but 
they did not 54% of the time. Combining both methods of provider identification was clearly superior to 
either method alone. This result underscores the difficulty in correctly identifying all attending providers 
(particularly where several providers participate) and the need train data collectors carefully. 
19. Jamaica: Improving the process of maternal mortality surveillance. This study was completed and 
two journal articles were prepared for submission last year, one on underreporting in the current maternal 
deaths surveillance system and the other on recent trends in maternal mortality in Jamaica. The study 
identified all deaths of women of child-bearing age in Jamaica during 1998-2003 and then determined 
-which-of-those deaths related to-pregnaney-using-e: · · · · · iewing. The result,.__ _____ _ 
were compared to official statistics covering the same period to estimate underreporting and to findings 
reported for 1981-83, 1986-87, and 1993-95 to reveal trends. Some results: Approximately 20% of 
maternal deaths were not reported. Underreporting was associated with not having a post-mortem, dying 
in the first trimester, and ineffective surveillance in some regions. A longer interval from pregnancy 
termination to death increased the odds that the death would not be reported as pregnancy-related, 
increasing from 3.5 in the first seven days to 6.05 between 7-41 days postpartum. Declines in direct 
obstetric deaths since the 1980s are probably associated with improved surveillance, improved access to 
referral obstetric care, and use of selected clinical protocols. During the 1990s indirect deaths from 
HIV/AIDS, cardiac disease, sickle cell disease, and asthma increased, offsetting the decline in direct 
deaths. These trends may typify countries where most births occur in hospitals. 
20. Kenya: Evaluation of cost and effectiveness of the IMCI CBT. This field test of the revised IMCI 
computer-based training (CBT), conducted in Kenya in June-July 2005, compared the cost and 
effectiveness of the CBT to the standard classroom training. Both the standard and computer-based 
trainings call for a follow-up one-year preceptorship. The standard course lasts 11 days with morning 
lectures and afternoon clinical practice; the CBT study course lasted six days with morning CBT sessions 
and afternoon clinical practice. Forty-nine clinicians who had not received prior IMCI training were 
randomly assigned to the CBT or standard course. Each trainee took a written pre- and post-tests and was 
judged by expert observers for compliance with IMCI standards in the case management of two simulated 
cases of childhood illness. No attempt was made to measure performance at the conclusion of the one￾year preceptorship. Some results: The CBT and standard course trainees were statistically equivalent in 
the post-test, in the gain from pre- to post-test, and in scores for compliance with IMCI standards in the 
case management of the simulated cases. The per trainee budgeted cost was $230 less for the CBT 
course, 29% less than the standard course and 12% less than the training program with the preceptorship, 
rendering the CBT course more cost-effective than the standard one. 
22. Nicaragua: Mother and baby friendly program as focused accreditation success. The Baby Friendly 
Hospital Initiative has become the world's largest focused accreditation program, fostering appropriate 
breastfeeding in over 19,000 Baby Friendly certified hospitals in 150 countries. The initiative is having 
problems with sustainability, but the Nicaragua Mother and Baby Friendly program is a notable 
exception, having grown in size and impact since its 1993 inception. A 1999 assessment concluded that 
the Nicaragua program was the likely cause of substantial improvements in infant feeding practices. The 
present study sought to determine whether the Nicaragua program has continued to have an impact on 
breastfeeding practices, and if so, what factors caused its success. Extensive interviews were held with 
staff at hospitals and health units and other key individuals throughout the country, and many documents 
and secondary data sources were reviewed. A physician's strike delayed study completion for six 
months. Some results: The Nicaragua program emphasizes both mother and baby and has expanded in 
recent years beyond hospitals to certify universities, health centers, health posts, health districts, and 
municipalities. The program enjoys the support of the Ministry of Health, which carries out certification 
QAP Year Four Self Evaluation 53 
and re-certification, and of national laws supporting breastfeeding. Self-assessment is widely used by 
health units to identify and correct problems, both within facilities and in the communities they serve. 
The findings will be reported in an international conference organized by UNICEF/Nicaragua in October 
2006, along with new UNICEF guidelines for baby-friendly programs. 
23. Nicaragua: Improved measures of SBA competency. QAP shortened and refined the skilled birth 
attendant knowledge test and consolidated the skills evaluations used in the four-country safe motherhood 
study. During July-August 2005, QAP worked with the Ministry of Health (MINSA), UNICEF, CARE, 
and PAHO to apply the revised instruments in a large-scale evaluation of SBA competency throughout 
Nicaragua: 1,358 medical and nursing personnel who attend deliveries took the knowledge test, and 584 
the skills evaluations. The Spanish report was completed in June 2006 and presented to MINSA for 
dissemination within Nicaragua. The English report is in preparation. Some results: The study found 
serious and widespread competency shortcomings. The lowest knowledge scores related to infection 
prevention 14 conect~, pregnane-y~induced hypertension-(-5 l-% correct), immediate newborn care (52% 
correct), labor monitoring/partograph (60% correct), and sepsis (65% correct). Higher knowledge scores 
related to hemorrhage (79% correct) and active management of third stage of labor (73 % correct). 
Interestingly, scores on the knowledge tests related to manual removal of the placenta, bimanual uterine 
compression, and immediate newborn care were higher than the corresponding skill scores. Responding 
to these findings, MIN SA is moving to establish national norms for birth attendant competency. 
28. Human Resources Assessment for HIV/AIDS Services Scale-up (Rwanda). Rwanda has committed 
to scale up its health services for prevention, care and treatment of HIV/AIDS, including treating 100,000 
with ART by 2007, but faces acute health workforce shortages. This study assessed the increase in health 
personnel needed to meet Rwanda's goals. Data collection and draft reports were completed in the first 
half of 2005, and preliminary results were reported in last year's Self-Evaluation. The final assessment 
(presented as three reports reflecting the study's phases) was completed this year, along with further 
policy analysis. One result of the study is that it will be virtually impossible to achieve the Rwanda scale￾up target of 100,000 ART clients by 2007 under reasonable assumptions about workforce, HIV 
prevalence, and VCT uptake rates. To increase the likelihood of achieving the target, Rwanda should 
consider using lower-skilled workers to perform many HIV I AIDS-related tasks currently performed by 
doctors, high-level nurses, and high-level laboratory technicians. Another issue that needs to be 
monitored and managed is the demand for and throughput of programs (VCT, PMTCT, and CD4 count 
monitoring) that channel clients into ART services. The workforce should be balanced among the various 
programs to minimize the overall unmet need. 
33. Tanzania: Counseling job aids and take-home materials on infant feeding for PMTCT. This 
intervention study aimed to improve the quality of counseling to and infant feeding practices by HIV￾positive and HIV-negative mothers to be more in line with updated WHO guidelines. It developed 
pictorial job aids that are now used to counsel mothers of any HIV status on infant feeding options, 
related take-home materials for the mothers, and a counselor training course. This study evaluated the 
impact of the intervention on a cohort of 59 mothers and infants, 30 in the intervention and 29 in the 
comparison group, both HIV-positive and HIV-negative. In-depth home interviews and observations 
were carried out with all mothers, and a second set of home interviews was carried out with a subset. A 
final report is in revision. Some preliminary results: Intervention counselors used the job aids with all 
their clients and were enthusiastically positive about them. Mother's knowledge in the intervention group 
was much greater than in the comparison group. For example, 93% of the intervention mothers gave a 
correct operational description of exclusive breastfeeding compared to 14% of the comparison mothers; 
most intervention mothers (83%) said the recommended duration of exclusive breastfeeding was six 
months for HIV-negative mothers and HIV-positive mothers who chose to breastfeed, whereas most of 
the comparison mothers (93%) thought the recommended duration was shorter. Counseling quality also 
increased in the intervention group: 87% of the intervention mothers said they had received counseling on 
how to care for their breasts, compared to only 7% of the comparison mothers; 97% of intervention 
54 QAP Year Four Self Evaluation 
mothers received a counselor demonstration (of breastfeeding or replacement feeding, depending on the 
mother's preference), while none of the comparison mothers did. 
Computer-Based Training 
The generic IMCI CBT produced at the end of Year Three was field-tested in Kenya in June and July 
2005 by ARTT International, a QAP subcontractor, in cooperation with the Kenya Ministry of Health and 
WHO. As reported above, the study found that the effectiveness of CBT course was essentially the same 
as that of the standard 11-day course, but budgeted costs per trainee for the entire training (course plus 
follow-up) were 12% less (about $230 less per trainee) for the CBT than for the standard course. This 
result of equivalent effectiveness but lower costs confirmed the findings of a previous study in Uganda 
that used an early version of the CBT program. The study report was completed in August 2006 and 
submitted to WHO and the Ministry of Health of Kenya. 
The revised version of the Spanish IMCI was delivered to QAP by subcontractor Dragonfly 
Communications in November 2005 and then sent for review to Bolivia's Ministry of Health and QAP's 
consultant in Bolivia. Final revisions were prepared by the MOH and shared with QAP in April 2006. 
Completion of the product has been delayed by Dragonfly's dissolution. 
At the same time, the Bolivia MOH expressed interest to QAP in documenting and evaluating the impact 
of the tuberculosis CBT developed by QAP and the MOH in 2003. The TB CD-ROM, tailored to the 
Bolivia national program, has been used throughout Bolivia and reproduced beyond the original 1500 
copies QAP had provided. Following a visit by Jorge Hermida in February 2006, a short survey was sent 
to several Departmental Secretariats of Health (SEDES) to inquire as to their use of the TB CBT. SEDES 
in Oruro, Cochabamba, Potosi, Santa Cruz, and several networks from La Paz answered. All have been 
using the CBT to train doctors, nurses, and auxiliary nurses since early 2004. Even though the National 
TB Program published and distributed a guide for the use of the CD-ROM, there have been wide 
variations in the duration of training among the SEDES, ranging from a few hours to a week. While 
further follow-up to the use of the TB CBT in the National TB Program is not possible due to recent 
changes in USAID programming in Bolivia, QAP is developing a proposal with the John Snow, Inc., 
Services Quality of Care activity to introduce quality directly observed treatment for TB services with 
NGOs. This effort will involve in-service training using the CBT and continuous team-based process 
improvement and will include evaluation of the effectiveness of the TB CBT. 
Technical Leadership 
The project continues to exert technical leadership in the field of quality assurance internationally, 
demonstrating USAID's commitment to improving developing country healthcare systems through 
leadership in applying QA approaches, especially adapting the improvement collaborative methodology. 
During Year Four, the project published six OR reports, a technical report, and an evaluation report (see 
Table 19). All were published electronically on the project website, and most were distributed in hard 
copy to limited audiences. 
Five articles were submitted to peer-reviewed journals during Year Four. Manuscripts on the findings 
from the national assessment of skilled birth attendant competence in Nicaragua and the demonstration 
phase results of the LAC EOC collaborative were not accepted by The Lancet for its maternal mortality 
series. The Nicaragua article is being revised for submission to the Bulletin of the World Health 
Organization. An article on the development of culturally sensitive breastfeeding counseling tools in the 
Tanzania's Kilimanjaro Region was accepted by the online journal Implementation Science, published by 
BioMed Central. The principal investigator of the Jamaica maternal mortality surveillance study has 
submitted two articles based on the study for publication. Work progressed on two other journal articles: 
one on the results of the four-country study on timeliness of care for obstetrical complications (third delay 
study) and the other on the pediatric hospital improvement collaboratives in four countries. 
QAP Year Four Self Evaluation 55 
Table 19: OAP Technical Publications, 7/1/05-6/30/06 
Operations Research Reports (Date Published) 
Furth, R, R Gass, and J Kagubare. 2006. Rwanda Human Resources Assessment for HIV/AIDS Scale-up. Phase 
3 Report: Staffing Implications and Scenarios for HIV/AIDS Services Scale-up (June 2006). 
Burkhalter B and L Jennings. 2006. Comparison of two methods for determining provider attendance during 
normal labor and delivery: Results from Benin, Ecuador, Jamaica, and Rwanda (April 2006). 
Furth, R, R Gass, and J Kagubare. 2006. Rwanda Human Resources Assessment for HIV/AIDS Scale-up. Phase 
2 Report: Sample Site Data Collection and Analysis (March 2006). 
Edson W, B Burkhalter, S Harvey, M Boucar, S Djibrina, J Hermida, P Ayabaca, M Bucagu, S Gbangbade, and A 
McCaw-Binns. 2006. Safe motherhood studies-Timeliness of in-hospital care for treating obstetric emergencies: 
Results from Benin, Ecuador, Jamaica, and Rwanda (March 2006). 
Burkhalter B, W Edson, S Harvey, M Boucar, S Djibrina, J Hermida, P Ayabaca, M Bucagu, S Gbangbade, and A 
McCaw-Binns. 2006. Quality of obstetric care observed in 14 hospitals in Benin, Ecuador, Jamaica, and Rwanda 
(March 2006). 
Furth, R, R Gass, and J Kagubare. 2005. Rwanda Human Resources Assessment for HIV/AIDS Services Scale￾up: Phase 1 Report: National Human Resources Assessment (October 2005). 
Other QAP Reports (Date Published) 
Boguslavsky V. 2005. Situational Analysis of the TB-HIV Co-Infection in Russia and Four QAP Project Regions: 
Samara, Saratov, Orenburg, and St. Petersburg. Technical Report (July 2005). 
Viteri, MA. 2005. Evaluation of the Latin American and Caribbean Maximizing Access and Quality Exchange. 
Evaluation Report (July 2005). 
Stephen Kinoti contributed, with Linda Tawfik, a background paper for "Working Together for Health," 
the 2006 World Health Report on the healthcare workforce. The paper focused on the toll HIV/AIDS has 
taken on Africa's healthcare workforce. The report summary is available at 
http://www.who.int/bookorders/anglais/detart l .jsp?sesslan= 1 &codlan=l &codcol=24&codcch=2006. 
QAP staff also made six presentations to USAID, donor and cooperating agencies, and host country 
officials during Year Four, and QAP work was presented at 10 international and regional conferences. 
QAP had an especially strong showing at the May 2006 Global Health Council (GHC) conference, with 
sponsorship of one skill-building workshop, two panels, and two round table discussions. QAP reports 
and CD-ROMs were distributed to GHC participants at URC's conference booth. Additional details are 
reported in Table 20. 
Management of the Project Website and Collaboratives Extranet 
Additional changes were made to the home page design of the project website (www.qaproject.org) and 
to the coding of internal pages to make the website fully compliant with accessibility standards set forth 
in the Americans with Disabilities Act and required under USAID branding and marking regulations. 
Ya-Shin Lin traveled to Rwanda in July 2005 to train local QAP staff and facility-based teams 
participating in the PMTCT-VCT collaborative in the use of the Collaborative Extranet and to begin 
posting previously collected data and improvement reports. The manufacturer of the Instant Intranet 
Builder software used to create the Extranet was contracted through two small, fixed-price purchase 
orders to make further enhancements to the Extranet site's look and functionality in response to feedback 
from users in Rwanda. During the year, 15 of the 16 original PMTCT sites entered data on the site for 
one or more indicators. Although additional indicators were added and team pages created for the 
expansion sites, only a few of the 21 expansion sites that became active in the PMTCT collaborative at 
the beginning of Year Four used the Extranet, most likely because of the planned closure of the PMTCT 
collaborative in August 2006. Extranet pages were created for the Nicaragua PHI collaborative, which 
will begin using the Extranet to display hospital team data in Year Five. 
56 QAP Year Four Self Evaluation 
Table 20: OAP Technical Presentations at Briefings and Conferences, 7/1/05-6/30/06 
Briefings and Presentations for USAID and Cooperating Agency Staff 
6/06: Larissa Jennings presented on QAP's experience with monitoring compliance with EOC indicators at a 
technical meeting sponsored by the Prevention of Postpartum Hemorrhage Initiative (POPPHI) held at PATH. The 
meeting's purpose was to discuss the strengths and weaknesses of two indicators related to active management of 
the third stage of labor that the Initiative has proposed to be routinely collected from current projects of all 
cooperating agencies. 
6/06: Maina Boucar and Kathleen Hill presented to the Office of U.S. Foreign Disaster Assistance on "Rapid 
Expansion of Nutritional Recuperation Services for Children in Government Facilities during the Nigerien Food 
Crisis and its Aftermath" reporting on the progress to date of the OFDA-funded addition to the Niger PHI 
collaborative to institutionalize nutritional recuperation services within MOH facilities. 
6/06: David Nicholas, Maina Boucar, Apolline Uwayitu, Victor Boguslavsky, Kim Ethier, Festus Kalokola, and 
Rachel Jean-Baptiste conducted a briefing at USAID on the results from HIV/ AIDS-related improvement 
collaboratives in Rwanda, Russia, Tanzania, and Uganda. 
4/06: David Nicholas made a presentation on the collaborative approach at the annual meeting of the CORE 
Group. 
11/05: David Nicholas discussed improvement collaboratives with members of the CORE Group through its E￾luminate webconference series. 
10/05: Bart Burkhalter gave a talk to students at the Bloomberg School of Public Health at Johns Hopkins 
University on "Operations Research in QA: Past Shoulders, Present Costs, Future Speculations." 
Conference Presentations 
President's Rachel Jean-Baptiste was invited to present the poster, "Promotion of Continuous Quality 
Emergency Plan for Improvement Initiatives During Rapid Scale-up of a National ART Program: The Case of 
AIDS Relief, Third Uganda." Deborah Ash was invited to present the poster, "An Innovative Training Strategy 
Annual Field Using Job Aids to Support Infant Feeding in the Context of HIV/AIDS," presenting QAP's 
Meeting, work in Tanzania. Donna Jacobs presented the poster, "Effective Strategies for Continuous 
6106, Durban Quality Improvement in PMTCT" on QAP's work in South Africa. Victor Boguslavsky 
was invited to attend the meeting as part of the official delegation from Russia. 
Global Health Jorge Hermida, Kathleen Hill, and Lani Marquez led the pre-conference workshop, 
Council, 6/06 "Implementing Best Practices in Essential Obstetric Care Using the Improvement 
Washington, DC Collaborative Approach." 
David Nicholas presented the paper, ''The Collaborative Approach to Improving ART in 
LDCs," as part of A panel organized by QAP, "Knowing Is Not Enough: Applying Classic 
Improvement Strategies to Anti-Retroviral Therapy." James Heiby moderated the panel, 
which also included presentations by Bruce Agins on HIV-QUAL work in Thailand and by 
Pierre Barker on IHl's HIV/AIDS improvement collaborative in South Africa. 
As part of the QAP-led panel, Strengthening PMTCT Through Innovative Infant Feeding 
Counseling Tools, Peggy Koniz-Booher described how the counseling job aids were 
developed and tested in 2004 with the technical support of URC/QAP and USAID. 
WHO' s Dr. Constanza V allenas presented ''WHO HIV and Infant Feeding Guidelines and 
Counselling Tools: Toward Global Utilization." Sebalda C. Leshabari, Muhimbili 
University College of Health Sciences-Tanzania/University of Bergen-Norway, presented 
"Operations Research to Test an Integrated Set of HIV/IF Job Aids," presenting the finding 
of the QAP OR study in Tanzania. 
Stephen Kinoti led the roundtable discussion, "Reducing Pneumonia Case Fatality in 
Malawi through Pediatric Hospital Improvement (PHI)." Ya-Shin Lin led the roundtable 
discussion, "Improving Pediatric Hospital Care," presenting the results of PHI 
collaboratives in four countries. 
Gender, Child Peggy Koniz-Booher gave the plenary address, "HIV and Infant Feeding: An Update on 
Survival, and Evidence, Recommendations and Challenges," at this international conference sponsored 
HIV/AIDS: From. by York University. 
Evidence to Pol\cy, 
5106, Toronto 
QAP Year Four Self Evaluation 57 
Third Latin Jorge Hermida made a plenary presentation at this joint meeting of the Latin American 
American Congress Congress on Quality of Health Care and the 4th National Conference of the Mexican 
on Quality of Health "National Crusade for Quality" ( Cruzada Nacional por la Calidad) on the experience of 
Care, 3/06, Mexico the Latin American EOC Collaborative (reducing maternal mortality is a main objectives of 
City the Mexican Government and its QA Program). During the Congress, the Latin American 
Society for Quality in Health Care (Sociedad Latinoamericana para la Calidad en 
Atenci6n de la Salud - SOMECASA) was formally founded and its constitution approved. 
The mission of this international NGO is to promote QA in health in the region, with 
operational links to the International Society for Quality Assurance in Health. QAP was 
elected a member of its first Executive Board. 
HIV/OVC Meeting, David Nicholas presented a conceptual framework for looking at and thinking about quality 
3/06, Windhoek and how to improve it within programming for orphans and vulnerable children, especially 
those affected by HIV/ AIDS. 
Third International Thada Bornstein made a plenary presentation entitled "Quality of Care" to explain QAP's 
RHINO Conference, approach to quality monitoring at the third international meeting of the Routine Health 
2/06, Chiang Rai, Information Network (RHINO). The meeting's theme was "Information for Action: 
Thailand Facility and Community Focus." 
American Steve Harvey presented a paper on QAP's work on the cultural adaptation of obstetric care 
Anthropological in Tungurahua, Ecuador. 
Association Annual 
Meeting, 12/05, 
Washington, DC 
American Public Mary Drake presented the paper, "Maximizing Opportunities-Collaborating for Rapid 
Health Association Scale-up of Quality Family Planning Services" describing Tanzania's family planning 
Annual Meeting, collaborative. 
12/05, Philadelphia, Stephen Kinoti presented the posters, "Scaling up Pediatric HIV I AIDS Care in Tanzania" 
PA and "An Innovative Model for Capacity Development to Implement and Expand Effective 
Pediatric Emergency Care," describing the coaching support system developed in Malawi 
with registrars from the College of Medicine. 
Rebecca Furth of Initiatives Inc. made the oral presentation, "Human Resources 
Implications of HIV/ AIDS Scale-up: The Case of Rwanda." 
International Union QAP staff led a post-graduate course on quality improvement entitled, "Quality 
Against Improvement and Treatment Adherence." Neeraj Kak led the workshop with a presentation 
Tuberculosis and on quality improvement in TB. Refiloe Matji made a presentation on strategies to improve 
Lung Disease treatment adherence. Sadia Parveen presented lessons from QAP's support in Bangladesh 
(IUATLD), 10/05, for expanding public-private partnerships in TB and improving supervision. Kim Ethier 
Paris and Olga Chernobrovkina presented preliminary results from the Russia HIV/AID 
collaborative in the area of TB/HIV co-infection. 
International Society Mandy Rose presented the paper, "Improving Pediatric Hospital Care: Affordable, 
for Quality in Health Feasible, Essential." 
Care Conference, Steve Harvey presented two papers: "Using client perspectives on quality of care to 
10/05, Vancouver improve cultural adequacy of obstetric care and promote hospital-based childbirth in 
Ecuador" and "Upgrading volunteer community health worker skills in malaria diagnosis: 
A job aid for malaria rapid diagnostic tests (RDTs)." 
3 MONITORING -Tracking of Performance 
Last year's Self Evaluation described our approach to results monitoring, which we establish in each 
field-based activity to build in routine tracking of compliance with standards in each QAP-assisted service 
delivery program. It also described the various mechanisms we use to monitor contract performance at 
the country and project levels, including monthly and quarterly reviews of contract activities. In Year 
Four, we continued to use these approaches to support local teams in 12 countries in monitoring quality as 
part of institutionalizing QA. This work tracks both country level and overall contract progress toward 
completion of planned activities and achievement of expected results. 
58 QAP Year Four Self Evaluation 
In response to last year's feedback from the US AID Performance Evaluation Committee, we focus here 
on progress made this year in addressing two critical aspects of performance monitoring: validating self￾assessed/self-reported data and sustainability and institutionalization of quality monitoring within routine 
operations. 
Improving Validity of Self-Reported Data 
Our approach relies on self-reported data to make the quality monitoring process feasible and sustainable 
in developing country health systems. In place of external evaluators, we train provider teams to collect 
data on quality indicators and track those indicators (often in visual displays or mn charts) to show 
change over time. Externally led assessments, while more rigorous, are much more costly and not 
sustainable in most health systems. While recognizing the trade-off between statistical rigor and 
sustainability, it is also important to keep in mind that the purpose of facility-level quality monitoring is 
to allow teams to measure their own progress toward improvement-that is, to show trends rather than 
demonstrate statistical significance. 
While QAP has found that extracting data from records and relating numerators and denominators is 
difficult at first for many health providers, especially in Africa, we have also seen that teams can learn to 
audit records for compliance with standards and can, with practice and coaching, gain proficiency in 
calculating and charting results. Coaches provide critical support to the quality monitoring process by 
reviewing data with teams, discussing any discrepancies, correcting misunderstandings about how 
indicators are calculated, and helping teams to gain confidence in their ability to collect and use quality 
data. 
During this past year, we took several steps to strengthen the validity of performance monitoring data: 
• Niger's PHI collaborative reformulated its indicators and revised data collection tools to focus on 
average adherence with case management standards, as opposed to proportion of cases treated 
according to all case management standards, an "all or nothing" measure. This change made the 
calculations easier and provided a more sensitive gauge of progress with a continuous rather than 
dichotomous variable. 
• CQI facilitators, supervisors, and quality improvement coaches in Ecuador, Honduras, Nicaragua, 
Niger, and South Africa accepted responsibility for reviewing clinical records during site visits to 
verify reported indicator values. 
• Coaches in Niger give written feedback to teams on any errors in data reporting and on areas for 
improvement. Teams report that they find written feedback motivating. 
• More extensive baseline surveys were carried out in Niger (on EONC) and in Uganda (on ART) at the 
start of these two new collaboratives to draw a broad picture of how facilities are doing vis-a-vis 
standards of care. Routine monitoring will focus on only a sub-set of indicators. For example, in 
Uganda, facility teams were asked to choose, for their monthly monitoring of progress, only one 
indicator from each of five categories of indicators (27 indicators in all) that were developed by the 
collaborative core technical team. In Niger, Lot Quality Assurance Sampling was used in the baseline 
assessment to minimize the number of records needed to determine which areas most need 
improvement. 
• In Rwanda, discussions at learning sessions of trends in the quality of data across teams helped to 
identify "system" problems-those that several teams were facing due to faulty processes at higher 
levels of the system. 
• As part of implementing a "service strategy," quality teams in Nicaragua regularly and publicly post 
quality monitoring data in health facilities. This practice raises client awareness of health workers' 
efforts to improve quality and clients' expectations of quality service and acceptable interpersonal 
treatment. 
QAP Year Four Self Evaluation 59 
• In Nicaragua, national and hospital-level teams in the PHI collaborative are tracking case fatality for 
severe diarrhea and pneumonia and correlating those rates with compliance with standards data as an 
indirect measure of the validity of performance monitoring data. 
Validity of self-reported data was a main topic of discussion at the Collaboratives Learning Week held in 
June 2006. Staff shared approaches and problems they had experienced with validating data and made 
these recommendations: 
• Simplify data collection tools to reduce errors. 
• Correlate the indicators and look for discrepancies in data (to find errors). 
• Supervisors and coaches need to audit data reported by teams during site visits sampling records from 
which data were taken. 
• Measure process indicators monthly when a new practice is first introduced and less frequently once 
processes stabilize. 
• Feed anomalies back to the team and have coaches use problems they find with data to motivate 
teams to improve their data reporting accuracy. 
The new OR study on validity of self-reported data launched in Ecuador this year (discussed in section 
2.1), the new one to be launched in Tanzania, and the ongoing OR study on the impact of the PHI 
collaborative in Niger are all expected to inform the development of systematic yet practical methods and 
tools for ongoing verification of the validity of data collected and reported by facility teams. 
Institutionalizing Monitoring of Compliance with Standards 
Institutionalization of continuous quality improvement methods in QAP-assisted countries progressed 
significantly during Year Four, especially in Latin America. 
• The Honduras Secretariat of Health now has a Quality Coordinator position in each Departmental 
Health Region to monitor and support the work of CQI teams in public facilities in the region, 
including regular audit of compliance with standards. As part of health sector reform activities, new 
institutional processes for monitoring quality of care have also been introduced: formal management 
agreements are now being signed between regional health directorates and hospitals that transfer 
funds to the hospitals for quality improvement activities, based on compliance with standards. The 
regional health directorates conduct a quarterly external assessment of compliance with 16 indicators 
by each hospital and disburse funds to the hospital based on attainment of standards, as determined by 
the assessors' record review. A similar process is in effect whereby the Extension of Coverage Unit 
of the regional health directorate conducts a bimonthly assessment of compliance with standards by 
decentralized healthcare providers. Payments to these providers for health services provided are 
affected to a certain extent by the provider's demonstrated level of compliance with standards. These 
processes are the direct product of QAP assistance to the Secretariat. 
• The indicators that QAP has promoted in Nicaragua for monitoring the quality of critical care 
processes for mothers and neonates have been incorporated into MINSA's official registers and 
reporting forms. The Directorate for Quality Control and Assurance (Direcci6n de Control y 
Aseguramiento de la Calidad) is responsible for promoting compliance with standards at the local 
level, which is measured by the quality monitoring indicators developed with QAP assistance. In 
each region (SILAIS), the coordinator for maternal and child health programs is responsible for 
reviewing facility-reported compliance data. 
• In Ecuador, the MOH actively monitors data on compliance with essential obstetric care and child 
care standards reported by each province. A full-time MOH data analyst enters monthly reports from 
each province on compliance with key standards of care into a national database. The central level 
also provides feedback to the provinces on the data reported. 
60 QAP Year Four Self Evaluation 
• In Niger, partograph forms used to provide 
delivery care did not have any place for health 
workers to record key elements of active 
management of the third stage of labor and 
essential newborn care, practices being scaled up 
there through the EONC collaborative. So as 
not to introduce a different form into the health 
system, QAP found a simple and low-cost 
solution: provide locally produced rubber stamps 
to improve the form, providing check-off 
reminders that will be seen during each delivery 
(see image at right). 
• In Rwanda, the Ministry of Health's new 
National Policy on Quality of Healthcare calls 
for regular self-assessment of the quality of 
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·····--·····-··········-················-·-- ·---·-• ...... ········································ ····--
healthcare provided and client satisfaction by each health facility as well as periodic evaluation of the 
quality of health facility performance and verification/validation of the performance data collected 
from health facilities by district supervisors. 
4 QUALITY - On-time Delivery and Lack of Defective Services 
and Products 
Quality of Technical Assistance, Research, and Written Reports 
In Year Four, QAP continued to demonstrate the robustness of the improvement collaborative 
methodology and its ability to produce measurable increases in compliance with critical standards of care 
for HIV/AIDS, maternal and neonatal health, life-threatening illnesses in young children, malaria, and 
tuberculosis. Our results in Niger, Rwanda, 
Nicaragua, Ecuador, and Honduras this year provide 
compelling evidence of the effectiveness of this 
approach for scaling up best practices. As noted last 
year, the large number of sites covered in these 
countries, the improvements documented in diverse 
systems of care, and the evidence of spread beyond 
initial sites attest to the effectiveness of the 
collaborative approach and the quality of QAP 
technical assistance that fostered these results. 
Through conference and special presentations and 
briefings (see Technical Leadership section for 
details), we have generated interest in the 
collaborative approach among other US AID 
cooperating agencies and begun plans for new 
collaboratives in the coming year that will be 
implemented by other organizations with QAP 
technical assistance or as joint efforts. 
USAID Missions have recognized the value added 
by QAP to their country portfolios and this past year 
increased funding to QAP in Honduras, Nicaragua, 
and Russia. (See Box 2 for Mission feedback.) 
QAP Year Four Self Evaluation 
Box 2. Feedback from USAID Mission Staff 
on the Quality of OAP Assistance and 
Products 
"!just attended a report from an assessment in 
Kilimanjaro area to assess peds HIV care. 
Despite all the bad news, one good piece of news 
they brought back was that the URC infant job 
aids were at evel)1 levelfacility they visited! Well 
done." ~ 
- Quality of Care & Service 
Delivery Specialist, 
US AID/Tanzania, June 7, 2006 
"Dear friends, This is just a note to say thank 
you for your absolutely outstanding work and 
dedication. The most important thing is that the 
regions highly value collaboration with you in 
their struggle with HIV/AIDS problems. The 
progress in thinking and actions in all four sites 
is extremely impressive." 
-- Project Manager, 
USAID/Russia, June 28, 2006 
61 
In Honduras, QAP's track record of effective technical assistance to the Secretariat of Health, success in 
institutionalizing QA approaches within regional health services, and innovative proposals for integrating 
quality within health sector reform initiatives led USAID/Honduras to substantially expand QAP's scope 
of work in FY06 and increase funding to the project by over 400%. In Nicaragua and Russia, Missions 
asked QAP to expand work to new technical areas (HIV/AIDS and family planning, respectively). 
The results achieved through the PHI collaborative in Niger, one of the poorest and most resource￾constrained countries in the world, persuaded another USAID office, OFDA, of the soundness of 
investing disaster response funds to piggyback onto QAP's ongoing work to establish new nutritional 
recuperation services in the Nigerien public health system. By leveraging the capacity for improved 
pediatric care developed among local MOH staff through the PHI collaborative and through strong 
partnerships with NGOs and UNICEF, QAP is helping the Ministry of Health of Niger to develop long￾term capacity for nutritional recuperation of severely malnourished children. 
Program materials developed with QAP assistance have received widespread recognition both within and 
outside the country of production. The high quality of the HIV and infant feeding job aids developed in 
Tanzania led to QAP assistance in adapting and field testing them this year in Uganda and Zimbabwe. 
Within QAP country programs, we have also successfully adapted tools and products developed in one 
country for use in others. Examples of our efforts to leverage USAID investment to benefit multiple 
countries this year include adaptation of the Tanzania infant feeding job aids for use in Benin and Niger 
and adaptation of our SBA competency assessment tools for use in Nicaragua and Niger. We also 
published a manual on cultural adaptation of delivery care with the Ministry of Health of Ecuador and 
Family Care International, which will be disseminated to health facilities throughout Ecuador. The 
manual was developed based on the demonstration of cultural adaptation of delivery care in Tungurahua 
Province in Year Three. 
Responsiveness and Timeliness 
The staff of QAP, both at headquarters and in field offices, takes pride in being highly responsive to 
USAID priorities and directives. This year, we worked closely with counterparts and USAID Missions to 
adjust and/or expand workplans to respond to major shifts and additions in scope of work that were 
instigated by Missions in South Africa (change in criteria for assisted facilities), Russia (addition of 
family planning component and phase-out of activities in two oblasts), Honduras (addition of health 
sector reform, family planning, and maternal and child health components), and Nicaragua (addition of 
HIV/AIDS component). 
We continue to follow very closely all guidance from USAID on branding and marking requirements, and 
this year completed a thorough review of the structure and individual web pages of the project website to 
ensure compliance with all accessibility provisions mandated by the Americans with Disabilities Act. 
While the project's major annual deliverables to USAID-the annual report and annual workplan-were 
submitted on time in Year Four, we continued to experience a delay in completing the Spanish version of 
the IMCI CBT CD-ROM. Our small business subcontractor, Dragonfly Communications, delivered the 
revised Spanish language product to us in November 2005, four months behind schedule. We submitted 
the product to the Bolivia's MOH the same week, but did not receive changes from them until April 2006. 
Since that time, Dragonfly has gone out of business. We are currently in negotiations with the former · 
President of Dragonfly to try to find alternative means of completing the product. Delays in receiving the 
data from the field test of the IMCI CBT in Kenya from subcontractor ARTT also delayed the launch of 
the IMCI CBT product. Data were not received until the spring of 2006, 10 months after the field work 
was completed. We finally published the results of the Kenya CBT field test in August this year and have 
now developed a manual to orient users to the features of the IMCI CBT product and how it can be 
integrated within pre-service and in-service training of health workers. Both cases show the trade-off of 
working with businesses with limited staff/resources, although like the USG we continue to be committed 
to supporting small enterprise and use them for couriers, travel, and other services. 
62 QAP Year Four Self Evaluation 
5 MANAGEMENT - Effective and Efficient Management of 
Resources 
Effective Coordination of Technical Activities 
The project continues to exercise the mechanisms described in last year's Self Evaluation to share 
information, results, and lessons across project activities (i.e. , monthly prioiity-setting meetings, quarterly 
review meetings, brown bags, and short email updates following t1ips and major events). These channels 
help ensure that all staff, including field and subcontractor staff, have a shared understanding of contract 
priorities and are aware of and able to learn from work at other project sites. In addition, the Project 
Director and the AID Project Manager meet weekly for three hours to review progress, problems and the 
latest AID guidance. A project maternal care group and a child care group meet regularly and 
communicate with interested field sites to discuss new technical advances and to coordinate work among 
countries. 
Increasing Efficiency 
Again in Year Four, QAP realized inc_!:eased use of local resources for our field operations. For the first 
time in project history, host country national (HCN) labor and benefit costs exceeded headquarters (HQ) 
staff spending, as follows: 
Year 1: 22% of project spending was for HQ salaries and 6% for HCN labor and benefits. 
Year 2: 19% of project spending went toward HQ salaries and 10% toward HCN labor and benefits. 
Year 3: HQ staff represented 17% of project spending, while HCN labor and benefits comprised 15%. 
Year 4: HQ staff represented 15% of project spending, while HCN labor and benefits comprised 17%. 
Meriting recognition, in particular, is the QAP Honduras office. As a result of their technical expertise as 
well as willingness to take on additional work, the field staff expanded from three full-time personnel at 
the end of Year Three to a current staff of 19. QAP's programs in South Africa, Tanzania, Uganda, 
Russia, and Nicaragua all expanded their activities and their HCN technical staff in Year Four. 
We continue to utilize other locally available expertise whenever possible rather than send external 
consultants, opting to subcontract with local organizations to provide technical support for specific 
activities. We continue working with COUNSENUTH in Tanzania for infant feeding training and 
identified a local printing firm in Uganda to produce Uganda-specific infant feeding job aids. 
As an indication of the extent to which project implementation is undertaken at the field level, by 
established field offices, for the whole of Year Four, field expenditures represented 64% of all project 
expenditures. Even more interesting is that for the first six months of Year Four, field expenditures 
represented 60% of project expenditures. For the second half of Year Four, field expenditures 
represented 67% of project expenditures. We expect this trend to continue through Year Five. 
The project continues its electronic dissemination of trip and technical reports, either via email or postings 
on the QAP website. Reports generated in the U.S. are now entirely produced in-house, with our only call 
for outsourced print jobs being poster presentations or lamination of job aids. We have also begun 
expanding use of voice-over-Internet to reduce long-distance charges. 
Use and Effective Integration of Subcontractors 
In Year Four, the project decreased its use of small businesses and subcontractors as compared to Years 
Two and Three. Our significant collaborative evaluation activity is largely directed and carried out by a 
small, woman-owned business, Encompass. While we continue to also rely on small businesses to meet 
many of our operational needs (travel arrangements, couriers, computer supplies, document translation, 
QAP Year Four Self Evaluation 63 
CBT programming, and short-term technical assistance), the demand for these services has decreased, 
largely because more expenditures take place in the field. 
Cost Control 
The cost control mechanisms mentioned in the last year's Self Evaluation continue to yield savings. We 
continue to operate within or under budget and can therefore consistently carry out more activities than 
originally set forth in annual workplans. The area of most significant cost control making additional funds 
available for direct project activities is URC's indirect cost savings. URC's indirect rates are among the 
lowest of AID contractors; nevertheless, URC has achieved cost savings in its indirect costs and has 
returned funds to all its projects, including QAP. 
We continue to require three competitive bids for all purchases exceeding $500. We closely monitor 
proposed expenditures requiring either purchase requisitions prior to purchases or, in the case of field 
offices, monthly expenditure projections that detail expected purchases by description and price. 
6 COLLABORATION - Effective Collaboration and Coordination 
Close collaboration with national and international implementing agencies is a hallmark of QAP work in 
our long-term country programs and a feature of the improvement collaborative approach, which brings 
different organizations together to share what they are learning to improve a specific system of care. In 
most of our collaboratives, a national level steering committee charged with oversight of the collaborative 
includes representatives from leading technical cooperation agencies working in that country. We invest 
in organizing these steering groups in order to develop consensus on goals and strategies and to 
incorporate best practices of other organizations in the collaborative's technical content. Both in 
collaboratives and in country technical assistance not involving a collaborative, we strive to leverage the 
resources USAID has channeled through QAP to achieve the greatest impact for the country by working 
with other partners and funding agencies. 
Examples from our field work in the past year include: 
• In Nicaragua, QAP continued to work closely and co-sponsor activities with UNICEF, the Pan 
American Health Organization (PAHO), CARE, UNFP A, Nicasalud Federation, and Management 
Sciences for Health. UNICEF, PAHO, and UNFPA have channeled resources into the creation of 
clinical training centers for EOC and pediatric care in selected SILAIS hospitals to replicate the 
training center model developed with·QAP assistance. In the area of HIV/ AIDS, QAP has worked 
closely with the other three USAID cooperating agencies in Nicaragua-DELIVER, the Pan 
American Social Marketing Organization (P ASMO), and the regional Proyecto Acci6n SIDA Centro 
America (PASCA)-to jointly advise MINS A on HIV/ AIDS standards and indicator development 
and to design and implement training activities in the local health systems. 
• In Russia, QAP worked with American International Health Alliance and the Healthy Russia 2020 
Project to implement training workshops on HIV counseling in the four intervention regions. QAP 
also worked with John Snow, Inc., to apply training and counseling materials developed under 
USAID's Maternal and Child Health Initiative in the new family planning collaborative. Although 
QAP directly supports activities in orily a few oblasts, we work closely with the Federal AIDS Center 
and Federal TB Health Care Delivery Center for HIV-infected Patients of the Ministry of Health and 
Social Development in the design of improvement strategies supported through the collaborative. 
Federal authorities served as content experts in the HIV-TB Round Table and inter-regional learning 
sessions held this year, as did representatives from the lead technical agencies supporting AIDS and 
TB projects in Russia: WHO, CDC, the Open Health Institute, and the Russian Healthcare 
Foundation. Stemming from this collaboration, QAP was invited to participate in trainings for Global 
Fund Round Four regions to share specific improvements that have been introduced through the 
collaborative. 
64 QAP Year Four Self Evaluation 
• 
• 
In Niger, we have partnered with UNICEF and two international NGOs (the faith-based organization, 
Islamic Relief, and Helen Keller International) to strengthen capacity of regional and district hospitals 
to offer nutritional recuperation services. The NGOs have experience establishing nutritional 
recuperation centers as part of disaster relief. 
In Uganda, QAP's work is subsumed under the Ministry of Health-led National Quality of Care 
Initiative. Our behind-the-scenes contributions have been critical in developing a technical leadership 
structure for improving the quality of all HIV/AIDS services in Uganda. QAP and the Regional 
Center for Quality in Health Care helped the MOH to create a steering committee that brings together 
all key HIV/AIDS partners working in Uganda, including CDC, DELIVER, and EGPAF. 
In several countries this past year, QAP's technical inputs leveraged financial contributions from other 
agencies to fund implementation and scale-up of quality improvement activities. I!l Ecuador, UNFPA 
funded all local ~osts for training facility teams in five provinces in continuous quality improvement and 
in clinical management of obstetric complications, including the purchase of training mannequins and 
covering the travel and per diem of QAP trainers. QAP also worked closely with Family Care 
International and Ecuador's MOH to develop this year the manual on cultural adaptation of delivery care, 
which grew out of the series of workshops we implemented together in Tungurahua Province in Year 
Three. In Nicaragua, UNICEF contributed $25,000 last year to support the PHI collaborative. In Niger, 
UNICEF is contributing in-kind resources to the nutritional recuperation centers being created with QAP 
technical support. 
At the global level, we continued to provide expertise in quality improvement and specifically in the 
implementation of collaboratives to members of the CORE Group. We developed a joint request for 
proposals with the CORE Group to implement a community-level improvement collaborative. The 
selected proposal, by Plan International, will implement a community-based malaria prevention 
collaborative in Benin, and QAP will assist the Plan team in Benin in Year Five. 
We contributed expertise in quality monitoring and improvement to the Routine Health Information 
Network (RHINO) conference in Thailand in February 2006 and to a meeting of USG cooperating 
agencies working in OVC programming in Namibia in March. We also worked closely with the Partners 
for Health Reform Plus and Rational Pharmaceutical Management Plus projects this year to refine the 
Health Systems Strengthening Assessment tools and apply them in Angola and Benin. With the new 
Prevention of Postpartum Hemorrhage Initiative, we shared our experiences with measuring and 
spreading AMSTL through our EOC collaboratives; we have since incorporated Initiative tools and 
indicators into our work in Niger and Benin. 
We also participated actively in consultative meetings of the STOP-TB Secretariat on strategies for 
public-private mix and laboratory strengthening in DOTS expansion. We again conducted a training 
workshop on TB quality improvement at the IUATLD annual meeting in October 2005. With WHO, we 
continued our long-standing collaboration on pediatric hospital improvement and malaria rapid diagnostic 
tests. A new malaria RDT activity was carried out jointly with WHO in Zambia in 2006. We also 
worked closely with the WHO office in Bangladesh to develop the strategy and training course on 
strengthening monitoring and supervision of DOTS. 
7 Opportunities for Improvement and New Directions 
While this document focuses on our results and achievements in Year Four, we have identified as part of 
our Self Evaluation exercise several key results areas that will be priorities in Year Five. 
1. Complete and disseminate the findings of field evaluations and cross-country analyses of QAP￾supported collaboratives 
The international meeting of collaborative teams in June 2006 and the field evaluations of QAP-supported 
collaboratives initiated in August have begun to generate valuable insights about how to best apply the 
QAP Year Four Self Evaluation 65 
collaborative approach in low- and middle-income countries and how to maximize collaboratives' results. 
These analyses will be completed in Year Five and the results presented in a series of papers for country 
policy makers and technical cooperation agencies. 
2. Document the sustained results of improvement collaboratives and how quality assurance 
interventions have become institutionalized in focus countries 
USAID has invested in promoting the institutionalization of quality assurance through QAP and other 
projects, and indeed quality assurance has become a mainstreamed health systems strengthening 
approach. QAP is positioned in several countries to document how improvement activities focused on 
key health services can be integrated into routine activities and supervised and supported by MOH 
provincial and district staff without donor support. In Year Five, we will document these experiences and 
specific examples of quality monitoring tools that have been adopted by Ministries of Health and NGOs. 
We will also carry out research in Honduras to document the impact of performance-based contracts and 
decentralized management schemes on health services quality. We will examine these programs from the 
perspective of their influence on institutionalizing QA functions. 
3. Complete and disseminate collaborative guidelines, tools, and training materials to facilitate 
mainstreaming of the collaborative approach 
Work begun in Year Four to define the core principles and steps in developing and managing 
collaboratives and to create training courses on improvement collaboratives will be completed and 
applied with NGOs and other cooperating agencies in Year Five. This effort will enable other USAID 
partner organizations to benefit from QAP's experience in this new field and spread the use of the 
collaborative approach beyond this project. Publication of the results of field evaluations of QAP 
collaboratives, a priority in Year Five, will also stimulate interest in the collaborative approach. 
4. Continue to expand work to integrate clients and communities in improvement activities and 
document these experiences 
In Year Four, the project strove to increase client involvement in quality improvement and linkages 
between improvement activities and community organizations/clients in Ecuador, Honduras, Russia, 
South Africa, and Tanzania. We will continue to strengthen community linkages in Year Five in these 
and additional countries, particularly to enhance the continuum of care for children and adults with 
HIV/AIDS. A new collaborative focused on community-level services is planned for Benin in Year Five. 
We will also step up efforts to document and disseminate the results of these experiences. 
5. Develop/produce a monograph on "Assuring the Quality of ART" 
Based on our work and that of other organizations, we will synthesize a monograph on assuring the 
quality of ART. This would include issues, challenges, strategies, practical activities, tools, and 
indicators and methodology for measuring quality at facility and community levels. 
6. Publish results in peer-reviewed journals 
Two manuscripts were submitted last year to The Lancet on the results of the project's regional EOC 
collaborative in Latin America and work to improve the competency of skilled birth attendants. While 
neither was accepted, we will redouble our efforts in Year Five to generate a larger number of quality 
manuscripts on the results of collaboratives in different clinical areas and countries and on the adaptations 
of the collaborative approach itself to the conditions in developing country health systems. We will also 
seek publication in a more diverse body of international health journals to increase likelihood of 
acceptance. 
66 QAP Year Four Self Evaluation 

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