QUALITY 
ASSURANCE 
PROJECT
Center for Human Services • 7200 Wisconsin Avenue, Suite 600 • Bethesda, MD 20814-4811 • USA
TECHNICAL REPORT SUMMARY
The Niger QAP/BASICS 
Joint Project
The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development
(USAID), under Contract Number HRN-C-00-96-90013. QAP serves countries eligible for USAID
assistance, USAID Missions and Bureaus, and other agencies and nongovernmental organizations
that cooperate with USAID. The QAP team consists of prime contractor Center for Human Services
(CHS), Joint Commission Resources, Inc. (JCI), Johns Hopkins University School of Hygiene and
Public Health (JHSPH), Johns Hopkins Center for Communication Programs (JHU/CCP), and the
Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO). It provides
comprehensive, leading-edge technical expertise in the design, management, and implementation
of quality assurance programs in developing countries. CHS, the nonprofit affiliate of University
Research Co., LLC (URC), provides technical assistance and research for the design, management,
improvement, and monitoring of healthcare systems and service delivery in over 30 countries.
T E C H N I C A L R E P O R T S U M M A R Y
The Niger QAP/BASICS
Joint Project Abstract
This summary presents the
objectives, findings, lessons
learned, and recommendations
of the fall 1998 evaluation of a
quality assurance (QA) program
in Niger, a French-speaking
country in West Africa with a
population of 10 million. The
Nigerien QA Project (QAP) began
in the Tahoua region in 1993 and
in 1997 merged with another
healthcare program—Basic
Support for Institutionalizing
Child Survival (BASICS)—to
become the joint QAP/BASICS
project. Later, the Konni District
(Tahoua) and the Boboye District
(Dosso) were selected for QAP/
IMCI (Integrated Management of
Childhood Illness) interventions;
this was the first time in the
history of international health
interventions that IMCI was
introduced in an environment
where QA practices were in
place.
Important lessons learned from
the evaluation of the first five
years of Nigerien QAP and QAP/
BASICS relate to the savings and
benefits derived from introducing
IMCI in a QA environment, the
ability of healthcare providers to
learn and adapt QA principles
and implement solutions, the
development of teamwork among
QA-trained staff, and the
importance of coaching and
meetings to support and sustain
QA activities. The story of QA in
Tahoua stands out as an
excellent example of how QA
activities can improve the quality
of care, even in the face of
severe resource constraints.
Table of Contents
I. Introduction ..................................................................................................... 1
A. Events Influencing Nigerien Healthcare in the Late 1990s ....................... 1
B. The Evaluation of the QAP/BASICS Project ............................................... 3
C. Healthcare Environment Pre-QAP .............................................................. 4
II. TAP Objective Number 1 ................................................................................ 5
A. Defining Quality .......................................................................................... 5
B. Immediate Results of the Supervisory System .......................................... 6
C. Improving Quality........................................................................................ 7
III. TAP Objective Number 2 ................................................................................ 9
A. Introducing IMCI in Niger ......................................................................... 10
B. Local Implementation ............................................................................... 10
C. Results of Introducing IMCI in a QA Environment ................................... 10
D. Dissemination of Information on the Nigerien QAP ................................. 12
IV. Cost Analysis of the Niger QAP/BASICS Project ......................................... 12
A. Sustainability Costs .................................................................................. 13
B. Basic QA and IMCI Training Costs .......................................................... 13
C. Training of Trainers ................................................................................... 13
D. Team-Based Problem Solving .................................................................. 13
E. Supervision and Coaching ....................................................................... 14
F. Supervision Checklist ............................................................................... 14
G. Quality Meetings ....................................................................................... 14
V. Lessons Learned .......................................................................................... 14
A. For Niger ................................................................................................... 15
B. For the International Health Community .................................................. 16
C. Main Factors Limiting QA ......................................................................... 16
VI. Recommendations ........................................................................................ 17
A. Establishment of Standards ..................................................................... 17
B. Supervision and Monitoring of Standards ............................................... 17
C. Coaching and Quarterly Meetings ........................................................... 17
D. Problem Solving ........................................................................................ 17
E. Sustainability ............................................................................................. 17
F. Dissemination and Documentation .......................................................... 18
Acknowledgement
The authors wish to express their appreciation to Youssef Tawfik, MD,
MPH; Xavier Crespin, MD, MPH; and Mamoudou Djingarey, MD, MPH,
for their participation on the evaluation team.
The evaluation team is indebted to the staff of the QAP/BASICS project
for their technical assistance throughout the mission and for the
secretarial help, transportation, and equipment they made available.
The team also appreciates the willingness of the departmental and
district health authorities in the Tahoua and Dosso Departments of
Niger to be available at all times.
The evaluation team acknowledges the support provided by the
USAID Mission in Niamey in funding this final evaluation and thanks
the agency for providing the Quality Assurance Project with the
opportunity to contribute to the success of the QAP/BASICS project in
Tahoua and Dosso. The evaluation team’s work was supported through
the Center for Human Services (USAID Contract No. HRN-C-00-96-
90013) and the BASICS Project (USAID Contract No. HRN 6006-C-00-
3031-00).
Recommended citation
Legros, S., E. Goodrich, and H. Abdallah. 2000. “The Niger QAP/
BASICS Joint Project.” Technical Report Summary 1(1). Published for
the U.S. Agency for International Development (USAID) by the Quality
Assurance Project (QAP): Bethesda, Maryland.
About this series
The Technical Report Summary series provides concise descriptions
and background information on the Quality Assurance Project’s
technical intervention results, evaluation results, and other project
activities. This summary is derived from a longer report that was
presented to Nigerien and U.S. officials immediately after the evalua￾tion. For a copy of the longer report, write to qapdissem@urc-chs.com
or call 301-941-8532. For more information on the evaluation of Niger’s
QAP/BASICS project, please contact slegros@urc-chs.com.
The Niger QAP/BASICS Joint Project (TRS) ■ 1
Stephane Legros, Elizabeth Goodrich, and Hany Abdallah
The Niger QAP/BASICS
Joint Project
Acronyms and Abbreviations
ARI Acute respiratory infection
BASICS Basic Support for
Institutionalizing Child Survival
BPS Basic Package of (Healthcare)
Services
CCM Combined Case Management
CHS Center for Human Services
IMCI Integrated Management of
Childhood Illnesses
ISQua International Society for Quality
in Health Care
MPH Ministry of Public Health
QA Quality Assurance
QAP Quality Assurance Project
RAHWP Rapid Assessment of Health
Worker Performance
TAP Technical Action Plan
USAID United States Agency for
International Development
WHO World Health Organization
I. Introduction
Based in Bethesda, MD, the Quality
Assurance Project (QAP) helps
developing countries improve the
quality of their healthcare services
by introducing quality assurance
(QA) tools and methods. Such tools
(e.g., checklists, flowcharts, cause￾and-effect diagrams) and methods
(e.g., standard setting, problem
solving) ultimately enable a
healthcare system to improve the
health outcomes of the population
served. QA has gained widespread
acceptance in healthcare settings,
particularly as part of health sector
reforms that seek to deliver cost￾effective, equitable, and high-quality
services. While many countries have
articulated goals for healthcare
quality, ineffective structures and
processes often hinder service
delivery. QAP is working to improve
those structures and processes by
introducing QA interventions.
The U.S. Agency for International
Development (USAID) created QAP
in 1990 to improve the quality of
healthcare, population, and nutrition
services in developing countries
through technical support to
healthcare facilities, USAID
Missions, and field-based cooperat￾ing agencies. The Center for Human
Services (CHS) has operated QAP
since its inception.
During its first five years, QAP
developed national and regional QA
programs, stimulated QA interven￾tions in 16 countries, and conducted
training activities in another eight.
Since the start of its second five￾year phase in 1996, QAP has been
placing greater emphasis on
demonstrating the cost-effectiveness
of QA interventions. Specifically, it is
seeking to: (a) determine the cost￾effectiveness of QA in national
programs, (b) document the impact
and cost-effectiveness of QA
through operations research, and
(c) establish accreditation and other
regulatory mechanisms. In 1993,
QAP began to assist the Ministry of
Public Health (MPH) in Niger in
institutionalizing QA methods in its
healthcare system. That program is
termed “the Nigerian QAP” or “the
QAP” hereafter.
A. Events Influencing
Nigerien Healthcare in the
Late 1990s
The Nigerien QAP experience was
affected by numerous events that
took place between its introduction
in 1993 and the evaluation in 1998.
2 ■ The Niger QAP/BASICS Joint Project (TRS)
Those events included the imple￾mentation of two other major health￾related programs and several events
outside the public health sector that
affected that sector, including a crop
failure-driven exodus that resulted in
reductions in healthcare utilization.
Figure 1 shows several of these
events, and Table 1 is a timeline of
significant dates in the implementa￾tion of the QAP and other major
healthcare developments. Descrip￾tions of some developments follow:
The QAP started in the Tahoua
Department of Niger in April 1993:1
The Nigerien QAP sought to provide
the government of Niger with both
technical and operational assistance
to improve the delivery of critical
primary healthcare services in a
limited demonstration region. This
effort first aimed to identify and
address the most prevalent illness￾related problems of this population
and then determine the resources
necessary to deliver a basic
package of services (BPS) to
prevent and/or solve those
problems.
After completing this introductory
work, the QAP introduced a quality
assurance system of management
for healthcare delivery through:
(a) clarifying, communicating, and
monitoring clinical and management
standards; (b) QA training; and
(c) implementing and supporting a
process for preventing and correct￾ing problems. In addition, the QAP
sought to improve the quality of
family healthcare service by increas￾ing effective coverage of the
population with preventive services,
improving case management of the
most prevalent conditions threaten￾Massive
exodus
Income
related to
1998 harvest
Health
Center
utilization
in Tahoua
Purchase
power linked to
1997 harvest
+
Direct cost –/+
recovery beginning
in 1998
– QAP
since
1993
+
Vertical training for Mother and Child
Healthcare/Extended Immunization Coverage
–
UNICEF
and ALAFIA
programs
+
CCM in 1995
then IMCI in
mid-1998
+
+
Complaint/Treatment
Strategies in 1993 –
–
Figure 1
 Factors Influencing Healthcare Utilization in Tahoua
Note: ALAFIA is a healthcare program sponsored by Germany.
Table 1
 Timetable of Major Healthcare Developments
QA Year BASICS and Other
QA introduced in Tahoua at the health center 1993 Cost recovery introduced in limited areas
and district levels
QA training begins 1994
QA training of health center supervisors 1995 BASICS introduced
QA conference in Tahoua CCM introduced in Boboye and Say Districts
 QA training continues 1996
QA introduced in Boboye
Training of trainers 1997
Start of joint QAP/BASICS project
Introduction of supervisory checklist
1st RAHWP
2nd RAHWP 1998
 International QA conference in Niamey
Evaluation
3rd RAHWP
1 Niger is divided into seven political regions or “departments,” and the term is used in this report in reference to a region and not to a
functional division of an organization. “Districts” are subdivisions of departments.
Cost recovery starts to be introduced in Konni,
Illéla and Boboye
Cost recovery continues to be introduced in
Konni, Illéla, and Boboye
IMCI introduced in Konni and Boboye
The Niger QAP/BASICS Joint Project (TRS) ■ 3
ing women and children, and
strengthening core support services.
While improving health outcomes,
the QAP aimed to demonstrate the
effectiveness and feasibility of
quality management strategies by
assessing the application of QA
interventions, analyzing their impact,
and disseminating the findings that
resulted.
A QAP resident advisor directed
in-country activities and worked
directly with the Tahoua Department
Healthcare Director, his staff, and
district healthcare personnel to
accomplish project objectives.
In 1993 cost recovery began in
limited fashion in Tahoua and then
evolved into different forms as it
spread to other regions:
Cost recovery requires patients to
pay for part of their health services
and medications and thus effects
their decisions of whether to seek
healthcare for themselves or their
dependents. In Niger, funds raised
through cost recovery were used to
replenish supplies of medications.
This improved the healthcare
system’s ability to provide services
and medications, which also
influenced decision making. The
evaluation assessed the effects of
cost recovery in the districts of
Konni, Illéla, and Boboye, where it
was implemented in late 1997 and
early 1998.
In 1995 an independent, USAID￾funded program called BASICS
(Basic Support for Institutionalizing
Child Survival)2 began:
BASICS supported the MPH in
introducing Combined Case
Management (CCM) for children
in primary healthcare facilities.3
Implemented within limited areas,
CCM revised national policies for
diarrheal diseases, acute respiratory
infection (ARI), and malaria.
In 1996 the QAP extended QA
beyond Tahoua to the Boboye
District in the Dosso Department:
This step would support the mid￾1998 introduction of the Integrated
Management of Childhood Illness
(IMCI) clinical guidelines.
Developed by the World Health
Organization (WHO), IMCI was later
incorporated as part of BASICS in
Boboye.
In early 1997 the QAP and BASICS
merged to become the QAP/BASICS
joint project in Niger:
QAP/BASICS focused on the
possibility of revising the approach
to the improvement of child
healthcare services at the district
level. The Konni District (Tahoua)
and the Boboye District (Dosso)
were selected for QAP/IMCI
interventions on the basis of the
availability of essential medicines
and the interest shown by staff. This
development is important to the
international health community
because it was the first time in the
history of international health
2 BASICS provides technical leadership to reduce child mortality and illness worldwide. It applies cost-effective, child-survival interventions
in six programmatic areas: sustaining immunization programs, integrated management of childhood illness (IMCI), strengthening the link
between nutrition and health, promoting and sustaining healthy behaviors, improving techniques for monitoring and evaluation, and
establishing public/private partnerships.
3 Primary healthcare facilities in Niger are generally small clinics staffed by a nurse or less-trained healthcare provider. These facilities
generally serve as the initial point of contact between a patient and health services; cases that cannot be treated at the health centers are
referred to hospitals and specialist facilities.
interventions that IMCI was intro￾duced in an environment where QA
practices were in place.
In the fall of 1998 the evaluation
took place:
At that time, QAP/BASICS was
ongoing in Tahoua Department and
Boboye. The evaluation team also
visited non-QAP facilities for
comparison.
B. The Evaluation of the
QAP/BASICS Project
In late 1998, USAID hired an
evaluation team to review and
assess the QAP/BASICS project. The
team consisted of four doctors who
specialize in public healthcare—one
from the Quality Assurance Project
in Bethesda, Maryland, one from
BASICS, and two from the Nigerien
MPH—and a healthcare program
assistant from USAID.
Just before the evaluation, the team
attended a USAID-funded interna￾tional conference in Niamey, Niger,
where the results of the QAP/BASICS
project were presented by those
involved in its implementation. Next,
the evaluation team reviewed all
QAP-related documents and visited
two department-level health director￾ates, six district headquarters (which
provide administrative and manage￾ment support for district hospitals
and healthcare centers), and 13
primary healthcare centers (health
centers). The team interviewed
about 60 individuals in all—from the
4 ■ The Niger QAP/BASICS Joint Project (TRS)
Nigerien healthcare system, the
QAP, BASICS, and other interna￾tional staff—and conducted two
focus groups of women who used
the healthcare facilities in seeking
care for themselves and their
children. Interviews were guided by
a multilevel questionnaire covering
different aspects of QA. The team
presented a preliminary report to the
MPH General Secretary and other
partners on the last day of the
evaluation to validate its findings
and recommendations.
The evaluation team used the USAID
1997/98 Technical Action Plan (TAP)
as its guiding document. Written by
USAID, the TAP set the objectives
for the QAP/BASICS project. Those
objectives are presented in Chap￾ters II and III.
The goals of the evaluation were to:
(a) assess QAP/BASICS’ success in
achieving those objectives, (b)
summarize the lessons learned from
introducing IMCI in a QA environ￾ment, (c) present a cost analysis for
sustaining QAP/IMCI in Niger after
the cessation of QAP/BASICS, and
(d) develop recommendations to
help the project expand into other
areas of Niger and the surrounding
countries that are, or may become,
interested in introducing IMCI in a
QA environment.
The evaluation team focused on:
(a) documenting the benefits of QA
institutionalization in the healthcare
integration process, (b) document￾ing programs that increased
healthcare workers’ qualifications
and motivation, and (c) evaluating
how standards and tools were
introduced to achieve the integration
of QA and IMCI approaches.
The evaluation team does not claim
to have made an exhaustive analysis
of project performance and results;
their efforts resulted in a broad
overview of QA accomplishments in
Niger. The team recognizes that
factors and programs other than
QAP/BASICS may have influenced
those accomplishments.
C. Healthcare Environment
Pre-QAP
Before QA activities began in 1993,
clinical standards were unknown to
Nigerien healthcare providers (see
Table 2). Health workers had no
understanding of or experience with
working in teams. Regional supervi￾sory competence was lacking, and
no district supervisory teams
existed. Healthcare workers could
receive training only by means of
vertical processes—no regular
meetings were scheduled to share
Table 2
Existing Standards for Patient Management and Health Center
Administration
Department Unit Standards and Guidelines Source Year
Child Health and Development Mother and Child Healthcare/ MPH 1993
Family Planning
Handbook of Clinical Procedures MPH 1995
for tuberculosis, malaria, and
malnutrition cases
Complaint/Treatment Strategies MPH 1993, revised
in 1998
Combined Case Management BASICS/MPH 1995
IMCI WHO/MPH/BASICS Mid-1998
Health Center Management Standard management procedures QAP/MPH 1996, revised
manual (administration, finance in 1998
organization, and health policy)
information and solve problems. In
addition, health managers and staff
had neither the knowledge nor the
tools to solve problems or improve
delivery systems.
Not only were many of the health
centers lacking the essential
equipment to provide a basic
package of services, but the
concept of a BPS was merely a
vague desire in the minds of a few
high-level managers who had
neither the information to design nor
the means to implement one.
Another example of the poor state of
healthcare in Niger before the QAP
is the fact that cleanliness was
largely unsatisfactory in most
facilities.
Table 3 presents the baseline
indicators and departmental
objectives that were in place as
Niger’s QAP began.
The Niger QAP/BASICS Joint Project (TRS) ■ 5
II. TAP Objective
Number 1
Institutionalize quality assurance in
two districts in Tahoua Department
and one in Dosso Department.
Strengthen the supervision teams’
management capabilities, revitalize
problem-solving teams, and support
and strengthen cost-recovery
Table 3
 BPS Baseline Indicators: 1993, 1997, and Objectives
 (Tahoua Department; in Percentages)
Indicators 1993 1997 Department Objective
Utilization rate of curative services (total population) 30 29.8 50
Infant consultation coverage rate (0–5 km.) 58 75.6 85
Prenatal consultation coverage rate (0–5 km.) 63 76.6 85
Nutritional rehabilitation recovery rate 14 24.8 25
Nutritional rehabilitation drop-out rate 15 16 10
Family planning utilization rate (total population) 5 14 7
BCG coverage (0–11 months) 35 76 100
Fixed coverage rate for measles (0–11 months) 24 55 80
Fixed coverage set rate of DTCP/3 (0–11 months) 63 68 90
Fixed return rate anti-tetanus vaccine 2/1 74 73 90
Source: Official Tahoua data
NB: These indicators were calculated from demographic data from the general population census
(1988) and revised according to the annual population growth rate in the Tahoua Department and
calculation methods recommended by Niger’s national health information system.
Demographic Data:
Children aged 0–11 months represent 4.7 percent of the population.
Expected pregnancies represent 52/1000 of the population.
Women of childbearing age represent 22 percent of the population.
activities in the Konni, Illéla, and
Boboye districts.
For this objective, the evaluation
team determined the degree of
institutionalization4 of QA in two
districts in Tahoua and one in Dosso,
measuring the capabilities of the
supervision teams and the problem￾solving teams, and considering the
effectiveness of the QAP’s efforts to
strengthen cost recovery. This
section presents the team’s findings
in these areas as they relate to the
three aspects of QA: defining
quality, assessing quality, and
improving quality.
A. Defining Quality
Standards are essential to achieving
customer satisfaction, but the
evaluation team found that Nigerien
health workers had difficulty manag￾ing the numerous clinical standards
(listed in Table 2) that had been
developed by the Nigerien govern￾ment, Tahoua Department manag￾ers, and donor partners. In addition,
some clinical protocols conflict with
others, causing confusion for
healthcare providers.
Standards of healthcare may be
communicated to health workers
through several means: preservice
training, inservice training, meetings
of health workers and/or supervi￾sors, the dissemination of publica￾tions bearing the standards,
on-the-job training through supervi￾sion, job aids, or any combination of
these. The evaluation team found
that through six regional (to West
Africa), national, and local training
sessions held in Niger in 1998, 39
Nigerien health staff received
training in the IMCI clinical guide￾lines. This number includes six who
received training of trainers. Through
documentation and other evidence,
the evaluation team found that 14
out of 18 health centers have at least
two IMCI-trained staff.
4 “Institutionalization” can be described as follows: When QA activities are formally and functionally incorporated into the structure of a
healthcare system or organization; are consistently implemented; and are supported by a culture of quality, as reflected in organizational
values and policies that advocate quality care.
6 ■ The Niger QAP/BASICS Joint Project (TRS)
Other standards were usually
communicated during quarterly
meetings and supervisory visits. The
QAP did not initially plan specific
training for the implementation of the
national standards it developed.
B. Assessing Quality
Monitoring and supervision systems
work together to ensure that
healthcare providers use standards
appropriately. To measure the extent
of their use and their effectiveness,
indicators must be established and
records kept, and supervisors must
ensure that the records are used for
supervision (to improve provider
performance). Supervisory activities,
including monitoring the use of
standards, were largely nonexistent
before the QAP began in Niger. The
concept of supervision implied an
authoritarian nature and a vertical
approach.
Within six months after the QAP
began, a Quality Council formed in
Tahoua. Comprised of department￾level healthcare managers, its
objective is to guide, coordinate,
and follow all actions relating to
quality improvement. It identified
supervision as the main vehicle to
introduce and strengthen QA in
Niger’s healthcare system. It called
for the creation of a supervisory
system, which began with a docu￾ment that lists several elements
essential to supervision, such as a
definition of supervision, objectives
of supervision, and methodology.
Thus began the journey from an
authoritarian style of supervision
toward a team approach. The
following details the activities and
results of the supervisory system.
1. Development and Activities
of the Supervisory System
The Quality Council initiated the
following measures:
■ Training in supervisory tech￾niques (each district has at least
four supervisors to guide and
assist health center problem￾solving teams)
■ District-level management teams
of two doctors, a manager, a
communicator, and an epidemi￾ologist, all trained in QA,
coaching, and/or supervision
(successfully formed in six of
eight districts of Tahoua)
■ Health worker training in techni￾cal equipment and inventory
management, and a stock
management system
■ Improvements in the car pool
system
■ Management standards and a
BPS
2. Immediate Results of the
Supervisory System
While the ultimate goal of the QAP
is to improve health outcomes,
reaching it requires intermediate
steps. The Niger QAP’s success in
improving health outcomes through
improved supervision would rely on
several intermediate achievements.
The evaluation team reviewed the
progress made and found as
follows:
The supervisory process was not
fully operational:
It calls for supervisory visits by the
department of each district every six
months and by the districts of each
of their health centers every three
months. While department visits
were still irregular at the time of the
evaluation, department staff had
made several information collection
visits, which may have resulted in
the kinds of improvements one
would expect from a supervisory
visit. Supervisory visits by district
staff of health centers were being
held as planned—every three
months—and had helped the health
centers acquire the technical and
financial support they needed,
which improved operations and staff
motivation.
Health workers had been trained to
ensure a functinal transport system:
Healthcare providers received
training in maintaining equipment
and managing inventory, and the car
pool system was strengthened,
although it was still not fully ad￾equate at the time of the evaluation.
Standards were being developed
and implemented:
Management standards and
standards for the delivery of the BPS
had been drafted, adopted, and
disseminated.
A supervisory checklist had been
developed:
The checklist has sections that help
supervisors monitor health worker
performance in following standards
relating to IMCI; prenatal, postnatal,
and infant consultations; immuniza￾tion coverage, etc. It also covers
cost recovery, community participa￾tion, monthly reports, and other
administrative reporting. From
interviews with those who use the
checklist, the evaluators concluded
that its strengths are that it is easy to
use and archive and that its most
important sections apply to IMCI and
community participation. Its weak￾nesses are that it is too long, its cost
recovery section does not request
the same information as the cost
recovery system in Tahoua, and that
The Niger QAP/BASICS Joint Project (TRS) ■ 7
sometimes the activities to be
monitored do not occur while the
supervisor is visiting the health
center.
A rapid assessment of health
worker performance (RAHWP) had
also been developed:
The RAHWP helps supervisors
determine the quality of health
services, especially those related to
IMCI. Using the RAHWP, supervisors
monitor health workers’ abilities to
perform activities like greeting a
caretaker appropriately, taking a
patient’s history, examining children
according to IMCI, classifying the
disease, identifying treatment,
verifying a child’s vaccination and
nutritional status, and counseling
mothers. The evaluation team found
that the RAHWP helps workers
improve their performance if results
are discussed with them. This tool’s
weaknesses are that it does not
cover health services other than
child health, that health workers are
not accustomed to such intense
scrutiny, and that it is time consum￾ing.
Managerial meetings were being
held:
Meetings of staff who engage in
supervisory activities to support QA
are held at two levels: (a) district
head doctors and staff, and (b)
health center managers of a district
and their supervision team. The
meetings provide a forum for
reflecting on and exchanging
information among health centers in
a single district or department. As
part of the information exchange,
participants benchmark successful
problem-solving activities. The
meetings also allow for the system￾atic review of health outcome
monitors (which, in turn, helps
develop data for future quality
improvement activities), the adoption
and communication of standards,
and training and self-evaluation.
C. Improving Quality
Once supervision is in place to
monitor the quality of healthcare
services, the next step in improving
customer satisfaction is identifying
problems that hinder improvements
in measurable healthcare outcomes
and finding solutions to those
problems. QAP advocates the use of
teams of healthcare providers to
implement this process. It also
instructs providers in using QA
methods, such as planning and
defining quality, quality monitoring,
and quality improvement to identify
problems and implement solutions.
To begin, Niger´s QAP trained over
520 health workers between 1993
and 1998. Courses included basic
QA training (400 trainees), coaching
(52), supervision (94), and IMCI (39).
Training was given every year from
1993 to 1998, with the largest
number trained in 1996. The
evaluation team felt that the high
density of trained staff contributed to
the level of teamwork among
problem-solving teams and made
problem solving possible despite
less-than-optimal mobility.
1. Problem-Solving Process
After training, those trained are
expected to return to their place of
work—a health center, district
hospital, or administrative office—
and participate in the development
and continuation of a “problem￾solving” team. Teams tend to have
three to eight members; composition
varies, depending on who has been
trained and the needs and re￾sources of the workplace. A health
center team might include a head
nurse, an assistant nurse, a tradi￾tional birth attendant, and the
director of the district office. QAP
recommends that community
members also participate, although
they generally are not trained (and
were not in Niger). In Niger, continu￾ous team membership was a
problem because of high staff
turnover.
Identifying problems:
While QAP trains health providers to
use data gathering and analysis to
identify problems, most of the
workers interviewed by the evalua￾tion team used brainstorming
instead. Brainstorming is also taught
by QAP but is appropriately used for
other steps in problem solving. QAP
teaches providers to use a selection
matrix to select a problem once
several are identified, and this
method was used in 90 percent of
the cases discussed with the
evaluation team.5 Criteria used for
selection usually included frequency
of the problem, its impact on other
activities, and its importance and
impact on service use.
The evaluation team found that 120
problem-solving cycles had been
started and were either continuing or
had been concluded at the time of
the evaluation. Another 27 had been
5 The selection matrix is a consensus development technique where a group of people who are familiar with the problems at hand are
asked individually to weigh the advantages and disadvantages of solving each of those problems. Through various scoring techniques,
individual preferences are combined to establish a group preference.
8 ■ The Niger QAP/BASICS Joint Project (TRS)
abandoned for reasons unknown
to the team. All cycles addressed
problems relating to the BPS,
meaning that problems relating to
logistics or health center manage￾ment failed to receive the attention
they probably warranted. The most
frequently addressed problems
related to either nutritional training
and rehabilitation or family planning.
Describing a problem:
The evaluation team found that
most teams had difficulty at first in
wording the description of their
problems, but all teams acquired
this skill with experience.
Problem analysis:
The evaluators also found that the
Nigerien problem-solving teams
performed problem analysis well,
especially with respect to using
cause-and-effect diagrams. How￾ever, the teams had difficulties
collecting data and never used
Pareto or control diagrams, which
QAP explains and recommends for
this step.
Identifying, applying, and analyzing
solutions:
The evaluation team rated Nigerien
health providers highly in identifying
viable solutions and using selective
criteria, such as cost and ease of
application. In applying solutions,
providers engaged in several types
of activities, such as raising the
public’s awareness and organizing
medical home visits. Local solutions
to problems were usually found
without significant outside help,
although occasionally the commu￾nity was asked to help build a facility
annex or contribute food for nutrition
presentations. The team felt that,
generally, the teams should ask for
community help more often.
Solution analysis helps teams
evaluate their success in solving a
problem and is especially important
if initial results from the problem
solving are unsatisfactory. The
evaluation team found that a review
was infrequently done; teams
tended to press on to a second
problem rather than assess the
impact of their solution. Alternatively,
they would analyze their solution but
not document their findings.
2. Results of Problem-Solving
Teams
The evaluation team found several
constraints to problem-solving
efforts, including the improper or
insufficient use of QA tools, conflict￾ing schedules, and lack of coach￾ing. On the other hand, the team
found appreciable improvements in
teamwork that can serve as a
foundation for improved healthcare.
Particularly significant were the
motivating and participatory atmo￾sphere for health workers, including
having doctors shift their focus to
patients’ expectations and satisfac￾tion, regular brainstorming to solve
problems, commitment on the part of
workers to solve problems at the
lowest level possible, and health
center management that seeks to
improve the quality of healthcare.
Drug-stocking and cost-recovery
systems were implemented to
organize the essential generic drugs
inventory, sustain routine support
activities, and finance restocking
(cost recovery and drug supply
management are described below in
the chapter on the second TAP
objective).
At the department level, the evalua￾tion team reported finding spontane￾ous problem-solving practices. For
example, rather than implement the
entire problem-solving process,
department staff would use part of it
to solve a problem in a day’s time.
3. The Coaching Mechanism
A coaching mechanism was estab￾lished to assist the problem-solving
teams by providing support and
facilitation. Coaches tend to be
district managers and healthcare
providers who have received
training in both basic QA and
coaching. Coaching results in closer
follow-up of the teams’ work and
provides the support, such as
advocacy for resources, necessary
to implement solutions. This mecha￾nism is especially important during a
team’s first cycle and at the begin￾ning of subsequent cycles. At the
time of the evaluation, there were 24
active coaches in Tahoua and four in
Dosso. The evaluation team con￾cluded that coaches significantly
contribute to the problem-solving
process by encouraging teams, that
they should be stronger at the
department level, and that they
should meet to share experiences.
4. Process Design/Redesign
Process redesign—where healthcare
providers go beyond problem
solving to restructure a system or
process—is still formative in Niger,
but the evaluators were impressed
with what they discovered. Although
Nigerien healthcare managers and
providers had no training or expo￾sure to process redesign, there was
evidence of spontaneous develop￾ment of these skills.
For example, providers realized
during their problem-solving
sessions that it would be more
efficient to offer all healthcare
services to patients during a single
visit, rather than have patients return
The Niger QAP/BASICS Joint Project (TRS) ■ 9
to the health center on the day the
needed service was scheduled. The
concept of integrating services—a
process redesign—was suggested
and implemented on a fairly wide
scale in the pilot areas.
Similarly, providers realized that new
mothers should have postnatal visits
and implemented the idea on their
own initiative. These examples
resulted directly from QA practice
and show that providers are going
beyond simple problem solving to
address faulty processes.
5. Results Analysis
The evaluation team found improve￾ments in most of the BPS indicators,
although other influences, such as
the implementation of cost recovery
and a crop failure-driven exodus,
hindered those improvements. For
example, the use of curative
services rose from 30 percent in
1993 to 37 percent in 1995, but then
dropped to just under 30 percent in
1997. The team believes that
improvements to the healthcare
system, some of them created by
QAP/BASICS, caused the increase
and that by forces outside QAP/
BASICS caused the decrease,
although this cannot be proven.
Other indicator data are in Table 3.
The improvements in the indicators
after the setbacks may have been
caused by a growing satisfaction
with healthcare services among the
Nigerien people. This in turn may
have been caused by: (a) improved
availability of medicines (cost
recovery income is used to resupply
medicines/drugs), (b) the integration
of services, and/or (c) lower medical
costs (prescriptions are less
expensive under cost recovery,
where people buy medications
through the public health system
rather than through a private
pharmacist). The evaluation team
notes that healthcare services in
Niger generally remain too expen￾sive, especially for rural families and
during the rainy season. The team
was pleased to see that patients,
now having to pay for services, are
demanding better quality, which is
expected to continuously improve
those services.
To make a comparison, the team
visited a health center that was not
part of the QAP/BASICS project or
the cost recovery system. It found
that the facility without these
programs lacked many valuable
features. It saw less organized
offering of services and activity
planning, no monitoring of follow-up
indicators, no use of data, no
awareness of any changes in health
outcomes, no provision of prescrip￾tions, and no integration of services.
III. TAP Objective
Number 2
Review, test, and distribute in Niger
and the surrounding countries a
model6
 to improve IMCI at the
district level. Improve the health
workers’ skills in IMCI. Disseminate
in Niger and the surrounding
region the materials produced and
lessons learned from the QAP/IMCI
approach.
For this objective, the evaluation
team looked at the Nigerien QAP’s
success in having certain aspects of
the healthcare system in the pilot
area become a model for implement￾ing IMCI: Lessons learned from that
effort were to be disseminated
throughout Niger and the surround￾ing countries. The team also
evaluated the impact of the QA
environment on health workers’ skills
in IMCI. As noted above, in 1995
BASICS worked with the Nigerien
MPH to introduce Combined Case
Management for children in primary
healthcare facilities. CCM helped
Niger revise policies for the treat￾ment of diarrheal diseases, ARI, and
malaria, thus reducing missed
opportunities to identify sick chil￾dren.
In early 1997, the newly merged
QAP/BASICS project began to focus
on revising the approach to the
improvement of child healthcare
services at the district level. The
Konni District (Tahoua) and the
Boboye District (Dosso Department)
were selected for QAP/IMCI inter￾ventions on the basis of the avail￾ability of essential medicines (in part
because of cost recovery) and the
interest shown by staff. IMCI focuses
on five conditions that cause child
mortality: diarrhea, ARI, malaria,
measles, and malnutrition; BASICS
was USAID’s main vehicle for
introducing IMCI in the late 1990s.
One of the objectives of the evalua￾tion was to make recommendations
that would help QAP/BASICS
expand into other departments of
Niger and into neighboring countries
interested in introducing IMCI in an
environment that has a quality
assurance system.
6 That is, the healthcare system in Niger where QAP/BASICS was implemented would serve as a model for neighboring regions in the
management of childhood illnesses.
10 ■ The Niger QAP/BASICS Joint Project (TRS)
A. Introducing IMCI in
Niger
The QAP/BASICS project provided
technical and managerial assistance
in introducing IMCI into the Nigerien
health system, including:
■ Planning, through a working
group, to adapt the IMCI generic7
standards to Niger’s specific
needs
■ Funding all 1998 workshops for
district managers in orientation,
QA training of trainers, and basic
QA training of health workers in
Konni and Boboye
■ Orienting MPH decision makers,
international partners, prominent
pediatricians, and health workers
in the pilot districts
■ Adapting national standards for
vertical programs and the generic
IMCI standards to account for
Niger’s relatively low rates of
malaria and parasitic infestation
and to reduce the signs for
evaluating dehydration
■ Training to communicate the IMCI
standards
■ Organizing the training events
B. Local Implementation
The evaluation did not directly
demonstrate that savings resulted
from introducing IMCI in a QA
environment. However, the evalua￾tion team does believe that greater
compliance to IMCI standards was a
direct result of QA and that QA
facilities should reap savings
through a reduced use of medicines
and personnel time. Also, better￾quality child care standards were in
place, thanks to the QAP and IMCI.
In addition, the pilot QA/IMCI
program taught international and
governmental healthcare planners
the specifics of implementing IMCI
standards in a QA environment,
including the provision of training in
IMCI skills and use of quality
improvement tools and methods.
1. Cost Recovery and Drug
Supply Management
While cost recovery was in effect in
both Konni and Boboye, the evalua￾tion team found that they were not
equally successful in developing
and implementing drug supply
systems. In Konni, the stockkeepers
were successfully managing
supplies, using payments from
clients to maintain stocks. In
Boboye, however, the team found
several missed opportunities that
were causing shortages. For
instance, first-line antibiotics
required for IMCI were generally
available but second-line antibiotics
were lacking.
While the availability of essential
medicines improved remarkably with
cost recovery, its impact on the use
of services warrants caution.
7 WHO has devised “generic” IMCI standards; they are adapted to fit the situation of each country where they are implemented.
Utilization rates before and after cost
recovery suggest that it caused a
decrease in usage. Figure 2 shows
changes in utilization for three
healthcare services in Konni before
and after cost recovery was imple￾mented. And, as mentioned above,
cost recovery can be beyond the
financial means of some families.
2. Health Indicators
QAP/BASICS has improved the
ability of health staff to collect,
analyze, and use data. The evalua￾tion team was particularly impressed
with Konni District staff’s analytical
ability to monitor health service
indicators (rates of family planning,
prenatal, and neonatal visits, and
vaccinations) and to detect malnutri￾tion, tuberculosis, and leprosy.
C. Results of Introducing
IMCI in a QA Environment
The evaluation team looked at
several factors that contributed to
the successful introduction of IMCI
in Niger’s districts with QA pro￾cesses in place. It found that in
Tahoua, where department and
Figure 2
Utilization of Services in Konni District
(1997 and 1998; January 1 to June 30)
New Patients Under
Five Years
Infant
Consultation
Prenatal
Consultation
17964
17828
11943
15457
8160
6935
1997
1998
The Niger QAP/BASICS Joint Project (TRS) ■ 11
district supervisory teams were
trained in both QA and IMCI,
supervisors are able to provide
technical support to primary
healthcare workers. The team is
concerned that IMCI quality could
erode if QA-trained supervisors are
transferred out of QA districts and
into those where QA has not been
implemented. Because the evalua￾tion occurred just three months after
IMCI was introduced at the health
center level, the team could only
tentatively assess the impact QA
was having on IMCI’s effectiveness.
The following summarizes some of
the findings.
1. Supervision
The supervision checklist discussed
with the first TAP objective evolved
with the introduction of IMCI to
ensure adequate monitoring of
health workers’ IMCI skills. (The
sections of the checklist that monitor
maintenance of essential medicines/
drugs and compliance with the cost
recovery system were also updated
to conform to changes in those
programs.)
The rapid assessment of health
worker performance (also discussed
with the first TAP objective) focuses
mainly on IMCI and is conducted
through observation of health
workers while they examine young
children. It also guides supervisors
in interviewing mothers to assess
their satisfaction with services and
the effectiveness of health worker
communications. The evaluation
team found the RAHWP valuable for
monitoring performance and
generating data to improve services.
The team also saw that feedback
from the assessment can foster
improved worker performance. The
second time this tool was used, a
higher percentage of mothers
received adequate counseling for
treating their children. On the other
hand, some indicators either did not
improve or declined between the
first and second use (Table 4).
2. Quality Improvement
All IMCI-trained staff in Konni and
Boboye had also had QA training,
including problem solving. The team
discovered that this training enabled
staff to recognize problems with
malnourished children and monitor
their progress. This resulted in
impressive improvements in the
indicators measuring dropout rates
in nutrition care. Still, serious
concerns remain: QA can neither
solve problems resulting from lack of
Table 4
Results of RAHWPs
(1997 and 1998; in Percentages)
Konni Illéla
Oct. 97 June 98 Oct. 97 June 98
n = 78 n = 41 n = 81 n = 32
Children checked for general danger signs 49 25 51 63
Children correctly examined 54 28 19 49
Children correctly treated 81 83 77 78
Mothers adequately counseled for the treatment 52 73 50 69
of their sick child
Mothers counseled for signs that merit bringing 75 83 33 50
their child back
Children having their nutritional status checked 93 45 6 16
Mothers who knew at least two general danger signs 43 83 79 53
Mothers who know how to give the prescribed 73 83 40 80
medicine to their sick child
Indicators
resources (e.g., breaks in the cold
chain caused by lack of refrigerator
fuel) nor detect defects in staff
clinical skills, although it can
continuously improve efforts to help
solve these kinds of problems.
3. Findings
While the evaluation team recog￾nizes that IMCI had just been
implemented in Niger, it did release
the following tentative findings:
■ Trained staff are capable of
applying the IMCI clinical
guidelines to examine and treat
children, and they can check
children’s vaccination and
nutrition status.
■ Many of the items necessary for
IMCI to be successful were
12 ■ The Niger QAP/BASICS Joint Project (TRS)
missing because of financial
restraints: no health center visited
had a respiratory rate counter;
Boboye had no IMCI forms; and
the urban health center in Konni
had no baby scale.
■ Health workers have to complete
five different records for each sick
child: the IMCI forms, the National
Health Information System tally
notebook, the Daily Register
Book, the Cost Recovery Regis￾ter, and the Card of Care. This
results in inefficiencies.
■ Health workers do not know what
to do with the completed IMCI
forms, undermining the program’s
effectiveness in monitoring trends
in child health.
■ Some completed IMCI forms
indicate that staff fail to complete
the nutrition section and/or to
refer children with malnutrition.
■ Some health staff need closer
supervision to complete the IMCI
forms correctly.
■ Only 11 percent of expected
follow-up visits actually occurred;
caretakers may not be able to
comply with IMCI standards that
encourage their return for a
follow-up visit.
■ A similar discrepancy exists
between children who exhibited a
general danger sign and should
have been referred to a hospital
and those who actually were. In
one set of records, only 9 percent
of children with a general danger
sign were referred. Either staff
failed to record the referrals or
they are reluctant to refer cases,
knowing that it is hard for caretak￾ers to go to the hospital because
of transportation difficulties.
■ The Konni and Boboye District
Hospitals are not prepared to act
as effective referral centers
because they lack needed
equipment, such as an oxygen
mask (Konni).
■ Some mothers received
insufficient instruction in using
prescriptions.
■ Cold chain problems and failures
to provide vaccinations are
undermining IMCI’s effectiveness.
D. Dissemination of
Information on the Nigerien
QAP
Before the QAP/BASICS merger, the
Nigerien QAP disseminated informa￾tion on its progress and experience,
reaching health providers and
managers both inside and outside
the country. At a QA conference in
December 1995 in Tahoua with over
200 people in attendance, present￾ers from all over the country dis￾cussed results from the problem￾solving teams. Two-and-a-half years
later, the MPH visited all the centers
involved, which resulted first in a
statement of intent to create a
national QA program, and ultimately
in a national QA policy (this had not
been implemented at the time of the
evaluation because of resource
restraints). In addition, through
quarterly meetings in Tahoua, staff in
regions beyond the pilot areas have
begun to learn about and generate
demand for QA.
In October 1998, which was after the
merger and just prior to the evalua￾tion, the international conference in
Niamey attracted 200 participants,
many from Niger and the surround￾ing region. Presentations addressed
the basic concepts of the QA
approach, the child survival
approach, QA rationale, the
problem-solving experience, IMCI,
supervisory activities and quarterly
meetings, the RAHWP, and measur￾ing client satisfaction.
The QAP staff participated in several
international and regional confer￾ences, study tours, visits, and
projects, including the International
Society for Quality in Health Care
(ISQua) conferences from 1993 to
1995, projects in Burkina Faso,
Cameroon, and Togo, a visit by an
Ivory Coast delegation to Tahoua, a
workshop and training in Rwanda, a
visit by African experts to Brazzaville
to define national QA strategies and
programs, and a QA workshop in
Niamey for French- and Portuguese￾speaking countries.
The QAP staff also participated in a
one-week study tour on QAP/IMCI in
Mali and collaborated with the
BASICS regional office in Senegal.
All of these activities contributed to
the broadcast of information on the
Nigerien QAP experience. The
evaluation team found that case
studies, lessons learned, develop￾ment of standards, procedural
improvements, activity analyses, and
all other QA documentation can be
duplicated in Niger and other
African Francophone countries
IV. Cost Analysis of the
Niger QAP/BASICS
Project
The evaluation team analyzed the
operational costs of implementing
and maintaining essential program
activities. The analysis focused on
costs incurred at the facility, district,
and department levels, relying
mostly on historical data from QAP/
BASICS. They did not measure the
full cost of technical assistance or
project-level costs and overhead, so
The Niger QAP/BASICS Joint Project (TRS) ■ 13
estimates do not reflect the alloca￾tion of indirect costs related to the
administrative infrastructure. Also,
government-set per diems were high
compared to devaluating salaries,
so personnel costs are higher for
activities that involve a per diem
(training, supervision, and coaching)
than they are for salary-based
activities (problem solving). The
former activities involve travel and
consequently require per diems. In
addition, several factors limit the
application of these figures to Niger:
government policies, the high cost
of fuel in Niger, and the fact that
spending was influenced by a
budget. Lastly, the team was unable
to obtain sufficient data to link the
costs of these activities with their
effectiveness.
A. Sustainability Costs
The evaluation determined that a
department with the size and
structure of Tahoua would need to
invest about 3.1 cents per capita per
year to sustain essential QA activi￾ties of training, supervision, coach￾ing, meetings, and IMCI. This figure
is the equivalent of 7.7 cents per
person within the catchment area of
a QA health center. The projected
level of investment capitalizes on
the other QA activities built into the
design of the program, including
the development of standards and
quality monitoring.
B. Basic QA and IMCI
Training Costs
The evaluation team concluded that
training, accounting for nearly 60
percent of total costs, constituted
the most significant cost category of
all the essential QAP/BASICS
activities. Training costs include per
diems for participants and trainers,
honoraria for trainers, transportation,
supplies, and refreshments. IMCI
training also included accommoda￾tions and site rental. The team
determined that it cost about $230 to
train one provider in basic QA and
$430 in IMCI (based on seven days
of QA training and 11 of IMCI
training). More than 50 percent of
the training costs was for per diems;
Figure 3 and Figure 4 show the
percentages of the costs of the
various components of QA and IMCI
training.
C. Training of Trainers
Training of trainers in QA helps
sustain program goals well into the
Honorarium
(5%)
Training Kits & Supplies
(19%)
Transport
(10%)
Local Technical Assistance
(7%) Refreshments
(5%)
Per Diem
(54%)
Based on four training sessions held between February and April, 1998
Figure 3
Breakdown of QA Training Costs
future. Such training is provided to
selected individuals after they
complete the basic QA training. The
evaluation found that in Niger the
cost ranged from $200 to $260 per
trainee.
D. Team-Based Problem
Solving
Costs from team-based problem
solving accrue mostly from meetings
and collecting data, and the atten￾dant administrative costs of these
activities. Problem-solving teams in
Niger typically have three to eight
members. Meetings average one to
two hours per week, and cycles
average three months. Costs varied
from $78 to $130.
Other Materials
(2%)
Training Kits & Supplies
(21%)
Transport
(7%)
Hall Hire
(10%)
Accomodations
(4%)
Per Diem & Honorarium
(56%)
Based on two training sessions held between August and September, 1998
Figure 4
 Breakdown of IMCI Training Costs
14 ■ The Niger QAP/BASICS Joint Project (TRS)
Data collection and supply costs
had significant cost components of
per diems to data collectors (ap￾proximately 30 percent), transporta￾tion or fuel costs (23 percent), and
markers (20 percent). Survey forms,
flip charts, and a record book
accounted for just over 25 percent.
The evaluation team noted that
these estimates are approximate
and would vary and that “safety
stocking” (where teams request
more supplies than necessary)
tends to inflate costs.
E. Supervision and
Coaching Activities
Having been instigated by the QAP,
supervision and coaching are new
costs to the Nigerien health system.
The evaluation tried to capture all
the costs associated with these
activities. The team notes that under￾or over-reporting of the number of
coaching visits may have occurred
because of idiosyncrasies in the
reporting process.
Coaching activities incur costs when
coaches visit health centers to
participate in problem solving.
Typically, two coaches would visit
two centers a day (each center is
scheduled for a monthly visit). In
addition to the per diem paid to
each coach are the costs of a driver
and gas. Two districts reported
having completed the coaching
schedule and served as the basis
for estimating costs. Averages
ranged from $15 to $20 per visit,
with per diems accounting for 5–15
percent and gas 70–80 percent.
All scheduled supervisory visits
were reportedly conducted in four
districts (Tahoua, Konni, Illéla, and
Madaoua). Estimates vary by
district, depending on the distribu￾tion of health centers in a district,
but ranged from $20 to $35 per visit.
F. Supervision Checklist
The evaluation team estimated the
cost of replicating the checklist,
which would entail buying a binder,
copying the checklist, and minimal
training in using the checklist. This
breaks down to approximately $14
per center to purchase a binder, $20
per year per center to make copies
of the checklist, and $33–42 per
supervisor for training.
G. Quality Meetings
The team estimated meeting costs
and found that per diems, transpor￾tation, and refreshments account for
substantial portions. The QAP/
BASICS project set a cap on the
amount that would be reimbursed for
meetings, which probably influenced
the amount spent on them.
District meetings are typically held
quarterly, attended by 18 staff, and
last two days; this costs about $200
per quarter. Department meetings
are also usually quarterly; attract 24
individuals from the districts,
department office, and MPH; and
last three days; they total $3000 per
quarter. Quality Council meetings
are bimonthly and attract 24 people
from a single area; they total $120
per meeting.
V. Lessons Learned
The presence of both the QAP and
BASICS in Niger presented a unique
opportunity for USAID and its
partners to merge the two projects,
improving IMCI’s effectiveness by
introducing it into a QA environment.
In addition to the obvious benefit of
reducing operational costs—which
the evaluation team believes to be
considerable though
unquantifiable—by combining the
projects, Niger benefited from the
synergistic effect of supporting IMCI
with quality assurance. For West
Africa and the international commu￾nity, it demonstrated a new ap￾proach for introducing IMCI, an
approach that starts with strengthen￾ing health support systems well
before IMCI is introduced.
In selected areas, QA interventions
were conducted at least a year
before IMCI training began and
resulted in a significant improvement
in supervision and the availability of
essential drugs (also facilitated by
cost recovery). The project suc￾ceeded in creating both a QA
supervisory system and trained
supervisory teams to provide
technical support to healthcare staff.
Peer coaching helped transform the
traditional authoritarian style of
supervision into a supportive,
problem-solving approach.
Between 1993 and 1998, the project
trained 400 healthcare workers in
problem solving, resulting in the
formation of over 77 problem-solving
teams. About 120 problem-solving
cycles were ongoing or had been
completed at the time of the evalua￾tion, improving the delivery of
prenatal and postnatal care, infant
consultations, family planning,
immunization coverage, and
nutritional rehabilitation.
The Niger QAP/BASICS Joint Project (TRS) ■ 15
The project also introduced a
number of training tools that contrib￾uted to the support of IMCI. The
program framework provided
indicators and offered a new
environment for managing
healthcare organizations. Healthcare
workers changed their behavior,
improved their performance,
developed a sense of teamwork,
and experienced increased motiva￾tion.
The pilot of the combined QAP/IMCI
approach demonstrates that
healthcare support systems can be
strengthened well before IMCI
training begins. This combined QAP/
IMCI approach is efficient and can
be used as a benchmark for other
Francophone African countries
considering a launch of IMCI.
A. For Niger
The merger of the QAP and BASICS
in Niger created a new way to
implement IMCI that starts with
interventions—such as the supervi￾sory checklist and drug stock
management—to improve the quality
of healthcare. These interventions
support IMCI, improving its viability
and effectiveness. Previously, IMCI
had never been introduced with
such support. In selected areas of
Niger, QA interventions had been
implemented a year or more before
IMCI training began and resulted in
significant improvements.
The joint project brought many
improvements to the healthcare
system in the target areas. First, it
created trained supervisory teams
that can provide technical support to
health facility staff. The concept of
coaching facilitated the develop￾ment of a supportive, team-based
approach to problem solving and
quality healthcare. Problem solving
has had a significant, positive
impact on the staff’s ability to
improve the quality of services at the
health center and district levels.
The project also introduced tools
that contributed to the support of
IMCI. The RAHWP proved valuable
not only in monitoring health worker
performance, but also in improving it
through timely feedback. Also, the
supervision checklist is a helpful,
comprehensive tool, albeit too long.
Because of problem-solving training
and practice, health providers can
identify and solve problems. They
now have the skills necessary to
collect, analyze, and use data; if
sustained, this will have a long-term
impact on healthcare services in
Niger. The problems identified
usually addressed issues connected
to integration of BPS-related activi￾ties, such as immunization. Using
data collected by the problem￾solving teams themselves rather
than from the national data system
would likely expand problem-solving
activities beyond the BPS.
Improved stocking of essential
drugs/medicines, boosted by cost
recovery, resulted in lower cost,
more reliably available drugs/
medicines, improved decision￾making on the part of consumers,
and ultimately, greater continuity of
care and integration of services.
The evaluation team learned that
several essential items were missing
from some health centers, including
IMCI forms, respiratory rate
counters, and baby scales. If
allowed to continue, this will have a
detrimental impact on IMCI’s
effectiveness.
In addition to the IMCI form, health
workers have to complete four
different records for each child.
Integrating these forms could lead to
better health worker performance.
While healthcare providers are now
capable of checking a child’s
vaccination status and have inte￾grated this service into daily
activities, problems in maintaining
the cold chain are limiting the
delivery of effective vaccinations.
This has a twofold downside. First,
children are not being vaccinated
because health workers realize that
a break in the cold chain has
spoiled the vaccines, or workers are
providing vaccinations without
knowing that the vaccines have
deteriorated. Either way, the popula￾tion is unprotected. Second, IMCI
records are incorrect, because staff
don’t realize that some vaccines
have spoiled, and they are unknow￾ingly reporting ineffective vaccina￾tions. An investment in maintenance
and new equipment could solve
these problems.
Results show that health workers
and caretakers are having difficulty
complying with IMCI standards
regarding referral of very sick
children and the need to return to
the health facility for follow-up visits.
This difficulty, caused by Niger’s
dispersed population, presents a
challenge not only to the health
delivery system but also to IMCI
standards. Further adaptation may
be needed to adjust the require￾ments for referral and follow-up visits
for this population.
The team discovered some troubling
aspects of healthcare service
delivery in the target areas. The
district hospitals in Konni and
Boboye are ineffective referral
centers because equipment and
trained staff are lacking. This means
that children are not receiving
16 ■ The Niger QAP/BASICS Joint Project (TRS)
appropriate care and that the
facilities cannot follow the IMCI
protocols. Furthermore, exit inter￾views with mothers at these hospi￾tals revealed that health providers
should improve their communica￾tions regarding prescriptions and
nutrition.
B. For the International
Health Community
The project enabled Niger to play a
leadership role in demonstrating an
effective new way to introduce IMCI.
Healthcare workers from many West
African countries have participated
in IMCI training in Niger, and Niger’s
experience in QA and IMCI was
presented at a number of regional
conferences and meetings. Consid￾ering the large number of trained
agents and trainers, prepared
materials, existing documentation,
and the success of the international
conference in October 1998, the
project’s replication in Francophone
Africa should be rapid. Further, the
project’s benefits could spread to
other continents. The supervision
system’s launch with the RAHWP,
supervision checklist, and coaching
methods were important experi￾ments that could benefit other QA
projects in Africa, Latin America,
and Asia.
Several aspects of the joint project
experience should serve as guide￾posts for those who will implement
similar endeavors in the future. First
and foremost, the evaluation
determined that the QA approach
helped improve the effectiveness of
IMCI by creating favorable condi￾tions, such as activity integration, a
referral system, and regular follow￾up of activities.
Using the problem-solving process,
the quality teams have consistently
improved the quality of healthcare
and services, although progress
varies. The greatest weakness of the
teams is their problem analysis,
specifically data collection and
interpretation.
Quality teams have greatest impact
when they are supported by: (a) a
supervision and coaching system
that the district manages, and (b) a
district coordination structure like
the Quality Council.
Discussion opportunities within the
problem-solving cycle generated
favorable group dynamics and
teamwork. Experience sharing is an
indispensable part of the system,
and the emergence of teamwork will
likely improve healthcare services in
the target areas for a long time to
come. Information sharing by
coaches helps capture successful
ideas from the health centers. Those
ideas can then be disseminated to
other facilities that might have
similar problems.
The integration of BPS activities is a
good example of process redesign
that all interviewed healthcare
workers noted as a product of QA
efforts. An illustration of this is the
new practice of providing immuniza￾tion every day at all the health
centers the evaluation team visited.
Problem-solving cycles average six
months in length and range from
three months to a year. Regular
coaching, if performed systemati￾cally—as is the case at the health
centers in the target areas—
shortens this cycle.
Community participation varies,
depending on the health center.
Since commitment from the commu￾nity leads to longer-lasting solutions,
the health centers should do more to
integrate community involvement
into their QA activities.
The sometimes dramatic improve￾ment in coverage and utilization
rates—along with user satisfaction—
following problem solving shows that
problems are not always caused by
a lack of means, but sometimes by
poor service organization or man￾agement problems.
Cost recovery had a positive impact
on the QA approach and IMCI.
Indeed, low-cost essential generic
drug availability stimulated continu￾ity of care and activity integration.
After a slight decrease when cost
recovery began, utilization rates
increased significantly in most
cases.
C. Main Factors Limiting
QA
The evaluation team identified
several factors that will limit the
success of QA unless improvements
are made, including:
■ Personnel mobility and motivation
■ Old refrigerators, maintenance
problems, gas shortages,
unreliable car/motorbike pools
■ Inaccurate and/or out-of-date
demographic data
■ Access to healthcare limited by
the dispersed nature of the
population
■ Confusion of health workers
caused by too many sets of
clinical standards
■ Unmet salary payments for health
workers, which were often
compensated with QAP per diem
payments for supervision,
coaching, and training activities
■ Time away from health centers to
attend training sessions
The Niger QAP/BASICS Joint Project (TRS) ■ 17
VI. Recommendations
The following is a summary of
recommendations developed by the
evaluation team.
A. Establishment of
Standards
The MPH should establish an official
inventory of existing, consistent
standards on child healthcare and
integrated health center manage￾ment and release this inventory as a
reference. It should also ensure that
the new IMCI standards effectively
replace the previous childcare
management standards.
The MPH should create standards to
improve the referral system and
strengthen district hospitals so that
they will be effective centers for
treating referral patients.
The MPH should also expand the
training of managers and healthcare
workers in drug stock management.
It should also improve procurement
(especially for IMCI forms, chronom￾eters, and baby scales) and the
functionality of the cold chain by
repairing or replacing old or dam￾aged refrigerators.
The archival system for completed
IMCI forms should be improved at
the district level to facilitate data
analysis and service evaluation.
Personnel transfers of QA-trained
staff should be encouraged only
within areas where QA is in place.
B. Supervision and
Monitoring of Standards
The MPH should incorporate the
quality indicators used in the
RAHWP into the national data
system.
The departmental level of the
healthcare system should regularly
update the supervisory system to
adapt to changes in IMCI and other
healthcare programs. The depart￾ments should promote the use of the
central supervisory checklist
(especially the patient interview
section) to reinforce their supervi￾sion of the districts. Semiannual
supervisory visits should include the
RAHWP. All supervisors should be
trained in coaching techniques.
Supervisors should combine
supervisory and coaching visits in
order to save time and money and
promote optimal supervision.
Healthcare workers’ performance
should be monitored closely to
ensure that they complete forms and
provide therapeutic and nutritional
advice. Supervisors should provide
workers with continuous feedback
on their performance assessment
results as quickly as possible to
enable improved performance.
The supervisory system should
create and support a follow-up
system for requests and suggested
solutions. A focal point for such
requests and suggestions from each
health center should be created at
the departmental and district levels.
C. Coaching and Quarterly
Meetings
Coaches should receive regular,
ongoing QA training. They should be
trained in data collection, process￾ing, and interpretation techniques
(given the importance of these skills
in monitoring activities). Monthly
coaching activities should be
conducted at the department and
district levels when new problem￾solving cycles occur. Guidance
should be provided to enable
department-level coaches to
continually update their knowledge.
Periodic meetings should be
scheduled at all levels on the
functioning of management teams.
In addition, quarterly meetings
should continue so that healthcare
workers will have ongoing training,
motivation, and opportunities to
evaluate themselves, share experi￾ences, and set benchmarks.
D. Problem Solving
Teams at the national, departmental,
and district levels should conduct
problem-solving cycles regularly to
improve support systems, retain
personnel, and prepare to learn
other, higher-level QA techniques,
such as quality design. Districts
should systematically encourage
community participation within the
problem-solving teams.
E. Sustainability
The MPH should support the rapid
implementation of a QA curriculum
in training schools and support and
distribute QA documents, including
a QA skills and methodologies
guide.
The MPH should investigate meth￾ods to use cost recovery to finance
essential QA activities. It should also
explain and show the QA cost/
activity system to various sponsors.
Other healthcare partners in each
district should be made aware of
QAP/IMCI activities.
On a departmental level, the MPH
should establish a transportation
system—including cars in working
condition, available spare parts, and
trained mechanics—to ensure the
viability of key QA activities (e.g.,
18 ■ The Niger QAP/BASICS Joint Project (TRS)
coaching, supervision, or transfers
required by IMCI).
Districts should encourage local
participation in covering costs for
fundamental QA activities (e.g., fuel
and food expenses, supplies for
quarterly meetings, coaching and
supervisory activities, and transpor￾tation). A plan should be developed
to transfer responsibility for the
project to other healthcare partners.
F. Dissemination and
Documentation
Each level of the healthcare system
should regularly coordinate opera￾tional research activities to dissemi￾nate results achieved. Regular
forums to share QA experiences
should be established. A sample
group should be created to do
operations research using the QAP/
IMCI experiences and progress in
Tahoua and Boboye. Supervisors
should train departmental and
district supervision teams in opera￾tional research. Additionally, service￾provider satisfaction has not been
documented and should be pursued
in further QAP/IMCI studies.