THE NIGER
QAP/BASIC JOINT PROJECT:
AN EVALUATION OF QA
ACTIVITIES TWO YEARS LATER
QUALITY
ASSURANCE
PROJECT
FEBRUARY 2007
This publication was produced for review by the United States Agency for International Development by
the Quality Assurance Project. It was authored by Sabou Djibrina, Wendy Newcomer Edson, Maina Boucar,
Adamou Diogou, and Hama Issa Moussa.
OPERATIONS
RESEARCH
RESULTS

OPERATIONS RESEARCH RESULTS 
THE NIGER 
QAP/BASICS JOINT PROJECT: 
AN EVALUATION OF QA 
ACTIVITIES TWO YEARS LATER 
February 2007 
Sabou Djibrina 
Wendy Newcomer Edson 
Maina Boucar 
Adamou Diogou 
Issa Moussa Hama 
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.
The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development 
(USAID) under Contract Number GPH-C-00-00004-00. The project serves developing countries eligible 
for USAID assistance, USAID Missions and Bureaus, and other agencies and nongovernmental 
organizations that cooperate with USAID. QAP offers technical assistance in the management of quality 
assurance and workforce development in healthcare, helping develop feasible, affordable approaches to 
comprehensive change in health service delivery. The project includes prime contractor University 
Research Co., LLC (URC), Initiatives Inc., and Joint Commission Resources, Inc. The work described in 
this report was carried out by the Quality Assurance Project under USAID Contract Number HRN-C-00-
96-90013 with the Center for Human Services, URC’s nonprofit affiliate, in partnership with Joint 
Commission Resources, Inc. and Johns Hopkins University.
Recommended citation: Djibrina S, Edson WN, Boucar M, Diogou A, and Hama, IM. 2007. The Niger 
QAP/BASICS Joint Project: An Evaluation of QA Activities Two Years Later. Operations Research 
Results. Bethesda, MD: Published for the U.S. Agency for International Development by the Quality 
Assurance Project. 
Acknowledgements: The authors wish to thank our partner at the Niger Ministry of Public Health, Dr. 
Gagara Magagi, Director of the Department of Health Protection and Health Establishments, Niger. We 
would also like to thank Mr. Adamou Diogou, Dr. Hama Issa Moussa, Dr. Bashir Sabo, and Dr. Ibrahim 
Souley, who collected the data from the health facilities in Tahoua and Maradi, and the observers: Mme. 
Massoudou Haoua Idrissa, Registered Nurse, Tchinta Health District; Mme. Mahamadou Rabi, Public 
Hygiene/Education for Health, Tahoua Regional Health Administration; Yaou Moussa, Registered Nurse, 
Tahoua Regional Hospital Center; Ahmid Mohamed, Hygiene and Sanitation Technician, Tchinta Health 
District; Issa Sountalma, Certified Nurse, Tchinta Health District; Nana Zouera Amadou, Certified Nurse, 
Tahoua Regional Hospital Center; Mamadou Mallam Adam, Program and Sanitation Information Office, 
Tahoua Regional Health Administration; Ramatou Moussa, Certified Nurse, Tahoua Regional Hospital 
Center; and Adakal Aboubacar, Tahoua Regional Health Administration. 
We would like to acknowledge the contributions of Dr. Diana Silimperi, Dr. Stephane Legros, Dr. Bruno 
Bouchet, Dr. Edward Kelley, Dr. Barton Burkhalter, Ms. Hany Abdallah, and Ms. Lauri Winter, all of 
URC/Bethesda at the time of the study, to the conceptualization of the project and the interpretation of 
results in this report. We would like to thank the healthcare workers whom we interviewed and observed 
in Tahoua and Maradi and the mothers of children who consented to the observations. 
TABLE OF CONTENTS 
LIST OF FIGURES AND TABLES.............................................................................................................ii
EXECUTIVE SUMMARY .........................................................................................................................iii
ABBREVIATIONS .....................................................................................................................................iv
I. BACKGROUND......................................................................................................................................1
A. Institutionalization of QA Activities ..................................................................................................1
B. Evaluation Framework........................................................................................................................2
II. PURPOSE OF THE STUDY ..................................................................................................................3
III. METHODOLOGY ................................................................................................................................3
A. Research Design .................................................................................................................................3
B. Study Sample ......................................................................................................................................3
C. Study Variables...................................................................................................................................4
D. Study Instruments...............................................................................................................................4
E. Data Collection Procedures.................................................................................................................5
F. Data Analysis......................................................................................................................................5
IV. RESULTS..............................................................................................................................................6
A. Research Question Number 1 .............................................................................................................6
B. Research Question Number 2 .............................................................................................................7
C. Research Question Number 3 ...........................................................................................................12
D. Research Question Number 4 ...........................................................................................................16
E. Research Question Number 5............................................................................................................18
V. CONCLUSIONS AND RECOMMENDATIONS................................................................................19
A. Discussion of Findings .....................................................................................................................19
B. Presentation of Results at Workshop in Niger..................................................................................21
REFERENCES ...........................................................................................................................................21
APPENDIX.................................................................................................................................................22
A1. Guide for Document Review at the Department Level ..................................................................23
A2. Interview with Staff of the Tahoua Regional Health Administration.............................................29
A3. QI Team Member Self-Assessment................................................................................................32
A4. Interview with Health Center Manager ..........................................................................................34
A5. Rapid Assessment of Health Worker Performance—Health Worker Observation ........................37
A6. Rapid Assessment of Health Worker Performance—Interview with the Mother Following IMCI 
Consultation............................................................................................................................................43
Niger Follow-up Evaluation of QA Activities · i
LIST OF FIGURES AND TABLES 
Figure 1: Institutionalization of Quality Assurance...................................................................................... 2 
Figure 2: Number of Completed QI Team Cycles by Calendar Year, Tahoua............................................. 8 
Figure 3: Percentage of Planned District Level Supervisory Visits Actually Completed, Tahoua............. 10 
Figure 4: Percentage of Planned District Level Quarterly Meetings Actually Held, Tahoua..................... 11 
Figure 5: Percentage of Planned Supervisory Visits from District to Health Center Actually Completed, 
Tahoua and Maradi ..................................................................................................................................... 13 
Figure 6: Percentage of Planned Quarterly Meetings Held at District and Regional Levels, Tahoua and 
Maradi......................................................................................................................................................... 14 
Table 1: QA Program Framework ................................................................................................................ 2 
Table 2: Niger Evaluation Framework.......................................................................................................... 4 
Table 3: Major Events Influencing the Political and Healthcare Environments, 1999–2000....................... 6 
Table 4: Health Policy Priorities, 1999–2000............................................................................................... 6 
Table 5: Donor Status by Region, 2000........................................................................................................ 7 
Table 6: Health Indicators, Tahoua, 1993-2000 ........................................................................................... 9 
Table 7: Self-evaluation Score for QI Teams by Team Dimension.............................................................. 9 
Table 8: Utilization of Data by Health Centers, Tahoua and Maradi ......................................................... 14 
Table 9: Percentage of Observed Health Workers Who Correctly Performed Tasks According to IMCI 
Guidelines, Tahoua 1998 vs. Tahoua 2001 and Tahoua 2001 vs. Maradi 2001 ......................................... 15 
Table 10: Percentage of Affirmative Responses from Mothers, Tahoua 1998 vs. Tahoua 2001 and Tahoua 
2001 vs. Maradi 2001 ................................................................................................................................. 15 
Table 11: Major Accomplishments of the Quality Assurance/BASICS Project as Perceived by Study 
Participants.................................................................................................................................................. 16 
Table 12: Continuing and Discontinued QA Activities in January 2001 as Perceived by Study 
Participants.................................................................................................................................................. 16 
Table 13: Factors that Assisted or Hindered the Sustainability of Project Accomplishments as Perceived 
by Study Participants .................................................................................................................................. 17 
Table 14: Suggestions by Study Participants for Strengthening the Institutionalization of Quality 
Assurance Project Accomplishments.......................................................................................................... 18 
Table 15: Recommendations for Replicating the Tahoua Experience........................................................ 20 
ii · Niger Follow-up Evaluation of QA Activities
EXECUTIVE SUMMARY 
The Tahoua (Niger) Quality Assurance/BASICS Joint Project was completed in December 31, 1998. The 
project had provided technical and operational support to basic health services in order to improve their 
quality through training, supervision, meetings, operational research, and provision of limited equipment. 
This study was designed to assess the continuation of quality assurance (QA) activities in Tahoua, two 
years after the close of the QAP/BASICS joint project and to compare selected healthcare activities in the 
departments of Tahoua and Maradi, also in Niger. 
The study was conducted in eight districts of Tahoua and four districts of Maradi. Interviews with 96 
Niger Ministry of Public Health (MOH) personnel were conducted at all levels of the health system, and 
documents were reviewed at 15 MOH office sites. Healthcare workers were observed to determine their 
compliance with the Integrated Management of Childhood Illness (IMCI) standards during consultations 
with sick children: 88 observations occurred in Tahoua and 38 in Maradi. Exit interviews were conducted 
with mothers or caretakers after the observed consultation: 86 in Tahoua and 38 in Maradi. 
The study sought to answer the following research questions: 
• What political, health policy, and health financing influences may have affected QA activities in Niger 
during 1999 and 2000 and in the Tahoua and Maradi Regions in particular? 
• How do the QA activities that took place in 1999 and 2000 in the Tahoua region after the project ended 
compare with the QA activities at the end of the project in 1998? 
• How do other activities in 1999 and 2000, such as supervision, quarterly meetings, standards 
development, and compliance with IMCI standards in the Tahoua region compare with the Maradi 
region? 
• What factors contributed to sustaining project achievements? 
• What recommendations can be made to ensure the sustainability of project achievements? 
Political events in Niger significantly influenced the sustainability of the Tahoua QA project. A military 
coup at the national level disrupted foreign aid and led to destabilizing elections. The new leadership 
reassigned health personnel at all levels, resulting in a devastating impact on the sustainability of QA in 
Tahoua: QA-trained health professionals were sent to other departments, and incoming personnel had 
neither training in nor exposure to QA. 
QA activities were supported at a reduced level by funds from the World Health Organization (WHO) 
during 1999 and 2000 in Tahoua. Supervisory visits, quarterly coordination meetings, and the number of 
quality improvement (QI) cycles all decreased in frequency in 1999 and 2000, well below the median 
frequency for the activity that was attained during the project. However, despite the lack of full funding 
for QA activities in Tahoua, supervision visits continued to follow the systematic approach developed 
during the project: comprehensive, two- to three-day quarterly meetings continued and were attended by a 
broad spectrum of personnel. 
In order to compare health worker performance over time, we repeated in 2001 a study originally 
conducted in Tahoua in December 1998, in the same health centers. The results show a decrease in all 
but one performance item, with significant decreases in “whether nutritional status was checked” (47.0% 
in 1998 to 5.4% in 2001), “whether the child was checked for two or more danger signs” (63.5% in 1998 
to 26.3% in 2001) and “whether the mother was counseled about the child’s treatment” (62.8% in 1998 to 
10.7% in 2001). We then compared health worker performance in 2001 in Tahoua with performance in 
Maradi. There were no significant differences in performance between the two regions, although 
“whether nutritional status of a child was checked” was greater in Maradi (26.7%) than in Tahoua (5.4%). 
Even though none of the health workers in Tahoua seeing patients was trained in IMCI, those in the 
district of Guidan Roumdji in Maradi had recently received IMCI training.
Niger Follow-up Evaluation of QA Activities · iii
The evaluation sought to measure the sustainability of QA in Tahoua, where several political and other 
events had combined to undermine QA efforts. Nevertheless, discussions with staff indicated good team 
spirit and communications at all levels, better supervision mechanisms (although frequency of supervision 
declined), and ongoing team activities targeting improved health outcomes (e.g., prenatal care, infant 
counseling, nutrition, etc.). Importantly from a quality assurance perspective, facilities that retained less 
than four QA-trained staff seemed unable to sustain team-based QI efforts. 
We specifically examined various QA activities (definition of quality standards, measurement of 
compliance with standards, quality improvement, documentation/communication, and capacity building) 
to assess which had continued for the two years following the project’s completion. Several activities had 
been discontinued, largely because of funding shortages and/or staff transfers, including some aspects of 
coaching and supervision, information sharing between districts, and QA training. Still extant, however, 
were activities to set and review standards, QI teamwork (where teams of four or more remained in a 
facility), intra-team knowledge sharing, data-based decision making, and training in clinical care. 
Certainly funding from the World Bank and WHO contributed to sustainability. The MOH decision to 
spread QA throughout the country through staff transfers from Tahoua to other areas reduced QA 
activities in Tahoua but may have stimulated or fostered QA in other regions. Opportunities to share 
knowledge (such as supervisory visits and quarterly meetings) contribute to sustainability, but they 
require funding, and Tahoua, which is geographically disparate, would require more funding for this 
activity than Maradi. 
Supervisory visits declined in frequency after the project ended but continued at a reduced level with 
UNICEF funding. Our comparison of supervisory visits between Tahoua and Maradi suggests that 
Tahoua was able to maintain supervisory visits despite funding and logistics difficulties because 
supervision was well organized, comprehensive, used trained supervisors, and underwent continuous 
improvement. Other elements that would indicate and ensure sustainability fared less well after the 
project ended, as detailed in the full report. 
ABBREVIATIONS 
AIDS Acquired Immunodeficiency Syndrome 
BASICS Basic Support for Institutionalizing Child Survival 
IMCI Integrated Management of Childhood Illnesses 
MOH Ministry of Public Health, Niger 
QA Quality assurance 
QAP Quality Assurance Project 
QI Quality improvement 
RAHWP Rapid Assessment of Health Worker Performance 
RHA Regional Health Administration 
UNICEF United Nations Children’s Fund 
USAID U.S. Agency for International Development 
WHO World Health Organization 
iv · Niger Follow-up Evaluation of QA Activities
I. BACKGROUND 
The Tahoua (Niger) Quality Assurance Project (QAP), begun in April 1993 by the Center for Human 
Services under funding from the U.S. Agency for International Development (USAID), was completed 
on December 31, 1998. The project covered all health facilities in the Department of Tahoua. In 1997, 
the project merged with the BASICS Project to become the Niger Quality Assurance/BASICS Joint 
Project, which focused its interventions on the health districts of Konni and Illéla in the Department of 
Tahoua and Boboye District in the Department of Dosso. The project also continued support for some 
activities in the other districts of Tahoua. The project’s aim was to provide technical and operational 
support to basic health services in order to improve their quality through training, supervision, meetings, 
operational research, and the purchase of small equipment. 
Encouraging results were achieved in the improvement of healthcare and services during the 
implementation of this project (please see Legros et al. 2000a for the end-of-project evaluation). By the 
end of the project, 100% of the senior staff at the Tahoua Regional Health Administration, 90% of the 
district health teams, and 85% of health workers were trained in basic quality assurance (QA) skills, and 
92% of health centers in the project area had at least one operational quality improvement (QI) team. All 
supervisors in the department had been trained in facilitative supervision, and 70% of them received 
training in coaching skills. Of note, among other things, was the development of increased team spirit 
through the involvement of the regional quality council and periodic meetings bringing together staff at 
all levels of the health sector in the region. In addition, there was a better understanding of health system 
processes and standards, better organization of services, and improved health indicators in Tahoua. It was 
assumed that accomplishments could be self-sustaining, as they had become an integral part of the 
regional system. Based on this assumption, we conducted this study to assess the continuation of QA 
activities and the level of QA institutionalization two years after the completion of the project. 
A. Institutionalization of QA Activities 
Institutionalization is an ongoing process in which a set of activities, structures, and values becomes an 
integral and sustainable part of an organization. Institutionalization of QA occurs when QA activities are 
formally and functionally incorporated into the structure of a health system (or organization), consistently 
implemented, and supported by a culture of quality, as reflected in organizational values and policies that 
advocate quality care (Franco et al. 2002). 
The essential elements for QA institutionalization operate within the organization’s sphere of influence 
(see Figure 1). They can be divided into three categories: support functions, structure, and internal 
enabling environment. Support functions are formal, ongoing processes for developing and maintaining 
the staff’s capacity to implement QA activities, for disseminating QA information, and for rewarding 
quality. These processes include capacity building of staff in QA, communicating and disseminating 
information about QA activities, and using incentives and recognition to reward quality work. Structure 
is the clear delineation of roles, responsibilities, and accountability for the implementation of QA 
activities. The internal enabling environment is an environment conducive to initiating, expanding, and 
sustaining QA. This includes written policies that support quality, leaders who work directly and openly 
to improve quality, organizational values that emphasize quality care and continuous improvement of 
services, and sufficient allocation of human and material resources. Evaluating the extent to which these 
essential elements are present in a QA program will provide information on the process of 
institutionalization of QA within the healthcare organization. 
 Niger Follow-up Evaluation of QA Activities · 1
Figure 1: Institutionalization of Quality Assurance 
Core Values
Leadership
Policy
Resources
Institutionalization of Quality Assurance
Support
Functions
QD
QI QC
Quality
Care
M
B. Evaluation Framework 
The QA program framework (Table 1) developed by QAP for the evaluation of the national QA program 
in Chile (Catsambas et al. 2002; Legros et al. 2000b) was utilized for this evaluation. Elements of the 
framework include the political and health policy environment within which the project took place; 
dissemination and communication of project results; the organizational structure and management of QA, 
including QI teams, supervision, and quarterly meetings; training in QA; utilization of monitoring data; 
compliance with the Integrated Management of Childhood Illness (IMCI) standards; and cost of 
sustaining QA activities in the project region. 
Table 1: QA Program Framework 
Functional Area Key Topics Addressed by the Evaluation 
Environment Health reform 
Key health sector policies 
Country culture
Overall QA program Description of QA activities within the health sector 
History of the QA program 
QA policies 
QA support functions Management and supervision of QA 
Training 
QA research 
Dissemination and communication 
Organizational culture 
QA activities Quality assessment and monitoring 
Quality design 
Quality improvement 
Standards 
Accreditation and licensing 
2 · Niger Follow-up Evaluation of QA Activities
II. PURPOSE OF THE STUDY 
The aim of the study was to assess the continuation of quality assurance activities in Tahoua two years 
after the close of the QAP/BASICS joint project, to describe factors that have contributed to the 
sustainability of QA activities in Tahoua, and to compare selected healthcare activities in Tahoua with 
those in Maradi. 
The study was conducted in all eight districts in Tahoua and all four in Maradi, as well as the Tahoua and 
Maradi Regional Health Administrations. The study included interviews and document review at the 
national, departmental, district, and health center levels. 
The research questions were: 
1. What political, health policy, and health financing influences may have affected QA activities in 
Niger during 1999 and 2000 and in the Tahoua and Maradi Regions in particular? 
2. How do the QA activities that took place in 1999 and 2000 in the Tahoua Region after the project 
ended compare with the QA activities at the end of the project in 1998? 
3. How do other activities in 1999 and 2000, such as supervision, quarterly meetings, standards 
development, and compliance with IMCI standards in the Tahoua Region compare with the 
Maradi Region? 
4. What factors contributed to sustaining project achievements? 
5. What recommendations can be made to ensure the sustainability of project achievements? 
III. METHODOLOGY 
A. Research Design 
In order to assess the sustainability of QA activities after the project close in December of 1998, a 
retrospective, descriptive study of ongoing QA activities in Tahoua in 1999 and in 2000 was combined 
where possible with a comparison of QA activities across time and across geographical areas. The 
comparison across time compared QA activities during the project with activities after the project closed. 
The comparison across geographic areas compared activities in Tahoua in 2000 with those in Maradi in 
2000. Maradi was selected as the comparison area in part because it did not have a QA program. The 
assessed activities included supervision, utilization of data, and performance according to IMCI 
standards. The Maradi region, in January 2001, had not implemented any activities in a planned QA 
extension project funded by the World Bank. The study was conducted from January to March 2001. 
B. Study Sample 
In Tahoua and Maradi, 96 Ministry of Public Health (MOH) personnel were interviewed at the national, 
regional, district, and health center levels. Open-ended questions eliciting information on replication of 
the Tahoua project and institutionalization of QA in Niger were asked of all study participants. 
Documents were reviewed at the same levels. All eight districts in Tahoua were included in the study as 
were all four districts in Maradi. A sample of eight health centers was selected in Tahoua, one in each 
district, and four in Maradi, also one in each district. At each health center MOH personnel were 
interviewed and documents reviewed. At the departmental level, the study included all staff members 
present at the time of the study, as all were involved in the implementation of QA activities. 
Observations of clinical care were conducted at 16 health centers in two districts of Tahoua and in eight 
health centers in two districts of Maradi. This sample included health workers conducting consultations, 
health center managers, and children and their mothers or caretakers. Ten consultations of children per 
health center were observed. Children were included if they were under five years of age, seen on an 
 Niger Follow-up Evaluation of QA Activities · 3
outpatient basis, and had new diagnoses of diarrhea, cough or respiratory problems, or fever. Exit 
interviews of mothers/caretakers of all children observed after the consultation were conducted if they 
(mothers/caretakers) were at least 16 years old and had been living with the child for at least 15 days. 
C. Study Variables 
Table 2 outlines the study’s evaluation framework by functional area, geographic area, research objective, 
and data source. 
Table 2: Niger Evaluation Framework 
Functional Area Geographic Area Research Objective Data Source 
Environment Niger, Tahoua, and 
Maradi regions 
Describe the political and health 
policies during 1999 and 2000 
Interviews, documents 
Organizational structure and 
management of QA: 
• Quality improvement 
teams 
Tahoua region Compare the number of QI teams 
functioning and number of 
completed QI cycles between 
Tahoua in 1998 and Tahoua in 2000 
Meeting reports, interviews with 
health workers 
• Quarterly meetings Tahoua region Compare the percentage of 
completed/planned quarterly 
meetings between Tahoua in 1998 
and Tahoua in 2000 and between 
Tahoua and Maradi in 2000 
Meeting reports, interviews with 
health workers 
• Supervision Tahoua and Maradi 
regions 
Compare the percentage of 
completed/planned supervisory visits 
between Tahoua in 1998 and Tahoua 
in 2000, and between Tahoua and 
Maradi in 2000 
Interviews with health workers, 
supervision records 
Training in QA Tahoua region Compare the number of people 
trained in QA between Tahoua in 
1998 and Tahoua in 2000 
Interviews with health workers, 
training records 
Utilization of monitoring 
data 
Tahoua and Maradi 
regions 
Describe the use of monitoring data 
by health centers 
Interviews with health workers 
Compliance with IMCI 
standards 
Tahoua region: Konni 
and Illéla 
Maradi region: G. 
Roumdji and Mayahi 
Compare compliance with IMCI 
standards at health centers between 
Tahoua in 1998 and 2000 and 
between Tahoua and Maradi in 2000 
Observation of health workers, exit 
interviews of mothers, interviews of 
health managers 
Dissemination and 
communication 
Niger, West Africa, 
globally 
Describe publications, reports, and 
missions within Niger and 
throughout West Africa 
Document review 
D. Study Instruments 
The four methods of data collection (health worker interviews, document review, observations of health 
workers, and interviews with mothers) were conducted at three different levels within the MOH, requiring 
instruments tailored for each level. The interview and document review guides were adapted from those 
used in prior QA evaluations. The interview guide solicited information about the healthcare 
environment, functioning of QA structures (QI teams, supervision, quarterly meetings), QA training, 
dissemination and communication, and utilization of monitoring data. A questionnaire on supervision 
and utilization of data developed for the study was administered to health center directors. A self￾administered questionnaire, the QI Team Member Self-Assessment tool, was given to the QI team 
members to measure the effectiveness of the QI teams. QAP had developed this tool and used it in 
previous studies of QI teams in Morocco and Kenya. The document review guide was used to review 
correspondence, supervision reports, and minutes of meetings relating to QA activities. These 
4 · Niger Follow-up Evaluation of QA Activities
instruments were pre-tested during a one-day workshop with the four MOH surveyors from the national 
level and two departments other than Tahoua and Maradi. 
The observation checklist used to collect data on healthcare workers’ performance in treating a sick child 
and consulting with his or her mother was the Rapid Assessment of Health Worker Performance 
(RAHWP), which had been pre-tested in previous research in Tahoua. This instrument was developed 
during the QAP/BASICS joint project (BASICS I Country Program: Niger 2002). The interviews with 
the mothers/caretakers of observed children were conducted using the RAHWP instrument for clients. 
English translations of the instruments used in the study are presented in the Appendix. 
E. Data Collection Procedures 
Data were collected by four MOH surveyors (two from the national and two from the departmental levels) 
during a five-week period in January and February 2001. Data were collected in two teams of two 
surveyors each. The two teams began in Tahoua for two weeks then spent a week in Maradi. They began 
at the department headquarters, interviewing staff and reviewing documents, then traveled to each district 
headquarters conducting interviews and document reviews. They then visited one health center in each 
district to conduct interviews and document review. These districts were selected according to proximity 
to the district office location or en route to the next district. After these data were collected, the 
observation of health workers and exit interviews of mothers occurred. A team of providers from Tahoua 
who had conducted these observations in the past was oriented to the study and retrained in one day. This 
team traveled to the 24 sites where data were collected during a two-week period. Finally, national level 
MOH personnel were interviewed in the capital, Niamey, by the two surveyors from the national level. 
A total of 96 MOH personnel were interviewed: 1 at the national level, 6 each at the departmental level in 
Tahoua and Maradi, 28 at the district level in Tahoua, 17 at the district level in Maradi, and 34 at Tahoua 
health centers and 4 at Maradi health centers. Documents were reviewed at 15 MOH office sites. 
Observations of health workers and exit interviews of mothers occurred at 16 clinics in Tahoua and 8 in 
Maradi. A total of 126 observations were performed: 88 in Tahoua and 38 in Maradi, and 124 mothers 
were interviewed: 86 in Tahoua and 38 in Maradi. 
F. Data Analysis 
The guided interview and document review data were transcribed into Microsoft Word and grouped 
according to question. The qualitative data were analyzed by reviewing the responses and identifying 
themes and categories of similar responses. The quantitative data were analyzed in a yearly run chart 
format where trends are noted in relation to the median. Where possible, the analysis included a 
comparison between Tahoua and Maradi. 
The observation checklist and client interview data were keyed and analyzed using EPI-Info. Selected 
indicators were analyzed using proportions in order to assess changes that occurred in Tahoua since the 
completion of the project and to compare with Maradi. 
We compared the behaviors of health workers in Tahoua and Maradi by developing facility-level 
averages for the 24 clinics of the proportion of health workers who were scored with a "Yes" on an item. 
Using the facility-level average, we compared the Tahoua clinics over time and the Tahoua and Maradi 
clinics using t-tests. A difference was judged significant if the probability of the t value was less than .05. 
A preliminary report was submitted for review by representatives of each group involved in the study 
during a one-day workshop in June 2001, in order to allow them to make contributions to the final report. 
These contributions were then incorporated into the final report. 
 Niger Follow-up Evaluation of QA Activities · 5
IV. RESULTS 
A. Research Question Number 1 
What political, health policy, and health financing influences may have affected QA activities in Niger 
during 1999 and 2000 and in the Tahoua and Maradi Regions in particular? 
Although both regions were affected by disease outbreaks, disruptions in food, and floods, the most 
important influence during the 1999–2000 period was political. A military coup at the national level 
disrupted foreign aid. Political turmoil surrounding elections further destabilized the situation. As a 
result of the change in political power, health personnel at all levels of the MOH were reassigned to 
different posts in different locales. In Tahoua, this had a devastating impact on the sustainability of QA 
as the health professionals trained in QA during the project were sent to other departments outside 
Tahoua. The incoming workers replacing Tahoua’s QA-trained ones had neither training nor exposure to 
QA and consequently focused on other activities that they deemed more important. These and other key 
events are summarized in Table 3. 
Table 3: Major Events Influencing the Political and Healthcare Environments, 1999–2000 
National Tahoua Maradi 
• A military coup influenced 
foreign (bilateral) 
cooperation 
• Food deficit 
• Meningitis epidemic 
• Electoral turmoil 
• Meningitis and cholera 
outbreaks 
• Drought, lack of pasture, 
food deficit 
• Insecurity (vehicle thefts) 
• Floods 
• Massive exodus and massive 
return of people from exodus 
• Islamist religious events 
• Cholera, measles, meningitis 
outbreaks 
• Food deficit 
• Floods 
• Change of government 
officials 
• Islamist religious events 
Similarly, health policy priorities at the national and regional levels also strongly affected activities in the 
health facilities. IMCI in Tahoua started at Konni under the auspices of the QAP, but during the two 
years after the end of the project, all IMCI-trained personnel were moved to other regions. IMCI 
supervisory visits continued, but no IMCI-trained personnel worked at the health centers. There was no 
financial support of IMCI in Tahoua after QAP ceased in Niger. However, IMCI expansion, supported by 
WHO, occurred in Maradi during this time period. The national and regional health policy priorities are 
outlined in Table 4. 
Table 4: Health Policy Priorities, 1999–2000 
National Tahoua Maradi 
• Adjustment of reproductive 
health strategies 
• Hygiene/sanitation 
• IMCI expansion to four 
new districts (WHO 
financing) 
• QA extension in Zinder, 
Tillaberi, and Diffa through 
a World Bank project 
• 1000 community health 
facilities (presidential 
commitment) 
• Integrated Basic Health 
Services (UNICEF) 
• Consolidation of cost￾recovery management tools 
• Decentralization 
• Integrating QA activities in 
the Minimal/ Essential 
Health Package 
• Expanded Program of 
Immunizations support 
project 
• Existing malaria and AIDS 
programs re-emphasized by 
the President of Niger 
• Integrated Basic Health 
Services (UNICEF) 
• IMCI 
• Permeated mosquito nets 
• Breast-feeding promotion 
• Acute flaccid paralysis 
• Integrated Epidemiology 
Surveillance Program 
• Health districts operation 
6 · Niger Follow-up Evaluation of QA Activities
In one district in Tahoua and in two districts in Maradi, new health policies included the integrated basic 
service (UNICEF) activities in health centers and the community. More political support of pre-existing 
malaria and AIDS programs occurred in Tahoua but was not accompanied by supplemental resources. 
Again in Tahoua, several cost-recovery tools in use were consolidated into a single, more efficient one. 
In general, new health initiatives in Tahoua decreased during the two years after the project closed. In 
contrast, five new health initiatives began in Maradi during the same period. 
As seen in Table 5, Tahoua lost funding from eight agencies in comparison to none lost in Maradi, 
although UNICEF ceased operations in two of six districts in Maradi. Tahoua gained only three new 
donors while Maradi gained seven. Overall, Tahoua saw a marked decrease in international donors for 
health initiatives. At the national level, most bilateral funding left Niger during this period, although 
UNICEF, WHO, and the World Bank remained. 
Table 5: Donor Status by Region, 2000 
National Tahoua Maradi 
• New: Cuban Cooperation 
• Ongoing: World Bank, 
UNICEF, WHO 
• Disengaged: French 
Cooperation, Netherlands 
Voluntary Service, USAID 
• New: Health Project II, 
WHO, Italian Fund for 
Agricultural Development 
• Ongoing: UNICEF, Lux 
Développement (in some 
districts), Development 
Program for Rural Zones 
• Disengaged:
QAP/BASICS, 
Pharmaciens Sans 
Frontières, German 
Cooperation, Italian 
Cooperation, Helen Keller 
International, Tarka Project, 
Lux Développement (in 
some districts), Cospe NGO 
• New: Lux Développement, 
Japanese International 
Cooperation Agency, 
Reproductive Health and 
Family Planning, World 
Vision, Integrated 
Epidemiology Surveillance 
Program, UNICEF in some 
districts, African 
Development Bank 
• Ongoing: UNICEF in 4 
districts 
• Disengaged: UNICEF in 2 
of 6 districts 
B. Research Question Number 2 
How do the QA activities that took place in 1999 and 2000 in the Tahoua Region after the project ended 
compare with the QA activities at the end of the project in 1998? 
The QA structure established by the project in Tahoua included quality improvement teams in the health 
centers, supervision and coaching from the department to districts and from districts to health centers, and 
quarterly coordination meetings at the department and district levels. 
1. Resources for Continuing QA Work in Tahoua 
At the end of the QAP/BASICS project, the MOH was committed to expanding QA into all departments 
of Niger. In order to fund this, it supported a World Bank loan to fund a QA extension program. As a 
result, some QA activities were supported at a reduced level by funds from the World Bank and WHO 
during 1999 and 2000 in Tahoua. WHO provided support for QA training in Tahoua for health workers 
at the district and health center levels and for supervision from the central to the regional level. The 
World Bank provided support for quarterly meetings in districts and for supervision from the region to 
districts and from districts to health centers. 
 Niger Follow-up Evaluation of QA Activities · 7
2. Quality Improvement Teams 
Quality improvement teams were established at all health centers during the QAP/BASICS project. They 
usually comprised health center staff or district hospital functional units. Their composition and number 
differed, depending on the district, but included an average of five members, including community 
participation of, primarily, matrons and community leaders. 
QI teams still existed at most health centers in the Tahoua region after the project, but in 1999 and 2000 
the numbers of active teams and completed “cycles” decreased. (A cycle is the identification of an 
improvement project and the implementation and evaluation of the solutions for the improvement 
project.) As Figure 2 shows, the number of completed QI cycles declined from 31 in 1998 to 21 in 1999 
and to 17 in 2000. Topics for improvement projects in 1999 and 2000 were prenatal care (seven), 
unassisted deliveries (five), vaccinations (three), family planning (seven), nutrition education (five), and 
infant consultation (three). These teams received coaching sessions during supervision visits. Asked in 
early 2001 when they had last met, half responded that they had met in the last three months and the other 
half in the last six months. 
Figure 2: Number of Completed QI Team Cycles by Calendar Year, Tahoua 
0
5
10
15
20
25
30
35
40
1994 1995 1996 1997 1998 1999 2000
Tahoua Median
The impact of this work, according to study respondents, was shown through improved health indicators, 
improved communications with clients, increased community involvement and initiatives, increased 
utilization of services (prenatal care, infant counseling, nutrition, family planning), fewer deliveries at 
home, and increased screening for protein energy malnutrition. See Table 6 for a summary of the health 
indicators for Tahoua from before the QAP project began in 1993 until the project’s close in 1998 and for 
the next two years through 2000. Virtually all health indicators decreased in 1999 with the exception of 
TB vaccine coverage, which showed a modest increase in 1999. 
During the project, QI teams had been the basis for most of the QA work in the region, with increasing 
numbers of teams forming each year during the five years of the project; by the end of the project some 
teams had been functioning for five years whereas others had functioned for less. This may explain why 
some teams continued to function after the project whereas others did not. Another explanation for fewer 
teams after the project may be that the size of most teams was very small: two or three people. So, when 
healthcare workers were transferred to other facilities, the team no longer existed and the QI work 
stopped. During the project, teams were motivated to work because they would present their experiences 
and results at quarterly meetings and would compete with their peers to see which work was best. (There 
was no financial reward for making improvements.) However, after the project ended, both supervisory 
8 · Niger Follow-up Evaluation of QA Activities
Table 6: Health Indicators, Tahoua, 1993–2000 
Health Indicators 1993 1994 1995 1996 1997 1998 1999 2000 
Rate (of total population) using curative 
services 30 28 37 33 30 23 24 16
Growth monitoring clinic coverage rate (0–5 
km.) 58 57 69 89 76 67 63 16
Prenatal consultation coverage rate (0–5 km.) 63 70 70 85 77 62 62 16
Ambulatory nutritional counseling recovery 
rate 14 19 15 14 25 37 35 29
Ambulatory nutritional counseling drop-out 
rate 15 17 14 11 16 28 11 14
Family planning utilization rate 5 5 7 11 14 NA* 1 1
Tuberculosis vaccine coverage (0–11 months) 35 60 87 107 76 72 79 17
Coverage rate for measles vaccine (0–11 
months) 24 37 61 83 55 78 66 10
Coverage rate for diphtheria, tetanus, 
pertussis/3rd dose (0–11 months) 63 59 62 66 68 67 52 11
Coverage rate for anti-tetanus 2 74 58 80 65 73 74 69 69
* NA = not available. 
visits and quarterly meetings decreased, so teams did not get the feedback, support, and motivation that 
they had during the project. Teams may not be sustainable after a project stops, or if they are, they may 
continue at a lower level of intensity unless there is a strong commitment from leadership and 
management at all levels. There was no funding earmarked specifically for QI teams after the project. 
In order to assess the effectiveness of the teams, we conducted a confidential team self-evaluation of 26 
team members from eight teams at health centers in Tahoua using the QI Team Member Self-assessment 
tool. The tool consists of a series of structured questions regarding team meetings, leadership, 
accomplishments, and working environment with a rating scale from 1 to 3, with 1 being “False” and 3 
being “Generally True.” Some questions were reverse scored. The highest possible score for each team 
dimension was 312. The dimension with the lowest score was “Positive Criticism,” which assessed the 
manner in which criticisms were conveyed and perceived. The dimension with the highest score was 
“Effective Meetings,” closely followed by “Positive Atmosphere” and “Team Accomplishments.” A 
summary of the scores is presented in Table 7. 
Table 7: Self-evaluation Score for QI Teams by Team Dimension 
Team Dimension Score Percentage 
Effective meetings 235 75 
Effective leadership 227 73 
Positive criticism 200 64 
Creativity 219 70 
Positive atmosphere 234 75 
Team accomplishments 234 75 
Average rating 225 72 
3. Supervision 
During the project, improving the supervision of health workers was a major focus. Even in 2000, some 
90% of supervisors had been trained in facilitative supervision techniques. Much of this training occurred 
during the project from 1994 to 1996 and in 1998. Some medical officers received their supervision 
training through a management short course taught at the district development center. The project trained 
 Niger Follow-up Evaluation of QA Activities · 9
teams of supervisors for each district in facilitative supervision techniques. This training was then 
incorporated into the national district team training curriculum in 1998. Also, a district-level supervisory 
team was established and a supervisory checklist developed during the project. In 1999 and 2000 the 
supervision checklist was still being used by Tahoua supervisors. Topics on the supervision checklist 
identified the main problems, which are listed below. 
As shown in Figure 3, the percentage of planned supervisory visits that were completed in Tahoua during 
1999 and 2000 (51% and 52%) had fallen below the median of 57.5%, showing a downward trend 
compared to supervisory visits completed in the last two years of the project (70% and 78%). 
Figure 3: Percentage of Planned District Level Supervisory Visits Actually Completed, Tahoua 
0
10
20
30
40
50
60
70
80
90
1995 1996 1997 1998 1999 2000
Tahoua Median
The main problems noted during supervision visits to clinics during 1999 and 2000 were failure to 
comply with the Standard Treatment Guidelines/Protocols, input shortages (forms, essential drugs, 
personnel, equipment), poorly kept Health Management Information System and cost-recovery records, 
poor inter-personal communication, and non-integration of activities. Positive points were compliance 
with IMCI standards and the Standard Treatment Guidelines/Protocols; improved availability of some 
drugs, lab supplies, etc.; integration of activities; well-kept supervision records and health indicator data; 
and extending a welcome to patients arriving at the clinics. While some clinics had problems complying 
with the Standard Treatment Guidelines/Protocols, others complied very well. 
Having trained supervisors use a checklist to review records and data is a project result that has lasted, 
although frequency did decrease after the project. The long distances between clinics and the poor roads 
make it very difficult logistically to complete a supervisory visit in the Tahoua region. During the 
project, QAP provided fuel and per diem for quarterly supervision, and after the project World Bank 
funds took over the support of supervision. While the procurement procedures during the project were 
easy and direct since the project was based in the region, the World Bank had much more laborious 
procurement procedures. These differences may account for a decrease in supervision, despite continued 
funding. Another reason that supervisory visits decreased may be that working vehicles were unavailable. 
During the project, the MOH often used QAP vehicles for supervisory visits. In addition, the World Bank 
did not require that supervisory reports be presented and discussed at quarterly meetings as QAP had. 
With the advent of cost recovery, planning and budgeting for supervision were to have been a priority in 
the district budget. 
4. Quarterly Meetings 
During the project, two- to three-day quarterly meetings were held at the district level and attended by 
workers from all of the health centers in the district, community representatives, and representatives of 
10 · Niger Follow-up Evaluation of QA Activities
NGOs and other organizations working in the community. They served to address district-wide issues 
and were a forum where supervisory reports and QI projects were presented and discussed. Like 
supervision and health center QI teams, they were a key QA activity during the project. 
Quarterly meetings continued in 1999 and 2000, but their frequency declined (Figure 4). The number of 
quarterly coordination meetings at the district level in Tahoua fell from project levels of 78% and 81% to 
56% and 44% after the project, well below the median of 63%. All districts in Tahoua had quarterly 
meetings except Illéla. At the Tahoua regional office only 50% of planned meetings were held in 1999 
and 2000. Topics covered during the quarterly meetings during 1999 and 2000 were health indicators, 
cost recovery, essential drug stock-outs, refrigeration, and QA work. 
Despite World Bank funds slated to support quarterly meetings, they occurred at reduced levels. Funding 
was necessary to sustain the meetings, as participants needed per diems, transportation, food, and lodging 
for the days-long meetings. The regularity of these meetings was key to maintaining the structure and 
organization of the region’s QA efforts as they gave continuity to the operational QA activities. Because 
they occurred less frequently, their effect on institutionalizing QA activities decreased. The lower 
frequency may have been the result of the same logistical difficulties as noted above in the Supervision 
section. 
Figure 4: Percentage of Planned District Level Quarterly Meetings Actually Held, Tahoua 
0
10
20
30
40
50
60
70
80
90
1995 1996 1997 1998 1999 2000
Tahoua Median
5. QA Training 
During the project, 430 MOH personnel at the regional, district, and health center levels were trained in 
QA, coaching, and supervision. In 1999 the QA training and reference manual was reviewed and 
modified, resulting in a shortened history of QA section, clarification of the monitoring content, addition 
of a short section on management, and a review and adaptation of the QA tools to reflect the local 
context. The revised training was also lengthened to 6–10 days. QA training, funded by the World 
Bank’s QA extension effort, continued after the project closed in other regions of Niger but not in 
Tahoua. 
6. Dissemination and Communication 
The QA work in Tahoua was disseminated widely after the project end. Presentations were given at 
international meetings; study tours were conducted for delegations from five countries and reports; and 
journal articles were written. The following list summarizes these activities: 
 Niger Follow-up Evaluation of QA Activities · 11
• Presentations at international conferences: International Society for Quality in Health Care 2000, 
Niger 2000, Cameroon 2000; 
• Study tours to Tahoua from Rwanda, Mali, Ivory Coast, Burkina Faso, and Guinea; and 
• Written reports: Bulletin “Oumani-Info Sante,” The Niger QAP/BASICS Joint Project Final 
Evaluation, and an ISQua journal article (Catsambas et al. 2002). 
C. Research Question Number 3 
How do other activities in 1999 and 2000, such as supervision, quarterly meetings, standards 
development, and compliance with IMCI standards in the Tahoua region compare with the Maradi 
region? 
1. Development and Communication of Standards 
During the QAP/BASICS project, standards were developed on the essential aspects of healthcare service 
delivery, such as administration, finance, standards, relationships with the community, healthcare 
organization, and health policy in Niger. The communication of standards occurred during quarterly 
meetings. 
In Tahoua, more standards were revised during 1999 and 2000 than in Maradi (four versus two). The 
following list summarizes those standards. 
Tahoua: 
• Growth monitoring standards 
•
•
•
•
•
Pharmacy organization and management 
Maternal child care and family planning at the district level 
Cost-recovery management tools at the district hospital 
Maradi: 
Development of a health clinic supervision chart based on MOH guidelines 
Supervision of community health workers by health clinic workers 
The topics for supervision standards in Maradi had already been addressed in Tahoua during the project. 
2. Supervision 
The percentage of planned supervisory visits that were completed in Tahoua was not significantly 
different than those in Maradi in 1999 (51% versus 73%) and in 2000 (52% versus 55%) (see Figure 5). 
In Tahoua a supervisory visit to one health center took a day to complete, whereas in Maradi supervisors 
would visit more than one center in a day. 
In Maradi 60% of the supervisors had been trained in supervision, compared to 90% in Tahoua. The main 
problems found during supervision in Maradi were similar to those in Tahoua and are discussed in the 
above Supervision section: poorly kept records for the Health Management Information System and cost 
recovery, failure to observe clinical standards, input shortages, poor management of drugs and personnel, 
poor financial management of cost recovery, poor integration of activities, and patients found the clinics 
non-welcoming. Positive points found during supervision were improvement in compliance with IMCI 
standards and improved financial management of cost recovery. The problems noted by supervisors in 
Maradi, such as poor integration of activities and poor patient reception in clinics, were areas that had 
received attention during the QAP project in Tahoua and were no longer cited as problems in supervision 
reports there. 
12 · Niger Follow-up Evaluation of QA Activities
Figure 5: Percentage of Planned Supervisory Visits from District to Health Center Actually 
Completed, Tahoua and Maradi 
0
20
40
60
80
100
1995 1996 1997 1998 1999 2000
Tahoua Maradi
During 1999 and 2000, Maradi received increased funding for supervision through UNICEF. Every 
district was able to purchase a four-wheel drive vehicle from UNICEF. This may have been the cause for 
an increase in the number of supervisory visits in Maradi during 1999. The proportion of completed 
supervisory visits in Tahoua declined after the project ended even though there were funds earmarked for 
supervision. From the standpoint of logistics, supervision is easier in Maradi as the districts are 
geographically smaller than those in Tahoua. The roughly similar rates of completion of supervisory 
visits between Tahoua and Maradi, despite the logistical and funding constraints in Tahoua, may have 
been due to the fact that supervision in Tahoua was viewed as a system and was consequently more 
organized, comprehensive, and based on trained supervisors. The system was “designed” by the district 
and regional staff. It was improved continuously through the revision of schedules, expanding the 
numbers of supervisors by training already-experienced clinicians (including nurses), modifying reporting 
requirements, and developing a supervisory checklist and guidelines for its use. Supervision was also 
linked to the quarterly meeting system where district supervisors were expected to report on their 
supervision findings. 
3. Quarterly Meetings 
As seen in Figure 6, the percentage of planned quarterly coordination meetings actually held in Tahoua at 
the district and regional levels in 1999 and 2000, respectively, was not significantly different from the 
proportion held in Maradi in 1999 (56% versus 58%) and in 2000 (44% versus 32%). 
Topics covered during the quarterly meetings were a review of activities conducted during the previous 
period, community participation, IMCI, and the development of the Annual District Implementation Plan. 
In Tessaoua, one of the meetings informed participants of the QA approach. This was due to the fact that 
the district medical officer had been transferred to Tessaoua from Tahoua. This individual trained his 
staff in QA and fashioned the supervisory system and quarterly meetings after the Tahoua approach. 
However, it is hard to compare quarterly meetings in Maradi with those in Tahoua as they are quite 
different. In Tahoua, these meetings are two to three days long and attended by all healthcare workers in 
the district, as well as representatives of the community and NGOs working in the community. They 
address district-wide issues and are a forum where supervisory reports and QI projects are presented and 
discussed. In Maradi, by contrast, quarterly meetings are one day long and attended only by the medical 
officers. They are a forum where only reports for UNICEF activities are presented without the discussion 
of other ongoing health activities. 
 Niger Follow-up Evaluation of QA Activities · 13
Figure 6: Percentage of Planned Quarterly Meetings Held at District and Regional Levels, Tahoua 
and Maradi 
0
20
40
60
80
100
1995 1996 1997 1998 1999 2000
Tahoua Maradi
4. Utilization of Data 
During the QAP/BASICS project, QI teams at the health centers were trained to base decisions on data 
and used health information system data to monitor the progress of their QI efforts. In order to measure 
utilization of monitoring data, a questionnaire was administered to the health center director at all 12 
centers in the study. At all of the health centers, the most recent report had been completed. Ninety-one 
percent of the health centers used the data in their work and over half conducted their own analysis of the 
data. The differences between the health centers in Tahoua and Maradi are displayed in Table 8. As the 
sample of health centers is small, it is difficult to draw any conclusions on the effect of the project on 
utilization of data. 
Table 8: Utilization of Data by Health Centers, Tahoua and Maradi 
(Percentage of Affirmative Responses) 
Tahoua 
n = 8 
Maradi 
n = 4 
Is your last Health Information System Report done? 75 100 
Do you use the information in the report for your work? 
•
•
•
•
•
•
•
Ordering medication and supplies 
Evaluating priorities 
Planning 
Epidemiological surveillance 
Educating community 
Education clinic personnel 
Seeking financial resources 
75 
50 
38 
25 
25 
50 
50 
0 
100 
50 
25 
75 
25 
100 
50 
25 
Do you receive feedback on your reports from the Health Information Office (during 
supervision, quarterly meetings, visits)? 
88 25 
Do you make graphic presentations of your data? 50 50 
Do you conduct or request specific analysis of your data? 75 25 
Do you have a monitoring system? 63 50 
Do you have a forum where you can discuss indicators with other health center 
workers? 
63 75 
Do you have a forum where you can discuss indicators with the district health team? 100 100 
Do you receive the bulletin, “Santé-Info” from the Health Information Office? 50 75 
Do you receive the monthly bulletin from the Health Information Office? 0 50 
14 · Niger Follow-up Evaluation of QA Activities
5. Compliance with IMCI Standards 
While the QAP/BASICS project funded IMCI training in Tahoua’s Konni District, no such training had 
been done in Illéla District. The December 1998 end-of-project evaluation had compared these districts 
in terms of health worker performance. The study used the Rapid Assessment of Health Worker 
Performance and involved observing health workers and interviewing caretakers after a child was treated. 
In order to compare health worker performance over time, we repeated this study in January 2001, at the 
same health centers as in 1998. The results are in Table 9, which uses a t test to show the significance of 
differences between Tahoua in 1998 and 2001, and between Tahoua and Maradi in 2001. After the 
project close, in 1999, all IMCI-trained workers in Konni were transferred to other regions outside 
Tahoua. Only the supervisors were trained in IMCI, not the health workers seeing patients. The results 
show a decrease in all but one performance item in Tahoua between 1998 and 2001. Significant 
decreases sere seen in “whether nutritional status was checked” (47.0% in 1998 to 5.4% in 2001), 
“whether the child was checked for two or more danger signs” (63.5% in 1998 to 26.3% in 2001), and 
“whether the mother was counseled about the child’s treatment” (62.8% in 1998 to 10.7% in 2001). 
Although none of the health workers in Tahoua seeing patients was trained in IMCI, those in Guidan 
Roumdji in the Maradi region had recently received IMCI training. There were no significant differences 
in performance between the two regions, although “whether nutritional status was checked” was greater 
in Maradi (26.7%) than in Tahoua (5.4%). This could be the result of the emphasis that the UNICEF 
project in Maradi placed on nutritional assessment. 
Table 9: Percentage of Correct Performance of Health Workers According to IMCI Guidelines, 
Tahoua 1998 vs. Tahoua 2001 and Tahoua 2001 vs. Maradi 2001 
Health Worker Performance 
Indicators 
Tahoua 
1998 
n = 16 
Test of 
Significance 
Tahoua 
2001 
n = 16 
Test of 
Significance 
Maradi 
2001 
n = 8 
Nutritional status checked 47.0 p<.001 5.4* NS 26.7 
Child correctly examined 37.3 NS 29.8 NS 31.7 
Child checked for two danger signs 63.5 p=.01 26.3 NS 12.1 
Child correctly treated 76.2 NS 78.9 NS 70.7 
Mother counseled about child’s 
treatment 
62.8 p<.001 10.7 NS 12.5 
Mother counseled on when to bring 
child back 
47.8 NS 32.8 NS 48.8 
Notes: * Sample size was 14 for Tahoua 2001question on nutritional status checked; NS = not significant. 
The performance assessment also examined maternal knowledge and suggestions for improving services 
through exit interviews (see Table 10). There were no significant differences between 1998 and 2001 in 
maternal knowledge or improvement ideas. When comparing Tahoua and Maradi, only one item was 
significantly different: “mothers who had suggestions on improvement” (44.0% in Tahoua versus 14.2% 
in Maradi, p = 0.02). This difference may reflect the QA focus on client satisfaction in Tahoua. 
Table 10: Percentage of Affirmative Responses from Mothers, Tahoua 1998 vs. Tahoua 2001 and 
Tahoua 2001 vs. Maradi 2001 
Maternal Indicators 
Tahoua 
1998 
n = 16 
Test of 
Significance 
Tahoua 
2001 
n = 16 
Test of 
Significance 
Maradi 
2001 
n = 8 
Mothers who had suggestions on 
improvement 
39.5 NS 44.0 p=0.02 14.2 
Mothers who know how to give 
medication 
75.0 NS 64.4 NS 55.7 
Mothers who know at least 2 danger signs 53.8 NS 68.5 NS 68.8 
Note: NS = not significant. 
 Niger Follow-up Evaluation of QA Activities · 15
D. Research Question Number 4 
What factors have sustained project achievements in Tahoua in 1999 and 2000? 
Thirty-four MOH personnel in Tahoua had an opportunity to respond to several open-ended questions 
related to the sustainability of the QA effort in Tahoua. The questions focused on the major 
accomplishments of the QAP/BASICS project (Table 11), their perception of what QA elements and 
activities were still ongoing in January 2001 (Table 12), and their perception of what factors had assisted 
or hindered QA activities (Table 13). 
Table 11 Major Accomplishments of the Quality Assurance/BASICS Project as Perceived by Study 
Participants 
Structure Process Outcome 
• Renovation of Tahoua Regional 
Health Administration 
• Provision of technical equipment 
and logistics support to the 
Tahoua RHA and to health 
districts 
• Training received on QA 
approach, coverage of different 
areas, and supervisory skills 
using a checklist 
• Enhancing staff knowledge of 
the health system 
• Supervision structure 
• Initiating and regularly convening 
the different coordination and 
review meetings 
• Improvements in maternal child 
care and family planning 
standards review process, 
development of supervision 
checklist facilitating district 
supervision of health centers 
• Setting up QI teams 
• Processes for data control, 
collection, and use 
• Operations research and surveys 
during QI team cycles 
• Integration of QA activities at all 
levels 
• Decision making based on data 
• Team spirit at all levels and good 
communication 
• Presentations at national and 
international conferences 
• Tahoua became a model for QA 
and a national resource for QA 
trainers 
• An increase in the region’s honor 
and credibility (Tahoua is always 
cited as an example.) 
• The pursuit, timeliness, and quality 
of meetings and supervision 
• The improvement of staff 
performance through local 
management of issues first and the 
provision of documents/ materials 
• Staff pride, increased motivation, 
and inspired creativity 
Table 12: Continuing and Discontinued QA Activities in January 2001 as Perceived by Study 
Participants 
QA Element Continuing QA Activities Discontinued QA Activities 
Quality 
definition 
• •
•
Setting and reviewing clinical standards, 
managerial capacity, and implementing QA 
approach 
Regularity of QA activities 
Some maintenance of equipment for 
districts with no donors (Illéla, Keita) 
Quality 
measurement 
• Continuous evaluation of activities (supervision •
integrated into coaching and monitoring) 
Some coaching and monitoring 
Quality 
improvement 
• The work of QI teams, exchanges through •
meetings, monitoring indicators, and 
competitiveness between teams 
Coaching of teams 
QA principles •
•
•
•
Teamwork during meetings of the quality 
council, coaching sessions, and quarterly 
meetings still being held 
Decision making based on data 
Some quality councils 
Some regular quarterly coordination 
meetings 
Documentation/ 
communication 
• •
•
•
•
QI team supervision and documentation continue 
at health clinics and district hospitals 
Regular supervision in some districts 
Exchange between districts 
Field trips and conferences 
Ader Santé Info newsletter 
Capacity 
building 
• Training in clinical care/coverage to strengthen •
compliance with standards 
Training sessions 
16 · Niger Follow-up Evaluation of QA Activities
Respondents noted that the regularity of quarterly meetings and supervision had decreased, although the 
quality of the supervision and meetings was still high. They also noted a lack of coaching of the QI teams 
and a discontinuation of the regional quality council, which had overseen QA program implementation. 
Respondents reported several ways that QA activities had either been helped or hindered. These ways 
were analyzed and categorized into the following topics: resource availability, motivation, results of the 
QAP/BASICS project, technical support, and personnel. They are summarized in Table 13. 
Table 13: Factors that Assisted or Hindered the Sustainability of Project Accomplishments as 
Perceived by Study Participants 
Factors 
Assisting 
Sustainability 
Description 
Factors 
Hindering 
Sustainability 
Description 
Resource 
availability 
•
•
•
•
•
The Regional Health 
Administration’s commitment to 
seek funding and support from some 
donors (WHO for QA activities and 
Health Project II; World Bank for 
supervision) 
The availability of trained staff and 
the appointment of a QA officer at 
the Regional Health Administration 
Resource 
availability 
Resource shortages or lack of 
funding 
Reduction of project benefits 
for staff (training, equipment/ 
materials, per diem) 
Project’s disengagement 
without closing notice (project 
closed when people were not 
ready to sustain project 
activities) 
Motivation •
•
•
•
•
•
•
•
•
•
Influence of external visitors 
Results obtained during the project 
Support from MOH and other 
donors 
Staff motivation and commitment 
Field trips outside the project 
District Health Management Team’s 
stability 
Motivation Decreased Regional Health 
Administration motivation 
and interest 
Lack of initiative in 
identifying new strategies for 
improving problems 
QA project close reduced 
staff’s motivation because it 
closed suddenly and no other 
assistance (training, 
equipment) supplanted it 
No conferences due to lack of 
funds 
Results of the 
QAP/BASICS 
Project 
•
•
•
•
•
•
•
•
Required integration of QA into 
basic package of clinic services 
Monitoring and follow-up by 
coaches 
Presence of community workers at 
the grassroots level 
Tangible results obtained 
Technical 
support 
All necessary support 
documentation not provided 
to the region 
Lack of close coaching 
Supervision does not always 
integrate QA 
Lack of timely or realistic 
planning 
Personnel •
•
•
•
•
•
Lack of QA training 
opportunities for new staff 
Sluggishness within the QI 
teams 
Staff instability/mobility 
Lack of will from staff, who 
consider QA as additional 
workload 
Lack of time 
No QA representative 
Respondents in Tahoua felt that the major accomplishments of the QAP/BASICS project could be 
summed up as a reinforcement of human resources capacity building, the institutionalization of some QA 
 Niger Follow-up Evaluation of QA Activities · 17
practices, an improvement in physical assets, and an improvement in the performance of the regional 
health system. 
E. Research Question Number 5 
An open-ended question asking for input on strengthening and sustaining QA accomplishments resulted 
in approximately 31 different responses. These recommendations were analyzed and categorized into the 
three elements of institutionalization: (a) internal enabling environment (policies, leadership, core 
organizational values, and adequate resources); (b) support functions (capacity building, communication 
and dissemination, and incentives and recognition); and (c) organizing for quality (structure to support 
QA implementation (delineation of roles, responsibilities, and accountability for the implementation of 
QA activities). They are presented in Table 14. 
Table 14: Suggestions by Study Participants for Strengthening the Institutionalization of Quality 
Assurance Project Accomplishments 
Elements of 
Institutionalization Suggestions 
Internal enabling 
environment (policies, 
leadership, core 
organizational values, 
adequate resources) 
1. Create a budget line item for QA at the national level and fund the action plan 
2. Adopt a national QA program involving beneficiaries 
3. Ask partners to include QA in their projects 
4. Urge donors to show interest for QA and to fund QA activities 
5. Increase political will 
6. Increase MOH involvement 
7. Provide the minimum resources in order to inculcate QA to new staff members 
8. Make resources available 
9. Re-establish QAP to give a new push 
10. Monitor and fund QA activities regardless of integration 
11. Provide material resources (such as flipcharts, etc.) 
12. Provide government funding for activities 
13. Put into place a QA sustaining mechanism at the Regional Health Administration 
or materialize institutionalization 
14. Continue to provide funding for regional and/or district action plans for the 
implementation of activities scheduled in the context of QA 
Support (capacity 
building, 
communication and 
dissemination, 
incentives and 
recognition) 
1. Integrate QA in the training curriculum in basic education schools 
2. Accelerate QA training and QA extension in the country 
3. Provide a QA training and refresher course for Tahoua staff 
4. Reduce personnel mobility 
5. Hold a round table of district managers on the sustainability of QA 
6. Sensitize staff on maintaining QA activities 
7. Conduct field trips to Tahoua and other QA sites 
Structure (delineation 
of roles, 
responsibilities and 
accountability for the 
implementation of QA 
activities) 
1. Create a QA focus point at the district level 
2. Integrate QA into the basic package of health services 
3. Organize regular coordination meetings 
4. Standardize results of completed QI cycles for replication elsewhere 
5. Coordinate donor interventions 
6. Continue quality council meetings on a regular basis 
7. Provide QA coaching from the regional level 
8. Focus on QA during supervision visits and coordination meetings 
9. Integrate QA into Health Management Information System aids 
10. Involve community in QA activities 
Note: Numbering is to facilitate discussion and does not imply priority order. 
18 · Niger Follow-up Evaluation of QA Activities
An open-ended question asking for suggestions that could be made to others before they replicate the 
Tahoua QA experience elicited approximately 40 recommendations. These recommendations were 
analyzed and reviewed for common themes based on similar intentions and internal cohesion of the 
theme. The resulting six categories of similar ideas were constructed: policy and planning, funding and 
resource allocation, structure, capacity building, training implementation, necessary attitudes. The policy 
and funding categories were then grouped together, for the sake of presentation, making five categories 
(see Table 15). 
V. CONCLUSIONS AND RECOMMENDATIONS 
A. Discussion of Findings 
Our findings suggest that although essential QA activities in Tahoua continued in 1999 and 2000 after the 
project close in 1998, their frequency decreased. This was true for supervision, quarterly coordination 
meetings, and quality improvement teams. The quality of care provided to patients at Tahoua health 
centers in 2001 declined for all but one performance item, and declined significantly for some key items, 
including checking a child for two or more danger signs and counseling mothers on the child’s treatment. 
Many factors can be identified as possible causes for the decline in QA activities and health worker 
performance in Tahoua. Two key factors are the transfer of staff and decreased resources. Staff transfer 
may be linked to both a change in the political party and a desire by the Niger MOH to extend the benefits 
of the Tahoua QA experience to other regions. To this end, the MOH identified, before the project close, 
funds to continue key QA activities in Tahoua as well as to extend QA to other regions. However, this 
lower level of funding was not enough to sustain QA activities at project levels, as seen with our results. 
Was Tahoua any different than other regions two years after the project closed? Based on our study 
findings, we can say that Tahoua did have an advantage over Maradi two years after the project ended. 
Tahoua had a more structured and comprehensive supervision system than Maradi, although the 
percentage of supervisory visits completed in 2000 was no different between the two regions. Quarterly 
coordination meetings were longer and more comprehensive in Tahoua than in Maradi but held with 
equal or slightly greater frequency. Standards that Tahoua had addressed during the project were only 
now being addressed in Maradi, and performance of health workers in Maradi was no different than in 
Tahoua—despite recent IMCI training in Maradi and a transfer of all IMCI-trained workers out of 
Tahoua. So, although the frequency of QA activities had decreased in Tahoua in 1999 and 2000, the 
quality of supervision, standards development, and quarterly coordination meetings was better than in 
Maradi. 
Some valuable lessons can be learned from the Tahoua experience after the end of the project. Not only 
must attention be paid to continued funding to ensure sustainability, but accountability for QA activities 
needs to be maintained through a strong QA management component. The suspension of the regional 
quality council must be seen as a constraining factor on the enabling environment for QA after the project 
ended. In addition, the dilution of trained health workers and supervisors in Tahoua led to a decrease in 
that region’s capacity to sustain QA, without necessarily leading to a spread of QA into areas that 
received these trained personnel. Anecdotal reports from transplanted personnel indicate that they faced 
sometimes insurmountable difficulties trying to start QI teams at facilities with no previous exposure to 
them. Any transfer of personnel must be accompanied by a planned extension of QA activities to that 
region so that those personnel are supported in their efforts to initiate QA activities. 
Finally, the strategy of generating ideas for improvements in QI teams that was implemented in Tahoua 
will not lead to sustained improvement if these teams cease to function. Instead, a better approach may be 
to link improvements with standards development and quality assessment, which has been implemented 
in other QAP country programs. Addressing gaps in performance through QA/QI methods will then lead 
to improvements in the system of care. 
 Niger Follow-up Evaluation of QA Activities · 19
Table 15: Recommendations for Replicating the Tahoua Experience 
Category Recommendations 
Policy and 
planning; 
Funding and 
resource 
allocation
1. Collaborate with those who show interest 
2. Conduct a field visit to Tahoua and take advantage of the experience there 
3. Conduct a thorough analysis of the situation in order to identify the real problems 
4. Do not put money as the ultimate factor of motivation and operation 
5. Establish a personnel management plan in order to reduce mobility (3 years minimum 
per trained worker) 
6. Favor local funding of communities, cities, etc. 
7. Identify a credible partner/ donor 
8. Identify partners/ donors who agree to fund the QA approach 
9. Make a solid action plan 
10. Obtain starting resources 
11. Provide incentives for staff performance 
12. Select pilot health centers before extension activities 
13. Take into account Tahoua’s shortcomings and provide solutions 
14. Use internal resources to conduct QA 
15. Visit places where QA works well 
Structure 1. Create working groups (teams) at all levels 
2. Find persuasive strategies for motivation with regard to projected results and their 
impact on community health 
3. Follow the teams and assign responsibilities at the regional level 
4. Organize monitoring in all health centers 
5. Reduce staff mobility 
Capacity 
building
1. Appraise existing skills/ competence (surveys) 
2. Begin with something concrete 
3. Conduct concrete activities in the field 
4. Identify motivated workers to train 
5. Integrate QA in schools 
6. Region needs to understand its population and epidemic data 
7. Train District Health Management Teams to ensure supervision 
Training 
implementation 
1. Begin staff training from the bottom up 
2. Call upon coaches who understand the training 
3. Continuously review training modules according to acquired experiences 
4. Implement QA right after training 
5. Improve the quality of staff training 
6. Let the first groups of trained staff work with those untrained before moving to 
another group 
7. Make a prioritized training plan 
8. Method requires executive training supported by documents/ materials 
9. Train health workers by increasing duration 
10. Use Tahoua trainers for training sessions 
Necessary 
attitudes 
1. Be patient in this process 
2. Be as participative as possible 
3. Convince staff on new QA policy 
4. Discard the “project” aspect while introducing the approach 
5. Don’t prejudge before starting 
6. Further sensitize community leaders 
7. Inform everyone involved about the approach 
8. Make QA everybody’s business 
9. Organize community sensitization sessions 
10. QA needs to start from the Ministry and run through the whole system 
11. Raise staff awareness of QA 
12. Sensitize staff on the importance of integrating QA into the basic health package 
13. Use necessary resources to change people’s behavior 
Note: Numbering is to facilitate discussion and does not imply priority order. 
20 · Niger Follow-up Evaluation of QA Activities
B. Presentation of Results at Workshop in Niger 
These results were presented at a workshop in Konni, Niger, on June 27, 2001. The 25 workshop 
participants included MOH personnel from the national, regional, district, and health center levels of 
Tahoua and Maradi. Deficiencies that were noted in the study results were addressed by three break-out 
groups. Their suggestions for increasing the regularity of supervision and quarterly meetings were to 
better coordinate the quarterly meetings between the regional and district offices, to find the necessary 
resources, and to scrupulously keep to the proposed schedule. 
As a result of the workshop, the following recommendations were made to the Niger MOH: 
1. Prioritize at the national level the resources and organizations needed when planning QA activities. 
2. Organize a one-day retreat in Tahoua on QA. 
3. Enlarge the role of the quality council in Tahoua to include the diffusion and spread of best practices. 
4. Diffuse the work of the QI teams throughout both regions. 
5. Help the health workers in Tahoua to adhere to QA norms. 
6. Decentralize team coaching in Tahoua to experienced personnel. 
7. Introduce QA into Maradi. 
REFERENCES 
BASICS I Country Program: Niger. See http://www.basics.org/programs/basics1/niger.html. Accessed 
June 2002. 
Catsambas TT, Kelley E, Legros S, Massoud R, and Bouchet B. 2002. "The evaluation of quality 
assurance: developing and testing practical methods for managers." International Journal for 
Quality in Health Care 14 Suppl 1: 75–81. 
Franco, LM, Silimperi DR, Veldhuyzen van Zanten T, MacAulay C, Askov K, Bouchet B, and Marquez 
L. 2002. Sustaining Quality of Healthcare: Institutionalization of Quality Assurance. QA 
Monograph Series 2(1). Bethesda, MD: Published for the United States Agency for International 
Development by the Quality Assurance Project. 
Legros S, Tawfik Y, Crespin X, Djingarey M, Goodrich E, and Abdallah H. 2000a. The Niger 
QAP/BASICS Project: Final evaluation. Evaluation Report 1(1). Bethesda, MD: Published for 
the United States Agency for International Development by the Quality Assurance Project. 
Legros S, Massoud R, Urroz O, and Kelley E. 2000b. The Chile Quality Assurance Project: Final 
Evaluation. Technical Report Summary 1(2). Bethesda, MD: Published for the United States 
Agency for International Development by the Quality Assurance Project. 
Winter L, Boucar M, Stinson W, Mason D, and Murphy G. 1997. Niger Country Report: Tahoua 
Project. Bethesda, MD: Published for the United States Agency for International Development 
by the Quality Assurance Project. 
 Niger Follow-up Evaluation of QA Activities · 21
APPENDIX 
Please note that the survey instruments have been modified for presentation here: All instruments were 
translated to English from their original versions in French, and space allowing respondent replies was 
eliminated to minimize the number of pages. 
Study instruments: 
A1. Guide for Document Review at the Department Level 
A2. Interview with Staff of the Tahoua Regional Health Administration Re: Supervision of Teams 
A3. QI Team Member Self-Assessment 
A4. Interview with Health Center Manager 
A5. Rapid Assessment of Health Worker Performance—Health Worker Observation 
A6. Rapid Assessment of Health Worker Performance—Interview with the Mother Following 
IMCI Consultation 
22 · Niger Follow-up Evaluation of QA Activities
A1. Guide for Document Review at the Department Level 
I. Standards 
1. Please list the activities at the health center and district for which new standards were 
developed: 
Health center level: 
District level: 
2. Describe the processes for developing these new standards for each of the activities: 
Activities Development Processes 
3. List the activities at the district and/or health center level for which out-of-date standards were 
revised/adapted: 
District level: 
Health center level: 
4. Describe the processes that were used to revise/adapt the old standards for each of these activities: 
Activities Revision Processes 
5. List the standards put in place (functionally), whether old or new, by activity: 
Activities Standards 
II. Supervision 
6. How many supervision visits were conducted by the department per year and per district in 1999 
and 2000? 
1999 2000 Districts 
Planned Conducted Planned Held Percentage Held 
7a. Supervision costs in 1999 
District Average per Diem: 
Supervisors 
Average per 
Diem: Drivers 
Average Distance 
per Visit 
Average Time Required for 
Each Visit (Person-Days) 
7b. Supervision costs in 2000 
District Average per Diem: 
Supervisors 
Average per 
Diem: Drivers 
Average Distance 
per Visit 
Average Time Required for 
Each Visit (Person-Days)
 Niger Follow-up Evaluation of QA Activities · 23
8. Indicate the supervised aspects by activity: 
Activities Supervised Aspects (Provide Details) 
9. Indicate the implementation rate of recommendations made in various chronological supervision 
reports: 
Report 1 Report 2 Report 3 Report 4 Report 5 
Number of recommendations 
Number of recommendations 
implemented 
Percentage implemented 
10. What were the five main problems encountered during supervision visits? Provide the most frequent 
(recurring) or the most serious. 
11. Indicate the number of active supervisors in the department: ______ 
Number trained in supervisory methods: _____ Percentage of supervisors trained: _____ 
12. Please indicate whether a regional analysis of the results of the supervisions exists: _____ 
If so, for which periods: ____________________ 
For how many districts? ______________ 
Positive Points Negative Points 
III. Meetings 
13. How many meetings were held during 1999 and 2000? 
1999 2000 Type of Meeting Planned Held Planned Held 
Percentage 
Held 
Staff 
Regional quality council 
Regional meeting of 
managers 
Coaches 
Partners 
14. List the quarterly meetings held indicating place, number of participants, type, and length from 
1999 to 2000. 
Date Meeting Was 
Held Location Number of 
Participants Type of Meeting Length 
1. 
2. 
3. 
4. 
24 · Niger Follow-up Evaluation of QA Activities
15a. The cost of quarterly meetings held in 1999 
Type of Cost Meeting 1 Meeting 2 Meeting 3 Meeting 4 
Per Diem 
Refreshments 
Photocopying 
Transportation 
Lodging 
Other 
Total 
15b. The cost of quarterly meetings held in 2000 
Type of Cost Meeting 5 Meeting 6 Meeting 7 Meeting 8 
Per Diem 
Refreshments 
Photocopying 
Transportation 
Lodging 
Other 
Total 
16. For each quarterly meeting held, indicate: 
Date Objectives Problems 
Identified 
Solutions/ 
Recommendations
System for 
Follow up 
Implementation of 
Recommendations
1. 
2. 
IV. Training in Quality Assurance 
17. For each QA training held, please indicate (and specify whether any training was not held): 
QA Training Date Length in Days Number of 
staff trained Level/ Category Number of 
Trainers 
Home Base of 
Trainers 
1. 
2. 
18. Cost of training: 
Type of Cost Training #1 Training #2 Training #3 Training # 4 Training #5 
Per diem 
Honoria 
Training documents 
Transportation 
Training materials/supplies 
Lodging 
Refreshments 
Other 
Total 
 Niger Follow-up Evaluation of QA Activities · 25
V. IMCI 
19. List the districts implementing IMCI. 
20. Indicate the number of staff trained in IMCI by year and by district. 
District 1999 2000 
Konni 
Illéla 
Tahoua 
Madaoua 
Bouza 
Keita 
Abalak 
Tchinta 
21. Analyze the IMCI supervision reports at the central level: What percentage adhere to standards? 
Indicator Supervision 
Level 1 
Supervision 
Level 2 
Supervision 
Level 3 
What were the significant gaps in the area of IMCI? 
What knowledge was acquired in the area of IMCI? 
22. What types of problems were identified regarding IMCI and resolved by using QA tools and 
principles? 
VI. Dissemination 
23. Analysis of outside visits from trip reports and information bulletins 
24a. Visits from outsiders: 
Dates Outsider Place Visited Objective 
24b. Regarding visits made to other facilities 
Dates Who Participated Place Visited Objective 
24c. Dissemination workshops 
Dates Place Who? Why? 
24d. Information bulletins and published articles: 
26 · Niger Follow-up Evaluation of QA Activities
VII. Costs 
25. Analysis of the annual action plans regarding costs related to the following activities: 
1999
Activity Funding Source Level Percentage 
Trainings 
Supervision 
Meetings 
Resolution of problems 
Coaching 
Other 
2000 
Activity Funding Source Level Percentage 
Trainings 
Supervision 
Meetings 
Resolution of problems 
Coaching 
Other 
26. Analysis of the financial reports of QA trainings to determine and compare the expected versus actual 
costs 
QA Training Expected Costs Actual Costs Difference 
VIII. Department-Level Indicators (Health Information Management System) 
Years 
Indicators 1998 1999 2000 
Departmental 
Objective 
Rate (of total population) using curative services 
Coverage rate for infant consultations (0–5 km.) 
Coverage rate for prenatal consultations (0–5 km) 
Recovery rate: ambulatory nutritional counseling 
Drop-out rate: ambulatory nutritional counseling 
Family planning utilization rate (of the total population) 
Tuberculosis vaccine coverage rate (0–11 months) 
Measles vaccine coverage rate (0–11 months) 
Diphtheria-tetanus-pertussis/3rd dose coverage rate (0-11 
months) 
Anti-tetanus 2 coverage rate 
 Niger Follow-up Evaluation of QA Activities · 27
IX. Documentation System Analysis 
27a. Presence of documents: List the documents analyzed. 
27b. Completeness of documents. 
To what extent were the documents completely filled out (in terms of content)? 
27c. Coherence of documents 
 1 2 3 4 5 
Little A lot
Describe storage system for documents. 
28 · Niger Follow-up Evaluation of QA Activities
A2. Interview with Staff of the Tahoua Regional Health Administration 
RE: SUPERVISION OF TEAMS 
Data Collector: ___/__/__/__ Date:____________ 
Respondent: _________________________________ Title/position: __________________________ 
Months/years in this position: _______________________ 
Environment 
 1. During the last two years, have public events affected your work (for example, drought, flood, 
epidemic, religious)? If so, please describe. 
 2. Were new health policies introduced? If so, please describe. 
 3. Who were the new partners during the last two years? 
Who were the partners who stopped participating? 
Implementation/Revision of Standards 
 1. Based on your experience, did the lessons learned from the project have an effect on clinical 
norms and the delivery of the Basic Package of Services? If not, why? 
 2. If so, what was done to develop/adapt new standards at the: 
a) District level? (If anything, review documents) 
Develop new standards 
Adapt new standards 
b) Health center level? (If anything, review documents) 
Develop new standards 
Adapt new standards 
 3. What was done to revise/adapt outdated norms at the: 
a) District level? (If anything, review documents) 
Develop new standards 
Adapt new standards 
b) Health center level? (If anything, review documents) 
Develop new standards 
Adapt new standards 
 4. Were new/revised standards communicated to personnel in charge of implementation? 
(If anything, review documents) 
 5. If so, what strategies were used to communicate the standards: a) training, b) supervision, c) 
memos, d) meetings, and/or e) other? (If anything, review documents) 
Supervision 
 1. Have you led activities on supervision strategies? If not, why? 
 2. If so, what issues did you address: a) supervision policy, b) supervision by the departmental level 
of the district level, c) supervision by the district level of the health center level, d) frequency of 
supervision, e) tools to use during supervision, f) financial policy, and/or g) other? 
(Review documents) 
 Niger Follow-up Evaluation of QA Activities · 29
 3. What is the staff position of supervisors at the departmental level: a) all department staff, 
b) department chief, c) deputy director of the health department, d) program manager, and/or 
e) other? 
 4. Is supervision integrated into the work routine? (Review documents) If not, why not? 
 5. What tools do you use during supervision: a) supervision checklist developed in Tahoua, 
 b) supervision guide from the MOH, c) other, or d) none? 
 6. If not the Tahoua checklist, please indicate why: a) inappropriate, b) difficult to follow, or 
c) other. 
QA Structures 
 1. Is the quality council still functioning? If not, why not? If so, how many meetings were held: 
In 1999? ______. In 2000? ______ 
 2. How many health centers have operational QI teams? Number of centers ______. 
Number with functioning teams ______. 
 3. How many QI cycles were completed in 1999? ______. In 2000? ______. 
4. What was the impact of the cycles on the regional indicators? 
 5. Was coaching integrated into supervision visits? If so, review documents. If not, why? 
Meetings 
 1. Are coordination meetings held? (Review documents) If not, why?
 2. If so, what is their frequency: a) monthly, b) quarterly, c) semi-annually, d) occasionally, or e) 
other? 
 3. Where are meetings held: a) department headquarters, b) rotated among districts, or c) other? 
 4. What positions do the participants hold: a) department staff, b) certified medical staff 
(Departmental Hospital Center, maternity), c) laborer, d) medical chief of district, e) district 
epidemiologist, f) other district supervision team members, g) MSP representative, h) other 
departmental representative, i) partners, and/or j) others? 
 5. Who prepares the agenda: a) MOH, b) the department, c) department staff, d) medical chief of 
district, e) previous meeting, f) other? 
 6. What types of problems were addressed during the past two years? What activities did they relate 
to? What were the solutions? (Review documents) 
 7. Was there a mechanism for following up the recommendations issued at quarterly meetings? If 
so, what was it? If not, why? 
QA Training 
 1. Have you revised the QA reference manual? If not, why? 
 2. If so, what changes were made? (Review document) 
 3. Have you provided training sessions in basic QA? If not, why? 
 4. If so, how many training sessions were held, what was the number of staff attending, their 
position, and level? (Review training guide) 
IMCI 
 1. Did you train staff in IMCI? If so, how many? If not, why? 
 2. Did you expand IMCI into other new districts? If not, why? If so, which ones? What were the 
funding sources? 
30 · Niger Follow-up Evaluation of QA Activities
 3. Have you provided supervision specifically in IMCI? If not, why? If so, how many supervision 
visits did you make? 
 4. Did you administer the Rapid Assessment of Health Worker Performance at the district level? 
Other Training Sponsored by MOH 
 1. Did you provide other training sponsored by the MOH or other partners? If so, training in what? 
If not, why? 
Dissemination of QA Experiences 
 1. What channels do you use to disseminate QA experiences: (Review communications plan): 
a) publication/bulletin, b) meeting, c) study tour, and/or d) other? 
 2. What were the main achievements? (Review documentation) If no achievements were made, 
why was that? 
Costs 
1. Did you research funding for QA activities? 
 2. If so, were they recorded in the annual action plan? 
3. Was there funding? If so, what were the funding sources: a) state, b) community, c) NGO 
(name), d) other? If not, what did you do? 
4. What areas were financed: a) norms and standard, b) measuring quality, c) quality improvement, 
and/or d) other? 
5. What was the cost of the following main activities: a) basic QA training, b) training of trainers in 
QA, c) supervision visits, d) coaching, e) quarterly meetings? (Review documentation) 
Institutionalization and Incorporation of QA Knowledge 
 1. In your opinion and based on your experience in Tahoua, what were the most significant 
accomplishments or lessons learned from QAP/BASICS? 
 2. To the extent lessons were learned, what do you think were the measurable improvements that 
had long-term impact on the department? 
 3. What elements could have been maintained during the two years after the project? 
 4. What factors supported such maintenance? 
 5. What factors hindered maintenance? 
 6. What elements could not be sustained? Why? 
 7. What suggestions do you have to improve or strengthen the institutionalization and community 
knowledge of the quality assurance project 
 8. What recommendations can you make for a region that would like to replicate Tahoua’s quality 
assurance project experience? 
 Niger Follow-up Evaluation of QA Activities · 31
A3. QI Team Member Self-Assessment 
Health center: ___________________________________ Date: _______________ 
Cadre: _________________________________________ Sex: _______ 
Month/year team was formed: ___/____ 
Estimated number of team meetings you attended: _____. Date of the last team meeting: ______ 
Please answer each question as honestly as possible. Indicate whether you believe the statement is 
generally true, partly true, or false. Your answers will be kept confidential. 
1. Effective meetings 
a. We don’t make much progress in team meetings. 
b. We seem to reach an impasse when a problem is discussed in team meetings. 
c. We follow team ground rules in our meetings. 
d. We don’t have difficulties making decisions during team meetings. 
e. Meeting minutes accurately reflect decisions made. 
f. Team members don’t complete their assignments between meetings. 
2. Effective team leadership 
a. The team leader is disinclined to accept new ideas. 
b. The team leader makes decisions without first discussing them with team members. 
c. The team leader asks for suggestions before expressing his/her own views. 
d. The team members choose only the facility director as team leader. 
e. The leader ensures that team meetings are held regularly. 
f. The leader encourages team members to speak openly and share responsibilities. 
3. Positive feedback 
a. When team members are criticized, they think they are no longer respected. 
b. Our team leader encourages positive feedback. 
c. In our teamwork, we draw lessons from our mistakes and try not to repeat them. 
d. Little time is devoted to reviewing what the team is doing, how it functions, or how to improve it. 
e. Team members aren’t defensive when they are criticized. 
f. Team members are reluctant to express criticism. 
4. Team creativity 
a. This team generates many new ideas. 
b. The team members are reluctant to suggest new ideas. 
c. The team members actively listen to new ideas. 
d. Good ideas are lost. 
e. Creative ideas are followed by real measures. 
f. Only certain members suggest new ideas. 
5. Positive environment 
a. Team members don’t say what they really think. 
b. Team members are not determined to see the team succeed. 
c. Team members are sufficiently at ease to talk openly at meetings, even if they disagree with one 
another. 
d. The team members care about each other, and don’t criticize each other unconstructively. 
e. Team members don’t really trust each other. 
f. Our team is energetic and stimulating. 
32 · Niger Follow-up Evaluation of QA Activities
6. Team accomplishments 
a. Our team wastes time with unproductive activities. 
b. Our accomplishments are too insignificant to justify the time we devoted to solving problems. 
c. We generally achieve our objectives. 
d. Team members seem to look for ways to keep up appearances rather than achieve our objectives. 
e. Our activities have contributed to improving the quality of healthcare in our center. 
f. I am proud to belong to this team. 
7a. What I liked about teamwork: 
7b. What I ultimately didn’t like about team work: 
8. Our team had difficulty with the following steps: 
a. Identifying and prioritizing the possible improvements 
b. Defining the problem 
c. Identifying the staff who would work on the problem 
d. Analyzing and studying the problem 
e. Choosing and developing a solution 
f. Implementing the solution 
g. Measuring the impact of the solution 
h. Starting on new problems 
9. My role on the team was (please choose one): team leader, reporter, timekeeper, or member. 
How were you picked: volunteered, chosen by other members, or assigned? 
10. With regard to the following tools and methods, indicate whether you could easily use them, could 
not use them, or are not familiar with the tool/method: 
a. Brainstorming 
b. Drawing flowcharts 
c. Drawing cause-and-effect diagrams (fishbone diagrams) 
d. Decision matrix 
11. Our facilitator/supervisor (Please indicate yes or no): 
a. Helped us develop and follow ground rules for working on the team 
b. Encouraged active participation by everyone 
c. Helped the team make decisions 
d. Stayed neutral during conflicts and didn’t interfere in the arguments/discussions 
e. Helped the team stay on track 
f. Provided advice and training 
g. Other (describe) 
12. Was the team’s performance limited by any of the following factors? (Please indicate whether the 
following statements are very true, partially true, or not true.) 
a. The team is not sufficiently familiar with the tools for solving problems. 
b. Team members don’t attend meetings. 
c. Team members don’t take responsibility for their actions. 
d. Time for teamwork is not available. 
e. The team lacks motivation. 
f. The team met. 
g. The leader is not effective. 
h. People make assumptions without having appropriate information. 
i. The problem is too difficult. 
j. Other (describe) 
 Niger Follow-up Evaluation of QA Activities · 33
A4. Interview with Health Center Manager 
Data Collector:___/__/__/__ Date:____________ 
Respondent: _________________________________ Title/position: ___________________________ 
Note: If the respondent indicates “Yes,” mark 1; if “No,” mark 0; if “Partly true,” mark 2; and if “I don’t 
know,” mark 3. 
Supervision
1 How long have your worked in this facility? _____ (months) 
2 Do you have a written job description? 1 0 
3 If so, is it easily available? 1 0 
4 Do you have a calendar that shows your supervisor’s visits? 1 0 
5 Did you have a supervision visit from the district level during the last six months of 
2000? If not, proceed to Question 7. 
1 0 
6 If so, how many supervision visits did you had? _____(number) 
7 If not, how long has it been since the last supervision visit from the district? _____ (days) 
8 During the last visit, did your supervisor use a supervision checklist? 1 0 
9 Were you told in advance that the supervisor was coming? If not, proceed to 
Question 11. 
1 0 
If so, how were you informed? 
a) Through a pre-existing calendar? 1 0 
b) By letter? 1 0 
c) By telephone/radio? 1 0 
10 
d) Another way? (Please specify) 1 0 
11 Were you informed of the objectives and content of the supervision visit? 1 0 
12 Were other healthcare providers informed of the visit? 1 0 
13 If so, by whom? 
14 Did you prepare before the supervisor’s arrival? 1 0 
What did the supervisor do? 
a) Observed healthcare providers provide services? 1 0 
b) Reviewed documents? 1 0 
c) Interviewed healthcare providers? 1 0 
d) Interviewed clients? 1 0 
15 
e) Anything else? (Please specify) 1 0 
What do you think of the length of the supervision visit? 
a) Short? 1 0 
b) Acceptable? 1 0 
16 
c) Long? 1 0 
17 Are you involved in the decision making regarding supervision? 1 0 
18 If so, please comment? 
During the last visit, what activities did your supervisor ask about? 
a) Malaria 1 0 
b) Curative care 1 0 
19 
c) Preventive care 1 0 
34 · Niger Follow-up Evaluation of QA Activities
d) Rehabilitation 1 0 
e) Nutritional counseling 1 0 
f) Infant counseling 1 0 
g) Family planning 1 0 
h) QA work 1 0 
i) Other (Please specify): 1 0 
Have you received feedback from the last supervision visit? If so, in what form? 1 0 
a) Written report 1 0 
b) Verbal report 1 0 
20 
c) Other (Please specify) 1 0 
What has your supervisor done to help you maintain your skills? 
a) Nothing 1 0 
b) Just-in-time training as the need arises 1 0 
c) Workshops/seminars 1 0 
d) Forwarding documented information 1 0 
21 
e) Other (Please specify) 1 0 
22 Do you have a supervision logbook? (If so, review) 1 0 
Utilization of Data 
23 Are you required to submit reports for the Health Information Management 
System? If not, proceed to Question 33. 
1 0 
24 Did you report for the last quarter of 2000? (Review if available) 1 0 
25 Do you use the information in these reports to help you in your work? 1 0 
If so, how do you use it (Choose a response): 
a) Order medications/ supplies 1 0 
b) Setting priorities 1 0 
c) Planning 1 0 
d) Disease surveillance 1 0 
e) Community awareness 1 0 
f) Staff awareness 1 0 
g) Research for seeking financial assistance 1 0 
26 
h) Other (Please specify) 1 0 
27 If not, why? 
28 Give two examples of decisions you took in the final quarter of 2000 that were 
based on data 
29 Have you received feedback from the Health Management Information System that 
you have discussed with your supervisor? If not, please proceed to Question 33. 
If so, what feedback did you get from your supervisor? 
a) Discussion 1 0 
b) Written report 1 0 
30 
c) Other (Specify) 1 0 
31 In what setting was this feedback provided? 
 Niger Follow-up Evaluation of QA Activities · 35
a) Supervision 1 0 
b) Quarterly meeting 1 0 
c) Supervision visit 1 0 
d) Other (Please specify) 1 0 
Did you make a graphical presentation of your data? (Review) If so, were they: 1 0 
a) Up-to-date? 1 0 
b) Correct? 1 0 
32 
c) Posters? 1 0 
33 If not, why? 
34 Did you make recommendations to the district based on your specific analyses of 
your data? 
1 0 
35 If so, please provide examples. 
36 If not, why? 
37 Do you have a monitoring system? 1 0 
If so, who calculates and analyzes the data at the health center level? 
a) Health center manager? 1 0 
b) All healthcare providers? 1 0 
c) Both of the above? 1 0 
d) A monitoring team? 1 0 
38 
e) Others? 1 0 
39 Do you have a forum for discussing improvement indicators with the healthcare 
providers at your health center? 1 0 
40 Do you have a way to share your improvement indicators with the district level?? 1 0 
41 If so, what is it? 
42 Do you receive the Santé Info bulletin from the Health Management Information 
System? 
1 0 
43 Do you receive the monthly Health Management Information System bulletin? 1 0 
44. What in your opinion are the positive aspects of the following systems? 
a) Monitoring? 
b) Supervision? 
45. Based on your experiences, what are the weaknesses of the following systems? 
a) Monitoring? 
b) Supervision? 
46. What suggestions do you have for making the monitoring system more effective in your health 
center? 
47. What suggestions do you have for making the supervision system more effective? 
36 · Niger Follow-up Evaluation of QA Activities
A5. Rapid Assessment of Health Worker Performance—Health 
Worker Observation 
OBSERVATION OF HEALTH PERSONNEL FOR CASE MANAGEMENT OF A SICK CHILD 
District : _______________________________ Date:___/___/___ 
Investigator’s Number:__________ 
Health Facility Name:_________________________ 
Health Worker: Type: [ ]Senior Nurse [ ]Regular Nurse [ ]Midwife [ ]Junior Nurse 
Child: Age in months:___________ (documented, if possible) Child’s Number:_____ 
Gender: ___ 1=Male; 2=Female Relationship of accompanying person: _______________ 
Note the beginning time of survey: Hour_______ Min________
WELCOME
- Were greetings exchanged between the health worker and the mother/accompanying person? 
Yes No 
- Did the health worker invite the mother to have a seat? Yes No 
The welcome was proper (proper if both responses are "Yes") Yes No 
1. What reasons did the mother give for the consultation? (Check all relevant answers) 
______Fever ______Cough/Difficulty in breathing 
______Diarrhea ______Ear Ache 
______Other (Specify)__________________ 
Is the following information on the child available to the health personnel at the time of the 
consultation? (Ascertained by him/her or by someone else before the consultation and entered into the 
child’s record) 
2. Health or care card Yes No 
3. Age, given by mother Yes No 
4. Weight Yes No 
If yes, did health provider verify nutritional status by using the Weight/Age Indicator? 
 Yes No 
5. Temperature: By thermometer Yes No 
By touching the child Yes No 
GENERAL EVALUATION 
Did the health worker look for danger signs: Looked Found
6. Child unable to drink or breastfeed Yes No Yes No 
7. Child vomits all that is ingested Yes No Yes No 
8. Child had convulsions/coma Yes No Yes No 
9. Child is drowsy/difficult to rouse Yes No Yes No 
The health worker looked for at least 2 signs of danger Yes No 
The health worker looked for all 4 signs of danger Yes No 
 Niger Follow-up Evaluation of QA Activities · 37
10. Did the health worker inquire about all the main symptoms (diarrhea, cough/difficulty breathing, 
fever, ear ache)? Yes No 
Complaint of diarrhea Yes No 
If no, go to complaint of cough/difficulty breathing 
Did the health worker ask about: 
11. The onset/duration of sickness? Yes No 
12. The presence of blood in the stools? Yes No 
Did the health worker look for the following signs of dehydration: 
13. Lethargy/unconsciousness/irritability? Yes No 
14. Thirst? Yes No 
15. Tenting of the skin? Yes No 
16. Sunken eyes/tears/dry tongue? Yes No 
Was the child correctly examined for diarrhea Yes No 
(correct if the three key signs (13-14-15) were inquired about) 
Complaint of cough/difficulty breathing Yes No 
If no, go to complaint of fever 
Did the health worker ask about: 
17. The onset/duration of sickness? Yes No 
Did the health worker look for: 
18. Frequency of breathing? Yes No 
19. Chest indrawing? Yes No 
20. Stridor/wheezing? Yes No 
Child was correctly examined for cough Yes No
(correct if the three responses (18-19-20) are "Yes") 
Complaint of fever Yes No
If no, go to complaint of ear ache 
Did the health worker ask about: 
21. The onset/duration of sickness? Yes No 
22. Previous history of measles? Yes No 
Did the health worker look for: 
23. Stiff neck/floppy neck in infants? Yes No 
24. Signs of measles: generalized skin eruptions, cough, nasal discharge, conjunctivitis? 
Yes No 
25. Throat infection/oral ulcerations ? Yes No 
The child was correctly examined for fever Yes No
(Correct if answers 23 and 24 are "YES") 
38 · Niger Follow-up Evaluation of QA Activities
Complaint of ear ache Yes No 
If no, go to question 29 
Did the health worker ask about: 
26. The onset/duration of sickness? Yes No 
Did the health worker look for: 
27. Infection of the auditory ducts? Yes No 
28. Tumefaction behind the ear? Yes No 
The child was correctly examined for ear ache Yes No
(Correct if 2 responses (27-28) are correct 
REFERRAL:
 29. Did the health worker find one or more signs of danger? Yes No 
 30. If yes, was the child referred to another level of care? Yes No 
 If not, why not? _________________________________________________________________ 
VACCINATION STATUS:
Did the health worker:
31. Ask whether the mother has the child’s health/care card with her? Yes No
32. Determine the vaccination status of the child? (Either by asking or by 
looking at the health card) If no, go to question 35 Yes No 
33. Establish that the child requires vaccination? Yes No 
34. Refer the child for vaccination? Yes No 
35. Determine the vaccination status of the mother/accompanying person? 
(Either by asking or by looking at the health card) If no, go to question 38 Yes No NA 
36. Establish that the mother/accompanying person needs vaccination? Yes No NA 
37. Refer the mother/accompanying person for vaccination? Yes No 
Correct determination of the vaccination status of mother/child Yes No NA 
(Correct if 32 and 35 = "Yes") 
38. If the mother is not in possession of the health card, did the health worker: 
- Criticize the mother? Yes No 
- Ask the mother to return with the health card/vaccination card? Yes No 
- Make an appointment? Yes No 
- Say nothing? Yes No
DIAGNOSIS
39. Did the health worker make a diagnosis? Yes No 
If «Yes», which? : 
40. Simple diarrhea Yes No 
41. Diarrhea with dehydration Yes No 
If yes, is it: ___1.moderate (Level B) __2. serious (Level C) __3. not specified 
 Niger Follow-up Evaluation of QA Activities · 39
42. Dysentery/bloody diarrhea Yes No 
43. Cough/cold Yes No 
44. Pneumonia Yes No 
If yes, is it: ___simple ___severe _____unspecified 
45. Ear ache (otitis) Yes No 
 If yes, is it ____average _______acute _____chronic 
46. Malaria Yes No 
If yes, is it ___simple ___ severe ___ unspecified 
47. Fever of other, unidentified origin Yes No 
48. Measles Yes No 
 If yes, is it ___simple ___with complications ___unspecified 
49. Malnutrition Yes No 
If yes, is it ___simple ____ severe ____ unspecified 
50. Other diagnosis Yes No 
If yes, specify:_______________________________________ 
TREATMENT
What did the health personnel administer or prescribe for the child? 
(Check all pertinent answers) Treatment Received Prescription
51. Quinine injection ____ ____ 
52. Chloroquine tablets/syrup ____ ____ 
53. Aspirin/Paracetamol ____ ____ 
54. Bathe child/lukewarm compresses ____ ____ 
55. Antibiotic injection ____ ____ 
Specify__________________ 
56. Antibiotic tablets/syrup ____ ____ 
Specify _________________ 
57. Vitamin A or other vitamins ____ ____ 
58. Iron/ Folic Acid ____ ____ 
59. Oral Rehydration Solution (ORS)/ 
Sugar & Salt Solution (SSS) ____ ____ 
60. Infusion (Ringers’ lactate solution, normal saline solution)____ ____ 
61. 5% glucose (dextrose) solution ____ ____ 
62. Metronidazole tablets/syrup ____ ____ 
63. Dietary advice/referral to CRENA 
(Ambulatory nutritional rehabilitation centers) Yes No 
64. Other (specify ____________________) ____ ____ 
40 · Niger Follow-up Evaluation of QA Activities
Complete at end of observation period 
65. List the different diagnoses made by the health worker (see above)________________________ 
_________________________________________________________________________________ 
Case of simple diarrhea treated with ORS/SSS without antibiotics? N/A Yes No 
Case of dysentery treated with an appropriate antibiotic? N/A Yes No
(Appropriate antibiotics = Ampicillin or Co-trimoxazole) 
Case of simple malaria treated with an appropriate medication? N/A Yes No 
(Appropriate = Chloroquine) 
Case of severe malaria treated with an appropriate medication? N/A Yes No 
(Appropriate = Quinine) 
Case of cough/cold treated without antibiotic N/A Yes No 
Case of simple pneumonia treated with an appropriate medication? N/A Yes No 
(Appropriate = Co-trimoxazole) 
Case of severe pneumonia treated with an appropriate medication? N/A Yes No 
(Appropriate = injectable antibiotic/referral) 
Case of acute Otitis media treated with an appropriate antibiotic? N/A Yes No 
(Appropriate = Penicillin G or Peniprocaine or injectable Ampicillin or syrup or Co-trimoxazole or 
Amoxicillin) 
Case of chronic otitis media treated without antibiotic? N/A Yes No 
Case of malnutrition received appropriate advice? N/A Yes No
TREATMENT IS APPROPRIATE FOR THE DIAGNOSIS? Yes No 
INTERPERSONAL COMMUNICATION 
Did the health worker: 
66. Explain how to administer the oral medications (tablets, syrup)? Yes No NA 
67. Demonstrate how to administer the oral medications (tablets, syrup)? Yes No NA 
68. Ascertain that the mother understands? Yes No NA 
Counseling for the treatment is correct? (if 66-68 = "Yes") Yes No NA
69. Encourage continuation of feeding/breast/bottle feeding? Yes No NA 
70. Encourage an increase in liquids? Yes No NA 
71. Explain to the mother when to return for follow-up for the child? Yes No NA 
72. Tell the mother to bring back the child for the following symptoms? Yes No NA 
a) The child does not drink or drinks very little Yes No NA 
b) The child refuses to eat or to suck milk Yes No NA 
c) The child's condition worsens Yes No NA 
d) The child has a high/persistent fever Yes No NA 
e) The child breathes very rapidly or with difficulty Yes No NA 
f) The child has bloody stools Yes No NA 
At least 2 danger signs checked "Yes" Yes No
 Niger Follow-up Evaluation of QA Activities · 41
73. Did the health worker ask an open-ended question to verify that the mother fully understands when to 
come back with the child? Yes No NA 
Were ORS/SSS given or prescribed to the child? Yes No 
If no, go to question 77 
If yes, did the health worker: 
74. Explain how to prepare the ORS/SSS? Yes No 
75. Explain to the mother how to administer the ORS/SSS? Yes No 
76. Establish that mother understands preparation, administration of ORS/SSS? Yes No 
Did the health worker: 
77. Ask the mother open-ended questions to see whether she fully understands? Yes No NA 
78. Correct any errors/congratulate the mother? Yes No NA 
79. Ask the mother whether she has any questions? Yes No NA 
The health worker uses effective interpersonal communication Yes No NA
Correct if all three responses (77, 78, 79) are “yes” 
NOTE THE TIME WHEN THE MOTHER LEAVES 
TIME WHEN THE INTERVIEW ENDS: Hour_________ Minutes________ 
LENGTH OF THE INTERVIEW: __________ minutes 
 END OF THE OBSERVATION OF HEALTH WORKER 
At the end of the consultation for the child, if the health worker did not verbally give the diagnosis 
for the child, interviewer should ask him/her and complete this form. 
42 · Niger Follow-up Evaluation of QA Activities
A6. Rapid Assessment of Health Worker Performance—Interview with 
the Mother Following IMCI Consultation 
INTERVIEW WITH THE MOTHER AT THE END OF THE IMCI CONSULTATION 
District : _______________________________ Date:___/___/___ 
Investigator’s Number:__________ 
Health Facility Name:______________________________ 
Health Worker: Type: [ ]Senior Nurse [ ]Regular Nurse [ ]Midwife [ ]Junior Nurse 
Child: Age in months:________ (documented if possible) Child’s number: ___________ 
Sex : ____ (1 = Male ; 2 = Female) Status of the accompanying person ___________________ 
Mother: Age (in years) ____________ 
Greet the mother or accompanying person and tell her/him that you would like to ask a few questions 
today’s visit to the health facility. 
Indicate the hour when interview begins: Hour_____ Min_____ 
If the accompanying person is not the mother, go to question 3 
SOCIOECONOMIC INFORMATION 
1. What is your marital status? ______Married ______Divorced _____Single ______Widowed 
2. Have you attended school? ____ French School ____Literacy school ___Koranic ____None 
 If French school, for how many years? _______Year(s) 
AVAILABILITY AND ACCESSIBILITY 
3. Which village or district do you come from?_________________(write the name in capital letters) 
4. What means of transportation did you use to come here today? 
______Walking _____Cart _____Vehicle/motorbike 
______Private car _____Other (specify): _______________ 
5. If you did not walk, how much did transportation cost you? _______francs CFA 
6. How much did you pay for healthcare? _______francs CFA 
7. Besides travel and care expenses, did you spend money for food or drink during your visit to the health 
center? Yes No 
 If yes, approximately how much ? ________francs CFA 
8a. Did you have problems getting here today? Yes No 
If yes, what was the main problem? (Check only one response) 
______It takes too much time to get here 
______Had to find someone to take care of the children at home 
______Had to miss work 
______No money 
______The health facility hours are not convenient 
______Other (specify)__________________ 
8b. At what time of day do you think that care is available at this center? 
______Morning ______Afternoon _____Any time 
MOTHER’S BEHAVIOR IN RESPONSE TO CHILD’S ILLNESS 
9. How long has your child been ill? 
______Today _____Number of days _______Do not know 
 Niger Follow-up Evaluation of QA Activities · 43
10. Did you take your child for care elsewhere before bringing him/her to this health facility? 
 Yes No 
 If yes, where did you bring him/her? (Check all applicable responses) 
_____Other Health Center _____Hospital _____Private Clinic/office _____Traditional Healer 
_____Pharmacist/Drug vendor ____Community Health Worker ___Other (Specify_____________ 
 If the child was taken elsewhere, how much did you pay for care? _____francs CFA 
11. When the child is sick, who makes the decision to bring the child to the health center? 
_____Herself _____Husband _____Other (specify)__________________ 
12. CHILD HAS DIARRHEA? Yes No 
If no, go to question 15 
If yes: 
13. Did you do something to treat the diarrhea at home? Yes No 
If yes, what did you do (Check all applicable responses) 
______Gave ORS 
______Gve SSS 
______Gave herb tea/ traditional medicine 
______Gave other treatment (specify)______________ 
14a. Had you ever heard of ORS/SSS for diarrhea? Yes No 
If no, go to question 15 
If yes: Why does one give ORS/SSS to children with diarrhea? (check all applicable responses)
_____To prevent dehydration (replace lost water/keep child from getting tired) 
_____To stop diarrhea _____Other (specify)___________ _____Does not know 
14b. Had you already been shown how to prepare ORS? Yes No 
If no, go to question 15 
14c. How do you prepare ORS? 
________Correct (mix one liter of water with a packet of rehydration salts) 
________Incorrect ________Does not know 
14d. How do you prepare SSS ? 
________Correct (mix one liter of water with 8 cubes of sugar and 2 pinches of salt using 3 fingers) 
________Incorrect ________ Does not know 
15 CHILD HAS FEVER? Yes No 
If no, go to question 17 
If yes: 
16. Did you do something to treat the fever at home? Yes No 
If yes, what did you do? (Check all applicable responses)
____Gave aspirin/paracetamol 
____Gave chloroquine/other anti-malarial 
____Gave antibiotics/capsules bought in the market 
____Bathed child/wrapped child in moist cloth 
____Removed child’s clothes 
____Gave herbal tea/traditional medicine 
____Gave other treatment (specify)____________ 
44 · Niger Follow-up Evaluation of QA Activities
17. CHILD HAS COUGH OR DIFFICULTY BREATHING? Yes No 
If no, go to question 19 
If yes : 
18. Have you done something to treat the child at home? Yes No 
If yes: What did you do? (Check all applicable responses)
_____Gave paracetamol/aspirin _____Gave antibiotics/capsules 
_____Gave an herbal tea/traditional medicine _____Gave a rub-down 
_____Gave cough syrup _____Gave other treatment (specify)_____________ 
19. CHILD HAS EAR ACHE? Yes No 
If no, go to question 21 
If yes : 
20. Have you done something to treat the child at home? Yes No 
_____Gave paracetamol/aspirin _____Gave antibiotics/capsules 
_____Put a product in the ear _____Dried the ear with a clean cloth/cotton 
_____Other (specify)___________________ 
KNOWLEDGE ABOUT CASE MANAGEMENT AT HOME 
21a. Did the health worker _____give or ____ prescribe medication today? 
If medications were given to the mother, fill in the table below. If not, go to question 21b. 
For each ORAL medication mentioned by the mother, fill in the table below by asking the following 
questions (compare mother’s responses with the health worker’s prescription): 
WHAT QUANTITY of tablets/capsules/spoonfuls will you give to the child for each dose? 
HOW MANY TIMES EACH DAY will you give this dose to the child? 
FOR HOW MANY DAYS will you give this treatment to the child? 
List the medications given to the mother________________________________________ 
Medication Dosage (Quantity of 
tablets/capsules/spoonfuls) 
Number of times/day Number of days
Chloroquine 
tablet/syrup 
Yes No N/A Yes No N/A Yes No N/A 
Antibiotic 
tablet/syrup 
Yes No N/A Yes No N/A Yes No N/A 
Paracetamol 
tablet/syrup 
Yes No N/A Yes No N/A Yes No N/A 
Aspirin tablet/syrup Yes No N/A Yes No N/A Yes No N/A 
ORS/SSS Yes No N/A Yes No N/A Yes No N/A 
Did the mother or accompanying person know how to administer correctly all the medications 
provided? Yes No 
21b. If medications were prescribed, did the health worker ask the woman to return for explanations? 
 Yes No 
 Niger Follow-up Evaluation of QA Activities · 45
22. Check below the complaint given by the mother (refer to questions 12/15/17/19): 
The child has: ____Diarrhea ____Fever/malaria ____Cough/difficulty breathing ____Ear ache 
22a. What will you do for the child after you return home? (Check all applicable responses) 
In general:
___Continue to feed the child ____Complete the full treatment 
___Don’t know ____Nothing 
___Continue to give milk to the child ____Bring the child back if his/her condition worsens 
___Give more liquids ____Return for the appointment given by the health worker 
Specifically: 
Diarrhea 
___Give ORS/SSS ____Give drink after each stool/vomiting ___Nothing ___NA 
Acute Respiratory Infection
___Give antibiotics ____Give a cough remedy ___Nothing ____NA 
Fever/malaria 
____Give an anti-malarial ____Give aspirin/paracetamol _____Tepid bath ___Nothing ___NA 
Ear Ache
____Give antibiotics ____Give aspirin/paracetamol ____Dry the ear with a clean cloth/cotton 
____Nothing ____NA 
Does the mother/accompanying person know at least 2 practices for home-based case 
management? Yes No 
22b. How will you know that the child’s condition has worsened? (Check all applicable responses) 
_____Fever appears or does not go away _____Vomiting begins or persists 
_____Child is unable to eat _____Child is unable to drink 
_____Diarrhea persists _____Child experiences convulsions 
_____Child’s chest caves in with each breath _____Other (Specify)________ 
 The mother knows at least 2 signs of severity to look for at home? Yes No
KNOWLEDGE ABOUT VACCINATIONS: 
23. Do you have the child’s health card/vaccination card with you? Yes No 
If the mother has the card, look at the dates of ALL VACCINATIONS ADMINISTERED from birth until 
today, and complete the table below. If not, go to 24b. 
Date of birth:___/___/___/ and Age/______months 
CHILDHOOD VACCINATIONS 
(Dates) 
RECEIVED
BCG/ Polio-O(at birth) Yes No 
DPT-1 Yes No 
DPT-2 Yes No 
DPT-3 Yes No 
Measles Yes No 
Does the child require vaccination? Yes No 
Did the child receive a vaccination today? Yes No
46 · Niger Follow-up Evaluation of QA Activities
24a. When will you return with the child to the health facility for the next vaccination? 
_____Knows _________Does not know _________NA 
24b. Do you have your vaccination card with you? Yes No 
If not, go to question 30 
25. If yes, copy down, in the table below, the tetanus vaccinations received by the mother. 
MOTHER’S VACCINATIONS RECEIVED
Anti-tetanus-1 Yes No 
Anti-tetanus-2 Yes No 
Anti-tetanus-3 Yes No 
Anti-tetanus-4 Yes No 
Anti-tetanus-5 Yes No 
Does the mother require vaccination? Yes No 
Did the mother receive a vaccination today? Yes No 
MOTHER’S SUGGESTIONS TO IMPROVE THE HEALTH SYSTEM: 
30. Is there anything that could improve the provision of health services that you received this morning? 
 Yes No 
31. If yes, do have any suggestions? (Note the suggestions given by the mother or accompanying person) 
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________ 
END OF THE INTERVIEW 
Indicate the hour of the end of the interview: Hour:_____ Minutes:_____ 
Duration of the interview:_________ 
Thank the woman for having answered your questions and ask her if she has any questions to ask of you. 
Check that she knows: 
 - how to prepare ORS/SSS for a child with diarrhea; 
 - when to return for the next vaccination; 
 - how to administer the prescribed medications; 
 - when to return if the child’s condition worsens; 
And if appropriate, correct the mother’s knowledge gaps or errors. 
 Niger Follow-up Evaluation of QA Activities · 47
QUALITY ASSURANCE PROJECT
University Research Co., LLC
7200 Wisconsin Avenue, Suite 600
Bethesda, MD 20814
Tel: (301) 654-8338
Fax: (301) 941-8427
www.qaproject.org