Improving Health Care in Low- and Middle-Income Countries, 1st ed. 2020 A Case Book

By James Heiby, USAID

Overall introduction to the book that explains the purpose of the book, a short explanation of what the improvement process is about, and briefly discusses what the book is not covering.

Case 1: Improving Quality of Care for Respiratory Tract Infections in Children: The Role of Capacity Building and Coaching in Supporting a Multi-Facility Improvement Team in Samtredia District, Georgia

By Tamar Chitashvili and Ekaterine Cherkezishvili, University Research Co., LLC

This case study describes the experience of a multi-facility quality improvement team in Imereti’s Samtredia District in Georgia that addressed the quality of care for respiratory tract infections among children. The case study details the design and implementation of the improvement effort, and provides details about the capacity building and coaching support provided to the team that helped lead to improved health outcomes.

Case 2: Integrating Gender to Improve Outcomes in an elimination of mother-to-child transmission of HIV Program at Ivukula Health Center III in Eastern Uganda

By Taroub Faramand, WI-HER, LLC

In partnership with Uganda's Ministry of Health, United States Agency for International Development (USAID)-funded projects joined expertise in quality improvement and nutrition to put into practice an initiative that addressed all aspects of ensuring healthy HIV-free infants. This case study focuses on how a successful pilot team in eastern Uganda used quality improvement tools to identify clinic inefficiencies and put into action a plan to eliminate mother-to-child transmission of HIV and improve nutrition assessment, care and support services. 

Case 3: Improving HIV counseling and testing in tuberculosis service delivery in Ukraine: it all starts with one good team

By Nilufar Rakhmanova, FHI 360

Because TB and HIV programs in Ukraine functioned separately as vertical programs—focusing on specific health conditions—they often missed a window of opportunity for diagnosing HIV at an earlier phase of infection. This case study describes how a successful pilot team in Chervonograd, Ukraine used quality improvement methods to raise the rates of HIV counseling and testing offered to clients tested for TB and how the team scaled up its successes to other sites.

Case 4: Strengthening accessibility of services to most vulnerable children through quality improvement approaches in community settings: Case of Bagamoyo district, Tanzania

By Flora Nyagawa, University Research Co., LLC

This case study describes a quality improvement approach to ensure implementation of the National Quality Improvement Guidelines for Most Vulnerable Children in Bagamoyo District, Tanzania. The case study largely focuses on the steps needed to organize improvement efforts; including how project participants formed teams, carried out introductory visits, initiated district and ward efforts, conducted baseline assessments, and built capacity. 

Case 5: Addressing behavior change with quality improvement methods in Guatemala

By Elena Hurtado, University Research Co., LLC

In Guatemala, quality improvement and collaborative learning methods were applied to two social and behavior change (SBCC) interventions to strengthen families' health and nutrition-related knowledge and behaviors. This case details the organization of the quality improvement effort and team formation, the role of coaches, and explores challenges to making the improvements a permanent part of health services.

Case 6: Scaling up a quality improvement initiative: Lessons from Chamba District, India

By Nigel Livesley, University Research Co., LLC

The Government of India, concerned with poor antenatal care outcomes in Chamba district, enlisted the help of a USAID-funded project with decades of experience in quality improvement. Healthcare practitioners and district officials were initially skeptical about the efficacy of quality improvement methods and reluctant to receive external technical assistance; however, the success of the program eventually won over key stakeholders. This case explores the role of leadership and early successes in creating buy-in for a quality improvement intervention, and the role the support of key stakeholders played in the scale-up of the effort.

Case 7: Promoting rational use of antibiotics in the Kyrgyz Republic

By Barton Smith, Edmonds Family Medicine, formerly with Abt Associates

In the Kyrgyz Republic, quality improvement methods were used to promote rational antibiotic use among prescribers. This case highlights the important role data collection, access, and analysis played in identifying and reducing incorrect prescription of antibiotics.

Case 8: Improving access to essential medicines through active engagement of district leadership in Kaborole District, Uganda

By Herbert Kisamba, University Research Co., LLC

With the expansion of health coverage in Uganda, the government began to shift its priorities to emphasize quality of health care and patient safety. In Kaborole District, the government decided to target timely ordering of medicines and tuberculosis treatment for district-level quality improvement work because these were two of the worst areas of performance within the health system. The intervention provided an opportunity to the senior-level staff of the district health system to appreciate modern quality improvement methods and apply them.

Case 9: Strengthening systems to improve nutrition care, support, and treatment in Malawi: Results from Balaka and Karonga districts

By Linley Hauya, University Research Co., LLC

Malawi was one of the first countries to integrate nutrition assessment, counseling, and support into its HIV and TB care framework and the government intended the provision of ready-to-use therapeutic food (RUTF) to be a cornerstone of care. However, incomplete national-level data on the number of people requiring RUTF frequently led to supply-shortages. Because RUTF was frequently unavailable, many health facilities did not bother recording the number of patients requiring it. This case discusses how district quality improvement teams were able to address this vicious cycle to improve patient care.

Case 10: Bridging the gap between emergency response and health systems strengthening: Designing quality improvement during the Zika outbreak

By Eric Baranick, University Research Co., LLC

In mid-2015, the Zika virus arrived in Brazil; within a year, the virus had travelled to 21 other countries in the Americas. As the magnitude of the epidemic unfolded, new and troubling evidence emerged about an uptick in birth defects in Zika-affected regions and their potential link to this virus, causing the WHO to declare Zika a public health emergency of international concern. This case explores the actions required to build a foundation for and implement quality improvement in a crisis setting.

Case 11: Use of an electronic medical record to drive national improvement, Haiti

By Joshua Bardfield, HEALTHQUAL International

In Haiti, an electronic medical record system drives national and local quality improvement efforts as part of a national quality management program supported by the U.S. President’s Emergency Plan for AIDS Relief. This case study describes how quality improvement teams transitioned from a paper-based to an electronic medical record system and how the government used analysis of the electronic data to set improvement priorities.

Case 12: Improving maternal and neonatal health in Mozambique

By Edgar Necochea, Jhpiego

Although more than half of deliveries in Mozambique occur at health facilities, high maternal mortality rates have persisted as a public health issue. To address concerns about the quality of health facility care, the Mozambique Ministry of Health launched the Model Maternities Initiative from 2009-2014, which represented about half of all maternities in the country, covering approximately one-third of all institutional deliveries. As part of this initiative, quality improvement teams used a standardized assessment tool to identify performance gaps and put in place rapid interventions—such as basic infection prevention practices and minor infrastructure repairs—to produce swift results. This case study demonstrates how it is possible to systematically improve the delivery of health services at the facility level, across an entire country, with very limited external assistance – despite the challenges faced, which are common to many low-income settings.

Case 13: The business case of quality in health care: A sustainable financing and technical assistance approach to quality improvement in Kenya

By Nicole Spieker, PharmAccess

Introducing international standards, stepwise certifications, and a transparent rating and improvement program to healthcare providers in Kenya has proven to be a successful approach towards sustainable quality assurance. This case study explores the introduction of medical and business quality standards at a single health facility and outlines the activities that were required to adhere to the new standards.

Case 14: Improving quality of voluntary medical male circumcision: A case study of Uganda

By John Byabagambi, University Research Co., LLC

Voluntary medical male circumcision (VMMC) has the potential to significantly reduce HIV transmission; however, as with any medical procedure, there is a need to assess the quality of VMMC service provision to ensure that procedures are safe and follow established norms and protocols. This case describes the experience of adapting VMMC assessment tools from high-income counties to the Ugandan context in a large number of health care facilities throughout the country and using these customized tools to address gaps in VMMC service delivery.

By James Heiby, USAID

A concluding chapter summarizes what these cases tell us overall about healthcare improvement in low- and middle-income countries, and specifically about different topics, including: getting improvement teams started, how teams test changes, support for improvement teams, learning from improvement, and scaling up improvement. In addition, this chapter addresses the question: “What’s next in QI?”, highlighting what we do not know and what we want to learn how to do better.

The chapter is authored by editor James Heiby and could be presented in the format of a narrative or an interview with other experts in quality improvement.