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USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project
URC is the lead implementer for the USAID Applying Science to Strengthen and Improve Systems (ASSIST) cooperative agreement of the Office of Health Systems in USAID’s Global Health Bureau.
In September 2017, URC was awarded a two-year extension to the USAID ASSIST Project. Under the terms of the extension, the USAID ASSIST Project will operate until September 29, 2019, complete all previously core- and Mission-funded activities, and focus on strengthening maternal, newborn, and child health (MNCH) and family planning/reproductive health services in Zika-affected countries in Latin America and the Caribbean.
ASSIST’s mission is to improve healthcare, strengthen health systems, and advance the frontier of improvement science in USAID-assisted countries. To achieve these aims, URC and its partners are:
- Fostering improvements in a range of healthcare processes through the application of modern improvement methods by host-country providers and managers
- Building the capacity of host-country systems to improve the effectiveness, efficiency, client-centeredness, safety, accessibility, and equity of the healthcare services provided
- Generating new knowledge to increase the effectiveness and efficiency of applying improvement methods in low- and middle-income countries
During the extension period, ASSIST is applying quality improvement methods to health systems strengthening efforts in Zika-affected countries, including the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Nicaragua, Paraguay, and Peru. Additionally in 2018, ASSIST is wrapping up country-level assistance in Cambodia, Indonesia, Kenya, Lesotho, Tanzania, and Uganda.
USAID and the U.S. Centers for Disease Control and Prevention (CDC) in Botswana invited URC to conduct a rapid analysis of existing quality improvement initiatives being implemented by the Ministry of Health (MOH). Botswana has invested heavily in the health care sector, developing multiple improvement frameworks under various names. However, the country is still not seeing improvements in key health indicators. For example, the most recent 2011 national maternal mortality rate (MMR) statistics indicate that the national MMR increased from 163 per 100,000 live births to 189 in 2011, roughly equal to the 2009 MMR. The top three causes of maternal death were eclampsia (12 cases unspecified as to time period), post-partum hemorrhage (11 cases), and post-abortion complications.
During interviews and visits with key MOH staff and site visits to Princess Marina Hospital and Nkoyaphiri Clinic in August 2012 (under USAID funding provided to the Health Care Improvement Project, or HCI, ASSIST’s predecessor project), the URC team found a gap between planning and implementation. Despite issues with execution, the building blocks for success were/are present: The team found that Botswana has a competent and committed health workforce with a strong desire to identify and fix problems and that workforce members are forthcoming about problems and weaknesses in a constructive way, looking for ways to improve.
- Recommend modalities for integration and enhancement of existing initiatives in order to yield tangible results that are in line with the Ministry strategy.
- Outline ways to empower and enhance the participation of senior management in quality improvement activities.
- Support the Ministry of Health in pursuing its national level goal of reducing maternal mortality from 160 to 80 per 1000 live births (Millennium Development Goal 5), setting a clear implementation schedule with explicit delegation of responsibilities and aligning activities at all levels to meet the national level goal.
- Use this experience to instill a strong culture focused on execution and build the capabilities to execute other improvements.
In 2012, PEPFAR requested technical assistance from the USAID Health Care Improvement Project (HCI) to ensure that HIV services, including those related to the prevention of mother-to-child-transmission (PMTCT), offered in Burundi respond to quality standards. Building on an initial assessment conducted by HCI, ASSIST partners URC and FHI 360 are supporting the Burundi government to improve the PMTCT clinical practices, address performance factors in the health workforce, and help the country improve its documentation and management of information.
Refining clinical protocols to match the international best practices in PMTCT care is expected to increase the number of pregnant women enrolled in PMTCT therapy, raise the level of adherence to treatment, and expand access beyond the women alone to reach also their husbands and children. But clinical protocols alone will not sustain quality care and expanded access.
To support Burundi in the strengthening of its health system in delivering HIV and primary care services throughout the country, the project will address systems challenges and human resources performance as key elements to maintaining quality of care. Clear job expectations, performance feedback, work environment, incentives, and appropriate competencies are factors critical to the success of any clinical improvement effort; and a strengthened workforce is a cornerstone to sustainable health systems.
- Provide technical assistance at the national, provincial and district levels to service providers and managers to implement improvement activities relating to PMTCT service integration with existing maternal, newborn and child health and HIV services.
- Apply collaborative improvement methods improve uptake of PMTCT services (by mothers, infants, and partners), retention of mothers and infants along the PMTCT cascade (services that flow from prenatal care to postnatal care for the mother-baby pair,) and quality of PMTCT services
- Support the MOH to address human performance factors to enhance providers’ productivity, motivation, and compliance with standards
- Initial efforts will focus on 70 sites in all 14 districts of the four target provinces of Kayanza, Kirundo, Muyinga and Karuzi. Later, ASSIST will support the Ministry of Health to spread best-practice interventions to four more USAID-supported provinces.
Building on several years of assistance to the National HIV program (PNPEC) under the USAID Health Care Improvement Project (HCI), ASSIST is supporting the Ministry of Health (MOH) to address key challenges in the delivery of antiretroviral therapy (ART) services. Those challenges include adherence to and retention in treatment, linkages and referral to community care services to reduce loss to follow-up, increasing survival rates, and preventing new infections.
ASSIST is also building the capacity of facility providers and implementing partners to address key challenges related to the prevention of mother-to-child transmission of HIV (PMTCT), including retention in treatment and the adherence to treatment of the mother-infant pair; linkages and referral to treatment and care services, including food and nutrition support; male involvement and couples counseling and testing services to increase PMTCT uptake; and integration of PMTCT with routine maternal-child health/ reproductive health services, adult and pediatric treatment services, and broader prevention programs.
ASSIST is also strengthening the leadership, management, and planning capacity of the MOH’s new Quality Improvement Unit.
- Support ART and PMTCT improvement activities in 80 sites in Abidjan, San Pedro, Daloa, and Bouaké
- Support the US Centers for Disease Control (CDC) and World Health Organization (WHO) laboratory accreditation program
- Assist the MOHH to develop national standards to improve the national health information system and strengthen monitoring and evaluation activities
- Strengthen the health system—through support for continuous improvement at the district and regional levels of the health system—to establish and maintain continuous improvement activities as an integral, sustainable part of the health system routine activities
- Identify the costs of poor quality in the HIV care program due to loss to follow-up to understand the budget impact of quality improvement interventions and their cost-effectiveness and to inform MOHH policies on HIV treatment
Democratic Republic of the Congo
URC is supporting the Ministry of Health in the implementation of nutritional assessment counseling and support (NACS) interventions.
URC is working with the Ministry of Labour, Health and Social Affairs (MoLHSA) and other stakeholders to address quality, consistency, and continuity of medical care; to improve access and use of evidence-based medical information by physicians; and to enhance the availability of modern evidence-based treatments.
In Imereti Region, URC is supporting referral and primary care facilities to improve the quality of cardiovascular disease, asthma, pneumonia, and chronic obstructive lung disease prevention and treatment. We are also supporting private providers and insurance schemes to adopt evidence-based clinical protocols.
USAID/India has invited the USAID ASSIST Project to help enhance the improvement capability in the Indian health system by engaging national and state structures to conduct improvements in maternal, neonatal, and child health along the continuum of care, including through public and private entities. The Government of India National Rural Health Mission would like ASSIST to focus its work at the national and state levels.
- Enhance commitment and capability of leaders at the national level, state and district levels to lead health care improvement.
- Develop the capacity to conduct improvement amongst health care workers at the national, state, district, facility and community levels.
- Work through state and district Government of India counterparts to form improvement teams to undertake projects in a number of facilities.
- Build the capacity of health care workers in both the public and private sectors to improve the effectiveness, patient centeredness, safety, accessibility, and equity of their services.
- Improve care along the R-MNCH+A continuum in priority USAID districts.
URC is working with the University of Indonesia to evaluate the quality of care provided in hospitals accredited by the Joint Commission International with that in hospitals accredited by Indonesia's national accreditation body, KARS. The Hospital Accreditation Process Impact Evaluation (HAPIE) was initiated in 2013 with a baseline assessment conducted under the USAID Health Care Improvement Project. The midline assessment (carried out in 2014) and the endline assessment are being carried out under the USAID ASSIST Project.
URC is supporting the Ministry of Health (MOH) and other USAID implementing partners to improve health service delivery by applying quality improvement techniques. We are working with the Ministry of Labour, Social Security and Welfare to institutionalize high-quality care for orphans and vulnerable children in local and national child protection programs. We are also advising the MOH on rolling out nationally its framework for improving health care through standards of care, pre-service and in-service training, and quality improvement.
Key Activities & Achievements
- Operationalizing Kenya's Quality Model of Health, including developing or revising standards of care, supporting a national quality management program, and ensuing that the health care system listens to its clients in health care.
- Establishing a framework to develop a national accreditation mechanism for the health sector.
- Ensuring the Government has systems in place to address problems in the quality of care and a policy to support the systems.
- Reviewing and developing standards of care for orphans and vulnerable children with the Ministry and facilitate their roll-out to service delivery points nationwide.
- Developing Centers of Excellence in targeted districts to support district- and facility-level quality improvement teams.
- The first National Policy Seminar, convened with ASSIST support in February 2013, brought together international and national experts who shared experiences and best practices on quality improvement policy, infrastructure, and accreditation.
URC is assisting the Ministry of Health and other implementing partners with the national roll-out of the Partnership for HIV-Free Survival (PHFS) Initiative in Lesotho. PHFS is a six-country initiative launched in March 2013 to assist the countries with their national efforts to improve postnatal HIV, maternal, and infant care and nutrition support through effective implementation of the 2010 World Health Organization (WHO) Guidelines on HIV and Infant Feeding. The other countries are Tanzania, Kenya, Uganda, Mozambique, and South Africa.
The Government of Malawi, supported by USAID, has started a process to standardize the provision of services for orphans and vulnerable children (OVC). Implementers have completed the development of draft standards and are now leading the process of piloting these standards, supporting communities to use quality improvement (QI) techniques to implement the standards, and setting up a transparent monitoring and evaluation (M&E) system. This system will provide information on how well children are doing (using the Child Status Index) and how well communities are adhering to the standards.
Building on work initiated by the USAID Health Care Improvement Project (HCI), the USAID ASSIST Project is supporting the Ministry of Gender, Children, and Social Welfare (MOGCSW) to facilitate the review and finalization of the draft OVC standards. ASSIST is supporting the piloting of the standards and helping the Government of Malawi support community-level QI teams. The project is also supporting the National OVC Task Force and implementers in applying quality standards to OVC services and working with the Partnership for HIV-free Survival to improve the quality of nutrition services for people with HIV.
- Support the MOGCSW to develop a quality management program for OVC services at the national level and support the OVC Technical Working Group.
- Pilot and finalize the OVC standards to see if they are feasible and effective in improving outcomes.
- Build the capacity of implementing partners to apply a quality management approach to enhance OVC service delivery.
- Strengthen the capacity of two model districts as QI resources in the country
URC assisted the Ministry of Women and Social Action to communicate service standards for orphans and vulnerable children to implementers and communities. We are working with service providers to improve their adherence to the standards and the wellbeing of children and families served.
URC supported the Government and other partners to develop and implement quality standards for home-based care for persons living with HIV. We are also supporting community-level activities to improve postnatal PMTCT care for HIV-infected mothers and their infants and maximize HIV-free survival of infants. Ensuring care is provided in line with 2010 WHO PMTCT guidelines reduces infant mortality and HIV transmission to exposed infants.
Prevention of unwanted pregnancy through timely access to high-quality family planning services is an important determinant of future maternal mortality and morbidity. Healthy timing and spacing of pregnancies is a highly cost-effective intervention for reducing maternal mortality and morbidity. The postpartum period, just after a woman delivers a baby, is a time when many women and their families want access to effective, affordable methods to prevent or delay a subsequent pregnancy. However, routine integration of modern family planning services into postpartum maternal care remains very limited in many settings.
Building on a World Health Organization-funded maternal health implementation research study, URC is working with the Niger MOH in one urban and one rural district to achieve better health and social outcomes for women of reproductive age and their children and families by promoting healthy timing and spacing of pregnancy with a focus on reducing unmet need for family planning services during the early and extended postpartum period.
- Test approaches to integrate routine postpartum family planning counseling and contraceptive services into postpartum care in referral and peripheral MOH maternities in an urban and a rural setting.
- Improve the quality of postpartum family planning counseling and contraceptive services.
- Improve women’s choice and access to long-acting contraceptive methods.
- Develop an implementation package that can be scaled up to other facilities in Niger.
The Nigerian Federal Ministry of Women Affairs and Social Development (FMWASD) in coordination with PEPFAR Nigeria, has been engaged in improving the quality of services for vulnerable children by developing national vulnerable children service standards. Building on work funded under the USAID Health Care Improvement Project (HCI), the USAID ASSIST Project is supporting institutional strengthening of FMWASD at the federal, state, and local government levels to develop and pilot standards for such services using quality improvement methodologies.
In fiscal year 2012, draft vulnerable children standards were reviewed by various stakeholders, resulting in a final draft. HCI facilitated the “training of coaches” to support piloting in 12 states. ASSIST is supporting the pilot to gather evidence from the application of services standards and to ascertain whether the proposed standards are doable, relevant, effective, and appropriate and whether using the standards makes a difference in the well-being of children.
- Build the capacity of Federal and State Ministry of Women Affairs and Social Development in piloting the draft service standards for vulnerable children in Nigeria.
- Gather evidence on the pilot by using improvement science.
- Integrate the draft standards into the National Plan of Action and the Monitoring and Evaluation Plan.
- Institutionalize quality improvement through piloting and creating communities of learning across stakeholders.
- Communicate standards to partners and other vulnerable children stakeholders.
URC is working with local partners to pilot a quality improvement intervention to increase injection safety in one province.
URC is providing provincial- and district-level support for HIV and AIDS care, maternal health care, family planning and primary health care programs, monitoring and evaluation, and quality improvement in 30 districts in five provinces. Our staff work directly with district and provincial health managers in supported provinces to improve the quality of care through providing support and mentorship in planning, implementation, evaluation and documentation. We are supporting the revitalization of primary health care, including supervision and strategic planning, and are working to improve use of district-level data through monitoring and evaluation support.
- Provide assistance for the development of Provincial Annual Performance Plans and for the preparation of operational and cost plans for HIV, the prevention of mother-to-child transmission of HIV, and antiretroviral treatment programs in all districts.
- Provide assistance to all districts for the development of district health plans.
- Provide support to the following national directorates: HIV/AIDS, Strategic Planning (M&E [monitoring and evaluation] and Information), District Health Services, and Quality Assurance.
- Work closely with all five provinces to develop and execute their research and evaluation agendas (e.g., evaluation of primary health care supervision in Mpumalanga).
Tuberculosis (TB) is one of the major public health problems confronting the Kingdom of Swaziland. Ministry of Health (MOH) statistics show that tuberculosis accounts for about 10% of in-patient morbidity in the country and is responsible for 20% of in-patient deaths. To compound this, an estimated 80% of TB-infected patients are co-infected with HIV. The high TB/HIV co-infection rate affects both case detection and treatment outcomes adversely.
The USAID ASSIST Project is using modern quality improvement approaches to expand the coverage of integrated TB/HIV diagnostics and treatment services and improve TB treatment outcomes as well as the quality of TB, TB/HIV, and multidrug-resistant (MDR) TB services. ASSIST works with the MOH through the National Tuberculosis Control Programme (NTCP), the Swaziland National AIDS Programme (SNAP), and the National Clinical Laboratory Services (NCLS) to apply lessons learned from established HIV/AIDS and TB quality improvement activities and thereby adapt integrated service delivery models and algorithms for health facilities and providers in Swaziland.
- Support the MOH and implementing partners to institutionalize modern quality improvement approaches.
- Contribute to health systems strengthening by building the capacity of model TB/HIV clinics and two Centers of Excellence for TB care and treatment.
- Support the expansion of Directly Observed Treatment for TB, including management of multidrug-resistant TB.
- Strengthen the capacities of the MOH and its partners to implement Infection control.
- Implement integrated TB/HIV prevention, care, and treatment activities.
- Enable and promote research to improve pediatric TB diagnosis.
Alcohol and tobacco use in Ukraine are among the highest in the world and pose a dual risk to the health of a woman and to her baby. Tobacco use during pregnancy increases the risk of miscarriage, preterm birth, low birth weight, and prenatal mortality, as well as asthma and sudden infant death syndrome. Approximately 2.5 million Ukrainian women smoke tobacco and their smoking increases with age, from 14.7% for women aged 15-24 to 19.8% for those aged 25-44. In comparison, 19.2% of US women age 18-44 reported smoking in 2011.
Alcohol use during pregnancy creates a risk of fetal alcohol syndrome (FAS) and related disorders, including mental and growth retardation and problems with vision, hearing, and behavior. Screening for FAS is not widely performed in Ukraine, but it appears to be highly prevalent. The 2007 Ukraine Demographic and Health Survey found that 62% of reproductive age women had at least one drink in the month before the survey, and 9% of women reported drinking once or twice a week.
To assist Ukrainian partners in reducing alcohol and tobacco use during pregnancy, the USAID ASSIST Project supports the implementation of evidence-based “Brief Physician Interventions” (BPIs.) These interventions are highly standardized, short counseling protocols that take place during an outpatient visit, usually accompanied by patient educational materials. They have been shown to be effective in US studies in promoting cessation of alcohol and tobacco use during pregnancy.
The approach is based on the “5 A’s”:
- Ask about substance use;
- Advise the patient to quit;
- Assess willingness to quit;
- Assist in quitting; and
- Arrange follow-up.
- Train trainers on evidence-based BPIs for tobacco and alcohol cessation and family planning counseling.
- Support training of health care providers on BPIs for tobacco and alcohol cessation and family planning counseling.
- Develop a clinical-organizational protocol (guideline) for BPI implementation nationwide.
- Develop a training curriculum for BPI and the facilitation of incorporating it into post-graduate medical education in one or two medical education institutions in Ukraine.
URC is providing technical assistance to the Zambian Ministry of Health to improve the quality of nutritional services for people with HIV.
About Improvement Science
The science underlying modern improvement is grounded in a “systems understanding,” drawing on psychology, organizational behavior, adult learning principles, and the statistical analysis of variation. The fundamental concept underlying all improvement is that “every system is perfectly designed to achieve exactly the results it achieves” (Paul Batalden, MD). To achieve better health outcomes, we must change the underlying processes that lead to those outcomes.
Improvement requires changes in the way we work, but not every change results in improvement. To ensure that changes improve the system’s performance, testing is required, as is measurement of results.
USAID ASSIST builds on the work of the USAID Health Care Improvement Project. From 2013 to 2017, ASSIST operated in 38 countries, supporting quality improvement efforts for HIV and AIDS, MNCH, malaria, tuberculosis, orphans and vulnerable children, and non-communicable disease services at both facility and community levels. During the extension period, ASSIST will continue to carry out functions related to research and evaluation, knowledge management, and global technical leadership not only as related to previous ASSIST work, but also for new Zika activities, to institutionalize the use of improvement methods for stronger health systems.
2012 to 2018
US Agency for International Development (USAID), Bureau for Global Health, Office of Health Systems
Harvard T.F. Chan School of Public Health
Institute for Healthcare Improvement (IHI)
Johns Hopkins Center for Communication Programs
World Health Organization (WHO)