APPLYING SCIENCE TO STRENGTHEN AND IMPROVE SYSTEMS

APRIL 2015

The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is made possible by the support of the American people through USAID’s Bureau for Global Health, Office of Health Systems. The USAID ASSIST Project is managed by University Research Co., LLC (URC) under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC’s global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard University School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; WI-HER LLC; and the World Health Organization Service Delivery and Safety Department. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or contact assist-info@urc-chs.com.

What is USAID ASSIST?

T he USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is a five-year

project of the Office of Health Systems of the USAID Global Health Bureau designed to improve the delivery of health and social services in USAID-assisted countries, strengthen health systems, and advance the frontier of improvement science.

The project supports the application of modern improvement methods by host country providers and managers in USAID-assisted countries. USAID ASSIST’s central purpose is to build the capacity of host country systems to improve the effectiveness, efficiency, client-centeredness, safety, accessibility, and equity of the services they provide. In addition to supporting the implementation of improvement strategies, the project seeks to generate new knowledge to increase the effectiveness and efficiency of applying improvement methods in low- and middle-income countries.

USAID ASSIST helps countries improve outcomes by strengthening the delivery of the following services:

• HIV and AIDS

• Maternal, newborn, and child health

• Non-communicable diseases and chronic conditions care

• Nutrition assessment, counseling and support

• Care and support for vulnerable children and families

• Reproductive health and family planning

USAID ASSIST Project Five-year Cooperative Agreement in the USAID Office of Health Systems

Members of the USAID ASSIST Project Technical Advisory Group (TAG): Ms. Katie Taylor (Deputy Assistant Administrator for the Bureau of Global Health, USAID), Dr. Enrique Ruelas (President, National Academy of Medicine, Mexico), Dr. Alex Rowe (Medical Epidemiologist, U.S. Centers for Disease Control and Prevention), Dr. Francis Omaswa (Executive Director, African Centre for Global Health and Social Transformation), Sir Liam Donaldson (WHO Envoy for Patient Safety and former Chief Medical Officer for the United Kingdom), and Mr. Derek Feeley (Executive Vice President, Institute for Healthcare Improvement). The TAG met on January 22, 2015 to give guid-ance to the project in its third year of implementation. Photo by Simon Hiltebeitel, URC.

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• Tuberculosis, malaria, and other infec-tious diseases

The project also works to strengthen the performance of the health workforce as well as community-based services and commu-nity linkages with facility-based care.

What Is Improvement Science?

The science underlying modern improvement in health care is grounded in a systems

understanding of work and draws on psychology, organizational behavior, adult learning, and 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).

Improvement requires change in the way we do work, though not every change is an improvement. The following core principles underlie the science of improvement:

• The work of delivering health care happens in processes and systems. Understanding them and changing them in ways to produce better results is at the heart of improving health care.

2 USAID Applying Science to Strengthen and Improve Systems Project

Botswana: USAID ASSIST is supporting the Ministry of Health (MOH) in pursuing its national level goal of reducing maternal mortality from 163 to 81 per 1000 live births (MDG 5) by supporting improvement efforts in facilities in all districts to apply obstetric best practices for the management of post-partum hemorrhage, pre-eclampsia, and post-abortion complications. In addition, ASSIST is contributing to the survival of HIV-positive pregnant women and the prevention of mother-to child transmission of HIV (PMTCT).

Burundi: The project is working with the MOH to improve the uptake of PMTCT services for mothers, their partners, and their infants and improve retention of mothers and infants along the PMTCT cascade. The project is also supporting a pilot activity in one district to strength-en community health worker (CHW) activities in support of PMTCT.

Cambodia: The project is working with the five professional councils that regulate doctors, dentists, pharmacists, nurses, and midwives to facilitate the development of a bottom-up and evidence-informed strategy to strengthen the health professions regulatory system.

Cote d’Ivoire: The project is building the capacity for improving care of the newly established MOH Directorate of Hospital Medicine to bet-ter coordinate implementation of improvement concepts and method-ologies to improve service delivery and is providing technical support to PEPFAR implementing partners to improve the quality of antiretro-viral therapy (ART) and PMTCT services in their supported facilities. ASSIST is also helping the MOH establish a quality improvement sys-tem in the country’s four university hospitals.

Democratic Republic of Congo: USAID ASSIST is supporting the MOH to improve nutrition services and retention in care for HIV clients through the integration of nutrition assessment, counseling, and sup-port into HIV care and treatment, in coordination with implementing partners FANTA and LIFT.

Haiti: The project is providing technical assistance to the Institute of Family Welfare and Research to disseminate the national service guidelines to improve the quality of care provided to vulnerable chil-dren and their families in seven departments.

India: The project is working with key actors in the Indian health system to enhance improvement capability by engaging health care leaders at the community, facility, district, state and national levels to lead health care improvement in priority districts in USAID-supported states. Improvements activities are focused on the reproductive health-maternal newborn child health-adolescent continuum in both public and private facilities.

Indonesia: In partnership with the Universitas Indonesia Center for Family Welfare, the project is evaluating the quality of care provided in hospitals undergoing Joint Commission International (JCI) and Indonesian Hospital Commission (KARS) accreditation.

Kenya: USAID ASSIST is supporting the MOH, the Ministry of Labor, Social Security and Services, and the National AIDS and STI Control Program to address system-level issues and work with USG imple-menting partners and county governments to design, develop and implement strategies that will enhance the quality of service delivery in the health sector, including: maternal, newborn and child health (MNCH) and reproductive health to reduce maternal and neonatal deaths; improving malaria case management and strengthening the national malaria program; HIV care and treatment; and the care of orphans and vulnerable children (OVC). The project also supports the implementation of the Partnership for HIV-Free Survival (PHFS) in Kenya.

Latin American Virtual Collaborative on Newborn Care: In part-nership with the LAC Newborn Health Alliance, the Kangaroo Care Foundation, the Pan American Health Organization, UNICEF, and the

USAID ASSIST Country Programs

Current USAID ASSIST Field Activities

LAC Newborn Communities of Practice

Haiti

NicaraguaMali

Niger

South Africa

Cote d’Ivoire

Botswana

Zambia

Kenya

Democratic Rep. of Congo

BurundiTanzania

Swaziland

Malawi

Lesotho

UgandaIndia

Ukraine

Cambodia

Indonesia

Maternal and Child Health

HIV/AIDS (including OVC)

Family Planning

Tuberculosis

Health Workforce and Community Health

3USAID Applying Science to Strengthen and Improve Systems Project

Mesoamerican 2015 Initiative, USAID ASSIST is providing web-based support to hospitals in the region to participate in a virtual improve-ment collaborative aimed at improving hospital care for newborn complications.

Lesotho: The project is supporting the Ministry of Health and other partners in the development of a national strategy for improving the quality of clinical services, strengthening linkages between HIV test-ing and counseling, antenatal care, MNCH, HIV care and treatment, PMTCT, and home-based care services. USAID ASSIST is supporting implementation of PHFS in Lesotho, focused on improving the quality, uptake, and retention of mother-baby pairs along the continuum of PMTCT services.

Malawi: The project is building the capacity of the Ministry of Gender, Children and Social Welfare, districts, and USAID partners to imple-ment national standards to improve services for orphans and vul-nerable children. In particular, the project is building the capacity of selected District Social Welfare Officers to promote coordination, transparency, cost efficiency, and sustainability in OVC programing. The project is also supporting implementing partners to assess the quality of voluntary medical male circumcision (VMMC) services.

Mali: The project is working with the MOH to apply improvement methods at the health facility and community levels to improve the quality of essential obstetric and newborn care in one region. USAID ASSIST is also supporting the MOH to improve anemia prevention and control activities in one demonstration district. In collaboration with the MOH and WHO Service Delivery and Safety, USAID ASSIST is supporting the introduction and testing of the Safe Childbirth Checklist (SCC) in Mali.

Nicaragua: The project is supporting the institutionalization of im-provement methods in pre-service training in HIV services in the ma-jority of medical and nursing schools in Nicaragua.

Niger: USAID ASSIST is supporting the Ministry of Public Health to apply improvement approaches to strengthen post-partum family planning services in district-level primary and secondary maternities. A main objective of the work is to build learning that can be general-ized to other settings to help governments, implementing partners, and other stakeholder to strengthen client-centered, effective, and safe post-partum family planning services.

South Africa: The project works with the Department of Health at all levels, providing technical assistance to build capacity of primary health care supervisors and facility managers in all provinces in stra-tegic planning, supervision, program review, training, and mentorship. USAID ASSIST works with provincial and district health authorities in USAID priority provinces to increase the quality of HIV prevention,

care, and treatment services. The project is also providing technical support to PEPFAR implementing partners to improve the quality and safety of VMMC services.

Swaziland: The project is supporting the MOH and implementing partners to institutionalize modern quality improvement approaches and strengthen the implementation of the WHO-recommended strat-egy for detection and cure of tuberculosis (TB), integration of TB and HIV services, TB infection control, and multidrug-resistant TB case management as part of implementation of the essential care package. The project is also supporting the MOH to implement a national frame-work for improving the effectiveness, efficiency, and sustainability of health care worker in-service training and performance improvement for community health workers supporting HIV/TB services.

Tanzania: The project supports the Ministry of Health and Social Welfare and implementing partners to apply improvement methods to increase the effectiveness of PMTCT, ART, vulnerable children services and protection, and community home-based care. USAID ASSIST is collaborating on PHFS activities to eliminate HIV infection in children and reduce deaths among HIV-infected mothers in three districts and supporting the national scale-up of PMTCT Option B+. The project also supports to efforts improve the quality of ART care for infants and children exposed or infected with HIV and to deliver safe VMMC services.

Uganda: The project is supporting the MOH, districts, implement-ing partners, and health facilities to improve the HIV continuum of response, improve the quality of voluntary medical male circumci-sion services, improve TB care, and implement the PHFS initiative. The project also supports the MOH to apply improvement methods to improve maternal, newborn, and child health services in primary care and referral facilities and apply lessons from pilot facilities to other sites. The project is also working with the Ministry of Gender, Labor and Social Development, the MOH, and OVC implementing partners to apply standards to improve services for vulnerable children and to improve the quality and safety of VMMC services by applying continu-ous quality improvement methodology and tools.

Ukraine: The project is assisting Ukrainian partners to reduce alcohol and tobacco use among pregnant women in Poltava Oblast through training and technical assistance for the implementation of standard-ized counseling protocols known as brief physician interventions.

Zambia: The project is working with the Ministry of Health and other implementing partners to integrate nutrition services into HIV care to improve health outcomes of HIV clients and increase their retention in care.

Improving retention of mother-baby pairs in care through the Partnership for HIV-Free Survival

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Kenya (n=17 facilities) Tanzania (Nzega, Mbeya & Mufindi) (n=30 facilities) Uganda (n=22 facilities)

USAID Applying Science to Strengthen and Improve Systems

Unfiversfity Research Co., LLC, 5404 Wfisconsfin Ave., Chevy Chase, MD 20815-4811 USA

TEL 301-654-8338 • FAX 301-941-8427 • www.usaidassist.org • assist-info@urc-chs.com

• Working in teams of different providers in-volved in delivering care is key to making changes work and fostering ownership of the changes to enhance sustainability.

• Testing changes to determine whether they yield the desired results is at the heart of improvement. Data are used to analyze processes, identify prob-lems, determine whether the changes have resulted in improvement, and act accordingly.

• Care should meet the needs and expectations of clients, patients, and communities.

• Shared learning, where multiple teams work on common aims and exchange what worked, what did not, how it worked, and why, is an essential part of improvement, producing better results in a shorter period of time than teams work-ing in isolation from each other.

USAID ASSIST builds the capacity of host country implementers to apply the sci-ence of improvement to health care and other services for vulnerable populations, to ensure that high-impact interventions reach every patient or client, every time, and improve outcomes.

USAID ASSIST Services

Country programs developed under USAID ASSIST systematically ad-dress key questions related to the

evidence base for achieving improvements in the focus area of the work and the imple-mentation strategy for the work planned. This deliberate design of country improve-ment programs under USAID ASSIST also addresses:

• How the improvement strategy will create the conditions for sustaining results after the project’s support is completed;

• Scaling up the improvements in care to the rest of the health system;

• Building capability within host country institutions to be able to conduct other improvements without external assis-tance—making improvement a perma-nent, institutionalized part of deliver-ing health services.

USAID ASSIST country improvement strate-gies also address the learning that will be accomplished through the work and how evaluation, research, and knowledge man-agement activities will support the country program’s objectives.

In this way, the project applies evidence-based improvement approaches within a given context to increase the likelihood of achieving the best possible outcomes while building the improvement competencies of host-country partners. The project aligns

evidence-based interventions in technical content areas—such as maternal, new-born, and child health, HIV/AIDS, and care for vulnerable children and families—with evidence-based approaches in improve-ment, including collaborative improvement, human performance technology, standards, and regulatory strategies.

USAID ASSIST country programs are de-signed with host-country leadership at the forefront to ensure context appropriateness and local ownership and will be in alignment with the goals of United States Government and global initiatives, including Ending Preventable Maternal and Child Deaths and Achieving an AIDS-Free Generation. Aligning with these priorities and policies ensures that considerations for marginalized and underserved populations and gender, age, and social differences are taken into account at all levels of implementation.

How to Obtain Services of USAID ASSIST

The USAID ASSIST cooperative agreement is designed to provide a streamlined process for USAID

Missions, Offices, and Bureaus to obtain services in health systems improvement. USAID ASSIST services from URC and its pre-approved team of partners are ready to support country institutions in developing and executing improvement strategies and programs.

To access technical support through USAID ASSIST, contact the Agreement Officer’s Representative, Dr. James R. Heiby, Medical Officer, Office of Health Systems, Global Health Bureau, USAID/Washington.

“Quality improvement is a high-

impact intervention which like the

others is not being implemented

to scale. It is a vehicle for all other

high-impact interventions to reach

our populations. The question that

we should be answering is how

we can lift QI to such a level that it

is recognized as the number one

high-impact intervention which

should be the driver of Universal

Health Coverage.”

Francis Omaswa, African Centre for Global Health and Social Transformation