At the clinic level, improvement teams reviewed and analyzed data from iSanté to set facility-specific priorities for improving PMTCT based on gaps identified using EMR data and causes identified using root cause analysis. They then selected interventions for pilot testing, assessed the impact of their changes, modified systems, or tested new changes and immediately integrated tested improvements into daily work by engaging staff and patients. Some interventions implemented at the clinic level included revision and dissemination of PMTCT guidelines to all staff involved in the care process, introduction of female case managers in all clinics to follow up on care of HIV-positive pregnant women, routine tracking of HIV-positive pregnant women by field agents in the community to re-engage patients in care, and early dispensing of ART to HIV-positive pregnant women.

Clinic-level obstacles to routine, consistent, and timely data entry were addressed to reinforce those systems. This included MSPP-supported QI coaching to clinic teams with annual on-site retraining on the EMR and correct data entry procedures, improving EMR access at point of care, institutional focus on immediate data entry directly into the EMR on day of care or directly after each patient visit, and systematic data entry of obstetrics–gynecology and pharmacy forms in iSanté.

The priorities identified at the national level and the changes in care initiated at the facility level to address these priorities have led to a marked improvement in the

**Fig. 4.2** ART enrollment for pregnant women (%) by review period, January 2008 to March 2019

number of HIV-positive women receiving appropriate care during pregnancy. Overall performance of the indicator measuring the percentage of HIV-positive pregnant women enrolled on ART has improved from an aggregate mean of 32% in January–June 2008 to an average of above 99% across review periods through March 2019 (Fig. 4.2). Since ART adherence during pregnancy is associated with reduced transmission of HIV to newborns, this improvement was likely associated with fewer HIV infections among infants born to HIV-positive mothers.

# *Health Facility Improvement Snapshot: Addressing Lost-to-Follow-Up at Bernard Mevs Hospital*

Bernard Mevs Hospital is located in western Haiti, in the town of Delmas, serving a catchment area that includes Haiti's capital, Port-au-Prince, and the neighboring counties of Delmas, Simmons, Cité Soleil, and other low socioeconomic populations in the region. Hospital services include surgery, pediatrics, family medicine, urology, orthopedics, critical care units, and HIV. There are 1956 active persons living with HIV (PLHIV) in care at the facility.

In January 2018, a facility performance review of data from iSanté revealed that only 74% of PLHIV were retained on highly active ART (HAART) at 12 months. As a result, a QI project team comprised of a social worker, a data-reporting officer, a community field agent, a pharmacist, a data clerk, and the HIV program coordinator was convened to analyze gaps in performance and propose changes based on their findings.

The QI team, as part of robust process improvement activities, used data from tracking of lost-to-follow-up to identify root causes of poor retention. Seven primary factors were identified and quantified during that analysis, including:

A series of changes, based on the causes identified, were then tested on the February 2017 cohort. First, the list of patients enrolled on HAART in February 2017 was extracted from the EMR with their 12-month retention status. Next, patients who were not active on HAART at 12 months were telephoned or tracked in the community using community navigators. Then, on a case-by-case basis, HAART delivery was adapted to the meet individual patients' needs. For example, for patients who experienced difficulty making routine visits to the hospital, multimonth dispensing of ART or community delivery of HIV drugs (at patient's home or meeting point) was implemented.

Of 12 PLHIV enrolled on HAART 12 months who were lost to care prior to the intervention, 11 were found and 1 was declared deceased. Of the 11 PLHIV found, 2 received community delivery of ARVs and 9 received multimonth dispensing. This strategy facilitated the increase of 12-month retention from 74% at baseline in January 2018 to 92% at follow-up in February 2018. The intervention was subsequently scaled up to the broader patient population of PLHIV at Bernard Mevs, where improvement has been sustained at or near 100% through March 2019 (Fig. 4.3).

# **Reflection**

Real-time access to patient-level, facility-level, and aggregate national-level data through iSanté has proved invaluable in supporting implementation of Haiti's MSPP-led national quality management program. With immediate access to data at the local level, and with support from national improvement coaches, improvement teams have the capability to quickly review and analyze data for improvement, assess performance of small-scale tests of change, and make adjustments to efficiently maximize effectiveness of QI activities. Nationally, production of aggregate data reports has facilitated identification of gaps in

**Fig. 4.3** Hospital Bernard Mevs 12-month retention on HAART

care—geographically and/or by area of care—which can be easily displayed for decision-making. This information is routinely used to inform national priorities and reinforce critical areas of care nationwide.

Through Haiti's coordinated national quality management program, which is characterized by strong leadership support from the MSPP, the electronic medical record has facilitated timely access to data for national improvement prioritization in multiple core areas of HIV care. Over the last decade, these have included prevention of mother-to-child transmission of HIV, co-trimoxazole prophylaxis, antiretroviral therapy, and family planning for HIV-positive women, among others.

Among the implementation challenges are familiar issues confronting low- and middle-income countries—issues that were exacerbated considerably in Haiti during these years due to multiple natural disasters, particularly the January 2010 earthquake that devastated much of the island's physical infrastructure and led to the death and displacement of hundreds of thousands of people. Deficiency in local infrastructure, particularly inconsistent access to electricity and information technology networks necessary to operate the EMR, has been one challenge to implementation. Nevertheless, the MSPP mitigated these issues at the onset by establishing local servers at 53 of the 108 iSanté clinics and hospitals and generators at all iSanté-equipped facilities, thus alleviating challenges associated with slow internet connections and facilitating automatic replication of patient data to a central data repository to ensure that patient information is not lost during power outages or natural disasters.

Successful exploitation of iSanté also relies on trained health-care staff within the MSPP for national deployment and support, as well as human resource capacity at the health-care facility level for daily operation of the system. Development of, and access to, an electronic medical record system is simply not sufficient; knowledge and capability for consistent and accurate data entry, analysis, and reporting are critical. The importance of local coaching support must be emphasized; coaches work directly with each facility to ensure that national priorities are understood, that QI knowledge and skills are reinforced among QI teams, and that data are routinely used to improve patient care.

The implementation of iSanté is an exceptional example of how real-time EMR data can be harnessed and used for improvement, which is even more extraordinary given the setting and multiple natural disasters confronted in Haiti over the last decade. Development and deployment of iSanté represent a unique step in improving the quality of patient care in Haiti and underscore the accomplishments of the national HIV quality management program in introducing and spreading improvement concepts around data use and analysis for quality improvement nationally. This includes noteworthy coordination and buy-in from the Government of Haiti, HIV program leadership, stakeholders, and the multiple partners and donor agencies whose support was vital for success in building technical capacity and management processes for implementation within the context of a national quality program.

**Acknowledgments** The authors appreciate the support provided by the Haiti Ministry of Health; the National HIV Program; the MSPP HIV QI team; Regional Coaching Teams; CDC-Haiti; the Health Resources and Services Administration; I-TECH; Kathleen Clannon; and Joan Monserratte.

# **Appendix 1. iSanté Indicators**

# **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

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# **Chapter 5 Bridging the Gap Between Emergency Response and Health Systems Strengthening: The Role of Improvement Teams in Integrating Zika Counseling in Family Planning Services in Honduras**

# **Maria Elena Banegas Arnold and Norma Aly Leitzelar**

**Abstract** This case describes how QI methods were applied in an emergency response context to improve health-care delivery during an infectious disease outbreak – the Zika epidemic that affected Honduras and other countries in Latin America and the Caribbean beginning in 2016. It describes the national-level efforts of both the Ministry of Health and Social Security Institute to strengthen health services in the context of a novel and rapidly spreading epidemic and shows the process of improving care at the facility level, through the experience of the Catacamas Polyclinic in the Olancho Region of Honduras. The case illustrates how the efforts of facility-level QI teams were supported by and coordinated with national-level efforts to develop and promulgate updated standards of care and train health workers in their application. Ministry of Health support for the QI activities included coaching support by central and regional-level QI coaches, support for monitoring of performance indicators, and facilitation of peer-to-peer learning among QI teams to scale up learning about how to improve Zika-related care.

**Keywords** Collaborative improvement · Counseling · Family planning · Honduras · Peer-to-peer learning · Performance monitoring · Quality of care · Zika

# **Background**

In early 2015, an outbreak of the Zika virus emerged in Brazil; within a year, the virus had spread 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 World Health Organization to declare Zika a public health emergency of

M. E. B. Arnold (\*) · N. A. Leitzelar

Formerly with University Research Co., LLC, Tegucigalpa, Honduras

<sup>©</sup> University Research Co., LLC 2020 59

L. R. Marquez (ed.), *Improving Health Care in Low- and Middle-Income Countries*, https://doi.org/10.1007/978-3-030-43112-9\_5

international concern, defined as "an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response" (World Health Organization).

The Zika virus was discovered in 1947 in the Zika forest of Uganda. It caused an epidemic in Micronesia in 2007 that spread to several countries in Oceania before reaching the Americas in 2014. The Zika virus spreads among people mainly through the bite of an infected mosquito – the same type of mosquito (*Aedes aegypti*) that transmits Chikungunya and dengue. In addition, the virus can be transmitted between people through sexual intercourse and from a pregnant woman to her baby during pregnancy or at birth. A Zika virus infection during pregnancy can cause microcephaly and other serious brain defects in the developing baby. In addition, there are a host of other possible health and development issues that are being observed in infants and children who were exposed to Zika in utero that continue to be under study.

By 2017, local transmission of the Zika virus had been detected in 148 countries in the Americas, Asia, Africa, and Oceania. Thirty-one countries or territories had reported cases of microcephaly and other central nervous system malformations, possibly associated with Zika virus infection or that suggest a congenital infection, and 23 of them have reported an increase in the incidence of Guillain-Barré Syndrome (GBS) and/or confirmation of Zika virus infection in GBS cases through laboratory tests. Thirteen countries or territories have reported incidence of sexual transmission of Zika.

In Honduras, 32,142 suspected Zika cases had been reported by 2016. Out of these cases, 665 were among pregnant women, 46% of whom were confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) test to have had a Zika virus infection during pregnancy. By late 2016, 134 cases of microcephaly were reported; of these, evidence of the mother having had a Zika virus infection during pregnancy was confirmed by a laboratory test (RT-PCR or serology) in only four cases. The highest incidence of Zika virus infections was recorded in five departments (and cities): Francisco Morazán (Tegucigalpa), Cortes (San Pedro Sula, Choloma, Villanueva), Yoro (El Progreso), Olancho (Juticalpa), and El Paraíso (Danlí).

# *The Zika Response*

As the epidemic unfolded, national governments across Latin America and the Caribbean and the international community quickly mobilized resources to respond to the threat. In Honduras, the national authorities implemented a multisectoral response, organized by the President of the Republic, which included the participation of the Ministries of Health, Education, and Social Inclusion as well as international health organizations like the Pan American Health Organization, USAID, and others. USAID provided technical and financial support through implementing organizations for a range of Zika response efforts, including vector control (ZAP Project), communication campaigns (UNICEF and Breakthrough Action), service delivery (USAID ASSIST Project), and community mobilization (PASMO, Global communities, Project CAZ). A coordination team was formed within the Honduran Ministry of Health (MOH), with the participation of technical staff from relevant MOH units (Health Surveillance, Service Networks Directorate, Primary and Secondary Care Departments, General Directorate of Standardization, among others). This group was named the Zika Strategic Command, and it became the focal point of coordination for all Zika activities in Honduras.

USAID requested in 2016 that one of its projects with decades of experience applying improvement methods to health care begin implementing activities in Latin America and the Caribbean to strengthen the ability of the health systems to respond to the Zika epidemic. Specifically, the project sought to integrate Zika care within family planning, prenatal, and newborn services to improve the capacity of the health system to deliver consistent, evidence-based, respectful, people-centered, high-quality Zika-related care to women of reproductive age, pregnant women, and mothers of newborns affected by Zika and their families. A key goal was to improve client and provider knowledge about Zika and its consequences, particularly for newborns, and about how to prevent Zika virus infection. To meet this need, in Honduras, the project coordinated with the two largest health service providers – the Ministry of Health and the Honduran Institute of Social Security (IHSS, for its acronym in Spanish) – to start an initiative to improve the quality of health services in both organizations.

# **Designing the Improvement Effort at the National Level**

# *Overview of the Honduran Health System*

The MOH is the largest provider of health services in Honduras, covering around 60% of the population. The IHSS serves the working population of the country that has health insurance, covering around 12% of the population (Carmenate-Milián et al. 2017). Within the MOH, there are two levels of care. Primary care is provided by teams in the community or health facilities that provide outpatient care with basic services in obstetrics, pediatrics, internal medicine, and, in some facilities, labor and delivery. Secondary care comprises inpatient services and specialized care provided through different types of hospitals.

The Zika Strategic Command (ZSC) drew on the technical expertise and experience of a multidisciplinary team that was responsible for coordinating health promotion and Zika prevention activities at the community, ambulatory, and hospital levels. The USAID ASSIST Project gave technical assistance to the ZSC to initiate its plan. One of ASSIST's first activities with the ZSC was to decide on appropriate indicators to conduct a baseline assessment of Zika care in the health facilities within the high-incidence departments. Given the recent emergence of Zika in the Americas, another important activity early in the response was to draft national guidelines for comprehensive management of patients with a suspected or confirmed Zika virus infection during preconception, pregnancy, delivery, and postpartum stages and for care of newborns affected by congenital syndrome associated with Zika virus (CSaZ).

At IHSS, the Medical Directorate created a technical team to implement activities within their institution, which included the participation of Epidemiological Surveillance and the Quality Management Unit and the coordination of the North-Western Region of the country, where more cases were concentrated. This technical team worked closely with the ZSC.

# *Site Selection*

For implementation of Zika care improvement activities in Honduras, the USAIDfunded project coordinated with the national-level Zika Strategic Command to select 42 health facilities for the initial improvement work; 12 of these facilities were hospitals (10 MOH and two IHSS), and the rest were primary care facilities (20 MOH and 10 IHSS). These facilities were selected because they had the highest incidence of suspected Zika cases. The 42 facilities were located in Atlántida, Choluteca, Cortes, El Paraíso, Olancho, Santa Barbara, and Yoro departments and the metropolitan regions of Tegucigalpa and San Pedro Sula. Within each region, a team of technical advisors from the MOH, IHSS, and the USAID-funded technical assistance project coordinated Zika service strengthening activities with the Health Region Coordinating Team and the managers of the selected primary care health facilities and hospitals.

# *Baseline Assessment*

One of the strategic objectives proposed by USAID-funded technical assistance project was the integration of Zika counseling in the services provided to women of reproductive age, mothers, and families to educate clients on Zika risks and complications and to teach and encourage clients to take personal protective measures and other actions to prevent Zika. As a first step, the MOH, IHSS, and USAID-funded project conducted a baseline assessment in the 42 priority facilities to understand what health service clients knew about the Zika virus and how to prevent it. The baseline tools were prepared by the USAID-funded project's regional technical team, for use in Honduras and other countries across the Latin American and Caribbean region. They were reviewed and adapted for use in Honduras by the Zika Strategic Command, the IHSS Zika team, and country-based technical staff of the USAID-funded project. The tools mainly focused on identifying whether Zika counseling and messages were being provided within key health services (family planning, prenatal, and postpartum care) and whether pregnant women could describe the risk of a Zika infection during pregnancy and ways to prevent Zika (including use of a condom to prevent sexual transmission of the virus), among other topics.

The baseline results showed that 20% of women of reproductive age and 22% of pregnant women could not identify Zika risks and complications (18/88). Only 43% of the women of reproductive age interviewed (40/107) could mention four or more personal protection measures to prevent Zika virus infection, but only 4% of these identified condoms as a protection measure against sexual transmission of the virus. When inquiring if the woman had received counseling on the risks of mother-tochild transmission of Zika while pregnant, 60% of patients who had visited an IHSS facility said they had received this information, but only 36% of those who had visited an MOH facility had.

At baseline, no clients were screened for Zika; however, a retrospective review of 145 patient records from the assessed facilities showed that 27% of sampled pregnant women had shown signs of an arbovirus-associated fever, 20% reported a skin rash, and 12% reported conjunctivitis – all potential signs and symptoms of Zika. At baseline, 75% of the 42 health facilities evaluated had condoms available. Less than half of health-care providers said that they had received training on Zika, and there were no standards or normative guidelines for Zika case management.

# *Development of and Training in Standards of Zika Care*

Given the baseline results, a technical group of MOH, IHSS, and other organizations, led by the MOH General Directorate of Standardization with the support of the USAID-funded project, prepared normative guidelines for Zika-related care, which were approved at the end of 2016, for women of reproductive age with suspected or confirmed Zika infection during preconception, prenatal, postnatal, and postpartum stages and for infants or children with suspected congenital syndrome associated with Zika.

Regional MOH and IHSS coaches were identified and trained beginning in November 2016. These coaches then replicated the training on Zika guidelines for health-care providers in a two-and-a-half-day facility-level workshop, which they have delivered since January 2017. The coaches also received training on healthcare improvement methods and tools.

The work to improve health care began by mid-2017. To strengthen Zika service delivery, the MOH and IHSS, with the support of the USAID project, developed collaborative improvement projects to implement Zika counseling in family planning (FP) services and in prenatal care and to screen newborns for microcephaly.

# *Formation of QI Teams*

After the workshop for coaches, the health region management support units were instructed to organize three types of collaborative improvement teams within participating facilities: Zika prevention in family planning, Zika screening and prevention in prenatal care, and Zika screening in newborn care. Hospitals typically had all three teams. Primary care facilities organized only family planning and prenatal care teams; in facilities with a small number of staff, organization of the prenatal care team was prioritized. The regional teams sent instructions to facility managers to organize improvement teams of 6–8 persons following specific profiles. Upon implementing improvement work, many teams incorporated new personnel who were not initially considered while other team members dropped out because they were not involved in direct patient care.

Once the teams were organized, two training sessions (each lasting 2 days) were held at each facility, with a period of 2 weeks between them. In the first session, trainers addressed the general health-care improvement approach, developing improvement aims, forming the QI team, developing a flowchart of the current care process, and developing indicators to measure progress. The second session, held after teams had begun analyzing the gaps in their existing care processes, focused on measuring indicators, identifying changes to test, developing a flowchart of the ideal care process, creating time series charts, and preparing an action plan for testing changes and measuring results.

# **MOH Support for Improvement Teams**

# *Coaching*

After the training, QI coaches, selected by the MOH Quality Department and health region staff, followed up with each facility-level QI team to support the care improvement process they were designing and implementing. Many coaches also belonged to respective health region's management support unit. Visits were scheduled in coordination with the MOH Quality Department or IHSS and with those responsible for the Zika response in the health region. The role of the national-level staff was to provide political support; keep the Service Network Directorate informed of the progress of activities; and attend meetings with the regional team and coaching meetings with improvement teams. In the case of IHSS, members of the Zika technical team from the USAID-funded project accompanied IHSS coaches on visits to QI teams.

Coaching meetings usually lasted 1 day, and if the facility had two or three improvement teams, the meetings would be longer to allow sufficient time to assist all three teams. During these meetings, the coach guided QI teams in conducting analysis of the improvement work, asking probes like: What is the indicator result? Did the change work? Was it enough? Do we need another change? In the event that the team had not collected data for the indicator, MOH, IHSS, and the USAID project coaches participated in data collection and analysis.

Monitoring of 12 performance indicators for the Zika response was implemented nationwide by the USAID-funded project in coordination with the MOH's Information Management Unit (*Unidad de Gestión de la Información*). With technical assistance provided by the USAID-funded project, the Information Management Unit, in coordination with primary and secondary care facilities, prepared a monitoring plan and, subsequently, held workshops for regional managers in charge of health facility monitoring. They also developed an improvement database for health facility staff to use to input data collected at the facility level; facility-level data reports were then sent to the regional level, and the regional level sent them to the national-level MOH Information Management Unit.

The project, in coordination with the MOH and IHSS, conducted periodic visits to verify the validity of the data reported to the MOH's Information Management Unit and the consistency of data in the registers, the monitoring instruments, and the improvement database. Results were analyzed in conjunction with the coaching team visit.

# *Shared Learning*

Improvement teams from different health facilities working on the same (or similar) aims have much to learn from each other. The improvement coach's role is fundamental in spreading learning. In Honduras, coaches shared successful ideas from one team with others and helped to transfer innovative change ideas from teams that had positive results to teams that did not experience such quick results. The coach's expertise and experience also played an important role in honing ideas and changes and guiding implementation.

The USAID-funded project also provided funding for QI team members from one facility to visit the QI team of another health facility to learn about and see the changes they were making in practice to help them understand the feasibility of replicating the successful changes within their own facility. The visiting teams often asked for support in replicating successful change ideas. Many requests were made to expand the improvement process to other health facilities in regions where the project worked.

In addition, the USAID-funded project and the MOH organized national learning sessions to bring teams together to exchange experiences. At these sessions, the USAID-funded project team employed knowledge management techniques to ensure that participants had an opportunity to share what they had learned and were engaged to learn from others. Through the experiences and results shared during these learning sessions, project staff were able to compile best practices implemented by teams working to improve Zika care within family planning services.

The first national learning session for the Zika family planning (Zika-FP) collaborative was held 6 months after starting the improvement process. Teams presented their changes and successful experiences in a series of interactive conversations that encouraged teams to learn from each other (see Box 5.1). The national learning session lasted for 2 days. Twenty-eight improvement teams in the Zika-FP improvement collaborative participated in the learning session, in addition to staff from the MOH, USAID, the USAID-funded project, and other implementing partners. During the session, the teams identified the changes that were currently being discussed for institutionalization. Table 5.1 shows a sample of the key changes that the Zika-FP teams recommended to others.

# **Box 5.1 Techniques to Foster Peer-to-Peer Learning**

In preparation for the national learning session, coaches selected a few teams that had excellent results from the changes they had implemented to address their improvement aims. Coaches provided these teams with a tool to document their experiences and asked them to identify a member who would be working as the "speed consultant" during the session. Many of the teams made posters to convey their results. Session participants sat at eight tables with a speed consultant at each. The consultant would speak for 20 minutes about the experience of his or her improvement team, sharing successful changes. After 20 minutes, participants would move to a new table. Participants had the opportunity to buy – or not buy – change ideas, symbolically paying the speed consultant to purchase compelling ideas, which helped to give a value to successful change ideas. Participants at the tables could present and "sell" their changes, thus promoting learning across teams.

# **Improving Zika Counseling and Care Within Family Planning Services at Catacamas Polyclinic in Olancho**

Catacamas Polyclinic, located in the city of Catacamas (population 40,912) in the Department of Olancho, offers specialty services for obstetrics and gynecology, prenatal ultrasonography, and pediatrics and has a special clinic to provide care to adolescents due to the high incidence of teenage pregnancy in the area served by this clinic.

The facility manager organized an improvement team composed of three nursing assistants (one of whom also served as the team coordinator), a professional nurse, and a general physician.

**Table 5.1** Key changes that Zika-FP improvement teams recommend to others

# *Setting Improvement Aims*

The improvement team decided to focus on integrating Zika in FP services for two groups: women of reproductive age and adolescents (both female and male). They set a different improvement aim for each group, based on the team's analysis of each group's needs in the context of Zika.

Given that the emergence of Zika in the Americas was so new, few health facilities had any processes in place to include Zika within existing care processes. When the Zika-FP team at Catacamas Polyclinic first started working on this topic, they found that no women or adolescents attended at the facility were receiving information and counseling on Zika and its complications.

For women of reproductive age, they set this improvement aim: "To increase Zika counseling to clients, partners, and/or men of reproductive age who attend the clinic for FP services and/or psychological services, documenting the services provided in the patient's medical record on a sheet designed for that purpose, from 0 to 100% between June 26 and December 31, 2017."

Then, they selected an indicator to measure achievement of their aim:

• Percentage of female and male family planning clients and/or partners who received FP/Zika counseling.

For adolescent care, they set this aim: "Increase knowledge about Zika virus prevention and transmission methods among the adolescent male and female population and/or partners that attend the adolescent care clinic by providing Zika counseling and/or Zika education sessions prior to clinical care (e.g., talks in the waiting room), during their medical appointment, and as they are exiting the health facility (educational room, comprehensive teenage counseling, consultation room, psychological care), documenting the care provided in the designated Zika counseling sheet, from 0 to 50% between June 26 and December 31, 2017."

They selected these indicators to measure achievement of their aim:

# *Analysis of the Current Care Process to Identify Gaps*

The team developed a flowchart of the existing care process for women of reproductive age and identified several problems. First, FP counseling was provided at the health facility through a nursing assistant trained as a counselor but who had other duties. FP counseling was only provided for some methods because the health facility has a high patient load, leaving the provider with little time for each woman and causing delays in receiving care. The FP service at the clinic had a FP counseling tool provided by MOH, but it was not used very often. This service was provided with limitations because the same counselor provided other reproductive health care. Zika counseling was not provided within family planning services or within psychology services. Even FP activities were not recorded on any form, except for a small note written in the medical record that read: "FP counseling provided."

The team observed similar challenges with adolescent care. The adolescent care clinic had been established 2 months prior and had a private space specifically designated for comprehensive counseling and consultancy. Approximately 26–30 teenagers received care daily at the clinic, causing prolonged wait times for care. Zika counseling was not provided there either.

The adolescent counseling room already existed with sufficient privacy, but the improvement team arranged for additional furniture such as a couch and additional chairs. They decorated the room with flowers so that patients would find the space to be more attractive. They began to supply condoms to patients in small packets.

The counseling room also had a waiting area that could seat five persons, so the team decided to give group talks on Zika while patients were waiting to talk individually with the counselor. This allowed them to reduce the individual counseling time since they simply needed to review the adolescent's understanding of the Zika counseling messages, which took less time than starting the counseling from scratch.

Some of the teams found that pregnant women would reject the condoms or throw them out after receiving them because they were afraid to ask their husbands to use them. To address this barrier, the teams began engaging men, holding meetings with them to discuss their role in preventing Zika transmission by using condoms.

# *Measuring Improvement*

Team members met to review a sample of randomly selected files obtained from the facility's statistics service. The improvement team found that the facility's current performance was 0% in their defined indicators when they made the first measurements at the time of the training workshops. The QI team created a form where they documented the clients' medical record number and listed messages on Zika signs and symptoms, transmission (mosquito bite, sexual, and mother-to-baby), prevention methods, personal protection measures, and complications, noting whether counseling was provided and whether it covered these key topics. This form served both as a means of data collection for the team and as a job aid for providers. The QI team also documented distribution of FP methods every month.

Data monitoring, which began in June 2017, was carried out on a weekly basis until January 2018, and monthly thereafter. Each week, a different person from the QI team was assigned to measure indicators. After they had collected data, the team would meet to consolidate and graph the results on a board provided by the USAID project for this purpose. The director of the health facility would include the indicator monitoring results as a topic of discussion during the monthly all-staff meeting.

# *Testing and Implementing Changes*

Table 5.2 presents the first changes tested by the Catacamas team to reduce gaps in the quality of Zika care within family planning services.

**Table 5.2** Changes tested to reduce gaps in the quality of Zika care within family planning services

For the first time, the facility staff began to recognize that counseling is a part of clinical care and began to understand the need to record it in order to follow up with the client. Also, around this same time, counseling services began to be recorded in the MOH official information system for the first time as part of changes initiated at the national level by the Zika Strategic Command.

Within a few weeks, the team realized that recording care was not useful if the service was disorganized. Under the original process of care, the doctor was responsible for providing Zika counseling, but patients mentioned that doctors used very technical language that they found difficult to understand. There was only one provider, an auxiliary nurse, who had been trained as a counselor, but this person was also providing other reproductive care services and could not cover everyone. In addition, counseling was not private, and family planning counseling was only provided for certain methods. The team decided to create a private space for counseling in the FP clinic. Initially, they assigned one counselor to provide counseling full time, but later, the facility trained more health-care providers as counselors (with MOH and USAID-funded project support). Currently, all nurses and the psychologist provide counseling, and there is a robust schedule of coverage to meet client demand while accommodating staff vacations, etc. The flow of care within the clinic was totally modified.

Changes introduced to improve the clients' knowledge of Zika are described in Table 5.3.

To conduct exit interviews with clients, they requested help from the psychologist (who was not part of the improvement team at the time). The team wanted someone outside the team to collect this data, so that there would be no potential bias and the result would be more reliable. The psychologist would not tell anyone

**Table 5.3** Changes tested to improve the clients' knowledge of Zika

when she was conducting exit interviews. (After some time, the psychologist became part of the team and then became the coordinator of all the teams organized and functioning in the facility.) Clients were interviewed as they left the health facility, using a survey instrument developed by the MOH and the USAID-funded project. Once the clients' knowledge had been assessed, the completed forms were shared with the improvement team for analysis and decision-making.

When analyzing the initial data from the exit interviews, the team realized that clients' knowledge was still very poor. Then, the team decided to create a flipchart with standard Zika information to teach Zika signs and symptoms, transmission methods (including sexual transmission), prevention through personal protective measures, and complications. When this change was introduced, their indicator went up to 100%. However, in subsequent exit interviews, they continued to find clients lacking important Zika knowledge, so they decided to use other information, education, and communication techniques, such as group talks, posters, and involving teenagers to educate their peers, to promote learning.

# *Other Activities That Contributed to Improvement*

who were already attending the clinic to train them to work with groups of adolescents to teach them about the Zika virus and how to prevent its transmission.

# **Results**

The improvement team introduced the identified changes and used team meetings to analyze the results of their indicators, shown in Figs. 5.1 and 5.2.

# **National-Level Monitoring of Zika Indicators**

Apart from the indicators monitored at the health facility level by the team as part of the improvement process, indicators were also monitored for follow-up at the national level by the USAID-funded project. The MOH's Information Management Unit started monitoring 12 Zika indicators with technical support from the project in June 2017. A monitoring plan was developed, followed by a monitoring plan training workshop to train health region technical teams and those responsible for monitoring and evaluating health facilities. Then, the Excel database provided by

**Fig. 5.1** Percentage of male and female clients and their partners attending family planning and psychological services who received Zika counseling, Catacamas Polyclinic, Honduras (Jun 2017– Jan 2018)

**Fig. 5.2** Percentage of male and female clients of the adolescent clinic and/or partners with knowledge about Zika, Catacamas Polyclinic, Honduras (Jun 2017–Jan 2018)

the USAID project was given to health facility staff, regions, and the MOH Information Management Unit. The indicator measurement report traveled from the team, who sent it to the database at the regional level; the regional level consolidated all the facility data and then sent it to the MOH Information Management Unit. Health regions also sent a copy to the MOH Quality Unit and the USAID project. This indicator monitoring motivated the facility teams to improve other indicators when results were not satisfactory.

# **Spreading the Knowledge**

In February 2018, the MOH, with the support of the USAID-funded project, conducted a second national learning session for teams from different health facilities to meet and share learning from their work improving Zika care in family planning services. During the learning session, the Catacamas Polyclinic improvement team presented their successful experience, and other teams spoke with them to ask how they did it and what activities they implemented.

The changes made by QI teams to improve Zika counseling in family planning services were analyzed at the national-level MOH office, with support from the USAID-funded project. To further support the efforts of the facility-level teams, the national-level technical team identified a need to improve the chapter of the National Family Planning Strategy on organization of family planning services. The National Family Planning Strategy is the official document guiding family planning activities in Honduras and was developed with USAID funding in previous years.

The flipchart for Zika counseling prepared by the Catacamas team was adapted by the USAID-funded project to standardize it for all improvement teams. The topics of Zika counseling, counseling in the pre-conception stages, pregnancy, postpartum, etc., were added to the flipchart's design.

The Catacamas Polyclinic decentralized services manager also identified successful changes made by the FP-Zika team that could be shared with lower level health facilities in the Catacamas catchment area that are part of the polyclinic's decentralized health services network.

The Olancho Health Region, in view of the success of its health facilities with the Zika care improvement process in FP services, took the initiative to expand the process to other service networks within the region.

# **Reflection**

The Olancho Region had a nurse leader, very empowered in her role as a regional Zika quality focal point. Within her role on the regional coordination team, she advocated for the need to expand the integration of Zika counseling in FP services to other health service networks.

As a result of the experience of the Catacamas Polyclinic, improvement teams have also been organized at the San Francisco de Juticalpa Hospital, which is the referral hospital in Olancho Health Region, some 30 minutes away from Catacamas. The hospital is now also providing Zika counseling and distributing condoms to both women of reproductive age and pregnant women to prevent sexual transmission of Zika.

An interesting piece of data from one of the quality improvement teams at the San Francisco de Juticalpa Hospital is the experience they had in the beginning of 2018. The MOH Management Planning Unit, which is in charge of planning and scheduling management activities at the national level, called the hospital's improvement team to ask if there was an error in the data or why there was a difference in condom delivery, since they were surprised that the hospital had tripled the number of condoms distributed. The doctor in charge of handling the information responded, explaining that the situation was due to the fact that they were delivering condoms in the Zika prevention framework, to both women of reproductive age and pregnant women.

Other health regions also have expansion plans to implement the counseling process in FP and postnatal care services. Tulane University conducted a study in the Metropolitan Health Region of Tegucigalpa, which assessed the quality of Zika and FP services. The results indicated that health facilities that have quality improvement teams have better results than facilities that do not have them. Given these results, the Metropolitan Health Region requested the USAID project to support the expansion of improvement to other new facilities.

The work of the teams, using data and transforming their processes, does make a difference.

75 5 Bridging the Gap Between Emergency Response and Health Systems Strengthening…

**Acknowledgments** The Zika improvement work in Honduras was supported by the USAID Office of Health Systems through the USAID Applying Science to Strengthen and Improve Systems Project, implemented by University Research Co., LLC under Cooperative Agreement Number AID-OAA-A-12-00101.

# **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# **Chapter 6 Scaling Up a Quality Improvement Initiative: Lessons from Chamba District, India**

**Nigel Livesley and Praveen Kumar Sharma**

**Abstract** To improve maternal and newborn survival, the Government of India launched the Reproductive, Maternal, Neonatal, Child, and Adolescent Health initiative in 2013. The initiative provided additional support to districts in states that fell within the bottom quartile on a number of health indicators, including the State of Himachal Pradesh. This case describes (1) how a USAID-supported project introduced the QI approach in Chamba District of Himachal Pradesh, (2) how the project provided initial support to form QI teams and get improvement work on maternal and newborn care started, (3) why the district government staff decided they wanted to scale up the use of QI, (4) how the district government spread QI to new blocks and facilities, and (5) what happened after the project withdrew support. The case also offers insights about key features of improvement work.

**Keywords** Antenatal care · Delivery care · Essential newborn care · India Maternal health · Post-natal care · Quality improvement · Reproductive health · Scale-up

# **Background and Setting**

India is home to over 1.2 billion people. It accounts for one fifth of all deliveries in the world and one quarter of all newborn deaths. The size and complexity of India create important challenges in delivering good health care.

© University Research Co., LLC 2020 77

N. Livesley (\*)

University Research Co., LLC, Abuja, Nigeria e-mail<EMAIL_ADDRESS>
P. K. Sharma Formerly with University Research Co., LLC (URC), New Delhi, India

L. R. Marquez (ed.), *Improving Health Care in Low- and Middle-Income Countries*, https://doi.org/10.1007/978-3-030-43112-9\_6

India is divided into 29 states and 7 union territories. States are further subdivided into districts, which range in population from fewer than 10,000 people to over 11 million. All levels of the health system are involved in providing health care: the central government sets the overall policy and provides the majority of finances, while state and district governments are responsible for service delivery.

To improve maternal and newborn survival, the Government of India launched the Reproductive, Maternal, Neonatal, Child, and Adolescent Health (RMNCH+A) initiative in 2013. The RMNCH+A initiative provided additional support to the districts in each state that fell within the bottom quartile on a number of health indicators.

Different states used different approaches to improve maternal and newborn survival. One approach used by the State of Himachal Pradesh was to request a United States Agency for International Development (USAID)-funded technical assistance project with decades of expertise in quality improvement (QI) to help specific facilities in priority districts of the state to use QI methods to deliver better care and to help the district governments develop strategies to spread and institutionalize the use of QI methods. This support started in December 2013 and ended in December 2015.

Chamba District was one of the four districts in Himachal Pradesh selected for support. With a population of 500,000, Chamba has 1 district hospital, 3 sub-district hospitals, 8 community health centers (CHC), 42 primary health centers (PHC), and 170 health sub-centers (HSC).1

Table 6.1 lists the key actors involved in this improvement case at each level of the health system.

# **Getting Started**

In September 2013, the QI project started working in India. Soon after arriving, the project director met the Joint Secretary for Reproductive and Child Health for the Government of India's Ministry of Health and Family Welfare to discuss QI and introduce the approach of the project. The Joint Secretary was interested in this approach of training frontline health workers in management skills and tools to identify and fix problems at the service delivery level. He wrote a letter to the Government of Himachal Pradesh introducing the project. The Joint Secretary also introduced the project staff to senior Himachal Pradesh officials during a visit to launch the RMNCH+A initiative in November 2013. This allowed the State Improvement Coordinator from the USAID-funded project to establish contacts with the state and district stakeholders. The Chamba District Improvement Coordinator (DIC) with the project remembers said, "*Our first step was to brief the*

<sup>1</sup>Primary health centers are 6–30 bed units staffed by 1 or 2 general doctors. Health sub-centers are two to six bed units staffed by nurses. Community health centers are 30 bed units staffed by at least 4 doctors, including a gynecologist and anesthesiologist.

**Table 6.1** Key actors in the Chamba District case

*district administration and health officials about the project and convince them of the positive impact they could achieve on maternal and neonatal mortality using the QI approach*." During an initial introductory meeting in November 2013, the State Improvement Coordinator and DIC briefed the Chief Medical Officer (CMO) and the Medical Officer Health on the fundamentals of QI and talked about how the project could support facilities in Chamba to deliver better care. The CMO and the

Medical Officer Health agreed that they could benefit from the project's support. They asked the DIC to meet with the district data assistant to identify facilities that could benefit from this approach.

The following week, after reviewing facility-level data with the district data assistant, the DIC met again with the CMO and Medical Officer Health to discuss which facilities they should target for the QI work. Based on what they heard, district officials and the QI project team jointly decided to start the work at the district hospital and in one CHC, two PHCs, and one HSC within Pukhri Block. The MOH felt that Pukhri was a sensible choice to pilot the interventions due to its proximity to district headquarters, making it easier to monitor, and because most facilities in Pukhri were sufficiently staffed. In addition, nearly 60% of all institutional deliveries in the district occurred in the five facilities listed above, thus providing a good opportunity for the project to demonstrate the effectiveness of the QI approach across all four periods of maternal and newborn health – antenatal, intrapartum, postnatal, and neonatal.

After the initial planning, the District Collector and CMO introduced the DIC and other staff from the project to the leaders and staff at the initial facilities, so that they could present the QI project and discuss what would be required of health facility staff participating in the intervention. Project staff explained that they planned to come to the facilities to form QI teams, and then facility staff and project staff would work together to improve quality of maternal and newborn health. A staff nurse at the regional hospital recalled, "*After meeting the QI project staff, some of us were a bit skeptical because we were already providing services 24 × 7, but others were excited by the possibility of doing something new!*"

In particular, the Block Medical Officer (BMO) for Pukhri was not initially enthusiastic about the selection of his block. He complained to the CMO, "*Why always Pukhri? How is it that we are the first block to get selected for any pilot in the district? Our teams are already overloaded with deliveries and newborn services*."

There was also considerable skepticism about external people providing support. The staff were initially distrustful of the DIC and viewed him as an outsider since he was not from the local health system. Many worried that he would highlight gaps in care to district and state leadership, creating "new problems" for them. Others questioned his ability to effect change and improve care in the facilities, given that he is not a doctor or nurse and therefor lacks the medical training that the facility staff have. "*Who is he to tell us what to do?!*" staff protested. However, the DIC persevered. Slowly, he earned their trust by continuously interacting with them in a respectful manner and taking all decisions in consultation and through mutual agreement, which reduced resistance. The Medical Officer Health remembers, "*His approach made facility staff feel that he is assisting them; not directing them to do things. When the staff realized that the DIC is there to help and guide them, they started co-operating with him*."

# *Initial Organization of the Improvement Work*

The process of setting objectives went through several iterations. First, a broad set of aims was taken up with the district officials. Project staff and district officials discussed the level of quality they would like to achieve for antenatal care (ANC), delivery, postnatal care (PNC), and essential newborn care (ENC) services. The parties then agreed on a set of specific aims to reach the expected level of quality, such as ensuring that hemoglobin and blood pressure are measured and patient history is taken during antenatal care to identify, refer, or manage high-risk pregnancies; administering oxytocin to women within one minute of delivery; monitoring postnatal vitals per protocol (11 times in 6 hours); and providing vitamin K to all newborns.

The DIC then worked with the facility staff to collect baseline data about these initial aims from the previous 6 months (going back to July 2013). At the same time, the CMO, Medical Officer Health, and the BMO validated each of these aims for their consistency with the government RMNCH+A guidelines of the National Health Mission.

After the district leaders and project staff finalized the general set of aims, the project team organized an initial training for the facility staff at the government training facility. Over the span of 2 days, the State Improvement Coordinator and DIC trained 45 government staff in seven basic steps to improve care (see Box 6.1). Training participants were invited through a letter from the CMO and included senior staff from the district, block, and each of the five facilities, as well as clinical staff involved in care for infants and pregnant and delivering women.

# **Box 6.1 Seven Steps to Improve Care**

During the workshop, the facilitators introduced the aims from which the facility staff could choose to work. As the participants were choosing aims, they expressed concerns about how feasible it would be to meet some of these aims given their workload. For example, they flatly refused to work on increasing the number of times a woman was assessed after delivery to the 11 times in the first 6 hours as stipulated in government guidelines. The State Improvement Coordinator and DIC did not emphasize these contentious areas. Instead, they asked the participants to focus initially on the specific aims that had less resistance from the group, such as giving oxytocin after delivery and improving antenatal care.

After the initial training, the facility staff were asked to go back to their facilities and follow the seven steps to improve care. One of the first things that the participants did upon returning to their facilities was to form one QI team per facility. To do this, the senior staff who participated in the training appointed the team members and outlined the aims of the improvement project to the QI team members. Thereafter, the DIC visited each team every 2–4 weeks and spent, on average, half a day helping them learn how to practically apply improvement methods to achieve their chosen aim. During these coaching visits, the DIC would review how they were doing on the steps and help them strengthen their skills for each step. For example, one coaching visit might focus on how to better use different QI tools, such as flowcharts and fishbone diagrams, to analyze systems to understand why the facility was not currently reaching their goal; another visit might involve helping the team plan how to use small-scale tests to see if one of their ideas was feasible and effective.

When asked how these coaching visits helped them, the QI teams responded:

In addition to the coaching visits, the project provided support through bimonthly learning sessions where the teams came together to discuss what they had been working on for the past 2 months. The QI meetings and learning sessions not only built an environment of reflection and learning, it created a sense of teamwork. One staff nurse at the regional hospital remembered, "*The exchange of lessons and experiences not only helped us learn, but also made us feel connected as one team, all working to address one problem. We were exchanging experiences beyond the aims we had undertaken!*"

Teams shared learning in many different ways. For example, nurses at PHC Pukhri shot short video clips on their mobile phones to share how they had changed care to make it easier for staff to give vitamin K and oxytocin. These clips helped communicate the details of how the labor room was organized and how care was provided, making it easier for staff from other facilities to understand the specific changes.

A third component of support was clinical trainings. Whenever the QI teams and the DIC identified additional training needs, trainings independent of learning sessions were conducted. Initially, the project provided training on technical issues for the staff, like testing of hemoglobin, injection of vitamin K in newborns, and the use of oxytocin for managing the risk of postpartum hemorrhage. Later, they coordinated with state officials to conduct training on safe delivery and newborn care and resuscitation. For these trainings, the government would provide their trainers, either from the regional hospital or from the state level, and the project would provide logistic support. This arrangement improved district participation in and ownership of the QI work.

# **Measurement and Results**

In initiating the improvement project, one of the first steps for teams was to set up data systems, with the help of the project staff, to support the work. In most cases, the existing government data systems were insufficient since they had limited detail on processes of care and had data quality issues. Often, health workers submitted inaccurate data to avoid getting in trouble – for example, recording that a woman had her hemoglobin measured in the antenatal period even if that was not true – and thus, problems were hidden.

The project staff helped the facility staff design simple tools to measure performance on the indicators related to their chosen aims. For example, they added new columns or rows into existing data collection sheets to record data that was relevant to their aims. The teams kept the data for their QI projects with themselves initially. Because they were not sharing them and because they were using them for their own purposes, the quality and validity of the data were substantially better than the data that they reported to the district.

Within a few months of starting the improvement work, the teams started to see evidence of substantial improvements in processes of care. Figure 6.1 shows improvement in the percentage of women receiving correct diagnostic care and an increase in the percentage of women being identified with high-risk conditions.

# **Institutionalizing and Spreading QI from 5 to 43 Facilities**

In May 2014, after 5 months of work, key stakeholders and QI team members met to share experiences and results. At this learning session, the CMO was impressed that all five facilities had achieved their stated aims and were sustaining their results. These results generated a lot of interest among the BMOs from blocks outside of Pukhri. The BMO from Pukhri, who was originally skeptical of this work and upset that the CMO had selected Pukhri as the pilot block, recounts that after seeing the results of the intervention in Pukhri, some of the other BMOs complained to the CMO of preferential treatment to Pukhri Block and requested the inclusion of their blocks as well in interventions to improve quality of maternal and newborn health services.

**Fig. 6.1** Percentage of women coming to the antenatal clinics in five facilities having a full history taken and hemoglobin and blood pressure measured and the percentage of women being identified with high-risk conditions

Inspired by the results, the BMOs in the other blocks started telling their staff to work on the same aims as the facilities in Pukhri. The ward sister from the civil hospital shared her experience working at one of the facilities that was told to replicate Pukhri's success: "*On the instructions of our medical officer, we started checking hemoglobin and blood pressure levels more frequently during antenatal care check-ups, giving an injection of oxytocin to mothers after delivery, and giving an injection of vitamin K to newborns. There was a lot of improvement, but for some reason we were unable to achieve and sustain the high level of results as in the QI project-supported facilities. Therefore, the SMO was keen to get the QI project working with us*."

At this point, the district leadership realized that simply setting specific aims and telling people to do better was not leading to results. They realized that the QI project must be providing a different type of support, so they asked the project to help them spread the QI model to two new blocks. The focus was more ambitious than simply improving the specific elements of care addressed in the previously supported facilities. Instead, the government wanted their own staff to be able to use QI approaches for any clinical area.

The leadership selected Choori Block because of its proximity to the district headquarters and Samote Block because of its distance from the district headquarters. District leadership also decided that existing Health Supervisors would take over the coaching role previously carried out by the DIC. "*We wanted to see whether or not these interventions will work as effectively without active oversight from the*  *external project,*" recalled the Medical Officer Health. They also wanted to see how well the Health Supervisors could perform the role of the DIC, so they included more health sub-centers (HSCs) in the spread facilities.

Between May and September 2014, the QI project staff supported the Chamba District government to develop a QI guideline detailing the roles and responsibilities of staff involved in the QI work. The guideline was based on how the project had supported the initial five facilities and highlighted three main organizational structures required to implement a QI project: facility-based QI teams, a managerial structure within and outside the facilities to support these teams, and a leadership structure that provides a clear direction for improvement as well as oversight and support during implementation. The guideline outlined key roles and responsibilities within these structures:

	- The leaders of each facility were each expected to form a QI team that would select initial aims of importance to them and then follow the other seven steps for improvement. The teams were expected to report on the progress of their improvement projects and share learning.
	- The managerial structure was composed of the BMO, who would support the larger facilities in each block, and the health supervisors, who would support the sub-centers. These staff assumed the role of the QI coach and visited each facility at least once a month to help the staff learn and implement QI projects. They were also asked to communicate with senior managers to help address issues, such as logistics, which were not always addressable at the facility level. The QI project provided 2 days of QI training to these staff, similar to the training that they provided to their own DIC.
	- The leadership structure was formed by block and district leaders. They ensured that all facilities understood their improvement priorities and also assigned time during all block and district meetings to discuss the QI work at the facilities. This structure also ensured that government funds were made available for QI activities, including QI training, coaching, and learning sessions.

With the structures in place and key actors informed of their roles, QI projects started in the 38 new facilities in September 2014. Leading up to the spread of the QI intervention, the district leadership had taken other steps to improve care in the scale-up or spread facilities, beyond the initial action of simply telling the sites that they needed to provide basic care at the same level as the sites with improvement teams. For example, in May 2014, the district provided the new sites with classroom training from government trainers on intrapartum care and the standards they were

**Fig. 6.2** Percentage increase in oxytocin injection and essential newborn care in 5 pilot sites and 38 spread sites, Chamba District, Himachal Pradesh, India (Oct 2013–Jun 2015)

supposed to follow. They also asked the spread sites to send monthly reports on their progress. However, as the nurse at the start of this section observed (and the data in Fig. 6.2 confirm), these interventions led to some moderate, short-term improvement, which facilities struggled to sustain. It was only when the new sites started using QI methods in September 2014 to address the poor processes at the root of these outcomes that they saw sustained improvement.

Figure 6.2 shows the data for oxytocin administration and delivery of components of essential newborn care in the 5 original QI sites and 38 spread sites.

# **Sustainability**

The project ended support to Chamba District in December 2015 due to changes in funding. During 2016, the State Government of Himachal Pradesh developed a plan to scale up QI support in all districts based on the experiences in Chamba. In January 2017, more than a year after the project had withdrawn support, the State Improvement Coordinator revisited Chamba while working with the government on their statewide plan.

He visited two sites that had been supported directly by the project and one spread facility. All facilities had sustained improvement on the original aims and were continuing data collection related to these aims. However, they had not picked new aims nor trained new staff on QI approaches. Speaking with a Health Supervisor who had been supporting spread facilities, he learned that the Health Supervisor had continued coaching for around 4 months after the project left, but then stopped when the CMO, who had led this initiative, was transferred to another district and the new leaders did not ask for updates on the QI work.

The statewide plan has incorporated the learning from the initial QI work, the spread through the government, and what happened after the project closed and has a strong emphasis on setting up and supporting formal structures and systems to support QI at all levels of the health system.

# **Reflection**

The work in Chamba highlights six important features of improvement work:

**Acknowledgments** The QI technical assistance to Chamba District described in this case was supported by the USAID Office of Health Systems through the USAID Applying Science to Strengthen and Improve Systems Project, implemented by University Research Co., LLC under Cooperative Agreement Number AID-OAA-A-12-00101.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

# **Chapter 7 The Business Case for Quality in Health Care**

**Nicole Spieker**

**Abstract** The Constitution of Kenya gives the government an oversight role in setting and enforcing quality standards for health services. While the Kenyan Ministry of Health has numerous policy documents and legal frameworks to enforce quality care, its capacity to perform inspection visits and enforce licensing requirements has been limited. To help support the institutionalization of a regulatory framework to promote quality health care, PharmAccess, a Dutch nongovernmental organization, launched a strategic collaboration with the Kenya Ministry of Health and the National Hospital Insurance Fund (NHIF) to embed accredited clinical and business quality standards into a national quality assurance system and to introduce the standards and quality improvement methodology into the contracting process of healthcare providers by the NHIF. This case focuses on the introduction of medical and business quality standards at St. Patrick Health Care Center, a private provider in Nairobi. The program has helped the facility to attract financial loans to improve the scale, scope, and quality of their services and to generate extra income by securing a contract with the NHIF to provide health-care services to NHIF members in addition to other private insurers.

**Keywords** Accreditation · Kenya · National Hospital Insurance Fund · Quality improvement plan · Quality standards · Stepwise certification

# **Background and Regulatory Framework**

The Constitution of Kenya gives the government the responsibility for ensuring the realization of the right to health—meaning equitable, affordable and quality health services for all citizens—as well as an oversight role in setting and enforcing quality standards for health services. Kenya has numerous policy documents and legal

N. Spieker (\*)

PharmAccess Foundation, Amsterdam, The Netherlands e-mail<EMAIL_ADDRESS>
<sup>©</sup> University Research Co., LLC 2020 89

L. R. Marquez (ed.), *Improving Health Care in Low- and Middle-Income Countries*, https://doi.org/10.1007/978-3-030-43112-9\_7

frameworks to support the national goal of health for all.1 Although quality of health services is implied in all these documents, as of 2019, they are still being reviewed to clarify how these policies should be implemented and are therefore not fully operationalized. Despite national and county governments motivated to make a difference, as in many low- and middle-income countries, ensuring quality health care in Kenya remains a major challenge. The capacity of government to perform inspection visits and enforce licensing requirements has been limited, and inspectors are often faced with the risk of having to close down facilities that are perhaps the only possibility for patients to receive care in a region. Importantly, the same enforcement mechanisms do not always apply to both public and private facilities, creating disparities in the health sector.

With weak enforcement of a regulatory framework to measure and enforce adherence to quality standards, patients and funders of health care face uncertainty regarding the availability and quality of services in the health sector (Ruelas et al. 2012; Das and Gertler 2007; Das and Hammer 2014; Øvretveit 2004; Peabody et al. 2006; Smits et al. 2014; Mate et al. 2013). This uncertainty hampers investments in the health sector, since patients are not willing to prepay for health care through risk pooling. Low utilization of health services and a lack of reliable income refrains health-care providers from investing in the quality, scope, and scale of their services. This results in a vicious cycle of poor supply of and poor demand for health care.

Transparency about the quality of care and care delivery is crucial to break this vicious cycle. Patients need to know what quality of care they can expect at a certain facility. Funders need data on quality and risk to assess the medical, financial, and accountability risks when considering long-term investments. Insurance companies need data to determine which providers their customers can use and to assure value for money. At a policy level, data on quality and risks assist governments and donors in their choices about how to best allocate their scarce resources to improve quality and lay the groundwork for a regulatory framework (Scott and Jha 2014). Data collected during facility inspections on size, scope, and quality of health-care services can support all these objectives across the sector and stakeholders.

To help create transparency of care provision and lay the basis for institutionalizing a regulatory framework, in June 2013, PharmAccess, a Dutch nongovernmental organization (NGO) dedicated to improving access to better health care in Africa, launched a formal, strategic collaboration with the Kenya Ministry of Health, the National Hospital Insurance Fund (NHIF) and the Health in Africa Initiative of the International Finance Corporation. The key objectives of the collaboration are to

<sup>1</sup> Including the Kenya Health Policy 2012–2030, the Kenya Vision 2030, the Kenya Quality Model for Health, the draft Health Bill 2012, the draft health financing strategy, and the Kenya National Health Sector Strategic Plan III for 2013–17.

embed accredited2 clinical and business quality standards into a national quality assurance system and to introduce the standards and quality improvement methodology into the contracting process of health-care providers by the NHIF. Use of uniform quality standards will create transparency on the size, scope, and quality of care of health-care facilities in Kenya and allow for benchmarking between facilities and regions. The results could be used to guide improvement within a facility but also for decision-making on NHIF insurance contracting, pay for performance, reimbursement based on quality of care, health system management, policy development, and access to credit.

PharmAccess' approach for this initiative has focused on public and private health-care facilities at the "bottom of the pyramid," such as dispensaries and health centers, which are the primary health-care distribution channel in low-income settings and often struggle with patient safety and quality demands. The program offers a stepwise certification process complemented by technical assistance whereby a facility pursues explicit levels of quality based on explicit criteria by implementing improvement plans to work toward the next level. Where financing for improvement is needed, facilities, through the Medical Credit Fund, can get access to affordable loans with local banks (PharmAccess Group). The Medical Credit Fund facilitates loans to clinics to stimulate growth and encourage new ways of financing health care.

Each quality level is recognized by a formal certificate. This creates an improvement path that offers positive incentives for health-care providers to enhance quality and ultimately qualify for accreditation when the highest level has been achieved. Whereas the latter objective might remain out of reach for many providers for some time to come, a pathway to work toward that objective can boost client, investor, and regulator confidence in the motivation and capacity of health-care providers to steadily enhance their performance.

# **Designing and Organizing the Improvement Effort**

Universal Health Coverage, one of the Sustainable Development Goals, has been adopted as an important national priority in the Constitution of Kenya in 2010 and part of the "Big Four" agenda of President Kenyatta. One of the drivers for Universal Health Coverage in Kenya is the National Hospital Insurance Fund (NHIF). The

<sup>2</sup>The PharmAccess health-care quality standards program, known as *SafeCare*, has been accredited by the International Society for Quality in Health Care. SafeCare (http://www.safe-care.org/ index.php?page=safecare-standards) is a collaboration between PharmAccess and the accreditation bodies Joint Commission International (United States) and the Council for Health Service Accreditation of Southern Africa (South Africa) designed to apply International Society for Quality in Health Care-recognized clinical standards that are realistic for resource-restricted settings. SafeCare dissects the improvement process of health-care providers in surveyable, measurable steps (Johnson et al. 2016).

NHIF is a publicly owned insurance corporation that provides insurance to adults in Kenya working in the formal sector but also offers the so-called SupaCover for the informal sector. For the NHIF to expand its insurance packages to all Kenyans, improving and ensuring the quality of care delivered by hospitals and clinics contracted by NHIF are critical. In order to expand coverage for its members, the NHIF developed and implemented an accreditation system for contracting providers. The management of NHIF, however, wished to have a system more aligned with international accreditation standards used by other countries, such as South Africa, Australia, the United States, Canada, and the Netherlands, based on International Society for Quality in Health Care-accredited clinical standards and evaluation processes. The system should also be part of a continuous improvement process for the facility and not just contracting. However, international accreditation standards such as those set by the Joint Commission International—globally considered the gold standard of health-care accreditation—are generally acknowledged as difficult to implement and maintain in settings where resource constraints hamper compliance. Few health-care facilities in low- and middle-income countries can afford the accreditation process, and once achieved, there are not enough incentives for facilities to make the investment worth it. In Kenya, as of 2019, only the Aga Khan Hospital and Gertrude's Children's Hospital in Nairobi have achieved Joint Commission International accreditation. For NHIF, therefore, the stepwise approach offered by PharmAccess was a better match as a basis to introduce international standards and yet support facilities to meet those standards by making structured, incremental improvements in quality.

PharmAccess built the capacity of the NHIF for a more structured quality system and to incorporate internationally recognized health-care quality and business standards into the NHIF's health-care facility contracting structure. For sustainable quality improvement, having the certification methodology embedded within the NHIF and used for contracting provides much-needed financial incentives for providers, as it provides them a regular income through the capitation system for outpatient services and fee-for-service for inpatient services the NHIF uses.

# *Inception of the Collaboration*

The quality improvement (QI) program began with the formation of a Steering Committee—consisting of the senior NHIF managers (the Chief Executive Officer and the Manager for Benefits and Quality Assurance), the Kenya program lead of the Health in Africa Initiative, and PharmAccess leadership—convened to discuss the strategic direction of the engagement and to draft a Memorandum of Understanding that described the overall objectives of the partnership. Against this framework, more detailed operational plans were designed to achieve the agreed objectives. The Steering Committee was also responsible for overseeing the implementation of the operational plans. Progress was discussed during regular meetings.

Drafting and implementing the operational work plan were the responsibility of the Technical Working Group, which organized monthly meetings. These meetings were attended by quality managers and assessors from each organization (NHIF, International Finance Corporation, and PharmAccess) who could steer the process of developing an operational plan and report back to the Steering Committee as well as their own staff when further input was needed. The Technical Working Group addressed capacity building of NHIF quality assessors, planning of the quality assessments, the quality and business standards that would be applied in the assessments, and embedding the assessments in the overall NHIF structure of contracting health-care providers. They developed an annual training schedule, list of training participants, meeting dates, plans for software implementation, and the organizational structure to support standards-based quality assessments and stepwise certification by the NHIF through its regional managers, who were responsible for implementation. The Technical Working Group provided the implementers with practical details about how the implementation of the standards and certification process should take place.

# *Capacity Building at the National Hospital Insurance Fund*

The NHIF, the Council for Health Service Accreditation of Southern Africa, and PharmAccess Foundation organized several five-day quality assessor trainings for NHIF Quality Assurance Officers from the 15 NHIF regions. The Quality Assurance Officers, drawn from various medical professions, including clinical officers, nurses, laboratory technologists, and public health officers, would be responsible for doing the actual assessments using the standards. The NHIF selected them based on their performance regarding quality assurance and their motivation and ability to drive quality improvement in each region and champion the process. The selection of the top performers in each region to serve as quality assessors would ensure that there would be adequate buy-in at the regional level. Pre- and post-tests were done to establish participants' knowledge and understanding of the standards and assessment process prior to and after the training. In addition to presentations and training materials, the participants discussed case studies, conducted a mock survey using the standards at three facilities, and developed a quality improvement plan using the supporting software system.

To become a qualified quality assessor, participants also needed to successfully complete two mentored quality assessments. Experienced assessors from PharmAccess accompanied the trainees to a health facility to evaluate their work during an assessment. This entailed conducting a full assessment in which the experienced assessor and the trainee both gathered data independently and then crosschecked their scores, incorporating peer-to-peer learning. Through discussion and comparison of his or her assessment with that of one of the surveyors, the trainee would identify areas of scoring that were not clear. These topics were then discussed between trainee and mentor, consulting scoring guidelines.

Next, five NHIF regions (Nairobi, Rift Valley, Nyanza, Eastern, and Central) were selected to start rolling out the quality assessments in their area. These regions conduct two assessments per month with the support of PharmAccess staff, resulting in 30 assessments in 3 months. By working together in assessment teams of two people to conduct assessments and review data at the regional level, the regions built internal capacity and became more efficient at conducting assessments and providing quality improvement support. Quality officers from the Ministry of Health joined several of the training sessions and field visits to ensure that they were involved in these activities and that the activities were aligned with national policies.

# **Improving Care at a Nairobi Health-Care Provider**

St. Patrick Health Care Center, located on a commercial road in Nairobi's densely populated Kayole area, is one of the go-to health-care facilities for the mainly poor and low-income population residing in the area. The facility is owned and managed by a woman who is a trained nurse by profession. The private, for-profit facility has 17 staff members and 26 beds and is open 24 hours a day, 7 days a week. The patients visiting the facility are mostly self-employed in retail activities, handicrafts, or personal services, like barbers and taxi drivers*.*

St. Patrick joined the stepwise certification program in early 2012. At the start of the QI program in March 2012, the facility signed a participation agreement and received a one-day, on-site training for the key staff (managing director, matron, and department leaders). This was done to ensure that the team understood the quality and business standards. An external assessment was then conducted by PharmAccess staff, which resulted in the development of a quality improvement plan outlining areas for improvement. The program provided quarterly monitoring and support visits to help St. Patrick's quality team and follow-up assessments in 2013 and 2016 to evaluate overall improvement. A short overview of the process is depicted in Fig. 7.1.

# *Assessment Standards, Scoring, and Certification*

The health-care quality and business standards included in the quality assessment cover the full range of clinical services and management functions, divided into 13 service elements grouped in four areas:

**Fig. 7.1** Timeline of SafeCare program activities at St. Patrick

Adherence to standards is measured by assessing each service element against a number of scoring criteria, which are measurable elements that define specific requirements. Each criterion is marked as "not compliant," "partially compliant," or "fully compliant"; a mark of "not applicable" is given if the service measured by the criterion is not provided at a given facility. PharmAccess experts then review the results and scores and assign a certification level based on a proprietary algorithm. This certificate is awarded to acknowledge the provider's progress on the quality journey. The program recognizes five levels of improvement, with the highest (Level 5) indicating a provider's readiness to apply for international accreditation.

The first quality assessment at St. Patrick was conducted in June 2012 to measure the level of quality of health services delivered by the facility and identify priorities for quality improvement. The assessment team, who had all successfully completed the assessor training, included a nurse, a laboratory technician, a pharmaceutical technician, and a business advisor. The assessment exercise took a day to complete. The data were reviewed by PharmAccess reviewers who discussed discrepancies identified, unclear comments, and ambiguous scores in the assessment data with the team leader, who then made the necessary adjustments to improve the quality of the assessment data. The data review and approval process took 2 weeks to complete. After the baseline assessment, St. Patrick Health Care Center achieved Level 2 certification, which indicated that "*The facility is starting to operate according to structured processes and procedures, some of which are captured in written guidelines and standard operating procedures. However, health care quality is still likely to fluctuate*."

# *Initiating the Improvement Process at St. Patrick*

An essential part of implementing the improvement process is the creation of a quality team within the facility that includes the facility's clinical leadership, usually the medical director and department heads, with a team lead among the staff spearheading the implementation process. The quality team lead at St. Patrick was a nurse who had attended various trainings on infection prevention and risk management. Other staff on the newly formed quality team included the human resources manager, sales manager, laboratory in-charge, pharmacy in-charge, nurse in-charge, kitchen supervisor, and support staff team supervisor. This multidisciplinary approach aimed to demonstrate that quality within the facility was every department's responsibility. Having a quality team is also in line with the national policy in Kenya that requires all facilities to have one. A simple policy and procedure document was drafted and adopted by the team, which outlined management of the team and general expectations of the team, to facilitate its effectiveness.

The health facility received a quality management training by the quality officers of PharmAccess, both in a classroom setting and at their workstations. The team leader presented a draft quality improvement plan (QIP) developed by PharmAccess to the facility's quality team to discuss the proposed activities and their distribution across the implementation period as well as assigning responsible persons for each activity. The draft QIP was developed based on a proprietary algorithm of PharmAccess that identifies noncompliant areas that are either high risk to patients, to staff, or to the business performance of the provider. During the meeting, inputs and activities suggested by the facility management and staff were incorporated. The team leader made subsequent adjustments and presented the revised QIP to the PharmAccess quality officer for review and approval. The purpose of this process is to ensure both local ownership of the plan and that essential gaps in quality are addressed and that the QIP is ambitious enough.

The team leader then proceeded to share the findings of the approved assessment and the QIP with the entire facility to encourage adoption of all the actions in the QIP. The facility-wide meeting provided an opportunity for all staff to hear the findings of the assessment and discuss the proposed activities as presented in the QIP. Slides highlighting departmental performance drew particular attention. The use of pictures taken during the assessment to show gaps and emphasize good practices resonated well with the staff, causing those present to accept and own the report. The approach that was taken was nonpunitive, to stimulate an open, learning environment.

**Table 7.1** Detailed improvements made at St. Patrick in human resources, pharmacy, laboratory services, and patient records management

## *Human resource management:*

High health-care staff turnover is a challenge in Kenya, and St. Patrick's situation is no different. On average, over one-third of their personnel leaves every year, although staff retention has now improved. The owner has completed and updated their personnel files, drafted job descriptions, and now facilitates continuous medical education every week

# *Medication management:*

Improvements to the pharmacy included privacy, efficiency, and inventory management. The dispensing window was moved so that clients can consult the pharmacist out of earshot of the waiting room, and there is a separate room for sensitive cases. Medicines are now stored in a locked cabinet. Hazardous and flammable materials are stored separately. The pharmacy now serves up to 200 people a day

# *Laboratory services:*

St. Patrick upgraded the lab 2 years ago, moving it to a larger room, installing separate sinks for staining and handwashing, and purchasing more equipment, such as TB and HIV testing kits. They monitor services with performance reports and have installed a standard operating procedure for every test, a tracking chart for expiration dates, and guidelines for the maintenance of lab equipment. There is also a visible price list with the expected report time for results. The number of lab tests has more than doubled, from 400 to about 850 per month. The lab generates a lot of income and has become the financial backbone of the facility

# *Patient records management:*

The facility management team procured computers and installed a hospital management system in all relevant areas. Digitalization of this key function not only improved management of records by providing privacy of patient information, but it also increased efficiency in storage of patient's data and overall communication across departments

An important aspect of this development is the ability of the facility to utilize the collected data by conducting monthly data analysis, hence making key decisions based on informed analysis

Each of the members of the quality team then coached the implementation process in their respective departments. Activities varied from the introduction of stock management tools and job descriptions to redesigning the patient flow process (see Table 7.1). Thereafter, the quality team met on a monthly basis to discuss progress on improvement activities in the different departments. The team lead kept the facility manager informed about progress and funding needs. All meeting discussions were documented in the quality team file. As a result of this consultative process, the staff at St. Patrick quickly embraced the quality improvement process.

The facility received technical assistance from PharmAccess quality officers, who visited the facility approximately every quarter to measure the extent to which the quality improvement plan was being implemented. These visits aimed to assist the facility quality team to identify bottlenecks and provided support to find solutions. The facility also had access to an online library with guidelines, checklists, protocols, and other materials developed by PharmAccess to help meet the program's quality standards.

Addressing quality gaps is not only about improving structures and procedures; financial investments in equipment and infrastructure are needed. The program has helped providers to unlock investments as they help the owners think about their work as a business. Shortly after joining the program, St. Patrick obtained a loan, as well as business training, through the PharmAccess Medical Credit Fund. With a Kenya shilling (Ksh) 500,000 (USD 5000) loan, they purchased computers, installed a computerized management system, internal phone lines, and a closed-circuit television system (a TV system primarily used for surveillance and security purposes). They also invested in having an external auditor check their financial accounts and made minor infrastructural improvements. The business training helped the facility to prepare for a larger loan qualification, draft a business plan, and prioritize its investments.

The initial assessment report was an eye-opener for them. "*We were not running the facility in the right way*," the owner explained. "*We had no administration office, no systems. We used to work from our pockets, writing on patient cards, and counting the shillings at the end of the day. SafeCare helped us to establish our gaps and set in motion interventions to improve ourselves. Now, our record keeping is accurate, and we have audited accounts and a digital client history that can be accessed at any time. The system has also helped minimize fraud and track the expiration dates of drugs in our pharmacy*."

The experience they gained in qualifying for their first loan through the Medical Credit Fund was instrumental in building a financially sound organization. Through the training and on-site support, they learned how to draft a business plan and which documents to deliver to the bank. Financial records were now neatly in place. They repaid their first loan within 6 months. Their track record and improved financial management enabled them to secure a Ksh. five million (USD 50,000) loan from a bank to invest in their laboratory and expand the facility.

"*It was difficult sometimes in the beginning because SafeCare requires a new way of thinking, both for us and for our staff*," the owner says. "*It's about accountability, transparency, and establishing procedures – in all departments, from the cleaners to the medical personnel. But now that our staff has seen what the program can do, they are fully on board and committed to continue to improve our quality*."

For instance, in the beginning, St. Patrick's quality team felt that improving the facility's documentation required additional work for which they did not have time. After some initial encouragement, they realized the benefits of their time investments; fewer insurance claims (both NHIF and commercial) were rejected, thanks to the improved documentation. The facility also implemented some very visible, patient-focused improvements; for example, the renovation of the waiting room, previously a crowded room that was the cause of complaints. The redesign process was easy to implement; it involved various departments and was considered "low hanging fruit," as it did not involve complex processes, training sessions, or issues that could be considered political, such as nonperforming staff. The renovation not only resulted in better patient flow but also elicited positive responses and compliments from the patients, which encouraged the staff members to continue on their improvement journey and experience pride in the results. Table 7.1 provides illustrative examples of improvement activities instigated at St. Patrick that contributed to overall better performance of the facility and compliance with the certification standards.

# *Technical Support for Improvement*

During the implementation process, one quality assurance officer from PharmAccess visited St. Patrick quarterly to monitor progress, identify bottlenecks, and support the quality team in finding appropriate solutions. The NHIF quality assurance manager accompanied the PharmAccess officer on two visits but had too many other responsibilities to provide regular support to specific facilities. St. Patrick Health Care Center was also encouraged to call the PharmAccess quality officer anytime if they needed specific assistance with any of their improvement activities.

During one quality team meeting, facility staff expressed the need to improve on the level of waste management and infection control in the facility. The main challenges in the facility included lack of color-coded bags for waste bins, lack of proper waste segregation at the point of generation, lack of proper storage of generated waste in the facility, and lack of a documented policy to guide staff on waste management and infection prevention. In addition, the facility was struggling with providing clean running water, soap, and hand-drying towels in key areas, such as the laboratory.

The quality team lead prepared a short presentation on waste management practices in the facility, using pictures and demonstrations (e.g., on proper hand washing techniques and waste management). This was then followed up by drafting of a quick plan of action that detailed what was required for improvement (e.g., procurement of coded bins, procurement of hand-drying towels, documentation of policies and procedures) and indicated the respective staff assigned to complete each activity, the budget required (if any), and finally, the period of completion for each specified activity.

# **Results**

St. Patrick Health Care Center began the improvement work at Level 2 certification (based on their baseline assessment scores), but achieved Level 3 certification within 6 months through changes implemented to improve quality of care. St. Patrick's significant progress in implementing their QIP qualified the facility for a third follow-up quality assessment in November 2016.

After the third assessment, the facility achieved a Level 4 certificate, making it one of the highest-performing facilities in terms of quality in Kenya. Level 4 certification means that "*The facility is regularly monitoring the implementation of treatment guidelines and standard operating procedures through internal record reviews and (clinical) audits. Most high-risk processes and procedures are controlled.*" After the third assessment, a new QIP was prepared to guide the facility in continuing to improve quality to advance to an even higher certification level.

Figure 7.2 shows the improvement in assessment scores achieved by St. Patrick over the three assessments. While the facility demonstrated an increase in most

**Fig. 7.2** St. Patrick quality assessment scores by service element. Note: Diagnostic imaging was introduced only before the third assessment

service elements, as is common with improvement trajectories, scores fluctuated somewhat with an overall positive trend. As St. Patrick does not have surgery services, this service element was not scored.

The next step is installing an operating theater. The facility is eager to continue improving quality of care to reach Level 5. "*SafeCare needs a lot of commitment, but you feel like you're in another world. It makes you feel like a professional*," said the owner.

# *Achieving National Hospital Insurance Fund Contracting*

During previous inspections by the NHIF of St. Patrick, the facility was unsure what was expected of them and what were the standards against which they were evaluated; as a result, St. Patrick failed to meet the criteria for NHIF accreditation. There was no manual or checklist used by the NHIF assessor, and St. Patrick was not offered advice on how to improve on shortcomings that prevented their NHIF accreditation. After the introduction of the program, the facility received a clear overview of what they were evaluated against and how to introduce the necessary changes to adhere to these standards. As a result, St. Patrick became NHIFaccredited in November 2012, ensuring a larger client base and income flow. Patient visits have risen, and the facility has also managed to contract with corporate clients and private medical insurance companies. In turn, the more regular income and client base from serving insured patients have been key to financing and sustaining the quality improvement work, apart from PharmAccess technical support.

# **Scaling Up and Sustaining the Certification Program**

Introducing international standards, stepwise certification, and a transparent rating and improvement program to health-care providers in Kenya has proven to be a successful approach toward sustainable quality assurance. The combination of using this approach in conjunction with NHIF contracting and embedding it in the framework of the national quality policy of the Ministry of Health offers both the incentive and the enforcement mechanism to encourage providers to participate in quality improvement initiatives. The case study of St. Patrick Health Care Center gives insights into the actual activities that are needed within a facility to meet adherence to the standards. These activities require both committed management and committed staff. In addition, financial means/access to credit, such as through the Medical Credit Fund, are also helpful.

Data on the overall effectiveness of the program in Kenya show that 84% of the participating facilities have improved their quality scores between the initial and second assessments, suggesting that the stepwise approach is, for many facilities, an efficient and effective approach.

In 2017 and onward, quality system coverage continues scaling up under NHIF ownership. Scaling up has also come with challenges and exposed gaps in the system. The NHIF Senior Manager for Benefits and Quality Assurance at the national office states, "*The national office led the discussions for the strategic partnership and involved the regional managers through internal strategic meetings. These discussions were held in the wider context of the NHIF quality assurance program and the proper integration in the NHIF annual work plans implemented by the regions. Some of the challenges the regional mid-level Claims and Quality Managers face are competing priorities within the NHIF, compounded by staff who perform both claims and quality. These issues have influenced our decision to start with a few regions with selected staff to get results and learn lessons that can be used to scale up*."

A key learning during implementation of the program is that much more engagement with facilities on issues of quality is needed. The providers need supportive supervision and guidance, rather than just inspections and enforcement. Facilities which have been contracted by the NHIF recently need to be regularly visited because they need to be taken through NHIF processes as well as be guided on how to carry out their quality improvement meetings. It is recognized that for the NHIF, this need can compete with other needs and demands, and policy discussions should be encouraged to determine whether in the future this role should remain with NHIF, or whether an independent quality improvement and assurance institute should take up this role.

In the beginning, facilities find the quality improvement process very demanding, but as they go along, they find it easier to work with the process. Most of the facilities which have fully embraced the quality improvement process find a lot of benefit in it, since they are able to plan and budget well for the facility, monitor goods and supplies, have good bookkeeping allowing them to track their finances,

and have a structured patient management process which improves client satisfaction. Another key motivator for facilities is that the NHIF can pay out their claims much faster as a result of improved bookkeeping and patient documentation. As the NHIF Regional Benefits and Quality Assurance Officer states, "*Our regional Claims and Quality Assurance Managers appreciate the stepwise accreditation standards and quality improvement methodology, since it makes their work easier, and they receive fewer complaints. Before the introduction of the stepwise accreditation standards, our work consisted of conducting inspections to see whether facilities complied with our quality and financial regulations. At the time, the NHIF concentrated more on fraud management than on quality issues*." He also advises that in order to introduce a quality program in an institution like the NHIF, it is important to study the organization well and understand its internal structures and how it relates externally. Such programs should always aim to build the capacity to develop homegrown strategies, and the process should be long term. Quality improvement programs must be institutionalized and driven by the facilities.

# **Reflection**

A main barrier to large-scale adoption of any quality program is the relatively high cost of quality assurance, currently funded primarily by donors. First, the focus should be on how to build sufficient local capacity to ensure local ownership and low costs; next, on how to embed the methodology within the health-care system to provide both enforcement and incentive strategies that guide facilities toward improvement.

"*Although quality improvement is seen as important, more work needs to be done to convince facility owners to bear some of these costs themselves*," adds the PharmAccess Country Director for Kenya. One way of promoting co-financing is to strengthen for health facilities the linkage between achieving a higher accreditation certificate and benefitting both financially (more patients and better contracts) as well as socially (awards and recognition among peers). For example, facilities in the neighborhood of St. Patrick have also asked to be in the program, and the owner of St. Patrick has been invited to talk about their experience and results at conferences and stakeholder meetings.

By requiring a minimum level (for example, Level 2) to participate in NHIF contracting and rewarding facilities that continuously show improvement with higher medical pay-outs, both enforcement and incentive mechanisms can be in place to sustain improvement. NHIF, PharmAccess, and the International Finance Corporation continue discussing possibilities of linking quality to the reimbursement of claims. A proposal has been made in the Health Financing Bill of Kenya to link quality to financing.

"*It takes time for quality to improve, and for those improvements to be sustained*," says a policy officer at the Health in Africa Initiative of the International Finance Corporation. "*It involves behavioral change in addition to increased motivation,*

*knowledge, resources, and organizational management. Long-term strategies need to be deployed for quality improvement, designed to go beyond the project life cycle. It should be ensured so that the results achieved are not lost. Linking quality improvement to pay-for-performance mechanisms motivates the health facilities to invest in improvement and sustain this work*."

Establishment of an independent accreditation body has now been endorsed in the health improvement policy, the draft health bill, and in the health financing strategy (currently under development). With policy implementation and regulation, quality improvement can be further encouraged in both the private and public sectors. The standards presented in this case study have been recognized as a key methodology for accreditation, and with franchises, private clinics, and the NHIF adopting parts of the methodology, a firm basis has been laid for institutionalization.

# *Author's Reflection*

To strengthen health systems in low- and middle-income countries, it is important that national governments step up their role as supervisor. They need to integrate licensing, transparent quality standards and benchmarks, and accreditation into health policies and to enforce compliance. Better data will help governments to allocate their scarce resources more efficiently to invest in quality improvement. Improvements in health-care quality can yield numerous benefits to populations, bringing increased access to health services that are safe, effective, and patient-centered.

The adoption and incorporation of the SafeCare standards by the NHIF and various other health system actors in Kenya build a platform to support increased trust and transparency in the system. The SafeCare methodology is embedded in a healthfinancing model that aligns incentives and gives regulators and insurers leverage to ensure sufficient quality in the health-care services that are procured. The partners in this program have developed and implemented a set of quality standards and a scalable assessment and scoring methodology that assist in laying the foundation for a sustainable, Kenya-owned quality monitoring system.

–Nicole Spieker, Director Quality, PharmAccess Foundation, August 2017

**Acknowledgments** The author thanks the following individuals for their contributions to the SafeCare application in Kenya:

Millicent Olulo, Regional Director for Advocacy and Partnerships, Former Country Director, Kenya, PharmAccess

Kasmil Masheti, Quality Manager, PharmAccess Mary Njoki, Quality Manager, PharmAccess Simeon Kirgotty, Former Chief Executive Officer, National Hospital Insurance Fund Joseph Githinji, Former Manager, National Hospital Insurance Fund Frank Wafula, Policy Officer, International Finance Corporation Njeri Mwaura, Policy Officer, International Finance Corporation Ann Maira, owner, St. Patrick Health Care Center

# **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

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# **Chapter 8 Promoting Rational Use of Antibiotics in the Kyrgyz Republic**

# **Barton Smith**

**Abstract** Antimicrobial resistance (AMR)—the resistance of disease-causing microbes to treatment with antibiotics and other antimicrobial drugs—is a growing global health threat worldwide, making it more difficult and more expensive to treat common infections such as pneumonia, bladder infections, and skin infections. The World Health Organization's global strategy for containment of AMR calls for provision of evidence-based clinical guidelines on diagnostic and treatment strategies for common infections; the education of providers on AMR and prescribing guidelines; and institutionalization of regular audits of prescribing practices, providing feedback to clinicians using comparison with peer groups or external standards. AMR is a serious problem in the Kyrgyz Republic, which has one of the highest rates of multidrug-resistant tuberculosis (TB) in the world (25% among new cases of TB; 56% among previously treated cases). In 2012, a United States Agency for International Development (USAID) project for improving health-care quality in the Central Asian Republics began working with partners in the Kyrgyz Republic to promote the rational use of antibiotics among prescribers by using principles of quality improvement. This case describes how these actors conducted baseline audits of use of antibiotics and then developed clinical protocols, training, and job aids to change prescribing practices of providers in pilot districts and how they introduced a database to track audit indicators and feed back the results to providers.

**Keywords** Antibiotics · Antimicrobial resistance · Audit and feedback · Clinical protocols · Evidence-based medicine · Kyrgyz Republic · Quality improvement · Rational use of antibiotics

# **Background**

In 2012, a US Agency for International Development (USAID)-funded project for improving health-care quality in the Central Asian Republics began working with partners in the Kyrgyz Republic to promote the rational use of antibiotics (RUA)

B. Smith (\*)

Virginia Mason Edmonds Family Medicine (Formerly with Abt Associates), Edmonds, WA, USA

© University Research Co., LLC 2020 105

L. R. Marquez (ed.), *Improving Health Care in Low- and Middle-Income Countries*, https://doi.org/10.1007/978-3-030-43112-9\_8

among prescribers by using principles of quality improvement. Antibiotic resistance among disease-causing bacteria is a worsening global health threat, making it more difficult and more expensive to treat common infections such as pneumonia, bladder infections, and skin infections. The World Health Organization (WHO) developed a global strategy for the containment of antimicrobial resistance (AMR) in 2001, which included promoting RUA as a key component of national strategies on AMR, knowing that indiscriminate use of antibiotics is strongly correlated with high levels of antibiotic resistance. Promoting RUA among clinicians involves provision of evidence-based guidelines on diagnostic and treatment strategies for common infections; the education of providers on AMR and prescribing guidelines; and institutionalization of regular audits of prescribing practices, providing feedback to clinicians using comparison with peer groups or external standards.

When the RUA initiative began in 2012, no routine surveillance of antibiotic resistance levels for common infections was conducted in the Kyrgyz Republic; therefore, only limited data were available to characterize the scope of the problem. However, the rate of multidrug-resistant tuberculosis (TB) in Kyrgyz Republic is one of the highest in the world (25% among new cases of TB; 56% among previously treated cases). Likewise, no routine auditing of antibiotic prescribing practices was conducted in the country prior to this initiative, but a survey of antibiotic prescribing patterns conducted by CitiHope International in one Kyrgyz hospital in 2007 showed that antibiotics were inappropriately prescribed in 73% of cases, were not indicated in 48% of cases where prescribed, and indicated but incorrectly selected in 25% of cases.

Although containment of AMR was not prioritized in the Kyrgyz national health strategy in effect from 2012 to 2015, the RUA initiative was strongly supported by the Ministry of Health (MOH), local partners, and international development partners, including the World Health Organization and the Medicines Transparency Alliance. In fact, a national working group on AMR was established shortly after the initiative began. While the national working group was informed of the activities, they were not directly involved in overseeing the RUA initiative.

One of the first activities under the RUA initiative of the project was to identify and characterize gaps in knowledge, attitudes, and practices (KAP) through a survey related to antibiotic use among consumers and prescribers to help establish the need for intervention and to ensure that planned activities were appropriately focused. The KAP survey showed that adult consumers take, on average, over two courses of antibiotics per year and identified many misconceptions about the usefulness of and indications for antibiotics among both consumers and physicians.

Figure 8.1 shows the key stakeholders in the RUA initiative in the Kyrgyz Republic. In addition to the MOH and project staff, two professional associations the Hospital Association of the Kyrgyz Republic (HAKR) and the Family Group Practice and Nurses Association (FGPNA)—played a central role. Both associations were created in the late 1990s to provide advocacy and support for their constituents. Both organizations began to coordinate quality improvement initiatives

**Fig. 8.1** Key stakeholders and their roles

through previous health reform projects funded by USAID between 1996 and 2009, which focused broadly on health system strengthening with a focus on improving primary care and reforming health financing. This project included a component on "Other Public Health Threats," under which the project launched the initiative to promote the rational use of antibiotics.

Located in the heart of Central Asia, the Kyrgyz Republic is a mountainous country with a population of nearly six million and is one of the poorest of the former Soviet Republics. The socialized health-care system includes an extensive network of primary health-care (PHC) facilities and hospitals, which are managed and financed independently from one another at the district and regional levels. Regional (*oblast*) Family Medicine Centers (FMCs) represent the highest administrative level of service delivery at the ambulatory level; district (*rayon*) FMCs are financed and managed independently from regional FMCs but are under the leadership of the regional FMC director, who also serves as the regional health coordinator. Health facilities are managed by physician directors; deputy directors are tasked with ensuring the quality of clinical services, including the coordination of continuing professional development of their health-care staff through the Kyrgyz State Medical Institute for Retraining and Continuing Education (KSMIRCE). The KSMIRCE is a State institute responsible for providing continuing medical education (CME) to all physicians and nurses throughout the country and has a network of regional-level family medicine training centers, each with at least two full-time family medicine physician and nurse trainers. The Family Medicine Department of the KSMIRCE has worked closely with the FGPNA since its inception to respond to training needs voiced by FGPNA members and to coordinate continuing medical education topics with QI initiatives.

# **Organizing the Improvement Effort**

# *Foundational Work with Implementing Partners*

The project's first task was to meet with local partners, who would serve as the primary implementers, to outline a general strategy and assign specific roles and responsibilities. The FGPNA and the HAKR were natural choices for key implementing partners: they were recipients of grants under the project, had worked on previous QI initiatives, and had institutionalized roles in supporting their constituents at the PHC and hospital levels to provide quality care. Within each organization were two or more individuals who had worked as external quality advisors on previous quality initiatives supported by USAID. During these first meetings, the FGPNA and the HAKR, together with the regional quality advisor (who was also a physician), agreed upon the strategic approach that would be used in the RUA initiative (see Fig. 8.2).

The project's regional quality advisor also met with family medicine trainers from the KSMIRCE to solicit their help in developing the training materials. As the KSMIRCE is responsible for approval of continuing medical education (CME) and annual CME training calendars, working through them was important for institutionalization and future scale-up of training. Figure 8.3 shows the overall timeline of the initiative to rationalize the use of antibiotics in Kyrgyz Republic.

**Fig. 8.2** Strategic approach used in the RUA initiative

**Fig. 8.3** Rational use of antibiotics initiative timeline

# *Choosing Improvement Priorities: Selecting Index Conditions*

Focus groups of clinicians were then organized by the FGPNA and the HAKR to define a list of "index" conditions for which antibiotics were often unnecessarily or incorrectly prescribed. This was done at the national level rather than the facility level for two reasons: first, all key stakeholders agreed that these conditions were unlikely to vary significantly between facilities; second, using one common set of conditions would allow the project to use the same audit instruments and training curriculum for all participants, compare results between facilities (peer comparisons), and collate data at district, regional, and national levels. The FGPNA gathered 14 physicians representing both urban (nine) and rural (five) PHC facilities, while the HAKR gathered 9 hospital-based physicians from the Bishkek facilities.

The next step was to determine what, if any, evidence-based clinical guidance existed to use as a standard for the development of audit instruments on the index conditions. Kyrgyz physicians are accustomed to using nationally approved clinical protocols (CPs) to guide their practice decisions following a broad initiative to develop CPs in 2000–2001; however, the number of approved CPs was limited, and principles of evidence-based medicine (EBM) were not known or widely applied to CP development prior to 2004, so there was concern that CPs on the index conditions might not be available or, if available, might not be evidence-based. For this reason, a desk review of existing CPs on index conditions was conducted by the regional quality advisor in conjunction with the EBM unit within the Kyrgyz Ministry of Health. No protocols existed on the four topics targeted at the PHC level. Of the five conditions targeted at the hospital level, evidence-based guidelines had been approved for three (pneumonia, asthma, and chronic obstructive pulmonary disease). No guidance was available for cystitis, and the CP available on pyelonephritis from 2003 contained many non-evidence-based recommendations on risk factors, diagnosis, and treatment. A decision was made at that point that the needed clinical protocols would be developed simultaneously with the training curriculum for the initiative, as evidence-based source materials were needed for both. CP development teams were composed of KSMIRCE family medicine trainers (for PHC protocols) and clinical specialists, with technical support from the regional quality advisor and with methodological support from the MOH EBM consultant.

# *Developing Audit Instruments*