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Quality Improvement Teams in South Africa Show Results

Since the 1994 elections, key policy goals of the Government of the Republic of South Africa have been to achieve universal access to primary health care and give greater priority to meeting the health needs of historically disadvantaged groups. The national health program is now devoting a greater proportion of resources to programs that target vulnerable groups and diseases of poverty, including measures to promote maternal, child and womens health and the control of communicable and infectious diseases, such as tuberculosis (TB), hepatitis, polio, measles, HIV/AIDS, and other sexually transmitted infections. Although access to care has expanded greatly, the governments health program still faces many hurdles in raising the quality of services provided and achieving improved health for all. South Africas spiraling HIV/AIDS epidemic is posing a major challenge to this effort, and mortality rates among the historically disadvantaged groups continue to be high.

At the national level, the government established the Directorate for Quality Assurance to spearhead the development of policies and standards to improve health service delivery. USAID is supporting these efforts, as well as steps to create quality assurance capacity at the provincial level. In Mpumalanga Province, one of South Africas least developed regions, the Department of Health has undertaken some improvements to healthcare quality, although these activities were not linked into a provincial quality assurance system.

In 1999, USAID requested that the QA Project work together with the bilaterally funded EQUITY Project to support the Mpumalanga Department of Health (MDOH) in institutionalizing a quality assurance system at the district and sub-district (ward) levels. The MDOH conducted clinical capacity audits throughout the province in 2000 and identified quality deficiencies in many areas, such as patient management, infection prevention practices, compliance with evidence-based guidelines, medical records, pharmaceutical management, and the referral system.

Pilot QA Program. Based on the audit findings, the MDOH worked with the QA and EQUITY projects to develop a pilot QA program to improve quality of care in three of the provinces 16 wards: Piet Retief, Philadelphia, and Nelspruit. Quality assurance committees were formed in each pilot ward and quality assurance coordinators identified to lead quality improvement initiatives and monitor results. The committees identified TB, HIV/AIDS, voluntary counseling and testing (VCT), antenatal/postnatal care, neonatal health, and reducing hospital-acquired infections as the priority areas for improvement at primary and hospital levels.

In the pilot wards, improvement efforts are focusing on both the content and process of care. To improve the content of care, compliance with evidence-based guidelines is being increased through training, better communication of guidelines/protocols, and supervision. The process of care is being improved by reorganizing care to increase effectiveness and efficiency, service redesign, regular monitoring of quality indicators, and introducing strategies to improve health provider motivation.

Quality Improvement Results. In the last year, over 800 health professionals received basic training in quality assurance methods and tools in the pilot wards. After training, QA committees undertook facility assessments to identify and prioritize problems. For example, the Piet Retief Hospital QA committee decided to focus first on neonatal health issues. The team conducted a record review to analyze the problem and identify possible causes and solutions. Based on the assessment results, the team introduced guidelines for management of labor and delivery and for managing neonatal asphyxia, hypothermia, and hypoglycemia. They conducted in-service training of hospital workers in the neonatal ward to orient staff in the use of the guidelines. Monitoring of maternal and fetal vital signs has improved, from once during the 4-12 hours of labor to monitoring now every two hours. This result is still short of the international standard of monitoring every 30 minutes, but due to staff shortages, the standard is not yet achievable. The team is also monitoring the number of stillbirths as an indicator of the quality of care during the labor process. Since the improved processes of care were introduced, there has been a steady decline in the number of stillbirths, as seen in the graph below.

Piet Retief Hospital: Stillbirths 20002001

APGAR scoring compliance in Piet Retief has increased from 20 percent before the intervention to 90 percent after the introduction of revised guidelines. Now almost all neonates receive a physical exam, although variations persist in the performance of individual providers. Data also show that there has been a declining trend in the neonatal mortality rates, as shown in the graph below. The QA committee is monitoring outcomes closely to see if these gains are consistently maintained and further improved.

Hospital Neonatal Mortality Rate/Piet Relief 2000/2001

To complement the hospital process of care improvements, traditional birth attendants in surrounding communities were trained in management of labor and health education to pregnant women and motivated to educate pregnant women regarding the importance of ante-natal care.

The TB program in the three pilot wards faces similar challenges. Opportunities for improvement exist in cure rate, case detection rate, compliance by patients and providers with treatment guidelines, recordkeeping, follow-up, etc. The QA committees in the three pilot wards are working to improving the process of care for TB patients by improving the availability of TB drugs in all facilities and orienting staff in the use of the national TB management protocol. Another improvement strategy has been to designate individuals in the community to serve as Directly Observed Treatment (DOT) supporters, to ensure that TB patients take their medications. Before a TB patient is released from the hospital, the designated DOT supporter is contacted to receive the patient in the community. In Piet Retief health ward, the staff has also created a physical map showing the location of all TB patients, to facilitate follow up.

Limited successes are already visible in all pilot wards. Preliminary data show that the case detection rates, compliance with treatment regiments, and smear conversion among TB patients have greatly improved in the past nine months. Again, the QA teams are monitoring performance indicators closely to see how these improvements can be maintained.

Other quality improvements efforts are underway in the three wards to reduce the rate of hospital-induced infections, reduce occupational hazards (e.g., sticks by contaminated needles), and improve the quality of voluntary HIV counseling and treatment. The MDOH is now developing plans to expand the pilot program activities to the other 13 wards in the province.

For more information on the QA Projects work in South Africas Mpumalanga Province, contact Neeraj Kak at nkak@urc-chs.com.